MEDICINE AND SURGERY "F"
Course of LABORATORY MEDICINE
Plasma Proteins
PLASMA PROTEINS

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The human blood plasma contains proteins at the total concentration of approx. 7 g/dL. Alterations in the concentration of plasma proteins and their relative abundance may vary in the course of diseases and provides important diagnostic clues.
Classification of the proteins present in the plasma is quite complex due to their large variety. It is important to distinguish between those proteins that are present in the plasma because this is where they exert their physiological function, and those that are accidentally present in the plasma because of the death of the cells in whose cytoplasm they exert their physiological function. Since all cells of our body are subject to some turnover, the finding of low levels of intracellular enzymes in the plasma is of no diagnostic significance; but large increases of these levels suggest acute disease with cell death (e.g. myocardial infarction, viral hepatitis, etc.). Most of the proteins that are physiologically present in the blood plasma are produced by the liver, the most relevant exception being that of the antibodies that are produced by plasma cells.
Audio: plasma proteins

SOME PROTEINS PLAYING THEIR PHYSIOLOGICAL ROLE IN THE PLASMA

Albumin (produced by the liver): a transporter of poorly soluble substances
Specific transporters (e.g. transferrin, ceruloplasmin, transcortin, haptoglobin ...)
Coagulation factors (produced by the liver)
Immunoglobulins (produced by the plasma cells)
Complement (produced by the liver or by macrophages)
Lipoproteins (produced by the intestine and modified by the liver)
Protein hormones (produced by endocrine glands)
Protease inhibitors

SOME PLASMA PROTEINS RELEASED BY THE DEATH OF THE CELLS

Aminotransferases sGOT (AST); sGPT (ALT): normally in the liver cells
Cytochrome c (skeletal muscle, heart)
Lactate dehydrogenase (heart, kidney, liver, skeletal muscle)
Creatine Phosphokinase (heart, skeletal muscle, brain)
Free hemoglobin (released by the erythrocytes during hemolytic crises)
Amylase
Alkaline phosphatase

Degradation and removal of the plasma proteins may occur via at least three different mechanisms: (i) most of the proteins physiologically present in the plasma, and some of those present because of cell death are removed by macrophages, Kuppfer cells and other scavenging cells, digested to aminoacids and recycled in the blood in this form; (ii) low molecular weight proteins (MW < 30-50 KDa) are filtered by the kidney and appear in the urine; many of the proteic hormones and of the proteins released by cell death fall in this category; (iii) a small number of plasma proteins are removed beacuse of specific consumption (e.g. fibrinogen) or transferred to the extracellular fluids.

METHODS FOR THE STUDY OF PLASMA PROTEINS
Total protein concentration is estimated using the reactions characteristic of some aminoacids or of the peptide bond, and applying specifci conversion factors. The classic method of Kjeldahl, consisting in the liberation of nitrogen as ammonia and titration of the latter compound is not used any more because it is expensive and time consuming. Biuret is a copper reagent that allows complexation of the metal with the peptide bond. The resulting product is blue colored and its concentration can be determined spectrophotometrically. The method of Lowry measures the Tyrosine concentration using a reagent for phenols (phosphotungstomolibdic acid), that again yields a blue complex whose concentration is measured by absorbance spectrophotometry. The average value of total protein concentration in healthy subjects is 7 g/dL.

Electrophoresis is the method of choice for protein fractionation:

A tiny amount of the serum or plasma under analysis is adsorbed onto a cellulose acetate strip equilibrated in an alkaline buffer; the positive and negative electrodes are connected to the ends of the strip and current is applied in order to attract the proteins towards the positive electrode. The more negatively charged is the protein, and the smaller its dimension, the faster it moves (it should be remembered that at alkaline pH ionizable groups of the aminoacid side chains are deprotonated, hence the negative charge of the protein). The proteins adsorbed on the strip are fixed and stained with a suitable dye and their concentration is measured using a reflectance spectrometer. The resulting graph can be used to quantitate the reflectance peaks, hence the relative protein concentrations in the serum or plasma. Albumin is the fastest moving protein and forms a sharp band; since this band consists essentially of a single chemical species its quantitation is very straightforward. The alpha1 and alpha2 globulin fractions are less mobile than albumin, followed by the beta globulin fraction. These fractions do not correspond to pure chemical species, and many different proteins co-migrate in the alpha1, alpha2 and beta band. Because of this reason quantitation of these bands in the electropherogram only gives a very generic information. Quantitation of specific proteins migrating in these bands, and possibly representing only a minor fraction of the band, cannot be obtained by electrophoresis and requires immunological methods (e.g. insulin can be measrued by radioimmunoassay). The slowest protein component is costituted by the gamma globulins and essentially corresponds to the antibodies. Since this fraction is large and is constituted by a unique family of proteins, its quantitation may shed light on diseases involving the B lymphocytes (see below).

Electrophoretic migration of some purified serum proteins superimposed on the plasma electropherogram. The figure shows that the bands of plasma electrophoresis correspond to complex protein mixtures, except for albumin and γ-globulins.

QUANTITATIVE COMPOSITION OF THE NORMAL PROTIDOGRAM
Albumin	52 - 68 %
α₁ - globulins	2.4 - 5.3 %
α₂ - globulins	6.6 - 13.5 %
β - globulins	8.5 - 14.5 %
γ - globulins	10.7 - 21 %

