Genetic Disorders of Mitochondrial and Peroxisomal Fatty Acid Oxidation and Peroxisome Proliferator-Activated Receptors
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Genetic Expression and Nutrition, edited by Claude Bachmann and Berthold Koletzko. Nestle Nutrition Workshop Series, Pediatric Program, Vol. 50. Nestec Ltd., Vevey/Lippincott Williams & Wilkins, Philadelphia, © 2003. Genetic Disorders of Mitochondrial and Peroxisomal Fatty Acid Oxidation and Peroxisome Proliferator-Activated Receptors Ronald J. A. Wanders Department of Pediatrics, Academic Medical Center; Department of Clinical Chemistry, University of Amsterdam, Amsterdam, The Netherlands Fatty acids are an important source of energy in humans, especially during fasting. Most tissues are able to degrade fatty acids to carbon dioxide and water, but in addi- tion, some organs—notably the liver—have the capacity to convert the acetyl-CoA units produced during |3 oxidation into the ketone bodies acetoacetate and 3-hydrox- ybutyrate. These are important fuels for certain organs, especially the brain. Fatty acids are the main source of energy in the heart. Indeed, under normal conditions 60% to 70% of the energy requirements of the heart are provided by fatty acid oxi- dation, and even more under certain conditions such as fasting and diabetes. In principle, fatty acids can be degraded by several mechanisms, including a, (3, and &) oxidation. However, most fatty acids are degraded by |3 oxidation, which can occur in the mitochondria or in the peroxisomes. It is generally agreed that the mito- chondria form the major site of fatty acid (3 oxidation, catalyzing the oxidation of all major dietary fatty acids. In recent years, tremendous progress has been made in the identification of patients affected by a genetic deficiency in either the mitochondrial or the peroxisomal (3 oxidation system, and defects in virtually all the steps involved have now been identified. Thanks to these efforts, reliable laboratory methods have now become available to identify patients with these conditions. Much remains to be learned, however, about the pathophysiologic mechanisms behind these disorders. In this respect, the role of peroxisome proliferator-activated receptors (PPARs) is in- triguing, especially since the metabolites accumulating as a result of a block in mito- chondrial or peroxisomal (3 oxidation are PPAR activators. In this chapter, I will describe our current state of knowledge about mitochondrial and peroxisomal fatty acid oxidation, with particular emphasis on the various inher- ited diseases and the role of PPARs. FATTY ACID OXIDATION Fatty acids may undergo a, 0, or a> oxidation. 85 86 MITOCHONDRIAL AND FATTY ACID OXIDATION Alpha-Oxidation a-oxidation is required for fatty acids with a methyl group at the 3-position, as 3- methyl branched chain fatty acids cannot undergo direct (3 oxidation. The mechanism of fatty acid a oxidation has remained mysterious ever since its discovery in the early 1960s, when the accumulation of the 3-methyl branched chain fatty acid phytanic acid (3,7,11,14-tetramethylhexadecanoic acid) was identified in patients suffering from a rare genetic disease known as Refsum disease. Patients with Refsum disease show various abnormalities including retinitis pigmentosa, cerebellar ataxia, periph- eral neuropathy, anosmia, and cardiac abnormalities (1). The finding of markedly raised phytanic acid concentrations has led to detailed studies of phytanic acid oxi- dation. These studies showed that phytanic acid undergoes oxidative decarboxyla- tion, with pristanic acid (2,4,6,10-tetramethylpentadecanoic acid) and CO2 as the end products, and that patients with Refsum disease cannot convert phytanic acid to pris- tanic acid and CO2. Despite intense efforts, the mechanism of phytanic acid a oxi- dation remained unclear until very recently. However, work from our laboratory and others has now established the sequence of events (Fig. 1 A), and most of the enzymes involved have been characterized, purified, and studied at the molecular level (2). This led to the identification of the enzyme defect in Refsum disease—at the level of phytanoyl-CoA hydroxylase (3)—and later to the resolution of the molecular basis of Refsum disease (4). Interestingly, phytanic acid has been found to be a powerful lig- and for some nuclear receptors, including PPARa (5-8), as discussed below. Omega-Oxidation ft Oxidation is a relatively minor pathway, like a oxidation. The initial step occurs in the smooth endoplasmic reticulum by to hydroxylases belonging to the CYP4A sub- family, with a oo-hydroxy fatty acid as the product. The CYP4A family of cytochrome P450 enzymes, which are constitutively expressed in liver and kidney, catalyze both the to and the (00-1) hydroxylation of long-chain fatty acids (9). The major w-hydroxy- lase expressed in