Suggested Pathology of Systemic Exertion Intolerance Disease: Impairment of E2/E3 Subunit of PDH

[sb4]

https://sci-hub.tw/10.1016/j.mehy.2019.109260

Systemic Exertion Intolerance Disease (SEID) or myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) has an unknown aetiology, with no known treatment and a prevalence of approximately 22 million individuals (2%) in Western countries. Although strongly suspected, the role of lactate in pathology is unknown, nor has the nature of the two most central symptoms of the condition – post exertional malaise and fatigue. The proposed mechanism of action of pyruvate dehydrogenase complex (PDC) plays a central role in maintaining energy production with cofactors alpha-lipoic acid (LA) and its counterpart dihydrolipoic acid (DHLA), its regeneration suggested as the new rate limiting factor. Decreased DHLA regeneration due to impairment of the E3 subunit or crossover of the swinging arms of the E2 subunit of PDC have been suggested as a cause of ME/CFS/SEID resulting in instantaneous fluctuations in lactate levels and instantaneous offset of the DHLA/LA ratio and defining the condition as an LA deficiency with chronic instantaneous hyperlactataemia with explicit stratification of symptoms. While instantaneous hyperlactataemia has been suggested to account for the PEM, the fatigue was explained by the downregulated throughput of pyruvate and consequently lower production of ATP with the residual enzymatic efficacy of the E3 subunit or crossover of the E2 as a proposed explanation of the fatigue severity. Functional diagnostics and visualization of instantaneous elevations of lactate and DHLA has been suggested. Novel treatment strategies have been implicated to compensate for chronic PDC impairment and hyperlactataemia. This hypothesis potentially influences the current understanding and treatment methods for any type of hyperlactataemia, fatigue, ME/CFS/SEID, and conditions associated with PDC impairment.

Apparently this has been discussed before but I missed it last time, so have just caught up. It's a paper from some Norwegian researches that found supplying oxalates in the form of some type of spinach drink, dramatically improved symptoms in some patients. This paper is laying out what they think the mechanism is.

I think these images help to explain what is going on:

As far as I understand it, they are proposing that something is stopping DHLA (dihydrolipoic acid)[Reduced lipoyllysine] from recycling back into LA (lipoic acid)[Oxidized lipoyllysine]. This causes a backup in the PDC (Pyruvate Dehydrogenase Complex) and Pyruvate does not get transformed into Acetyl-CoA, leaving an energy deficit.

Now is the bit that gets confusing. They say that 2 pyruvate need to enter into the mitochondria and react with PDC for the enzyme to work. This is because one of the pyruvate needs to enter the E1 complex and the other needs to get transformed into lactate, and in the process recycle the NADH+H+ that is generated at the last step of the PDC in the E3 complex.

So in healthy people there apparently is a 1:1 ratio of Pyruvate and Lactate (in the mitochondria?). However, and I am not sure if this is correct, what happens in CFS is the 2 pyruvate enter the mito, one is converted to lactate, and the other stays as pyruvate when it should be converted to Acetyl-CoA. This is because DHLA is not recycling into LA backing up the whole system.

Then I assume the relative lack of Acetyl-CoA causes the mito to ask for more pyruvate or perhaps the left over pyruvate gets turned into Lactate via LDH. This causes a spike in Lactate whenever the cell is mildly stressed or needs to use more energy. I would have though this increased Lactate would be due to pyruvate backlog turning into Lactate in the cytosol in order to replace the missing energy from Acetyl-CoA.

Now they intend to get around this problem using oxalates. As far as I am aware oxalate reverses the conversion of Pyruvate to lactate and of Pyruvate to Oxaloacetate. Since Pyruvate has 3 choices, convert to Lactate, Oxaloacetate, or Acetyl-CoA, perhaps by "inhibiting" the other 2 we can force more Acetyl-CoA. It appears they are advocating doing this in conjuction with providing LA and possibly Riboflaving / Thiamine to try to overcome the DHLA block.

