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CARBOHYDRATE S
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OBJECTIVES
carbohydrates; Describe carbohydrates according to composition, classification, chemical properties Discuss the metabolism of CHO in the body Explain the mode of actions of different hormones in the maintenance of blood 3/10/12
TOPICS
Biochemistry
Classification Metabolism
Clinical
Significance
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Carbohydrates
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Classification
Carbohydrates
are composed of C,
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Monosaccharides
Cannot
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Disaccharides
Composed of 2 monosaccharides joined by glycosidic linkage Sucrose: glucose + fructose Lactose: glucose + galactose Maltose: 2 glucose units
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Oligosaccharides
Chaining
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Polysaccharides
Made
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Carbohydrates
Glycoside
bonds: chaining of
sugars
When
two carbohydrate molecules join, a water molecule is produced When they split, one molecule of water is used to form the individual compound (Hydrolysis)
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Reducing
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Metabolism
Primary source of Brain depends on
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Fate of Glucose
Ingested:
pancreatic amylase to dextrins and disaccharides (lactose, sucrose, maltose) Maltase: breaks down maltose to 2 glucose units Lactase: lactose to glucose and galactose Sucrase: sucrose to glucose and fructose
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Fate of Glucose
Glucose
(inside the cell) shunted into three possible metabolic pathways (glucose-6-phosphate)
Embden-Myerhof Pathway Hexose monophosphate pathway Conversion of glucose to glycogen
(glycogenesis)
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converted to glucose-6phosphate (ATP) catalyzed by hexokinase 3-C molecules of pyruvic acid TCA acetyl-CoA (aerobic) (32 ATPs) 2ATPs (no oxygen) lactic acid
Anaerobic
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6-
phosphogluconic acid
Formation
of ribose-5-phosphate and
NADPH
(RBC lacking mitochondria, thus, no
TCA cycle)
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c. Glycogenesis
Glucose-6-phosphate
glucose-1-
Liver,
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Terms
Glycolysis Metabolism of glucose molecule to pyruvate or lactate for the production of energy Gluconeogen Formation of glucose-6esis phosphate from noncarbohydrate sources Glycogenolysi Breakdown of glycogen to s glucose for use as energy (glucose-6-phosphatase in liver; none in the liver) Glycogenesis Conversion of glucose to 3/10/12 glycogen for storage
(liver)
gluconeogenesis
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Glucagon
Alpha Cells
Other hormones
Adrenal
Glands
(stress)
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Glucocorticoids: increases glucose Decreases intestinal entry into the cell Increases gluconeogenesis Increases glycogenolysis
Other hormones
Anterior
Pituitary Glands
cortisol is decreased
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Other hormones
Thyroid
Gland
Thyroxine: increases plasma glucose Increases glycogenolysis Gluconeogenesis Increases intestinal absorption of glucose
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Insulin
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Functions
Stimulates
breasts
inhibits glucose production in insulin-
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Molecular Characteristics
Peptide
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Site of Production
Beta
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amount of des 31, 32 is cosecreted with insulin in adults In healthy infants and preterm neonates, however, proinsulin and 32,33 split proinsulin concentrations are higher
Elevated
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proinsulin (intact and partially processed) levels are seen in the following.