Audio: plasma proteins

A LIST OF SOME IMPORTANT PROTEINS IN THE PLASMA
Albumin is the protein present at the highest concentration in the blood plasma (3.5-5.5 g/dL, accounting for over than half the total protein concentration). Albumin is a non-specific carrier of poorly soluble substances (e.g. unconjugated bilirubin, steroid hormones, heme, drugs, etc.) and is produced by the liver. Several genetic variants are known. Albumin is soluble in distilled water as well as in physiological saline solutions, and is rich in acidic aminoacids that confer to it a low isoelectric point (approx. 4.5); as a consequence in the electrophoresis is migrates fast towards the positive electrode and very few plasma proteins move faster than albumin (e.g. pre-albumin, the carrier specific for thyroid hormones). Albumin is produced by the liver and its circulating half-life is approx. 20 days; cells that require aminoacids for protein synthesis may uptake and digest albumin.
The concentration of albumin is increased in all clinical conditions causing hemoconcentration (e.g. vomiting, diarrhoea, severe burns, etc.); it is decreased during chronic liver diseases (because of impaired biosynthesis), in nephrotic syndrome (because of loss in the urine) and in severe malnutrition. Since albumin is the major determinant of the colloido-osmotic pressure of the blood hypoalbuminemia is usually associated with oedema and ascites, especially if hypoalbuminemia is due to a liver disease causing portal hypertension (e.g. cirrosis).
Measurement of albumin concentration is directly made on the electrophoretic protidogram, given the characteristic electrophoretic mobility and the great relative abundance.

reduced albumin/total protein concentration
increased loss	nephrotic syndrome (severe burns?)
reduced production rate	advanced states of liver failure malnutrition, selective malnutrition (kwashiorkor)

Haptoglobin is produced by the liver. It binds to free hemoglobin produced by hemolysis of red blood cells preventing the reaction of the heme iron with xygen, that may produce reactive oxygen species (ROS).

Hemopexin is produced by the liver. It binds to the free heme and prevents its reactions with oxygen.

Transferrin is produced mainly by the liver and has the function of transporting iron.

Caeruloplasmin is produced bythe liver and has the physiological function of transporting copper. In the electrophoresis it migrates with the alpha2 globulin fraction

Protease inhibitors. The blood plasma contains several proteins that act as inhibitors of serine proteases, in particular of trypsin, chymotrypsin and related pancreatic enzymes. These are collectively called serpins (for SERine Protease INhibitors). Pancreatic enzymes may be occasionally readsorbed in the blood. Since these enzymes are able to promote the coagulation of fibrinogen and would cause diffuse intravascular coagulation and several other adverse effects, it is important that the plasma is able to neutralize their activity. The most important protease inhibitors physiologically present in the blood are alpha1 antitrypsin, alpha1 antichymotrypsin, and alpha2 macroglobulin.

Complement is a system of several plasma proteins that migrate in the electrophoretic fraction of the beta-globulins and plays a function in the defence from infections. The proteins of complement circulate in the blood in the form of inactive precursors, and when activated they acquire enzymatic activities (mainly as esterases) that allow them to damage the lipid bilayer of the (bacterial) cell membrane. Excessive response of the complement may also damage the cells of the organism. Complement is activated by the antigen-antibody complexes; by the C-reactive protein; and by some fungi, bacteria and viruses. There is also an alternative activation pathway, that does not involve immunocomplexes and requires instead the specific serum protein Properdin. Several genetic defects of complement are known that cause increased propensity to infectious diseases.

Acute Phase Proteins are produced and released in the blood serum during a variety of pathological stimuli causing cell necrosis in any tissue. Common causes may be inflammation, infection, and cancer. During acute phase reactions some plasma proteins may appear decreased (e.g. albumin), partly due to the relative increase of acute phase proteins. Other increase slightly (e.g. complement components C3 and C4; protease inhibitors; haptoglobin; caeruloplasmin). The concentration of a few proteins increases very markedly (up to 1000-fold): C-reactive protein and serum amyloid A (SAA). Acute Phase Proteins (especially C-reactive protein and SAA) are generic indicators of inflammation and tissue damage (like increased ESV) and their increase suggests that further diagnostic tests are needed; however they give little information on the possible underlying pathology. In children and young adults common conditions to consider are rheumatic fever, rheumatoid arthritis and other autoimmune diseases, bacterial infections; in older subjects cancer should be also considered.
C-reactive Protein is produced by the liver and is a pentamer of 23 kDa subunits. It derives its name from its ability to bind to the C-polysaccharide of the Streptococci. In healthy adults its serum concentration is <1 mg/dL (or <90 nM); during acute inflammation its concentration increases very significantly (up to 100- to 1000-fold). Its function is to combine with several infectious agents and to activate complement.
Serum Amyloid A is a HDL apolipoprotein, present in the serum of healthy adults at concentration <3 mg/dL. Its physiological function is the transport of liposoluble substances (notably oxidized cholesterol derivatives) to the liver.

Immunoglobulins are produced by the plasma cells and migrate in the fraction of the gamma-globulins (actually this fraction only contains immunoglobulins). The γ-band of the electropherogram may be decreased in immunodeficiencies and may present a broad increase in the course of chronic bacterial infections (polyclonal gammapathy) or a sharp peak in the course of multiple myeloma (monoclonal gammapathy: a large amount of identical immunoglobulins produced by a B-lymphocyte neoplasm).

Audio: plasma proteins

Further readings:
Understanding and Interpreting Serum Protein Electrophoresis. American Family Physician, Jan 1, 2005 Issue

