Galactosemic cataract

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A Galactosemic cataract is cataract which is associated with the consequences of galactosemia.

Galactosemia

Galactosemia is one of the most mysterious of the heavily-researched metabolic diseases. It is a hereditary disease that results in a defect in, or absence of, galactose-metabolizing enzymes. This inborn error leaves the body unable to metabolize galactose, allowing toxic levels of galactose to build up in human body blood, cells, and tissues. [NLM|galactosemia] Although treatment for galactosemic infants is a strict galactose-free diet, endogenous (internal) production of galactose can cause symptoms such as long-term morbidity, presenile development of cataract, renal failure, cirrhosis, and cognitive, neurologic, and female reproductive complications. Galactosemia used to be confused with diabetes due to the presence of sugar in a patient’s urine. However, screening advancements have allowed the exact identity of those sugars to be determined, thereby distinguishing galactosemia from diabetes.cite journal |author=Kinoshita JH |title=Cataracts in galactosemia. The Jonas S. Friedenwald Memorial Lecture |journal=Invest Ophthalmol |volume=4 |issue=5 |pages=786–99 |year=1965 |month=Oct |pmid=5831988 |doi= |url=http://www.iovs.org/cgi/pmidlookup?view=long&pmid=5831988 a 786 b 789 c 789–90 d 792 e 795–6 f 797]

Diagnosis

Infants are generally tested for galactosemia at birth, although the disease can present with symptoms throughout life. A small blood sample is taken from the infant, generally from the heel, and tested for low levels of galactose-metabolizing enzyme activity. If the family of the baby has a history of galactosemia, doctors can test prior to birth by taking a sample of fluid from around the fetus (amniocentesis) or from the placenta (chorionic villus sampling or CVS). [cite journal |author=Fensom AH, Benson PF, Blunt S |title=Prenatal diagnosis of galactosaemia |journal=Br Med J |volume=4 |issue=5941 |pages=386–7 |year=1974 |month=Nov |pmid=4154122 |pmc=1612460 |doi= |url=] Galactosemia is inherited in an autosomal recessive manner, meaning a child must inherit one defective gene from each parent to show the disease. Heterozygotes are carriers, because they inherit one normal gene and one defective gene. [ [http://learn.genetics.utah.edu/units/disorders/whataregd/galactosemia/ Galactosemia] The University of Utah, Genetics Science Learning Center. 2008.] Carriers have been known to show milder symptoms of galactosemia.

Introduction to Galactose Metabolism

Galactose and glucose are the two monosaccharide sugar components that make up the disaccharide sugar, lactose. Lactose is found primarily in milk and milk products. Galactose metabolism, which converts galactose into glucose, is carried out by the three principal enzymes in a mechanism known as the Leloir Pathway. The enzymes are listed in the order of the metabolic pathway: galactokinase (GALK), galactose-1-phosphate uridyltransferase (GALT), and UDP-galactose-4’-epimerase (GALE).

Galactose Metabolism: The Leloir Pathway

Glucose is the primary metabolic fuel for humans. It is more stable than galactose and is less susceptible to the formation of nonspecific glycoconjugates, molecules with at least one sugar attached to a protein or lipid. Many speculate that it is for this reason that a pathway for rapid conversion from galactose to glucose has been highly conserved among many species.cite web |url=http://www.ommbid.com/OMMBID/the_online_metabolic_and_molecular_bases_of_inherited_disease/b/abstract/part7/ch72 |title= Galactosemia |chapter=72 |author=Fridovich-Keil JL, Walter JH |format= |work=The Online Metabolic and Molecular Bases of Inherited Disease |accessdate= a 4 b 21 c 22 d 22] The main pathway of galactose metabolism is the Leloir Pathway, however humans and other species have been noted to contain several alternate pathways as well. The Leloir Pathway was first discovered by the eponymous Luis Federico Leloir in 1948 at the Fundacion Instituto Campomar in Argentina. Because Leloir was the first to elucidate the mechanism of galactose metabolism, he was also the first to determine the cause of galactosemia. After being awarded the 1970 Nobel Prize in Chemistry "for the discovery of sugar nucleotides and their role in the biosynthesis of carbohydrates," Leloir celebrated by famously drinking champagne from test tubes with his research team. The Leloir Pathway consists of the latter stage of a two-part process that converts β-D-galactose to UDP-glucose. The initial stage is the conversion of β-D-galactose to α-D-galactose by the enzyme, mutarotase (GALM). The Leloir Pathway then carries out the conversion of α-D-galactose to UDP-glucose via three principle enzymes. Galactokinase (GALK) phosphorylates α-D-galactose to Galactose-1-phosphate, or Gal-1-P. Galactose-1-phosphate uridyltransferase (GALT) then transfers a UMP group from UDP-glucose to Gal-1-P to form UDP-galactose. Finally, UDP galactose-4’-epimerase (GALE) interconverts UDP-galactose and UDP-glucose, thereby completing the pathway.cite journal |author=Bosch AM |title=Classical galactosaemia revisited |journal=J. Inherit. Metab. Dis. |volume=29 |issue=4 |pages=516–25 |year=2006 |month=Aug |pmid=16838075 |doi=10.1007/s10545-006-0382-0 |url= a 517 b 516 c 519]