What I have been able to piece together from another thread is that 2 people tried high oxalates (through spinach I believe) and felt better for a short while then worse. However, according to the researches, there where a handful of people they tested this drink on who achieved remission as long as they kept drinking the drink.

I am particularly interested in this as I have significantly improved my carb tolerance (though it is still not great) by taking MCT oil with carbs. I speculate that the mechanism is via providing cells (/the liver) with so much Acetyl-CoA from the MCTs that pyruvate will ignore PDH and instead go through PC into Oxaloacetate. These researches seem to be presenting a similar mechanism for oxalates.

 

[Wishful]

My first reaction is that it's the wrong track, at least for a cause or treatment for ME. I don't seem to have any lactic acid issues, or abnormal limitations of my muscle mitochondria, but I do have the neurological symptoms. Thus to me, this is not the cause of ME; it might be something to do with a common secondary (or even further down) effect of ME.

I can't totally rule out lactic acid or pyruvate problems in my brain, but I haven't encountered any evidence to support those.

It is something else for people with lactic acid or muscle mitochondrial issues to experiment with. However, it doesn't make me want to rush out and eat some rhubarb leaves.

 

[Chris]

Thanks for finding and passing on this paper--way beyond me, but seems to fit in with the growing evidence (Naviaux, Mella and Fluge, et al) that this pyruvate complex is at the heart of our problem, and not the mitos themselves, as we used to think. I note that one author has ME, and that they are preparing a follow-up paper with a therapeutic focus--I look forwards to that.

I suspect that the text may be a bit cleaned up before publication-for instance, I find the following sentence (p.11) less than clear: "a precursor of oxalate, DCA, has reduced therapeutic effects in ME/CFS/SEID patients"--reduced in comparison to what? I am one of those who tried DCA, and though I did find some modest increase in available energy, that was overcome by the neuropathy, despite my taking Comhaire's recommended supplements. But then I am 86, at the opposite end of the age scale from those kids who seemed to have no trouble.

 

[SlamDancin]

@sb4 This is interesting timing sb because I recently purchased a tub of Spinach powder.

Not for this reason, I read been reading about how spinach powder contained a natural opioid peptide called Rubiscon, that had the ability to activate Delta opioid receptors as well as D1 dopamine receptors. Therefore, it has both analgesic and learning enhancement benefits.

It does seem to have some immediate benefits in that I feel better after taking a couple teaspoons.

However, delta opioid agonists are known to initiate torpor and I wonder if this is why people taking spinach powder long term start to feel worse after a while.

Here’s the article on DOR and torpor;

https://mybiohack.com/blog/hibernation-induction-triggers-torpor-mimetics

 

[junkcrap50]

Norwegian researches that found supplying oxalates in the form of some type of spinach drink,

I vaguely remember something about this. Weren't the "researchers" just average joes and not trained or educated in the sciences. I also thought that their whole product was considered a scam, since they stopped selling their powder, refused to ID what was their secret ingredient/supplement, and refused to publish their research.

 

[sb4]

I know that messing around with oxalates can cause gut issues and does have the potential for kidney stones. I decided to do a little reading on kidney stones and found this article.

As far as I understand it, you can help minimize the risk of kidney stones with potassium citrate. Basically, citrate can bind calcium to prevent calcium oxalate stones. If the PH of your diet is high (or you take K citrate), then your kidneys will push citrate out into the urine to lower PH. When citrate is in the urine it binds the oxalate.

Citrate and Oxalate
You would think I had exhausted the topic by now, but no. NaDC1 and slc26a6, the citrate transporter and the anion transporter (oxalate is an anion it can transport) which disengages NaCl transport from NHE3, themselves interact in relation to kidney stone formation.
At least in animals and in cell experiments, the two transporters – which are present in a complex within the renal cell membrane – interact as in the figure. Slc26a6 inhibits NaDC1, so that when actively transporting oxalate into tubule fluid citrate reabsorption is reduced, urine citrate rises, and binds urine calcium to reduce risk of calcium oxalate stones. When oxalate secretion is minimal, NaDC1 increases to salvage citrate.
These animal and cell experiments imply that in human urine citrate and oxalate excretions should show parallel changes; this has not been tested.

