Four Years' Experience in the Diagnosis of Very Long-Chain Acyl-CoA Dehydrogenase Deficiency in Infants Detected in Three Spanish Newborn Screening Centers.

Identification of very long-chain acyl-CoA dehydrogenase deficiency is possible in the expanded newborn screening (NBS) due to the increase in tetradecenoylcarnitine (C14:1) and in the C14:1/C2, C14:1/C16, C14:1/C12:1 ratios detected in dried blood spots. Nevertheless, different confirmatory tests must be performed to confirm the final diagnosis. We have revised the NBS results and the results of the confirmatory tests (plasma acylcarnitine profiles, molecular findings, and lymphocytes VLCAD activity) for 36 cases detected in three Spanish NBS centers during 4 years, correlating these with the clinical outcome and treatment. Our aim was to distinguish unambiguously true cases from disease carriers in order to obtain useful diagnostic information for clinicians that can be applied in the follow-up of neonates identified by NBS.Increases in C14:1 and of the different ratios, the presence of two pathogenic mutations, and deficient enzyme activity in lymphocytes (<12% of the intra-assay control) identified 12 true-positive cases. These cases were given nutritional therapy and all of them are asymptomatic, except one. Seventeen individuals were considered disease carriers based on the mild increase in plasma C14:1, in conjunction with the presence of only one mutation and/or intermediate residual activity (18-57%). In addition, seven cases were classified as false positives, with normal biochemical parameters and no mutations in the exonic region of ACADVL. All these carriers and the false positive cases remained asymptomatic. The combined evaluation of the acylcarnitine profiles, genetic results, and residual enzyme activities have proven useful to definitively classify individuals with suspected VLCAD deficiency into true-positive cases and carriers, and to decide which cases need treatment.

Pulmonary surfactant protein A interacts with gel-like regions in monolayers of pulmonary surfactant lipid extract.

Epifluorescence microscopy was used to investigate the interaction of pulmonary surfactant protein A (SP-A) with spread monolayers of porcine surfactant lipid extract (PSLE) containing 1 mol % fluorescent probe (NBD-PC) spread on a saline subphase (145 mM NaCl, 5 mM Tris-HCl, pH 6.9) containing 0, 0.13, or 0.16 microg/ml SP-A and 0, 1.64, or 5 mM CaCl(2). In the absence of SP-A, no differences were noted in PSLE monolayers in the absence or presence of Ca(2+). Circular probe-excluded (dark) domains were observed against a fluorescent background at low surface pressures (pi approximately 5 mN/m) and the domains grew in size with increasing pi. Above 25 mN/m, the domain size decreased with increasing pi. The amount of observable dark phase was maximal at 18% of the total film area at pi approximately 25 mN/m, then decreased to approximately 3% at pi approximately 40 mN/m. The addition of 0.16 microg/ml SP-A with 0 or 1.64 mM Ca(2+) in the subphase caused an aggregation of dark domains into a loose network, and the total amount of dark phase was increased to approximately 25% between pi of 10-28 mN/m. Monolayer features in the presence of 5 mM Ca(2+) and SP-A were not substantially different from those spread in the absence of SP-A, likely due to a self-association and aggregation of SP-A in the presence of higher concentrations of Ca(2+). PSLE films were spread on a subphase containing 0.16 microg/ml SP-A with covalently bound Texas Red (TR-SP-A). In the absence of Ca(2+), TR-SP-A associated with the reorganized dark phase (as seen with the lipid probe). The presence of 5 mM Ca(2+) resulted in an appearance of TR-SP-A in the fluid phase and of aggregates at the fluid/gel phase boundaries of the monolayers. This study suggests that SP-A associates with PSLE monolayers, particularly with condensed or solid phase lipid, and results in some reorganization of rigid phase lipid in surfactant monolayers.

Self-aggregation of surfactant protein A.

