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Lixia Zhang
Contents
Basic Concepts For Diagonostic Enzymology Enzyme Assay Procedures Liver Diseases * Markers Of Liver Diseases * Patterns Of Liver Enzymes And Markers For Interpretation Of Disease * Myocardial And Skeletal Muscle Disease * Pancreatic Diseases Miscellaneous Enzymes Suggested Readings * Important
Diagnostic enzymology involves the measurement of enzymes in body fluids for the diagnosis of disease. In most cases, serum or blood levels are the most useful, although urine, cerebrospinal, and extracellular fluid levels are sometimes important. This chapter focuses on the analytical aspects and clinical significance of important enzymes that are measured for diagnostic purposes.
The major emphasis is on the use of these enzymes for the diagnosis of diseases involving the liver, myocardium, skeletal muscle, pancreas, and bone. In the case of myocardial infarction and skeletal muscle injury, nonenzyme markers such as myoglobin and troponin are also discussed.
Most enzymes that are used for diagnostic purposes have no direct physiologic role in the blood: Their presence under normal circumstances is the result of natural aging and turnover of cells.
Single-Reagent Kinetic Assays Start Reagent Activity Assays Enzyme Activity Calculations Mass Measurements
Mass Measurements
These assays are particularly useful for isoenzyme analysis, as antisera can be directed toward specific isoenzymes, isoforms, or subunits. Mass measurements are also used to measure the concentration of protein markers (e.g., myoglobin) that do not possess enzymatic activities.
LIVER DISEASES
LIVER ANATOMY
LIVER
LIVER DISEASES
The enzymes ALT and AST, ALP, LDH, GGT, and (to a lesser extent) 5'-nucleotidase (5'NT) are commonly measured for the assessment of liver function. None of these markers is specific for any single liver disorder.
LIVER DISEASES
This section covers liver dysfunction, describes individual liver enzymes and their laboratory measurement , and explains how patterns of liver enzyme data can be used to aid in the diagnosis of liver diseases.
LIVER DISEASES
Inclusion:
Acute Hepatocellular Injury Cholestatic Liver Diseases Chronic Liver Diseases Alcoholic Liver Disease
Metabolic
Liver Diseases -2
Cholestatic Liver Diseases Name of Diseases Intrahepatic Obstruction Extrahepatic Obstruction Markers Bilirubin ALP,GGT,5-NT Bilirubin ALP,GGT,5-NT
ALT
20%AST
GGT
80% AST
ALP
Plasma alkaline phosphatase activity as a function of age and sex(men , women). Horizontal lines refer to multiples of the adult upper reference limit.
GGT
reference indication hepatobiliary diseases alcoholism
distribution
liver (most) men 9-50 U/L Prostate (little) women 8-40 U/L Prostate (little) in 37C
5'-NT
indication
distribution
cytosolic membrane-bound increased activity enzyme that 5'-phosphate in the serum reflects esters of nucleotides. hepatobiliary diseases
10-40 U/L
Unlike some disorders such as acute pancreatitis and myocardial infarction, for which there are enzyme markers that are primarily used for one disorder and have high diagnostic efficiencies, there are no enzyme markers that are specific for any single liver disease.
When evaluating these disorders, therefore, it is appropriate to consider a panel of markers, sometimes called live function tests (LFTs). usually includes bilirubin, AST, ALT,ALP,and sometimes GGT and 5'NT although these tests can reflect various disease processes in the liver, they do not reflect hepatic reserve for synthesis and metabolic functions
Acute Injury
When Acute Hepatocellular Injury :
AST and ALT and are therefore rarely used for diagnostic purposes. ALP, GGT, and 5'NT are not as markedly elevated.
acute hepatitis
(viral or toxic)
ALT and AST elevated>1000U/L ALT elevated in 3 to 4 weeks after infection ALT return to normal within 8 to 12 weeks preclinical incubation phase is longer and ALT and AST may remain normal for 2 to 6months ALT and AST return to normal within 2 to 3months
ALT and AST elevated 5 to10 fold ALT and AST return to normal or subnormal
Relationship of AST and ALT to ALP and GGT in Hepatitis Relationship of AST and ALT to ALP and GGT in
Cholestasis -1 -1
The best markers for intrahepatic and extrahepatic cholestasis are ALP, GGT, and 5'NT The largest elevations (four- to 10-fold) of ALP are typically seen in obstruction owing to gallstones or malignancy and in biliary cirrhosis.
