The term plasma proteins refers to the proteins of the blood plasma circulating between the blood and the interstitial fluid compartments. Specimens are serum, plasma, urine, cerebrospinal fluid, saliva, amnion fluid, aspirated fluids (ascites, pleural exudate) and feces. Under physiological conditions, the distribution of these proteins is at a steady state between the fluid compartments . The term also includes other proteins such as immunoglobulins, enzymes, and blood clotting factors.
Functionally, plasma proteins are classified into:
- Transport proteins; they bind and transport hardly water-soluble substances; albumin, for example, is an important transport protein
- Acute phase proteins; they are associated with inflammation; the C-reactive protein, for example, is an important acute phase protein
- Proteins of the immune defense systems, for example immunoglobulins and complement factors
- Proteins shed within the scope of cell membrane changes, for example the soluble transferrin receptor
- Factors and inhibitors of plasmatic coagulation
- Oncofetal proteins; they are produced by tumors or physiologically produced during the fetal period (e.g., α-fetoprotein).
The serum concentration of plasma proteins depends on synthesis, catabolism, distribution in intracellular and extracellular fluid compartments, loss into “third space” (ascites, pleural effusion) or to the outside (proteinuria) . Plasma proteins are determined in cases of:
- Normo-, hypo- or hyperproteinemia defined by determination of total protein in serum
- Dysproteinemia, a disturbance in the plasma protein composition. In this case, serum protein electrophoresis shows an atypical protein pattern
- Special clinical questions as single protein (e.g., haptoglobin in presumed hemolytic anemia).
Whereas immunoglobulins (Ig) are produced by the plasma cells, the non-Ig proteins are primarily synthesized in the hepatocytes, with the following exceptions: β2-microglobulin and the transferrin receptor, which are shed by cells as surface proteins, as well as complement factor D, a protease involved in the activation of the alternative complement pathway and produced by adipocytes.
Like lysosomal proteins and cell membrane proteins, plasma proteins are produced by the polyribosomes of the rough endoplasmic reticulum. The general mechanism for the synthesis of proteins is the same in all body cells. The synthesis of proteins includes the following steps:
DNA in the cell nucleus is the carrier of the genetic information, and a copy is produced in the form of RNA by RNA polymerase . After the intervening sequences (or introns) are turned off, the messenger RNA (mRNA) is produced. This mRNA transfers the information regarding which protein will be synthesized from the cell nucleus to the cytoplasm. The regulation of transcription is achieved through regulatory proteins (transcription factors) that bind to specific DNA sequences of the gene to be regulated, and exert either a positive or negative effect on protein synthesis. For example, if an acute phase reaction occurs, the pro inflammatory cytokines will bind to the hepatocyte plasma membranes. This signal induces to the activation of the nuclear proteins that bind to the corresponding DNA sequences in the nucleus, thus leading to an amplified transcription of acute phase proteins such as C-reactive protein.
The mRNA base sequence is translated into a defined amino acid sequence. Translation takes place on the ribosomes of the endoplasmic reticulum, to which the mRNA becomes attached.
Plasmaprotein synthesis takes place in the ribosomes of the endoplasmic reticulum. The ribosomes are composed of ribonucleic acids and proteins that are produced by the nucleolus. Most proteins acquire two additional peptides on the N-terminal end during synthesis, a hydrophobic peptide and a pro peptide. The hydrophobic peptide is composed of 15–30 amino acids, and serves as a pilot peptide to guide the protein through the membrane of the endoplasmic reticulum in its lumen. The pilot peptide is immediately cleaved after the protein is discharged through the lumen of the endoplasmic reticulum. The folding of the peptide into its final tertiary structure takes place via the formation of disulfide bridges in the endoplasmic reticulum. Certain proteins are transported from the lumen of the endoplasmic reticulum into the lumen of the Golgi apparatus for secretion. The pro peptide remains on the protein while it matures in the vesicles of the Golgi apparatus or is stored in the secretory granules. The pro peptide is cleaved shortly before the release of the protein from these organelles .
Co translational or post translational protein modification
Protein modifications start as the protein passes through the lumen and the cisterns of the endoplasmic reticulum and Golgi apparatus. The majority of the plasma proteins are glycoproteins and some are lipoproteins.
Other co translational or post translational modifications
Oxidation of C atoms 3 and 4 which results in the formation of thioester binding, phosphorylation of, for example, α2HS-glycoprotein and binding of phospholipids.
The glycosylation of proteins is important for the folding into a tertiary structure, and for their functioning and degradation . There are two types of protein glycosylation, N-glycosylation and O-glycosylation. They are classified into:
- N-glycosylated type: most proteins are glycosylated by forming a covalent N-bond between the amino acid asparagine and a carbohydrate residue composed mainly of mannose. This step begins in the lumen of the endoplasmic reticulum. In a subsequent process that occurs over multiple stages, a transformation of the carbohydrate chains takes place wherein the terminal position is often bound to N-acetyl neuraminic acid, while galactose is linked at the preterminal position.
- O-glycosylated type: some plasma proteins contain sugar residues that are bound via the OH-groups of the amino acids serine and threonine. O-glycosylation takes place in the Golgi apparatus.
Microheterogeneity of glycoproteins
All glycoproteins exhibit heterogeneity, since they are derived from a population with various oligosaccharide sequences (glycoforms). The variation comes from the different numbers of carbohydrate chains, the varying chain length and the differing end substitutions that are borne by the amino acid skeleton. As a result, each glycoprotein can occur in forms having different net electric charges. This is manifested in the electrophoresis as micro heterogeneity. Thus, for example, acidic α1-glycoprotein exhibits seven bands with isoelectric focusing at acidic pH. Differences in the glycosylation of IgG have an effect on immunoregulation .
Lipoproteins are proteins that are coupled covalently with lipids (e.g., in the cell membranes). Thus, a fatty acid can bind to an N-terminal glycine as an amide, or to cysteine as a thioester. Plasma lipoproteins are non covalent aggregates of lipids and proteins.
Following post translational modification, the secretory plasma proteins are stored in vesicles that are separate from the Golgi apparatus. These vesicles fuse with the plasma membrane of the cell, and the proteins are released into the extravascular compartment via exocytosis. The pro peptide plays an important role in this process.
Plasma proteins are continuously redistributed in both directions between the vascular and interstitial compartments. This takes place via diffusion through the capillary walls, pinocytotic transport through the capillary endothelium or over the intercellular connections of the tissue cells . The distribution depends on molecular weight. The higher the molecular weight, the greater will be the intravascular proportion of that protein (). Large proteins, such as fibrinogen, α2-macroglobulin and IgM remain predominantly in the extravascular compartment, and will only enter circulation to a limited extent via the intercellular connections between the endothelial cells or through pinocytosis. However, the reverse flow from the tissue into the blood vessels occurs through the lymph vessels. Glomerular filtered plasma proteins are absorbed by the cells of the proximal tubule through pinocytosis, and are degraded in these tubule cells.
The quantity of plasma proteins transferred from the intravascular to the extravascular compartment is organ-dependent; the levels are high in the liver, but quite low in the brain so that the protein concentration in the cerebrospinal fluid is about 300-fold lower than in the plasma. In the case of systemic disorders, however, the vascular permeability can change drastically and can lead to the development of exudations in the form of effusions or edema.
Plasma protein degradation occurs in all somatic cells (see also ). The released amino acids are used by the cells for resynthesis of proteins; only essential amino acids must be taken in with food. Desialation plays an important role in the breakdown of glycoproteins. The intactness of the carbohydrate side chains protects the protein from degradation . Removal of sialic acids and reduction of carbohydrates by membrane-bound or circulating enzymes favors pinocytosis and intracellular degradation by lysosomal enzymes .
Organs and tissues that are significantly involved in the degradation of proteins include:
- The hepatocytes; they are easily reached by plasma proteins since the liver sinusoids lack basement membranes and endothelial cells have marked intracellular fenestrations
- The kidneys; following glomerular filtration, low molecular weight proteins are taken up by the brush border of tubular cells by pinocytosis and subsequently degraded by lysosomal enzymes
- The endothelial cells of capillaries; although these cells display only minimal capacity for pinocytosis, their catabolic potential is high because of the large size of the capillary bed.
The degradation rate of plasma proteins varies and is described by their half-life (albumin 19 days, ceruloplasmin 4 days, transferrin 8 days, IgG 23 days, IgA 5 days and IgM 5 days).
- Glycation; the most common reaction is the binding of glucose or other reducing substances to proteins. The carbonyl groups of the sugars and the amino groups of the protein form a Schiff base that quickly forms a stable keto amine through molecular rearrangement (Amadori product). In further reactions involving oxidation, the Amadori product is converted into an advanced glycation end product (AGE). Glycated hemoglobin is a typical Amadori product (see ).
- Direct oxidation by reactive oxygen species forming advanced oxidation protein products (AOPPs). The main AOOPs include methionine sulfoxide from oxidation of methionine and 3-nitro tyrosine from nitration of tyrosine.
- Carbamylation from the binding of isocyanic acid to amino acids, especially to ε-NH2 groups of lysine residues. The isocyanides form due to spontaneous dissociation of urea or reaction of thiocyanate catalyzed by myeloperoxidase in the presence of H2O2.
The organism tries to maintain the total protein concentration in the intravascular compartment at a constant level within certain limits. For instance, in infectious diseases, the elevated level of acute phase proteins and immunoglobulins is compensated for by a reduction in the concentration of negative acute phase proteins (albumin, transthyretin, transferrin, apolipoproteins). In multiple myeloma, the monoclonal increase in immunoglobulins is compensated for a long time by suppression of polyclonal immunoglobulin production.
The daily physiological turnover of plasma proteins is about 25 g and depends on the amino acid pool available for protein synthesis. This pool, in turn, is dependent on numerous variables.
Reduced plasma protein synthesis
Genetically induced; inflammation, hepatopathies (liver cirrhosis, acute hepatitis), nutritional protein deficiency, hypothyroidism, malabsorption syndrome, alcoholism, lymphoma, metastasized carcinoma.
Increased plasma protein synthesis
Inflammation, fever, hyperthyroidism, hyper cortisolism, increased release of growth hormone, protein-losing syndrome, iron deficiency, stimulation of the immune systems and clonal increase in the number of immunoglobulin-producing plasma cells (multiple myeloma).
Genetic impacts on plasma protein synthesis
Impacts may present clinically in the form of protein deficiency, protein increase or protein dysfunction. For instance, a protein may:
- Not be synthesized (e.g., hereditary IgA deficiency)
- Be synthesized with a structural defect and thus not be released from the cell (e.g., hereditary α1-antitrypsin deficiency)
- Be secreted as a structurally similar but functionally inactive variant (e.g., C1-esterase inhibitor in hereditary angioneurotic edema).
In certain clinical concerns, the determination of the concentration or activity of particular plasma proteins provides important help in the diagnosis of diseases, for example:
- CRP if systemic inflammation is suspected
- Haptoglobin in presumed intravascular hemolysis
- α1-antitrypsin in pulmonary emphysema.
In addition, the finding of a normal plasma protein concentration is also of important differential diagnostic value in order to rule out certain diseases.
Plasma protein profile
The plasma protein profile allows differential diagnostic conclusions.
During the course of the disease (acute symptoms) or during therapy, the plasma protein concentration and its changes during the disease course may provide conclusions as to the activity, severity and possible complications of the condition. The time in point when normalization is achieved has important prognostic implications.
Because of the high intravascular proportion of plasma proteins in relation to the interstitial fluid, a concentrating effect may occur before or during blood collection, thus simulating falsely elevated protein concentrations. This is the case, for example, if the patient does not sit for at least 15 min. prior to blood collection and venous occlusion during blood collection lasts for more than 3 min. The sample should be analyzed the same day. If this is not possible, it is better to store the sample at 4 °C than at –20 °C if deep-freezing at –70 °C is not feasible. Storage at 20 °C is associated with a measurable decline in protein concentration after 36 hours that affects many proteins.
Immunochemical methods are used to determine plasma proteins. For the determination of an unknown plasma protein concentration a constant amount of specific antibodies is employed. Refer to . The critical factors which determine whether the immunocomplexes which are formed can be detected in a soluble form or a precipitable form include besides the plasma protein concentration to be determined, the ratio of the plasma protein to the antibody concentration (curve according to Heidelberger and Kendall, refer to . In antibody excess, soluble immune complexes are formed. The measurement of the immune complex concentration is made nephelometrically or turbidimetrically.
In immunonephelometry, light from a helium neon laser is directed through the cuvette and is scattered by the immune complexes; this scattered light is then focused on a detector by means of a lens system. The electrical signal of the detector is proportional to the light scattering intensity. The concentration of the plasma protein concentration can be determined from the light scattering signal with the help of a calibration curve. In the case of kinetic-nephelometric plasma protein determination, changes in the scattered light are measured at short intervals, while the endpoint method allows the reaction to occur for a defined period of time (e.g., 15 or 30 min.). By adding further plasma protein or antibodies, it is possible to check whether the measurement occurred on the slope of the Heidelberger and Kendall curve (see ). This is the case if the addition of sample (plasma protein) results in an increase of the measurement signal or if the addition of antibodies produces no change in the measurement signal.
In immunoturbidimetry soluble immune complexes are formed by the addition of the plasma protein to antibodies and a buffer containing accelerator that allows kinetic measurement according to the fixed time principle. The increase of absorption at 334 or 340 nm is measured within a defined time period.
Calibrators for the plasma protein assays are standardized using the BCR/IFCC/CAP RPPHS reference material, also know as CRM 470.
The detection limit for the immunonephelometric and immunoturbidimetric tests, which is about 10 mg/L, can be increased by a factor of 10 to 100 if the specific antibodies are bound to latex particles (latex-enhanced assays).
Since the introduction of the reference preparation BCR/IFCC/CAP RPPHS, also known as CRM 470 (now ERM-DA470), which contains reference values for the plasma proteins listed in , the accuracy of plasma protein determinations has improved . ERM-DA472/IFCC has been certified for CRP. The successor reference preparation of ERM-DA470, referred to as ERM-DA470k/IFCC, was reproduced in the same quality and spiked with CRP and β2-microglobulin .
12. Zegers I, Keller T, Schreiber W, Sheldon J, Albertini R, Blirup-Jensen S, et al. Characterization of the new serum protein reference material ERM-DA470k/IFCC: value assignment by immunoassay. Clin Chem 2010; 56: 1880–8.
The determination of TP is based on the following premises:
- Each individual protein reacts the same way in the method of determination as any of many other proteins in the serum, plasma or body fluids
- All proteins are pure polypeptide chains with approximately 16% of their mass consisting of nitrogen
- The proteins are compared to bovine serum albumin since the latter is used as a calibrator in the method of determination.
Presence of the following symptoms, conditions or diseases: inflammation, proteinuria, edema, polyuria, chronic renal disease, chronic liver disease, chronic diarrhea, malignant tumor, increased susceptibility to infections, bone pain, rheumatic symptoms of undeterminable localization, lymphomas, external and internal hemorrhages, pregnancy, pre- and postoperative state, monoclonal gammopathy, shock, burns, patients requiring intensive medical care, investigation of an acute decrease in hemoglobin.
The Biuret method has proven useful for quantitative determination of serum TP. Determination of TP in urine, cerebrospinal fluid (CSF) and other body fluids is performed using various methods. The most reliable method is the Biuret reaction after acid precipitation of proteins. For CSF and urine, dye-binding methods, especially the Coomassie method, and light scattering techniques are employed.
Principle: the Biuret method is dependent on the presence of peptide bonds in the proteins. If a protein solution is treated with Cu(II) ions in a weakly alkaline solution, a colored chelate is formed between the Cu(II) ion and the carboxyl oxygen and amide nitrogen of the peptide bond. A requirement for this reaction to take place is the presence of at least two peptide bonds (tripeptide). Amino acids and dipeptides do not react. The intensity of the resulting violet color varies in a linear fashion with the number of peptide bonds and hence with the protein concentration over a broad range. The Biuret reagent contains copper sulfate, sodium potassium tartrate, potassium iodide and sodium hydroxide. The Cu(II) ions are kept in solution as a tartrate complex at alkaline pH while potassium iodide prevents auto reduction of Cu(II).
The method is not standardized, and the molarities of the Biuret reagent components have been modified in many ways, but a candidate reference method is described . Bovine serum albumin is recommended for calibrating the TP determination. If determined manually, 1 part serum is added to 50 parts Biuret reagent, and after a 30 min. incubation at room temperature the absorption of the test sample and that of the standard are measured against Biuret reagent at 546 nm.
Principle: the textile dye Coomassie Brillant Blue G 250 (CBB-G250) is in its leukoform in slightly acidic solution, and has an absorption maximum at 465 nm. CBB-G250 reacts rapidly with proteins forming a protein-dye complex which causes shift of the absorption maximum to 595 nm . At low levels, the absorption is approximately linear with the protein concentration. This method is acceptable for TP determinations in urine and cerebrospinal fluid.
Principle: in specimens that are low in protein such as urine and cerebrospinal fluid are denatured by addition of trichloroacetic acid. The denatured proteins scatter short-wavelength light. The measurable light scattering signal is proportional to the TP concentration over a certain concentration range. Light scattering methods are used for TP determination in cerebrospinal fluid and urine specimens .
Serum, plasma (heparin), urine, CSF, aspirated fluid: 1 mL
This section is limited to the clinical interpretation of TP levels in serum and plasma. For an assessment of
Deviations of serum TP from the reference interval indicate the presence of dysproteinemia or are a sign of hypoproteinemia or hyperproteinemia based on disorders in the water and electrolyte balance.
From a differential diagnostic point of view, the conditions can be distinguished by additional performance of serum protein electrophoresis and determination of hematocrit.
Electrophoretically, dysproteinemia is associated with a quantitative shift in the pattern of the protein fractions, while hematocrit is unchanged.
Both dehydration and hyper hydration lead to uniform increases or reductions in serum protein concentrations, while no shift in protein bands occurs during serum protein electrophoresis. However, the hematocrit is abnormal.
Hypoproteinemia is mostly due to a reduction in albumin, and is less frequently due to a decrease in antibody synthesis (). Clinical symptoms of pronounced hypoproteinemia include the development of edema and effusions in body cavities. Hypoproteinemia may be due to:
- Disturbance in protein synthesis
- Protein malnourishment
- Protein malabsorption
- Protein-losing syndrome
- Dilution hypoproteinemia.
Hyperproteinemia is rarer than hypoproteinemia because in the event of an increase in globulins, a regulatory reduction in albumin ensues. Therefore, in hyperglobulinemia, the total protein concentration remains within the reference interval for a long period of time. Hyperproteinemia above 80 g/L is found in about 3.5% of clinical patient samples.
The blood should be collected with the patient in a supine position since blood samples obtained in an upright position lead to the measurement of up to 10% higher TP concentration. The discrepancy is even higher in patients who tend to develop edema. After more than 3 min. of venous occlusion during blood collection, the protein concentration may increase by up to 10%. Blood sampling after vigorous muscle activity may lead to a rise in TP concentration by up to 12%.
Serum or plasma can be used for TP determination. Due to fibrinogen, average TP concentration in plasma is higher than in serum (i.e., by 2.5 g/L in blood donors, by 3.6 g/L in outpatients, by 4.6 g/L in in-patients and by 6.6 g/L in in-patients with a CRP > 50 mg/L) . The patient does not need to be in a fasting state for the blood collection.
Method of determination
a) Low NaOH concentration (0.1–0.2 mol/L) and high CuSO4 concentration (10–30 mmol/L).
b) High NaOH concentration (0.5–0.8 mol/L) and low CuSO4 concentration (4–6 mmol/L). The Biuret reagents of these groups have a low reagent blank value, while the determination is only linear up to a protein concentration of 1.4 g/L as a rule.
The Biuret method reacts with some amino acids, dipeptides and other substances forming a 5-membered or 6-membered ring complex with Cu. These complexes have a higher absorption maximum (blue) than peptides and proteins (pink) .
Infusion solutions: protein-containing infusion solutions such as oxypolygelatin as well as polypeptides that are derived from degraded gelatin and cross-linked via urea bridges are also detected in the reaction to a varying extent, depending on the Biuret reagent used. Polyglucose such as dextran and sugar solutions such as glucose, mannitol, sorbitol and fructose lead to color intensification and simulate elevated protein levels; dextran, in addition, causes turbidity. Hydroxyethyl starch and synthetic materials such as polyvinylpyrrolidone do not enter into the reaction .
Other interfering substances: ammonium salts (e.g., contained in enzyme preparations) may simulate falsely low levels as a result of protein precipitation. Tris(hydroxymethyl)-aminomethane leads to falsely elevated TP concentrations since it reacts with the Biuret reagent to yield a protein-like color reaction.