Environmental factors of physiological relevance such as pH, calcium, ionic strength, and temperature can affect the state of self-aggregation of surfactant protein A (SP-A). We have studied the secondary structure of different SP-A aggregates and analyzed their fluorescence characteristics. (a) We found that self-aggregation of SP-A can be Ca(2+)-dependent. The concentration of Ca(2+) needed for half-maximal self-association (K(a)(Ca)()2+) depended on the presence of salts. Thus, at low ionic strength, K(a)(Ca)()2+ was 2.3 mM, whereas at physiological ionic strength, K(a)(Ca)()2+ was 2.35 microM. Circular dichroism and fluorescence measurements of Ca(2+)-dependent SP-A aggregates indicated that those protein aggregates formed in the absence of NaCl are structurally different from those formed in its presence. (b) We found that self-aggregation of SP-A can be pH-dependent. Self-aggregation of SP-A induced by H(+) was highly influenced by the presence of salts, which reduced the extent of self-association of the protein. The presence of both salts and Ca(2+) attenuated even more the effects of acidic media on SP-A self-aggregation. (c) We found that self-aggregation of SP-A can be temperature-dependent. At 20 degrees C, SP-A underwent self-aggregation at physiological but not at low ionic strength, in the presence of EDTA. All of these aggregates were dissociated by either adding EDTA (a), increasing the pH to neutral pH (b), or increasing the temperature to 37 degrees C (c). Dissociation of Ca(2+)-induced protein aggregates at low ionic strength was accompanied by an irreversible loss of both SP-A secondary structure and SP-A-dependent lipid aggregation properties. On the other hand, temperature-dependent experiments indicated that a structurally intact collagen-like domain was required for either Ca(2+)- or Ca(2+)/Na(+)-induced SP-A self-aggregation but not for H(+)-induced protein aggregation.

Interactions of pulmonary surfactant protein A with phospholipid monolayers change with pH.

The interaction of pulmonary surfactant protein A (SP-A) labeled with Texas Red (TR-SP-A) with monolayers containing zwitterionic and acidic phospholipids has been studied at pH 7.4 and 4.5 using epifluorescence microscopy. At pH 7.4, TR-SP-A expanded the pi-A isotherms of film of dipalmitoylphosphatidylcholine (DPPC). It interacted at high concentration at the edges of condensed-expanded phase domains, and distributed evenly at lower concentration into the fluid phase with increasing pressure. At pH 4.5, TR-SP-A expanded DPPC monolayers to a slightly lower extent than at pH 7.4. It interacted primarily at the phase boundaries but it did not distribute into the fluid phase with increasing pressure. Films of DPPC/dipalmitoylphosphatidylglycerol (DPPG) 7:3 mol/mol were somewhat expanded by TR-SP-A at pH 7.4. The protein was distributed in aggregates only at the condensed-expanded phase boundaries at all surface pressures. At pH 4.5 TR-SP-A caused no expansion of the pi-A isotherm of DPPC/DPPG, but its fluorescence was relatively homogeneously distributed throughout the expanded phase at all pressures studied. These observations can be explained by a combination of factors including the preference for SP-A aggregates to enter monolayers at packing dislocations and their disaggregation in the presence of lipid under increasing pressure, together with the influence of pH on the aggregation state of SP-A and the interaction of SP-A with zwitterionic and acidic lipid.

Effect of acidic pH on the structure and lipid binding properties of porcine surfactant protein A. Potential role of acidification along its exocytic pathway.

Pulmonary surfactant protein A (SP-A) is synthesized by type II cells and stored intracellularly in secretory granules (lamellar bodies) together with surfactant lipids and hydrophobic surfactant proteins B and C (SP-B and SP-C). We asked whether the progressive decrease in pH along the exocytic pathway could influence the secondary structure and lipid binding and aggregation properties of porcine SP-A. Conformational analysis from CD spectra of SP-A at various pH values indicated that the percentage of alpha-helix progressively decreased and that of beta-sheet increased as the pH was reduced. The protein underwent a marked self-aggregation at mildly acidic pH in the presence of Ca2+, conditions thought to resemble those existing in the trans-Golgi network. Protein aggregation was greater as the pH was reduced. We also found that both neutral and acidic vesicles either with or without SP-B or SP-C bound to SP-A at acidic pH as demonstrated by co-migration during centrifugation. However, the binding of acidic but not neutral vesicles to SP-A led to 1) a striking change in the CD spectra of the protein, which was interpreted as a decrease of the level of SP-A self-aggregation, and 2) a protection of the protein from endoproteinase Glu-C degradation at pH 4.5. SP-A massively aggregated acidic vesicles but poorly aggregated neutral vesicles at acidic pH. Aggregation of dipalmitoylphosphatidylcholine (DPPC) vesicles either with or without SP-B and/or SP-C strongly depended on pH, being progressively decreased as the pH was reduced and markedly increased when pH was shifted back to 7.0. At the pH of lamellar bodies, SP-A-induced aggregation of DPPC vesicles containing SP-B or a mixture of SP-B and SP-C was very low, although SP-A bound to these vesicles. These results indicate that 1) DPPC binding and DPPC aggregation are different phenomena that probably have different SP-A structural requirements and 2) aggregation of membranes induced by SP-A at acidic pH is critically dependent on the presence of acidic phospholipids, which affect protein structure, probably preventing the formation of large aggregates of protein.

