The molecular blueprint for nearly all enzymes, structural proteins, cellular transport proteins, and other constituents that are responsible for carrying out the complex reactions involved in metabolism is stored as deoxyribonucleic acid (DNA) in the nucleus of the cell. A small amount of DNA of critical importance to metabolism also is contained in cellular organelles called mitochondria. DNA is organized into smaller units, termed genes, which direct the production of specific proteins or enzymes. In 1945 American geneticists George Beadle and Edward Tatum proposed a central tenet of molecular biology, the “one gene-one enzyme” principle, which states that a single gene directs the synthesis of a single enzyme. This principle has been refined to account for the fact that not all gene products are enzymes and that some enzymes are composed of multiple structural units encoded by different genes. Nevertheless, the one gene-one enzyme theory had immediate implications when applied to Garrod’s initial theories regarding inborn errors of metabolism. Inherited metabolic diseases were postulated to occur when a gene is mutated in such a way as to produce a defective enzyme with diminished or absent function. In 1948 methemoglobinuria became the first human genetic disease to be identified as being caused by an enzyme defect. In 1949 American chemist Linus Pauling and colleagues demonstrated that a mutation causes a structural alteration in a protein; hemoglobin (the protein in red blood cells that carries oxygen to the tissues of the body) extracted from normal human red blood cells was shown to behave differently from hemoglobin taken from persons with the hereditary disease sickle-cell anemia. Thus, it was determined that mutant genes that direct the formation of abnormal proteins with altered function cause inborn errors of metabolism.

Inheritance

The inheritance of inborn errors of metabolism is most often autosomal recessive, meaning that two mutant genes are required to produce the signs and symptoms of disease. The parents of an affected child are most often asymptomatic carriers, because 50 percent of normal enzyme activity is adequate to maintain sufficient health. When two carriers of a deleterious trait produce offspring, however, there is a 25 percent chance of having an affected child, a 25 percent chance of having a child without the mutant allele, and a 50 percent chance of having a child who is also a carrier. In genetic terms, the carrier of an autosomal recessive condition has only one mutant gene (heterozygous), while an affected individual has two mutant genes (homozygous). All human beings have approximately six recessive mutant alleles in their genomes, but it is relatively rare for an individual to mate with someone who carries a mutation in the same gene. However, in cases of parental consanguinity, there is an increased risk of having a child with an autosomal recessive condition, because a common genetic background is shared.

Unlike autosomal recessive diseases, autosomal dominant diseases are expressed when only one mutant gene is present. These disorders show a strong family history, unless the condition arose from a new spontaneous mutation in an individual. A heterozygous individual has a 50 percent chance of passing the disorder to his offspring. Individuals with autosomal dominant disorders show a wide spectrum of disease severity, and carriers of a dominant trait may even appear asymptomatic.

Genetic material in the nucleus is found packed into DNA-protein complexes called chromosomes. Females have two X chromosomes, while males have an X and a Y chromosome. If a mutant gene is part of the X chromosome, the resulting disease is called X-linked. All male offspring who inherit an X-linked mutation are affected, because the Y chromosome of the XY pair does not have a compensating normal gene. Because the mutation is on the X chromosome and males transmit only the Y chromosome to their sons during fertilization, fathers do not transmit the disease to their sons. They can, however, transmit the carrier state (i.e., the mutant X chromosome) to their daughters. A heterozygous female carrier, meanwhile, has a 50 percent chance of producing a carrier daughter or affected son.

X-linked inheritance is complicated by the process of X chromosome inactivation (lyonization) in females. Although females carry two X chromosomes, early in embryonic development one of the X chromosomes is inactivated in each cell. The process of X chromosome inactivation is usually random, resulting in the formation of two cell lines in a given female who carries an X-linked disease mutation; one cell line has an inactivated normal X chromosome, and the other has an inactivated abnormal X chromosome. However, it is possible that a higher proportion of normal X chromosomes will be inactivated in a given individual, with the resultant appearance of symptoms of disease in various degrees. Such females are known as manifesting heterozygotes. Examples of X-linked disorders include ornithine transcarbamylase deficiency (an enzyme deficiency resulting in high blood levels of ammonia and impaired urea formation), X-linked adrenoleukodystrophy (a disorder that is characterized by progressive mental and physical deterioration and adrenal insufficiency), and Lesch-Nyhan syndrome (a disorder of purine metabolism that is characterized by the excretion of large amounts of uric acid in the urine, neurological disturbances, and self-mutilation).

The transmission of genes that are located in mitochondria (i.e., not contained in the nucleus of the cell) is termed maternal (mitochondrial) inheritance. Mitochondrial DNA (mtDNA), although much smaller than nuclear DNA, is critical in cellular metabolism. Most of the energy required by a cell to drive its metabolism is produced in mitochondria by proteins in a series of electron donor-acceptor reactions that make up the electron-transport, or respiratory, chain. Mitochondria are located in the cytoplasm of the ova and are inherited from the mother. Spermatozoa also have mitochondria, but these do not become incorporated into the developing embryo. When a cell divides, the mitochondria are randomly distributed to daughter cells. Each mitochondrion contains 2 to 10 copies of mtDNA, and each cell contains numerous mitochondria. In a given cell of a person with a mitochondrial disorder, the number of normal mitochondria may be greater than the number of abnormal mitochondria, and the cell may function well. On the other hand, if a cell contains a significant percentage of abnormal mitochondria, this cell and any tissue containing many such cells will exhibit impaired function. Affected children may demonstrate a spectrum of abnormalities, from appearing normal or mildly affected to being severely compromised, depending on the degree of mitochondrial dysfunction and the extent of tissue involvement.