Potassium Citrate Pills
Raise Urine Citrate and pH
The expected changes are a decrease of proximal tubule reabsorption through reversal of the effects of chronic acid load. ET-1 signalling must fall, citrate reabsorption must fall because NaDC1 is no longer stimulated by ET-1 and because proximal tubule fluid pH will rise and with it the fraction of trivalent negative citrate.
Urine bicarbonate and urine pH will also rise. Partly, blood bicarbonate will rise and with it filtrate bicarbonate concentration and pH. NHE3 transport will be decreased vs. chronic diet acid loading, the baseline in the first world countries, and much of the proton secretion will be used in reclamation of bicarbonate. Naturally, NH3 production will be greatly reduced because the Pyk-2 sensing system will be signalling a higher pH.
Increases in Citrate and pH Vary Among People
But the biology is complex enough that in some people the main response will be citrate, and in other bicarbonate. Given all of the regulatory steps and signalling pathways involved a variety of responses is inevitable. Clinically this means one must measure and determine if the main effect is mainly increase of citrate excretion or of pH and therefore of CaP SS.
What is the Ideal Dose?
A nimble answer is enough to match net acid production – urine sulfate excretion is a decent index. I suspect that answer because of the problem of high urine pH in some people, and because as a clinician I never find it perfectly suits most patients. Yet it is a good starting dose because it aims at neutral acid base balance.
A Simple Pill with Powerful Effects
Physicians who treat kidney stones may well be the main ones who prescribe alkali loads to people with normal kidney function over months or even years or decades of life. This is indeed a remarkable physiological and clinical experiment, and that we do it makes the physiology and cell biology of acid base balance a central topic in clinical practice of stone prevention.
Likewise patients who take this humble medicine undergo what amounts to a reversal of cultural norm, which is a condition of chronic acid loading.
Thence, and for this reason, I have written a very long article about the topic, for physicians and their patients, and especially for scientists who know more about this topic than I do but may not see things from exactly the same view point.

My first reaction is that it's the wrong track, at least for a cause or treatment for ME. I don't seem to have any lactic acid issues, or abnormal limitations of my muscle mitochondria, but I do have the neurological symptoms. Thus to me, this is not the cause of ME; it might be something to do with a common secondary (or even further down) effect of ME.

Perhaps it will only help in some people, or like you say, perhaps you have lactic acid problems in brain cells instead.

I will point out here that I do not get PEM however, ever since onset of my illness I have had increased lactic acid build up feeling in my muscles from doing minimal tasks. This occurred even when I was in good shape. At my worst I couldn't even stretch my arms in the morning for intense lactic acid buildup. I would have to do mini 1 second stretches and then suffer burning muscles for 20 seconds or so.

If I combine this with carbs making me worse like clockwork, and my increased tolerance to them with MCT then in my case the PDH stuff seems to fit. Even if it is not the cure for me, it has the potential to significantly improve quality of life.

Perhaps only a subset have this problem though, who knows.

 

[sb4]

I vaguely remember something about this. Weren't the "researchers" just average joes and not trained or educated in the sciences. I also thought that their whole product was considered a scam, since they stopped selling their powder, refused to ID what was their secret ingredient/supplement, and refused to publish their research.

I think we are talking about the same people. I think at least one of them was a researcher, something to do with fish. No idea they were selling a product. As far as I understand they are trying to get there spinach drink patented. They tried to publish something but got told off for unethical practices, they were treating patients without getting the go ahead. I think they are still trying to publish as the paper I linked is written by them and only got accepted 10 days ago. So it appears they are still working on it.

