| Cryptopyrroluria, nitrosative stress and mitochondrial disease
© Dr. sc. med. Bodo Kuklinski
As a result of previous medical tests to 821 patients (with ages varying from infancy up to over 70 years) a positive correlation between pathologically increased cryptopyrrole values and nitrosative stress was detected. Cryptopyrrolics indicate a high NO (Nitrogen monoxide) synthesis, measured by detecting pathologically high citrulline amounts in urine or by increased NO concentrations in the expired air. Citrulline is an amino acid, which is a by-product derived from the NO synthesis from arginine + oxygen = NO + citrulline NO and citrulline are not stable values. They show very rapid fluctuations, especially under physical strain, which are accompanied by a high oxygen consumption in the metabolic level, especially in the mitochondria. This NO synthesis is highly likely the induced NO synthesis (iNOS). With this diagnosis, many important consequences concerning the thematic approach to diagnoses, therapies and estimation of pyrroluria reveal, that it is not an autonomous form of disease, but rather an accompanying symptom of an organic disease affecting several organs NO is formed in four different synthetic ways in the organism:
Both NO forms are calcium – dependent and serve as neural chemical messengers during the transmission of neuronal signals.
NO has the property, to bind itself on iron or especially on FeS-bearing enzymes and block them. This bondage is reversible and can be broken up by partial pressure of the oxygen. This would explain the hunger for oxygen of the affected patients. The biochemical effects of an increased NO synthesis are:
Other iron-bearing enzymes, which react to NO are:
Due to the fact that in mitochondria functions such as the cell respiration, the ATP-synthesis, the citric acid cycle, the fatty acid oxidation, the glutamine synthesis, partially the steroid hormone synthesis and the beginning of the glucose- new formation (gluconeogenesis) take place, massive metabolic deficits are developed, which in turn are expressed clinically in form of disturbances in blood synthesis (e.g. porphyria), in lactose intolerances, above all however in a chronic energy deficit. This effect is noticeable particularly in the organs with high energy demands such as the central nervous system and the musculature. Affected patients suffer from a chronic energy deficit; they are easier fatigued, need longer relaxation breaks, the ability to concentrate is possible only for short periods of time. Stamina performances in particular, that need energy derived from the fatty acid oxidation, are almost impossible. The continuous feeling of hunger forces the affected persons to always eat; carbohydrates however, often block the energy production further (pyruvate dehydrogenase deficit in the mitochondria), so that this resulting continuous urge to eat does not replace the energy deficit, but, on the contrary, augments it. Energy carriers of the carbohydrates can not be utilised, instead they lead to a compulsory fat synthesis, whereas proteins and fatty acids can be better utilised energetically, since they can enter the citric acid cycle through the acetyl coenzyme A. A clinical result of this effect is the tendency to increased fat deposition, chronic hunger, chronic hypoglycaemia and tendency to high cholesterol levels. The inhibition of the citric acid formation increases further the energy deficit, since the acetyl coenzyme A can not be expelled from the mitochondria in the cell, because this expulsion is only possible via the citrate-shuttle. Further consequences are disturbances in the blood formation (hemosynthesis), so that porphyre diseases may arise, chronic immune insufficiency with affinity for infection, thyroid gland malfunctions or a reduced availability of γ-amino butyric acid (GABA). The chronic energy deficit is consequently expressed in a chronic tiredness and fatigue syndrome. The amino acid citrulline has the property to be stored in certain proteins such as e.g. fibrinogen. This citrullinated fibrinogen acts as an antigen and triggers auto immune reactions, i. e. aseptic (not bacterial) inflammatory reactions especially in the joints and the spinal column, so that as a result chronic crucial joint complaints or even chronic pains in the lumbar spinal column arise, which have nothing to do with physical strain. If there is a longer chronic condition, joint rheumatism may be developed. The blocking of mitochondrial energy metabolism has the effect, that mitochondria become literally free radical cannons, which trigger an oxidative stress. If additional chemical stimulations occur, then the Th1-lymphocytes release increasingly Interferon γ, which in turn is a strong stimulant for a further iNO synthesis. Aseptic inflammatory reactions trigger the release of tumour necrosis factor α, which in the course of the inflammatory process leads to an increased iNO-formation as well. This chronic energy deficit forces the cells, in order to maintain their survival, to turn on secondary “emergency power supply aggregates“such as the membrane bound NADH-Oxidoreductase or the aerobic glycolysis. At the same time proto- oncogenes are activated. In addition another effect takes place, namely that NO in the body leads to an increase in the formation of nitrosamine, so that here a higher risk for genetic mutations is developed. During this chronic energy deficit brain cells are in a particular dilemma, since the sedating GABA-influence no longer exists; instead glutamate receptors take over. The calcium influx induced by this effect due to the lack of energy in the brain cells can not be replaced; a continuous calcium overload takes place in the cells and leads to hyperactivity, high irritability of the brain. The activation of the glutamate-NMDA-receptors