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Porphyrins II. David Hart Dec 13, 2006. HEME. CH 3 -. Bonkovsky ASH Education Book December 2005. Hentze, Muckenthaler & Andrews Cell, Vol 117, 285-297, April 30, 2004. Hepcidin. Lecture Outline. Heme function Heme synthesis and regulation Iron metabolism Porphyrias - PowerPoint PPT Presentation
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David Hart
Dec 13, 2006
HEME
CH3-
BonkovskyASH Education BookDecember 2005
Hentze, Muckenthaler & AndrewsCell, Vol 117, 285-297, April 30, 2004
Hepcidin
Lecture Outline
• Heme function
• Heme synthesis and regulation
• Iron metabolism
• Porphyrias
• Heme degradation
Disorders of Heme Synthesis
• X-linked Sideroblastic Anemia
• Lead Poisoning
• Iron Deficiency Anemia
• The Porphyrias
Porphyrias
• Inherited defects in heme synthesis– Accumulation and excretion of porphyrins– Pattern depends on which enzyme affected– Decreased heme synthesis derepresses hepatic ALAS
• Most are Autosomal Dominant • Erythropoietic, Hepatic or Mixed• Acute and Chronic
– Acute: Neurovisceral attacks
• Porphyrin accumulation: Photosensitivity– Formation of reactive oxygen species– Damage tissues, Release lysosomal enzymes
FuseliThree WitchesTate
Gillray 1791Weird Sisters
Tate
Very Rare Recessive Porphyria
Lead Poisoning
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
AcuteHepatic
PBG and ALA (Neurotoxic)Accumulate in Urine
PBG in Urine: Diagnostic ScreenNeurovisceral Attacks
No Photosensitivity with AIP
Hydroxymethylbilane Synthase
Lead Poisoning
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
ALA-D Porphyria
Acute PorphyriasClinically indistinguishable (Locus Heterogeneity)
PBG in Urine: Diagnostic Screen• Agents which induce cytochrome P450
– Drugs, Alcohol, Hormones• Precipitated by fasting, treated with glucose • After puberty; more in women• Begin with minor behavioral changes• Proceeds to autonomic and sensomotoric
neuropathy; Convulsions• Pain: Back, Extremities, Abdomen• Hypertension and Tachycardia• Arrhythmias; cardiac arrest
AcuteHepatic
Erythropoietic
RECESSIVEPorphyrin accumulation: PhotosensitivityPorphyrins are Fluorescent compoundsFormation of reactive oxygen species,
Activate Complement
Lead Poisoning
Hydroxymethylbilane Synthase
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
Clin Med2005:5
Dr. Meyer-Betz1912
GM Murphy, Dermatologic Therapy, March 2003
CEP
CEPNEJM9/7/2006
mccaskey4.home.mindspring.com
Erythropoietic
AcuteHepatic
Chronic
Lead Poisoning
Hydroxymethylbilane Synthase
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
Porphyria Cutanea Tarda (PCT)
• Most common Porphyria– 80% sporadic
• Hepatic and Erythropoietic• Photosensitivity• Uroporphyrin accumulates in Urine
– Red-Brown in natural light
• Clinical expression in 4th - 5th decade• Decrease in UROD activity by Iron-dependent mechanism
– Alcohol, viruses, drugs, hormones– HFE Hemochromatosis
• Venesection, Chloroquine
Autosomal Dominant PCT (Hepatoerythropoietic Porphyria)
• Hepatic UROD activity < 50% during symptoms