Phase transitions in films of lung surfactant at the air-water interface.

Pulmonary surfactant maintains a putative surface-active film at the air-alveolar fluid interface and prevents lung collapse at low volumes. Porcine lung surfactant extracts (LSE) were studied in spread and adsorbed films at 23 +/- 1 degrees C using epifluorescence microscopy combined with surface balance techniques. By incorporating small amounts of fluorescent probe 1-palmitoyl-2-nitrobenzoxadiazole dodecanoyl phosphatidylcholine (NBD-PC) in LSE films the expanded (fluid) to condensed (gel-like) phase transition was studied under different compression rates and ionic conditions. Films spread from solvent and adsorbed from vesicles both showed condensed (probe-excluding) domains dispersed in a background of expanded (probe-including) phase, and the appearance of the films was similar at similar surface pressure. In quasistatically compressed LSE films the appearance of condensed domains occurred at a surface pressure (pi) of 13 mN/m. Such domains increased in size and amounts as pi was increased to 35 mN/m, and their amounts appeared to decrease to 4% upon further compression to 45 mN/m. Above pi of 45 mN/m the LSE films had the appearance of filamentous materials of finely divided dark and light regions, and such features persisted up to a pi near 68 mN/m. Some of the condensed domains had typical kidney bean shapes, and their distribution was similar to those seen previously in films of dipalmitoylphosphatidylcholine (DPPC), the major component of surfactant. Rapid cyclic compression and expansion of LSE films resulted in features that indicated a possible small (5%) loss of fluid components from such films or an increase in condensation efficiency over 10 cycles. Calcium (5 mM) in the subphase of LSE films altered the domain distribution, decreasing the size and increasing the number and total amount of condensed phase domains. Calcium also caused an increase in the value of pi at which the maximum amount of independent condensed phase domains were observed to 45 mN/m. It also induced formation of large amounts of novel, nearly circular domains containing probe above pi of 50 mN/m, these domains being different in appearance than any seen at lower pressures with calcium or higher pressures in the absence of calcium. Surfactant protein-A (SP-A) adsorbed from the subphase onto solvent-spread LSE films, and aggregated condensed domains in presence of calcium. This study indicates that spread or adsorbed lung surfactant films can undergo expanded to condensed, and possibly other, phase transitions at the air-water interface as lateral packing density increases. These phase transitions are affected by divalent cations and SP-A in the subphase, and possibly by loss of material from the surface upon cyclic compression and expansion.

Differential partitioning of pulmonary surfactant protein SP-A into regions of monolayers of dipalmitoylphosphatidylcholine and dipalmitoylphosphatidylcholine/dipalmitoylphosphatidylglycerol.

The interaction of the pulmonary surfactant protein SP-A fluorescently labeled with Texas Red (TR-SP-A) with monolayers of dipalmitoylphosphatidylcholine (DPPC) and DPPC/dipalmitoylphosphatidylglycerol 7:3 w/w has been investigated. The monolayers were spread on aqueous subphases containing TR-SP-A. TR-SP-A interacted with the monolayers of DPPC to accumulate at the boundary regions between liquid condensed (LC) and liquid expanded (LE) phases. Some TR-SP-A appeared in the LE phase but not in the LC phase. At intermediate surface pressures (10-20 mN/m), the protein caused the occurrence of more, smaller condensed domains, and it appeared to be excluded from the monolayers at surface pressure in the range of 30-40 mN/m. TR-SP-A interaction with DPPC/dipalmitoylphosphatidylglycerol monolayers was different. The protein did not appear in either LE or LC but only in large aggregates at the LC-LE boundary regions, a distribution visually similar to that of fluorescently labeled concanavalin A adsorbed onto monolayers of DPPC. The observations are consistent with a selectivity of interaction of SP-A with DPPC and for its accumulation in boundaries between LC and LE phase.