I will say I don't like how they are being so mysterious about it. I imagine they would say it's not safe to give out the recipe as one person they tried it on went blind for 40 minutes. However it seems to be mainly spinach so currently I have a hard time understanding how it could be dangerous. If it weren't for the other PDH stuff that is chiming with my experience I would have probably written this off.

 

[sb4]

I think oxalates effect on Oxaloacetate is to convert it back into pyruvate. This would make sense as a feedback mechanism if you look at the TCA cycle. If too much Oxaloacetate is converted from pyruvate, it can't be used so is broken down into oxalate and acetate. I assume these products then inhibit further conversion of pyruvate to oxaloacetate by inhibiting PC and promoting the enzyme that reverses the reaction. I would also assume that the products encourage PDH to convert the excess pyruvate to Acetyl CoA so that the TCA can keep spinning and more oxaloacetate can be used up.

Oxalate
Oxalate, an inhibitor of both lactate dehydrogenase [72] and transcarboxylase [73], was also found to be an effective inhibitor for PC from a variety of sources. For example, oxalate was a non-competitive inhibitor with respect to HCO 3− (Ki = 60-300 μM [62]) in rat liver PC and a non-competitive inhibitor with respect to pyruvate (Ki = 70 μM) for PC isolated from yeast [74] as well as PC from rat liver (Ki = 50-130 μM [62]) and chicken liver (Ki = 12 μM) [69]. Barden and co-workers [75] extended the initial kinetic studies of oxalate inhibition of chicken liver PC. Steady-state kinetic analysis determined that, while the inhibition was uncompetitive with respect to pyruvate for the pyruvate carboxylation reaction, oxalate inhibition was competitive with respect to oxaloacetate for the decarboxylation reaction, confirming results previously obtained from pulsed NMR experiments [35]. Avidin inactivation studies in the presence of oxalate [35] provided a dissociation constant of 8.9 μM for the oxalate-PC complex, nearly three orders of magnitude lower than that determined for oxamate, indicating that the bidentate chelation of oxalate to the Mn2+-metal centre most likely increases the affinity of the enzyme for the inhibitor. McClure [62] probed the effect that the inhibition of the CT domain with oxalate had on the affinity for substrates in the BC domain by studying the steady-state kinetics of the pyruvate carboxylase reaction catalyzed by PC from rat liver. As expected, oxalate was also found to be a non-competitive inhibitor with respect to MgATP.

Similar to oxamate, oxalate also inhibits gluconeogenesis in isolated mitochondria and hepatocytes. Dennis et al. [76] determined that oxalate had no inhibitory effect on pyruvate transportation into the mitochondria; therefore the inhibition of glucose production was presumably due to the direct inhibition of PC by oxalate. In subsequent studies, both Yount and Harris [77] and Tonon and co-workers [78] found that the infusion of isolated rat hepatocytes with oxalate significantly inhibited hepatic gluconeogenesis from alanine, pyruvate and lactate as determined from the concentrations of the metabolic intermediates. In bicarbonate-deficient media, where PC activity became completely rate-limiting, the inhibition of glucose production by oxalate was even more apparent, further supporting the idea that oxalate was directly inhibiting PC activity [77]. The addition of 100 μM of oxalate reduced the steady-state levels of oxaloacetate by 48% in rat liver cells [79] and physiological concentrations of oxalate (50-100 μM) were found to partially impair the mitochondrial metabolism of pyruvate, resulting in decreased anaplerosis due to the oxalate inhibition of PC [80].

I wonder how this leads to getting around the PDH inhibition / LA deficiency? All I can think of is that enough Pyruvate accumulates thanks to PC and LDH being inhibited to force high enough "chemical pressure" to make PDH work again. Any ideas?

 

[PhoenixDown]

https://sci-hub.tw/10.1016/j.mehy.2019.109260
Systemic Exertion Intolerance Disease (SEID) or myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) has an unknown aetiology, with no known treatment and a prevalence of approximately 22 million individuals (2%) in Western countries.

