Electrophoretic characterization of acidic and neutral amylo 1-4-glucosidase (acid maltase) in human tissues and evidence for two electrophoretic variants in acid maltase deficiency

A randomized multicenter clinical trial comparing isosmolar icodextrin with hyperosmolar glucose solutions in CAPD. MIDAS Study Group. Multicenter Investigation of Icodextrin in Ambulatory Peritoneal Dialysis

The osmotic effectiveness of a large molecular weight glucose polymer fraction (Icodextrin) as a novel "colloid" osmotic agent in peritoneal dialysis was established, but the long-term safety remained undetermined. A randomized, controlled multicenter investigation of Icodextrin in ambulatory peritoneal dialysis (MIDAS) was undertaken to evaluate the long-term safety and efficacy by comparing daily overnight (8 to 12 hr dwell) use of isosmolar Icodextrin (282 mOsm/kg) with conventional 1.36% (346 mOsm/kg) and 3.86% (484 mOsm/kg) glucose exchanges over six months. Two hundred and nine patients were randomized from 11 centers, with 106 allocated to receive Icodextrin (D) and 103 to remain on glucose (control group; C); 138 patients completed the six month study (71 C, 67 D). All patients were divided into weak (1.36%) or strong (3.86%) subgroups based on their use of glucose solutions overnight during the pretreatment baseline period. The mean (+/- SEM) overnight ultrafiltration (UF) with D was 3.5 times greater than 1.36% glucose at eight hours [527 +/- 36 vs. 150 +/- 47 ml; 95% confidence interval (CI) for the difference +257 to +497 ml; P < 0.0001] and 5.5 times greater at 12 hours (561 +/- 44 vs. 101 +/- 48 ml, 95% CI for the difference +329 to +590; P < 0.0001) and no different from that of 3.86% glucose at eight hours (510 +/- 48 vs. 448 +/- 60 ml, 95% CI for the difference -102 to +226 ml; P = 0.44) and at 12 hours (552 +/- 44 vs. 414 +/- 78 ml, 95% CI for the difference -47 to +325 ml; P = 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)

Aneurysms and vacuolar degeneration of cerebral arteries in late-onset acid maltase deficiency

We present a case of late-onset acid maltase deficiency (AMD) with pronounced involvement of the liver and skeletal muscles. In addition, and in contrast to other adult cases of AMD, the case presented here shows CNS pathology with hypodense and hyperintense white matter areas on CT and MRI scans, and myelin changes ranging from focal areas of demyelination to necrosis. Neuropathologic changes seem to be related to unusual vascular pathology consisting of vacuolar degeneration of small and large arterial blood vessels. Vacuoles of varying size, partly filled with granular PAS-positive material, were found in pericytes and smooth muscle cells of arterial vessel walls. Electron microscopy revealed lysosomal and cytoplasmic free glycogen in smooth muscle cells in the intima of large cerebral arteries as well as in pericytes of arterioles and capillaries. Accumulation of glycogen locally was associated with severe cellular damage and necrosis. The formation of a great number of small aneurysms of intracerebral arteries is thought to be the result of cell damage in the vessel walls.

Heat-stable protein that stimulates acid alpha-glucosidase

A hot-water extract of bovine spleen and guinea pig liver exhibited the ability to enhance acid alpha-glucosidase activity, with methylumbelliferyl alpha-glucoside, glycogen or maltose as substrate. The level of activator required for maximal stabilization was similar for all three substrates, indicating direct action on the enzyme rather than on substrate. The stimulator was partially purified by chromatography with gel-permeation (apparent Mr 20,000-24,000), ion-exchange and C4 reverse-phase columns. It was retained by a narrow-pore dialysis tubing and destroyed by treatment with Pronase, and is presumably a protein. The stimulating protein protected the enzyme against denaturation by heat or incubation with a buffer of high ionic strength in the absence of substrate. RNA inhibited the enzyme, and the activator protein was able to counteract the effect. Activating material was found in a variety of mouse and rat tissues, as well as human urine.