Hemolysis: 0.8 g of Hb/L resemble a 2% protein increase . If bovine serum albumin is used as the standard, each mg of Hb mimics approximately 2 mg of protein since the globin enters into the Biuret reaction.
Lipemia: markedly lipemic serum samples simulate elevated TP concentrations by causing turbidity of the reagent mixture and must be cleared prior to determination.
Bilirubin: serum concentrations > 5 mg/dL (85 μmol/L) cause falsely increased TP levels in the Biuret reaction unless a sample blank (with the exception of copper sulfate) is measured.
X-ray contrast media: depending on their composition, X-ray contrast media can cause falsely elevated TP concentrations.
Coomassie method and light scattering technology: while the Biuret reaction has about the same percental absorption coefficient for all proteins, this does not apply to the Coomassie method . Using the light scattering technology, globulins are determined too low in comparison to albumin .
In a closed container at room temperature up to 1 week, at 4 °C up to 1 month, in a deep-frozen state > 1 year.
Plasma TP is composed of > 100 structurally known proteins; the biological function is known in detail for about 50 proteins. Albumin, α1-, α2- and β-globulins are synthesized by the parenchymal cells of the liver, while the proteins of the γ-globulin fraction (i.e., the immunoglobulins) are synthesized by plasma cells. The half-life of proteins ranges from a few hours (e.g., acute phase proteins) to as long as 3 weeks (e.g., IgG and albumin).
The liver has a significant functional reserve capacity for protein synthesis (3-fold for the synthesis of albumin, 6-fold for the synthesis of fibrinogen), and translation and transcription are usually not disturbed with the onset of liver disease .
Glucagon and malnutrition (due to a lack in nutrients and/or poor dietary habits), especially a deficiency in the amino acid tryptophan, exert an inhibitory effect on the synthesis of proteins.
Glucocorticoids, growth hormone, insulin and thyroid hormones have a stimulatory effect on the hepatic synthesis of proteins.
Hepatic protein degradation takes place after endocytic uptake of proteins by the hepatocytes. This involves, for example, binding of glycoproteins to an asialoglycoprotein receptor on the hepatocyte membrane after removal of the N-acetylneuraminic acid (NANA) that is located in a terminal position at the carbohydrate side chains. The glycoproteins are subsequently internalized by pinocytosis.
Protein degradation involves two pathways:
- In the lysosomes mediated by the action of peptidases and proteases under acid pH conditions
- In the cytosol, by proteolytic enzymes under neutral pH conditions. The proteins to be degraded are bound to the protein ubiquitin that is present in cytosol, and thus targeted proteins are broken down by proteases first into peptides and ultimately into amino acids .
Decreases in hepatic protein degradation can result from:
- A reduced number of asialoglycoprotein receptors on the hepatocyte. This condition has been described, for example, in liver cirrhosis. As a result of this, plasma concentration of asialylated glycoproteins is elevated.
- Increased sialylation (covalent binding of NANA) of proteins and, thus, a delay in desialylation and a reduced uptake by the hepatocytes. Increased sialylation has been described for GGT in acute alcoholic liver injury and for ALP in primary biliary cirrhosis.
The degradation of nonsialylated albumin is still largely unknown.
The physiological importance of plasma proteins lies in the maintenance of the colloid osmotic pressure as well as in their function as a vehicle for lipids, metabolic products, hormones and minerals; several proteins display enzymatic activity.
Many abnormal processes in the organism cause an alteration in the protein composition of the plasma (dysproteinemia) but often do not lead to protein concentrations outside the reference interval.
Plasma volume-induced changes of TP concentration, as seen after infusions or severe diarrhea, may be recognized by a synchronous pattern of hematocrit and TP concentration.
Absolute changes in total protein in plasma are due to either a decrease in albumin or an increase or decrease in immunoglobulins. Proteins that physiologically migrate in α1-, α2- and β-globulin fraction during electrophoresis are rarely subject to changes that result in marked hypoproteinemia or hyperproteinemia. An absolute increase in albumin does not occur.
1. Doumas BT, Bayse DD, Carter RJ, Peters Jr T, Schaffer R. A candidate reference method for determination of total protein in serum. I. Development and validation. II. Test for transferability. Clin Chem 1981; 27: 1642–54.
5. Reed AH, Cannon DC, Winkelman JW, Bhasin YP, Henry RJ, Pileggi VJ. Estimation of normal ranges from a controlled sample. I. Sex-and age-related influence on the SMA 12/80 screening group of tests. Clin Chem 1972; 18: 57–61.
Serum protein electrophoresis (SPE) is performed to diagnose dysproteinemias. The separation of serum proteins takes place at alkaline pH as a function of the protein’s net charge, isoelectric point and molecular weight. For medical diagnostic purposes, proteins are separated:
- Either on a cellulose acetate medium into the six classic factions transthyretin, albumin, α1-, α2-, β- and γ-globulins in healthy individuals
- Or on agarose gel medium, where specimens from healthy individuals exhibit 8–11 fractions
- Using capillary zone electrophoresis, where up to eight protein fractions can be separated in healthy individuals.
Diagnosis and disease monitoring in patients with
- Monoclonal gammopathies
- Acute and chronic inflammatory response
- Protein-losing syndromes (kidney, gastrointestinal tract, skin, exudates and transudates).
Pathological results in basic laboratory investigations, for example:
- Elevated erythrocyte sedimentation rate
- Increased or decreased serum total protein concentration.
Principle: the fractionation of serum proteins on certain media, especially cellulose acetate is a function of the voltage, electroendosmosis, pH of the separation buffer and the pK value of the individual protein. The placement of the sample on the supporting medium relative to the cathode and anode will affect and determine the degree of separation and resolution of the individual proteins. A multi-sample applicator is used to apply the sample, which is most often placed near the cathode. The separation of the proteins takes place at constant voltage (200 to 250 V) with a separation time of approximately 20 min. in a separation buffer of pH 8.2–8.6. The serum proteins migrate anodically and separate into bands (zones) comprising the fractions albumin, α1-, α2-, β- and γ-globulins. The bands are stained with protein dyes (Ponceau Red S, Amido Black 10B); any non specifically adsorbed dye on the supporting medium is washed out in de colorizing baths. After staining, proteins are identifiable by a characteristic pattern of colored bands which appear on the electrophoretogram, and by the relative intensities of these bands. The quantitative evaluation of the electrophoretogram is performed by densitometric scanning after rendering the cellulose acetate support transparent.
Automatic print out of the densitometer provides following results:
- A scan that indicates the optical density of individual bands ()
- The percentages representing the proportions of the individual band relative to the optical density of the entire electrophoretogram
- The protein concentration of the individual band in g/L relative to the total protein concentration in the sample.
Principle: serum protein separation using agarose as supporting medium is comparable with electrophoresis on cellulose acetate medium, except that a separation time of 30–60 min. is necessary. The higher electroendosmosis, provides a better separation of serum proteins ().
Agarose gel electrophoresis is widely used as a basic method for the separation of proteins, which can be further supplemented by other techniques that demonstrate the proteins more sensitively (e.g., by immunochemical techniques such as immunoelectrophoresis or immunofixation electrophoresis or by enzymatic methods for the measurement of isoenzymes).
Principle: the separation of proteins is carried out in liquid medium in a narrow-bore capillary (20–200 μm), to which a high-voltage potential is applied. In this system, the electroendosmotic separation effect on the individual proteins is greater than their electrophoretic mobility. The separation takes place in the direction of the cathode. There, the proteins are quantified through UV measurement of the peptide bonds. With the help of a data processing program, a graph comparable to that from zone electrophoresis is produced for the following 8 fractions: pre albumin, albumin, α1 acidic glycoprotein, α2-globulin, hemopexin, transferrin, complement, and γ-globulin.
Serum: 1 mL
The use of serum protein electrophoresis represents an effective way to diagnose dysproteinemia.
Dysproteinemias are quantitative or qualitative changes in the protein composition of serum and are closely related to numerous diseases. In the electrophoretogram, dysproteinemias are linked to a disease state and are mainly recognizable when albumin or protein groups are affected exhibiting an increase, or decrease of protein fractions or an extra band . Examples of such proteins or protein groups are albumin, acute phase proteins, the transthyretin-transferrin group and immunoglobulins.
The proportion of albumin decreases in any condition associated with an absolute rise in globulins (α, β, γ); thus, total protein usually remains within the reference interval.
Acute phase proteins
Acute phase proteins migrate in the α1- and α2-globulin fraction and are elevated by 50–300% in acute inflammatory conditions but are decreased in acute hepatitis, chronic active liver disease and protein-losing syndrome.
Pre albumin, also known as transthyretin, migrates in front of the albumin band; usually, 50–70% of the transthyretin are bound in a complex with the retinol-binding protein. Both proteins are decreased in nutritional protein deficiency or in general energy deficiency conditions due to fasting states or in patients under intensive care.
Transferrin migrates in the β-globulin fraction, is elevated in iron deficiency and decreased in a protein and energy deficiency state and in the presence of any acute and chronic inflammatory condition. This also applies to anemia in chronic disease.
Members of the transthyretin-transferrin protein group react to all cases of acute and chronic inflammation with a decrease and are termed as the negative acute phase proteins.
These proteins have antibody function and represent the γ-globulin but in part also the β-globulin fraction. Increases in immunoglobulins are referred to as gammopathies.
In the electrophoretogram these gammopathies cause a broad-based γ-globulin band and are due to a disease that activates the humoral immune defense.
The monoclonals form a narrow-based M-spike within the globulin band. The M-spike is caused by the excessive production of an immunoglobulin or an immunoglobulin fragment by a single plasma cell clone. Clinically, this presents mainly as multiple myeloma or as Waldenström’s macroglobulinemia. The M-spike is localized in the γ– globulin band or β-globulin band, and is referred to as M-spike (M = monoclonal = myeloma = M-formation of the gradient with the albumin fraction in the electrophoretogram).
Selective increases of one or several Ig classes or Ig subclasses but of both light chain types. The Ig class or Ig subclass has limited heterogeneity of antibodies. The γ-globulin zone displays one or mostly several bands (sawtooth pattern).
Isolated protein changes
With the exception of albumin, α1-antitrypsin and IgG, they are not detectable by cellulose acetate electrophoresis but better detectable by capillary zone electrophoresis.
There may be some bands that deviate from the usual electrophoretogram. These appear in SPE with a frequency of approximately 0.7%, and are either supernumerary, and thus situated atypically between the normal bands, or directly superimposed over another band. They become recognizable when their protein concentration exceeds 2 g/L. They result either from the extreme increased production of a plasma protein, or from a technical error while the SPE is being carried out.
The SPE does not allow a diagnosis to be directly established; however, based on the presence of dysproteinemia and the pattern of the electrophoretogram (constellation type), the following interpretations are possible:
- Allocation of certain diseases or groups of diseases to characteristic types of pattern
- Evaluation of disease activity
- Monitoring of disease course.
Because of the quantitative determination of individual plasma proteins, SPE has lost a lot of its value and is/was used:
SPE is not standardized. Cellulose acetate electrophoresis with Ponceau red staining and CZE have generally comparable reference intervals.
Capillary zone electrophoresis (CZE)
CZE has the following advantages over cellulose acetate electrophoresis and agarose gel electrophoresis:
- Markedly lower imprecision /, /
- CZE and immunonephelometric assays yield very similar results in the quantitative determination of albumin .
α1-antitrypsin (AAT) deficiency: CZE should not be used for screening for AAT deficiency if the result is based on the lower reference interval value (). In a study , however, 86% of the ZZ phenotypes and 29% of the MZ phenotypes were detected at a cutoff ≤ 0.21 g/L (see also ).
Hemolytic serum: causes a small peak in the anodic part of the γ-globulin band.
Monoclonal gammopathies: CZE is more sensitive in the detection of monoclonal gammopathies than cellulose acetate electrophoresis (sensitivity 74%) and agarose gel electrophoresis (sensitivity 86%). However, diagnostic sensitivity is only 95% compared to immunofixation electrophoresis .
- Low concentration of monoclonal IgA (total IgA below 3.2 g/L). The monoclonal IgA overlooked by CZE migrates in the β-globulin zone and is hidden under the C3 or transferrin band
- Low concentration of monoclonal IgM (total IgM below 2.1 g/L)
- Free light chains in serum
- Monoclonal IgD
- Monoclonal Ig with a high isoelectric point, that migrate in the cathodic part of the γ-globulin zone are readily detectable in agarose gel electrophoresis, but may be not detectable in CZE.
Specificity of SPE in monoclonal gammopathies
Monoclonal gammopathies are detected in serum protein electrophoresis by the presence of M-gradient or hypogammaglobulinemia. However, extra bands hiding monoclonal immunoprotein can infrequently occur. The laboratory must verify such electropherograms by extending the analysis order (reflex testing) and additionally perform immunofixation electrophoresis. In a study , reflex testing had to be performed in 13.2% of 5992 SPEs. When doing this, numerous monoclonal gammopathies were detected that would have been missed had the assessment of the M-gradient been the sole criterion for monoclonal gammopathy ().
Interference of monoclonal antibody therapies with SPE
Therapeutically used monoclonal antibodies represent both chimeric human – mouse immunoglobulins such as rituximab (Rituxan), siltuximab, infliximab (Remicade), cetuximab (Erbitux) and humanized antibodies such as trastuzumab (Herceptin), vevacizumab (Avastin), adalimumab (Humira). Under therapy, these IgG Kappa monoclonal antibodies reach a concentration of approximately 100 mg/L and higher. They can be detected by immunofixation electrophoresis and CZE and, in SPE, migrate in the middle of the γ-globulin zone, whereas rituximab and trastuzumab migrate in the cathodic portion of the γ-globulin zone .
The therapeutic monoclonal antibodies become undetectable in patients approximately 3 months after the cessation of therapy (5 half-lives).
Serum stored in a closed container at room temperature is stable for 1 day and at 4 °C for up to 1 week.
In the laboratory, control sera are comparable to human sera for measurement controls of the day-to-day precision and the accuracy.
3. Bienvenu J, Graziani MS, Arpin F, et al. Multicenter evaluation of the Paragon CZE 2000 capillary zone electrophoresis system for serum protein electrophoresis and monoclonal component typing. Clin Chem 1998; 44: 599–605.
6. Lichtinghagen R, Pietsch D, Brand K. Evaluation of an automated capillary electrophoresis system for serum protein electrophoresis with the determination of gender-specific reference values. Clin Lab 2010; 56: 119–26.
8. Tate J, Caldwell G, Daly J, Gillis D, Jenkins M, Jovanovic S, et al. Recommendations for standardized reporting of protein electrophoresis in Australia and New Zealand. Ann Clin Biochem 2012; 49: 242–56.
9. Slev PR, Williams BG, Harville TO, Ashwood ER, Bornhorst JA. Efficacy of the detection of α1-antitrypsin Z deficiency variant by routine serum protein electrophoresis. Am J Clin Pathol 2008; 130: 568–72.
12. Katzmann JA, Stankowski-Drengler TJ, Kyle RA, Lockington KS, Snyder MR, Lust JA, et al. Specificity of serum and urine protein electrophoresis for the diagnosis of monoclonal gammopathies. Clin Chem 2010; 56: 1899–1900.
13. Mc Cudden CR, Voorhees PM, Hainsworth SA, Whinna HC, Chapman JF, Hammett-Stabler CA, et al. Interference of monoclonal antibody therapies with serum protein electrophoresis. Clin Chem 2010; 56: 1897–8.
Albumin is the most important binding and transport protein of the organism. Its physiological functions include:
- Maintenance of colloidal osmotic pressure in the vessels
- Binding and transport of metabolites, metal ions, bilirubin, free fatty acids, phospholipids, amino acids, hormones (steroid hormones, thyroid hormones) and drugs
- To serve as an amino acid pool for the tissues through albumin hydrolysis
- Major antioxidant in plasma
- Binding and removal of substances produced during cell regeneration.
Determination of albumin is clinically relevant:
- In serum for diagnostic investigation of dysproteinemia
- In urine for early diagnosis of kidney damage, especially in diabetes mellitus and hypertension (see )
- In cerebrospinal fluid for detecting blood-brain barrier dysfunction (see ).
This following section is limited to a description of the significance of albumin in serum.
- Protein loss (nephrotic syndrome, burns, exudative enteropathy)
- Diagnostic investigation of edematous state
- Prognosis in elderly, hospitalized patients as well as mortality in patients with poly trauma and patients under intensive care
- Index of nutritional state in developing countries.
Serum, heparin anticoagulated blood: 1 mL
Only a decrease in the serum albumin concentration is of clinical significance. Hyper albuminemia based on an absolute increase in the albumin level does not occur.
- Reduced synthesis (e.g., as seen in liver dysfunction) or in protein deficient diets
- Expansion of the extravascular compartments (e.g., as in capillary leakage, sepsis or shock)
- Losses into “third space” (e.g., in the case of edema, ascites or pleural effusion)
- Losses to the exterior (e.g., as observed in nephrotic syndrome, burns or exudative enteropathy)
- Acute phase response (albumin synthesis is down regulated in favor of the acute phase proteins); albumin is a negative acute phase protein
- Pregnancy because the plasma volume increases by 40%
- Congenital defect of albumin synthesis.
The concentration of albumin in serum is also viewed as a global, rough indicator of the health and nutritional status of an individual. This especially applies to the elderly and to chronically ill individuals. This does not come as a surprise because albumin responds by a decrease in concentration in numerous clinical disorders (). In large epidemiological studies, albumin was associated with many health-related variables. Although the results of these studies may be partially inconsistent, they do indicate that sociodemographic, lifestyle-related and illness-related factors correlate with hypoalbuminemia .
In comparison to immunoturbidimetric and immunonephelometric assays, the bromocresol green method yields higher concentrations, but approximately 10% lower concentrations in lithium heparin plasma than in serum .
If blood is not collected with the patient in a supine position or having been sitting for at least 15 minutes, a 5–10% increase in the albumin concentration should be anticipated because of hemoconcentration.
Albumin has a molecular weight of 66.3 kDa, is synthesized in the liver and is the only plasma protein of that size with no carbohydrate chain. Daily synthesis rate ranges from 150–250 mg/kg of body weight; this requires about 12–20% of the hepatic protein synthesis capacity /, /.
The functional domains of albumin are shown in . The N-terminal part of albumin is the binding site for divalent forms of transition metals such as iron, cobalt, nickel and copper. The N-terminus consists of an aspartate-alanine-histidine sequence and is unstable. In the presence of hypoxemia, for example in acute myocardial infarction, free radicals are produced and acidosis develops. Under these conditions, albumin is modified (ischemia-modified albumin, IMA) and the bound transition metals are released . The concentration of IMA is determined based on its binding capacity for cobalt in the Albumin Cobalt Binding Test. IMA binds less cobalt than normal albumin does.
Besides binding metals, albumin transports fatty acids, acts as an antioxidant and has detoxifying capacity. These properties are due to the thiol residue of cysteine 34 (). In patients with stroke, hepatic failure or spontaneous bacterial peritonitis, albumin therapy leads to improved clinical condition. It is assumed that this effect is due to the anti oxidative and detoxifying properties of albumin .
Synthesis of albumin is decreased by:
- Increase in the oncotic pressure in extracellular fluid of the liver
- Reduced availability of amino acids
- IL-6-induced stimulation of synthesis of acute phase proteins.
Thyroxine, glucocorticoids and anabolic steroids exert a stimulatory effect on the synthesis of albumin.
The exchangeable albumin pool ranges from 3.5–5.0 g per kg of body weight corresponding to 250–350 g in an individual weighing 70 kg. Approximately 35–40% of this quantity are located in the extravascular space with the largest portion of it in skin and muscles. The liver itself stores only approximately 0.3 g. Albumin that is synthesized by hepatocytes reaches the circulation via the hepatic vein. Approximately 10-fold the quantity of albumin synthesized daily travels from the intravascular to the interstitial space and returns again via lymph vessels.
In comparison to an upright position, plasma albumin concentration declines by about 15% after a supine position has been assumed for at least 30 min.
The half-life of albumin is 19 days. Approximately 0.1 g are lost daily via diffusion into the gastrointestinal tract and 15 mg through the kidneys. Catabolism of albumin, like that of other plasma proteins, occurs in many tissues, especially the capillary endothelial cells, and is the result of continuous pinocytosis. Catabolism is decreased in hypoalbuminemia, although fractional degradation is normal. The plasma albumin concentration mostly depends on defects in distribution and much less on defects in synthesis. If food is withheld, albumin concentration declines below the lower reference interval value after one week at the earliest. In nutritional protein deficiency, the extent of edema correlates only weakly with albumin concentration.
