A simple dried blood spot method for therapeutic drug monitoring of the tricyclic antidepressants amitriptyline, nortriptyline, imipramine, clomipramine, and their active metabolites using LC-MS/MS.

Therapeutic drug monitoring (TDM) of tricyclic antidepressants (TCAs) is considered useful in patients with major depressive disorder, since these drugs display large individual differences in clearance, and the therapeutic windows of these drugs are relatively small. We developed an assay for determination of amitriptyline (ATP), nortriptyline (NTP), imipramine (IMP), desipramine (DSP) clomipramine (CMP) and desmethyl-clomipramine (DCMP) in dried blood spots (DBS). A fast and robust LC-MS/MS method was developed and analytically validated for simultaneous determination of ATP, NTP, IMP, DSP, CMP, and DCMP in DBS. Six mm circles were punched out from DBS collected on Whatman DMPK-C paper and mixed with acetonitrile: methanol 1:3 containing the internal standard. The extract was analyzed by LC-MS/MS. Total LC-MS/MS runtime was 4.8 min. The assay was linear in the range 20-500 µg/L for all compounds. Overall-assay accuracy and precision were<20% for the lower limit of quantification (LLOQ), except for CMP (CV=22.3%), and <15% at other concentrations. The initial LLOQ was 20 µg/L however for CMP and DMCP it was increased to 40 µg/L. The blood volume per spot did not influence the results, but a low hematocrit (≤ 30%) was associated with a >15% negative bias for all compounds. Punching at the perimeter of the blood spot instead of the center was associated with a positive bias. A good correlation was found between patients plasma and DBS samples of ATP, NTP and DMCP, but not for CMP. In addition, proportional differences were found. This LC-MS/MS method was analytically validated for determination of TCAs in DBS. Future validation will focus on the clinical application of the method.

Determination of venlafaxine and O-desmethylvenlafaxine in dried blood spots for TDM purposes, using LC-MS/MS.

Dried blood spot (DBS) sampling and quantitative analyses of many current therapeutic drug monitoring (TDM)-guided drugs are advantageous because of the minimal invasive sampling strategy. Here, a fast and robust LC-MS/MS method was developed and analytically validated for simultaneous determination of venlafaxine (VEN) and O-desmethylvenlafaxine (ODV) in DBS. Six-millimeter circles were punched out from DBS collected on Whatman DMPK-C paper, and the DBS was extracted with acetonitrile/methanol at 1:3. The total run time was 4.8 min. The assay was linear in the range of 20-1,000 µg/L for both VEN and ODV. Assay accuracy and precision was well within limits of acceptance (LLOQ = 20 µg/L). Normal hematocrit concentrations (0.30-0.50) did not influence the results neither did a normal spot volume (40-80 µL). Punch position at the perimeter instead of the center of the blood spot gave a bias ranging from 2.4 to 10.4%. Correlation between plasma and spiked DBS samples was high. The concentrations found in spiked DBS samples were higher than those in plasma, indicating that a conversion factor for translation of DBS to plasma values is needed. This analytically validated method is suitable for determination of VEN and ODV in DBS and applicable for TDM. The method will be used for TDM of VEN in the Dutch CYSCE multicenter trial (NCT01778907).

HLA-C mismatches induce strong cytotoxic T-cell reactivity in the presence of an additional DRB/DQB mismatch and affect NK cell-mediated alloreactivity.

BACKGROUND: The functional relevance of HLA-C mismatches in an alloresponse is still much debated, putting into doubt the relevance of matching for this antigen in selection of an allogeneic bone marrow donor. In addition to presenting peptides to T cells, HLA-C also functions as a ligand for killing inhibitory receptors (KIRs) on natural killer (NK) cells. In the current study we provide an in vitro basis to address the question of whether mismatches for this antigen are a risk factor for acute graft-versus-host disease (GVHD). METHODS AND RESULTS: By analysis of cytotoxic and helper T-lymphocyte precursor frequency (CTLp-f and HTLp-f) in 153 pairs, we are able to show that isolated HLA-C mismatches appear less immunogenic than do isolated HLA-A mismatches. Strikingly, the presence of an HLA-C mismatch next to a HLA-DRB or HLA-DQB mismatch leads to a synergistic increase in CTLp-f outcome. Moreover, we are the first to show that absence of a single inhibitory epitope as a result of an HLA-C mismatch can be sufficient to induce NK mediated alloreactivity, that is, kill and proliferate. CONCLUSIONS: We conclude that, in most cases, isolated HLA-C mismatches may be acceptable with respect to T-cell-mediated alloreactivity; however, the presence of a strong helper epitope (DR/DQ mismatch) appears sufficient to overcome the low immunogenicity of HLA-C. HLA-C mismatches that affect KIR epitopes, can induce NK mediated alloreactivity. This suggests that, in HLA-A-, -B-, -DR-, and -DQ-matched patients, NK cells may play a role in the induction and development of acute GVHD.

