Arch Dis Child: first published as 10.1136/adc.47.251.41 on 1 February 1972. Downloaded from Archives of Disease in Childhood, 1972, 47, 41. Ketosis in Hepatic Glycogenosis J. FERNANDES* and N. A. PIKAAR From the Department of Paediatrics, The University, Utrecht, and Central Institute for Nutrition and Food Research, Zeist, The Netherlands Fernandes, J., and Pikaar, N. A. (1972). Archives of Disease in Childhood, 47, 41. Ketosis in hepatic glycogenosis. The occurrence of ketosis in 41 patients with liver glycogenosis and a control group of 22 children was investigated. Fasting ketosis was present in children with a deficiency of the debranching enzyme system and in young children with a deficiency of the phosphorylase system, but never in patients with a glucose-6-phosphatase deficiency. Oral tolerance tests on a patient deficient in debranching enzyme showed that the blood levels of glucose and ketone bodies changed in the opposite direction. It is argued that, for biochemical reasons, the occurrence of ketosis in patients with a glucose- 6-phosphatase deficiency is improbable. Ketosis has generally been considered to be a (Howell et al., 1962; Hug and Schubert, 1967; characteristic feature of glycogen storage disease Kelsch and Oliver, 1969; Rennert and Mukhopad- in childhood (van Creveld, 1928, 1932; Howell, hyay, 1968). Because of the conflicting evidence Ashton, and Wyngaarden, 1962; Hug and Schubert, we decided to gather more data on ketosis in patients copyright. 1967; Kelsch and Oliver, 1969; Lowe et al., 1962; with the three most common types of glycogenosis, Rennert and Mukhopadhyay, 1968; Sidbury, e.g. glucose-6-phosphatase deficiency, deficiency Gitzelmann, and Fisher, 1961; Sokal et al., 1961). of the debranching enzyme system, and deficiency While studying some aspects of the carbohydrate of the phosphorylase system. and fat metabolism of children with glycogenosis of the liver (Fernandes and van de Kamer, 1965; Patients and Methods Fernandes and Pikaar, 1969), we were puzzled by The investigation comprised 41 patients and 22 normal the fact that, though we frequently encountered children. The relevant clinical and biochemical data http://adc.bmj.com/ fasting ketosis in our debranching enzyme- and of the patients are presented in Tables I-III. The phosphorylase-deficient patients, we never saw patients with a glucose-6-phosphatase deficiency were it in our patients with glucose-6-phosphatase diagnosed by enzymic assay of a liver biopsy (Table I). deficiency. The patients with a deficiency ofthe debranching enzyme The normal fasting levels of ketone bodies in the system were diagnosed by enzymic assay of the leuco- blood of the latter seemed the more unexpected as cytes: in three of them an enzymic assay of a liver they have the strongest tendency towards hypo- glycaemia of all types of glycogenosis patients, and TABLE I on September 26, 2021 by guest. Protected it is known that hypoglycaemia causes a rise of the Enzyme Assays in 5 Children with Glucose-6- free fatty acid concentration in the plasma. Thus, phosphatase Deficiency under hypoglycaemic conditions one might expect an enhanced rate of fatty acid oxidation and ketone Case No. Glucose-6-phosphatase in Liver body synthesis in the liver to compensate for the 1 0.07* deficient glucose supply. Therefore, in glucose-6- 2 0 00* phosphatase deficiency even more than in other 3 0.08* 4 0° OOt types of glycogenosis, ketosis would be expected to 5 00°°t occur frequently. Indeed, many authors implicitly assume, or even explicitly state, this to be the case *,moles Pi/min per g tissue (Hers, 1964), normal range 2-10. Enzyme assays by Professor H. G. Hers (Louvain). Received 29 July 1971. t gmoles Pi/min per mg protein measured on the total homogenate *Present address: Sophia Children's Hospital and Neonatal Unit, (Harper, 1962), normal range 5 9-93 (N = 7). Enzyme assays by Rotterdam Medical School, Rotterdam, The Netherlands. Dr. J. F. Koster (Rotterdam). 