More pronounced albumin losses to the exterior (e.g., as seen in patients with nephrotic syndrome) lead to an increased synthetic rate. Since synthesis of albumin is linked to synthesis of cholinesterase, the activity of this enzyme is increased in serum in patients with albumin loss. Absolute albumin increases in serum do not occur. Elevated levels are almost always due to pseudo hyperalbuminemia (e.g., as in exsiccosis).
Many drugs bind to albumin. Hypoalbuminemia can, therefore, be associated with an increase in the free, pharmacologically active portion of a drug. Drugs that are strongly bound to albumin are, for example, phenytoin and valproic acid. In these patients, hypoalbuminemia can lead to an increased pharmacological effect despite constant dosage of the drug. The binding capacity of albumin for therapeutic drugs may also be altered. For instance, in the presence of renal insufficiency, albumin has a decreased binding capacity for phenytoin and salicylic acid.
Genetic structural variants of albumin are detected in serum protein electrophoresis or are incidental findings (e.g., during the determination of thyroid hormones). For instance, in familial dysalbuminemic hyperthyroidism, total T4 is elevated in the face of normal FT4. The underlying cause is an abnormal albumin with increased binding capacity for T4.
7. Jalan R, Schnurr K, Mookerjee RP, Sen S, Cheshire L, Hodges S, et al. Alterations in the functional capacity of albumin in patients with decompensated cirrhosis is associated with increased mortality. Hepatology 2009; 50: 555–64.
10. Yuki RL, Bar-Or D, Harris L, Shapiro H, Winkler JV. Low albumin level in the emergency department: a potential independent predictor of delayed mortality in blunt trauma. J Emergency Med 2003; 25: 1–6.
11. Feldman JG, Gange SJ, Bacchetti P, Cohen M, Young M, Squires KE, et al. Serum albumin is a powerful predictor of survival among HIV-1-infected women. J Acquired Immune Deficiency Syndromes 2003; 33: 66–73.
14. Galliano M, Campagnoli M, Rossi A, Wirsing von König CH, Lyon AW, Cefle K, et al. Molecular diagnosis of analbuminemia: A novel mutation identified in two American and two Turkish Families. Clin Chem 2002; 48: 844–9.
15. Meng QH, Krahn J. Lithium heparinised blood-collection tubes give fasely low albumin results with an automated bromcresol green method in haemodialysis patients. Clin Chem Lab Med 2008; 46: 396–400.
AAT belongs to the family of serine protease inhibitors, also referred to as serpins. These inhibitors form irreversible complexes with, and thus inactivate, serine proteases such as elastase, chymotrypsin, trypsin and thrombin. AAT is, therefore, also referred to as α1-proteinase inhibitor (α1-Pi). It is encoded by the gene SERPINA1. Approximately 120 genetic variants of AAT are known. AAT deficiency is usually diagnosed following the diagnosis of chronic obstructive pulmonary disease (COPD), liver disease or, in some countries, within the scope of newborn screening if familial AAT deficiency is known to exist.
- Normal (referred to M; M1, M2, M3, M4): the normal variants are characterized by plasma levels in the general population
- Deficient variants: these variants are characterized by missense mutations e.g., the common Pi*Z (Glu342 Lys) and Pi*S (Glu264Val) mutations. Included are the variants with small deletions (Mmalton, Mheerlen, Q0amersfoort, Mwürzburg) with decreased but still detectable serum concentrations of AAT
- Null variants (Q0) with no detectable AAT serum concentration. Null variants result from nonsense or frameshift mutations leading to premature stop codons.
Contrary to AAT deficiency, elevated AAT has no clinical relevance. However, causes of elevated AAT must be taken into consideration when assessing AAT deficiency.
- Patients with COPD, asthma, unexplainable liver disease and necrotizing panniculitis
- Individuals with persistent air flow restriction
- Siblings of individuals with known AAT deficiency.
Three strategies are followed for diagnosing AAT deficiency:
- Determination of serum AAT concentration. If the concentration is below a certain cutoff value, the phenotype of the AAT deficiency is determined.
- Phenotyping of AAT for determining the isoform pattern. A disadvantage of this approach is that Pi*null alleles cannot be identified because no proteins are synthesized in this variant.
- Genotyping of SERPINA1 [Serpin peptidase inhibitor, clade A (alpha-1 antiproteinase, antitrypsin), member 1].
Instead of classifying the AAT type, some laboratories immediately perform AAT genotyping if the AAT concentration is lower than a specific cutoff value.
Serum protein electrophoresis: among the proteins of the α1-globulin fraction, AAT is the protein that is predominantly stainable by protein dyes. In homozygous AAT deficiency, the α1-globulin fraction may be strongly diminished or absent. A normal α1-globulin band does not rule out AAT deficiency. See also .
Proteinase inhibitor (Pi) capacity
Principle: depending on the AAT concentration in the patient’s sample, addition of patient serum to a trypsin-catalyzed reaction inhibits the activity of a defined quantity of trypsin that was previously added . In the test reaction, residual active trypsin releases p-nitroaniline from the added substrate (benzyl-arginine-p-nitroanilide or tosyl-glycyl-lysine-4-nitro anilide acetate); the absorption increase of this reaction product is spectrophotometrically measured at 405 nm. The Pi capacity is primarily determined under therapeutic aspects.
Determination of the AAT phenotype
The AAT phenotype of a patient is determined using isoelectric focusing (IEF) in polyacrylamide gel with a pH gradient of 3.5–5.0. The variants (isoforms) of AAT present in band patterns based on their migration in a pH gradient. Z0 (null), ZZ and SZ, which are the essential of 100 Pi variants with pathogenic significance, can be easily differentiated . The patterns show multiple bands of different mobility, reflecting different AAT glycosylation. Interpretation of the results is influenced by artifacts such as age of the sample and storage conditions.
Classification of the AAT genotype
Genomic DNA is extracted from EDTA whole blood, and PCR is performed followed by melting point analysis. Primers are used for genes containing the Z allele and the S allele . Most commercial tests for molecular identification detect the common AAT variants Pi*S and Pi*Z. However, more than 30 variants also associated with AAT deficiency are not detected.
- AAT concentration (serum): 1 mL
- Pi capacity (citrate plasma): 2 mL
- DNA analysis (EDTA blood): 5 mL
* Values are 5th and 95th percentiles. Conversion: mg/L × 19.6 = μmol/L
AAT is primarily synthesized by the hepatocytes, but also by monocytes, alveolar macrophages and granulocytes. The serum concentration depends on the genotype.
During acute phase response, AAT concentration usually increases to a maximum of 3-fold. Levels > 5 g/L are measured in patients with squamous cell cancer and adenocarcinoma. With the exception of tuberculosis, levels of such magnitude do not occur in any other pulmonary disease . A 1–2-fold increase in concentration can also occur during pregnancy and when taking oral contraceptives.
AAT alleles are autosomal co dominantly inherited. More than 100 genetic variants have been described. Pi*M with six subtypes M 1–M 6 is the normal allele and is present in more than 90% of the normal population. The normal subtypes are distinguished by different amino acids due to the substitution of individual bases in the DNA. The PiMM phenotype is associated with a normal concentration and inhibitor capacity of AAT.
Clinical symptoms of AAT deficiency involve the lungs, liver and skin. The following symptoms suggest the presence of AAT deficiency:
- Unexplainable COPD
- Viral hepatitis-marker-negative or non-alcohol-induced liver disease
- Necrotizing panniculitis.
The majority of patients with decreased AAT concentration and COPD or AAT-deficiency-induced liver disease are either homozygous for PiZ*, compound heterozygous for S and Z alleles (PiSZ) or have a null allele.
Approximately 3.4 million people worldwide (1 in 1500 to 1 in 10,000, depending on the population group) have severe AAT deficiency, and 116 million are carriers of a Pi*Z allele or Pi*S allele, with the highest prevalence found in Europe .
The following distinction is made:
- Individuals with severe AAT deficiency due to homozygosity (PiZZ) or compound heterozygosity (PiSZ) or null alleles. These individuals have an increased risk of COPD in their 3rd to 5th decade of life and of chronic liver disease at a later age.
- Individuals with mild to moderate AAT deficiency have a low risk of COPD. This refers to genotypes that are heterozygous for AAT deficiency-related alleles such as PiMZ (odds ratio 2.31 compared to PiMM) or the Pi*S allele . The latter is more common in many European populations than the Pi*Z allele. Characteristics of selected AAT variants are listed in .
In many patients, AAT deficiency is not detected and the mean interval between initial symptoms and diagnosis is 8 years. Patients are 46 years of age on average at the time of diagnosis and have already consulted a doctor at least three times because of their symptoms . In all, only about 5% of AAT deficiency-related cases are detected since many patients are asymptomatic and only 1% of the patients with COPD have AAT deficiency .
The determination of the AAT concentration within the scope of screenings is an important criterion for the detection of AAT deficiency. The lower reference interval value should not be used as a cutoff for the screening because the protein concentrations of PiMM types and deficiency-related types overlap. Severe AAT deficiency is generally ruled out in concentrations above 1.0 g/L , but types with mild AAT deficiency, who also have a risk of COPD, may be missed. For instance, in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA) , 95% of the AAT variants, including all clinically relevant ones, were detected at an AAT concentration ≤ 1.13 g/L. Classification of the patients in subgroups based on the AAT concentration led to the genotype distribution presented in .
The prevalence of the ZZ phenotype is 1 in 1639 newborns according to a Swedish study and 1 in 5097 in a study performed in the USA. The decrease in AAT concentration in these individuals is below 35% of the mean of PiMM types, corresponding to below 0.70 g/L. This also applies to phenotypes SZ, Szero and Zerozero.
Liver disease should not be ruled out in the differential diagnosis of neonatal cholestasis associated with normal AAT concentrations. This is due to rare heterozygous variants. Therefore, it is recommended in neonatal cholestasis and suspected AAT deficiency to perform electrophoretic AAT phenotyping or genotyping .
In carriers of a deficiency allele, the reason for an AAT concentration that still falls within the reference interval may be the acute phase function of the protein in inflammation. Such cases can be discriminated by the simultaneously elevated C-reactive protein.
In AAT concentrations < 1.0 g/L, phenotyping is performed using IFE, whereas up to 22% of the carriers of deficiency-related alleles (Mheerlen, Q0amersfoort, Mwürzburg, Q0soest) are diagnosed by genotyping .
Substitution therapy in patients with AAT deficiency is performed by using highly purified AAT. Treatment consists of a once-weekly administration of 60 mg/kg of body weight. This dosage is sufficient to maintain a mean serum AAT concentration of 0.3 g/L . For further information refer to Ref. .
Anticoagulants such as buffered citrate, potassium oxalate, sodium fluoride or EDTA lead to falsely low AAT levels when determining both the concentration and the trypsin inhibitory capacity; heparin, on the other hand, does not interference in either method .
Method of determination
The genotyping of individuals with AAT deficiency using commercial assays only detects those with Pi*Z and Pi*S alleles, but not those with null alleles or other rare variants.
When determining the AAT concentration cutoff value, below which further genotyping and phenotyping are to be performed, care must be taken to take the reagent manufacturer into account because there still are marked differences between the individual manufacturers. In the literature, the cutoff values range between ≤ 1.1 and ≤ 1.0 g/L /, /.
AAT is a glycoprotein with a molecular weight of 51 kDa and occurs in approximately equal concentrations in plasma and in interstitial fluid. Its synthetic sites, besides hepatocytes, include alveolar macrophages and monocytes. The daily synthetic rate is 34 mg/kg of body weight and the half-life is 6–7 days.
- Antithrombin which causes the inactivation of released proteases of the coagulation system, such as thrombin and FXa
- The C1 esterase inhibitor which controls the activation of the complement system
- The plasmin activator (PA) inhibitor (PAI). The PAI inhibits the PA, which converts plasminogen into plasmin and thus activates fibrinolysis.
The AAT, also known as α1-proteinase inhibitor, inhibits the serine proteases trypsin, chymotrypsin as well as pancreatic and especially polymorphonuclear-granulocytic elastase. Elastase cleaves connective tissue structures such as collagen and elastin. This step is necessary for the formation of pus and the liquefaction of an inflammatory site. However, in tissue surrounding the inflammatory site, AAT limits the elastase effect in order to prevent tissue damage from becoming too widespread.
The serpins differ from other proteinase inhibitor families by the complex manner of protease inhibition associated with a drastic change in structure (). For instance, mutations in the gene SERPINA1 lead to a change in protein conformation so that the protein can still be synthesized but no longer secreted in the endoplasmic reticulum. This results in a conformation disorder including the precipitation of protein aggregates in the hepatocyte and hepatocellular degeneration as well as AAT deficiency .
AAT exerts its effect mainly on epithelial and serous surfaces. Development of pulmonary emphysema in patients with AAT deficiency is thought to be caused by an imbalance between elastase and AAT. Imbalance is due to an activation of granulocytes by the platelet-activating factor, which is released by macrophages and granulocytes; as a mediator of inflammation, this platelet-activating factor stimulates granulocytes to release peroxidases and elastase.
A significant part of the mutants in the gene SERPINA1 has no influence on protein expression and function. However, several alleles encode an AAT that either exists in the circulation at decreased concentration or is dysfunctional.
- Deficiency alleles such as Pi*Z. The Glu342Lys mutation changes the protein structure of the AAT protein. This results in an aggregation and polymerization of the molecule in the endoplasmic reticulum of the hepatocytes including the precipitation and formation of hepatocellular inclusion bodies.
- PiS-protein allele. The protein of this Glu264Val mutation polymerizes but is secreted and relatively quickly eliminated from the blood; as a result, serum concentration is only 60% of the normal value.
- Null alleles; they either produce no transcript or garbled or unstable AAT causing degradation already prior to secretion from the cell .
- Dysfunctional alleles encode an AAT that does not bind to elastase but to other proteins such as antithrombin.
Individuals with the PiSS phenotype always produce sufficient AAT so that severe AAT deficiency does not manifest and clinical symptoms manifest but rarely.
Carriers of a Pi*Z allele are characterized by decreased AAT concentration and decreased inhibitor capacity regarding polymorphonuclear-granulocytic elastase. This results in unrestricted elastase activity and development of COPD. The Z variant of AAT has an unstable conformation leading to the polymerization of several AAT molecules and the formation of hepatocellular inclusion bodies.
Hence, liver disease in carriers of Pi*Z alleles is not based on AAT deficiency but on abnormal AAT polymerization. The β chain of the AAT molecule in the rough endoplasmic reticulum has an altered conformation causing the entire molecule to become unstable. As a result, the peptide chain of the second AAT molecule is able to incorporate into the structure of the first molecule causing the formation of a dimer (). The entire process can multiply, leading to the formation of polymers that can no longer be released from the endoplasmic reticulum and precipitate as a result. The resulting inclusion bodies are subject to degradation. The development of hepatocellular necrosis is thought to depend on the balance between AAT aggregation and inclusion body degradation. The fact that aggregate formation increases with increasing temperature is an explanation why newborns with the ZZ phenotype with fever more often develop liver disease than those without fever.
2. Balderacci AM, Barzon V, Ottaviani S, Corino A, Zorzetto M, Wencker M, et al. Comparison of different algorithms in laboratory diagnosis of alpha1-antitrypsin deficiency. Clin Chem Lab Med 2021; 59 (8): 1384–91.
5. Braun A, Meyer P, Cleve H, Roscher AA. Rapid and simple diagnosis of the two common α1-proteinase inhibitor deficiency alleles PiZ and PiS by DNA analysis. Eur J Clin Chem Clin Biochem 1996; 34: 761–4.
9. Zorzetto M, Russi E, Senn O, Imboden M, Ferrarotti I, Tinelli C, et al. SERPINA1 gene variants in individuals from the general population with reduced α1-antitrypsin concentrations. Clin Chem 2008; 54: 1331–8.
12. Lang T, Mühlbauer M, Strobelt M, Weidinger S, Hadorn HB. Alpha-1 antitrypsin deficiency in children: liver disease is not reflected by low serum levels of alpha-1 antitrypsin – a study on 48 pediatric patients. Eur J Med Res 2005; 10: 509–14.
13. Snyder MR, Katzmann JR, Butz ML, Yang P, Dawson DB, Halling KC, et al. Diagnosis of α1-antitrypsin deficiency: an algorithm of quantification, genotyping, and phenotyping. Clin Chem 2006; 52: 2236–42.
14. Prins J, van der Meijden BB, Kraaijenhagen RJ, Wielders JPM. Inherited chronic obstructive pulmonary disease: new selective-sequencing workup for α1-antitrypsin deficiency identifies 2 previously unidentified null alleles. Clin Chem 2008; 54: 101–7.
26. Chapman KR, Chrostowska-Wynimko J, Koczulla AR, Ferrarotti I, McElvaney NG. Alpha I antitrypsin to treat lung disease in alpha I antitrypsin deficiency: recent developments and clinical implications. Int J of COPD 2018; 13: 419–32.
Laboratory tests to detect light drinking and alcohol abuse offer the opportunity to objectively verify the information about alcohol consumption provided by a person or patient. A differentiation is made between :
- Direct biomarkers; these markers are created when ethanol is metabolized or reacts with substances in the body
- Indirect biomarkers, which undergo typical changes in response to acute or chronic alcohol consumption e.g., increase in gamma glutamyl transferase or increase of mean cell volume (MCV) of red cells.
An overview is provided of the alcohol markers ethanol, ethyl glucuronide, carbohydrate deficient transferrin, and some indirect biomarkers.
Alcohol refers to ethanol which may carry synonyms of ethyl alcohol. The molecular weight of ethyl alcohol (chemical formula: CH3CH2OH) is 46 Da and the density is 0.79. If another alcohol is consumed, it must be specifically identified and the medical effect differently assessed .
Note the following Tables and Figures:
Anaerobic metabolim of ethanol generates direct markers of alcohol like ethyl glucuronide (EtG). This compound is a product of the conjugation reaction catalyzed by UDP-glucuronosyltransferase (). EtG is nonvolantile, water-soluble, stable, and detectable long after complete elimination of alcohol. EtG is concentrated by almost 200 times in urine as compared to serum; the window of detection in urine is up to 90 h. This makes EtG a preferred marker for the detection of alcohol consumption in medical and forensic diagnostics .
The structure of transferrin (Tf), the Fe3+-transporting protein, usually consists of two branched carbohydrate chains with a sialic acid residue at the end of each of the four branches. Tetrasialo transferrin, for example, is intact Tf. Long-term continuous consumption of more than 60–80 g of pure alcohol per day causes defective Tf glycosilation. This results in an increase in Tf isoforms lacking one or two N glycans (e.g., disialo Tf, monosialo Tf and asialo Tf) (). These isoforms are correlated with chronic alcohol abuse and are collectively referred to as carbohydrate-deficient transferrin (CDT). The quantitative determination of CDT is used for diagnosing chronic alcohol abuse. CDT is currently the best indirect biomarker in this context because it yields the lowest rate of false-positive results compared to other laboratory assays .
- Breath test: up to 10–12 h after the last drink
- Alcohol in blood or urine: up to 10–12 h after the last drink
- Ethyl glucuronide in blood: up to 20 h after the last drink
- Ethyl glucuronide in urine: up to 24 h after small quantities of alcohol, up to 130 h after excessive consumption
- Carbohydrate deficient transferrin: chronic excessive drinking.
Alcohol in blood, serum, and plasma
Principle of alcohol dehydogenase (ADH) method: in the forward direction ethanol is oxidized in the presence of NADP to aldehyde and NAPH2. The reaction is catalyzed by the enzyme ADH (EC 188.8.131.52).
Ethyl glucuronide in urine
CDT immunoassay in serum/plasma
Principle: the CDT immunoassay is based on the application of a monoclonal antibody that is specifically directed against CDT isoforms lacking one or several N-glycans . The Tf concentration is determined simultaneously in a second immunoassay. Polystyrene particles coated with a monoclonal anti-CDT antibody are agglutinated by CDT-coated polystyrene particles. The CDT in the sample inhibits the reaction between the antibody coated and CTD-coated particles in a dose-dependent manner. The extent of agglutination depends on the CDT concentration in the sample. The increase in light scattering measured by nephelometry is recorded and %CDT is calculated based on simultaneously determined Tf.
Serum: 1 mL
Urine: 5 mL
Threshold to differentiate between patients with and without alcohol dependence:
- Ethanol in serum/plasma: 5 mg/L. Threshold for recent alcohol intake; end of drinking not longer than 1 day ago .
- Ethyl glucuronide in urine: 100–200 μg/L. Any drinking the night before should be detectable the following morning with these cutoffs
- CDT in serum/plasma: relative threshold (immunoassay): ≤ 2.5% .
Alcohol biomarkers are ordered to objectively evaluate alcohol consumption, excessive alcohol abuse, and to monitor alcohol abstinence. The selection of the biomarker is dependent on the amount of consumed alcohol and the width of the time window between the last alcohol consumption and collection of the sample to be analyzed.