• Additional decrease from reversible inactivation
• C282Y HFE causes earlier onset
PCT; www.Utah.edu
Erythropoietic
AcuteHepatic
AcuteHepatic
Photosensitivity(Unlike AIP)
Lead Poisoning
Hydroxymethylbilane Synthase
Chronic
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
medlib.med.utah.edu
NormalLiver
www.med.niigata-u.ac.j
Granular, Dark Reddish BrownSurface of Liver in Hemochromatosis
Lecha, Herrero, Ozalla, Dermatologic Therapy, March 2003
HepaticPorphyria
AcuteHepatic
Erythropoietic
AcuteHepatic
AcuteHepatic
Photosensitivity
Lead Poisoning
Hydroxymethylbilane Synthase
Chronic
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
Hair AnalysisLancetJuly 2005
Lancet July 23-29, 2005
• King George III (1738-1820)• Likely diagnosis of Variegate Porphyria
– Proposed 1969 based on family tree
• Lock of hair showed high lead– Widespread use in his era
• Extremely high levels of arsenic– Likely secondary to medications
LancetJuly 2005
Color of Urine“Alicante Wine”
http://www.aw-bc.com/mathews/GH/HEME.GIF
Introduction of Fe2+ into PPIXOccurs spontaneously, but
Enhanced by FERROCHELATASEAn enzyme which is inhibited by LEAD
http://www.photodermatologie.de
AcuteHepatic
AcuteHepatic
Erythropoietic
AcuteHepatic
Erythropoietic
Photosensitivity
Lead Poisoning
Hydroxymethylbilane Synthase
Chronic
ALA-D Porphyria
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
Erythropoietic Protoporphyria
• Presentation in early childhood• Burning, stinging pain with sunlight• Subsequent skin changes• Expression requires low-expression allele
in trans– 10% of population of France and UK– IVS3-48 alternative splice acceptor– With AD mutation FECH 35% of normal– Homozygosity does not cause disease
• Beta carotene: free radical scavenger
www.immunochemistry.com
GM Murphy, Dermatologic Therapy, March 2003
EPP
GM Murphy, Dermatologic Therapy, March 2003
EPP
www.goa-world.ne
AcuteHepatic
AcuteHepatic
Erythropoietic
AcuteHepatic
Erythropoietic
Photosensitivity
Lead Poisoning
No PhotosensitivityWith Lead
Lead Poisoning
Hydroxymethylbilane Synthase
Chronic
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
ALA-D Porphyria
http://www.photodermatologie.de
AcuteHepatic
AcuteHepatic
Erythropoietic
AcuteHepatic
Erythropoietic
Photosensitivity
Iron Deficiency
“Free” ErythrocytePPIX accumulatesin Lead Poisoning and Iron Deficiency
Lead Poisoning
Hydroxymethylbilane Synthase
Chronic
X-linked Sideroblastic Anemia
X-linked Sideroblastic Anemia
ALA-D Porphyria
Porphyrias: Genetics / Epigenetics
• 5 out of 7 are Low-penetrance Autosomal Dominant
• Most mutations are restricted to one family
• Rare Homozygotes very severe• No dominant negative mutants described• 50% residual activity is normally sufficient
Molecular basis of “low penetrance”
• Genotype/phenotype correlations
• Increased demand– Fasting (low Glucose)– Cell, August 26, 2005
• Low expression allele in trans
• Iron / HFE hemochromatosis can directly inhibit enzymes
• Other epigenetic phenomena
Treatment
• Medical Support during acute attacks• Treatment for pain and vomiting• Glucose infusion until Hemin available• Intravenous Hemin