Neutral maltase of human granulocytes: localization on the extracytoplasmic side of the plasma membrane and some properties

Neutral maltase is an alpha-glucosidase (alpha-D-glucoside glucohydrolase, EC 3.2.1.20) which is present in human granulocytes and B-lymphocytes but not in T-lymphocytes. These cells have been reported to contain a renal-type neutral maltase which cross-reacts with an antiserum raised against kidney brush-border enzyme. No study has been performed to assess the subcellular localization of the enzyme. Molecular properties of leukocyte neutral maltase from any species are unknown. We report in this paper that neutral maltase is present on the extracytoplasmic side of human granulocyte plasma membrane. These results are supported by subcellular fractionation on Percoll gradient and by papain digestion of intact granulocytes. The enzyme is probably an integral membrane protein. The anchorage to the lipid bilayer may be similar to that of the stalked brush-border hydrolases. Some properties of granulocyte neutral maltase were also determined on a plasma membrane-enriched fraction. The enzyme cleaves maltose and nigerose but not other glucosides disaccharides and oligosaccharides. The Km for maltose is (+/- SD) 0.78 (+/- 0.06) mM, that for nigerose 21.05 (+/- 1.43) mM. The Vmax for nigerose is 0.83-fold that for maltose. Tris, maltotriose, maltotetraose, and maltopentaose were inhibitors of granulocyte neutral maltase.

Reappearance of embryonic neutral alpha-glucosidase isoenzyme in acid maltase-deficient muscle of Japanese quail

Two neutral alpha-glucosidase isoenzymes were isolated from the muscle of Japanese quails with late-onset acid maltase deficiency. One isoenzyme is predominantly expressed in embryonic muscle and the other in adult muscle. The time of switching from one to the other of these two neutral alpha-glucosidases was the same as in normal birds. The glycogen content in acid maltase-deficient muscle was not inversely proportional to the amount of embryonic neutral alpha-glucosidase. From the results, we conclude that (i) the transition of neutral alpha-glucosidase from the embryonic to the adult type is not influenced by the disease, and (ii) the embryonic neutral alpha-glucosidase seems not to be directly correlated with glycogen storage in skeletal muscle. In acid maltase-deficient muscle, the activity of the embryonic type began to increase again from 14 days after hatching, and attained a level corresponding to 18% of the total neutral alpha-glucosidase activity at 3 months (P less than 0.025). Its biochemical characteristics were the same as those of the normal embryonic neutral alpha-glucosidase. It should be clarified why the reappearance of the normal embryonic type occurs in acid maltase-deficient adult muscle and whether or not the reappearance of the embryonic neutral alpha-glucosidase represents regenerating muscle.

alpha-Glucosidase isoenzymes in normal and acid maltase-deficient human skeletal muscles

One acid alpha-glucosidase and two neutral alpha-glucosidases were separated from human skeletal muscle by DEAE-cellulose column chromatography. The appearance of the two human neutral alpha-glucosidase isoenzymes was found to be age dependent. We called them "fetal" and "adult" neutral alpha-glucosidases. The biochemical properties of the fetal and adult types of neutral alpha-glucosidases appeared to be similar to those previously reported for neutral alpha-glucosidases AB and C, respectively. The neutral alpha-glucosidase activity in the column eluate of the infantile acid maltase deficiency (AMD; 5-month-old) muscle was completely of the adult type, whereas 18% of the total neutral alpha-glucosidase activity in age-matched control muscle was of the fetal type. In contrast, the eluate of the late-onset AMD (32-year-old) muscle contained both the adult and fetal neutral alpha-glucosidases, 68 and 32%, respectively.

The "muscular variant" of Pompe disease: clinical, biochemical and histologic characteristics

We report on a 2-yr-old boy with progressive muscular weakness and respiratory failure. There was no clinical evidence of heart muscle involvement. Autopsy showed marked intralysosomal glycogen deposition in skeletal muscle and liver with no histological evidence of glycogen deposition in cardiac muscle. The activity of the lysosomal enzyme alpha-1,4-glucosidase was deficient in skin fibroblasts, skeletal muscle, cardiac muscle, and liver; however, the enzymatic activity in peripheral blood leukocytes was in the low normal range. The child's mother had normal enzymatic activity in leukocytes but heterozygote levels in skin fibroblasts.