The Accumulation of Galactose and Subsequent Pathways

Reduction to Galactitol

In galactosemic patients, the accumulation of galactose becomes the substrate for enzymes that catalyze the Polyol Pathway of carbohydrate metabolism. The first reaction of this pathway is the reduction of aldoses, types of sugars like galactose, to sorbitols, types of sugar alcohols. [Kolatkar, Nikheel Dr. "Aldose Rudctase Inhibitors." Your Total Health. http://yourtotalhealth.ivillage.com/aldose-reductase-inhibitors.html] Recent data suggests that aldose reductase is the enzyme responsible for the primary stage of this pathway. Therefore aldose reductase reduces galactose to its sugar alcohol form, galactitol. This reaction is depicted in step 4 of Fig. 1. Galactitol, however, is not a suitable substrate for the next enzyme in the Polyol Pathway: polyol dehydrogenase. Thus, galactitol idly accumulates in body tissues and is excreted in the urine of galactosemic patients. Accumulation of galactitol has been attributed to many of the negative effects of galactosemia, and high concentrations of galactitol have been found in people with classic galactosemia (GALT deficiency), galactokinase deficiency, and epimerase deficiency.

Oxidation to Galactonate

Accumulated galactose can also undergo an alternative reaction: oxidation to galactonate. The mechanism of galactonate formation is still unclear. However, recent studies suggest that galactose dehydrogenase is responsible for converting galactose to galactonolactone, which then spontaneously or enzymatically converts to galactonate. Once formed, galactonate may enter the pentose phosphate pathway. Thus, oxidation to galactonate serves as an alternate form of metabolizing galactose. This oxidative pathway renders accumulated galactonate less harmful than accumulated galactitol.

Types of Galactosemia and the Prevalence of Cataract

The presence of presenile cataract, noticeable in galactosemic infants as young as a few days old, is highly associated with two distinct types of galactosemia: GALT deficiency and to a greater extent, GALK deficiency.

An impairment or deficiency in the enzyme, galactose-1-phosphate uridyltransferase (GALT), results in classic galactosemia, or Type I galactosemia. [cite journal |author=Bosch AM, Grootenhuis MA, Bakker HD, Heijmans HS, Wijburg FA, Last BF |title=Living with classical galactosemia: health-related quality of life consequences |journal=Pediatrics |volume=113 |issue=5 |pages=e423–8 |year=2004 |month=May |pmid=15121984 |doi= |url=http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=15121984] Classic galactosemia is a rare (1 in 47,000 live births), autosomal recessive disease that presents with symptoms soon after birth when a baby begins lactose ingestion. Symptoms include life-threatening illnesses such as jaundice, hepatosplenomegaly (enlarged spleen and liver), hypoglycemia, renal tubular dysfunction, muscle hypotonia (decreased tone and muscle strength), sepsis (presence of harmful bacteria and their toxins in tissues), and cataract among others. The prevalence of cataract among classic galactosemics is markedly less than among galactokinase-deficient patients due to the extremely high levels of galactitol found in the latter. Classic galactosemia patients typically exhibit urinary galactitol levels of only 98 to 800 mmol/mol creatine compared to normal levels of 2 to 78 mmol/mol creatine.