ENZYMES IN THE BLOOD PLASMA
As already stated, in addition to the proteins that exert a physiological function there, the human blood plasma (or serum) may contain enzymes released by the death of cells of every organ of the organism. In the healthy individual the plasma concentration of these enzymes is low, but non-zero, because of the physiological turnover of the cells of every tissue. In several acute and chronic diseases (including inflammation, infarction and cancer), the concentration of some of these enzymes may markedly increase, thus providing important diagnostic clues.
Enzymes are usually quite easy to quantitate, thanks to their specific activity: a chromogenic substrate (i.e. a physiological or artificial substrate whose transformation by the enzyme causes a change in its spectrocopic properties) is added to the patient's plasma, and the velocity of its conversion to the product is followed by absorbance spectroscopy. The rate of substrate transformation is correlated to the enzyme concentration by the Michaelis and Menten equation:
v = [E] k_cat [S] / (K_M + [S])
where [S] is the substrate concentration and k_cat and K_M are the kinetic parameters characteristic of the enzyme. Given that the precise values of k_cat and K_M may vary because of the experimental conditions, the laboratory standardizes its own process using purified commercial samples of each enzyme. When measured with functional methods, the enzyme concentration is expressed in Standardized Units per mL (U/mL). The effective value of the Standardized Unit varies with different enzymes (since each requires its own experimental conditions), but the concept is always the same: a Unit is the amount of enzyme that transforms one mMole (or microMole or other amount) of substrate in one minute (or one second).
Other methods to quantitate the enzymes' concentration in the blood plasma are by electrophoresis, and by immuno-assays (these may be expensive since they require that the laboratory buys specific antibodies for each enzyme of clinical interest). In some instances the enzyme of interest may have special spectroscopic properties (e.g. cytochrome-c contains a heme group), allowing direct measurement by means of absorbance or fluorescence spectroscopy.
Isoenzymes. Some enzymes are coded by more than a single gene and exist in the form of several variants called isoenzymes. These isoforms of the same enzyme have specific tissue distributions and patterns. A typical example is observed in the case of Lactate dehydrogenase that is a tetramer made up by two types of subunits, called H (for heart, prevalent in the heart cells) and M (for muscle, prevalent in muscle cells). The H and M subunits can assemble freely so that the tetrameric enzyme may have formulas such as H₄, H₃M₁, ..., M₄. From the physiological point of view these variants behave very similarly, but from the clinical standpoint their identification is important for diagnosis.
Some relevant enzymes, together with their diagnostic relevance, are described below.

Lactate dehydrogenase (LDH) is a tetramer made up of two types of subunits, called H and M. The enzyme catalyzes the reversible reduction of piruvate to lactate that occurs in anaerobic glycolysis (i.e. when glycolysis exceeds the ability of the mitochondrion to oxidize the acetyl-CoA derived from the decarboxylation of piruvate, due to insufficient availability of oxygen; the most typical condition is strenuous muscular effort):
CH₃-CO-COOH + NADH + H⁺ <==> CH₃-CHOH-COOH + NAD⁺
Lactate dehydrogenase is present in many metabolically active tissues, e.g. the heart, skeletal muscle, kidney, and is increased in clinical conditions causing the death of these tissues (e.g. myocardial infarction, renal infarction, crush syndrome with multiple muscular lesions). The characterization of isoenzyme variants is clinically relevant: the two types of polypeptide chains may form pure or mixed tetramers with formulas H₄ (called LDH₁), H₃M (LDH₂), H₂M₂ (LDH₃), HM₃ (LDH₄), M₄ (LDH₅). In cardiac and renal lesions tetramers containing prevalently H-type subunits predominate, whereas the opposite holds in the case of lesions of the liver or the skeletal muscle.

Creatine (phospho)kinase (CK or CPK) is a dimeric enzyme; two isoforms exist called M (for muscle) and B (for brain); it characteristic or the myocardium (CPK₂ corresponding to the dimer BM); of the skeletal muscle (CPK₃, MM); and of the Central Nervous System (CPK₁, BB). CK catalyzes the reversible exchange of phosphate groups between ATP and creatine; phosphocreatine acts as a reservoir of high energy phosphate groups, especially useful to sustain muscular contraction during anaerobic strenuous muscular effort. The CK concentration in the serum of healthy adults is < 30 U/mL and is significantly increased in myocardial infarction and in acute disorders of the muscles or the Central Nervous System (e.g. traumas, cerebral infarction, etc.).

Amylase is produced by the salivary glands and by the pancreas; its function is the hydrolysis of starch and glycogen of alimentary origin. Its serum concentration may be strongly increased in the course of acute pancreatitis, but this finding is inconstant since during this disease the pancreatic proteases (most notably trypsin and chymotrypsin) are also released and may degrade the other pancreatic enzymes before they reach the blood. The same applies to lipase (which is not produced by the salivary glands). Two isoenzymes of amylase exhist, called S (present primarily in the salivary glands and the lung) and P (in the pancreas).

Pancreatic proteases: Trypsin, Chymotrypsin, Elastase and other enzymes are secreted in the gut and play the physiological function of digesting alimentary proteins; they are released in the blood during episodes of acute or chronic pancreatitis. They cause major symptoms (mortality of acute pancreatitis may exceed 30%) since they are able to digest many proteins present in the plasma: e.g. thay may cause Disseminated Intravascular Coagulation because of direct conversion of fibrinogen into fibrin and because of the activation of thrombin; transformation of angiotensinogen to angiotensin and degradation of the latter; etc. Free pancreatic proteases do not usually attain very high levels in the plasma in their active form since they are counteracted by Serpins (see above).

Alkaline phosphatase is produced by several organs, including the placenta, liver, bone cells, kidney, and gut. The enzyme's activity is poorly specific as it hydrolyzes the phosphoric esters of several alcohols (including phosphorylated proteins). The enzyme is released in the blood by all diseases causing death of the cells of these organs. Cancer of these organs is an important cause of increased serum alkaline phosphatase, due to the fact that cancer cells are subject to rapid turnover and many of them die because of poor oxygenation of the cancer tissue.

Acid phosphatase is produced by several tissues, notably by the prostate and is significantly increased in advanced cases of prostatic cancer, especially if metastases are present. Other conditions causing increased concentration of acid phosphatase are prostatic hyperplasia, multiple myeloma, Gaucher's disease, and hemolytic anemia. The physiological function and substrates of this enzyme are very similar to those of alkaline phosphatase, from which it differs because it is most active at acidic pH

Aminotransferases (transaminases) are characteristic of liver cells. They catalyze the reversible exchange of amino-groups between alpha-chetoacids and alpha-aminoacids: e.g. the reaction catalyzed by ALT is the reversible conversion of alpha-chetoglutaric acid and alanine into glutamic acid and piruvic acid, as follows:
COOH-CH₂-CH₂-CO-COOH + CH₃-CHNH₂-COOH <==> COOH-CH₂-CH₂-CHNH₂-COOH + CH₃-CO-COOH
The most important aminotransferases are Alanine Aminotransferase (ALT; also called Glutamate-Pyruvate Transaminase, GPT or sGPT) and Aspartate Aminotransferase (AST; also called Glutamate-Oxaloacetate Transaminase, GOT or sGOT). Other tissues containing these enzymes are the heart, skeletal muscle and the Central Nervous System The reference values of these enzymes are <40 U/mL. The transaminases are elevated in several acute conditions such as myocardial or cerebral infarctions; however they attain their highest levels and are diagnostic for liver diseases. In acute viral hepatitis their serum concentration may exceed 500 U/mL; in chronic conditions (e.g. alcoholic liver disease, cirrosis) they rarely exceed 300 U/mL. Under most circumstances, increased serum concentration of ALT and AST is associated with other signs of liver disease (e.g. jaundice-hyperbilirubinemia; itch due to reabsorption of bile salts; pale stools and dark urine; increase of gamma-glutamyl transpeptidase).