generates superoxide (O2°−). This increased formation of superoxide through the glutamate receptor, die mitochondrial release of superoxide and the superoxide formation rates due to chronic inflammatory processes as well as the membrane bound NADH-oxidoreductase lead to a further worsening of the situation, since NO together with the superoxide free radicals form the toxic peroxynitrite (ONOO°). NO has the property, to bind itself with a higher affinity to superoxide than superoxide to the detoxifying superoxide dismutase in mitochondria (manganese -dependent) and in the cell plasma (copper superoxide dismutase and zinc superoxide dismutase). With the formation of peroxynitrite the mitochondrial function is irreversibly impaired. NO° and O2° create a lethal cocktail! Peroxynitrite is highly toxic, has an oxidative function and is stored on aromatic amino acids such as tryptophane or its by-products such as serotonine. The storage in phenylalanine leads to storages in tyrosine or catecholamine for example, so that even auto immune reactions in the thyroid gland and in the neurotransmitters can be triggered. A typical example is the Hashimoto thyreoiditis. The storage products are nitrated amino acids, e.g. nitrotyrosine, which nowadays are detectable, just like citrullinated peptides. Peroxynitrite and nitrated amino acids can be traced at early stages during chronic inflammatory processes, especially in the nervous system as well as in multiple sclerosis, amyotrophic lateral sclerosis, but also in arteriosclerosis and other diseases. As a result, disturbances in the hormonal household and in the neurotransmitters in the brain occur. By a chronically increased ONOO° formation the risk of auto immune diseases is increased as well. With the irreversible inhibition of the mitochondrial function and the permanent firing by oxygen free radicals cells and cell nucleus DNA are damaged, and in addition damage in the mitochondrial genome takes place. Mitochondria possess a round-shaped genome, consisting of 37 DANN molecules, which due to low histone protein content are not reparable. The damage of the mitochondrial genome does not occur immediately, but rather after a certain incubation period. The reason is, that each mitochondrial gene possesses 500 to 1.000 copies. If 5 to 10 % of the copies are damaged, clinically there is still not an important loss in the performance. The degree of heteroplasmy amounts only 5 to 10 %. If this degree is increased to 40 or 50 %, obvious losses in the performance of mitochondrial functions are indicated. Most often disturbances in the pyruvate kinase accompanied by disturbances in the carbohydrate breakdown are encountered. Carbohydrates from sugars and nutrients can not be broken down to energy. They lead to a lactacidosis with a lactate to pyruvate ratio higher than 10: 1. Through the formation of the lactacidosis the metabolic disturbances and fatigue are worsened. Mitochondrial genetic damages are inherited from the mother, not from the father. This explains among others, that cryptopyrroluria can also be inherited. Since NO disturbs the blood formation as well as the function of other blood bearing substances, a cryptopyrroluria occurs. During the daily course it shows strong fluctuations, can be evaluated as a stress factor for the nervous system and leads to the known deficits in vitamin B6 and zinc. These deficits are not detectable by serological analyses. Much more convincing is the analysis for cystathionine in the urine. It is increased, when the vitamin B6 demand in the organism can not be met, although serum values may still lie in the standard range or even higher. A zinc deficit can be indicated especially by intracellular analyses, less by serological analyses. Within the context of the mitochondrial diseases, cryptopyrroluria is for the survival function of the body an important regulatory quantity. The zinc deficit is important, since numerous kinases become inactive because of it and the phosphorylation of vitamin B6 and vitamin B1 is no longer possible to full extent. Therefore secondary deficits occur due to a vitamin B6 deficit, e. g. neurotransmitter formation, protein synthesis and transamination reactions. The low zinc levels are probably desirable by the organism, because during low energy yield situations the intake of zinc would additionally inhibit the aconitase in the citric acid cycle and apart from that, zinc activates further the glutamate receptor (NMDA receptor). In such a situation the energy deficits and the state of irritability would increase. The brain has priority for the maintenance of its performance ability and for the securing of minimal energy availability. Disadvantages are vitamin B6 utilisation disturbances, but also the increased risk for further disorders/diseases. Particularly rich in zinc is the retina, the prostate gland and the hippocampus, an organ responsible for the conversion of the short term memory to long term memory in the brain. By a zinc deficit, vitamin A can not be transported either, since the protein binding retinol is dependent on zinc. This situation explains the fact that cryptopyrrolics often react with massive side effects to a zinc intake. Light forms instead, show rapid clinical, cerebral improvements by administration of vitamin B6 and zinc. In light cases the affected persons indicate a strong appetite for meat dishes, in severe cases there is an aversion against meat, since the conversion of muscle protein to body own protein is dependent on vitamin B6 and if there is a corresponding strong deficit in zinc and/or Vitamin B6, the organism can not break down normally foreign proteins. A chronic energy deficit in the nervous system often leads to an additional activation of C nerve fibres. These surround mast cells in a network form, so