Galactokinase (GALK) deficiency, or Type II galactosemia, is also a rare (1 in 100,000 live births), autosomal recessive disease that leads to variable galactokinase activity levels: ranging from high GALK efficiency to undetectably-low GALK efficiency. The early onset of cataract is the main clinical manifestation of Type II galactosemics, most likely due to the high concentration of galactitol found in this population. [cite journal |author=Timson DJ, Reece RJ |title=Functional analysis of disease-causing mutations in human galactokinase |journal=Eur. J. Biochem. |volume=270 |issue=8 |pages=1767–74 |year=2003 |month=Apr |pmid=12694189 |doi= |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0014-2956&date=2003&volume=270&issue=8&spage=1767] GALK deficient patients exposed to high-galactose diets show extreme levels of galactitol in blood and urine. Studies on galactokinase-deficient patients have shown that nearly two-thirds of ingested galactose can be accounted for by galactose and galactitol levels in the urine. Urinary levels of galactitol in these subjects approach 2500 mmol/mol creatine as compared to 2 to 78 mmol/mol creatine in control patients.A decrease in activity in the third major enzymes of galactose metabolism, UDP galactose-4’-epimerase (GALE), is the cause of Type III galactosemia. GALE deficiency is an extremely rare, autosomal recessive disease that appears to be most common among the Japanese population (1 in 23,000 live births among Japanese population). [OMIM|230350|Galactose Epimerase Deficiency] While the link between GALE deficiency and cataract prevalence seems to be ambiguous, experiments on this topic have been conducted. A recent 2000 study in Munich, Germany analyzed the activity levels of the GALE enzyme in various tissues and cells in patients with cataract. The experiment concluded that while patients with cataract seldom exhibited an acute decrease in GALE activity in blood cells, "the GALE activity in the lens of cataract patients was, on the other hand, significantly decreased." [cite journal |author=Shin YS, Korenke GC, Huppke P, Knerr I, Podskarbi T |title=UDPgalactose epimerase in lens and fibroblasts: activity expression in patients with cataracts and mental retardation |journal=J. Inherit. Metab. Dis. |volume=23 |issue=4 |pages=383–6 |year=2000 |month=Jun |pmid=10896300 |doi= |url=http://www.kluweronline.com/art.pdf?issn=0141-8955&volume=23&page=383] The study’s results are depicted below. The extreme decrease in GALE activity in the lens of cataract patients seems to suggest an irrefutable connection between Type III galactosemia and cataract development.

Introduction to the Mechanism of Galactosemic Cataract Formation

A cataract is an opacity that develops in the crystalline lens of the eye. [cite journal |author=Richter L, Flodman P, Barria von-Bischhoffshausen F, "et al" |title=Clinical variability of autosomal dominant cataract, microcornea and corneal opacity and novel mutation in the alpha A crystallin gene (CRYAA) |journal=Am. J. Med. Genet. A |volume=146 |issue=7 |pages=833–42 |year=2008 |month=Apr |pmid=18302245 |doi=10.1002/ajmg.a.32236 |url= ] The word cataract literally means, "curtain of water" or "waterfall," because cataract stems from the absorption of water by the lens, causing lens fibers to swell and become opaque. The mechanism by which galactosemia causes cataract is not well understood, but the topic has been approached by researchers for decades, notably by the ophthalmologists, Jonas S. Friedenwald and Jin H. Kinoshita. Through this collective effort, a general mechanism for galactosemia’s causation of presenile cataract has come into form.

Galactitol's Harmful Influence

In galactosemic cataracts, osmotic swelling of the lens epithelial cells (LEC) occurs. Osmosis is the movement of water from areas of low particle concentration to areas of high particle concentration, to establish equilibrium. Researchers concluded that this osmotic swelling must be the result of an accumulation of abnormal metabolites or electrolytes in the lens. Ruth Van Heyningen was the first to discover that the lens’s retention of dulcitol, synonymous for galactitol, induces this osmotic swelling in the galactosemic cataract. [cite journal |author=Schoon DV |title=Cataracts related to enzymes of galactose metabolism |journal=Metab Pediatr Ophthalmol |volume=5 |issue=3-4 |pages=219–23 |year=1981 |pmid=6273670 |doi= |url=] However, galactose concentration must be fairly high before the enzyme, aldose reductase, will convert significant amounts of the sugar to its galactitol form. As it turns out, the lens is a favorable site for galactose accumulation. The lens phosphorylates galactose at a relatively slow pace in comparison to other tissues. This factor, in combination with the low activity of galactose-metabolizing enzymes in galactosemic patients, allows for the accumulation of galactose in the lens. Aldose reductase is able to dip into this galactose reservoir and synthesize significant amounts of galactitol. As is mentioned above, galactitol is not a suitable substrate for the enzyme, polyol dehydrogenase, which catalyzes the next step in the carbohydrate metabolic cycle. Thus, the sugar alcohol idly begins to accumulate in the lens.

