This failure to<unk>  the AMP molecules has three major effects. First, significant amounts of AMP are lost from the cell and the body. Second, ammonia is not freed when the cell does work. Third, the level of IMP in the cell is not maintained. * The first effect—the loss of AMP—is mostly significant because AMP contains ribose, a sugar molecule that is also used to make DNA, RNA, and some enzymes. Though the body can manufacture some ribose and obtain more from RNA-rich sources such as beans and red meat, this loss of ribose due to MADD is sometimes sufficient to create a shortage in the body, resulting in symptoms of severe fatigue and muscle pain. This outcome is especially likely if the individual regularly exercises vigorously or works physically over a period of weeks or months. * The second effect, the absence of ammonia, is not well understood. It may result in a reduction of the amount of fumarate available to the citric acid cycle, and it may result in lower levels of nitric oxide (a vasodilator) in the body, reducing blood flow and oxygen intake during vigorous exercise, though this may be offset by increased levels of adenosine, another vasodilator. * The third effect, the reduction in IMP, is also not well understood. It may somehow result in a reduction in the amount of lactic acid produced by the muscles, though serum lactate is typically slightly elevated with MADD. The following is a very simplified model of what may be going on inside a muscle cell with AMPD deficiency. There are two major semi-stable states: one with intra-cellular glycogen available, and one with glycogen exhausted. Both states are modified by how much the citric acid cycle is down-regulated by default. Start from the state where glycogen is available and the citric acid cycle is severely down-regulated. Once the cell has received a non-trivial load, and has expended the phosphocreatine reserve, a small quantity of ATP will become discharged down to AMP. AMP will instantly up-regulate myophosphorylase, which will start liberating glucose from glycogen and make it available to the glycolytic pathway, producing pyruvate and recharging AMP back to ATP. Due to the greater availability of pyruvate as a substrate, and pyruvate also contributing a citric acid cycle intermediate, α-ketoglutarate, while consuming glutamate, the citric acid cycle will also speed up. The combination of glycolysis and the citric acid cycle now balances ATP production with ATP demand and the pool of AMP does not grow further. Because all pyruvate is not burned down in the citric acid cycle — a consequence of the pyruvate's concentration regulating its burning at this moment — the excess is converted to lactate and passed into blood as lactic acid. In muscle cells with normal AMPD activity, the purine nucleotide cycle would now start to gradually add fumarate to the pool of the citric acid cycle intermediates. This would decrease the excess rate of pyruvate production by increasing its consumption, increase the rate of AMP recharge to ATP by the citric acid cycle, and consequently reduce liberation of glucose from glycogen, until increased supply of blood-borne fuels allows to shut down glycogenolysis completely. In muscle cells with AMPD deficiency, ATP production rate of the citric acid cycle will not be synchronized with ATP demand. It was demonstrated, that muscle cells, that lack AMPD1, stock and consume significantly more glutamate, and produce more alanine in this state, compared to healthy controls, which indicates occurrence of a higher concentration of pyruvate in the cell during exercise. The pool of AMP also grows bigger than in the controls, which would cause higher rate of glucose liberation from glycogen. This state can last for as long as glycogen is available, and can be prolonged by constantly eating carbohydrate-rich food. If the load on muscles is greater than the body's ability to recycle lactate back into glucose, lactate will start to build up in the blood. Once lactate reaches its renal re-absorption threshold (5–6 mmol/l in general population), it gets lost to urine, wasting many calories (and producing bright matte yellow particles on surfaces where urine dries). At about the same time the kidney will also start correcting blood acidity by acidifying urine. Overly acidic urine causes irritation that feels like a frequent urge to urinate (with little volume) and a "hot" urine. In order to excrete lactate, kidney must also excrete magnesium as an obligatory cation, which may lead to acute and chronic magnesium deficiency. Supplementary magnesium in the form of lactate or citrate may be rapidly lost in the same way. Because magnesium is essential to aerobic metabolism, over time, magnesium loss may lead to a vicious cycle, where the citric acid cycle