- Direct methods encourage self-reporting of patients (Alcohol Use Disorder Identification Test or AUDIT).
- Indirect methods comprise clinical tests, indirect questionnaires and laboratory investigations.
- Diseases induced by chronic alcohol abuse are shown in
- Typical laboratory markers of alcoholism are shown in .
Alcohol consumption is defined according to the Dietary Guidelines for Americans 2015–2020 of the US Department of Health and Human Services and US Department of Agriculture:
- Moderate drinking is up to 1 standard drink per day for women and up to 2 drinks per day for men
- A heavy drinking day is defined as over 3 standard drinks for women and over 4 standard drinks for men
- Binge drinking is a pattern of drinking that brings blood alcohol concentration levels to 0.08 g/dL (17.4 mmol/L). This typically occurs after 4 standard drinks for women and 5 drinks for men in about 2 hours.
- Heavy alcohol use is binge drinking on 5 or more days in the past month.
- Low risk drinking for developing alcohol use disorders is no more than 3 drinks on any single day and no more than 7 drinks per week (for women) and no more than 4 drinks on any single day and no more than 14 drinks per week (for men).
- Alcohol use disorder is a chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.
Measures of blood alcohol such as breath test, alcohol determination in blood or urine can only detect alcohol use during the preceding 12 hours, making them suitable for detection current intoxication only .
Ethyl glucuronide (EtG) can be detected in blood within 45 min. after alcohol consumption and the time window in serum is by up to 8 h longer compared to ethanol. In urine EtG can be proven for up to about 24 h even after consumption of small quantities. After excessive consumption the window of detection is up to 130 hours .
- Any drinking the night before are detectable the following morning with EtG cutoffs of 100 or 200 μg/L. Twenty-four hours after drinking, sensitivity is poor for light drinking, but good for heavier consumption.
- At 48 hours, sensitivity is low following 6 drinks or less.
- Increasing the cutoff to 500 μg/L leads to substantially reduced sensitivity.
- The 100 μg/L cutoff detected > 76% of light drinking for two days, and 66% at 5 days
- The 100 μg/L cutoff detected 84% (1day) to 79% (5 days) of heavy drinking
- The 200 μg/L cutoff detected > 55% of light drinking and > 66% of heavy drinking across 5 days
- The 500 μg/L cutoff identified 68% of light drinking and 78% of heavy drinking for 1 day with detection of light (2–5 days < 58%) and heavy drinking (5 days < 71%) decreasing thereafter.
Carbohydrate-deficient transferrin (CDT) is the most specific biomarker of chronic alcohol abuse. Increased amounts of CDT appear with high prevalence in serum if alcohol abuse of 50–80 g of alcohol per day are consumed on at least 7 consecutive days. The %CDT decreases to within the reference interval after abstinence with a half-life of approximately 14 days . The %CDT varies only slightly in unchanged alcohol consumption. During alcohol withdrawal, the decrease in %CDT in relation to the initial value is conclusive in longitudinal assessment .
Advantages of %CDT determination
No correlations have been found between the serum concentrations of CDT and Tf . The proportion of CDT in Tf (%CDT) is recommended as an assessment criterion for compensating changes in Tf concentration due to electrolyte/water imbalance or an increase/decrease in Tf concentration. %CDT has the following advantages over concentration data:
- Fewer false-positive findings (increased diagnostic specificity) in individuals with normal alcohol consumption and elevated Tf concentration (e.g., in the presence of iron deficiency) .
- Fewer false-negative findings (increased diagnostic sensitivity) in individuals with chronic alcohol abuse and low Tf concentration due to acute or chronic infections, hemochromatosis and tumor diseases .
GGT and %CDT
No correlations have been found between GGT activity and %CDT. The combined determination of CDT and GGT makes sense due to the high diagnostic sensitivity of GGT and the good diagnostic specificity of CDT.
%CDT and MCV
Venous blood collection without specific preparation of the patient; CDT is not influenced by food intake or time of day. Daily intraindividual CDT fluctuation is 8%.
Method of determination
In chromatographic and electrophoretic methods, the TF phenotype D leads to falsely high %CDT and the TF phenotype B leads to falsely low %CDT values. This is not the case in the homogeneous CDT immunoassay. The latter assay is also not interfered by the serum of patients with hepatic disease.
EtG can be detected in samples at low levels and can be positive after exposure to alcohol from non-beverage sources or incidental exposure, which lead to false positives. Some healthcare workers, who are exposed to alcohol containing hand washes repeatedly throughout the day, might be positive if tested shortly thereafter. Using a cutoff of 200 μg/l might reduce the risk of such false positives .
CDT in serum is stable for 30 hours at room temperature, for up to 7 days at 4 °C, and for several months to years at –22 °C; CDT increases by 25% after 3 days at room temperature. CDT is not affected by repeated freezing and defrosting. When stored at 4 °C in airtight test tubes, EtG concentration remains relatively constant.
- The amount of alcohol contained in drinks is expressed most commonly as percent by volume (% v). The (% v) multiplied with the density of ethanol gives the percentage of the drink in grams ()
- The total amount of alcohol consumed in grams is calculated according to
- The concentration of blood alcohol is calculated from the amount of alcohol consumed taking into account the reduction weight. Explanation: muscles and brain take up more alcohol in relation to bone and adipose tissue. The body weight must be corrected by the reduction factor 0.7 for calculating the relation of the amount of alcohol to the body weight (body weight × 0.7 = reduction weight). The reduction weight multiplied by the blood alcohol concentration (‰) expresses the amount of consumed alcohol ().
- Within a few hours following alcohol consumption, the blood alcohol level can be used to calculate the amount of alcohol consumed ()
- The serum alcohol concentration (mmol/L) is converted into blood alcohol concentration (‰) according to .
Ethyl glucuronide (EtG)
None oxidative metabolism of ethanol generates compounds, which are called direct markers of alcohol. This group includes EtG, ethyl sulfate and phosphatidyl ethanol. EtG is formed by glucuronidation following exposure to ethanol. The molecular mass is 222 g/mol, the molecular formula is C8H14O7, and the elimination half-life is 2–3 hours. The concentration of serum EtG is a function of two opposing influences; dose of alcohol consumed and time window elapsed between consumption and sample collection. The concentration in urine is dependent on diuresis. The intake of alcohol contained in large volumes of water results in a steep decline of EtG level in urine. Therefore a minimum requirement on the urine creatinine concentration is > 20 mg/dL (1.77 mmol/L).
Carbohydrate-deficient transferrin (CDT)
There are three known causes of Tf heterogeneity:
- Variation of the amino acid structure of the polypeptide chain due to genetic polymorphism. Using starch gel electrophoresis, the wild type TfC can be differentiated from the more quickly migrating type TfB and the slower cathodic type TfD. All genetic variants have normal iron binding capacity.
- The iron content. Among the four isoforms, diferric Tf binds iron in the N-terminal and C-terminal domains, monoferric Tf binds iron in the N-terminal and C-terminal domains and apo-Tf has no bound iron ions. The N-terminal domain has dominant iron binding capacity.
- The carbohydrate chains. Each of the two oligosaccharide chains in the N-terminal domain structurally varies in branching, with mostly bi- or tri-antennary structure. Each antenna is terminated by sialic acid.
The following CDT isoforms are distinguished: asialo Tf (< 0.5%), monosialo Tf (< 0.9%), disialo Tf (< 2.5%), trisialo Tf (4.5–9.0%), tetrasialo Tf (64–80%), pentasialo Tf (12–18%), hexasialo Tf (1.0–3.0%) and heptasialo Tf (< 1.5%). The isoelectric point of the isoforms depends on the number of sialic acid residues.
The alcohol-induced increase in CDT concentration is due to ethanol-induced and/or acetaldehyde-induced defective synthesis of the N-carbohydrate chains of Tf. For instance, lower activities of galactosyl transferase and N-acetyl glucosaminyl transferase are measured in the serum of alcoholics.
3. Shukla L, Sharma P, Genesha S, Ghadigaonkar D, Thomas E, Kandasamy A, et al. Value of ethyl glucuronide and ethylsulfate in serum as biomarkers of alcohol consumption. Indian J Psycol Med 2017; 39: 481–7.
5. Lowe JM, Mc Donell MG, Leickly E, Angelo FA, Villadarga R, McPherson S, , et al. Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients. Alcohol Clin Exp Res 2015; 39: 905–10.
6. Weimann W, Schaefer P, Thierauf A, Schreiber A, Wurst FM. Confimatory analysis of etylglucuronide in urine by liquid-chromatography/electrospray ionization/tandem mass spectrometry according to forensic guidelines. J Amer Mass Spectrometry 2004; 15: 188–93.
8. Delanghe JR, Helander A, Wielders JPM, Pegelharing JM, Roth HJ, Schellenbeg F, et al. Development and multicenter evaluation of the N latex CDT direct immunonephelometric assay for serum carbohydrate-deficient transferrin. Clin Chem 2007; 53: 1115–21.
9. Jatlow PI, Agro A, Wu R, Nadim H, Toll BA, Ralevski E, et al. Ethylglucuronide and ethyl sulfate assays in the clinical trial, interpretation and limitations: results of a dose ranging alcohol challenge study and two clinical trials. Alcohol Clin Exp Res 2014; 38: 2056–65.
13. Helander A,, Böttcher M, Fehr C, Dahmen N, Beck O. Detection times for urinary ethyl glucuronide and ethyl sulfate in heavy drinkers during alcohol detoxification. Alcohol Alcohol 2009; 44: 55–61.
14. Mc Donell MG, Skalisky J, Leickly E, McPherson S, Battalio S, Nepom JR, et al. Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients. Drug Alcohol Depend 2015; 157: 184–7.
16. Borg S, Helander A, Voltaire Carlsson A, Högström Brandt AM. Detection of relapses in alcohol-dependent patients using carbohydrate-deficient transferrin: improvement with individualized reference levels during long-term monitoring. Alcohol Clin Exp Res 1995; 19: 961–3.
17. Stauber RE, Vollman H, Pesserl L, Jauk B, Lipp R, Halwachs G, Wilders-Trusching M. Carbohydrate-deficient transferrin in healthy women: relation to estrogens and iron status. Alcohol Clin Exp Res 1996; 20: 1114–7.
18. de Feo TM, Fargion S, Duca L, Mattioli M, Cappellini MD, Sampietro M, Cesana BM, Fiorelli G. Carbohydrate-deficient transferrin, a sensitive marker of chronic alcohol abuse, is highly influenced by body iron. Hepatology 1999; 29: 658–63.
25. Mukamal KJ, Conigrave KM, Mittleman MA, Camargo CA, Stampfer MJ, Willett WC, Rimm EB. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in man. N Engl J Med 2003; 348: 109–18.
Ceruloplasmin (Cp) is the copper (Cu)-carrying protein in the circulation. A Cp molecule binds 6 Cu atoms; 90% of the Cu in plasma are present in the form of Cp-Cu complexes functioning as the source of Cu supply to peripheral organs such as the brain and kidneys.
Cp is synthesized in the liver. The hepatocytes secrete Cp as copper (Cu)-carrying protein into the circulation. Cp is an acute phase protein and, in serum protein electrophoresis, migrates in the α2-globulin band.
Moreover, the functions of Cp include:
- Ferroxidase activity (regulation of the oxidative status of iron and other metal ions); for instance, Cp oxidizes Fe2+ to Fe3+
- Anti oxidative effect (influence of the redox state of plasma) due to the prevention of metal-ion-catalyzed oxidation of lipids in the cell membrane
- Oxidation of nitrogen monoxide (NO.) and influence on NO. homeostasis (see ).
The serum Cp concentration is diagnostically relevant because a low level suggests the presence of Wilson’s disease and Menkes disease. For diagnosing Wilson’s disease, Cp should be assessed in association with the urinary Cu excretion. See .
- Exclusion of Wilson’s disease in all children with suspected autoimmune hepatitis or non-alcoholic fatty liver disease (NAFLD). Wilson’s disease is to be suspected in children above 5 years of age who have sonographically detectable fatty liver or any form of acute liver failure /, /.
- Hepatitis-marker-negative liver disease in childhood or adolescence (suspected Wilson’s disease)
- Patients with extra-pyramidal, cerebellar or cerebral symptoms of subacute or chronic nature. The most common initial symptoms are difficulties in speaking and swallowing (suspected Wilson’s disease)
- Neurodegenerative symptoms and signs of connective tissue disease in infants and small children (suspected Menkes disease).
Immunoassay and immunonephelometric or immunoturbidimetric assays.
Serum: 1 mL
Wilson’s disease is only the decrease in serum Cp concentration that is clinically relevant. However, when assessing the Cp concentration, diseases and conditions must be taken into consideration that may lead to an increase in Cp and mask a decrease in concentration.
Elevated Cp levels in serum up to 3-fold the upper reference interval value may occur as part of the acute phase response in inflammation, especially during bacterial infections. Serum protein electrophoresis shows an increase in the α2-globulin fraction.
Depending on the dose, intake of oral contraceptives or estrogens during menopause leads to a 20–30% increase in serum Cp concentration. Cp can be elevated as high as three-fold during pregnancy.
WD may present as liver disease, a neurologic disorder,.a psychiatric illness or a combination of these disorders. Clinically evident WD is relentlessly progressive and ultimatively fatal, if untreated . WD is an autosomal recessive condition, results in a Cu deposition in the hepatocytes, brain, iris and kidney. The excretion of Cu into the bile is delayed and the incorporation of Cu in Cp is impaired. Most patients present with predominantly hepatic or predominantly neurological Cu disorders. WD is a monogenic, autosomal recessively inherited condition. The causative gene ATP7B encodes a Cu-transporting P-type ATPase . The latter can be associated with symptomatic or asymptomatic involvement of the liver. WD can manifest at any age, although usually before the age of 50 years older age does not rule it out .
Liver disease of WD
In children hepatic WD ranges from mild liver disease and fatty liver disease to cirrhosis. Infrequently, WD manifests as acute liver failure, the first manifestation of WD.
Clinical findings: severe coagulopathy, hepatic encephalopathy, acute intravascular hemolysis.
Laboratory findings: the liver enzyme pattern indicates moderate elevations of ALT, AST, and ALP and progression to renal failure. A ratio of increase of ALP/total bilirubin of < 4 and a ratio of AST/ALT > 2.2 was 100% sensitive and specific for diagnosing WD.
Neurologic disorders of WD
Psychiatric disorders of WD
- Serum ceruloplasmin (Cp): Concentrations of 11 to 14 mg/dL are reported although levels < 5 mg/dL strongly supports WD. However serum Cp is not adequate for WD.
- 24 hours copper excretion in urine > 40 mg
- Kayser-Fleischer rings by means of slit-lamp examination
- Hepatic parenchymal copper level of 250 μg/g dry weight
- ATP7B mutations: More than 500 ATP7B mutations have been described. Most are missense mutations, small deletions/insertions in the coding region, or splice junction mutations . Among Caucasians in Europe and North America, the point mutation H1069Q is the most common ATP7B mutation and 50–80% of WD patients carry at least one H1069Q allele.
Firm genotype-phenotype associations for other more common ATP7B mutations do not reveal a clear correlation. In a study , mutations in both chromosomes were diagnosed in 57% of the patients with WD. Approximately 15% of the patients showed no mutation; this was attributed to undetected mutations in the promoter region and exons that had not been analyzed.
There is an association between the presence of the ATP7B H1069Q mutation, the incidence of neurological symptoms and age.
- Neurological symptoms in 63%, 43% and 15% of the cases, respectively
- A mean age of 20.9, 15.9 and 12.6 years.
In another study , patients with WD presenting with neurological symptoms were 20.2 ± 10.8 years of age, and those with hepatic symptoms were 15.5 ± 9.6 years of age. Diagnosing of the disease took 44.4 months in the patients with neurological symptoms and 14.4 months in the patients with hepatic symptoms.
Prevalence of Wilson’s disease
Diagnostic approaches of WD
Evidence of WD is based on the correct assignment of clinical symptoms of hepatitis, neurological symptoms of disease, and on laboratory investigations. In a retrospective study , the prevalence of diagnostic parameters in patients with WD are shown in . Patients with cholestatic liver disease were found at the time of diagnosis in 173 patients with WD at a mean age of 17 years with predominantly hepatic symptoms and at a mean age of 24 years with predominantly neurological symptoms.
A laboratory test by itself does not provide evidence of, or rules out, Wilson’s disease. In genetic diagnostics of mutations, total sequencing does not cover the entire gene. Moreover, the determination of the hepatic Cu concentration leaves doubt in the case of ambiguously elevated levels .
Wilson’s disease and other disorders associated with a decrease in Cp level are shown in:
Method of determination
Cp is a labile protein and is easily fragmented in serum or during determination. Immunonephelometry and immunoturbidimetry are less affected by this problem than radial immunodiffusion . Serum and urinary Cu concentrations should be determined using the atomic absorption method.
The populations of industrial countries have a daily dietary intake of 5 mg Cu via the upper gastrointestinal tract. Since many components of the diet are rich in Cu, there is practically no Cu deficiency. Cu is taken up by the liver via the portal circulation within 4 hours and 6–8% Cu bound to Cp appear in the plasma within 24 hours. See also .
Cp is a glycoprotein with a molecular weight of 132 kDa and has a carbohydrate content of about 9%. The Cp molecule binds 6 Cu atoms.
Cp is synthesized in the hepatocyte as apoCp. The Cu atoms are incorporated post translationally, followed by the binding of the carbohydrate side chains.
Incorporation of Cu atoms into apoCp occurs intracellularly by P1-type ATPase (ATP7B). The Cu atoms in CP are mostly in the Cu(II) state. The entrance of Cu atoms via the CTR1 receptor into the cell is not the rate-limiting step for uptake of Cu from Cp. It seems highly likely that a reductase is needed to provide Cu(I) for uptake .
In comparison to Cp with a half-life of 4 days, apoCp has an intra- and extracellular half-life of only a few hours.
The body’s Cu homeostasis is critical because the liver is the only organ to eliminate enterally absorbed Cu. This is achieved via excretion into the bile. Normally all of the excess Cu intake is later excreted so that the body’s Cu pool remains constant . Cu is not subject to enterohepatic circulation because it is excreted into the bile as a non-absorbable complex.
Physiological functions of Cp include:
- Regulation of transport, availability and redox potential of iron (Fe) as a result of its ferroxidase activity. For instance, if functional iron is required for erythropoiesis, Fe3+ is released from ferritin via reduction to Fe2+. However, since the transport protein transferrin can only bind Fe3+, Fe2+ is immediately oxidized to Fe3+ by Cp. Furthermore, all Fe2+ resorbed by the intestinal mucosa is oxidized to Fe3+ by hephaestin or Cp before binding to transferrin.
- Prevention of metal-ion-catalyzed per oxidation of membrane lipids. This per oxidation is thought to be a causative cofactor of many disorders such as atherosclerosis or neurotoxicity. Cp reacts either directly with the super oxide ion radical (O2–.), or oxidizes Fe2+ or Cu2+ and thus prevents their catalytic effect for lipid per oxidation and the damage of cellular structures .
Paradoxically, Cp changes from antioxidant to oxidant in the absence of divalent cations or under acid pH conditions. For instance, it is thought to play a significant role in LDL oxidation induced by monocytes/macrophages. Thus, under monocyte/macrophage stimulation, increasingly synthesized Cp may promote atherosclerosis.
The hepatocytes play an essential role in the body’s Cu metabolism. Following binding of the Cu to the intracellular Cu transport protein ATP7B, the hepatocyte controls Cu absorption via ATP7B by mediating:
- Binding of Cu to Cp
- Cu excretion into the bile after the Cp is saturated with Cu.
In WD, the cellular Cu balance is disturbed by a mutation-related dysfunction of the Cu transporter ATP7B. This results in intracellular accumulation of Cu. If all metallothionein in the cytoplasm and Cp are saturated, the free Cu has a toxic effect. This toxic effect leads to changes in the mitochondrial structure, defective DNA synthesis, modified protein synthesis and decrease in glutathione. All processes in combination may result in hepatocellular necrosis and Cu release. As these processes usually proceed slowly in most patients, the disease remains clinically inapparent in many cases.
In WD, the liver can produce apo-Cp, but Cu is not incorporated into the Cp molecule and accumulates primarily in the hepatocytes and secondarily in other tissues. In general, no clinical manifestations are observed prior to 5 years of age. They usually develop around the age of 15.
- Cu accumulation; Cu accumulates diffusely in the cytosol of hepatocytes. Cu content of the liver is increased, while aminotransferases are usually normal or only slightly elevated. Elevated levels are only coincidentally detected in clinically asymptomatic patients.