Ensuing Osmotic Pressure

As galactitol concentration increases in the lens, a hypertonic environment is created. Osmosis favors the movement of water into the lens fibers to reduce the high osmolarity. Figures 2 and 3 show how water concentration increases as galactitol concentration increases inside the lens of galactosemic animals sustained on a galactose diet. This osmotic movement ultimately results in the swelling of lens fibers until they rupture. Vacuoles appear where a significant amount of osmotic dissolution of fiber has taken place. What are left are interfibrillar clefts filled with precipitated proteins: the manifestation of a cataract. Friedenwald was able to show that periphery lens fibers always dissolve before fibers at the equatorial region of the lens. This observation has been confirmed by more recent experiments as well, but is still unexplained. The progression of galactosemic cataract is generally divided into three stages; initial vacuolar, late vacuolar, and nuclear cataract. The formation of a mature, nuclear, cloudy galactosemic cataract typically surfaces 14 to 15 days after the onset of the galactose diet. Fig. 6 depicts the three stages of galactosemic cataract with their respective changes in lens hydration.

Changes in Lens that Accompany Galactitol Accumulation and Osmotic Swelling

As cataract formation progresses due to galactitol synthesis and subsequent osmotic swelling, changes occur in the lens epithelial cells. For instance, when rabbit lenses are placed in high-galactose mediums, a nearly 40% reduction in lens amino acid levels is observed, along with significant ATP reduction as well.cite journal |author=Mulhern ML, Madson CJ, Danford A, Ikesugi K, Kador PF, Shinohara T |title=The unfolded protein response in lens epithelial cells from galactosemic rat lenses |journal=Invest. Ophthalmol. Vis. Sci. |volume=47 |issue=9 |pages=3951–9 |year=2006 |month=Sep |pmid=16936110 |doi=10.1167/iovs.06-0193 |url=http://www.iovs.org/cgi/content/full/47/9/3951] Researchers theorized that this reduction in amino acid and ATP levels during cataract formation is a result of osmotic swelling. To test this theory, Kinoshita placed rabbit lenses in a high-galactose environment, but inhibited the osmotic swelling by constantly regulating galactose and galactitol concentrations. The results show that amino acid levels remained relatively constant and in some cases even increased.

Thus, from these experiments it would appear that the loss of amino acids in the lens when exposed to galactose is primarily due to the osmotic swelling of the lens brought about by dulcitol [galactitol] retention.

Interestingly, galactosemic patients will also present with amino aciduria and galactitoluria (excessive levels of amino acids and galactitol in the urine).

Osmotic swelling of the lens is also responsible for a reduction in electrolyte concentration during the initial vacuolar stage of galactosemic cataract. The water that is osmotically flowing into the lens fibers is not accompanied by ions such as Na+, K+, and Cl-, and so the electrolyte concentration inside the lens is simply diluted by the influx of water. The net concentration of the individual ions does not change during the initial vacuolar stage however. In Fig. 7, note the decrease in electrolyte concentration due to osmotic swelling during the initial vacuolar stage of galactosemic cataract. But when comparing it to the dry weight of the ions, note that there is no change in individual ion concentration at this stage. However, Kinoshita’s experiments showed a remarkable upswing in electrolyte concentration toward the latter stages of the galactosemic cataract and in the nuclear stage in particular. This observation seems to be explained by the continuous increase in lens permeability due to the osmotic swelling from galactitol accumulation. Cation and anion distribution becomes erratic, with Na+ and Cl- concentrations increasing while K+ concentration decreases as seen in Figures 8 and 9. Researchers have postulated that as the cataractous lens loses its ability to maintain homeostasis, electrolyte concentration eventually increases within the lens, which further encourages osmotic movement of water into the lens fibers, increasing lens permeability even more so. This damaging cycle may play a pivotal role in accelerating the rupture of lens fibers during the most advanced, nuclear stage of the galactosemic cataract.

Building on Friedenwald and Kinoshita

Although advancement has been slow to come during the decades of research dedicated to the galactosemic cataract, some notable additions have been made. In 2006, Michael L. Mulhern and colleagues further investigated the affects of the osmotic swelling on galactosemic cataract development. Experiments were based on systematic observation of rats fed a 50% galactose diet. According to Mulhern, 7 to 9 days after the onset of the galactose diet, lenses appeared hydrated and highly vacuolated. Lens fibers became liquefied after 9 days of the diet, and nuclear cataract formation appeared after 15 days of the diet.

The experiment concluded that

Apoptosis in lens epithelial cells (LEC) is linked to cataract formation.