human liver and kidney is CYP4A11, which is functionally similar to the rat CYP4A1. The co-hydroxy fatty acids produced by the initial hydroxylation re- action then undergo two dehydrogenations to generate the corresponding co-keto fatty acids and w-carboxy fatty acids. These reactions are catalyzed by alcohol and aldehyde dehydrogenases in the cytosol. Subsequently, the dicarboxylic acids are activated to their CoA esters by an acyl-CoA synthetase present in the endoplasmic reticulum (10). The long-chain dicarboxylyl-CoA esters produced then appear to undergo several B ox- idation cycles in the peroxisome to produce medium-chain dicarboxylyl-CoA esters that undergo final oxidation to CO2 and H2O in the mitochondrion (Fig. IB). Beta-Oxidation 3 Oxidation is the main mechanism whereby fatty acids are broken down, and in- volves a sequence of four reactions including dehydrogenation, hydration, dehydro- genation again, and thiolytic cleavage (Fig. 2). Both mitochondria and peroxisomes Phytanic acid CoASH, ATP phytanoyl-CoA synthetase[ AMP, PP,- phytanoyl-CoA 2-ketoglutarate, O2 I phytanayl-CoA hydroxylase ( 2 succirtate, CO2 2-OH-phytanoyl-CoA H2O I 2-OH-phytanoyl-CoA lyase formate + CoASH -< formyl-CoA pristanal NAD(P)* phstanal dehydrogenase | NAD(P)H' pristanic acid CoASH, ATP I phstanoyl-CoA synthetasel 5 AMP, PP, pristanoyl-CoA B-oxidation Long-chain fatty acid NADPH, O2 omega-hydroxylase ( 1 NADP, H2O omega -OH-LCFA NAD alcohol dehydrogenase NADH omega -keto-LCFA NAD aldehyde dehydrogenase NADH omega -carboxy-LCFA CoASH, ATP acyl-CoA synthetase AMP, PP, Long-chain dicarboxylyl-CoA I B-oxidation in peroxisomes FIG. 1. Schematic representa- tion of the fatty acid a oxidation system (A) and the u> oxidation B medium-chain dicarboxylyl-CoA system (B). 88 MITOCHONDRIAL AND FATTY ACID OXIDATION MITOCHONDRIAL (J-OXIDATION PEROXISOMAL B-OXIDATION ATP 4. Fatty acyl-CoA Fatty acyl-CoA ' FAD jAcyhCoA dehydrogenases]] Acyl-CoA oxidases Enoyl-CoA 3-OH-acyl-CoA 3-OH-acyl-CoA NAD -^.^JL JL _ NAD -]3-hydroxy acyl-CoA dehydrogenases^ NADH ^~ ^ ^ ^NADH 3-keto-acyl-CoA 3-keto-acyl-CoA 3-keto acyt-CoA thlolases (n-2) acyl-CoA (n-2) acyl-CoA FIG. 2. The mitochondrial and peroxisomal 3 oxidation of fatty acids. The first step in the (5 oxi- dation of fatty acids in mitochondria is catalyzed by acyl-CoA dehydrogenases but in peroxi- somes by acyl-CoA oxidases. Both acyl-CoA dehydrogenases and acyl-CoA oxidases are flavo- proteins which use different mechanisms for the reoxidation of enzyme-bound FADH2. In case of mitochondrial acyl-CoA dehydrogenases, enzyme-bound E-FADH2 is reoxidized by electron transfer flavoprotein (ETF) followed by reoxidation of reduced ETF by ETF-dehydrogenase, so that the electrons ultimately enter the respiratory chain at the level of ubiquinone. In case of acyl- CoA oxidases, enzyme-bound FADH2 is directly reoxidized by molecular oxygen to produce H2O2. Steps 2, 3, and 4 are catalyzed by enoyl-CoA hydratases, 3-hydroxyacyl-CoA dehydro- genases, and 3-ketothiolases, which catalyze identical reactions. RC, respiratory chain. use the same mechanism for p oxidation of fatty acids, although the two systems dif- fer in many respects as summarized below. Oxidation of Fatty Acids to CO2 and H2O in Mitochondria Versus Peroxisomes Peroxisomes lack a citric acid cycle and thus cannot degrade the acetyl-CoA units produced during fatty acid oxidation to CO2 and H2O. Available evidence indicates that the acetyl-CoA units produced in peroxisomes are transferred to mitochondria in the form of acetylcarnitine (11,12). M1T0CH0NDRIAL AND FATTY ACID OXIDATION 89 Peroxisomal 3 Oxidation Versus Mitochondrial (3 Oxidation In mitochondria the first step in the 3 oxidation of fatty acids is catalyzed by various acyl-CoA dehydrogenases, all FAD-linked, which donate their electrons to the respi- ratory chain, thus generating adenosine triphosphate (ATP). In peroxisomes, how- ever, the acyl-CoA oxidases—which are also FAD linked—donate their electrons di- rectly to molecular oxygen to produce H2O2 which is subsequently decomposed to H2O and O2. Consequently, one cycle of 3 oxidation in peroxisomes is at most half as efficient as 3 oxidation in mitochondria in terms of ATP production. Role ofCarnitine in Peroxisomal and Mitochondrial 3 Oxidation Camitine plays an indispensable role in both mitochondrial and peroxisomal 3 oxida- tion, but at different levels. In the mitochondria, camitine is involved in the transfer of long-chain fatty acids across the mitochondrial inner membrane by the concerted ac- tion of camitine palmitoyltransferase 1 (CPT1), mitochondrial camitine/acylcarnitine translocase (CACT), and camitine palmitoyltransferase 2 (CPT2) (13). In peroxi- somes, however, camitine plays no role in fatty acid uptake but does play an indis- pensable role in the transfer of chain-shortened fatty acids from peroxisomes