Increase of C-reactive protein and decrease of surfactant protein A in surfactant after lung transplantation.

In this study, we asked whether the serum acute-phase protein C-reactive protein (CRP) increased in large surfactant aggregates after lung transplantation and analyzed the changes in composition and interfacial adsorption activity of those aggregates. Single left lung transplantation was performed in weight-matched pairs of dogs. A double-lung block from the donor animal was flushed with either modified Euro-Collins solution (EC) (n = 6) or University of Wisconsin solution (UW) (n = 6) at 4 degrees C followed by immersion in cold EC or UW for 22 h. The left donor lung was transplanted. The recipient dog was then reperfused for 4.5 h. Irrespective of the preservation fluid, gas exchanged was impaired in the transplanted lung after 4.5 h of reperfusion. Large surfactant aggregates obtained from this lung showed reduced ability to rapidly adsorb to an air-liquid interface. Phospholipid (PL) content and PL composition of surfactant from lung transplants was similar to that of the control lungs. However, the content of surfactant protein A decreased after reperfusion. In addition, Western blot analyses showed that levels of CRP increased in surfactant from transplanted but not from donor lungs. The addition of human CRP to control surfactant (CRP:PL weight ratio, 0.01:1) caused a decrease of surfactant adsorption. We conclude that the impairment of adsorption facilities of surfactant from transplanted lungs may be correlated with decreased levels of surfactant protein A and increased levels of CRP. The presence of elevated levels of CRP in bronchoalveolar lavage could be a very sensitive marker of lung injury.

Comparison of lipid aggregation and self-aggregation activities of pulmonary surfactant-associated protein A.

1. We compared the Ca2+ dependence of the self-aggregation of surfactant protein A (SP-A) with that of vesicle aggregation induced by SP-A. The Ca2+ concentration required for half-maximal activity of lipid aggregation was 0.74 +/- 0.29 microM (n = 4) for pig SP-A and 98 +/- 5 microM (n = 2) for dog SP-A. In contrast, the threshold concentration of Ca2+ required to induce self-association of both pig and dog SP-A was 0.5 mM. The Ca2+ concentration needed for half-maximal self-association was 2.36 +/- 0.15 mM (n = 4) and 0.70 +/- 0.06 mM (n = 2) for pig and dog SP-A respectively. 2. We also compared the effect of Ca2+ on the trypsin sensitivity of lipid-free and membrane-bound SP-A. At 1 microM Ca2+, the tryptic digestion patterns of dog and pig lipid-free SP-A were quite different. Dog SP-A was very sensitive to proteolysis, being almost completely digested by 30 min, while pig SP-A was very resistant, even after 12 h. After protein aggregation of lipid-free SP-A (at 5 mM Ca2+), the accessibility of the trypsin cleavage targets of the protein depended on the SP-A species (self-aggregated pig SP-A became more sensitive to degradation than its non-aggregated form, whereas self-aggregated dog SP-A was less susceptible). In contrast, membrane-bound SP-A, from either pig or dog, was clearly protected from trypsin degradation at both low (1 microM) or high (1 mM) Ca2+ concentrations. The protection was slightly higher at 1 mM Ca2+ when the extent of lipid/SP-A aggregates was maximal. 3. On the other hand, vesicle aggregation activity of SP-A was decreased by 30-40% by removing the oligosaccharide moiety of the protein, whereas self-aggregation was not influenced by deglycosylation. The presence of mannan (at concentrations not lower than 10 micrograms/microliters) decreased vesicle aggregation induced by dog and pig SP-A by a mechanism that is independent of the binding of mannan to the carbohydrate-binding domain of SP-A. Self-aggregation of SP-A was not affected by the presence of sugars. 4. From these results, we conclude that: (1) the process of lipid aggregation induced by SP-A cannot be correlated with that of self-association of the protein occurring at supramillimolar concentrations of Ca2+; and (2) the N-linked carbohydrate moiety of SP-A and the ability of SP-A to bind carbohydrates are not involved in lipid aggregation.