Cholestasis -2 -2 AST and ALT are generally only slightly elevated in cholestasis, rarely more than 500 U/L. Measurement of total and direct bilirubin are also important in making the diagnosis of obstructive jaundice.
o sel ptl u M i i
De Ritis AST/ALT) -2 -2
Disease Acute disorders of the liver acute viral hepatitis infectious mononucleosis chronic disorders of the liver alcoholic liver disease postnecrotic cirrhosis chronic active hepatitis chronic persistent hepatitis AST/ALT <1.0 >1.0
normal
De Ritis AST/ALT) -3
Intrahepatic and Extrahepatic obstruction
Disease AST/ALT Couses
1.5 1.5
De Ritis AST/ALT) - 4
Intrahepatic and Extrahepatic obstruction Other laboratory tests: ALP extrahepatic >intrahepatic Conjugated bilirubin extrahepatic >intrahepatic Amylase extrahepatic >intrahepatic
o sel ptl u M i i
Relationship of AST and ALT to ALP and GGT in Alcoholic Live Disease
sel ptl u M i i
The largest increases of AST relative to ALT are seen in myocardial and skeletal muscle diseases
AST/ALT>10.0
Markers of Alcohol
Markers of alcohol use that most widely used marker for alcoholism is GGT Significant elevations of GGT are also observed after prolonged drinking episodes of several months or more. it is not a specific test Other markers currently being studied include carbohydrate-deficient transferrin and fatty acid ethyl esters.
CHD: coronary heart disease UA: unstable angina AMI: acute myocardial infarction
A: Stable coronary artery plaque not vulnerable for rupture. B: Unstable plaque that is vulnerable for rupturing by shear stresses.
Rupture of this plaque leads to the syndrome of unstable angina, the disease that immediately precedes an AMI.
Both conditions, collectively known as acute coronary syndromes, can produce chest pain at rest, lead to specific changes in tile electrocardiogram, and a mild or severe release of enzymes and proteins into blood.
Chronic congestive heart failure (CHF) is seen in cardiomyopathies and valve disease. New markers are being developed, such as brain natriuretic peptide (BNP) that might have a role in the management and monitoring of these patients.
Evidence of high CK activity in the serum is useful for the diagnosis and evaluation of both acute and chronic skeletal muscle diseases. The measurement of enzymes and isoenzymes is useful in the diagnosis of muscle disorders.
CK (creatine kinase) -1 -1
The reference range of total CK at 37C : 38-174U/L for adult men 96-140 U/L for adult women.
CK (creatine kinase) -2
CK Isoenzyme Tissue Distribution
CK (creatine kinase) -3
CK Isoforms and CK Variants
CK (creatine kinase)
-4 -4
CK and CK Isoenzyme Analytical Measurements Most normal samples will exhibit a single band owing to CK-MM. Patients with AMI will have high concentrations of CK-MM and MB.
CK (creatine kinase)
-5
CK (creatine kinase)
CK Isoenzyme Reference values
-6
CK-MB : Cutoff values for electrophoresis and immunoinhibition are usually set around 5% of total CK or 10 U/L.For immunoassays, decision limits are expressed in mass quantities and are approximately 5 to 10ng/mL. CK-BB is normally absent in adult serum. CK-MB and CK-BB levels are higher in children
Myoglobin
found in all skeletal muscle and myocardial tissues myoglobin was an early marker for AMI Reference limits for serum myoglobin vary but are generally less than 100 g/L Myoglobin is also increased in patients with skeletal muscle disease or injury, and in patients with acute or chronic renal failure.