Gamma-glutamyl transpeptidase (or gamma-glutamyl transferase, gammaGT) is an enzyme that transfers a residue of glutamic acid from a donor (usually glutathione) to an acceptor (a free aminoacid or a xenobiotic). It is involved in several detoxification reactions in the liver, kidney, brain, heart and other tissues. From a clinical standpoint, elevated serum gammaGT is usually an indication of liver disease.

Principles of clinical investigation: the typical screening of serum enzymes involves measuring the activity of six enzymes, that taken together provide an important clinical picture, and indicate the direction of further investigation: ALT, AST, LDH, CPK, alkaline phosphatase (ALP), possibly acidic phosphatase (ACP), and γ-glutamyl transpeptidase (γ-GT). The pattern of the increase of concentration of (some of) these enzymes provides information on possible diseases of the liver, heart, hematopoietic tissue, bone, skeletal muscle and prostate and may raise suspicion of acute inflammatory or ischemic diseases (e.g. viral hepatitis, myocardial infarction) or cancer.

	Heart	Brain	Prostate	Placenta	Intestine	Bone	Liver	Kidney	Pancreas	Sarcoidosis	Leukocytes
Principal enzymes that can be tested in routine screenings
Creatine phosphokinase (CK, CPK)	+++	+++
Aspartate transaminase (AST, GOT)	++	++					+++
Alanine transaminase (ALT, GPT)							+++
Lactate dehydrogenase (LDH)	++
Alkaline phosphatase (ALP)				+++	+++	+++	+++	+++			+++
Acidic phosphatase (ACP)			+++
γ Glutamyl transferase (γGT)							+++	+++

Other enzymes that can be measured to refine the diagnostic information
Prostate Specific Ag (PSA)			+++
Amilase									+++
Lipase *									+++
Angiotensin Converting Enzyme (ACE)										+++
Hydroxybutanoate dehydrogenase (HBD)	+++
Myoglobin	++
Troponin(s)	+++
Lysozyme											+++

Notes:
*: lipases can be released by the endothelial cells under heparin treatment.

When measuring serum enzymes one is effectively searching for indication of cell death in a specific tissue or organ; thus enzymatic measurements should be coupled to measurements of organ function:
- Kidney: kidney damage (aterosclerotic; neoplastic; due to infection or to autoimmune reactions) is revealed by increased levels of ALP and γ-GT; it should be complemented with the measurement of glomerular filtration rate (GFR) usually estimated by the clearance of creatinine (normal values 80-12 mL/min.), and by the measurement of serum concentrations of urea (normal value < 50 mg/dL) and creatinine (normal value < 1.5 mg/dL).
- Liver: liver damage (toxic; neoplastic; due to viral infection; etc.) is revealed by increased levels of AST, ALT, ALP, and γ-GT. It is usually associated to hyperbilirubinemia and jaundice (normal value of bilirubin < 1 mg/dL). In advanced cases of chronic liver failure hypoalbuminemia (normal value > 3.5 g/dL) and hyperammonemia (normal value 10-35 μmol/L).
- Myocardial infarction causes a complex enzymatic pattern (see Table), associated to ECG alterations. In severe cases arrhythmias may be present, possibly complicated by venous hypertension (pulmonary or systemic). Ultrasonography reveals an area of the myocardium which does not contract and scintigraphy reveals that the same area does not uptake the tracer. Coronarography may reveal the obstruction. The enzymatic pattern of the heart may be quite similar to those of the brain, the skeletal muscle, and to some extent the smooth muscle.
- Cancer has high cellular turnover and may mimic the enzymatic pattern of the tissue from which it originates. Special attention should be paid to prostate cancer (increased ACP and PSA may be early signs), and to hematological cancers (leukemias and lymphomas may cause increased ALP and lysozyme; diagnosis is established by the finding of cancer cells circulating and/or in the bone marrow).

PANCREATITIS; PANCREAS FUNCTIONS The pancreas plays two major physiological roles:
1) it produces the digestive enzymes of the small intestine: proteases (trypsin, chymotrypsin, elastase, etc.); lipase and phospholipase; amylase.
2) In the Langerhans islets it produces insulin and glucagon, the protein hormones responsible for the control of glycemia and glucose metabolism.
Acute pancreatitis is a life treatening condition in which the digestive enzymes become activated inside the organ and start digesting it. It may be caused by obstruction of the pancreatic duct. Pancreatitis causes a severe abdominal pain and systemic symptoms due to the facta that damage of small veins causes the pancreatic enzymes to appear in the blood, where they may cause disseminated intravascular coagulation (pancreatic proteases are able to digest fibrinogen), cardiocirculatory shock (proteases degrade angiotensin), etc.
Laboratory diagnosis of pancreatitis relies on the detection of amylase activity in the blood (lipase activity may be measured as well). Since the plasma contains protease inhibitors, protease activity is not a reliable indicator of the severity of the disease.
As a consequence of an episode of pancreatitis type I diabetes may develop.

Organ Pathology. It is not uncommon that a patient complains of severe but poorly specific symptoms (low grade fever, malaise, headache, fatigue, etc.) that do not suggest any clear organ pathology or diagnosis. In these cases a blood test, possibly coupled to other laboratory investigations may provide essential clues.
There are essentially two types of signatures of organ pathology that the clinical laboratory can detect: (i) chemical, biochemical or physical parameters pointing to the function impairment; and (ii) presence in the blood of organ specific enzymes or proteins indicative of cell death and release of intracellular proteins in the bloodstream.

