Glucose 6-phosphate

dehydrogenase
deficiency
 Glucose 6-phosphate dehydrogenase deficiency
(G6PD deficiency)

Definition
• It is an inherited disease characterized by hemolytic anemia caused by
inability to detoxify oxidized agents.

• G6PD deficiency is the most common disease producing enzyme anomalies

in humans, affecting more than 200 million individuals worldwide.
worldwide
The highest prevalence in the Middle East, tropical Africa & Asia.
Asia

• G6PD Deficiency is caused by 400 different mutations in gene coding for

G6PD, only few of them causes the clinical symptoms of the disease.
 Mode of inheritance of G6PD Deficiency

• It is X- linked recessive genetic disorder (gene is carried on X-chromosome).

• The gene is present on the X chromosome

• The inheritance follows specific pattern:

Males have one X chromosome

So, they will be diseased if they have the affected gene (xY)

Females have 2 X chromosomes

may be homozygous or heterozygous

Homozygous:
Homozygous are diseased (xx)
Heterozygous:
Heterozygous are not diseased BUT: carriers (Xx)
& can transfer the disease to their sons
 Normal
Heterozygous (carrier)
Mother
( Xx )

•
x X of 50%
Daughters
Normal are normal
Father carriers
(XY) X Xx XX
of 50%
Sons are
affected

Y Yx YX

Punnet Square for X-linked Recessive Inheritance

Reduced glutathione
  •

Oxidized glutathione
 Decreased amounts of reduced glutathione
due to decreased production of NADPH

Reduction of amounts of NADPH in RBCs in G6PD deficiency causes decrease

in reduction of oxidized glutathione to reduced glutathione.

Role of reduced glutathione in RBCs:

RBCs

1- Reduced glutathione gets rid of ROS including hydrogen peroxide.

2- Reduced Glutathione helps to keep sulfhydryl groups of hemoglobin

protein in the reduced state.
 Uses of NADPH in normal cellular metabolism

Role in fatty acid synthesis (reductive agent) -1

Role in antioxidant mechanisms (part of -2

glutathione system)

Role in oxygen-dependent phagocytosis by WBCs -3

Role in synthesis of nitric oxide (NO) -4

 Role of NADPH in antioxidant mechanisms

Hydrogen peroxide (H2O2) is one member of the family of reactive oxygen

species (ROS).
 
Reactive oxygen species (ROS)
ROS are formed from partial reduction of
molecular O2 i.e. adding electrons to oxygen leading to the formation of
superoxide,
superoxide hydrogen peroxide and hydroxyl radical.
radical
 
ROS are formed continuously from aerobic metabolism of drugs and
environmental toxins or diminished antioxidants. All these lead to
oxidative stress.
stress
 
ROS cause damage to DNA, protein and unsaturated lipids of the cells
including cell membranes.
They are implicated in cancer, chronic inflammatory disease and aging.
 
 
Reactive Oxygen Species (ROS)
 Role of NADPH in antioxidant mechanisms (cont.)

The cell has different protective mechanisms that serve to minimize the
toxic potential of ROS (antioxidant effect) as follows:

A) Enzymes that catalyze antioxidant reactions:

i- Catalase & superoxide dismutase enzymes

catalyze the conversion of the toxic ROS to harmless products.

ii- Glutathione reductase

reduces oxidized glutathione to reduced glutathione

B) Antioxidant chemicals:

Vitamins E, C and -carotene (precursor of vitamin A) reduce ROS .

 Role of NADPH in antioxidant mechanisms (cont.)

Reduced Glutathione:
Glutathione

Reduced Glutathione (G-SH) reduces hydrogen peroxide (H2O2) into

oxidized glutathione (G-S-S-G) and water. The reaction is catalyzed
by glutathione peroxidase

Oxidized glutathione is reduced to reduced glutathione by

glutathione reductase using NADPH as a source of reducing
equivalents.
 
 Decreased amounts of reduced glutathione
due to decreased production of NADPH

Reduction of production of reduced glutathione results in:

1- A decrease in detoxication of peroixides. This causes damage to RBCs

membrane and hemolysis (ending in hemolytic anemia).

2- Hemoglobin protein is denatured forming insoluble masses (Heinz

bodies). Heinz bodies attach to red cell membranes.
Membrane proteins are also oxidized.
Accordingly, red cells become rigid and removed from the circulation

by macrophages in the spleen and liver ending in anemia

 Decreased amounts of reduced glutathione
due to decreased production of NADPH

Deficiency of G6PD occurs in all cells of affected individual.

It is severe in RBCs because the only pathway to form NADPH in RBCs
is
pentose phosphate pathway (using G6PD).
 Precipitating factors in G6PD deficiency:

• Individuals who have inherited one of the many G6PD mutations do not show
clinical manifestation.

• Some of patients with G6PD develop hemolytic anemia if they are exposed or
ingest any of the followings oxidizing agents:

1-Oxidant drugs:
drugs

Antibiotics : e.g. sulfamethoxazole

Antimalarias : e.g. primaquine
Antipyretics : e.g. acetanilid

2- Favism:

The hemolytic effect of ingesting of fava beans is not observed in all

individuals with G6PD deficiency but all patients with favism have G6PD
deficiency
 G6PD Variants

• Most G6PD variants are caused by point mutations in the G6PD gene.

• Some of these point mutations do not disturb the structure of the

enzyme's active site and hence, do not affect enzyme activity.

• Other point mutations may lead to production of mutant enzymes with one
or more of the following:

altered catalytic activity,

activity
decrease stability
an alteration of binding affinity for NADP+ or Glucose 6-phosphate.

• The severity of diseases usually correlates with the amount of

residual enzyme activity in the patient’s red cells.
 G6PD Variants

G6PD Variants can be classified into :

Class III (G6PD Group A-) :

A moderate form of the disease
RBCs contain unstable G6PD enzyme, but normal activity in younger RBCs and
reticulocytes.
Accordingly, only older RBCs are hemolysed in a hemolytic episode.
 
Class II mutations (G6PD Mediterranean):
More severe
G6PD enzyme shows normal stability but, very low activity in all RBCs.
 
Class I mutations:
It is often associated with chronic non spherocytic anaemia
(occurs even in absence of oxidative stress).
 G6PD Variants

• Both G6PD Mediterranean and G6PD A- represent mutant enzymes

that differ from the normal variants by a single amino acid. This
change is due to DNA changes in the form of point mutations or
missense mutations.

• Frame shift mutations or large deletions have not been identified

indicating that the complete absence of G6PD is lethal.

• Mutation causing non spherocytic hemolytic anemia are clustered near

the carboxyl end of the enzyme, whereas mutations causing milder
forms of the disease tend to be located at the amino end of the enzyme.
 Diagnosis of
G6PD Deficiency Hemolytic Anemia
• Diagnosis of hemolytic anemia
• CBC and reticulocytic count

• Screening:
• Qualitative assessment of G6PD enzymatic activity
• (UV-based test)

• Confirmatory test:
• Quantitative measurement of G6PD enzymatic activity

• Molecular test:
• Detection of G6PD gene mutation