The role of ceruloplasmin in iron metabolism.

The importance of ceruloplasmin in iron metabolism was studied in swine made hypoceruloplasminemic by copper deprivation. When the plasma ceruloplasmin level fell below 1% of normal, cell-to-plasma iron flow became sufficiently impaired to cause hypoferremia, even though total body iron stores were normal. When ceruloplasmin was administered to such animals, plasma iron increased immediately and continued to rise at a rate proportional to the logarithm of the ceruloplasmin dose. The administration of inorganic copper induced increases in plasma iron only after ceruloplasmin appeared in the circulation. Thus, ceruloplasmin appeared to be essential to the normal movement of iron from cells to plasma. Studies designed to define the mechanism of action of ceruloplasmin were based on the in vitro observation that ceruloplasmin behaves as an enzyme (ferroxidase) that catalyzes oxidation of ferrous iron. Retention of injected ferrous iron in the plasma of ceruloplasmin-deficient swine was significantly less than that of ferric iron, reflecting impaired transferrin iron binding. Rat ceruloplasmin, which has little ferroxidase activity, was much less effective than porcine or human ceruloplasmin in inducing increases in plasma iron. These observations suggest that ceruloplasmin acts by virtue of its ferroxidase activity. Eight patients with Wilson's disease were evaluated in order to investigate iron metabolism in a disorder characterized by reduced ceruloplasmin levels. Evidence of iron deficiency was found in six of these, and in five of the six, plasma ceruloplasmin was less than 5% of normal. In comparison, the two patients without evidence of iron deficiency had ceruloplasmin levels of 11 and 18% of normal. It is suggested that iron deficiency tends to occur in those patients with Wilson's disease who have the severest degrees of hypoceruloplasminemia, possibly because of defective transfer of iron from intestinal mucosal cells to plasma.

Ceruloplasmin assays in diagnosis and treatment of human lung, breast, and gastrointestinal cancers.

Ceruloplasmin was assayed as enzyme activity, as antigen, and as total copper in serum samples from 150 male lung cancer patients and comparable numbers of male controls. By all three assays, ceruloplasmin was significantly increased above the normal before treatment, and the degree of elevation was related to TNM stage [i.e., the International Union Against Cancer classification system based on extent of primary tumor (T), condition of lymph nodes (N), and absence of presence of metastases (M)]. Surgery had no immediate effects, but in patients who evidence of disease for longer periods, ceruloplasmin returned to nearly normal values. High levels of ceruloplasmin was elevated in 6 of 9 patients before tumor recurrence; 2 of 3 smokers (in the first panel of sera) with elevated ceruloplasmin levels subsequently developed lung cancer. The relative merits of the three assays were compared. Some sex- and age-related differences among normal controls were apparent. The results of pilot studies on men with gastrointestinal cancer and women with breast cancer are presented. It is concluded that only in limited situations will assays of ceruloplasmin aid in diagnosis, prognosis, and long-term monitoring of cancer patients.

Copper deficiency and erythrocuprein (2Cu, 2Zn-superoxide dismutase).

The activities of 2Cu,2Zn-superoxide dismutase, ferroxidase (ceruloplasmin), catalase and glutathione peroxidase were measured in the blood of rats during copper depletion. Two control groups of animals were used; one received the regular diet containing all essential components including copper and the other group was maintained on a diet, containing 1% the amount of copper in normal diet, copper being supplied as Cu(Leu)2 in the drinking water. Both groups showed no detectable differences, either in the copper content of blood or in the measured four enzymic activities. Excessive copper (injected intraperitoneally) caused only an insignificant rise in the enzymic activities (0-10%) compared to either control. After starting copper depletion ferroxidase activity decreases to 15% on the 15th day, while the 2Cu,2Zn-superoxide dismutase activity decreases to 40% on the 45th day. Ferroxidase activity shows rapid but transient changes immediately after perturbation in plasma copper levels. By contrast, the 2Cu,2Zn-superoxide dismutase activity more closely parallels the overall copper deficiency. Dietary repletion with copper raises the 2Cu,2Zn-superoxide dismutase activity to 94% and the ferroxidase activity to 80% of the control values within 36 h. Apart from the copper-dependent anemia catalase activity was decreased. However, 15 days after the start of the copper depletion catalase activity rises again and reaches the control value on the 40th day and a 30% stimulation was even seen on the 58th day. Upon copper repletion catalase activity reaches 166% of the control within 14 days. No copper-dependent differences of glutathione peroxidase activity were seen regardless whatever copper level was present in the rats.