Troponin
Troponin is consists of three isotypes Troponin-T (cTnT) Troponin-I (cTnI ) Troponin C (cTnC) cTnT and cTnI are better diagnostic markers for AMI than existing enzymes such as CK- MB
clinical signs and symptoms specific changes in electrocardiographic recordings elevated serum enzymes and proteins total CK, CK-MB, LDH, and LDH isoenzymes myoglobin and the cardiac troponins
Early Diagnosis:
Myoglobin CK Isoforms
Definitive Diagnosis : CK-MB Troponin Late Diagnosis : LDH cTnT and cTnI
95 90 60 40 75
75 60 95 85 95
0 0 98 95 98
0 0 50 90 98
70 90 95 85 90
The cardiac troponins (T or I) are the most efficient markers available today for diagnosis of AMI The specificity of troponin is also increased over CK-MB or myoglobin cardiac troponin has been recommended by the NACB as the preferred marker for the definitive diagnosis of AMI With the development of structural markers such as cTnT and cTnI, the NACB has recommended discontinuance of LDH isoenzymes
The important enzyme markers of skeletal muscle necrosis include total CK, CK-MB, and, to a lesser extent, AST and aldolase. In cases of concomitant skeletal muscle injury and AMI, measurement of troponin allows differentiation between skeletal muscle injury and myocardial damage.
total CK
in serum
PANCREATIC DISEASES
In Acute Pancreatitis
Laboratory findings include an elevated serum amylase, amylase clearance, and lipase.
Amylase and lipase levels rise within a few hours after onset and remain elevated for 36 to48 hours.
In Acute Pancreatitis
Sensitivity and specificities in Acute Pancreatitis Sensitivity specificities accuracy Amylase Lipase 90% 90 % 40% 60% 95.8%
In Chronic Pancreatitis
Serum enzyme levels in chronic pancreatitis are less useful than in the acute presentation. Amylase and lipase levels are very often within normal limits and may actually be low during the end stages of the disease
Acute pancreatitis pos 29.0 neg 99.4 Chronic pancreatitis pos 13.6 neg 99.5
In Other Disorders
Injury to or obstruction of surrounding tissue, such as a perforated ulcer or peritonitis, may also cause compression of the pancreas, resulting in enzyme release. Elevations of amylase, immunoreactive trypsin, and, to a lesser extent, lipase also occur in other nonpancreatic disorders. Amylase of high levels are seen in patients with renal failure.
MISCELLANEOUS ENZYMES
MISCELLANEOUS ENZYMES
MISCELLANEOUS ENZYMES -1
ACP
Measurement of acid phosphatase was primarily used for monitoring patients with prostatic cancer.
With the development of prostate-specific antigen (PSA), assays for acid phosphastase, if used at all, are only used on rare occasions.
MISCELLANEOUS ENZYMES - 2
CHE
Low levels of PCHE are found in patients with various forms of liver disease.
MISCELLANEOUS ENZYMES - 2
CHE
Nonhepatic disorders, such as AMI, infections, and pulmonary embolism, have also been shown to decrease PCHE levels. The activity of PCHE is also important in monitoring industrial and agricultural workers who use and are exposed to organophosphate insecticides.
MISCELLANEOUS ENZYMES - 3
ACE
It is produced by the lungs and catalyzes the conversion of the decapeptide angiotensin I to the decapeptide angiotensin II. It is a vital enzyme in the control of aldosterone secretion and regulation of blood pressure.
MISCELLANEOUS ENZYMES - 3
ACE
It is elevated in approximately 50% to 80% of cases of sarcoidosis, a multisystem granulomatous disease that most commonly involves the lungs.
MISCELLANEOUS ENZYMES - 4
G6PD