that by irritations increasingly histamine is released. The chronic histaminosis (histadelia) has a stimulatory action to the brain and peripherally it is a question of time, when allergies against external factors (pollen, dust etc.) would occur. The affected persons are not diseased because of the pollen, the mites etc. to allergic reactions, but rather to an increased release of histamine and a disturbed break down of histamine. The diamine oxidase needs copper and vitamin B6 for the breakdown of histamine. Although in the brain there is no DAO available, many methylation reactions, which need S-adenosyl methionine, take place. S-AM however, in order to maintain its reactivity, needs an adequate methionine supply obtained by meat as well as a adequate supply of vitamin B6, folic acid and vitamin B12. If not enough meat is consumed, affected persons have an additional deficit in vitamin B6, Vitamin B12 and methionine. Because of this the brain and the peripheral organs can not break down histamine adequately. Besides, S-AM is necessary for the synthesis of adrenaline, the formation of the sleep hormone melatonine from serotonine and for the synthesis of polyamines such as spermidine and spermine, which play an important role during cell division and cell maturity. A zinc deficit leads to functional weakness of the Zn/Cu superoxide dismutase. Apart from that, by zinc deficit glutathion-S-transferases become inert. Affected persons show a very sensitive reaction to foreign and harmful substances. In addition, NO inhibits the cytochrome P450 enzymes, which are very important for the phase-I-detoxification. The metabolic consequences of a mitochondrial disease are significantly more serious, about which there will be no further detailed description at this point. As a summary we observe and identify, that cryptopyrroluria signals only a concomitant symptom of a significantly more serious disturbance in the mitochondrial level, which triggers performance deficits in several organs and if not attended properly, leads to massive health disorders in a multi organic level. Mothers with KPU and mitochondrial diseases portray an increased risk for complications during pregnancy. NO activates the uterine contractions and opens the cervix. Consequences of this effect are premature births. Metabolic deficits and the chronic NO surplus lead to disturbances in the maturity of the infant brain. Visual, acoustic and motoric centres, the interconnection of the right and left brain hemispheres, the dominance of the left temporal lobe are under developed, exactly as the interconnection of neurons with each other. These children grow up with obvious neurological and psychological deficits. Children with ADHS have a brain volume smaller by 3 % than without ADHS. Further symptoms of mitochondrial diseases are an higher risk for neurodermatitis, nasal polyps, inflammations of the middle ear, bronchitis, allergies and many more diseases. The physician speaks of comorbidities, but they are not. The result of the above is that the treatment for pyrroluria only for light forms is the administering of B-vitamins, zinc and other micronutrients, because in the end cryptopyrroluria must be treated as a mitochondrial disease. This treatment is only possible by using micronutrients, which have an influence upon the electron transport of mitochondria and secure an improvement of the citric acid cycle. If we observe the diseases appearing in childhood such as ADS, ADHS, syndromes of neurodermatitis, fatigue, pain and allergy of children, we notice that these are not isolated diseases, but rather always the expression of mitochondrial disease, since they can be detected by the increased NO rates of formation or of citrulline synthesis. A cause-oriented therapy is consequently possible only with mitochondrial treatment measures, however not with the symptomatic treatment with Ritalin, corticoids or other medication, which act upon the immune system. The development of allergies against proteins in early childhood are not by themselves allergic reactions, but rather the expression of an increased release of histamine, a disturbed breakdown function of histamine and a nitrosative stress. Numerous dipeptidases of the small intestine (enzymes breaking down proteins) can only act in the presence of zinc (zinc- dependent). Some allergies such as protein allergies or cow-milk allergies are caused by this effect. Since by these mitochondrial diseases, disturbances in the breakdown of lactose, fructose and gluten are unavoidable, such symptoms are developped. It would be wrong to place children and youths on a diet, since this is not a therapy treating the primary cause. High NO and histamine open and consequently damage the blood brain barrier. This way, disturbances in the nerve cells in the long run are unavoidable. By numerous affected persons a pathological increase in the brain barrier protein S-100 or the neuron specific enolase could be detected. With the mitochondrial therapy, numerous symptoms/ diseases such as neurodermatitis, the fatigue syndrome, exhaustion, pains in the cervical spine, in the joints and allergy can be treated successfully at the same time. Apparently old known facts, if seen from the point of view of the mitochondrial disease and of the nitrosative stress, can result to completely new, scientifically founded and causal therapy possibilities, which so called evidence based therapy measures such as treatment with ritaline of children with ADHS, treatment of neurodermatitis with immune modulators or calcineurine inhibitors, corticoid therapy of allergies etc. remove the indication. Finally, cryptopyrroluria is a symptom of a mitochondrial disease. Doz. Dr. sc. med. Bodo Kuklinski Specialist for internal medicine /Environmental medicine Rostock, 26. November 2004 |