SERUM ENZYMES AND TYPICAL LABORATORY FINDINGS OF SOME COMMON CLINICAL CONDITIONS
organ	functional parameters	enzymes
brain infarction or hemorrage	neurological symptoms; abnormal reflexes and other functional symptoms	CPK
lung and airways	hemogas analysis: reduced arterial PO₂; increased arterial PCO₂; respiratory acidosis
Heart / Myocardial infarction	increased central venous pressure; cardiac asthma; ...	Strongly increased CPK (predominant isoform CPK₂); increased Lactate dehydrogenase; increased Glycogen phosphorylase, Troponin-T, Myoglobin, and Cytochrome-c (+electrocardigraphic alterations; non captating region in the heart scintigraphy)
Acute viral hepatitis	jaundice; mixed hyperbilirubinemia; specific antigens and antibodies	Strongly increased ALT and AST; increased Alkaline phosphatase
Chronic disease liver and biliary ducts (e.g. cirrhosis)	increased bilirubin (conjugated, unconjugated or both); jaundice; possibly reduced serum albumin and other serum proteins	GOT, GPT, ALP
gastrointestinal tract		ALP
kidney	increased blood urea nitrogen; increased creatinine; possibly anemia (reduced production of erythropoietin); reduced GFR	ALP, γGT
Prostatic cancer		increased serum Acid phosphatase
endocrine system	increased or decreased hormone concentration (specific for each gland); biochemical signs of abnormalities of metabolic (e.g. altered glycemia, increased or decreased basal metabolism, ...)	autoantibodies?
Acute or chronic pancreatitis	increased WBC count; pain; possible hyperglycemia due to destruction of Langerhans islets	increased serum Amylase and Lipase; Lactate dehydrogenase; AST; and proteases
Leukemias, lymphomas and other blood malignancies	anemia, reduced platelet count, severely increased or decreased leukocyte count, altered electrolytes	increased LDH, lysozyme

Macroenzymes: enzymes in the blood plasma may form high molecular weight complexes with other macromolecules; these are called macroenzymes. As a general rule the clinical significance of the macroenzyme is the same as that of the enzyme; however the half life in the circulation may be increased, thus macroenzymes may lead to an overestimation of the severity of the patient's condition; in some cases the persistence is so increased as to cause an abnormal result in a healthy individual.
Examples of macroenzymes. Commonly observed macroenzymes are the complexes of enzymes with immunoglobulins (usually IgG; amylase and LDH preferentially bind to IgA). Binding occurs at the antigen binding site, thus the presence of macroenzymes may be assimilated to a form of immune self reactivity, possibly caused by cross reactivity with the homologous enzymes from occasionally encountered pathogens, or by the fact that the intracellular enzymes are sequestered antigens for which the immune system has no tolerance. The presence of macroenzymes of this type is a benign condition, generally devoid of special clinical implications, except for the possible diagnostic and therapeutical errors. Another example of macroenzyme is the complex of serine proteases with alpha2 macroglobulin (a specific protease inhibitor); the presence of this macroenzyme may indicatea mild episode of pancreatitis and justifies further investigation. Creatine kinase may form homopolymers, that qualify as macroenzymes; these may suggest the presence of severe liver disease or colon adenocarcinoma, thus an accurate clinical investigation of the patient is mandatory.

Questions and exercises:
1) Absence or severe reduction of the γ-band in the serum electrophoresis suggests:
An immunodeficiency
Nephrotic syndrome
Liver failure
Severe malnutrition

2) The proteins physiologically present in our blood are mainly produced by:
The liver
The liver, with the important exception of α globulins that are produced by plasma cells
The liver, with the important exception of β globulins that are produced by plasma cells
The liver, with the important exception of γ globulins that are produced by plasma cells

3) The most relevant enzymes released in the serum as a consequece of diseases causing liver cells death are:
Aminotransferases (ALT, AST), alkaline phosphatase, γ-glutamyl transpeptidase (γGT)
Aminotransferases (ALT, AST), acidic phosphatase, γ-glutamyl transpeptidase (γGT)
Aminotransferases (ALT, AST), alkaline phosphatase, cytochrome-c
Aminotransferases (ALT, AST), lactate dehydrogenase (LDH), creatine kinase (CPK)

4) The serum concentration of proteic hormones can be measured by means of:
Electrophoresis
Radioimmunoassay
Biological tests
All the preceding tests

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Thank you Professor (lecture on bilirubin and jaundice).

The fourth recorded part, the one on hyper and hypoglycemias is not working.
Bellelli: I checked and in my computer it seems to work. Can you better specify
the problem you observe?

This Presentation (electrolytes and blood pH) feels longer than previous lectures
Bellelli: it is indeed. Some subjects require more information than others. I was
thinking of splitting it in two nest year.

Bellelli in response to a question raised by email: when we compare the blood pH
with the standard pH we do not mean to compare the "normal" blood pH (7.4)
with the standard pH. Rather we compare the actual blood pH of the patient, with
the pH of the same blood sample equilibrated under standard conditions.
Thus, if we say that standard pH is lower than pH we mean that equilibriation with
40 mmHg CO2 has caused absorption of CO2 and has lowered the pH with respect
to its value before equilibration.

(Lipoproteins) Is the production of leptin an indirect cause of type 2 diabetes since
it works as a stimulus to have more adipose tissue that produces hormones?
Bellelli: in a sense yes, sustained increase of leptin causes the hypothalamus to adapt
and to stop responding. Obesity ensues and this in turn may cause an increase in the
production of resistin and other insulin-suppressing protein hormones produced by the
adipose tissue. However, this is quite an indirect link, and most probably other factors
contribute as well.