Copper deficiency in humans.

Copper is an essential trace element that is required for a number of enzymes which are necessary for normal metabolic function. Metabolic balance studies have demonstrated that daily copper losses are approximately 1.3 mg/day. In order to remain in copper balance, the average adult male must consume a diet which contains at least 2 mg copper/day. It has been assumed that most diets satisfy this requirement because of the ubiquitous presence of copper in most foodstuffs. Recent studies, however, have shown that dietary copper may often fall below the estimated daily needs. Nevertheless, clinically evident copper deficiency has been documented in only a few situations. Of these disorders. Menkes' syndrome has been most intensively studied. This x-linked abnormality is associated with copper deficiency due to impaired gastrointestinal copper absorption. However, the clinical disorder cannot be corrected readily with copper replacement, thus suggesting that Menkes' syndrome may reflect more than simple copper deficiency. Nutritional copper deficiency appears to be well documented in two situations: (1) the newborn, usually premature, undergoing rapid growth on a diet poor in copper, and (2) the patient maintained on total parenteral nutrition for long periods of time without copper supplementation. In both of these situations, anemia and neutropenia are the most striking hematologic abnormalities associated with copper deficiency. Sideroblastic changes as well as nuclear maturation defects observed in erythroid precursors. However, suggest that there is an effect of copper deficiency on the hematopoietic system which cannot be explained solely by defective plasma iron transport.

Serum zinc, copper, and ceruloplasmin levels in male alcoholics.

Twenty male alcoholics aged 29 to 69 years (mean 45.80 + SD 10.97) were compared with controls for serum zinc, copper, and ceruloplasmin levels. The serum zinc level of the alcoholic patients was significantly lower than that of the control group (t = 3.3005, p less than 0.005). The serum copper and ceruloplasmin levels of the alcoholics tended to be higher than those of the controls, but the difference was not statistically significant. A significantly positive correlation between serum zinc and albumin levels (r = 5.41, p less than 0.01) was also found. The nutritional state of the alcoholics may not be an adequate explanation for their low serum zinc level. It is suggested that further research on alcohol as a toxic agent might focus on trace element-containing enzymatic defects in brain peptides and hormones to promote fuller understanding of the psychopathology associated with alcohol abuse.

Decreased plasma enkephalins in copper deficiency in man.

Twenty-four male subjects participated in a study in which the effect of feeding diets low in copper (1.03 mg/day) on plasma opiates was determined. The subjects were fed a low-copper diet for 11 wk with either starch or fructose as a major source of carbohydrate. Feeding low-copper diet decreased serum copper level significantly. In addition, plasma leu- and met-enkephalins decreased significantly while beta-endorphin levels rose. On repletion with copper (3 mg/day) for 3 wk, plasma enkephalins increased while beta-endorphin levels decreased to pretest values. These results suggest that feeding low copper decreases plasma enkephalins, which may reflect a copper-dependent process affecting enkephalin biosynthesis and/or release.

Indices of copper status in humans consuming a typical American diet containing either fructose or starch.

Twenty-four male subjects originally participated in a study to determine the effects of feeding diets comparatively low in copper (1.03 mg/day/2850 kcal) and containing either 20% fructose or starch on indices of copper status. During the course of feeding the diets for 11 wk, four of the subjects exhibited heart-related abnormalities and were removed from the study. Fructose ingestion had no effect on serum ceruloplasmin activity or serum copper concentration but did significantly reduce cuprozinc superoxide dismutase (SOD) activity of erythrocytes as compared to starch. Repletion of the subjects with 3 mg copper/day for 3 wk significantly increased SOD levels in subjects previously fed fructose but not starch. Apparent copper balance was significantly greater when the subjects consumed the fructose as compared to the starch diet. These results suggest that the type of dietary carbohydrate fed can differentially affect indices of copper status in humans.

Trace element status in multiple sclerosis.