- Cu redistribution; if a critical threshold of Cu accumulation has been reached in the cytosol of the hepatocytes, Cu is redistributed into the lysosomes. During this process, Cu is also released into plasma. In most patients, redistribution occurs slowly and, hence, the patients remain clinically inapparent. In some of them, redistribution takes place rapidly and a lot of Cu is released into plasma. Chronic active hepatitis occurs and may progress to liver failure. Hepatitis or liver failure is caused by intravascular hemolysis due to release of large quantities of Cu into plasma as well as toxicity-related hepatocellular necrosis. From a differential diagnostic point of view, it is important to note that in liver failure due to Wilson’s disease ALT, in relation to bilirubin, is only minimally elevated, the AST/ALT ratio is > 2, and ALP tends to be reduced .
- Development of liver fibrosis and Cu accumulation in extrahepatic organs.
In patients, in whom Cu redistribution in the hepatocyte is accompanied by a clinically inapparent course, histological findings early on include morphological nuclear changes of periportal hepatocytes and steatosis similar to that seen in alcoholic fatty liver. Subsequently, liver fibrosis develops with progression to liver cirrhosis. Among the extrahepatic changes, neurological alterations predominate. The Kayser-Fleischer corneal ring is an ocular manifestation of the disease. Because of splenomegaly, some of the patients have leukopenia and thrombocytopenia.
4. Dati F, Schumann G, Thomas L, Aguzzi F, Baudner H, Bienvenu O, et al. Consensus of a group of professional societies and diagnostic companies on guidelines for interim reference ranges for 14 plasma proteins in serum based on the standardization against IFCC/BCR/ CAP reference material (CRM 470). Eur J Clin Chem Clin Biochem 1996; 34: 517–20.
9. Merle U, Weiss KH, Eisenbach C, Tuma S, Ferenci P, Stremmel W. Truncating mutations in the Wilson disease gene ATP7B are associated with very low serun ceruloplasmin oxidase activity and an early onset of Wilson disease. BMC Gastroenterol 2010; 10: 8.
11. Stapelbroek JM, Bollen CW, van Amstel JK, van Erpecum KJ, van Hattum J, van den Berg LH, et al. The H1069Q-Mutation in ATP7b is associated with late and neurologic presentation of Wilson’s disease: results of a metaanalysis. J Hepatol 2004; 41: 758–63.
16. da Costa CM, Baldwin D, Portmann B, Lolin Y, Mowat AP, Mierli-Vergani G. Value of urinary copper excretion after penicillamine challenge in the diagnosis of Wilson’s disease. Hepatology 1992; 15: 609–15.
Extracellular hemoglobin (Hb) and cell-free heme are toxic breakdown products of hemolyzed erythrocytes. The liver synthesizes the scavenger proteins haptoglobin (Hp) and hemopexin (Hx) which bind extracellular Hb and heme respectively.
Hp binds Hb to form high-molecular weight Hp-Hb complex. In this complexed form, Hb is sequestered within the vasculature and the passage of Hb outside the vessels is prevented. Plasma clearance of Hp-Hb complexes occurs via binding to the CD163 receptor, which is expressed by hepatic and splenic macrophages .
Diagnosis and monitoring of hemolytic diseases.
Haptoglobin sub typing
Polyacrylamide gel electrophoresis, isoelectric focusing.
Serum: 1 mL
Both a decrease and an increase in Hp concentrations as well as the Hp phenotype may be clinically significant. Decreased concentrations indicate in vivo hemolysis. Increased serum concentrations are mostly due to the acute phase reaction of Hp and are found to occur in conjunction with inflammation, infections and autoimmunopathy. Certain Hp phenotypes are risk factors of systemic diseases.
In serum, Hx is much less often altered than Hp and when such an alteration occurs, Hx is almost exclusively affected by a decrease, as seen in severe hemolytic anemia. As a rule, Hx is determined if Hp has declined to non measurable levels.
Elevated Hx levels are rare and are only of clinical relevance in patients with melanoma.
In any hemolytic case, the serum Hp concentration depends on the Hp type of the individual and the concentration of lysed erythrocytes. The allele frequencies (HP1 and HP2) differ significantly worldwide . For instance, the HP1 frequency ranges from 7% in parts of India to 70% in parts of West Africa. The HP1 frequency is between 31% and 40% in Europe, between 20% and 40% in Asians and, in North America, is 41% in Caucasians, 52% in Afro-Americans and 31% in Asians and Orientals.
Since Hp phenotypes are associated with different serum Hp concentrations, the reference interval for Hp is very broad. Without electrophoretic phenotyping and application of a phenotype-specific reference interval, it is therefore impossible to
- Detect mild chronic hemolysis
- Estimate the severity of a hemolytic reaction merely based on the Hp concentration.
Normal Hp concentrations are to be expected despite an underlying hemolytic disease if a concomitant inflammatory disease leads to increased synthesis of Hp as an acute phase protein. This is the case if the C-reactive protein (CRP) is elevated. Therefore, the CRP should be determined besides Hp for diagnosing a hemolytic reaction ().
Further diseases and conditions associated with decreased Hp
- Acute and chronic liver diseases
- Malabsorption syndrome
- Congenital Hp decrease or deficiency (e.g., as seen in 30% of black Nigerians and in 1/1,000 Caucasians).
Diseases and conditions associated with elevated Hp concentration
- Acute phase response (e.g., acute and chronic active inflammations, acute tissue necrosis, malignant tumors)
- Intrahepatic and extrahepatic cholestasis, Hodgkin’s disease, nephrotic syndrome, rheumatoid arthritis, iron deficiency anemia
- New synthesis of unknown etiology, such as multiple myeloma, amyloidosis .
Decreased serum Hx concentrations are measurable if the Hp concentration has declined to non measurable levels because of pronounced hemolysis. Heme containing molecules are only bound if their concentration exceeds 6 mg/L.
Even in the presence of pronounced hemolysis, Hx is never completely undetectable in serum . Hx and Hp function at different levels (i.e., initially Hp is reduced, then Hx). Causes of a divergent behavior pattern between Hp and Hx are listed in .
Hx is better suited than Hp for assessing the extent of hemolysis. The following facts are in favor of Hx:
- Hp is too sensitive, depends on the Hp phenotype and already displays markedly reduced levels in the presence of mild to moderate hemolysis
- As an acute phase protein, Hp increases in the presence of inflammatory processes and thus may mask a hemolytic reaction
- Hx is still measurable even in massive hemolysis.
Reductions in Hx without an underlying hemolytic reaction
- Chronic liver disease
- Porphyria cutanea tarda
- Malabsorption syndrome.
Diseases and conditions associated with elevated Hx
Inflammation accompanies hemolysis and injury and is associated with increased oxidative stress driven in part via heme-mediated events. The function and concentration of many proteins is impaired by oxidative modifications from reactive oxygen species (ROS). Heme-Hx complexes resist oxidative damage. Heme binding by Hx protects against heme toxicity in hemolytic diseases and conditions, sepsis and sickle cell disease. This protection is sustained by heme-hemopexin complexes in biological fluids that resist oxidative damage during the heme-driven inflammation.
Apo-hemopexin is vulnerable to inactivation by reactive nitrogen species (RNS) and ROS that covalently modify amino acids. It is supposed that during inflammation apo-hemopexin is nitrated and oxidized in niches of the body containing activated RNS- and ROS-generating immune and endothelial cells, potentially impairing Hx protective extracellular antioxidant function. The reason is tyrosine nitration in the heme binding site of pro-hemopexin/hemopexin .
Method of determination
In radial immunodiffusion, Hp 2-1 and Hp 2-2 have slower diffusion rates than Hp 1-1 since they are more markedly polymerized.
Hp concentration increases continuously after birth up to the age of about 40 years. Women have higher concentrations than men.
The HP gene exists in two allele types, HP1 and HP2 so that there are three Hp phenotypes: Hp 1-1, Hp 2-1 and Hp 2-2. These phenotypes are differently distributed worldwide, presumably due to genetic drift and natural selection .
Hp is a glycoprotein composed of four polypeptide chains, two light α-chains and two heavy β-chains. The α-chain is genetically polymorphic; the synthesis is encoded by the two above-mentioned alleles. Little is known about the polymorphism of the β-chain. The structure of the Hp molecule is shown in .
Hp binds oxyhemoglobin, methemoglobin, isolated hemoglobin α-chains, α/β dimers and heme-free hemoglobin H but not deoxygenated hemoglobin, heme, hemoglobin H, isolated hemoglobin β-chains or myoglobin. Its physiological function is to prevent renal losses of hemoglobin and, thus, a loss in iron; this is based on the fact that unlike Hb the Hp-Hb complex, on account of its high molecular weight, is not glomerularly filtered . Hp is primarily expressed by the liver, but also produced by the lungs, kidneys, spleen, thymus and heart.
Any reduction in the erythrocyte life span leads to an increase in hemolysis. The localization of lysis depends on both the extent of the hemolytic process and the mechanism by which each erythrocyte is damaged . Depending on the phenotype, 1.5 mg of Hp bind approximately 1 mg of Hb in plasma. Clearance of the Hp-Hb complex by the reticuloendothelial system is approximately 15 mg per 100 mL of plasma per hour. If more Hb occurs intravascularly in relation to the quantity of Hp produced by the liver, Hp concentration declines as a measurable sign of hemolysis. In liver parenchymal damage with reduced synthesis capacity, a decrease in Hp occurs early on. If inflammatory processes are simultaneously present, Hp reacts as an acute phase protein and, despite a mild hemolytic process, increased Hp consumption is compensated by an increase in the synthesis rate; hence, the serum concentration remains within the reference interval.
Elimination of free hemoglobin by Hp
- From the hem iron, which can react with endogenous H2O2 to produce free radicals, which in turn may cause oxidative tissue injury, especially in the kidney
- From the potency of hemoglobin to be a scavenger of NO, a signaling molecule that functions as a regulator of smooth muscle relaxation, endothelial adhesion molecule expression, and platelet activation and aggregation. The reaction of hemoglobin with NO is irreversible, leading to the production of nitrate and methemoglobin. NO scavenging limits the bioavailability of NO and thereby impairs NO homeostasis.
The effects of free hemoglobin are neutralized by binding to Hp. The hemoglobin-Hp complex is directed to the CD163 receptor expressing macrophages, which internalize the complex (). In the macrophage, the globin portion of the hemoglobin is degraded in the lysosomes, while heme is degraded by hem oxygenase-1 to Fe2+, CO and biliverdin. Fe2+ induces the synthesis of apoferritin, which binds Fe2+. Thus, Fe2+ is prevented from forming reactive oxygen species via the Fenton reaction.
In excessive hemolysis, the Hp-CD163-mediated scavenging mechanism is exhausted and fHb and heme are present in plasma. Both are important contributors to disease states associated with hemolysis which is characterized by free hemoglobin, heme induced inflammation and toxic cell damage. Reactive oxygen species (ROS) and reactive nitrogen species (RNS) impaire antioxidant functions. For instance, 50% of patients with sickle cell disease have endothelial dysfunction due to the constant presence of fHb and heme.
In inflammatory conditions (extra corporeal circulation, sickle cell anemia) the synthesis of Hp and CD163 is up regulated by interleukin-6 to increase the fHb removal capacity. Hp does not bind to CD163. FHb binds with low affinity to CD163, provided that fHb was not oxidized by H2O2 . Hp-bound Hb cannot be oxidized because it is protected. In contrast to the high-affinity Ca2+-dependent binding of the Hp-Hb complex to CD163, the low-affinity binding of non-oxidized fHb is a possibility for Hb removal if fHb concentrations are high.
The Hp phenotypes differ in their free hemoglobin removal functionality, also regarding CD163 interaction. The protective capacity of the phenotype Hp 1-1 against free hemoglobin-mediated oxidation is thought to be better than that of Hp 2-2. This might explain the different diseases associated with the Hp haplotypes.
Elimination of free hemoglobin by Hx and albumin
If Hp binding capacity has been exhausted, free hemoglobin occurs in plasma. Free hemoglobin is either oxidized to methemoglobin, followed by its dissociation into heme and globin, or oxidation of heme follows after dissociation. In both cases, hematin derivatives with Fe3+ are present. Hx binds these hematin derivatives with high affinity and albumin does with low affinity (). Albumin is not involved until large quantities of hemoglobin are released; in this case, as methemalbumin, it gives the serum a coffee-brown color. Like Hx, albumin transports hematin derivatives to the reticuloendothelial system. If, during degradation of erythrocytes, heme is directly cleaved from hemoglobin due to enzymatic action Hx is mainly consumed while Hp may remains unaffected (e.g., as observed in hemorrhagic pancreatitis).
Oxidation of hemoglobin to methemoglobin and further degradation is achieved by the reticuloendothelial system. Detection of methemoglobin in plasma is always a sign of massive hemolysis.
Free Hb in plasma is glomerularly filtered at a clearance rate of 5 mL/min. In the proximal tubule, Hb is reabsorbed and heme iron released from hemoglobin is stored in the form of ferritin and hemosiderin, followed by its re utilization. If tubular epithelia are overloaded due to pronounced hemolysis, these cells degenerate, are sequestered and appear in urine as hemosiderin-carrying epithelial cells that are stainable with the Prussian blue reaction. Hemosiderinuria is, therefore, considered to be a valuable indicator of severe acute and chronic intravascular hemolysis.
Hemoglobinuria occurs when tubular reabsorption capacity is exhausted because of a massive hemolysis.
Hx has a molecular weight of 80 kDa and, like Hp, is synthesized in the liver. Whereas Hb is exclusively bound by Hp, heme and heme derivatives are only bound by Hx and albumin. Hx has a high affinity toward heme and removes these substances from the plasma after cleavage of fHb into a heme and a globin portion. It only responds in the presence of pronounced hemolysis (i.e., if free Hp is no longer available). Hx is not an acute phase protein. Hx deficiency develops in patients with sepsis that is life-threatening.
Several diseases in which Hx plasma levels increase are associated with inflammation, increased activity of nitric oxide synthase, and oxidative stress. Thus Hx is expected to be exposed to high levels of oxidative species. Because proteins can be inactivated by oxidative modifications from exposure to ROS and RNS it is supposed that the increased levels of modified Hx might be a physiological response to damage, in which case Hx is functional, i.e., capable of binding to heme or to Hx receptors. The protective extracellular antioxidant function of Hx is impaired during heme-driven inflammation because apo-Hx is is vulnerable to inactivation by RNS that cause tyrosine nitration in the peptide YYCFQGNQFLR in the heme-binding site of Hx .
16. Buehler PW, Abraham B, Vallelian F, Linnemayr C, Pereira CB, Cipollo JF, et al. Haptoglobin preserves the CD 163 hemoglobin scavenger pathway by shielding hemoglobin from peroxidative modification. Blood 2009; 113: 2578–86.
21. Nakagawa T, Muramoto Y, Hori M, Mihara S, Marubayashi T, Nakagawa K. A preliminary investigation of the association between haptoglobin polymorphism, serum ferritin concentration and fatty liver disease. Clin Chim Acta 2008; 398: 34–8.
22. Levy AP, Hochberg I, Jablonski K, Resnick HE, Lee ET, Best L, et al. Haptoglobin phenotype is an independent risk factor for cardiovascular disease in individuals with diabetes: The Strong Heart Study. J Am Coll Cardiol 2002; 40: 1984–90.
23. Graw JA, Mayeur C, Rosales I, Liu Y, Sabbisetti VS, Riley FE, et al. Haptoglobin or hemopexin therapy prevents acute adverse effects of resuscitation after prolonged storage of red cells. Circulation 2016; 134; 945–60.
Immunocompetent individuals have an acquired immune system that is divided into the following two functional mutually cooperative but developmentally independent units:
- Thymus (T) lymphocyte system; it represents a functionally heterogeneous group of cells concerned with immune regulation and antigen elimination. The T lymphocyte system is primarily responsible for cellular immunity.
- Bursa or bone marrow (B) lymphocyte system; B lymphocytes differentiate into plasma cells which synthesize and secrete immunoglobulins (Ig) after an antigenic stimulus.
Ig represent a heterogeneous group of proteins with antibody functions (i.e., they are capable of binding antigens). Their synthesis is the adaptive response to the antigen structure that will be bound. The structure of the antibody binding site is synthesized to correspond with the configuration of the antigen with which the antibody will react.
Ig have the following effector functions:
- Formation of immune complexes with antigens that are amenable to phagocytosis
- Binding to the membrane receptors of immune cells in order to activate them
- Reaction with plasma proteins (e.g., with complement components, and activation of these proteins in order to eliminate the antigen).
Ig have a common basic structure, consisting of two identical heavy (H) chains and two identical light (L) chains (). The chains are joined together by disulfide bonds. The amino terminal ends of the light and heavy chains of the Ig molecule form the variable region. The variable regions of the Ig differ in their amino acid sequences, since these are responsible for the specificity towards the antigen determinants. Within the variable regions, there are areas of lesser and greater variability in the amino acid composition; these latter are also referred to as the hyper variable regions /, , /.
The heavy chains of the Ig molecule consist of a variable and a constant region. Each of the two polypeptide chains is comprised of a series of globular regions also referred to as domains, with substantial amino acid homology.
N-terminal domains of H and L chains contain variable amino acid sequences (V region) determining the antigen specificity. The N-terminal amino acids of the V region form a functional pocket into which the epitope of the antigen fits. Surfaces of the antigen binding site and epitope are complementary to each other, so that the concavities of the one are filled by the convexities of the other. The complementarity is not only physical but also chemical in nature. The contacts of binding site and epitope include van der Waals forces, hydrogen bridge bonds between polar groups and ion pair bonds between differently charged side chains /, /.
The constant regions of the heavy chains include domains (CH regions) with certain structural and antigenic differences that allow their classification into Ig subclasses.
- The first (CH1) and the second domain (CH2) form the hinge region. Because of this region, the Ig molecule is capable of transforming from the T form, in which it is in solution, into the V form, which it assumes during antigen binding.
- The CH2 domain binds the complement protein C1q, which activates the classic pathway of the complement system
- The third domain CH3 mediates binding of Fc fragment to Fc receptor of immune cells such as granulocytes, monocytes/macrophages and antigen dependent cytotoxic cells (ADCC)
- The combination of CH2 and CH3 acts as an additional domain for binding, for example, to granulocytes and natural killer (NK) cells.
- Papain cleaves the Ig molecule into three fragments: Two identical Fab fragments consisting of the complete L-chain, the variable region and a portion of the constant region of the H-chain
- A fragment consisting of the constant regions of the two heavy chains, linked via disulfide bridges. Since this fragment crystallizes, it is also referred to as Fc fragment (fragment crystallizable).
Kappa- and lambda-L-chain types are differentiated. Each Ig molecule has either two kappa- or two lambda-L-chains since a B cell can only synthesize one type of L-chain. L-chains have a molecular weight of about 22 kDa and consist of an amino-terminal, variable region and a carboxy-terminal, constant region. The L-chain is connected to the heavy chain via a disulfide bond between a cysteine molecule in the constant regions of both chains. B cells produce approximately twice as many kappa chains as lambda chains. The term monoclonal free light chain or, if detectable in urine, Bence Jones protein refers to L-chains of one type that are not bound to heavy chains and are synthesized and secreted by malignant B-cell proliferation. Because of the cysteine molecules, they are prone to dimerization.
Polyclonally synthesized free light chains are of the kappa and the lambda types and are detected in about equal amounts in a sample; traces are present in the urine (e.g., associated with infectious diseases).
The structure of the H-chain determines the Ig class of an Ig molecule. Differences between individual Ig classes concern their amino acid sequence, molecular weight, carbohydrates, antigenicity, allotypic heterogeneity and electrophoretic mobility. Five major Ig classes are distinguished, with each of them displaying two identical H-chains: IgG has γ-heavy chains, IgA has α-heavy chains, IgM has μ-heavy chains, IgD has δ-heavy chains and IgE has ε-heavy chains.
The J-chain is a peptide connecting two Ig molecules of the same class (connection piece). Ig molecules of M and A classes exhibit polymorphism. IgM occurs mostly as a pentamer and IgA as a dimer. IgM monomers as well as IgA monomers are each only connected via a single J-chain. J-chains are glycoproteins with a molecular weight of 15 kDa and bind via disulfide bonds near the carboxy-terminal end of the heavy chains ().
As a dimer, secretory IgA, which is synthesized by plasma cells of the respiratory, genitourinary and gastrointestinal tracts and released into secretions, contains a secretory component that protects the Ig molecule from peptidase-mediated degradation (). The secretory component is a glycoprotein with a molecular weight of 60 kDa. Dimeric IgA is not bound to the secretory component until it penetrates the epithelial layer, where the secretory component is synthesized by epithelial cells. This secretory component is detectable in secretory IgA deficiency.
