Clinical diversity in glycogenosis type II. Biosynthesis and in situ localization of acid alpha-glucosidase in mutant fibroblasts.

The molecular basis of clinical diversity in glycogenosis type II (Pompe's disease) was investigated by comparing the nature of acid alpha-glucosidase deficiency in cultured fibroblasts from 30 patients. Biosynthetic forms of acid alpha-glucosidase with different molecular mass were separated electrophoretically and identified by immunoblotting. Immuno-electron microscopy was employed to determine the intracellular localization of mutant enzyme. Our studies illustrate that maturation of acid alpha-glucosidase is associated with transport to the lysosomes. Deficiency of catalytically active mature enzyme in lysosomes is common to all clinical phenotypes but, in the majority of cases, is more profound in early onset than in late onset forms of the disease. Thus, the results suggest that the clinical course of glycogenosis type II is primarily determined by the amount of functional acid alpha-glucosidase. The role of secondary factors can, however, not be excluded because three adult patients were identified with very low activity and little enzyme in the lysosomes.     

The determination of amylo-1,6-glucosidase in biopsy specimens from human chorion]

This method has been developed for the prenatal diagnosis of a grave hereditary disease, a deficiency of amylo-1,6-glucosidase (A-1,6-G) activity. The methods suggested earlier did not rule out the effects of other glucosidases, that could result in false-positive data if the fetus was involved. The new method for measuring A-1,6-G activity includes sedimentation of acid alpha-glucosidase with rabbit blood antiserum to human placental acid alpha-glucosidase. A-1,6-G activity is estimated from the difference in glucose accrement with limit dextrin and glycogen used as substrates. A-1,6-G activities were measured in 15 chorion samples obtained in the first trimester of pregnancy by the developed method, and normal values of this parameter established, making up 39.77 +/- 8.1 nmol/h per g of protein. The method may be useful in the prenatal diagnosis of type III glycogenosis.     

A simple differential immunoprecipitation assay of urinary acid and neutral alpha-glucosidases for glycogenosis II

A specific assay for acid alpha-glucosidase in urine was developed to facilitate the diagnosis of glycogenosis II. This enzyme activity was calculated as a difference between the alpha-glucosidase activities before and after immunoprecipitation with antiserum to acid alpha-glucosidase. Acid alpha-glucosidase accounted for 86% of the total activity in control urine. All the cases of various clinical types of glycogenosis II showed either a marked decrease or a complete deficiency of this enzyme activity. A marked decrease of acid alpha-glucosidase was demonstrated by immunoblotting of the urine from patients with late-onset forms of this disease. These results indicate that assays of urinary acid alpha-glucosidase by this immunological method are useful for detection of the various types of glycogenosis II.     

Intravenous administration of phosphorylated acid alpha-glucosidase leads to uptake of enzyme in heart and skeletal muscle of mice.

The lysosomal storage disorder glycogenosis type II is caused by acid alpha-glucosidase deficiency. In this study we have investigated the possible applicability of mannose 6-phosphate receptor-mediated enzyme replacement therapy to correct the enzyme deficiency in the most affected tissues. Bovine testes acid alpha-glucosidase containing phosphorylated mannose residues was intravenously administered to mice and found to be taken up by heart (70% increase of activity) and skeletal muscle (43% increase); the major target organs. The uptake of nonphosphorylated human placenta acid alpha-glucosidase by heart and skeletal muscle appeared to be significantly less efficient, whereas uptake of dephosphorylated bovine testes enzyme was not detectable. The phosphorylated bovine testes acid alpha-glucosidase remained present in mouse skeletal muscle up to 9-15 d after administration, with a half-life of 2-4 d. Besides being measured in skeletal muscle and heart, uptake of phosphorylated bovine testes and nonphosphorylated human placenta acid alpha-glucosidase was measured in several other organs, but not in brain. The increase of acid alpha-glucosidase activity was highest in liver and spleen. We concluded that application of mannose 6-phosphate receptor-mediated enzyme replacement therapy may offer new perspectives for treatment of glycogenesis type II.     