We compared trace element status in multiple sclerosis (MS) patients (n = 27) with and without treatment with corticosteroids and groups of healthy subjects. Concentrations of plasma ceruloplasmin, selenium, and zinc and erythrocyte (RBC) glutathione peroxidase, Se, and Zn were similar in all groups. RBC copper concentrations were significantly lower in MS patients than in control subjects (mean +/- SEM: 0.048 +/- 0.005 vs 0.060 +/- 0.002 mumol/g Hb) because of decreased RBC Cu with steroid therapy. RBC Zn-Cu ratios were significantly higher (14.9 +/- 1.0 vs 10.1 +/- 0.3) in MS patients than in control subjects, differing in both groups of MS patients. In MS and control subjects, RBC Cu correlated significantly with RBC Zn (r = 0.56, 0.49). Disease acuity and disability had no effect on trace-mineral status. These data suggest that in MS there is altered Cu and Zn homeostasis that may cause or result from the disease and is influenced by corticosteroid therapy. Systemic trace element alterations might provide clinically useful markers of MS.

Relationship between levels of blood lipids, vitamins C, A, and E, serum copper compounds, and urinary excretions of tryptophan metabolites in women taking oral contraceptive therapy.

To evaluate which women using oral contraceptive agents might be at risk, biochemical indices known to be affected by the estrogens and progestogens were studied in women who take oral contraceptive agents, in women who do not use oral contraceptive agents, in women in third trimester of pregnancy and 6 weeks after parturition, and in men with normal and high blood lipid levels. The most consistent changes due to oral contraceptive agents were in serum levels of copper, triglycerides, and vitamin A and in the urinary excretion of xanthurenic acid and niacin derivatives before and after a tryptophan load test. There was only a slight suggestion, with no statistical significance, that serum vitamin C levels decreased when the serum levels of ceruloplasmin were high. The highest blood pressures and serum triglycerides and vitamin A levels were obtained in those women who ingested the highest level of estrogens. Pregnant women had the lowest levels of serum vitamin A. The oral contraceptive agents users had the lowest average levels of carotenoids corresponding to the highest average levels of vitamin A in the serum. Thus, estrogens not only increase the rate of change of tryptophan to niacin but may also increase the rate of conversion of carotene to vitamin A. Relative reactivity to oral contraceptive agents and possible risk to a patient might be evaluated by a profile of blood pressure and serum triglycerides, copper, and vitamin A.

PIP: To determine if methods can be developed which will show those patients for whom oral contraceptive agents (OCAs) constitute a hazard, data on blood lipids, serum levels of Vitamis-A, E, and C and copper are reported. Results of the tryptophan load test are also given. This tes t is related to the levels of pyridoxine in the tissues. The program was designed to show the relationship of any changes to each other, and to get a better understanding of their significance. Results are compared from subjects taking OCAs, from those not taking OCAs, from women in the last trimester of pregnancy, from women after parturition, and from males. All blood and urine samples were taken at 21 days after the beginning of subjects' menstrual periods, except for those who were pregnant and males. There were 49 women taking a variety of OCAs. 32 not taking OCAs served as controls. Included were 22 pregnant women in the last trimesters of their pregnancies. Of these, 11 were tested again 6 weeks postpartum. 9 men with high blood lipids and 12 men with normal lipid levels were also tested. Diastolic blood pressures averaged higher in the group taking OCAs (p less than .01), except for the males who were older or who wer known to have high lipids. Serum cholesterol levels in OCA users were unaltered. Serum phospholipids showed some increase in OCA users (p less than .05). Triglycerides show ed the greatest increase in OCA users (p less than .001), especially in those taking the most estrogen. The pregnant women had high serum levels of cholesterol, triglycerides, phospholipids, and total lipids. All of these levels were found to be less at 6 weeks postpartum. Serum copper levels were increased in all OCA users to above 1.5 mcg/ml but in only 2 of the nonusers to this level. Serum Vitamin-A was increased in the OCA user group (p less than .001). The pregnant women had relatively low levels of Vitamin-A. This increased by 6 weeks after parturition to the level of OCA users. An 8-hour urine collection after a 2-g tryptophan load showed at 6 times increased excretion of xanthurenic acid in those using OCAs as compared with nonusers. An increased ability of pregnant women to convert tryptophan to nictionic acid was shown. It is not known to what degree the biological changes caused by OCAs are undesirable. However, it is assumed that women showing the greatest changes are at greater risk. Analyses which may serve as incicators of potential risk include serum triglycerides, copper, and Vitamin-A levels. Carbohydrate intolerance and triglyceride elevation have been associated. Blood pressure measurements should be included in any profile.

The interaction of type of dietary carbohydrates with copper deficiency.