is further down-regulated, lactate production is increased, and magnesium loss is increased again. Although probably unrelated to AMPD deficiency, if the person happens to have a high load of d-lactate in the blood (mostly from food and colonic fermentation), the precipitate, the lactate loss and the magnesium loss may occur even before l-lactate (mostly from muscles) reaches its renal re-absorption threshold. This happens because l-lactate and d-lactate compete with each other for renal re-absorption, and because d-lactate has a significantly lower renal re-absorption threshold, <1 mmol/l. In order to keep the excreted metabolites in solution, the kidney also has to excrete water. This is in contrast to complete oxidation of lactic acid, which would actually yield metabolic water for the body. This may lead to onset of acute thirst some tens of minutes into exercise in this state, if the water balance in the body was neutral initially. If the muscle load is small, lactate is mostly recycled back into glucose or burned by other cells in the body. However the newly generated glucose is made available to all cells in the body, not just to muscle cells. The ability of the body to assimilate lactate may also be diminished, if working muscle cells cannot take up glucose from blood, due to myophosphorylase maintaining a higher concentration of it inside loaded cells, and if liver has already filled its glycogen stores up to capacity. So, ultimately, in this state, working muscle cells are destined to lose all glycogen. AMP breakdown to adenosine in this state is minor, because the pool of AMP is kept small by the vigorous regulatory action of myophosphorylase. Maximum continuous exertion is limited by the onset of burning sensation from lactate accumulation in muscles. Eventually, all glycogen is exhausted, and the muscle cell enters another semi-stable state. During this transition, up-regulation of the citric acid cycle due to abundance of pyruvate is reversed, and a substantial part of the ATP pool is necessarily discharged down to AMP, which allows the citric acid cycle to be sped up by some other mechanism (perhaps by the allosteric mechanism that reacts to the lower concentration of ATP, or by amplification of the residual AMPD activity by the bloated AMP pool), until ATP production is balanced with ATP consumption. AMP conversion to adenosine, excretion to the blood (as AMP and its various metabolites), further conversion to uric acid and excretion to urine becomes significant for some time, until all AMP is eliminated from the muscle cell. The muscle movements become noticeably less precise. Breathing slows down, and from this moment reacts very weakly to the load and not at all to the perceived effort. It becomes hard to rapidly increase the load on a muscle, as in McArdle's disease, and such a rapid load increase will dump even more purines into blood and urine (looking like translucent or rust-colored sharp shiny crystals and being highly irritating). The same situation would occur if blood flow to muscle cells becomes insufficient (except that somewhat less AMP is spilled over, and somewhat more of it is metabolized inside the muscle cell). On the other hand, there will be no lasting muscle pain from lactate, and continuous aerobic activity is possible. Oxidation of odd-numbered saturated fatty acids may provide another mechanism, although very gradual, to up-regulate citric acid cycle during exercise. As the short-term regulation of ATP production becomes very weak after the exhaustion of glycogen, the medium-term regulation becomes enabled, but with a progressively weaker authority at higher purine nucleotide energy charge levels, which causes some differences in symptoms compared to McArdle's. In McArdle's, the highly active AMP<unk> , which additionally experiences amplification from the bloated AMP pool due to the lack of the moderating effect of myophosphorylase, is able to produce a readily observable "second wind" phenomenon almost exactly 7 minutes after a significant load increment. In AMPD deficiency, glycogen-less muscles will feel mostly the same by the time they become able to take another load increment. A load decrement may produce some sense of relief, though, if the pool of the citric acid cycle intermediates built up so far is sufficient to maintain full purine nucleotide energy charge at the lower load. It is unclear, what, if anything, does it take to unknowingly trigger
Adenosine monophosphate deaminase deficiency type 1
Adenosine deaminase 2 deficiency
Adenosine deaminase deficiency
Galactose-1-phosphate uridylyltransferase deficiency
3-Methylcrotonyl-CoA carboxylase deficiency
Ornithine aminotransferase deficiency
Ribose-5-phosphate isomerase deficiency
Adenine phosphoribosyltransferase deficiency