Effects of N-hydroxyethyl-1-deoxynojirimycin (BAY m 1099) on the activity of neutral- and acid alpha-glucosidases in human fibroblasts and HepG2 cells

The effect of the glucose analogue N-hydroxyethyl-1-deoxynojirimycin (BAY m 1099) on the activity of alpha-glucosidases was studied in human fibroblasts and HepG2 cells. BAY m 1099 inhibits neutral and acid alpha-glucosidase activities of both cell types in a dosage-dependent and reversible manner. Inhibition of endoplasmic reticulum glucosidases I and/or II is suggested by delayed processing of lysosomal (acid) alpha-glucosidase. Competitive inhibition of mature acid alpha-glucosidase leads to lysosomal accumulation of glycogen as in glycogenosis type II. There seems to be little risk, however, of inducing this storage disorder when using the drug in a dose of 50 mg per os for treatment of type II diabetes. In high doses, the drug may prove useful for studying the pathogenesis of glycogenosis type II in vitro or in animal models.     

Characterization of the molecular defect in infantile and adult acid alpha-glucosidase deficiency fibroblasts.

Different clinical expressions of acid alpha-glucosidase deficiency have been described. The present study was undertaken to investigate the basic metabolic defect in the infantile and adult forms of the disease. Acid alpha-glucosidase (EC 3.2.1.20) was purified from normal and from adult acid alpha-glucosidase deficiency fibroblasts. The pH optimum; Michaelis constant; electrophoretic mobility in starch; thermal denaturation at pH 4.0 and 7.0; and inhibition by turanose, alpha-methylglucoside and trehalose were the same in purified enzyme from normal and mutant cells. Placental acid alpha-glucosidase was purified to, or near, homogeneity. Monospecific antibodies raised against the enzyme in each of three enzyme peaks obtained from the last purification step were found to cross-react with the enzyme of all three peaks, and with purified, normal fibroblast enzyme. Cross-reacting material (CRM) also was identified in fibroblast lysates from normal subjects and from both forms of acid alpha-glucosidase deficiency. The amount of CRM in the adult form appeared to be significantly less than in normal cells or cells from the infantile form. Enzyme activity was demonstrated in the immune complexes of the normal and adult acid alpha-glucosidase deficiency fibroblasts, but not of the infantile form. Competition for antibody binding sites was observed between normal and both types of mutant enzymes. The findings indicate that this case of infantile acid alpha-glucosidase deficiency is the result of a structural gene mutation which causes the synthesis of a catalytically inactive (CRM-positive) enzyme protein. It appears that in the adult form, the mutation causes a reduction in the amount of the enzyme protein present in the cells.     

Two alpha-glucosidases in cultured amniotic fluid cells and their differentiation in the prenatal diagnosis of Pompe's disease.

A sensitive fluorometric assay utilizing 4-methylumbelliferyl-alpha-D-glucopyranoside has been developed for the determination of alpha-glucosidase. The enhanced sensitivity was achieved by increasing the solubility of the substrate with a water miscible organic solvent. With this system, cultured amniotic fluid cells were found to have two major forms of alpha-glucosidase with somewhat overlapping acidic pH optima; one with pH optimum at 4.5 is deficient in Pompe's disease (type II glycogenosis), while one with pH optimum at 6.0 is not affected in this disease. Specificity for the pH 4 form of alpha-glucosidase was achieved by exploiting the greater thermal lability of the pH 6 enzyme. The pH 6 form of the enzyme was also detectable in freshly prepared extracts of cultured fibroblasts. The procedure is direct and simple and has been applied to the prenatal diagnosis in two pregnancies at risk for Pompe's disease.     