Coating in vitro of erythrocytes with Tamm Horsfall-protein.

A method is described to coat isolated peripheral blood erythrocytes in vitro with Tamm-Horsfall Protein (THP, uromodulin). Coating of erythrocytes with THP was accomplished by incubation of the cells in the presence of THP, made monomeric by incubation in a high urea concentration. THP-coating of erythrocytes was dependent on the THP-concentration, maximal coating being obtained at a protein concentration > or = 250 mg/ml. The best coating results were obtained if, during the co-incubation of erythrocytes with THP, urea was removed while the sodium chloride concentration was increased up to a physiologic concentration by means of dialysis. This alteration in chemical conditions promotes THP-polymerisation. Erythrocytes coated in this way could be preserved for at least 5 weeks in preserving solution, making them an interesting source of testing and control material. Coating of erythrocytes with THP could also be accomplished under conditions in which THP was preserved in a monomeric form, which suggests that peripheral blood erythrocytes having binding-sites for THP.

Application of a monoclonal antibody against a neoepitope on activated C4 in an ELISA for the quantification of complement activation via the classical pathway.

In order to study the activation of the complement system via the classical pathway we have attempted to raise antibodies specific for C4 activation products. Of 20 mouse monoclonal antibodies (mAbs) obtained, one appeared to react with an activation dependent epitope exposed on the activation products C4b, C4bi, C4c (C4b/c) as well as on iC4, but not on native C4. Using this antibody as a capture antibody and polyclonal biotinylated antibodies against C4 as detecting antibodies we developed an ELISA for the quantification of C4b/c in biological fluids. The lower limit of detection was approximately 0.025 nmol C4b/c per litre. Mean C4b/c levels in plasma samples collected from healthy volunteers in tubes containing 10 mM EDTA and 0.05% (w/v) polybrene, final concentrations, appeared to be 30 nmol/l. The potential of the ELISA procedure for evaluating complement activation in clinical samples was demonstrated.

Separation of different forms of the fourth component of human complement by fast protein liquid chromatography.

Disruption of the thiolester in native C4 yields a 'C4b-like C4' molecule (iC4) that functionally resembles C4b and is therefore probably accompanied by conformational changes in the C4 molecule. In most purified C4 preparations, iC4 and C4b are present to a variable extent. In this study we evaluated the use of fast protein liquid chromatography (FPLC) to resolve and isolate these various forms of C4. C4 was purified from fresh human plasma in a 4-step procedure that included barium citrate adsorption, polyethylene glycol 6000 (PEG) precipitation, Q-Sepharose Fast Flow and mono Q ion exchange chromatography. The final preparation appeared to be homogeneous on SDS-PAGE and under reducing conditions consisted of three bands that corresponded to the intact alpha, beta and gamma chains of C4. In some preparations the alpha' chain of C4b was also observed. On a Mono Q column the purified C4 preparations could be separated into three peaks that by hemolytic assay and SDS-PAGE were characterized as representing native C4, and monomeric and dimeric iC4 (or monomeric and dimeric C4b). Finally, the apparent KA of the various forms of C4 for C4b-binding protein (C4BP) was investigated. The monomeric iC4 and C4b species demonstrated similar C4BP binding affinity with an apparent KA of 5.6-6.4 x 10(8) M-1, whereas their dimeric forms demonstrated a higher affinity for C4BP with an apparent KA: 0.9-2.3 x 10(9) M-1. Binding of native C4 to C4BP was undetectable.

Demonstration in human plasma of a form of C3 that has the conformation of "C3b-like C3".

Disruption of the thioester in native C3 yields a C3 molecule that functionally resembles C3b. It has been proposed that this C3 molecule (iC3) plays a key role in initiation of the alternative pathway of the C system. However, its presence in plasma has never been demonstrated. We investigated the presence of iC3 in plasma, using mAb that recognize iC3 as well as C3 activation products but not native C3. One of these mAb, anti-C3-5, which binds iC3 via its C3a moiety, was used together with polyclonal 125I-anti-C3c to develop a RIA for iC3. Plasma incubated with methylamine yielded a strong response in this RIA, whereas neither fresh plasma nor serum in which the C system had been activated by incubation with aggregated IgG, did show this strong response. The specificity of this RIA was further demonstrated by additional experiments including experiments with purified preparations of the various forms of C3. Mean level of iC3 in freshly obtained plasma samples from 10 normal donors was 27 nmol/liter, which is 0.49% of total C3. Analysis by SDS-PAGE of C3 species that had been immunoprecipitated by mAb antiC3-5, revealed that some iC3 consisted of C3 molecules with an intact alpha-chain whereas another part consisted of iC3 molecules with an alpha-chain that had been cleaved by factor I. Thus, this study shows that fresh human plasma contains a C3 species with the conformation of "C3b-like C3" (iC3).