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).

Biochemical genetics of the Lapland dog model of glycogen storage disease type II (acid alpha-glucosidase deficiency)

A recently described canine model (Lapland dog) of glycogen storage disease type II (GSD II, Pompe disease, acid alpha-glucosidase deficiency) was identified with several biochemical genetic methods. Complementation studies in which fibroblasts from a GSD II dog were fused with fibroblasts derived from control dogs and from human patients with different clinical forms of the disease did not lead to restoration of acid alpha-glucosidase activity in the heterokaryon cell populations. These results indicate that acid alpha-glucosidase deficiency is the primary defect in canine GSD II and that there is a close genetic parallelism with human GSD II. Immunotitration analysis of the residual acid alpha-glucosidase activity in the canine GSD II fibroblasts and liver demonstrated that this residual activity was not due to acid alpha-glucosidase enzyme, in which respect canine GSD II was similar to the infantile form of the human disease. Double immunodiffusion studies showed the presence of catalytically inactive acid alpha-glucosidase enzyme protein in canine GSD II. This is consistent with a structural gene mutation. It is concluded that canine GSD II in the Lapland dog is a homologous model of the infantile form of human GSD II, a conclusion in concordance with clinical and pathological studies.

Multiple neutral maltase activities in normal and acid maltase-deficient human muscle

The subcellular distribution and isoelectric focusing profile of neutral maltase were investigated in human skeletal muscle from controls and patients with acid maltase deficiency. After subcellular fractionation of normal muscle by differential centrifugation, 75% of the neutral maltase activity was soluble and 13% sedimented with a "microsomal" fraction; the relative specific activity was highest in this latter fraction. After isoelectric focusing (pH gradient 3.5 to 10) of a soluble fraction from control muscle, three peaks of activity were observed: peak 1 had exclusively neutral maltase activity; peak 2 had predominantly neutral maltase activity; and peak 3 had acid maltase activity predominating. The soluble fraction of muscle from a patient with infantile acid maltase deficiency showed no detectable activity at acid pH in any of the peaks and the neutral maltase peaks were unaltered. In muscle from a patient with late-onset acid maltase deficiency the focusing pattern for neutral maltase was similar to controls; the small amount of residual activity at acid pH was found in peak 3.

Canine glycogen storage disease type II. A biochemical study of an acid alpha-glucosidase-deficient Lapland dog

A biochemical study was performed in a Lapland dog suspected of glycogen storage disease type II (acid alpha-glucosidase deficiency, Pompe's disease). Glycogen content was substantially elevated in heart and skeletal muscle but not in the liver. Severely reduced activities of acid alpha-glucosidase (EC 3.2.1.20) were found in heart, skeletal muscle, liver and cultured tongue fibroblasts. The deficiency was located in the glycoprotein fraction, which supported its lysosomal origin. The electrophorogram showed after acid incubation that the affected dog was missing the activity band, while after neutral incubation the pattern was similar to control. The obtained biochemical data are compared with the known data of the human pathology.

Characterization of neutral isozymes of human alpha-glucosidase: differences in substrate specificity, molecular weight and electrophoretic mobility

We have previously defined two isozymes of neutral alpha-glucosidase (alpha-D-glucoside glucohydrolase, EC 3.2.1.20) on the basis of differences in electrophoretic mobility and designated these neutral alpha-glucosidase AB and alpha-glucosidase C (Swallow, D.M., Corney, G., Harris, H. and Hirschhorn, R. (1975) Ann. Hum. Gen. 38, 391-406). We now describe differences between the two isozymes with respect to molecular weight, solubility in (NH4)2SO4, glycosylation, isoelectric point and substrate specificities. Neutral alpha-glucosidase C is precipitable in 40-60% (NH4)2SO4, has a molecular weight of 92 000, an isoelectric point of 5.5 and releases glucose from glycogen as well as from low molecular weight artificial and natural substrates containing alpha 1-4 glucosidic linkages. Neutral alpha-glucosidase AB precipitates at 0-40% (NH4)2SO4, binds to concanavalin A, has a molecular weight of greater than 150 000, and does not utilize alpha 1-4 linked glucose substrates larger than a disaccharide. Neutral alpha-glucosidase AB migrates more rapidly to the anode than alpha-glucosidase C when agarose, Cellogel, acrylamide or starch are used as support media. Both isozymes are equally inhibited by Zn2+.