Partial characterization of leucocyte alpha-glucosidase in late onset glycogenosis type II

We describe partial characterization and properties of leucocyte alpha-glucosidase from a patient with clinical features intermediate of juvenile and adult onset forms of glycogenosis type II. Acid and neutral alpha-glucosidase activities toward 4-methylumbelliferyl glucopyranoside as substrate were studied in total leucocytes, and separately in lymphocytes and granulocytes. Lymphocytes, which showed markedly reduced activities of acid alpha-glucosidase in the patient, are the most reliable peripheral blood cells for the diagnosis of glycogenosis type II. Moreover, the ratio of acid/neutral alpha-glucosidase activities, especially in lymphocytes, is a useful parameter for the diagnosis. In lymphocytes, the Km values of both acid and neutral alpha-glucosidases were essentially the same between the patient and normal controls; the Vmax value of acid alpha-glucosidase from the patient was markedly reduced, and the Vmax value of neutral alpha-glucosidase from the patient was reduced by 36% as compared with that from normal controls. Heat-inactivation experiments revealed that acid alpha-glucosidase activities of lymphocytes were relatively heat-stable, while both acid and neutral alpha-glucosidases of granulocytes were heat-labile. No differences in these properties, however, could be detected between the patient and normal controls.     

Leucocyte alpha-1,4- and alpha-1,6-glucosidase activities towards oligosaccharides in late onset glycogenosis type II

We describe the partial characterization and some properties of leucocyte alpha-glucosidase towards disaccharides with the alpha-1,4 (maltose) and alpha-1,6-glucosidic linkage (isomaltose) and tetrasaccharides with the alpha-1,4 (maltotetraose) and alpha-1,6-glucosidic linkage (tetrasaccharide, Glc alpha 1----6Glc alpha 1----4Glc alpha 1----4Glc, which was isolated from the urine of a patient with glycogenosis type II). Leucocyte alpha-glucosidase showed optimal activity towards all four oligosaccharides under two conditions, acidic (pH 4.0-4.5) and neutral (pH 6.0-6.5) regions. Our comparative studies on enzyme kinetics showed that leucocyte alpha-glucosidase was able to hydrolyze both the 1----4 isomers and the 1---6 isomers at acidic and neutral pH. Acid alpha-glucosidase could hydrolyze maltose about 10 times faster than isomaltose, and maltotetraose about 5 times faster than tetrasaccharide isolated from urine. In leucocytes of the patient with late onset glycogenosis type II, acid alpha-glucosidase activities towards maltose, isomaltose, maltotetraose and tetrasaccharide isolated from urine showed 75.3%, 67.4%, 76.5% and 41.4% of normal control values, respectively. Neutral alpha-glucosidase activities towards these four oligosaccharides were normal. Tetrasaccharide with alpha-1,6-glucosidic linkage might be accumulated by the impaired hydrolysis in the circulation as well as the leakage of undegraded glycogen to the circulation from the affected muscle.     

Physico-chemical and immunological properties of acid alpha-glucosidase from various human tissues in relation to glycogenosis type II (Pompe's disease).

The physico-chemical and immunological properties of acid alpha-glucosidase from various human tissues have been studied. Heat stability of acid alpha-glucosidase from heart, liver and skeletal muscle is identical, but for kidney some different results are obtained. Identical isoelectrofocussing patterns are found for heart, liver and skeletal muscle. Furthermore, the effect of antiserum against human liver acid alpha-glucosidase on the activity of acid alpha-glucosidase from various tissues is studied. The results are discussed in relation to glycogenosis type II (Pompe's disease).     