Elevated plasma levels of the anaphylatoxins C3a and C4a are associated with a fatal outcome in sepsis.

PURPOSE AND PATIENTS AND METHODS: Both complement and contact system of coagulation have been implicated in the pathophysiology of sepsis. We therefore measured levels of the complement activation products C1-C1-inhibitor complexes and C3a in serial plasma samples (obtained every six hours) from 48 patients with clinically suspected sepsis, and related these levels to the clinical outcome. C4a was also measured in samples obtained on admission. RESULTS: C3a levels were elevated in 47 patients at least once during the observation period. These levels appeared to be considerably higher in patients who died than in patients who survived. This difference was found for the levels on admission (p = 0.0003), as well as for the highest (p = 0.0010) and the lowest (p less than 0.0001) levels encountered in each patient. The mortality in patients with plasma C3a levels of 13 nmol/liter or less on admission (27 patients) was 33 percent, compared with 86 percent in patients with levels of 14 nmol/liter or more. Patients with septic shock had significantly higher C3a levels than normotensive patients (p values between 0.046 and 0.004). No significant differences in C3a were found between patients who had respiratory distress syndrome and those who did not. C4a levels in plasma samples obtained on admission were elevated in 43 patients. These levels correlated very significantly with C3a levels (p less than 0.0001), and showed similar associations with a fatal outcome. C1-C1-inhibitor complexes were elevated in 23 patients at least once during the observation period. These patients had significantly higher levels of C4a and C3a than patients with normal amounts of C1-C1-inhibitor complexes. Patients who died had higher levels of C1-C1-inhibitor complexes than patients who survived. However, this difference was not significant. CONCLUSION: On the basis of our results, we propose that activation of the complement system via the classical pathway is involved in the development of fatal complications in sepsis.

Disruption of the internal thioester bond in the third component of complement (C3) results in the exposure of neodeterminants also present on activation products of C3. An analysis with monoclonal antibodies.

Hydrolysis of the internal thioester bond in native C3 is thought to be a key event in initiating the alternative pathway of C activation, because the resulting C3(H2O) acquires "C3b-like" properties. Therefore, disruption of the internal thioester bond is probably accompanied by conformational changes in the C3 molecule. In this study, we demonstrate that such conformational changes indeed occur; 7 of the 19 mAb raised against C3 or C3 activation products recognized epitopes exposed on C3(H2O) but not on native C3. One of these epitopes is located on the C3a part, three on the C3c part, and another three on the C3d,g part. Because the 7 mAb bound equally well to C3 incubated either with MgCl2 or with methylamine (which primarily disrupts the thioester), the conformational changes detected by the mAb apparently occur after disruption of the thioester. Furthermore, the epitopes were also present on the corresponding C3 activation products. Immunoblotting experiments revealed that the epitopes for the three anti-C3d,g mAb were located on the C3d part, C-terminal to the thioester. The epitopes for 2 of the 3 anti-C3c mAb were located on the C-terminal alpha-chain fragment of C3c. Thus, this study provides immunochemical evidence for the biologic resemblance between C3(H2O) and C3 activation products. Implications of these findings for the activation process of C3 are discussed.

A modified competitive inhibition radioimmunoassay for the detection of C3a. Use of 125I-C3 instead of 125I-C3a.

Levels of C3a in plasma are currently measured by a competitive inhibition radioimmunoassay (RIA) in which 125I-C3a is used as a tracer. In this paper, we describe a modification of this RIA: 125I-C3 instead of 125I-C3a is used. The lower limit of detection of this modified RIA is 6 ng of C3a per ml of plasma (i.e. 0.66 nmol/l). This RIA, performed with polyclonal anti-C3a antibodies coupled to a solid phase, appeared to be 30 times more sensitive compared with an RIA in which a monoclonal antibody against C3a is used. In vitro activation of the complement system in serum by aggregated IgG, zymosan, and cobra venom factor resulted in the generation of significant amounts of C3a. Assessment of the C3a levels by the modified RIA in serial plasma samples from patients who underwent cardiopulmonary bypass, yielded results very similar to those described in the literature for the established C3a-RIA. Thus, the modified C3a-RIA offers a convenient alternative for the detection of C3a in plasma samples.