(Urea cycle) what is the meaning of "dissimilatory pathway"?
Bellelli: a dissimilatory pathway is a catabolic pathway whose function is not to produce
energy, but to produce some terminal metabolyte that must be excreted. Dissimilatory
pathways are necessary for those metabolytes that cannot be excreted as such by the
kidney or the liver because they are toxic or poorly soluble. Examples of metabolytes
that require transformation before being eliminated are heme-bilirubin, ammonia,
sulfur and nitrogen oxides, etc.

Talking about IDDM linked neuropathy can be the C peptide absence considered a cause of it??
Bellelli: The C peptide released during the maturation of insulin, besides being an indicator
of the severity of diabetes, plays some incompletely understood physiological roles. For
example it has been hypothesized that it may play a role in the reparation of the
atherosclerotic damage of the small arteries. Thus said, I am not aware that it plays a direct
role in preventing diabetic polyneuropathy. Diabetic neuropathy has at least two causes: the
microvascular damage of the arteries of the nerve (the vasa nervorum), and a direct
effect of hyperglycemia and decreased and irregular insulin supply on the nerve metabolism.
Diabetic neuropathy is observed in both IDDM and NIDDM, and requires several years to
develop. Since the levels of the C peptide differ in IDDM and NIDDM, this would suggest
that the role of the C peptide in diabetic neuropathy is not a major one. If you do have
better information please share it on this site!

In acute intermitted porphyria and congenital erythropoietic porphyria why do the end product
of the affected enzymes accumulate instead of their substrate??
Bellelli: First of all, congratulations! This is an excellent question.
Remember that a condition is which the heme is not produced is lethal in the foetus; thus
the affected enzyme(s) must maintain some functionality for the patient
to be born and to come to medical attention. All known genetic defects of heme
biosynthesis derange but do not block this metabolic pathway.
Congenital Erythropoietc Porphyria (CEP) is a genetic defect of uroporphyrinogen
III cosynthase. This protein associates to uroporphyrinogen synthase (which is present
and functional in CEP) and guarantees that the appropriate uroporphyrinogen isomer is produced
(i.e. uroporphyrinogen III). In the absence of a functional uroporphyrinogen III
cosynthase other possible isomers of uroporphyrinogen are produced together with
uroporpyrinogen III, mostly uroporphyrinogen I. The isomers of uroporphyrinogen
that are produced differ because of the positions of propionate and acetate side chains,
and this in turn is due to the pseudo symmetric structure of porphobilinogen. Only
isomer III can be further used to produce protoporphyrin IX. Thus in the
case of CEP we observe accumulation of abnormal uroporphyrinogen derivatives, which, as
you correctly observed are the products of the enzymatic synthesis operated by
uroporphyrinogen synthase.
The case of Acute Intermittent Porphyria (AIP) is similar, although there may be variants
of this disease. What happens is that either the affected enzyme is a variant that does not
properly associate with uroporphyrinogen III cosynthase or presents active site mutations
that impair the proper alignement of the phoprphobilinogen substrates. In either case
abnormal isomers of uroporphyrinogen are produced, as in CEP.
Also remark that in both AIP and CEP we observe accumulation of the porphobilinogen
precursor: this is because the overall efficiency of the biosynthesis of uroporphyrinogens is
reduced. Thus: (i) less uroporphyrinogen is produced, and (ii) only a fraction of the
uroporphyrinogen that is produced is the correct isomer (uroporphyrinogen III).

is it possible to take gulonolactone oxidase to synthesize vitamin C
instead of vitamin C supplement?
Bellelli: no, this approach does not work. The main reason is that
the biosynthesis of vitamin C, as almost all other metabolic processes, occurs intracellularly.
If you administer the enzyme it will at most reach the extracellular fluid but will not be
transported inside the cells to any significant extent. Besides, there are other problems
in this type of therapy (e.g. the enzyme if administered orally, may be degraded by digestive
proteases; if administered parenterally, may cause the immune system to react against a
non-self protein). In theory one could think of a genetic modification of the inactive human
gene of gulonolactone oxidase, but the risk and cost of this intervention would not be
justified. In addition to these considerations, except for cases of shipwreckage or
other catastrophes, a proper diet or administration of tablets of vitamin C is effective,
risk-free and unexpensive, thus no alternative therapy is reasonable. However, I express my
congratulations for your search on the biosynthesis pathway of ascorbic acid.

Resorption and not reabsorption would lead to hypercalcemia ie bone matrix being broken down.
Bellelli: I am not sure to interpret your question correctly. Resorption indicates destruction of the bone matrix and release of calcium and
phosphate in the blood, thus it causes an increase of calcemia. Reabsorption usually means active transport of calcium from the renal tubuli to the blood, thus
it prevents calcium loss. It prevents hypocalcemia, and thus complement bone resorption. To avoid confusion it is better use the terms "bone resorption" and "
renal reabsorption of calcium". If you have a defect in renal reabsorption, parthyroid hormone will be released to maintain a normal calcium level by means of
bone resorption; the drawback is osteoporosis.

In Reed and Frost model: I haven't understood what is the relationship
between K and R reproductive index. Thank you Professor!
Bellelli: in the Reed and Frost model K is the theoretical upper limit of
R₀. R the reproductive index is the ratio (new cases)/(old cases) measured after
one serial generation time. R₀ is the value of R one measures at the beginning
of the epidemics, when in principle all the population is susceptible.

What is the link between nucleotide metabolism and immunodeficiencies and mental retardation?
Bellelli: the links may be quite complex, but the principal ones are as follows:
1) the immune response requires a replication burst of granulocytes and lymphocytes, which in turn requires
a sudden increase of nucleotide production, necessary for DNA replication. Defects of nucleotide metabolism
impair this phase of the immune defense. Notice that the mechanism is similar to the one responsible of
anemia which requires a sustained biosynthesis of nucleotides at a constant rate, rather than in a burst.
2) Mental retardation is mainly due to the accumulation of nulceotide precursors in the brain of the
newborn, due to the incompletely competent blood-brain barrier.