Glycogen storage disease type II: enzymatic screening in dried blood spots on filter paper

BACKGROUND: Glycogen storage disease II is characterized by a deficiency of the lysosomal enzyme acid alpha-glucosidase. Currently, glycogen storage disease II is diagnosed by demonstrating the virtual absence or a marked reduction of acid alpha-glucosidase activity in muscle biopsies, cultured fibroblasts, or purified lymphocytes. Early diagnosis and treatment of glycogen storage disease II are considered to be critical for maximum efficacy of the enzyme replacement therapies that are in development. However, these existing diagnostic methods are not suited for newborn screening. We developed an assay useful for newborn screening for glycogen storage disease II. METHODS: A series of three enzyme assays to measure the alpha-glucosidase activities in dried blood spots on filter paper was developed. The measurement of acid alpha-glucosidase activity with minimal interference by other alpha-glucosidases was accomplished using maltose as an inhibitor. The method was used on samples from glycogen storage disease II patients, obligate heterozygotes, and healthy controls. RESULTS: Glycogen storage disease II patients were distinguished from carriers and healthy controls using the series of enzyme assays. CONCLUSIONS: We developed a simple and noninvasive screening method for glycogen storage disease II. The method could be incorporated into newborn screening.     

Acid alpha-glucosidase deficiency in cultured fibroblasts with phenotype 2 of acid alpha-glucosidase

The enzyme acid alpha-glucosidase shows a polymorphism determined by two alleles, namely phenotypes 1, 2-1 and 2. We report that the activity of acid alpha-glucosidase, measured in fibroblasts homozygous for isozyme 2 is significantly reduced. In fibroblasts harvested at early confluency the activity in the strain with phenotype 2 of acid alpha-glucosidase was 23% and 5% compared to the levels in normal phenotype 1 strains using maltose and glycogen as substrate, respectively. At late confluency, the same fibroblasts showed an increase in activity to 60% and 15% of normal, respectively. At both early and late confluency, two fibroblast strains with the adult form of acid alpha-glucosidase deficiency had activity of approximately 7% of the activity in normal phenotype 1 fibroblasts with both substrates. In general, an increased amount of glycogen was measured in deficient fibroblasts, including the strain with phenotype 2, but overlapping was observed with normal cells. These findings show that fibroblasts homozygous for the isozyme 2 allele have a reduced ability to hydrolyse the natural substrate, glycogen.     

Heterogeneity of glycogenosis with alpha-1,4-glucosidase deficiency: enzymatic studies in three families (author's transl)]

The authors describe four cases of atypical forms of glycogenosis with alpha-1,4-glucosidase (acid maltase) deficiency. The results of clinical, microscopic, histochemical, enzymological and immunological studies are described. Acid maltase activity has been studied in muscle, leukocytes and fibroblasts. The authors show no difference in the properties of acid maltase; the authors study the purified enzyme from various tissues.     

Diagnosis of Pompe's disease using leukocyte preparations. Kinetic and immunological studies of 1,4-alpha-glucosidase in human fetal and adult tissues and cultured cells

Kinetic and immunological studies of 1,4-alpha-glucosidase show that the distribution of acid, renal and neutral alpha-glucosidase at pH 4.0 and 6.5 is as follows: in liver and cultured fibroblasts and amniotic fluid cells the activity at pH 4.0 is mainly due to the acid enzyme. Even at pH 6.5, the activity is largely due to the residual activity of the acid enzyme. In kidney and leukocytes, however, the activity by acid enzyme at pH 4.0 represents only 30-60% of the total activity and the remaining activity is from renal enzyme. At pH 6.5, the activity is almost exclusively of renal enzyme. Renal alpha-glucosidase has a higher affinity for maltose (Km, 0.8 mmol/l) than acid enzyme, however; for glycogen acid enzyme shows the highest affinity (20.7 g/l). There is no significant difference in the kinetic characteristics of alpha-glucosidase between fetal and adult tissues. In kidney, however, a relative increase in renal enzyme to acid enzyme with age is found, i.e. in fetal kidney the alpha-glucosidase activity at pH 4.0 is more than twice that at pH 6.5, whereas in adult kidney, the activity ratio at pH 4.0-6.5 is approximately 1. Antibodies for human liver acid alpha-glucosidase decrease the alpha-glucosidase activity in normal leukocytes by 22-75% at pH 4.0 (0.54-3.8 nmol/min per mg protein). The decrease is significantly lower in patients with Pompe's disease (0-0.11 nmol/min per mg protein) as well as in their parents and some siblings (0.15-0.70).     