The heterogeneity of antibodies can be subdivided into isotypic, allotypic and idiotypic variations.
Isotypes have the same constant domains. Isotypic variations consist of differences in H-classes, L-types and domains, which are present in all healthy members of a given species. The synthesis of isotypes is encoded by genes, which are present in all human beings.
Allotypic variation is defined as an allele-induced variation of the Ig within a species. Allotypes usually occur as variants of the constant region of the H-chains. For instance, Gm factor is responsible for the regulation of the constant H-chain region of IgG. More than 25 different Gm (genetic marker) allotypes are known. Allotypic variants are often the result of an amino acid substitution within the H-chains.
Idiotypes have the same variable domains. The idiotypic variation relates to the diversity at the antigen binding site. The Ig synthesized by a plasma cell clone is normally completely identical (i.e., it consists of a uniform idiotype). An alteration (e.g., an amino acid exchange in the variable region of the antigen binding site) may lead to idiotypic variation. Such antibodies differ even if they belong to the same isotype and allotype. Many monoclonal components (para proteins) are probably idiotypic variations.
Ig classes IgG, IgA, IgM, IgD and IgE are present in descending order of concentration in the serum of healthy individuals /, /. Within the IgG class, the subclasses IgG1, IgG2, IgG3 and IgG4 are differentiated, and the class IgA includes the subclasses IgA1 and IgA2, while the IgM class contains the subclasses IgM1 and IgM2. The physicochemical and biological properties of the individual Ig classes are listed in .
IgG consists of two identical H-chains with a molecular weight of about 50 kDa and two identical L-chains with a molecular weight of about 22 kDa. In primary infections (primary antibody response), IgG are usually secondary antibodies and, in repeat infection with the same organism, primary antibodies (secondary antibody response). Approximately one half of total body IgG is present in plasma, while the other half is distributed in the body fluids. When performing serum protein electrophoresis, IgG is located in the γ-globulin fraction. Under standardized conditions, the subclasses IgG2 and IgG4 migrate toward the anode, whereas IgG1 and IgG3 migrate toward the cathode. Fetal IgG originates from maternal blood and during the first 20 weeks of gestational age has a concentration corresponding to approximately 10% of that found in the mother.
Fetal infections during this time period do not cause an increase in IgG. Between the 22nd and the 28th week of gestational age, placental permeability markedly increases, thus accounting for the fact that at this point of time the fetal IgG concentration is equal to that in maternal blood. Concentrations of IgG1, IgG3 and IgG4 are the same, whereas fetal IgG2 concentration is lower than the maternal one. After delivery, maternal IgG decreases in the circulation of the newborn with a half-life of approximately 30 days, thus resulting in a residual concentration of only 3.5–4.0 g/L by the 3rd to 4th month. As infant’s own IgG synthesis gets under way, serum IgG concentration slowly increases, reaching a concentration of 7–8 g/L by the end of the first year and adult levels prior to the age of 16 years () .
The synthesis of IgG subclasses during the course of an immune response depends on the nature of antigens, their site of entry and the duration of antigen exposure. The antibody response is directed against:
- Protein antigens, such as bacteria and viruses, mediated by IgG1 and IgG3 and induced by CD4+T-cells
- Polysaccharide antigens (e.g., encapsulated bacteria such as Pneumococcus, Streptococcus group A but also H. influenzae) mostly mediated by IgG2 and partly IgG1 and not induced by CD4+T-cells
- Polyvalent antigens such as snake venoms, parasites, insects and food components in the case of chronic antigen stimulation and mediated by IgG4. The IgG4 antibodies, like IgE, bind to surface receptors of mast cells.
- Native DNA, mediated by IgG1 and IgG3 autoantibodies.
The IgG subclass response is regulated and modulated by interleukins; the number of existing B-cell sub populations in a tissue region also plays an important role. For instance, in the blood of healthy individuals, B cells with cytoplasmic IgG1 and IgG2 dominate, whereas in the tonsils B cells with IgG1 and IgG3 are predominant.
Because of its binding to the Fc receptor of the immune cell, the Fc fragment of the IgG molecule is of significant importance in the immune response. The Fc fragment mediates:
- The uptake of IgG coated bacteria by macrophages. The Fc fragment of the IgG molecule is bound by the Fc receptor of the macrophage; the bacterium is engulfed and incorporated into the macrophage in a zipper-like manner
- Clearance of IgG-containing immune complexes according to the aforementioned mechanism
- The antibody-dependent cellular cytotoxicity (ADCC) via effector cells such as monocytes/macrophages, granulocytes and lymphocytes. These cells have Fc receptors to which the Fc fragment of the IgG-loaded target cell binds. These cell is subsequently destroyed.
The IgG catabolism is proportional to the plasma concentration (i.e., enhanced in the case of a high IgG level and low in the case of a low concentration). Accordingly, the half-life is 70 days in case of a low IgG synthetic rate, but may be shortened to 11 days if the IgG synthetic rate is high.
IgM circulates in the serum as a pentamer, has a molecular weight of 971 kDa and consists of five monomers that are covalently linked via disulfide bonds and connected via five connection pieces (J-chains). Small amounts of monomers and hexamers are also present in the circulation. Each μ-chain contains one V region and four C regions.
Serum IgM comes in two flavors, pre-immune without exposure to exogenous antigen also known as natural IgM that is spontaneously produced, and the second type is exogenous antigen induced or immune IgM antibodies //.
The majority of IgM in serum is comprised of natural IgM antibodies. The two prominent features of natural IgM are poly reactivity and auto reactivity. The natural IgM antibodies are reactive with many conserved epitopes that are shared by microbes and self antigens. The production of natural IgM appears to be triggered by interaction with self antigens. In addition to providing early defense against microbes, natural IgM plays an important role in immune homeostasis, and provides protection from consequences of autoimmunity and inflammation.
Immune IgM is the first antibody secreted during an initial immune response to an exogenous antigen. Mature naive B cells in response to antigens undergo clonal expansion and differentiation into Ig secreting cells.
75–80% of IgM are located intravascularly. In serum protein electrophoresis, IgM migrates between the γ-globulin and the β-globulin fraction. Because of slight differences in the μ-chain, two IgM subclasses are distinguishable. The pentameric form of the IgM molecule has ten antigen binding sites, but only five of these are usable for antigen binding due to steric hindrance. The pentameric IgM can be split into monomers by SH group cleaving reagents.
Besides pentameric and monomeric IgM, a secretory IgM with a secretory component is present in body secretions much like IgA. The essential functions of IgM in immune response are the agglutination of pathogens and the activation of the classic complement pathway.
Maternal IgM does not cross the placental barrier. The healthy fetus as well as the newborn have an IgM concentration that is about 10% of the adult level and is produced by the fetus itself.
After birth, IgM synthesis rises markedly: 50% of the adult IgM concentration are reached after the first 4 months of life and the adult level is reached at the age of 8–15 years (). The fetus by itself can synthesize IgM in larger quantities from the 20th gestational week. Intrauterine infection can, therefore, cause a steep increase in the IgM concentration, and IgM levels > 0.2 g/L in cord blood are a criterion pointing to such an infection.
The IgM class includes the natural antibodies such as AB0 blood group isohemagglutinins, cold agglutinins (anti-i, anti-I), heterophilic antibodies, saline erythrocytic antibodies as well as antibodies to IgG (e.g., rheumatoid factors).
The catabolism of IgM is independent of the serum concentration.
IgA antibodies occur as serum IgA and as secretory IgA.
Approximately 90% of IgA are present in a monomeric form with a molecular weight of 160 kDa and 10% in a polymeric form. Serum IgA tends to form complexes, especially with albumin, but also with enzymes, thus forming macroenzymes. Half of the serum IgA is located intravascularly and occurs in two subclasses. The ratio of the two IgA isotypes IgA1/IgA2 is 9/1. In serum protein electrophoresis, IgA migrates in the cathodic part of the β-globulin and the anodic part of the γ-globulin fraction.
Since IgA does not cross the placental barrier, it is not present in fetal blood. After birth, the synthesis of IgA begins slowly; by the end of the first year, the infant has about 25%, by 3.5 years of age approximately 50% and by 16 years of age 100% of the adult serum level (). The function of serum IgA is not known in further detail. It activates complement via the alternative pathway and has specific antibody functions. The catabolism of IgA is independent of the serum concentration.
This IgA molecule is composed of a unit of two IgA molecules, which are connected via a J-chain and have a secretory component (). Secretory IgA is produced by plasma cells that are located in the lamina propria of mucous membranes. It is synthesized independently from serum IgA. Therefore, deficiency in serum IgA does not necessarily imply deficiency in secretory IgA. Secretory IgA is the predominant Ig of body secretions such as saliva, tears, colostrum, nasal secretions, tracheobronchial mucus, gastrointestinal secretions and breast milk. Newborns and infants are supplied with IgA via breast milk and, hence, are passively immunized against gastrointestinal infections. Essential functions of secretory IgA are: the binding of microorganisms on mucous membranes, activation of the alternative complement pathway and activation of inflammatory reactions. Inside epithelial cells, IgA is thought to neutralize intracellular microorganisms. In the lamina propria of mucous membranes, IgA binds antigens in the form of immune complexes and secretes them on the mucomembranous surfaces. This prevents the circulation from being overloaded with immune complexes. Individuals with secretory IgA deficiency are found to suffer more commonly from mucosal infection, atopy and autoimmune disease.
IgD has a high carbohydrate content with numerous oligosaccharide chains. Due to the fact that the two δ-chains are only held together via disulfide bonds and due to the abundance of lysine and glutamic acid in the hinge region, the molecule is prone to proteolysis.
Together with IgM antibodies, IgD antibodies are located on the cell membrane of B cells as antigen receptors. In cord blood, IgD is not detectable or only detectable in minimal concentrations; adult levels are reached at 2–5 years of age.
The distribution of IgD in the body is identical to that of IgM. The exact function of IgD is unknown, but this Ig class is thought to include antinuclear antibodies (ANA) as well as antibodies to insulin and penicillin. The higher the serum level of IgD, the slower its catabolism (i.e., the plasma concentration of IgD is inversely related to IgD catabolism).
The ε-heavy chain, like the μ-chain of the IgM, possesses five domains, which explains the molecular weight of 72.5 kDa. IgE binds via the domains Cε3 and Cε4 to the high-affinity receptor FcεRI located on mast cells and basophil granulocytes. Moreover, it binds to the low-affinity receptors FcεRII or CD23 present on monocytes, lymphocytes and eosinophil granulocytes.
IgE antibodies are also referred to as reagins. Their distribution in the body is identical to that of IgA and their catabolism, at a half-life of 2.5 days, is high. The serum IgE level does not represent the effective IgE load of the organism since the predominant IgE synthesis sites are located in the respiratory tract, gastrointestinal tract and lymph nodes. Because of its affinity to mast cells, some IgE is bound to the IgE receptors of these cells.
IgE antibodies mediate type I hypersensitivity reaction of the immediate type. Harmless, polyvalent antigens, such as pollen or house dust mites, stimulate mucosal B cells at the site of entry to synthesize specific IgE. This process is mediated by CD4+T cells. Specific IgE binds via Fc receptors to mast cells that are now sensitized. During the next contact of the polyvalent antigen with the sensitized mast cell, bound IgE antibodies are cross-linked, the cell is de granulated and mediators are released, which cause, for example, symptoms of hay fever, asthma and atopic eczema.
IgG, IgA, IgM, IgD
Immunoassays such as enzyme, fluorescence or luminescence immunoassays.
IgM in cord blood
Latex agglutination test for rapid determination of IgM; latex particles are coated with anti-IgM.
If secretory IgA levels are measured in saliva by employing radial immunodiffusion and specific plates (LC-partigen plates), which contain antiserum to serum IgA, the measured levels are multiplied by 3.25 in order to compensate for the molecular weight. Reducing pretreatment of saliva using dithiotreitol is recommended .
IgG, IgA, IgM, IgD, IgE
Serum, body fluids: 1 mL
IgG subclasses: same as for IgG.
Secretory IgA: saliva, tear fluid, intestinal juices and/or feces.
If immunoglobulin determination has to be performed in a neonate, as much cord blood should be collected as possible.
1 U IgE = 2.4 ng
- Hypogammaglobulinemias that may be associated with numerous diseases. The decrease in Ig can be due to reduced synthesis, increased loss or hyper catabolism of Ig or a combination of causes.
- Polyclonal gammopathies that may be due to an increase in antibodies of one or several Ig classes. The spectrum of diseases causing polyclonal gammopathy is broad and includes, for example, infections, chronic liver diseases, autoimmune disorders.
- Monoclonal gammopathies that are characterized by a narrow band (M-gradient) in the γ-globulin fraction in serum protein electrophoresis. M-gradients are caused by excessive proliferation of a B-cell clone, which synthesizes Ig of one class and one type ().
If hypogammaglobulinemia is present, one should
- Determine the extent of the antibody deficiency by measurement of the Ig of each class and subclass
- Perform more detailed examinations concerning differentiation of the antibody deficiency, see .
Extent of antibody deficiency
Ig deficiencies can be of varying extent:
- One or all Ig classes or Ig subclasses are absent or strongly decreased
- The Ig of one Ig class or Ig subclass are moderately reduced as compared to an age-matched group of healthy individuals
- The Ig of the Ig classes and of some of the Ig subclasses are normal but, within a certain subclass, an antibody response cannot be established. For instance, a selective antibody synthesis defect can be present in the IgG2 subclass involving only antibodies to pneumococcal polysaccharide.
A decrease in serum Ig level due to hyper catabolism occurs in hyper metabolic states. For example, such a state is present in patients with hyperthyroidism; it can be associated with a reduction in Ig of all Ig classes. In patients with myotonic dystrophy, serum Ig are also reduced because of a shortened half-life. Antibodies to Ig are also rarely a cause for the rapid elimination of Ig from the circulation.
With an influx of antigens into the organism, clonal selection operates to activate those B cells with antigen receptors for which the antigen has a high affinity. Usually, after primary contact of the immune system with such an antigen, several B cells are activated to a varying extent. They proliferate and mature into antibody-producing plasma cell clones .
During an infection with complex agents (e.g., microorganisms); many antigens are produced because of antigen processing and presentation to the B cells. The selection of several T-cell stimulated B cells leads to their clonal proliferation and specific antibody production. This results in polyclonal immune response.
Polyclonal immune response
Polyclonal immune response leads to an increase in serum Ig, involving either one or several Ig classes and both Ig types. A broad-based increase in the γ-globulin fraction is detectable in serum protein electrophoresis.
Oligoclonal immune response
The oligoclonal immune response results from limited activation of B cells, also referred to as limited heterogeneity. Possible causes include: nature of the antigen, lack in reactivity of the immune system or contact of the antigen with tissues that are poor in immunocompetent cells (e.g., the central nervous system).
Diagnosis of polyclonal and oligoclonal gammopathies
The diagnosis of polyclonal or oligoclonal Ig increases is based on screening by serum protein electrophoresis; a more differentiated diagnosis is possible by quantitative determination of Ig classes and Ig subclasses or, in cerebrospinal fluid, by isoelectric focusing and subsequent immunofixation.
In diseases causing hypergammaglobulinemia, quantitative Ig determination in conjunction with the clinical picture as well as serological and clinical chemistry findings can provide results that contribute to a diagnosis, differential diagnosis, disease monitoring and formulating a prognosis.
This may be the case for:
- Acute and chronic infections
- Liver diseases
- Diseases of the central nervous system
- Intrauterine and perinatal infections.
- Ig determination in hypergammaglobulinemia
The indications are limited, in which the differentiation of hypergammaglobulinemia by means of quantitative Ig determination is clinically useful for the diagnosis of a disease. Usually, especially in infectious diseases, an increase in one or several Ig classes (with a similar Ig pattern) occurs . No specific Ig pattern exists that occurs exclusively in a certain disease and by itself is of diagnostic value. However, the Ig pattern may be an important supplemental finding and may, in combination with the overall clinical picture, contribute to differential diagnosis, assessment of the course of the disease and formulating a prognosis.
An isolated polyclonal Ig increase in one Ig class or a more pronounced increase in one Ig class within the Ig pattern are valuable in differential diagnosis.
Isolated IgM increase
In combination with the clinical picture and especially if present for several days, an isolated IgM increase is a sign for an initial infection of the organism by a pathogen (primary reaction).
In newborns, an IgM increase in cord blood is considered to be a nonspecific sign of an infection acquired in utero.
Isolated IgG increase
In an acute infectious disease with normal or only mildly elevated IgM, an isolated increase in IgG is a sign of secondary response of the immune system to an already known pathogen. Chronic infections elicit primarily to an isolated IgG increase, while chronic active infections cause an increase in IgG, occasionally accompanied by elevated IgM and/or in IgA.
Isolated IgA increase
In liver diseases, a relatively higher IgA increase or an isolated IgA elevation suggests toxic damage (e.g., due to alcohol, hormonal contraceptives, antidepressants).
The Ig pattern is not very conclusive if two or more Ig classes are increased. While increases in all three Ig classes are often found in liver cirrhosis, conclusions concerning the etiology of chronic liver disease can only be reached to a limited extent based on the Ig pattern ().
The assessment of the course of an inflammatory event that employs quantitative Ig determination should be based on the Ig pattern. Persistently elevated Ig concentrations argue for a sustained assault on the organism by the antigen, and the Ig will decline in the course of overcoming the infection process and the normalization for eliminating the extracellular antigen. The magnitude of the IgG concentration is a measure of the activity of the inflammatory process, especially in virally induced chronic liver disease, chronic bacterial infection, connective tissue disease and other autoimmune diseases. In toxic liver damage, the intensity of inflammation correlates with IgA concentration .
During the course of infectious diseases affecting certain organs, the Ig concentration, and especially that of IgM, is of prognostic value. Persistence of elevated IgM levels at a time when a decline is expected suggests the transition to a chronic process, while continuously rising IgG levels suggest the transition to a chronic active process. In some infections such as borreliosis, patients can have persistent IgM antibodies for years without any clinical symptoms.
Because of the transplacental transfer of IgG, the newborn has the same IgG antibody pattern as the mother. An infection of the newborn cannot be recognized by methods that only detect IgG antibodies because maternal IgG antibodies are not distinguished from those produced by the fetus as result of an infection .
From the 20th week of gestational age, the fetus is capable of producing IgM antibodies and from the 30th week it can also synthesize IgA. From this time point, intrauterine infections, due to various viruses (rubella, cytomegaly, herpes simplex, varicella, mumps, measles, influenza, hepatitis B, parvovirus B19), treponema pallidum or toxoplasma gondii are detectable by elevated IgM and/or IgA concentrations in the newborn blood (cord blood). The incidence of infections in newborns is reported to be 2–4% .
Because of the simple and rapid measurement, the IgM concentration in cord blood serum is considered to be a good screening test. A concentration > 0.20 g/L is regarded to be an indicator of an infection.
A significant percentage of cases with intrauterine infection remains unrecognized because of the lack of clinical manifestations in the newborn or exhibits only a slight IgM increase.
In the presence of elevated IgM, clinical symptoms are only found in one third of newborns. The reason for the low diagnostic specificity is either placental leakage or contamination of cord blood with maternal blood. An infection is unlikely if the IgA concentration is also elevated and if, during a second test after 5 days, the levels of IgA and IgM in neonatal blood have markedly decreased (half-life: 5 days).
A persistence or increase in IgM indicates the presence of an infection acquired in utero or during the perinatal period. In such a case, infection-specific IgM or IgA antibodies should be determined by enzyme-linked immunosorbent assay (ELISA).
The Ig increase is not infrequently limited to increases in certain antibody populations. These antibodies may belong to one or several Ig classes or to only one Ig subclass although they are still of polyclonal origin (i.e., they are present as kappa- and lambda-light chain types). In serum protein electrophoresis on cellulose acetate but more commonly on agarose, one or several distinct bands are visible against the diffuse background of the γ-globulin band (sawtooth pattern).
Standardization and quality assurance
Method of determination
Radial immunodiffusion: this method is relatively resistant to interferences. An antigen excess phenomenon must be kept in mind, recognizable by the presence of fuzzy precipitation along the margin. Aggregated Ig simulate falsely low Ig concentrations, while Ig fragments simulate falsely high ones.
Immunonephelometry: interferences in this methodology include light-scattering contaminants such as micro clots, cells from inadequately centrifuged samples, particles derived from proteins of the cerebrospinal fluid and microbial contaminations. In principle, problems should be anticipated in samples after deep-freezing or in hyperlipidemic samples. Nephelometric assays properly detect antigen excess and are approximately 10 times more sensitive than turbidimetric assays that are not latex particle-enhanced.