How can ornithine transaminase defects cause hyperammonemia? Is it due to the accumulation
of ornithine that blocks the urea cycle or for other reasons?
Bellelli: ornithine transaminase is required for the reversible interconversion of ornithine
and proline, and thus participates to both the biosynthesis and degradation of ornithine. The enzyme is
synthesized in the cytoplasm and imported in the mitochondrion. Depending on the metabolic conditions
the deficiency of this enzyme may cause both excess (when degradation would be necessary) or defect
(when biosynthesis would be necessary) of ornithine; in the latter case, the urea cycle slows down. Thus
there is the paradoxical condition in which alternation may occur between episodes of hyperammonemia
and of hyperornithinemia.

When we use the Berthelot's reaction to measure BUN do we also have to
measure the concentration of free ammonia before adding urease?
Bellelli: yes, in principle you should. Berthelot's reaction detects ammonia,
thus one should take two identical volumes of serum, use one to measure free ammonia,
the other to add urease and measure free ammonia plus ammonia released by urea. BUN is
obtained by difference. However, free ammonia in our blood is so much lower than urea that
you may omit the first sample, if you only want to measure BUN.

Why do we have abnormal electrolytes in hematological neoplasia e.g.
leukemia?
Bellelli: I do not have a good explanation for this effect, which may have
multiple causes. However, you should consider two factors: (i) acute leukemias cause a massive
proliferation of leukocytes (or lymphocytes depending on the cell type affected) with a very
shortened lifetime; thus you observe an excess death rate of the neoplastic cells. The dying
cells release in the bloodstream their content, which has an electrolyte composition different
from that of plasma: the cell cytoplasm is rich in K and poor in Na, thus causing hyperkalemia.
(ii) the kidney may be affected by the accumulation of neoplastic white cells or their lytic products.

Gaussian curve: If it is bimodal is it more likely to be a "certain diagnosis" than if it is
unimodal or does it only show the distinguishment from health?
Bellelli an obviously bimodal Gaussian curve indicates that the disease is clearly
separated from health: usually it is a matter of how precise and clear-cut is the definition of the disease.
For example tuberculosis is the disease caused by M. tuberculosis, thus if the culture of the sputum is
positive for this bacterium you have a "certain" diagnosis (caution: the patient may suffer of two diseases,
e.g. tuberculosis and COPD diagnosis of the first does not exclude the second). However, in order to have
a "certain" diagnosis it is not enough that distribution of the parameter is bimodal, it is also required that the
patient's parameter is out of the range of the healthy condition: this is because a distribution can be
bimodal even though it is composed by two Gaussians that present a large overlap, and the patient's
parameter may fall in the overlapping region. Thus, in order to obtain a "certain" diagnosis you need to
consider not only the distribution of the parameter(s) but also the patient's values and the extent of the
overlapping region.

Prof can you please elaborate a bit more on the interhuman variability and its difference
with the interpopulation variability please?
Bellelli: every individual is a unique combination of different alleles of the same genes;
this is the source of interindividual variability. Every population is a group of individuals who intermarry and
share the same gene pool (better: allele pool). Every allele in a population has its own frequency. Two
population may differ because of the diffferent frequencies of the same alleles; in some cases one
population may completely lack some alleles. The number and frequencies of alleles of each gene
determine the variance. If you take two populations and calculate the cumulative interindividual variance
of the population the number you obtain is the sum of two contributions: the interindividual variance within each population, plus the interpopulation variance
between the means of the allele frequencies. For example, there are human population in which the frequency of blood group B is close to 0% and other populati
ons in which it is 30% or more.

Prof can you please explain again the graph you have showed us in class about thromboplastin?
(Y axis=abs X axis= time)
Bellelli: the graph that I crudely sketched in class represented the signal
of the instrument (an absorbance spectrophotometer) used to record the turbidity of the
sample (turbidimetry). The plasma is more or less transparent, before coagulation starts.
When calcium and the tissue factor (or collagen) are added. thrombin is activated and begins
digesting fibrinogen to fibrin; then fibrin aggregates. The macroscopic fibrin aggregates cause
the sample to become turbid, which means it scatters the incident light. The instrument reads
this as a decrease of transmitted light (i.re an increase of the apparent absorbance) and the
time profile of the signal presents an initial lag phase, which is called the protrombin or
thromboplastin time depending on the component which was added to start coagulation
(tissue factor or collagen).

Prof can you please explain the concept you have described in class about
the simultaneous hypercoagulation and hemorrhagic syndrome? How can this occur?
Bellelli: The condition you describe is observed only in the Disseminated
Intravascular Coagulation syndrome. Suppose that the patient experiences an episode of
acute pancreatitis: tripsin and chymotripsin are reabsorbed in the blood and proteolytically
activate coagulation causing an extensive consumption of fibrinogen and other coagulation
factors. Tripsin and chymotripsin also damage the vessel walls and may cause internal
hemorrages, but at that point the consumption of fibrinogen may have been so massive that
not enough is left to form the clot where the vessel has been damaged, causing an internal
hemorrage. Pancreatitis is a very severe, potentially lethal condition, and DIC is only one of
the reasons of its severity.

You said that certain drugs (ethanol, cocaine, cannabis, opiates...) cause a
necessity of higher and higher dosage, for two reasons: the enzyme in the liver is inducible and
the receptors in the brain are expressed less and less. So, first, I am not sure I got it right, and
second I did not understand how expressing less receptors leads to a necessity of higher
dosage.
Bellelli: You got it correctly, but the detailed mechanism of resistance may
vary among different substances, and not all drugs cause adaptation.
The reason why reducing the number of receptors may require an increased dosage of the drug
is as follows: suppose that a certain cell has 10,000 receptors for a drug. When bound to its
agonist/effector, each receptor produces an intracellular second messenger. Suppose that in
order for the cell to respond 1,000 receptors must be activated. The concentration of the
effector required is thus the concentration that produces 10% saturation. You can easily
calculate that this concentration is approximately 1/10 of the equilibrium dissociation constant
of the receptor-effector complex (its Kd), the law being
Fraction bound = [X] / ([X]+Kd)
where [X] is the concentration of the free drug.
After repeated administration, the subject becomes adapted to the drug, and his/her cells
express less receptors, say 5,000. The cell response will in any case require that 1,000
receptors are bound to the effector and activated, but this now represents 20% of the total
receptors, instead of 10%. The drug concentration required is now 1/4 of the Kd.
Continuing administration of the drug further reduces the cell receptors, but the absolute
number of activated receptors required to start the response is constant; thus the fewer
receptors on the cell membrane, the higher the fraction of activated receptors required.