Determination of acid alpha-glucosidase activity in blood spots as a diagnostic test for Pompe disease

BACKGROUND: Pompe disease is an autosomal recessive disorder of glycogen metabolism that is characterized by a deficiency of the lysosomal acid alpha-glucosidase. Enzyme replacement therapy for the infantile and juvenile forms of Pompe disease currently is undergoing clinical trials. Early diagnosis before the onset of irreversible pathology is thought to be critical for maximum efficacy of current and proposed therapies. In the absence of a family history, the presymptomatic detection of these disorders ideally can be achieved through a newborn-screening program. Currently, the clinical diagnosis of Pompe disease is confirmed by the virtual absence, in infantile onset, or a marked reduction, in juvenile and adult onset, of acid alpha-glucosidase activity in muscle biopsies and cultured fibroblasts. These assays are invasive and not suited to large-scale screening. METHODS: A sensitive immune-capture enzyme activity assay for the measurement of acid alpha-glucosidase protein was developed and used to determine the activity of this enzyme in dried-blood spots from newborn and adult controls, Pompe-affected individuals, and obligate heterozygotes. RESULTS: Pompe-affected individuals showed an almost total absence of acid alpha-glucosidase activity in blood spots. The assay showed a sensitivity and specificity of 100% for the identification of Pompe-affected individuals. CONCLUSIONS: The determination of acid alpha-glucosidase activity in dried-blood spots is a useful, noninvasive diagnostic assay for the identification of Pompe disease. With further validation, this procedure could be adapted for use with blood spots collected in newborn-screening programs.     

Biochemical diagnosis of hepatic glycogen storage diseases: 20 years French experience.

French experience of 242 cases of liver glycogenoses is reported. Screening tests based on serum biochemical data and glucagon tolerance tests are briefly reviewed. The diagnosis of types I glycogen storage disease (GSD) was ascertained in 73 patients' liver biopsies by measurement of glycogen content and by studying the glucose-6-phosphatase system. Liver biopsies were also required at the beginning for the diagnosis of other hepatic GSDs; later on, the possibilities of diagnosis using peripheral blood cells were investigated. Eighty-four cases of type III GSD were confirmed by measurement of debranching enzyme activity and glycogen content using either liver biopsies (78 cases) and/or erythrocytes (37 cases); enzyme determination was also performed in leukocytes and/or fibroblasts for 18 patients. Twenty-four cases of type VI GSD underwent liver biopsies, and the diagnosis could be confirmed using mononuclear or polymorphonuclear cells for 11 of these patients. Sixty-one patients were identified as type IX GSD; phosphorylase kinase deficiency was demonstrated in erythrocytes for all patients, and a liver biopsy was analyzed for 26 of these cases. From this experience, the possibilities of diagnosis of liver GSD using peripheral blood cells are emphasized.     

Glucose-6-phosphatase deficiency and hyperlipaemia

Liver biopsies from two patients with glucose-6-phosphatase deficiency were found to contain a high de novo fatty acid synthesizing activity from citrate as the carbon source. Liver biopsies from controls, from patients with debranching enzyme deficiency or from one patient with insulinoma showed much lower rates of long-chain fatty acid synthesis.

From this investigation it is concluded that there is no correlation between fatty acid synthesis in the liver and the insulin and/or glucose levels in the blood. However, there may be a positive correlation between the activity of the rate-limiting step in long-chain fatty acid synthesis and the lactate level in the blood.     