Immunoturbidimetry: turbidimetric Ig determinations, usually measured with clinical chemistry analyzers, are prone to interference by samples with high absorbance, as seen in hyperbilirubinemic, hemolytic or hyperlipidemic sera. Antigen excess is easily overlooked and inappropriately low Ig levels are determined.
Immunoglobulin G (IgG) accounts for about 10–20% of plasma proteins. IgG can be further divided in 4 subclasses, named, in order of decreasing abundance IgG1, IgG2, IgG3, and IgG4. Although they are more than 90% identical on the amino acid level, each subclass has a unique profile with respect to antigen binding, immune complex formation, complement activation triggering of effector cells, half-life, and placental transport /, /. Differences in the properties are presented in :
- Suspicion of a defective immune response in patients with frequent infections
- Monitoring of immunotherapy with inhalative antigens
- Suspicion and monitoring of IgG4-related disease
Serum, plasma (heparin, EDTA), body fluids (cerebrospinal fluid, bronchoalveolar lavage): 1 mL
The most common method measuring IgG subclasses is immunonephelometry There are two major vendors. Some laboratories use the IgG subclasses LC-MS/MS method. The methods are calibrated to the international reference material ERM-DA470K.
Quantitation of the amount of each IgG subclass in a given serum sample allows identification of selective IgG subclass deficiencies and IgG subclass increase i.e., IgG4 related disease.
IgG subclass deficiency is present if the concentration of one or several IgG subclasses decreases below the age-related reference interval values. In childhood, IgG subclass deficiencies are three times more common in boys than in girls. This changes during puberty so that in adults the female/male ratio is 2 : 4. In children, IgG2 deficiency occurs most commonly, while in adults IgG1 and IgG3 deficiencies are the most common .
Most patients with IgG subclass deficiency suffer from frequent respiratory tract infections . Therefore, IgG subclass analysis is part of the routine diagnostic examination in patients who are susceptible to respiratory tract infections. The most important diseases associated with IgG subclass deficiency are described in . IgG subclass deficiencies may occur in an isolated form or associated with other immune defects (IgA, IgM, IgG, complement deficiencies, and T-cell defects, ataxia teleangiectatica).
More commonly, a certain Gm phenotype is associated with low IgG subclass concentrations. Individuals who are homozygous for G3m(21) have very low IgG3 concentrations . G2m(23)-negative individuals not only have low IgG2 levels but, after vaccination with polysaccharides (pneumococci), also show poorer vaccination response as compared to heterozygote carriers of this defect . Occasionally, familial clusters are encountered.
In many cases, decreased IgG subclass concentrations may be clinically manifest as infectious diseases and may also occur secondarily after therapy with steroids, sulfasalazine and carbamazepine /, /.
As in IgA deficiency, many patients with IgG subclass deficiency are healthy. Especially in children, a temporary decrease (delayed maturation) of IgG2 is often present . For diseases associated with IgG subclass deficiency, see .
In many cases, the cause for IgG subclass deficiency is a regulatory defect in the immune response. In some patients with IgG2 deficiency, an impaired synthesis of interferon has been described . Deletions on chromosome 14 have been found but in very rare cases in the area of the gene cluster encoding the constant region of the H chain .
Further testing to characterize the immune deficiency
IgG subclass deficiency is primarily considered to be an indicator of impaired immune response /, /. Further, more detailed examinations are required in order to characterize the underlying immune defect and to estimate its clinical relevance .
For instance in patients with IgG subclass deficiency:
- The synthesis of specific antibodies to proteins (tetanus, diphtheria) is usually not affected
- The production of polysaccharide-specific antibodies (e.g., pneumococcal antigen) is reduced in some patients. Detection of naturally acquired polysaccharide antibodies is not very conclusive for the identification of patients with an actual specific immune defect. Vaccination against pneumococci is recommended.
Assessment of functional activity of the immune system following pneumococcal vaccination
An adequate pneumococcal vaccination response is present if the pneumococcal antibody titer in the global test (ELISA, 23-valent vaccine as antigen) rises to > 1,000 U/mL 4–6 weeks after the vaccination or if a significant vaccination response (> 1 μg/mL, calibrated according to the WHO standard 89 SF) is detectable involving five examined pneumococcal serotypes . An adequate vaccination response is detectable in the majority of the patients with IgG2 subclass deficiency /, /. If a vaccination response < 500 U/mL is measured in the global test, no significant vaccination response to any of the individual serotypes is usually detectable. If a titer < 500 U/mL is confirmed by repeat vaccination, relevant IgG subclass deficiency is diagnosed including a defect of polysaccharide-specific immunity. Depending on the clinical presentation, such a disorder necessitates prolonged therapy (antibiotic prophylaxis or immunoglobulin replacement therapy).
IgG4-related disease (IgG4-RD) was described originally in the pancreas as sclerosing pancreatitis, now referred to as type 1 IgG4-related autoimmune pancreatitis (AIP). Shortly thereafter, however, the identification of a variety of extra-pancreatic organ involvement linked by unique histopathological features led to the recognition that AIP was part of a systemic condition /, /.
- A set of unique histopathological features. The hallmarks are lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis, and mild to moderate tissue eosinophilia.
- Elevations in serum IgG4 concentrations.
IgG4-RD can involve almost any organ e.g., the pancreas biliary tree, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate thyroid, pericardium, and skin .
There is no evidence that the IgG4-autoantibodies described so far in IgG4-RD contribute directly to pathogenesis. The role of IgG4 itself in the disease process remains unclear. IgG4-RD tends to form tumefactive lesions. As a result, patients are often suspected of having malignancy.
IgG4-RD presents in a subacute fashion in most patients, without rapid onset of constitutional symptoms such as fever. The clinical presentation is usually indolent, with signs and symptoms becoming evident over months or even years. High spiking fevers and other manifestations of systemic inflammation that mimic infections are classically absent. IgG4-RD typically comes to medical attention because of single-organ involvement, but more widespread disease is often observed following a detailed workup. Involvement by IgG4-RD of different organs can occur either simultaneously or metachronously, with the emergence of one newly affected organ following another. IgG4-RD has a predilection for middle-aged to elderly men /, /.
Diagnosis of IgG4-RD
Diagnosis of IgG4-RD requires both histopathological confirmation and clinicopathological correlation. Serological findings are largely non-specific. Acute phase reactants such as erythrocyte sedimentation rate and C-reactive protein are usually elevated to a moderate degree. Peripheral blood eosinophilia and increased serum IgE occur in almost 30% of patients. Some patients have positive low-titre anti-nuclear antibodies. Although serial measurement of serum IgG4 is often useful in the assessment of disease activity, they should never be used as the sole determinant of treatment decisions .
High serum IgG4 concentrations occur in 60–70% of patients, typically in those with multi-organ involvement. Unfortunately, elevation of IgG4 can be associated with conditions other than IgG4-RD e.g., systemic vasculitides, connective tissue disease, infections and malignancies . Some IgG4-RD patients have normal serum IgG4 concentrations despite histopathologic and immunohistochemical findings in tissue .
- Elevated serum IgG4 > 135 mg/dL
- Histopathology: IgG4+/IgG+ cell ratio > 0.4
- Swelling or damage of affected organ
- Histopathology: more than 10 IgG4-positive cells per high power field
- Even in the absence of elevated serum IgG4, as long as there is organ involvement plus more than 10 IgG4-positive cells per high power field, and the IgG4+/IgG+ cell ratio > 0.4, a diagnosis of IgG4-RD may still be made.
The sum of the individual IgG subclasses should not deviate by more than 10% from the measured total IgG (plausibility check). If this is not the case, in an abnormal distribution of the IgG subclasses, a control of both measured parameters (IgG subclasses and total IgG) should be performed.
Method of determination
LC-MS/MS should be the preferred method for measurement of IgG subclasses. In a study , using immunonephelometric IgG subclass reagents analytic errors were noted in patients with increases in IgG4. The sum of the individual IgG subclasses was substantially greater than the measured total IgG concentrations, and the IgG4 concentration was always less than the IgG2 concentration. Using a tryptic digest LC-MS/MS method as reference to quantify the IgG subclasses biases of the immunonephelometric measurements compared with the correspondent LC-MS/MS measurements was observed. The biases potentially reflect two analytical phenomena caused by immunonephelometry:
- Cross reactivity of sample IgG4 with IgG2 reagents
- Measurement of IgG1 and IgG2 that represent an aggregate of the target Ig and nonspecifically IgG4 (IgG4 bound to either the target Ig or the reagent Ig).
In each case, these proposed phenomena would explain the observation of IgG4-dependent positive biases with immunonephelometric IgG1 and IgG2 concentration measurements as compared with the corresponding LC-MS/MS measurements .
Using immunonephelometric methods contaminations inducing light-scattering interfere with this method (e.g., micro clots, cells from inadequately centrifuged samples, particles derived from proteins of the cerebrospinal fluid and microbial contaminations). In principle, problems should be anticipated in samples after deep-freezing or in hyperlipidemic samples.
Reference intervals of IgG subclasses
The reference intervals of the IgG subclasses for children are age-dependent. By 6 months of age, IgG1 and IgG3 concentrations are about 50% of the adult level which is reached by 3 years of age. IgG2 and IgG4 are produced in a delayed fashion; during the 1st year of life, their concentrations are 25% and during the 3rd year of life 50% of the adult level.
Subclass assays yield different results. Whereas the reference intervals for IgG1 and IgG2 from Siemens and The Binding Site are similar , there is a marked difference in those for IgG3 and IgG4. This is due to the fact that the standards established by The Binding Site are based on the material ERM-DA470k, while those established by Siemens are based on WHO 67/97, later replaced by Sanquin M1590. Hence, the reference intervals of a given manufacturer should be used consistently in a given case.
The function of the 4 IgG subclasses is to eliminate invading pathogens and their products. The Ig structure is adapted to these functions. Ig have the following functional units:
- A Fab portion with a variable region for antigen detection
- An Fc portion mediating the effects of the molecule. The Fc portion binds complement and reacts with Fcγ -receptors on the surface of the defense cells such as polymorphonuclear granulocytes and monocytes/macrophages. This results in the inactivation and/or elimination of the Ig-bound antigen. The fact that 4 IgG subclasses do not have a uniform Fc portion causes their functional differences /, /.
Antibody response to membrane proteins and soluble proteins (T cell-dependent antigens such as, for example, viral and bacterial antigens) primarily induce IgG1 and with lower levels IgG3 and IgG4. IgG antibodies against proteins (tetanus toxin) and viral antigens are predominantly IgG1 and IgG3. IgG1 deficiency is associated with recurrent infections. IgG1 reaches an adult serum level at the age of 1–4 years; the other Ig subclasses reach approximately 50% of the adult level at this age. Adult levels are finally reached in the adolescent period.
T cell independent antigens like the polysaccharide capsule of H. influenzae and S. pneumonia lead mostly to an IgG2-restricted antibody response. Antigens are pneumococcal antigen, teichoic acids, dextran HIB-PrP. Low concentrations of IgG2 often occur in association with a deficiency in IgG4 and/or IgA1 and IgA2.
Being a potent pro-inflammatory antibody IgG3 is particularly effective in the induction of effector functions. Decreased IgG3 levels are frequently associated with other subclass deficiencies.
Allergens are often good inducers of IgG4 and IgG1 in addition to IgE. In a non-infectious setting IgG4 antibodies are often formed following repeated or long term exposure to antigens. Allergen-specific antigens (bees’ venom) under conditions of hyposensibilization stimulate antibody production primarily in the IgG4 subclass. Helminth or filarial parasite infections may result in the formation of IgG4 antibodies.
IgG4-RD is a chronic inflammatory condition that affects almost any organ in the same patient. Molecular mimicry has been proposed to play a role. The target antigens for these IgG4 antibodies seem evolutionarily conserved, because purified patient IgG4, but not IgG4 from healthy donors are deposited at the base of acini or pancreatic duct cells .
3. Schauer U, Stemberg F, Rieger CHL, Borte M, Schubert S, Riedel F, et al. IgG subclass concentrations in certified reference material 470 and reference values for children and adults determined with the Binding Site reagents. Clin Chem 2003; 49: 1924–9.
6. Oxelius VA, Carlsson AM, Hammarstrom L, Bjorkander J, Hanson LA. Linkage of IgA deficiency to Gm allotypes; the influence of Gm allotypes on IgA-IgG subclass deficiency. Clin Exp Immunol 1995; 99: 211–5.
12. Inoue R, Kondo N, Kobayashi Y, Fukutomi O, Orii T. IgG2 deficiency associated with defects in production of interferon-gamma; comparison with common variable immunodeficiency. Scand J Immunol 1995; 41: 130–4.
13. Plebani A, Ugazio AG, Meini A, et al. Extensive deletion of immunoglobulin heavy chain constant region genes in the absence of recurrent infections: when is IgG subclass deficiency clinically relevant? Clin Immunol Immunopathol 1993; 68: 46–50.
17. Macdermott RP, Nash GS, Auer IO, Shlien R, Lewis BS, Madassery J, Nahm MH. Alterations in serum immunoglobulin G subclasses in patients with ulcerative colitis and Crohn’s disease. Gastroenterol 1989; 96: 764–8.
24. Van den Gugten G, Demarco ML, Chen LYC, Chin A, Carruthers M, Holmes DT, Mattman A. Resolution of spurious immunonephelometric IgG subclass measurement discrepancies by LC-MS/MS. Clin Chem 2018; 64: 735–42.
25. Wilson C, Ebling R, Henig C, Adler T, Nicolaevski R, Barak M, et al. Significant, quantifiable differences exist between IgG subclass standards WHO 67/97 and ERMDA470k and can result in different interpretation results. Clin Biochem 2013; 46: 1751–5.
27. French MA, Denis KA, Dawkins R, Peter JB. Severity of infections in IgA deficiency: correlation with decreased serum antibodies to pneumococcal polysaccharides and decreased serum IgG2 and/or IgG4. Clin Exp Immunol 1995; 100: 47–53.
Cold reacting and cold precipitating proteins are differentiated into cold agglutinins, cryoglobulins and fibronectin-containing immuno complexes . Cold agglutinins are proteins capable of agglutination and hemolysis of erythrocytes below body tempeature.
Cold agglutinins are capable of agglutination and hemolysis of erythrocytes via complement activation (cryohemolysin) at temperatures below 37 °C and redissolve on rewarming. Cold agglutinins belong to the IgM class. The IgM antibody-antigen complex, a trigger of the classic complement pathway, generates the C3 convertase C4bC2a. The convertase catalysis C3 proteolysis into C3a and C3b, which in turn triggers opsonization and extravascular hemolysis in the liver. Cold agglutinin disease is caused by cold agglutinins, which are IgM antibodies that bind to I antigen on red cells when temperatures are below or at 37 °C. A titer < 1 : 128 is significant and a definite temperature below or at 37 °C (temperature amplitude). A lower titer or a temperature amplitude higher than 25 °C are not clinically. Patients with cold agglutinin disease have chronic anemia, fatigue, acute hemolytic crisis, agglutination-mediated acrocyanosis and a higher risk of thromboembolism. Cold agglutinin disease is distinguished from cold agglutinin syndrome:
- Cold agglutinine syndrome is transient and secondary to infections and overt malignant autoimmune conditions.
- Cold agglutinine disease is a low-grade B cell lymphoproliferative disorder that can be detected in blood or bone marrow. There is no clinical or radiologic evidence of malignancy.
- Rutiximab depletes B cells and induces partial responses in about 50%
- Sutimlimab, a humanized monoclonal antibody prevents cold agglutinin-mediated complement deposition on erythrocytes.
Refer also to
The patient presented with dark urine, jaundice, and anemia after an upper respiratory tract infection 1 week earlier. Laboratory studies showed anemia and findings consistent with hemolysis. In the peripheral blood smear red cells, reticulocytes, and neutrophils coated with agglutinated erythrocytes, forming rosettes, were found. Phagocytosis of erythrocytes in macrophages and neutrophils were also found. The cold agglutinin titer was 1 : 1024, the serology for antibodies of Mycoplasma pneumoniae, Epstein-Barr virus and other common respiratory viruses was negative. The diagnosis of autoimmune hemolytic anemia from cold agglutinin syndrome associated with an upper respiratory infection was made .
- Type I (monoclonal). This type represents individual monoclonal immunoglobulins, generally associated with lymphoproliferative diseases.
- Type II (mixed type). Type II consists of mixed immunoglobulins with a monoclonal component and is strongly associated with hepatitis C infection.
- Type III (polyclonal). This type is constituted by a mixture of polyclonal immunoglobulins and is associated mainly with a wide range of infectious, autoimmune, and liver disease.
Skin symptoms: Raynaud’s phenomenon, purpura, livido reticularis, ecchymosis, ulceration, ischemic necrosis.
- Sampling: blood samples for the determination of cryoglobulins are collected in three 4–5 mL tubes without gel anticoagulant to obtain a total of 4–6 mL of serum after centrifugation
- Detection: a minimum of 2 hours for clotting and centrifugation at 37 °C, serum than is decanted into conical-bottomed tubes and placed at 4 °C for 7 days.
- Differentiation of precipitated cryoglobulins. The goal of cryoglobulin differentiation is their classification into types I–III. The cryoglobulin type allows conclusions regarding etiopathogenesis and, thus, facilitates the interpretation of clinical symptoms.
1. For the detection of cryoglobulins, serum is incubated into a tube at temperatures of 4 °C until 15 days. Precipitate is visible for most type I cryoprecipitates within 24 hours, type II and type III cryoglobulins can take several days. Precipitates appear as a white and translucent pellet, as fine or thick flakes, as cryogels or as crystals.
2. For the characterization the cryoprecipitate is isolated by cold centrifugation, the supernatant is discarded and for quantification of the cryoglobulin the cryocrit is determined. For further investigations the cryoprecipitate is washed with cold isotonic NaCl or PBS-buffer and suspended in 0.5 mL NaCl. The sample is placed at 37 °C for 2 hours to dissolve the precipitate. For removal of precipitated proteins, like albumin, three washes in cold NaCl are recommended and the precipitate placed at 37 °C for 2 hours to dissolve the cryoglobulin.
- Immunonephelometric investigation of IgA, IgG and IgM to determine the protein components of the cryoglobulin. A serum concentration of about 33 mg/L (diagnostic sensitivity of 73% with a diagnostic specificity of 70%) has been reported for the diagnosis of clinical manifestations .
- Immunofixation electrophresis; determination of the monoclonality and the cryoglobulin isotypes (IgG, IgA, IgM, kappa or lambda) and hence clonality of the precipitate concentration become visible after centrifugation
- Rheumatic factor activity in the cryoprecipitate
- Determination of complement proteins or of CH50 in the serum of the patient. Hypocomplementemia is often associated with type I or type II cryoglobulinemia.
Spectrophotometric detection of cryoglobulins
Two methods are published:
- An assay was described based on the spectrophotometric detection of a difference in optical density between two aliquots of serum sample incubated at 4 °C and 37 °C respectively.
- In a second study the increase of turbidity during the cryoglobulin aggregation was determined. Measurements were performed using a dual-beam spectrophotometer with a cell whose temperature was maintained at 10 °C.
- Whole blood without an anticoagulant: 10 mL
A blood sample is collected in a 8–10 mL prewarmed tube.
The incidence of cryoglobulinemia is much higher than that of cryofibrinogenemia. For instance, in the Sheffield Protein Reference Unit, 887 samples were analyzed for cryoglobulinemia in 2004–2008 . As a result of the analysis, 188 cryoglobulinemias and 5 cryofibrinogenemias were detected. The prevalence of types is listed in .
Negative evidence of cryoglobulin does not exclude cryoglobulinemia because, in many cases, improper handling of the samples yields false-negative results. The concentrations of C4 and CH50 are surrogate markers.
Hypocomplementemia is often associated with:
- Cryoglobulin-induced immune complex activity
- Type I or mixed cryoglobulinemia
Normal complement concentrations do not allow any conclusions.
Cryoglobulin-induced diseases are associated with immunoglobulin precipitation during cold exposure. Physiologically, small amounts of cryoglobulins are produced and eliminated by the hepatocytes via a specific receptor. Cryoglobulin deposits in the glomeruli are removed by monocytes/macrophages . Precipitation of cryoglobulins in the vessels causes the development of vasculitis, especially in the skin, kidneys and peripheral nervous system. Clinical manifestation of cryoglobulinemia depends on the organs affected. Histologically, a leucoclastic vasculitis secondary to vascular deposition of immune complexes is seen . This leads to ischemia, necrosis and purpura. About 50–70% of symptomatic patients with cryoglobulinemia have liver involvement, arthralgia and asthenia, and about 25% have renal involvement. The incidence of nervous system involvement is 36%.