Influence of C3 level on the determination of C3d in plasma and synovial fluid by radial immunodiffusion.

The influence of C3 levels on the determination of C3d in plasma and synovial fluid by radial immunodiffusion was investigated. In the method used, C3 is precipitated by 11% polyethylene glycol (PEG), and C3d is measured in the supernatant. In 51 healthy donors, a weak though significant correlation between C3 and C3d levels was found. The mean concentration of C3d was 1.6% of that in aged serum from healthy donors. So, small amounts of C3 (i.e., 1-2% of the normal plasma level) in the 11% PEG supernatants may contribute significantly to the C3d levels measured. A radioimmunoassay that detects C3, C3b, iC3b and C3c was used to measure C3 levels in the PEG supernatants. In PEG supernatants of 4 plasma samples, 0.3-0.6% of the C3 level in normal plasma was found, whereas in those of 2 synovial fluids much higher levels were found (4-10% of the normal plasma level). When purified 125I-labeled antibodies against C3c were added to the gel of the radial immunodiffusion, C3c antigen was detected in the precipitation rings obtained with all PEG supernatants of plasma samples from patients. Therefore, the quantitative contribution of C3 to the precipitation rings in the C3d radial immunodiffusion was analyzed after the addition of an excess of anti-C3c antibodies to the gel. No effect on the size of the C3d-precipitation rings obtained with plasma samples from patients was observed. However, the C3d precipitation rings obtained with synovial fluids were significantly smaller when the gel used in the radial immunodiffusion contained an excess of anti-C3c antibodies together with the anti-C3d serum. We conclude that it is necessary to add an excess of anti-C3c antibodies to the gel used for the radial immunodiffusion, for the determination of C3d levels in synovial fluid. An antiserum against human C3b, which contains both anti-C3c and anti-C3d antibodies, can be used for this purpose.

Low molecular weight C1q in systemic lupus erythematosus.

In sera of patients suffering from an exacerbation of systemic lupus erythematosus (SLE), increased amounts of abnormal C1q were detected, contrasting with decreased or even undetectable levels of normal C1q in these sera. When analyzed immunochemically by double immunodiffusion, this low m.w. C1q (LMW-C1q) appeared to be identical with the defective C1q in serum of individuals with an inherited, homozygous inability to produce functional plasma C1q. These persons show a tendency to develop SLE-like syndromes. Like the genetically defective C1q, the abnormal C1q molecule in SLE sera was hemolytically inactive, did not incorporate in C1, was found in the supernatant of euglobulin-precipitated serum, and appeared in the break-through fraction of a cation-exchange column. Sucrose gradients and gel filtration analyses supported the putative identity of the molecules. SDS-PAGE and immunoblots revealed the presence of subunits that reacted with antibodies against C1q and confirmed the C1q-like nature of LMW-C1q. Low levels of LMW-C1q were also detected in serum and plasma of normal individuals. A radial immunodiffusion technique was used to measure LMW-C1q in the serum of 54 patients. Although these patients were not selected for parameters of disease activity, their levels of LMW-C1q were significantly higher than those of normal individuals and children with decreased C3 levels due to acute glomerulonephritis.

Influence of ionic strength, EDTA concentration, endogenous C1q and polyanions on the 125I-C1q-binding test.

Several parameters of the 125I-C1q-binding test were investigated: ionic strength, pH, concentration of EDTA, influence of serum C1q and the possibility of interference by polyanions. Lowering the ionic strength of the borate buffer resulted in increased precipitation of 125I-C1q in normal human serum. This increase was dependent on the presence of serum proteins, probably immunoglobulins. When the concentration of the EDTA was decreased, increased precipitation of 125I-C1q in normal human serum was also observed. This was prevented by adding NaCl to the EDTA solution. However at very low concentrations of EDTA (too low to chelate all calcium ions in the serum), increased precipitation of 125I-C1q in normal human serum was observed even in the presence of added NaCl. Addition of purified C1q to sera from patients with very low C1q levels had varying effects on the results of the C1q-binding test: (a) it decreased the C1q-binding activity of some sera, probably by competition with 125I-C1q for binding sites on the immune complexes; (b) it increased the C1q-binding activity of other sera, probably by enhancing the precipitation of immune complexes as a consequence of the cross-linking effect of C1q; or (c) it had no influence, possibly due to the opposite effects of (a) and (b). The addition of dextran sulphate resulted in a dose-dependent increase in the 125I-C1q-binding activity of normal human serum. This effect was dependent on the interaction of dextran sulphate with either C1q or low-density lipoproteins and was prevented by addition of polybrene to the assay. However, addition of polybrene to sera with a high C1q-binding activity scarcely influenced binding activity.