Alterations in specific activity of lysosomal alpha-glucosidase in cystic fibrosis

Cultured skin fibroblasts derived from patients with cystic fibrosis contain 2.1-fold more acid alpha-glucosidase (EC 3.2.1.3) than normal fibroblasts. This difference is amplified to 2.3-fold when the cells are extracted in Triton X-100. In a study of 14 fibroblast cell lines derived from CF homozygotes and heterozygotes, normal individuals and patients with other recessively inherited disorders, normal individuals could be distinguished from either CF homozygotes or heterozygotes based on the ratio of acid alpha-glucosidase to beta-hexosaminidase when fibroblasts were extracted in either water or Triton X-100. However, the best distinction could be made with water extracts as there was no overlap among individual data points in the three categories. The acid to neural alpha-glucosidase ratio only distinguished CF homozygotes from normal individuals when cells were extracted in Triton X-100. The use of a ratio relationship of acid alpha-glucosidase with beta-hexosaminidase allows the comparison of data from multiple experiments on different days of assay and on cells at different passage numbers. These results suggest that alpha glucosidase may have a role in the primary defect in cystic fibrosis.     

Separation of acid and neutral alpha-glucosidase isoenzymes from fetal and adult tissues, cultivated fibroblasts and amniotic fluid cells by DEAE-cellulose and sephadex G-100 column chromatography.

Isoenzymes of alpha-glucosidases (EC 3.2.1.20) from various human organs and body fluids from fetuses and adults were separated by DEAE-cellulose column chromatography and gel filtration using Sephadex G-100. A minicolumn (0.35 X 2.5 cm) was used for the DEAE-cellulose column chromatography of extracts from tissues as well as cultivated cells of skin fibroblasts and amniotic fluid. The enzyme activity in the eluates was measured by the use of a methylumbelliferyl derivative as substrate and a very sensitive Microscope fluorimeter. In most tissue samples alpha-glucosidase was eluted mainly as a single peak when monitored at acid pH and as two peaks when the activity was measured at neutral pH in both columns. Another small peak representing alpha-glucosidase was found in fresh extracts of cultured cells on DEAE-cellulose columns. Neutral alpha-glucosidase especially in fibroblasts was extremely sensitive to storage at -20 degrees C. DEAE-cellulose column chromatography of plasma and amniotic fluid showed similar elution patterns of alpha-glucosidase. Differences were noticed in the elution pattern of urine from infants and adults. The tissue distribution and the different characteristics of the enzyme in samples of various origins and ages were discussed.     

Glycohydrolases in diabetes: characterization of acid alpha-glucosidase from liver and neutral alpha-glucosidase from sera of diabetic patients and controls

Acid alpha-glucosidase activity measured in the supernatant fraction of liver homogenates obtained from adult-onset diabetic patients is significantly decreased when compared to controls (2.86 +/- 1.18 and 5.79 +/- 1.82 nmoles/min/mg protein +/- S.D., respectively). The biochemical properties (Km values, thermostability, pH optimum, isoelectric focusing profiles) of acid alpha-glucosidase obtained from the livers of diabetic patients were similar to those of acid alpha-glucosidase obtained from the livers of controls. Mixing studies gave additivity of acid alpha-glucosidase activity suggesting that neither inhibitors nor activators are present (in diabetic and control livers, respectively). Neutral alpha-glucosidase activity measured in the sera of diabetic patients was significantly increased when compared to controls (4.35 +/- 1.82 and 2.44 +/- 1.05 nmoles/h/ml +/- S.D., respectively). Neutral alpha-glucosidase in the sera of diabetic and control patients has a similar pH optimum but the enzyme in the serum of diabetics has a slightly lower apparent Km value for the 4-methylumbelliferyl substrate (0.6 vs. 0.9 mmol/L) and slightly increased thermostability. Experiments involving dialysis of patient serum, addition of glucose to patient serum and mixing of control and diabetic patient sera all suggest that glucose exhibits only slight inhibition of serum neutral alpha-glucosidase activity. Isoelectric focusing indicates that neutral alpha-glucosidase activity in the sera of diabetic patients is consistently different from the enzyme in the sera of control patients in that a significantly smaller percentage of activity is found in the acidic region with pI values less than 4.8.