states occur when insulin and glucose concentrations are found to be inappropriate with each other. Below are the effects of the changes in insulin level. Insulin deficiency (absolute or relative)
DM
Increased insulin secretion Insulin resistant patients Increased insulin with decreased glucose level suggests inappropriate secretion or 3/10/12 administration of insulin
secretion
insulinomas decreased glucose (<50 mg/dL) elevated insulin and proinsulin levels Hypoglycemic symptoms
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C-Peptide
Measured
in conjunction with insulin and blood glucose to help indentify cause of hypoglycemia
C-peptide and insulin are secreted in
equimolar amounts in the portal vein ratio in serum: 5:1 to 15:1 molar concentration of C-peptide in blood > insulin due to hepatic clearance of insulin
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Increased
Decreased
Absolute deficiency
Decreased
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Insulin
antibodies
decreased in immunoassays
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Glucagon
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Functions
stimulates
glucose production
regulates
hepatic :
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Glucagon
results
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other
functions
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deficiency results in
hypoglycemia
Excessive
glucagon increase
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elevations
Cirrhosis Diabetes Cushings syndrome Acromegaly Pancreatitis Renal insuffiency Patients with multifunctional
neuroendocrine tumors
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SOMATOSTATIN
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Function
inhibits
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Site of Production
Delta cells 5 to 10%
of islets of Langerhans
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level
Somatostatin
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SPECIMEN CONSIDERATION
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Specimen Used
Whole blood Plasma Serum CSF (60-75% Pleural fluid Urine
of blood glucose)
Plasma/serum
Special Considerations
Glucose
1. 2. 3. 4.
Serum Specimen
Serum
Appropriate for glucose analysis if serum is separated from cells within 30 minutes Sodium fluoride preservative should be added to specimen, if serum is in contact with cells for longer than 30 minutes, to prevent glycolysis In serum specimens without bacterial contamination or leukocytosis, results are still acceptable even if separation is delayed for up to 90 minutes When refrigerated, serum or plasma glucose remains stable for 48 hours
is separated from cells within 30 minutes Greater than 30 minutes use NaF
Serum
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Whole blood
Give
refrigerated, 2mg of sodium fluoride/mL of whole blood prevents glycolysis for up to 48 hours
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= reducing sugar
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Folin-Wu Method
Oldest
method
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Nelson-Somogyi
Cu2+
Arsenomolybdic
Mo
(BLUE)
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2. O-Toluidine Method
Dubowski
Method
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3. Enzymatic
Most
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Glucose Oxidase
Spectrophotometric
-D-glucose + O2 (glucose oxidase) Dgluconolactone + H2O2 Gluconolactone + H2O Gluconic acid H2O2 + chromogen O2 receptor (O-dianisidine; 4 amino-phenazine; O-toluidine) (peroxidase) colored chromogen + H2O (BLUE) Disadvantage: this reaction is inhibited by high 3/10/12 concentrations of uric acid, vitamin C, bilirubin,
Reaction)
Assay (Trinders
Glucose Oxidase
Electric
Current Assay
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i. -D-glucose + 2[Fe(Cn6)]3- + H2O (glucose oxidase) D-gluconic acid + 2[Fe(Cn6)]4- + 2H+ 2[Fe(Cn6)]4- 2[Fe(Cn6)]3- + 2e Disadvantage: this system is affected by partial pressure of
Glucose Oxidase
ii. -D-glucose + O2 (glucose oxidase) D-gluconolactone + H2O2 H2O2 2H+ O2 + 2e- (combi of GOD and Clark Electrode Method)
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Glucose Dehydrogenase
Spectrophotometric
Glucose Dehydrogenase
Electric
Current Assay
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Glucose + pyrroloquinoline quinine (PQQ) (glucose dehydrogenase) gluconolactone PQQH2 PQQH2 + 2[Fe(CN6)]3- PQQ + 2[Fe(Cn6)]4- + 2H+
Hexokinase
Measures
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Hexokinase
Spectrophotometric
Assay
Glucose + Mg ATP (hexokinase) glucose6phosphate + Mg ADP Glucose-6-phosphate + NAD(P) (glucose6-phosphate dehydrogenase) 6phosphogluconolactone + NAD(P)H + H+ (colored)
Note: 3/10/12
CLINICAL SIGNIFICANCE
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Clinical Significance
Hyperglycemia Hypoglycemia Insulinoma
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Hyperglycemia
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Hyperglycemia
Increase WHY?