41 Arch Dis Child: first published as 10.1136/adc.47.251.41 on 1 February 1972. Downloaded from 42 Fernandes and Pikaar TABLE II TABLE III Enzyme Assays of 7 Children with Deficiency of Enzyme Assays of 29 Children with Deficiency of Debranching Enzyme System Phosphorylase System Debranching Enzyme Phosphorylase b Phosphorylase in Phosphorylase Case Case Kinase in Leucocytes (2) b Kinase No. Leucocytes Liver No.No. Leucocytes (1) -AMP + AMP in Liver (1) (1) (2) (1) (2) 1 0-57 5 15 - 1 0-00 - - - 2 0-11 5 24 0-16 2 0 00 0 00 0 00 0 00 3 0-11 3 13 - 3 0 06 0-00 0-13 0-00 4 0 09 2 21 - 4 0 00 - - - 5 0-08 8 21 - 5 0 00 - - - 6 0-10 - - - 6 0-00 - - - 7 0-08 4 15 - 7 0-00 0-25 0-20 0-25 8 0-41;0-55 6 13 - 9 0 04 2 13 - Normal 0-33-1-59 0-31-0-51 0-51-2-30 0-13-0-61 10 0 07 4 11 - range N=6 N=2 N=5 N=4 11 0-08 3 14 - 12 0-08 3 16 - 13 0 06 1 23 - (1) nmoles glucose produced from phosphorylase limit dextrin/ 14 0-00 3 20 - min per mg protein (Huijing, 1964). 15 0 04 4 17 0-06 (2) nmoles glucose incorporated/mm per mg protein (Hers, 1964). 16 0 09 5 16 - The enzyme assays were performed by Dr. J. H. van de Kamer 17 0-07 6 15 - (Utrecht), Dr. J. F. Koster (Rotterdam), or Professor H. G. Hers 18 0-12 7 15 - (Louvain). 19 0-11 4 14 - 20 0-16 2 17 - 21 0 09 4 17 - biopsy was performed as well (Table II). The patients 22 0-02 5 21 - with a deficiency of the phosphorylase system were 23 0 09 3 16 - diagnosed by enzymic assay of the leucocytes (Table 24 0-02 0 3 - III). These patients, Cases 1 and 8 to 25 0-07 3 16 - excepted, belong 26 0-08 4 23 - the phosphorylase kinase-deficient type (Huijing, 1967); 27 0 12 3 22 0-09 copyright. most belong to two large pedigrees (Huijing and Fer- 28 0-10 4 18 - nandes, 1969). 29 0-05 3 17 _ The finding of a deficiency of phosphorylase kinase Normal 0-56 + 0-19 19 ± 6 24 + 6 0 27-098 in the leucocytes was confirmed by enzymic assay of a (Mean + SD) (Mean + SD) (Range) liver biopsy in Cases 2, 15, and 27. N = 58 N = 39 N = 39 N- 5 The ketone bodies, acetone, 3-ketobutyrate, and 3- hydroxybutyrate were estimated separately in capillary (1) Units phosphorylase b activated/min per mg protein (Huijing, blood. The method of Peden (1964) was used in a 1967). (2) nmoles glucose-l-phosphate produced from soluble starch/min scaled-down version. The results were the same as with per mg protein (Huijing, 1967). The enzyme assays in the leuco- http://adc.bmj.com/ the original method. cytes were performed by Dr. F. Huijing (Miami), those in the liver Glucose was estimated with glucose oxidase (reagent by Dr. J. F. Koster (Rotterdam). set TC-M of Boehringer and Soehne, Mannheim, West Dr. F. Huijing kindly gave advice on the adaptation of his method Germany), and nonesterified fatty acids (NEFA) were of phosphorylase kinase assay in leucocytes to liver biopsies. estimated with a micromodification of Dole's method in with a (Fernandes and van de Kamer, 1965; Trout, Estes, and patients glucose-6-phosphatase deficiency. Friedberg, 1960). The fasting ketone body level in the phosphorylase- As regards the procedure of the oral tolerance tests, deficient patients is age-dependent (Fig. 2): the 2 g glucose or casein per kg body weight was administered tendency towards ketosis declines with age to on September 26, 2021 by guest. Protected as a 10% solution. disappear around the age of 7. Results Additional experiments. After oral glucose General survey. Fig. 1 represents the fasting administration to a patient with a debranching blood levels of total ketone bodies in patients with enzyme deficiency, the fasting ketosis disappeared different types of liver glycogenosis and controls. completely (Fig. 3A). The administration of The preceding fasting period was 8 to 14 hours galactose or fructose to the same patient had an except for one infant with a glucose-6-phosphatase equally favourable effect (data not shown). Oral deficiency whose tendency towards hypoglycaemia casein administration to this patient was followed did not permit a fast longer than 4 to 6 hours. by only slight decrease in the ketosis (Fig. 3B). A striking ketosis was present in most children with In the same child with a debranching enzyme a debranching enzyme deficiency and several deficiency, ketone body concentrations were esti- children with a phosphorylase deficiency, but not mated during prolonged fasting. 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