The mucolipidoses: identification by abnormal electrophoretic patterns of lysosomal hydrolases

The human mucolipidoses (ML) are characterized by abnormal activities and abnormal electrophoretic patterns of fibroblast lysosomal hydrolases. These altered mobility patterns can be used to confirm the clinical diagnosis of the four mucolipidoses. The mobility patterns of one nonlysosomal and seven lysosomal enzymes were tested in fibroblasts from two ML I (sialidosis type 2, infantile), fifteen ML II (I-cell disease), eight ML III (pseudohurler polydystrophy), and one ML IV patients. A single sialidosis type 2, juvenile, line was also examined. Characteristic mobility patterns were found which identify each of the four mucolipidoses. Both the ML I and sialidosis type 2 juvenile lines displayed anodal mobility patterns, but distinct differences between the two disorders were observed. Lysosomal hydrolases from ML II lines demonstrated reduced activities or had altered mobilities. Differing electrophoretic patterns demonstrated the presence of at least two groups within the clinical phenotype diagnosed as ML II, indicating heterogeneity. The ML III lines showed normal electrophoretic patterns for most lysosomal hydrolases. The ML IV line expressed normal mobilities for every enzyme studied, with a single exception. The electrophoretic patterns of only beta-hexosaminidase, acid phosphatase-2, alpha-galactosidase, and esterase A4 were sufficient to identify and distinguish the different mucolipidosis types. Electrophoretic variation was also seen in liver but not kidney extracts from three ML II patients. beta-Hexosaminidase and alpha-mannosidase B secreted into the medium by ML II and ML III fibroblasts had mobility patterns different from normal and from their intracellular patterns. These data suggest that the mucolipidoses are genetically distinct with heterogeneity within them.

Studies on the activities and properties of lysosomal hydrolases in fractionated populations of human peripheral blood cells

Studies have been carried out on the activities and properties of the isozymes of alpha-mannosidase, alpha-glucosidase and beta-glucosidase in granulocytes, monocytes, lymphocytes and platelts from peripheral blood of heatlhy adult donors. The findings reveal the differences in activities as well as a characteristic distribution of the different molecular forms of these lysosomal hydrolases in specific cell types. Therefore, the results obtained with unfractionated total leukocyte smples from different subjects may vary according to the distribution of cell types in the circulation. Granulocytes and monocytes show only the acid alpha-mannosidase activity whereas lymphocytes and platelets show both acid and neutral activities. The specific activity of acid alpha-mannosidase in granulocytes and monocytes is higher than in lymphocytes and platelets. By DEAE-cellulose chromatography, the acid alpha-mannosidase in granulocyte and monocyte extracts elutes as two peaks, but only one peak is seen in lymphocytes. All cell types show both acid and neutral alpha-glucosidase activities. The specific activities of both isozymes are higher in granulocytes and monocytes than in lymphocytes and platelets. Monocytes show a higher acid than neutral activity. All other cell types show a higher neutral activity. Beta-Glucosidase in all cell types is mainly membrane-bound and it can be released by Triton X-100 and sodium taurocholate. Taurocholate also stimulates the beta-glucosidase activity of granulocytes, monocytes and lymphocytes whereas it inhibits the activity of this enzyme in platelets. These results indicate that variations in the total number of leukocytes and in the relative proportion of the various cell types in health and disease may yield inconsistent or unreliable values for enzyme activity in the diagnosis of lysosomal storage disease and in carrier detection.