Normally, in hyperglycemic state, insulin
Absolute or relative deficiency of hormone Increase production of other hormones affecting glucose metabolism
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Diabetes Mellitus
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Diabetes Mellitus
A
group of diseases in which blood glucose levels are elevated due to deficiency in insulin secretion or due to abnormal insulin action or both. Plus manifestations of hyperglycemic state
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Blood Glucose > 200 mg/dL + DM symptoms Blood Glucose > 126 mg/dL
Fasting
OGTT
with a 2-hour postload (75g glucose load) level > 200 mg/dL
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to a condition where in the glucose homeostasis the serum glucose levels are not high enough to be classified as diabetes for classification
Fasting Blood Glucose >110mg/dL (6.1
Criteria
mmol/L) but < 126mg/dL (7.0mmol/L) OGTT after 2 hours >140mg/dL (7.8mmol/L) but less than 200 mg/dL 3/10/12 (11.1 mmol/L)
referred to as Syndrome X
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Classification of DM
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Type 1 DM
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Type 1 DM
Represents
all DM Cellular-mediated, autoimmune destruction of insulin producing beta cells in the pancreatic islets causing absolute insulin deficiency childhood and adolescence
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Type 1 DM
Genes
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Type 1 DM
(ICA512) Glutamic acid decarboxylase antibodies (GAD 65) Insulin autoantibodies (IAA) Tyrosine phosphatase-like protein antibodies (IA-2) or insulinoma associated antigen-2 and 2 autoantibodies (IA-2A and IA-2A)
Note: used in the familial studies where it was found out that at least 2 of these 3/10/12
Type 1 DM
Laboratory findings:
low insulin and C-peptide levels
Untreated
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Type 2 DM
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Type 2 DM
Individual
develops resistance to insulin with an insulin secretory defect, resulting to relative insulin deficiency (not absolute)
Most common type of DM Adult onset seldom results to DKA milder symptoms than type 1 But likely to go to hyperosmolar coma,
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Type 2 DM
Risk factors: Obesity Sedentary lifestyle Lack of physical exercise Family history Advanced age Ethnicity (African-American, Latinos, Native
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Type 2 DM
Characteristics of type 2 DM patients: Most are obese Insulin-resistant Impaired peripheral glucose utilization Decreased glucose transport in muscle and
adipose tissues Inappropriately high hepatic glucose production Undiagnosed for many years
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Type 2 DM
These mechanisms usually lead to progressive cell failure and decreased insulin production contributing to increased insulin deficiency. This is the reason why some type 2 DM require insulin 3/10/12 therapy, in contrast to others whose diabetes can still
tolerance, the pancreas has to secrete extra insulin In the event that the pancreas becomes incapable of increasing its insulin secretion impaired glucose homeostasis or type 2 DM develops Hyperglycemia is also toxic to the cells of the pancreas, disrupting cell function and impairing insulin secretion.
