Amino acids

Urea Cycle and

Associated Disorders
Learning objectives

Significance of urea cycle
Reactions of urea cycle
Hyperammonemias
Associated disorders of urea cycle
Diagnosis and Treatment

2
Urea cycle
Major pathway of nitrogen excretion in humans
Occurs exclusively in the liver (Mitochondria and cytoplasm)
Known as the Urea Cycle or the Krebs-Henseleit Cycle or
Ornithine cycle
One of the nitrogen atoms of urea is from aspartate (Glutamate
is the immediate precursor of both ammonia)
Other nitrogen atom is from free NH
3
and
Carbon atom comes from HCO
3
- (derived by hydration of CO
2
)
NH
2
-C-NH
2

O
Free NH
3
Aspartate
CO
2
Glutamate
AST
BLOOD
NH
3

CO
2
+

2ATP

+

2ADP+Pi

Carbamoyl Phosphate

L-Citrulline

Ornithine

Pi

MITOCHONDRIA

CYTOSOL

L-Citrulline

Argininosuccinate

Ornithine

Arginine

Aspartate

ATP

AMP+PPi

Fumerate

Malate

OAA

KG

Glu

CPS I
N-acetyl
glutamate
Ornithine trans
carbamoylase
Argininosuccinate
synthetase
Arginase
Argininosuccinate
lyase
UREA

H
2
O

KIDNEY
LIVER

????
????
????
Summary and Stoichiometry of Urea Cycle
cytosol
mitochondrial matrix
carbamoyl phosphate
P
i

ornithine citrulline
ornithine citrulline
urea aspartate
arginine argininosuccinate
fumarate
TCA cycle
NH
3
+ HCO
3

Pyrophosphate is rapidly hydrolyzed, and so the equivalent of four molecules of ATP
are consumed in these reactions to synthesize one molecule of urea.
The synthesis of fumarate by the urea cycle is important
because it links the urea cycle and the citric acid cycle
Fumarate is hydrated to malate, which is in turn oxidized to
oxaloacetate.

Regulation of Urea cycle
Short-term regulation of the cycle
CPS-I allosteric activator N-acetylglutamate.
Steady-state concentration of N-acetyl glutamate set by
acetyl-CoA & glutamate & by arginine (positive
allosteric effector of N-acetyl glutamate synthetase)
Long term regulation
At the gene level.
- Dietary proteins enzyme concentrations
- Starvation enzyme levels as proteins are
degraded and quantity of nitrogen that must be
excreted

Fate of Urea
Bulk of the urea excreted by kidney
Small amount lost through the
gastrointestinal tract acted on by bacterial
urease CO
2
+ NH
3
Important cause of Hyperammonemia in
individuals with renal failure
Treated by antibiotics to reduce the number
of intestinal bacteria
Clinical importance of Blood Urea estimations
Whole urea molecule is assayed/ only the nitrogen
component of urea (the blood or serum urea
nitrogen, i.e., BUN or SUN) is measured.
BUN, is roughly one-half (28/60 or 0.446) of the
blood urea.
Normal range of urea nitrogen in blood or serum is
5 to 20 mg/dl, or 1.8 to 7.1 mmol urea per liter.
Range is wide variations due to protein intake,
endogenous protein catabolism, state of hydration,
hepatic urea synthesis, and renal urea excretion
Renal failure- BUN, Liver disorder- BUN
The Urea, BUN and serum Creatinine are screening
tests of renal function.


Ammonia Metabolism
Imbalance leads to Hyperammonemia
Normal ammonia levels are between 5-35 mol/L
Toxicity can rise above 1000 mol/L
Symptoms neurotoxic tremors, slurring of speech,
somnolence, vomiting, cerebral edema and blurring of vision and
later coma and death
Possible reason for the symptoms:
























Sources
Glutamine
Intestinal bacterial urease
NH
3
+
H C COO
-
CH
2
CH
2
COO
-
O

H C COO
-
CH
2
CH
2
COO
-
+

NAD
+
(or NADP
+
)

+

NH
3

TCA cycle


Urea


NADH
+
(or NADPH
+
)

+

L-Glu DH
Acquired causes
Liver disease
Common cause of Hyperammonemia in adults.
Acute process Ex: viral hepatitis, ischemia, or
hepatotoxins(alcohol, drugs)
Chronic liver diseases (cirrhosis end stage) : Biliary atresia,
Alpha1-antitrypsin deficiency, Wilson disease, Cystic fibrosis,
Galactosemia, Tyrosinemia
Renal
Urinary tract infection with a Urease-producing organism,
such as Proteus mirabilis, Corynebacterium species, or
Staphylococcus species, This usually happens in association
with high urinary residuals

Arginase
Hyperammonemia:
Type I
Type II
Inherited Defects of Urea Cycle
Carbamoyl phosphate
synthetase I

Argininosuccinate
lyase
Citrullinuria
Argininosuccinic acidemia
Argininemia
Inherited Defects of the Urea Cycle
Inheritance- Autosomal Recessive ,except
hyperammonemia type 2 which is inherited X-Linked
Recessive & is most common
All defects characterized by ammonia intoxication
Severity of the disease is influenced by the position
of the defective enzyme in the pathway-more severe
when block occurs at reactions 1& 2

Clinical symptoms manifest during first weeks of life
Vomiting, Failure to thrive, Protein intolerance,
Intermittent ataxia, irritability, lethargy, & mental
retardation

Inherited Defects of the Urea Cycle
Hyperammonemia Type 2
- Defect : Ornithine Transcarbamoylase (OTC)
- Mode of inheritance: X-linked Recessive
- Symptoms: hyperammonemia, blood glutamine
BUN, orotic aciduria, cerebral edema,
lethargy, convulsions , coma and death
- Reason for orotic aciduria



CO
2

NH
3

+


Carbamoyl
phosphate


Citrulline


Urea


OTC


Orotic acid synthesis


Orotic aciduria


{ Pyrimidine
synthesis}


CPS I





15
Establishing the Diagnosis
Laboratory data useful in the diagnosis of UCDs
include-
Plasma ammonia concentration, pH, CO
2
,
quantitative plasma amino acids analysis, and
analysis of urine organic acids and urine Orotic acid
Diagnosis-
- Very high plasma ammonia concentration
- Elevated blood glutamine
- Decreased blood urea nitrogen (BUN)
Strong indication for the presence of a UCD .
Treatment:

Long term: Dietary restriction.
(Low protein diet with sufficient calories)
Supplemented with Arginine

Short term: Dialysis
Administration of Nitrogen scavengers
e.g. Sodium benzoate, Phenylpyruvate
Urine
Hippurate(Benzoyl glycine)
Glycine
Benzoyl CoA
Benzoyl CoA
CO
2

NH
3

+


+


ATP


CoASH
NH
3

Mechanism