Use of immobilized antibodies in investigating acid alpha-glucosidase in urine in relation to Pompe's disease

(1) A simple method is described for the isolation of the lysosomal enzyme, acid alpha-glucosidase (alpha-D-glucoside glucohydrolase, EC 3.2.1.20) from normal human liver. Antibodies raised against the purified enzyme were immobilized by covalent coupling to Sepharose 4B. (2) Acid alpha-glucosidase can be quantitatively removed from normal urine by incubating with an excess of immobilized antibody. With p-nitrophenyl-alpha-glucoside as substrate, acid alpha-glucosidase accounts for 91 +/- 3% of the total alpha-glucosidase activity at pH 4.0 IN Normal urine. (3) In urine from a patient with the infantile form of Pompe's disease ('acid maltase deficiency'), no alpha-glucosidase activity could be removed by the immobilized antibody, in agreement with the fact that acid alpha-glucosidase is absent in these patients. (4) In urine from patients with the late-onset form of Pompe's disease, 46 +/- 11% of the alpha-glucosidase activity at pH 4.0 can be removed by incubation with immobilized antibodies, indicating that residual acid alpha-glucosidase activity is present in urine of these patients. The residual acid alpha-glucosidase activity amounts to about 5% of that in the urine of control persons. (5) If acid alpha-glucosidase is adsorbed to immobilized antibodies, the activity can still be measured with p-nitrophenyl-alpha-glucoside as substrate. The Km for p-nitrophenyl-alpha-glucoside is not significantly changed by adsorbing purified acid alpha-glucosidase to immobilized antibodies. (6) The properties of acid alpha-glucosidase from urine of patients with late-onset Pompe's disease were compared with those of acid alpha-glucosidase from normal urine, both adsorbed to immobilized antiserum. The pH-activity profile of the enzyme from urine of patients with late-onset Pompe's disease can not be distinguished from that of the normal urinary enzyme. The Km for p-nitro-phenyl-alpha-glucoside of the two enzymes is identical, both at pH 4 and 3. The titration curves of the two enzymes with immobilized antibodies are identical.

Adult-onset acid maltase deficiency: a postmortem study

In a postmortem study of a patient with adult-onset acid maltase deficiency (AMD), morphological abnormalities were confined to skeletal muscle and consisted of a vacuolar myopathy. Acid maltase activity, however, was approximately 6% of normal in muscle, liver, and brain, and 3% of normal in heart. Kinetic characteristics, and inhibition by antibodies and Zn++, showed that the residual activity was "authentic" acid maltase. Neutral maltase activity was normal in muscle and liver, but decreased in brain (55% of normal) and heart (19% of normal). Although the relative decrease of acid maltase was similar in different tissues, absolute residual activity was lowest in skeletal muscle: this may explain the selective involvement of this tissue in late-onset AMD.

Properties of the alpha-glucosidase from various human tissues in relation to glycogenosis type II (Pompe's disease)

The physico-chemical and electrophoretical properties of alpha-glucosidases from various human tissues and urine have been studied. There were some differences among Peak I enzymes (neutral alpha-glucosidases) obtained from liver, heart, muscle, kidney and urine. These differences are based on different effects of tris(hydroxymethyl)aminomethane and various thermostabilities of the Peak I enzymes. Electrophoretically, the Peak I enzyme activity at pH 6.5 from control tissues displayed a two-banded pattern except in kidney and urine. In the patient with the adult form of Pompe's disease the faster band of the Peak I enzyme from heart and muscle was not found and the slower band of the Peak I enzyme from liver was more cathodic. The results are discussed in relation to glycogenosis type II (Pompe's disease).