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Any degree of glucose intolerance with the onset or first recognized during pregnancy (>20 weeks AOG)
Causes: Metabolic hormonal changes Increased perinatal Macrosomia Hypoglycemia Hypocalcemia 3/10/12
complications:
Diabetes
Screening using 50-g oral glucose
load
After 1 hour > 140 mg/dL (7.8 mmol/L) OGTT (75 g glucose load)
OGTT
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Fasting: 105 mg/dL One hour: 190 mg/dL 2 hours: 165 mg/dL 3 hours: 145 mg/dL
Pathophysiology
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Pathophysiology
1. Insulin deficiency (absolute/relative) 2. Hyperglycemia Hyperosmolar state Glucosuria Polyuria 3. Hyperosmolar state Polydipsia Polyuria 4. Less ATP Decreased energy Polyphagia 5. Gluconeogenesis (weigth loss) ketone bodies (blood and urine) LIVER fail accumulation of ketones DKA 6. DKA Kussmaul Kien Breathing CO2 7. Hyperosmolar state Brain Confusion 8. Glucose cannot be utilized by brain ketogenesis deplete Confusion
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Long term effects: Retinopathy blindness Cataract Peripheral neuropathy Autonomic neuropathy Poor wound healing Amputation Nephropathy ESRD CVD atherosclerosis, hypertension Immunocompromised
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Review
Type I DM IDDM Insulin deficiency <10% of DM Juvenile onset Non-obese Type II DM NIDDM Insulin resistance >90% DM Adult onset Obese
Prone to DKA Seldom DKA Tx: insulin administration Diet, exercise, oral hypoglycemic agent, seldom insulin 3/10/12
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condition associated with shortened RBC survival, such as hemolysis or acute blood 3/10/12 loss, will lower HgbA1c level
Any
Blood Glucose (mg/dL) 120 150 180 210 240 270 300 330 360 3/10/12
HgbA1c (%) 6 7 8 9 10 11 12 13 14
Fructosamine Assay
Assay
used to asses glycemic control over a short period of time (3-6 weeks) serum protein
Glycated
Fructosamine
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also results from nonenzymatic glycation (Maillard Reaction) between glucose and amino acid of protein
Indication Normal fructosamine level Excellent bloodglucose (sugar)control Good bloodglucose (sugar)control Fair bloodglucose (sugar)control Poor bloodglucose (sugar)control
Fructosamine Assay
Disadvantages: Result is affected by changes in the
levels Heparin affects the test Monthly monitoring in order to obtain information similar to performing HgbA1C (2-3 months)
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HYPOGLYCEMIA
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HYPOGLYCEMIA
low plasma glucose levels usually overnight plasma glucose
of less than 45mg/dL (2.5 mmol/L) + associated group of symptoms that are relieved by ingestion of food or carbohydrates
Occur
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when:
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Drugs (ethanol, salicylates, haloperidol) Insulinoma Islet hyperplasia/nesidioblastosis Persistent hyperinsulinemic hypoglycemia of infants Noninsulinoma pancreatogenous hypoglycemia syndrome Familial hypoglycemia from insulin, sulfonylurea or repaglinide Severe exercise Ketotic hypoglycemia
Drugs (disopyridine; B-adrenergic blocking agents; dispensing error) Sulfhydryl or thiol-containing drugs with autoimmune insulin syndrome Unripe akee fruit (hypoglycins A and B) and undernutrition
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Pentamidine Pneumocystis carinii pneumonia Propoxyphene (cerebral malaria) Topical salicylates (renal failure) Sulfamethoxazole and trimethoprim (renal failure)
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SGA infant Beckwith-Weidemann Syndrome Erythroblastosis fetalis Infant of DM mother Glycogen storage disease Defects in amino acid and fatty acid metabolism Reyes syndrome
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patient
Total parenteral nutrition and insulin therapy Questran interference with glucocorticoid absorption Shock
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Presents with hypersecretion of insulin Healthy appearing individuals documented hypoglycemia + no coexistent disease or ingestion of potential hypoglycemic drug Diagnostic:
72-hour prolonged supervised fasting: to identify
insulin-mediated hypoglycemia
Note: Insulin administration and sulfonylurea or repaglinide, a short acting insulin secretagogue treatment can mask hyperinsulin secretion, thereby proper diagnosis needs to be performed
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Proinsulin: > 5 pmol/L C-peptide: > 200 pmol/L B-hydroxybutyrate: < 2.7 mmol/L Good plasma glucose response to 1mg
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FRUCTOSE METABOLISM
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General Considerations
Fructose is abundant in most diets and is present in Western diets of up to 110 g/day intermediates are essential to glycolysis and gluconeogenesis
Frustoce
almost zero level fasting state Lab: difficult to measure Specificity: gas, liquid, and thin layer