There is a lack of correlation between serum cryoglobulin concentration, and severity of disease. Many patients have cryoglobulinemia without symptoms even when serum cryoglobulin levels are high . Cryoglobulins in most of the patients exist in low concentration (100–300 mg/L).
Cryoglobulins undergo reversible condensation upon changing temperature and concentration. Various morphologies of IgG cryoglobulin condensates (e.g., including crystals, amorphous aggregates and gels) exist in different patients .
Mixed cryoglobulinemia, an autoimmune disease characterized by the formation of cold-precipitable cryoglobulin complexes composed of immunoglobulins, is recognized as the most common extrahepatic disease induced by hepatitis C infection.
Based on the immunoglobulin composition mixed cryoglobulinemia has two types of immunoglobulins: type II cryoglobulins consisting of polyclonal IgG and monoclonal IgM with rheumatoid factor (RF) activity and type III cryoglobulins characterized by polyclonal IgG with polyclonal IgM . Mixed type II and polyclonal type III are generally associated with diseases. Approximately 95% of cryoglobulins are immune complexes that contain rheumatoid factor. Usually the RF is monoclonal or polyclonal IgM, although other immunoglobulins may be found. Type II and type III cryoglobulins account for about 50–60% and 25–30%, respectively. Mixed type II is generally associated with diseases where there is a chronic infection such as HCV, chronic hepatitis B or human immunodeficiency virus infection, and in autoimmune diseases such as Sjögren syndrome. More than 90% of patients with mixed type II cryoglobulinemia are infected with hepatitis C virus .
In HCV-related mixed cryoglobulinemia, the majority of patients have asymptomatic cryoglobulinemia, and only 10–15% of these patients will develop cryoglobulinemic symptoms characterized by small vessel vasculitis, glomerulonephritis, and neuropathy due to immune complex deposition and activation of the complement cascade in small blood vessels. The prevalence of cryoglobulin is 2–4 times higher in HCV than in HBV .
A differentiation is made between monoclonal and mixed forms of cryoglobulinemia. The mixed forms (type II and type III) account for up to 90% of cryoglobulinemias, the monoclonal form (type I) accounts for approximately 10%. About 95% of the mixed forms are based on chronic hepatitis C, the remaining forms are of different nature.
Monoclonal cryoglubilinemia is usually associated with plasma cell dyscrasia such as multiple myeloma, smoldering myeloma, monoclonal gammopathy of undetermined significance (MGUS), Waldenstroems disease and accounts for 10% of cryoglobulins.
Type I cryoglobulins precipitate at higher temperatures (≤ 32 °C) than mixed cryoglobulins. Concentrations can range between 60 mg/L and 60 g/L.
Clinical manifestations are hyper viscosity syndrome with symptoms of peripheral vascular obstruction, purpura or dermal manifestation (Raynaud’s phenomenon). Type I is rarely associated with vasculitis. Joint manifestations are seen if the cryoglobulin (usually IgG3) precipitates in crystallized form.
The cryocrit is usually high and protein concentrations are > 1 g/L in many cases. Examination for evidence of monoclonal IgG or IgM. The rheumatoid factor is negative, complement decreases are not continuously detectable.
Mixed cryoglobulinemia, an autoimmune disease characterized by the formation of cold-precipitable cryoglobulin complexes composed of immunoglobulins, is recognized as the most common extrahepatic disease induced by hepatitis C infection.
- Type II cryoglobulins consisting of polyclonal IgG and monoclonal IgM with rheumatoid factor (RF) activity
- Type III cryoglobulins characterized by polyclonal IgG with polyclonal IgM.
Mixed type II and polyclonal type III are associated with diseases. Approximately 95% of cryoglobulins contain rheumatoid factor (RF). Type II and type III cryoglobulins account for about 50–60% and 25–30%, respectively. Mixed type II is generally associated with diseases where there is a chronic infection such as hepatitis C, chronic hepatitis B or human immunodeficiency virus (HIV) infection, and in autoimmune diseases such as Sjögren syndrome. A shared feature of these disorders is chronic inflammation, high antigen load and antigen-driven dysregulation of the B-cell system . More than 90% of patients with mixed type II cryoglobulinemia are infected with hepatitis C virus . According to a study higher frequencies of TH1 cells and activated memory B cells were associated with type II asymptomatic mixed cryoglobulinemia in HCV infection.
In HCV-related mixed cryoglobulinemia, the majority of patients have asymptomatic cryoglobulinemia, and only 10–15% of these patients will develop cryoglobulinemic symptoms characterized by small vessel vasculitis, glomerulonephritis, and neuropathy due to immune complex deposition and activation of the complement cascade in small blood vessels.
If the RF is monoclonal the mixed cryoglobulinemia is referred to as type II. If the RF is polyclonal, the cryoglobulinemia is referred to as type III. Infections can cause either type II or type III cryoglobulinemia. Associated diseases with type III cryoglobulinemia are post streptococcal glomerulonephritis, chronic infections and essential cryoglobulinemia .
As a rule, mixed cryoglobulins precipitate at temperatures ≤ 23 °C. Positive evidence of rheumatoid factor in type II, complement decrease is continuously detectable.
In the presence of this cryoglobulinemia, the precipitated protein dissolves at temperatures higher than 37 °C, for example at 56 °C. These forms of cryoglobulinemia are rare but have been described in association with multiple myeloma, Sjögren’s syndrome and cryoglobulin-occlusive membranoproliferative glomerulonephritis .
Cryofibrinogenemia is diagnosed when EDTA plasma that is clear at 37 °C develops a precipitate when it is cooled to 4 °C. Cryofibrinogenemia is subdivided into an essential (primary) and a secondary form . The primary form is rare. The prevalence of secondary cryofibrinogenemia without clinical symptoms is said to be 13% in hospitalized patients. Primary cryofibrinogenemia often develops spontaneously in healthy individuals, while secondary cryofibrinogenemia is associated with an underlying chronic inflammatory disorder in the context of a malignant tumor, diabetes mellitus, inflammation, collagen vascular disease or active infection. The female/male ratio is 1.4 : 1.
The main clinical symptoms in patients with cryofibrinogenemia are cold intolerance, cutaneous ischemia such as purpura, livido reticularis and acral skin ulcerations. These patients live in colder climate zones and report a temporal association between cold exposure and the onset of symptoms.
According to one of the few cases described to date, the laboratory-diagnostic findings in essential cryofibrinogenemia included a cryocrit of 5% and a protein concentration of the cryoprecipitate of 850 mg/L. The cryofibrinogen precipitate must be distinguished from the heparin-precipitable fraction, which also forms in normal individuals during cold exposure if heparinized plasma is used instead of EDTA plasma .
Temperature control is particularly important in the preanalytical phase of type I cryoglobulins because these cryoglobulins precipitate at higher temperatures and can also be present at concentrations > 5 g/L. High concentrations of monoclonal cryoglobulins tend to precipitate earlier at higher temperatures. For type III cryoglobulins, temperature control is not crucial because they slowly precipitate over a period of days .
Cryoglobulin detection using the precipitate method is due to false negative results because the standard pre analytical procedures to collect blood (tube preheating, transport in container, sedimentation, and/or centrifugation at 37 °C) are not exist in many laboratories .
Highly concentrated cryoglobulins can precipitate at any sample kept at temperatures higher than 4 °C.
A negative cryoglobulin result in the presence of a suggestive clinical context (vasculitis, Raynaud phenomenon, peripheral neuropathy, arthralgia, glomerulonephritis) should be repeated because 10% of samples with a negative initial negative test are found to be positive with subsequent tests.The patient should come directly to the laboratory for cryoglobulin determination to avoid preanalytical transport problems .
Cryoglobulins: Washing of the cryoprecipitate
The cryoprecipitate must be washed at cold temperature prior to protein determination to remove contamination by other serum proteins.
1. Merlini G, Aguzzi F, Whicher JT, Chir B, Navolotskaia O. Cryoglobulins. In: Ritchie RF, Navolotskaia O, eds. Serum proteins in clinical medicine. Scarborough: Foundation for Blood Research, 1996: 11.05-1–05.
11. Meng QH, Chibbar R, Pearson D, Kappel J, Krahn J. Heat insoluble cryoglobulin in a patient with essential type II cryoglobulinemia and cryoglobulin-occlusive membranoproliferative glomerulonephritis: case report and literature review. Clin Chim Acta 2009, Aug 406; 170–3.
14. Minopetrou M, Hadziyannis E, Deutsch M, Tampaki M, Georgiadou A, Dimopoulou E, et al. Hepatitis C virus (HCV) related cryoglobulinemia: cryoglobulin type and anti-HCV profile. Clin Vaccine Immunol 2013, 20: 698–703.
15. Kong F, Zhang W, Feng B, Zhang H, Rao H, Wang J, et al. Abnormal CD4+ T helper (Th) 1 cells and activated memory B cells are associated withtype III asymptomatic mixed cryoglobulinemia in HCV infection. Virology J 2015; 12: 100. .
17. Agarwal A, Clements J, Sedmak DD, Imler D, Nahman NS Jr, Orsinelli DA, et al. Subacute bacterial endocarditis masquerading as type III essential mixed cryoglobulinemia. J Am Soc Nephrol 1997; 8: 1971–6.
Cryofibrinogenemia is diagnosed when EDTA plasma that is clear at 37 °C develops a precipitate when it is cooled to 4 °C. Cryofibrinogenemia is subdivided into an essential (primary) and a secondary form . The primary form is rare. The prevalence of secondary cryofibrinogenemia without clinical symptoms is said to be 13% in hospitalized patients. Primary cryofibrinogenemia often develops spontaneously in healthy individuals, while secondary cryofibrinogenemia is associated with an underlying chronic inflammatory disorder in the context of a malignant tumor, diabetes mellitus, inflammation, collagen vascular disease or active infection/1/. The female/male ratio is 1.4 : 1.
In the presence of the following symptoms and/or conditions/diseases: cutaneous ischemia such as purpura, livido reticularis, ecchymosis, ulceration, ischemic necrosis and gangrene (rare).
Cryofibrinogen can be detected in healthy asymptomatic individuals as many as 2% to 9%. The main clinical symptoms in patients with cryofibrinogenemia are cold intolerance, cutaneous ischemia such as purpura, livido reticularis and acral skin ulcerations. These patients live in colder climate zones and report a temporal association between cold exposure and the onset of symptoms . According to one of the few cases described to date, the laboratory-diagnostic findings in essential cryofibrinogenemia included a cryocrit of 5% and a protein concentration of the cryoprecipitate of 850 mg/L. The cryofibrinogen precipitate must be distinguished from the heparin-precipitable fraction, which also forms in normal individuals during cold exposure if heparinized plasma is used instead of EDTA plasma .
2. Natali P, Debbia D, Cucinelli MR, Trenti T, Amati G, Spinella A, et al. Analysis of cryoproteins with a focus on cryofibrinogen: a study on 103 patients. Clin Chem Lab Med 2022; 60 (11): 1796–1803.
β2-M forms the non-variable light chain of the class I major histocompatibility complex (MHC) and is found on the surfaces of nearly all nucleated cells (). When MHC is degraded, the MHC associated β2-M is released into circulation. This results in a constant production rate of free β2-M of 2.4 mg/kg/day. β2-M is a non-glycosylated polypeptide with a molecular mass of 11.8 kDa. Due to its small size, β2-M is present in the glomerular filtrate of the kidney and other body fluids. Elevated β2-M serum levels are measured in chronic renal failure, lymphoproliferative disorders, conditions with high cell turnover, inflammations and infections.
- Monitoring and assessment of therapy in lymphoid neoplasia, especially non Hodgkin lymphoma, Hodgkin’s lymphoma and multiple myeloma
- Assessment of the glomerular filtration rate, especially in children
- Diagnosis and monitoring in tubulointerstitial kidney damage
- Monitoring of β2-M in dialysis patients
- Assessment of renal function after kidney transplantation and early detection of Cytomegalovirus infection
- Detection of a rejection episode after allogenic bone marrow transplantation
- Monitoring of disease progression in patients with HIV infection
- Diagnosis of fetal infections.
Serum, plasma: 1 mL
Random urine sample to which 0.5 mL of 2n NaOH is added in order to obtain a pH > 6. 10 mL of this urine sample need to be delivered to the clinical laboratory. It is used, for example, as part of occupational-medical examinations.
Urine collection, 6–8 h collection period; collection to be performed only during the daytime. This allows monitoring of the urine pH and, if necessary, alkalinization of the urine by adding 2n NaOH. The urine collection over the specified period of time is indicated for detection of acute, toxic injury to tubules.
The concentration of β2-M in serum and its excretion in urine provide valuable information only:
- In the presence of specific clinical problems
- If other diseases that may also have an impact on synthesis or excretion of β2-M, have been ruled out first. For example, if the glomerular filtration rate is to be estimated, no lymphoid neoplasia should be present or the presence of a tubulointerstitial renal disease should be ruled out when the therapy of a lymphoid neoplasia is to be assessed.
In the presence of constant serum levels, an acute rise in concentration or fractional urinary excretion of β2-M indicates tubular damage. In serum concentrations > 6 mg/L and normal GFR, the tubular reabsorption capacity is exceeded and the concentration in urine cannot be used as an indicator of tubular damage . In such cases, it is better to determine the excretion of α1-microglobulin. Refer to . This is recommendable in general because α1-microglobulin in urine is more stable than β2-M.
In the presence of a pH < 6.0, β2-M is denatured within a period of 2 hours , even in the bladder. As a result of such degradation, it can no longer be immuno-chemically determined. Consequently, examination of the urine should not involve the first morning urine (usually with a pH < 6.0) but instead should employ a random daytime urine sample or a urine sample collected during the daytime. The pH must be checked after voiding and, if necessary, alkalinization should be performed by adding a few drops of 2n NaOH.
Children have slightly higher serum concentrations than adolescents and adults as well as individuals over the age of 60.
β2-M is the light chain protein of the MHC class I antigens and thus present on the membrane of all nucleated cells. It is located on the outside of the cell membrane and is not covalently bound to the heavy chain of the MHC class I antigen. Thus, it is free to exchange with β2-M in the body fluids, where more than 98% are present in the form of a free monomer.
The expression of MHC class I antigens and, thus, of β2-M on the cell membranes of immune defense cells (especially of lymphocytes) is stimulated by cytokines of the hemolymphatic system. The β2-M production is increased in all diseases associated with activation of the immune system such as bacterial infections, certain viral infections and autoimmune diseases (e.g., rheumatoid arthritis). The main synthesis site for β2-M is lymphocytes. Healthy individuals with a body weight of 70 kg synthesize 9 mg of β2-M/hour. The half-life is 40 min. The kidney is the main elimination site and glomerular filtration is approximately 210 μg/min. and 99.9% of β2-M are reabsorbed in the proximal tubules.
Changes in serum β2-M level or β2-M excretion are caused by increased production, reduction in GFR or tubular reabsorption.
Since the lymphatic system is the main synthesis site of β2-M, all conditions with an increased proliferation rate of lymphocytes are associated with elevated serum concentrations; this applies, in particular, to multiple myeloma, Hodgkin’s lymphoma, chronic lymphocytic leukemia and other malignant non Hodgkin lymphomas. In these diseases, the determination of β2-M is a good indicator for monitoring the disease and assessing the treatment outcome. Monoclonal Ig level and serum β2-M concentration show a parallel course in about 70% of the patients. The β2-M concentration is not elevated in some patients despite marked monoclonal gammopathy. This is explained by changes in renal function in myeloma patients . Other diseases associated with pronounced activation of the cellular immune response and elevated serum β2-M are certain autoimmune diseases, infectious mononucleosis, and transplant rejection episodes .
A reduction in GFR prolongs the half-life of β2-M, and serum level increases exponentially i.e., is inversely related to GFR (this relationship applies to the entire filtration range). An increase in serum concentration may occur with a GFR decline to below 80 [mL × min–1 × (1.73 m2)–1]. Reports concerning a correlation between abnormal serum creatinine and serum β2-M concentrations differ. The usefulness of β2-M for assessment of GFR is limited by the fact that other diseases may also cause an elevation .
β2-M is reabsorbed in the brush border of the proximal tubule, followed by its catabolism into amino acids. Excretion of β2-M is increased in tubular damage (e.g., due to bacterially induced interstitial nephritis, cadmium nephropathy and amino glycoside-induced tubular necrosis). Patients with amino glycoside-related nephrotoxicity have a urinary excretion > 10 mg in an 8-h urine collection.
In cadmium-exposed individuals, a relationship exists between exposure duration, the cadmium concentration in blood and β2-M excretion. In individuals with prolonged occupational exposure to cadmium, increased β2-M excretion should be expected after an exposure period of about 10 years .
In Cytomegalovirus infection, an increase in CD8+ T lymphocytes occurs, which is responsible for an increase in serum β2-M concentration.
Increased serum β2-M serum levels in malignant lymphomas are presumably due to increased cell turnover. Another theory is based on the fact that in malignant lymphomas the cell membrane of lymphocytes carries less β2-M than in healthy individuals. This is thought to be caused by a defect in the α-chain of MHC class I antigens, which subsequently binds less β2-M. Because an intact MHC class I antigen structure is a prerequisite for recognition of altered cells by cytotoxic lymphocytes, these altered cells are not recognized and, hence, they are able to proliferate.
1. Terrier N, Bonardet A, Descomps B, Cristol JP, Dupuy AM. Dermination of β2-microglobulin in biological samples using an immunoenzymometric assay (chemiluminescence detection) or an immunoturbidimetric assay: comparison with radioimmunoassay. Clin Lab 2004; 50: 675–83.
11. Bien E, Balcerska A. Serum soluble interleukin-2 receptor, β2-microglobulin, lactate dehydrogenase and erythrocyte sedimentation rate in children with Hodgkin’s lymphoma. Clinical Immunology 2009; 70: 490–500.
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The condition occurs after the therapeutic administration of nonhuman protein. Serum sickness is a type-III-hyper-sensitivity reaction due to the formation of antigen-antibody complexes.
Clinical findings: fever, nonpruritic morbilliform rash across the torso, arms, and on the legs.
Laboratory findings: neutropenia, C-reactive protein (> 80 mg/L) elevated, low C3 and C4 concentrations, negative blood culture.
Data expressed in g/L. Values are 2.5th and 97.5th percentiles.
Clinical and laboratory findings
Clinical and laboratory findings
Distribution of albumin and globulin fractions in % of the total protein for adults
* Values are the 2.5th and 97.5th percentiles.
* The values apply to protein bands stained with Ponceau red S on cellulose acetate sheet.
G, globulin; description of symbols: ↑ increased, ↓ decreased, ↑↑ strongly increased, ↓↓ strongly decreased
Disease and/or cause
Data expressed in g/L; values are 2.5th and 97.5th percentiles
Clinical and laboratory findings
* Dysfunction regarding the inhibition of the elastase activity of polymorphonuclear granulocytes.
National Institute on Alcohol Abuse and Alcoholism (USA)
1 fluid ounze; fl oz (USA) = 28.4 mL; 1 standard drink corresponds to 14 g of alcohol
Clinical and laboratory findings
Clinical and laboratory findings
BW, body weight; MW, molar weight in Dalton (Da). Conversion factors: mg/dL × 0.2171 = mmol/L
mmol/L × 4.61 = mg/dL
Data expressed in g/L
Clinical and laboratory findings
Score system I
Score system II
Evaluation in score system I or score system II: 4 or more points = diagnosis established;
3 points = diagnosis possible, more tests are needed; 2 or less points = diagnosis very unlikely
* absence of acute hepatitis, ULN, upper level of normal
Data expressed in g/L. * Values are the 5th and 95th percentiles.
Hereditary hemolytic anemias
Acquired hemolytic anemias
Clinical and laboratory findings
n, normal; ↑, increased; ↓, decreased
* Values expressed in mg/L; ** classic pathway; synthesis rate in mg/kg body weight per day
Data expressed in g/L; values expressed as 5th and 95th percentiles.
Clinical and laboratory findings
PMN, polymorphonuclear neutrophils; SPA, Staphylococcus aureus protein A
Data expressed in g/L. Values are the 2.5th and 97.5th percentiles. The reference intervals in the top rows are provided by Siemens, those in the bottom rows are provided by The Binding Site.
Clinical and laboratory findings
* Particle-enhanced immunoassay; values are the 2.5th and 97.5th percentiles
Figure 18.3-2 Separation of serum proteins on agarose gel electrophoresis. Alb, albumin; αLP, α-lipoprotein; α1-AT, α1-antitrypsin; Om, orosomucoid; Gc, Gc globulin; α2M, α2-macroglobulin, Hp2-1, haptoglobin type 2-1; β-LP, β-lipoprotein; Hpx, hemopexin; C3, ceruloplasmin; Tf, transferrin; Fg, fibrinogen.