as lactic dehydrogenase, or LDH) is found in the cells of almost all body tissues. The enzyme is especially concentrated in the heart, lier, red blood cells, kidneys, muscles, brain, and lungs. LDH helps to produce energy by catalyzing the reersible reaction between pyruic and lactic acids. !hen certain conditions in"ure cells in tissues containing LDH, it is released into the bloodstream. Fig. 1. The active site of LDH showing the relative arrangement of reacting groups. Fig. 2. A ribbon diagram of the structure of LDH in the vicinity of the active site. The protein is shown in gray two Arg residues shown in red !ADH is shown with its adenosine "yellow#$ pyrophosphate "blue#$ and nicotinamide "green# moieties. The total LDH can be further separated into fie isoenzyme namely# LDH$% is found mainly in the heart. LDH$& is primarily associated with the system in the body that defends against infection (reticuloendothelial system). LDH$' is found in the lungs and other tissues. LDH$( in the kidney, placenta, and pancreas LDH$) in lier and striated (skeletal) muscle The relatie amounts of a particular isoenzyme of LDH in the blood can proide aluable diagnostic information. *ormally, leels of LDH$& are higher than those of the other isoenzymes. +eference alues for normal leels of LDH isoenzymes can generally be found within the following ranges# LDH$%# %,$&,- LDH$&# &,$',- LDH$'# %.$&)- LDH$(# .$%/- LDH$)# /$%/-. 0ncreased leels of LDH$% are seen in myocardial infarction, red blood cell diseases like hemolytic anemia, kidney disease including kidney transplantation re"ection, and testicular tumors. 0ncreased leels of LDH$& are found in lung diseases such as pneumonia and congestie heart failure, as well as in lymphomas and other tumors. 1leations of LDH$' are significant in lung disease and certain tumors. 1leations of LDH$( are greatly increased in pancreatitis. High leels of LDH$) are found in lier disease, intestinal problems, and skeletal muscle disease and in"ury, such as muscular dystrophy and recent muscular trauma. 2ertain diseases hae classic patterns of eleated LDH isoenzyme leels. 3or e4ample, an LDH$% leel higher than that of LDH$& is indicatie of a heart attack or in"ury5 eleations of LDH$& and LDH$' indicate lung in"ury or disease5 eleations of LDH$( and LDH$) indicate lier or muscle disease or both. 6 rise of all LDH isoenzymes at the same time is diagnostic of in"ury to multiple organs. 7ne of the most important diagnostic uses for the LDH isoenzymes test is in the differential diagnosis of myocardial infarction or heart attack. The total LDH leel rises within &($(. hours after a heart attack, peaks in two to three days, and returns to normal in appro4imately fie to ten days. This pattern is a useful tool for a delayed diagnosis of heart attack. The LDH$% isoenzyme leel, howeer, is more sensitie and specific than the total LDH. *ormally, the leel of LDH$& is higher than the leel of LDH$%. 6n LDH$% leel higher than that of LDH$&, a phenomenon known as "flipped LDH" is strongly indicatie of a heart attack. The flipped LDH usually appears within %&$&( hours after a heart attack. 0n about .8- of cases, flipped LDH is present within (. hours of the incident. 6 normal LDH$%9LDH$& ratio is considered reliable eidence that a heart attack has not occurred. 0t should be noted that two conditions might cause eleated LDH isoenzymes at the same time and that one may confuse the other. 3or e4ample, a patient with pneumonia may also be haing an acute heart attack. 0n this instance, the LDH$% leel would rise with the LDH$& and LDH$'. :ecause of this complication, some laboratories measure only the LDH$% and consider an eleated LDH leel with LDH$% higher than (8- to be diagnostic of heart damage. %ther Factors that can affect LDH Levels ;trenuous e4ercise may raise leels of total LDH, specifically the isoenzymes LDH$%, LDH$&, and LDH$). 6lcohol, anesthetics, aspirin, narcotics, procainamide, fluorides, and mithramycin may also raise leels of LDH. 6scorbic acid (itamin 2) can lower leels of LDH. OTHER SERUM MARKERS AND DEVELOPMENT: Myoglobin: <yoglobin is a protein found in skeletal and cardiac muscle which binds o4ygen. 0t is a ery sensitie indicator of muscle in"ury. Howeer, it is not specific for cardiac muscle, and can be eleated with any form of in"ury to skeletal muscle. The rise in myoglobin can help to determine the size of an infarction. 6 negatie myoglobin can help to rule out myocardial infarction. 0t is eleated een before 2=$<:. (=umar and 2annon, >art 0, &88?) BNP: :$type natriuretic peptide (:*>) is released from entricular myocardium. :*> release can be stimulated by systolic and diastolic left entricular dysfunction, acute coronary syndromes, stable coronary heart disease, alular heart disease, acute and chronic right entricular failure, and left and right entricular hypertrophy secondary to arterial or pulmonary hypertension. :*> is a marker for heart failure. (;aenger and @affe, &88,) CRP: 2$reactie protein (2+>) is an acute phase protein eleated when inflammation is present. ;ince inflammation is part of atheroma formation, then 2+> may reflect the e4tent of atheromatous plaAue formation and predict risk for acute coronary eents. Howeer, 2+> lacks specificity for ascular eents. (;aenger and @affe, &88,) !i"in: a potentially candidate marker for myocardial infarction. (&8%() RE#ERENCES: 3lores, @anis. BLactate Dehydrogenase Test.B Cale 1ncyclopedia of <edicine, 'rd ed.. (&88/). +etrieed @une %?, &8%( from 1ncyclopedia.com# http#99www.encyclopedia.com9doc9%C&$ '()%/88?('.html Harey, +. 6., Harey, +. 6., D 3errier, D. +. (&8%'). LippincottEs illustrated +eiews# :iochemistry. >hiladelphia# !olters =luwer Health9Lippincott !illiams D !ilkins. Lincoln T6, @oyce C3, (&88?). ;elf$sustained replication of an +*6 enzyme. <.<.<. +a"a, 6. +a"a, <.<. 0mran, 6.<.0. ;antha and =. Deasena, (&8%%). 1nzymes 6pplication in Diagnostic >rospects. &iotechnology$ 1'( )1*)+. >orcelli, 6.<., 6. Chelli, 2. 2eccarelli, <. Lang and C. 2enacchi et al., (&8%8). The genetic and metabolic signature of oncocytic transformation implicates H03% destabilization. Human <ol. Cenet., %?# %8%?$%8'&. !orthington :iochemical 2orporation. (&8%() 0ntroduction to 1nzymes. <anual of 2linical 1nzyme <easurements %?,&.