chromatography
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Fructokinase deficiency
Clinically:
Fructosuria NOT associated with any
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Isoenzyme A
Seen:
embryonic tissue adult muscles
Manifestations:
mental retardation short stature hemolytic anemia abnormal facial expression
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Isoenzyme B
Seen: adult liver kidney intestines Manifestation: hereditary fructose intolerance most frequent error of fructose metabolism) Symptoms after ingestion of fructose, sucrose, and sorbitol
Complications are either acute or chronic Acute: poor feeding, failure to thrive, hypoglycemia, vomiting Chronic: hepatomegaly with hepatic dysfunction, kidney 3/10/12 damage, retinal damage, and death
Isoenzyme C
Predominantly
seen in nervous
tissue
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Fructose-1-6bisphosphonate deficiency
impairment of gluconeogenesis In infants: life-threatening episodes of lactic In older individuals, episodes occur: after prolonged fasting after depletion of glycogen store during periods of physiologic stress
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acidoses hypoglycemia
Long
GALACTOSE METABOLISM
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General Considerations
Lactose:
in milk
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Galactosemia
autosomal
recessive genetic
disorder infant cannot digest lactose partially metabolized galactose extremely toxic to
brain, liver, and kidneys
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Total Galactose Test/ Bacterial Assay Beutler Fluorescent Test Hill Test
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Test
elevated galactose and galactose-1-phosphate coli : grows in the presence of galactose or galactose-1-phosphate
E.
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to screen galactokinase and galactose-1-phosphate uridyl transferase levels measures NADPH production which is coupled with fluorescence
Test
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Hill Test
Fluorometric
levels Fluorescence: visible only when total galactose is increased (> 8-10 mg/dL)
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phosphate Neonates prone to E. coli sepsis, liver dysfunction with hepatomegaly and cataracts Central nervous system disease and primary ovarian dysfunctions are complications of this deficiency even if individuals are screened and treated with galactose-free diet 3/10/12
Galactokinase deficiency
More benign syndrome Complications: cataracts and
UDP-galactose-4-epimerase
psudotumor cerebri
deficiency syndrome
GLYCOGEN METABOLISM
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GLYCOGEN METABOLISM
Glycogen
storage diseases
dysfunction, which are related to normal function and breakdown of glycogen. Tissues primarily affected
liver muscles
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Biochemical Reaction Accumulation of normal glycogen in liver and kidney; hyperuricemia Accumulation of normal glycogen in lysosomes of all organs Accumulation of normal glycogen in
IV
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Moderate accumulation of normal glycogen in skeletal muscle lowered blood lactate and pyruvate levels in physical activity Lowered acitivity of total liver phosphorylase (phosphorylaseactivating system intact); accumulation of normal glycogen in the liver
Accumulation of normal glycogen in the muscle Enzyme defect in the liver, but
LACTIC ACIDOSIS
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General Considerations
Lactic acidosis accumulation of lactic acid d/t defects in lactic acid metabolism Lactic acid is a dead-end product of glycolysis Can also be formed from pyruvate through enzymatic action of lactate dehydrogenase
Lactic acid is strong acid (pKa = 3.9), so that in physiologic systems it is dissociated into lactate and hydrogen ions
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Hypoxic Condtions
Localized Hypoxic
condition mitochondrial respiration not possible inability of the Krebs Cycla to release fully stored energy of fats, carbohydrates and protein (compensatory mechanis) production of energy through substrate phosphorylation (2 ATP) rapid accumulation of lactic acid
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Hypoxic Condtions
The
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Nonhypoxic Conditions
No
Mechanism:
interference with normal metabolism of
acetyl-CoA through Krebs Cycle Glycolysis in the absence of Krebs cycle leads to rapid lactic acid accumulation
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Nonhypoxic Conditions
Selected
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measured enzymatically using lactate dehydrogenase with NADH loss followed spectrophotometrically NV: 0.4 to 2.1 mmol/L lactic acid levels should be suspected when a patient has
elevated anion gap [Na+ - (total CO2 + Cl-)] of
Abnormal
greater than 12
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