Is anyone else angry that they are conflating SEID with CFS?

 

[sb4]

Is anyone else angry that they are conflating SEID with CFS?

I always assumed it was just another name for CFS.

 

[JES]

I vaguely remember something about this. Weren't the "researchers" just average joes and not trained or educated in the sciences. I also thought that their whole product was considered a scam, since they stopped selling their powder, refused to ID what was their secret ingredient/supplement, and refused to publish their research.

AFAIK it was a Norwegian couple behind the idea and the woman had a degree in some fish thing, as @sb4 mentioned. She was or probably still is an ME/CFS patient, so I wouldn't considering them scammers. I think she improved herself when using this "product", which is why they decided to go forward with the idea.

The way I understood it, the biggest issue was that various protocols were not followed and the patients who received the treatment were not formally under any trial, the trial was registered prospectively. I also read through the entire patent document, which by the way is still available here. In the document on page 16 table 2 it is actually mentioned in plain text that the main ingredient of this drinkable is spinach, which is why I don't understand what they are trying to patent exactly.

It all seemed a bit amateurish, but in my N=1 experience there was a real effect from taking spinach alone. I noticed a sudden surge of energy beginning around 30-60 minutes after the first spinach dose. At the time I was convinced this was "the cure", but fast forward a couple of days and I started to feel quite a bit worse. I noticed worsening of POTS symptoms starting around 3-5 hours after intake. I also started developing kidney pain out of nowhere, which I believe was due to the oxalates. A normal person's microbiome should be able to digest the insoluble oxalates from foods, but if this doesn't happen, there is a real risk of oxaluria and blood oxalate levels rising. I suspect the stomach of many of us is so compromised that playing around with oxalic acid might not be very safe.

The other interesting point I noticed was that I failed to get the same initial positive effects from other oxalic acid containing fruits like strawberry and banana. The same null effect from these other foods is documented by the researchers on page 16. This all makes me think there was something really working behind their idea, but how to safely administer such high oxalate dosages to sick people is another question.

 

[Hip]

I don't seem to have any lactic acid issues, or abnormal limitations of my muscle mitochondria, but I do have the neurological symptoms.

According to the Myhill ME/CFS subtypes, Group A patients use use increased anaerobic glycolysis (which produces lactic acid) to partially compensate for the overall energy metabolism dysfunction.

Whereas the Group B patients (which are generally more severe) use an alternative route to increased glycolysis, most likely the adenylate kinase reaction (which I believe does not result in lactic acid).

Is anyone else angry that they are conflating SEID with CFS?

I wish people would stop using SEID entirely, it's a pointless name change for a disease which already has two established names, so we don't need any more. Fortunately it has not caught on, and the CDC are not using it on their website.

 

[SlamDancin]

@sb4 @JES @ScottTriGuy @junkcrap50

Good research y’all. Since it’s been said even by the patent holders that other high oxalate foods don’t seem to work the same as Spinach, I wanted to bring back up Rubiscolins (I misspelled these in my previous post), which are unique opioid peptides apparently unique to Spinach (and other green leafy vegetables).

https://mybiohack.com/blog/rubiscolins-rubisco-spinach-opioid

This article gives some possible hints at why Spinach may help ME/CFS with mechanisms outside of their oxalate content.

 

[msf]

My first reaction is that it's the wrong track, at least for a cause or treatment for ME. I don't seem to have any lactic acid issues, or abnormal limitations of my muscle mitochondria, but I do have the neurological symptoms. Thus to me, this is not the cause of ME; it might be something to do with a common secondary (or even further down) effect of ME.

I can't totally rule out lactic acid or pyruvate problems in my brain, but I haven't encountered any evidence to support those.

It is something else for people with lactic acid or muscle mitochondrial issues to experiment with. However, it doesn't make me want to rush out and eat some rhubarb leaves.