Why does hyperosmolarity happen in type 2 diabetes and not in type 1?
Bellelli: Hyperosmolarity can occur also in type 1 diabetes, albeit
infrequently. The approximate formula for plasma osmolarity is reported in the lecture on
electrolytes:
osmolarity = 2 x (Na⁺ + K⁺) + BUN/2.8 + glucose/18
this is expressed in the usual clinical laboratory units (mEq/L for electrolytes, g/dL for non-
electrolytes). The normal values are:
osmolarity = 2 x (135 + 5) + 15/2.8 + 100/18 = 280 + 5.4 + 5.6 = 291 mOsmol/L
Let's imagine a diabetic patient having normal values for electrolytes and BUN, and glycemia=400 mg/dL:
osmolarity = 280 + 5.4 + 22.4 = 307.8 mOsmol/L
The hyperosmolarity in diabetes is mainly due to hyperglycemia, even though other factors
may contribute (e.g. diabetic nefropathy); however the contribution of glucose to osmolarity is
relatively small. As a consequence in order to observe hyperosmolarity the hyperglycemia
should be extremely high; this is more often observed in type 2 than in type 1 diabetes, for
several reasons, the most relevant of which is that in type 1 diabetes all cells are starved of
glucose, and the global reserve of glycogen in the body is impoverished: there is too much
glucose in the blood and too few everywhere else, thus reducing, but not abolishing, the risk of
extreme hyperglycemia. Usually in type 2 diabetes the glycogen reserve in the organism is not
impoverished, thus the risk of extreme hyperglycemia is higher.

Hemostasis and Thrombosis lecture: I don't understand why is sodium citrate
added to the serum solution to measure the prothrombin time.
Bellelli: in order to measure PT or PTT you want to be able to start the
coagulation process at an arbitrary time zero, and measure the increase in turbidity of the
serum sample. To do so you need (i) to prevent spontaneous coagulation with an anticoagulant;
and (ii) to be able to overcome the anticoagulant at your will. Citrate (or oxaloacetate; or EDTA)
has the required characteristics: it chelates calcium, and in this way it prevents coagulation;
but you can revert its effect at your will by adding CaCl₂ in excess to the amount
of citrate. You cannot obtain the same effect with other anticoagulants (e.g. heparin) whose
action cannot be easily overcome.

Dear professor I cannot do the self evaluation test because it says the the
time has expired It is not possible because I havent even started them
Bellelli: this is due to the fact that the program registers your name and
matricola number from previous attempts. I shall fix this bug. Meanwhile try to use a fake
matricola number.

How is nephrotic syndrome associated hypoalbuminemia as you described
in methods of analysis of protein because seems counterintuitive
Bellelli: nephrotic syndrome is an autoimmune disease in which the
glomerulus is damaged and the filtration barrier is disrupted; diuresis is normal but there is
loss of proteins (mostly albumin) in the urine.
I m sorry i confused polyurea with hypoalbuminemia but my question still
stands during glomerulonephritis you mentioned something of polyurea as compensation
i could not follow how this compensation mechanism works and collapse after some time in
glomerulonephritis
Bellelli: the condition you describe is NOT characteristic of acute
glomerulonephritis. In glomerulonephritis there is damage of the glomerulus and severely
impaired GFR. Thus the diuresis is severely reduced, and due to impaired filtration proteins
appear in the urine.
The condition you describe corresponds to the initial stage of chronic kidney failure,
usually due to atherosclerosis, diabetes, hypertension or other type of damage of the kidney
tissue. In this case GFR is impaired, albeit to a lesser extent than in glomerulonephritis, and the
excretion of urea is reduced. This leads to increased BUN. However the increased concentration
of urea reduces the ability of the tubuli to reabsorb water, because of osmotic reasons, yielding
compensatory polyuria. The patient has reduced GFR but normal or increased diuresis (urine
volume in 24 hours). To some extent this effect is beneficial, as it favors the elimination of
urea; however it cannot completely solve the problem and in any case the progression of the
disease leads to kidney insufficiency. In its essence the point is that a moderately reduced GFR
can be partially compensated by reduced tubular reabsorption; a severely reduced GFR cannot.

Lecture on Hemogas analysis interpretation of complex cases standard pH
Why if PCO2 is less than 40 mmHg it is absorbed during equilibration? Thank you in advance
Bellelli: if PCO2 of the patient's blood sample is less than 40 mmHg, when
the machine equilibrates with 40 mmHg CO2 the gas is absorbed: i.e. the new PCO2 becomes
40 mmHg and the total CO2 of the sample increases; as CO2 is the acid of the buffer, the
standard pH (in this case) decreases, whereas standard bicarbonate will slightly increase.

Professor I don't understand how we arrive to this formula: Accuracy =
sensitivity x prevalence specificity x (1-prevalence)
Bellelli: ok, this relationship is poorly explained in your text, I shall improve its explanation.
We use the following definitions:
prevalence = sick individuals / total population;
accuracy = (true+ + true-) / total population;
sensitivity = true+ / sick individuals = true+ / total population x prevalence;
specificity = true- / healthy individuals = true- / total population x (1-prevalence);
thus we can rewrite:
sensitivity x prevalence = true+ / total population;
specificity x (1-prevalence) = true- / total population;
accuracy = sensitivity x prevalence + specificity x (1-prevalence)

Why do we use RNA primer in PCR and not DNA primers? I thought the
beginning of the sequence of the gene segment that is going to be formed is made of DNA
Bellelli: DNA polimerases require the RNA primers that are synthesized by
the enzyme primase. DNA primers do not exist in vivo and would not be recognized by DNA
polimerases.

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