Inhibition of human liver beta-galactosidases and beta-glucosidase by n-bromoacetyl-beta-D-galactosylamine

N-Bromoacetyl-beta-D-galactosylamine is an irreversible inhibitor of the 'acid' and the 'neutral' beta-galactosidases (beta-D-galactoside galactohydrolase, EC 3.2.1.23) of human liver. The inactivation of acid beta-galactosidase appears to involve a group with a pKa = 4.5. The inhibition of neutral beta-galactosidase only occurs above pH 8.0. Both enzymes are protected against inhibition by the presence of substrates, suggesting that the inhibitor reacts with the active site of the enzymes. Other lysosomal hydrolases are not inhibited by N-bromoacetyl-beta-D-galactosylamine, with the exception of 'neutral' beta-glucosidase (beta-D-glucoside glucohydrolase, EC 3.2.1.21). The pH dependence of neutral beta-glucosidase inactivation is essentially identical to that of the neutral beta-galactosidase. Inhibition of beta-glucosidase by this galactose derivative suggests that the same enzyme may bind glucosides and galactosides. Furthermore, both neutral beta-galactosidase and beta-glucosidase are inactivated at 52 degrees C with a half-life of 7.5 min. The presence of a single enzyme with both beta-glucosidase and beta-galactosidase activities is also supported by mixed-substrate experiments.

Identity and activities of lysosomal enzymes in parenchymal and non-parenchymal cells from rat liver

1. Intact parenchymal and non-parenchymal cells were isolated from rat liver. The parenchymal cells were purified by differential centrifugation, while non-parenchymal cells were obtained free of parenchymal cell contamination by preferentially destroying the parenchymal cells with the aid of pronase (0.25%). 2. The ability to isolate pure intact parenchymal and non-parenchymal cells permitted the characterization and measurement of specific activities of various lysosomal enzymes, representing the main functional hydrolytic activities of the lysosomes in these distinct cell types. 3. Lysosomal enzymes catalysing the hydrolysis of the terminal carbohydrate moiety of glycoproteins and glycolipids were not particularly enriched in the non-parenchymal cells as compared to parenchymal cells. The ratio of the specific activities of non-parenchymal cells over parenchymal cells varied between 0.7 for N-acetyl-beta-D-hexoseaminidase to 2.1 for alpha-glucosidase. This suggests no specific role of the non-parenchymal cells in the hydrolysis of terminal carbohydrate moieties of glycoproteins and glycolipids. 4. The enzymes acid phosphatase and aryl sulphatase, representing the phosphate and sulphate hydrolyzing activities, were enriched in the non-paranchymal cells as compared to the parenchymal cells by a factor of 2.5. 5. The most important peptidase cathepsin D, representing protein breakdown capacity, is enriched in the non-parenchymal cells as compared to parenchymal cells by a factor 6.0, suggesting a possible specific function of non-parenchymal cells in protein breakdown. 6. The most enriched lysosomal enzyme, representing lipid hydrolysis, is acid lipase, which is enriched in the non-parenchymal cells with a factor of 10. 7. The distribution of lysosomal enzymes between parenchymal and non-parenchymal cells suggests different functional roles of the lysosomes in these cell types. It can be concluded that the non-parenchymal cells possess a set of lysosomal enzymes which makes them extremely suitable for a phagocytic and antimicrobial function in the liver.

Acid alpha-glucosidase: a new polymorphism in man demonstrable by 'affinity' electrophoresis

1. A new polymorphism of the enzyme acid alpha-glucosidase is described. The three phenotypes, 1, 2-1 and 2, appear to be determined by two alleles alpha-GLU1 and alpha-GLU2 at an autosomal locus. The allele frequencies in Europeans are approximately alpha-GLU1 = 0-97 and alpha-GLU2 = 0-03. 2. The polymorphism is not detectable after electrophoresis on other support media (cellogel and agarose) and evidence is presented that the separation is effected by a difference in binding of the isozyme products of the two alleles to the support medium starch, which contains alpha-1-4 and alpha-1-6 linked glucose units. We have called this type of separation affinity electrophoresis. 3. No difference in the kinetic properties of the two enzymes could be demonstrated using 4-methyl umbelliferyl alpha-D-glucopyranoside and maltose as substrates or maltose and turanose as inhibitors, but it is possible that differences might exist when macromolecular substrates are used. 4. One individual with the rare homozygous genotype has been found. There is at present no indication that this genotype is associated with a pathological condition.