I think we have discussed this before, but I am struggling to understand what stops you doing more than a few minutes of certain types of exercise if it isn't lactic acid - I wasn't aware that biology had other ways to stop humans over exerting themselves, except for making them faint and giving them heart attacks (not being facetious here, I really don't know of any alternative mechanisms). I just intentionally exercised a muscle to exhaustion for the first time since I got ME, (and have not suffered too much PEM thanks to using ALA etc), and I am pretty sure lactic acid was the reason why I stopped.

 

[msf]

By the way, guuguuguuguuguuguug! (Popeye reference).

 

[SlamDancin]

@msf I believe my research into CSF contacting ciliated neurons showed that Somatostatin expressing neurons were able to basically tell the organisms to stop moving in cases of severe CNS injuries. It’s interesting because delta opioid receptors are involved in this process in some way I can’t remember at the moment but Spinach essentially acts as a Delta opioid agonist. Food for thought and I will look back at my research into this.

At one point I sent Ron Davis a hypothesis that CSF contacting neurons, delta opioid receptors and pH (acidity) changes in the CSF (through ASIC3 channels) could create torpor. He never responded.

Also PDH is dysregulated after stroke and causes secondary damage. Stroke sometimes causes something called Post Stroke Fatigue Syndrome. If I’m not mistaken Stroke is an extreme CNS injury. Someone needs to take a look at PFS and see if those patients also experience PEM and have abnormal nano needle results. Maybe it will have to be me but I’m still only about 50% improved from guinea pigging my own research on myself.

 

[msf]

@msf I believe my research into CSF contacting ciliated neurons showed that Somatostatin expressing neurons were able to basically tell the organisms to stop moving in cases of severe CNS injuries. It’s interesting because delta opioid receptors are involved in this process in some way I can’t remember at the moment but Spinach essentially acts as a Delta opioid agonist. Food for thought and I will look back at my research into this.

At one point I sent Ron Davis a hypothesis that CSF contacting neurons, delta opioid receptors and pH (acidity) changes in the CSF (through ASIC3 channels) could create torpor. He never responded.

Interesting, but are you suggesting that the exercise might induce a temporary neuronal injury? Or just that exercise produces somatostatin that stops already damaged muscles working? This is the first time I have heard of somastin.

I think Davies probably concentrates on the more likely leads first, and there are a lot of people with ME who complain about lactic acid (way more than would be expected by chance).

 

[SlamDancin]

@msf Before I even go back into the research, just imagine someone with CCI or horrible scoliosis trying to exercise and conceptually how that might create an immediate extreme exacerbation or yes a new CNS injury basically.

The Lights group at U of Utah have consistently found higher levels of ASIC3 after exercise than healthy controls. ASIC3 signals through somatostatin containing neurons to, as the literature says, stop “motor activity.”

 

[msf]

@msf Before I even go back into the research, just imagine someone with CCI or horrible scoliosis trying to exercise and conceptually how that might create an immediate extreme exacerbation or yes a new CNS injury basically.

The Lights group at U of Utah have consistently found higher levels of ASIC3 after exercise than healthy controls. ASIC3 signals through somatostatin containing neurons to, as the literature says, stop “motor activity.”

Yes, I am not doubting the possibility, although I do not know anything about the area, I am just saying that the PDC fits well both with many patients descriptions of their problems and the idea of disturbed metabolism in immune cells. I wrote a blog about this a while ago. Also, my own experiments have pretty much validated that PDC is involved in my own case, and my father had the same illness as me, which sounds a lot like the illnesses of a lot of other people on this forum (admittedly not all).

 

[msf]

Perhaps someone who understands the chemistry better than me could suggest whether taking oxalate should be more or less effective than taking things that affect PDC directly (such as ALA and DCA), or things that affect AMPK (like reservatrol). These supplements have had a dramatic effect on me (with peripheral neuropathy side effects in the case of DCA), so the idea of a supplement that might be more effective than these is very exciting!