Essentially, the study suggested that the mechanism outlined by Friedenwald and Kinoshita, which centers on osmotic swelling of the lens fibers, is just the beginning in a cascade of events that causes and progresses the galactosemic cataract. Mulhern determined that osmotic swelling is actually a cataractogenic stressor that leads to LEC apoptosis. This is because osmotic swelling of lens fibers considerably strains LEC endoplasmic reticula. As the endoplasmic reticulum is the principle site of protein synthesis, stressors on the ER can cause proteins to become misfolded. The subsequent accumulation of misfolded proteins in the ER activates the unfolded protein response (UPR) in LECs. UPR initiates apoptosis, or cell death, by various mechanisms, one of which is the release of reactive oxygen species (ROS). Thus, according to recent findings, osmotic swelling, UPR, oxidative damage, and the resultant LEC apoptosis all play key roles in the onset and progression of the galactosemic cataract. Other studies claim that the oxidative damage in LECs is less a result of the release of ROS and more because of the competition between aldose reductase and glutathione reductase for nicotinamide adenine dinucleotide phosphate (NADPH).cite journal |author=Stevens RE, Datiles MB, Srivastava SK, Ansari NH, Maumenee AE, Stark WJ |title=Idiopathic presenile cataract formation and galactosaemia |journal=Br J Ophthalmol |volume=73 |issue=1 |pages=48–51 |year=1989 |month=Jan |pmid=2537652 |pmc=1041642 |doi= |url=http://bjo.bmj.com/cgi/pmidlookup?view=long&pmid=2537652 a 48 b 49] Aldose reductase requires NADPH for the reduction of galactose to galactitol, while glutathione reductase utilizes NADPH to reduce glutathione disulfide (GSSG) to its sulfhydryl form, GSH. GSH is an important cellular antioxidant. Therefore, what exactly the key roles are for these cataractogenic factors is not yet fully understood or agreed upon by researchers.

Treatment for Galactosemia and the Galactosemic Cataract

Galactosemic infants present clinical symptoms just days after the onset of a galactose diet. They include difficulty feeding, diarrhea, lethargy, hypotonia, jaundice, cataract, and hepatomegaly (enlarged liver). If not treated immediately, and many times even with treatment, severe mental retardation, verbal dyspraxia (difficulty), motor abnormalities, and reproductive complications may ensue. The most effective treatment for many of the initial symptoms is complete removal of galactose from the diet. Breast milk and cow’s milk should be replaced with soy alternatives. Infant formula based on casein hydrolysates and dextrin maltose as a carbohydrate source can also be used for initial management, but are still high in galactose. The reason for long-term complications despite a discontinuation of the galactose diet is vaguely understood. However, it has been suggested that endogenous (internal) production of galactose may be the cause. The treatment for galactosemic cataract is no different from general galactosemia treatment. In fact, galactosemic cataract is one of the few symptoms that is actually reversible. Infants should be immediately removed from a galactose diet when symptoms present, and the cataract should disappear and visibility should return to normal. [ [http://www.patient.co.uk/showdoc/40001734/ EMIS and Patient Publications.] 2008.] Aldose reductase inhibitors, such as sorbinil, have also proven promising in preventing and reversing galactosemic cataracts. AR inhibitors hinder aldose reductase from synthesizing galactitol in the lens, and thus restricts the osmotic swelling of the lens fibers. Other AR inhibitors include the acetic acid compounds zopolrestat, tolrestat, alrestatin, and epalrestat. Many of these compounds have not been successful in clinical trials due to adverse pharmokinetic properties, inadequate efficacy and efficiency, and toxic side effects. [cite journal |author=Da Settimo F, Primofiore G, Da Settimo A, "et al" |title=Novel, highly potent aldose reductase inhibitors: cyano(2-oxo-2,3-dihydroindol-3-yl)acetic acid derivatives |journal=J. Med. Chem. |volume=46 |issue=8 |pages=1419–28 |year=2003 |month=Apr |pmid=12672241 |doi=10.1021/jm030762f |url=] Testing on such drug-treatments continues in order to determine potential long-term complications, and for a more detailed mechanism of how AR inhibitors prevent and reverse the galactosemic cataract.

References

ee also

*Galactose
*Galactosemia
*Metabolic disorder
*Cataract

External links

* [http://ghr.nlm.nih.gov/condition=galactosemia Genetics Home Reference]
* [http://yourtotalhealth.ivillage.com/aldose-reductase-inhibitors.html Your Total Health]
* [http://www.patient.co.uk/showdoc/40001734/ Patient UK]
* [http://www.essortment.com/all/whatarecatarac_rbsp.htm eSSORTMENT]
* [http://pennhealth.com/ophth/conditions/cataracts.html The University of Pennsylvania Health System]
* [http://www.galactosemia.org/galactosemia.asp Parents of Galactosemia Children]
* [http://learn.genetics.utah.edu/units/disorders/whataregd/galactosemia/ The University of Utah, Genetics Science Learning Center]
* [http://www.dshs.state.tx.us/newborn/teachgal.shtm Arizona Department of Health Services]
* [http://www.mayoclinic.com/health/cataracts/DS00050 MayoClinic.com]