– Decreases synthesis of ALAS
• Avoid Sunlight -carotene, a free-radical scavenger• Chronic transfusion for Erythropoietic
Degradation of Heme
• At end of their 120 day lifespan, red blood cells are taken up and degraded by the reticuloendothelial (RE) system (liver and spleen)
• 85% heme for degradation from RBC• 15% immature RBC, cytochromes
from extraerythroid tissues
N
NH N
HNH3C-
H3C-
-CH=CH2
-CH3
CH2
CH2
COOH
CH2
CH2
COOH
CH3
Fe2+
CH=CH2HEME
N
NH N
HNH3C-
H3C-
-CH=CH2
-CH3
CH2
CH2
COOH
CH2
CH2
COOH
CH3
Fe2+
CH=CH2
MACROPHAGEtakes up HEME
Heme Oxygenaseis Inducible by a variety of agents
Inhibited by TinProtoporphyrin
N
NH N
HNH3C-
H3C-
-CH=CH2
-CH3
CH2
CH2
COOH
CH2
CH2
COOH
CH3CH=CH2MACROPHAGEHemeOxygenase
Step 1NADPH O2
Fe3+
OH
N
NH N
HNH3C-
H3C-
-CH=CH2
-CH3
CH2
CH2
COOH
CH2
CH2
COOH
CH3CH=CH2MACROPHAGEHemeOxygenase
Step 2Fe3+ COReleased
O O
BILIVERDIN
HO also has Cytoprotectiveeffects
J Cell Mol Med 2006
NH
CH
VM
N CH
PM
NH
CH
MP
NH
O
VM
O
BILIVERDIN
NH
CH
VM
N CH
PM
NH
CH
MP
NH
O
VM
O
NH
CH
VM
NH
CH2
PM
NH
CH
MP
NH
O
VM
O
BILIVERDIN
BILIVERDIN REDUCTASE+ NADPH
BILIRUBIN
BILIRUBIN ALBUMINLow AlbuminAnionic Drugs:SalicylatesSulfonamides
BILIRUBIN ALBUMIN
Unbound BilirubinCan enter CNSCause Kernicterus in Neonate
Bilirubin Released from Macrophage, binds to Albumin in the Plasma
BILIRUBIN ALBUMIN
LIVER BILIRUBIN LIGANDIN
CONJUGATION with2 MoleculesGlucuronic Acid fromUDP-glucuronic acid
BilirubinGlucuronyltransferase
Bilirubin Diglucuronide BILEActiveTransport
BILIRUBIN: Unconjugated (Indirect)
LIVER
CONJUGATIONBilirubinGlucuronyltransferase
Bilirubin Diglucuronide:Conjugated (Direct) Bilirubin
VAN DEN BERGH COLORMETRIC REACTIONTOTAL BILIRUBIN: Soluble in Methanol
Less Soluble in Aqueous Solution, reacts more slowly
More Soluble, reacts more quickly
GALL
BLADDER
Ac
tiveT
ran
sp
ort
Bilirubin Diglucuronide
LIVER
Bilirubin Diglucuronide
UROBILINOGEN STERCOBILIN
KID
NE
YB
ILE
INTESTINAL BACTERIA
UrobilinogenUrobili
nogen
Enterohepatic
Circulation
UROBILIN
Bilirubin
GALL
BLADDER
Ac
tiveT
ran
sp
ort
BilirubinDiglucuronide
LIVER
Bilirubin Diglucuronide
UROBILINOGEN STERCOBILIN
KID
NE
YB
ILE
INTESTINAL BACTERIA
UrobilinogenUrobili
nogen
Enterohepatic
Circulation
UROBILIN
BILIRUBINHEMOLYSIS: Unconjugated(Indirect) Hyperbilirubinemia
GALL
BLADDER
Ac
tiveT
ran
sp
ort
Bilirubin DG
LIVER
Bilirubin Diglucuronide
UROBILINOGEN STERCOBILIN
KID
NE
YB
ILE
INTESTINAL BACTERIA
UrobilinogenUrobili
nogen
Enterohepatic
Circulation
UROBILIN
BILIRUBIN
NEONATAL JAUNDICE: Unconjugated Hyperbilirubinemia
www.mtwthailand.org
home.hawaii.rr.com
GALL
BLADDER
Ac
tiveT
ran
sp
ort
Bilirubin Diglucuronide
LIVER
KID
NE
YB
ILE
INTESTINAL BACTERIA
UROBILIN
Bilirubin OBSTRUCTIVE JAUNDICEDirect (Conjugated) Bilirubin
GALL
BLADDER
Ac
tive
Tra
ns
po
rt
Bilirubin DG
LIVER
Bilirubin Diglucuronide
UROBILINOGEN STERCOBILIN
KID
NE
YB
ILE
INTESTINAL BACTERIA
Urobilinogen Dark Urine
BILIRUBIN
HEPATOCELLULAR JAUNDICE: Unconjugated Hyperbilirubinemia
ENTEROHEPATIC
CIRCULATION
www.privivka.ru
Carotenemia