The present study was designed to determine if the more severe copper deficiency in rats fed sucrose and fructose, as compared to starch, is due to a specific effect of the fructose or to a nonspecific effect of any simple carbohydrate. Seventy weanling male rats were fed, for 9 wk, copper-deficient diets or copper-supplemented diets containing either 62% starch, fructose, or glucose. Decreased hematocrit, serum copper, and ceruloplasmin concentrations but increased heart and liver weights, total liver lipid, and hepatic iron concentrations were found in all copper-deficient rats regardless of the dietary carbohydrate. Feeding rats the high glucose diet decreased plasma albumin and liver glycogen but increased blood urea nitrogen when compared to rats fed starch. However, rats fed fructose generally exhibited a more severe copper deficiency as compared to rats fed either starch or glucose. The severity was characterized by lower (p less than 0.05) body weight, liver glycogen, hematocrit, serum copper, and albumin. Conversely, liver and heart weights, blood urea nitrogen, and plasma glutamic oxaloacetic transaminase were higher (p less than 0.05). Plasma cholesterol was increased by copper deficiency only in rats fed fructose or glucose. During the study, 17 of the 40 rats fed copper-deficient diets died; 66% of those fed fructose, 26% fed glucose, and 30% fed starch. These results suggest that the fructose moiety of sucrose is responsible for the increased severity of copper deficiency in rats fed sucrose as compared to starch.

Laboratory tests and diagnostic procedures in evaluation of liver disease.

Evaluation of liver disease can be a difficult and imposing problem for general internists and noninternists alike. Physicians are often faced with a confusing array of what are commonly referred to as "liver function tests"; indeed, with the advent of and commonplace use of automated serum testing batteries, these findings are increasingly frequent in asymptomatic persons. Abnormalities in liver function are occasionally discovered incidentally when the testing battery is performed without suggestion of liver disease. There are numerous examples of algorithms and flow diagrams designed with an aim toward aiding clinicians in completion of an adequate diagnostic evaluation when faced with a particular set of abnormalities on "liver function tests." However, a clearer understanding of these tests and others, which are in a broader sense tests of liver function, might be of greater value than such a systematic and regimented approach to the evaluation of liver disease.

Paroxysmal choreoathetosis: report of five cases and review of the literature.

Paroxysmal choreoathetosis is a rare, involuntary movement disorder. Attacks occur spontaneously or may be induced by movement, startle, or anxiety. The movements are tonic, dystonic, or choreoathetotic. Sporadic and, more commonly, familial cases have been reported. Onset occurs most often during childhood, and the course is nonprogressive. Response to anticonvulsant therapy is usually excellent. Five cases of the sporadic form of paroxysmal choreoathetosis are reported. Three of the five patients had attacks after initiation of movements such as rising from a chair. Results of physical examination were normal in four patients. One child had mild hemiatrophy and unilateral hyper-reflexia. Results of laboratory studies, including determinations of serum calcium and ceruloplasmin levels, EEGs and CAT scans of the head, were normal. The attacks ceased in all patients after treatment with either phenytoin or carbamazepine.

Macular degeneration and elevated serum ceruloplasmin.

Macular degeneration associated with age and drusen, an important cause of visual loss, is associated clinically with alterations in the retinal pigmented epithelium. Because the pigmented epithelium is a copper-rich tissue with antioxidant properties, the copper economy in patients and controls were studied by measuring ceruloplasmin. Ceruloplasmin, a multifunctional, copper-binding alpha-globulin, was significantly elevated in non-related patients as compared with controls (691 +/- 153 mg/L vs 312 +/- 64; P less than .001), both by the p-phenylenediamine oxidation technique and radial immunodiffusion assay. When 53 members of a large family were divided clinically into persons with and without macular degeneration, the ceruloplasmin concentrations were not significantly different from each other, but were elevated as compared with non-related controls (P less than .001). These differences were not due to an intragroup age mismatch. A group of patients with retinitis pigmentosa had normal serum ceruloplasmin concentrations. This study suggests a relationship between serum ceruloplasmin, trace metals, and the tissue alterations associated with macular degeneration that deserves further investigation.

Effect of copper and zinc status on susceptibility to cadmium intoxication.

The effects of dietary cadmium on copper and zinc metabolism in animals are described. Emphasis is given to situations involving chronic exposure to low levels of cadmium, to the identification of population groups most at risk, and to the protective effect of dietary supplementation with copper and zinc. The mechanism of the interaction between the metals and the involvement of metallothionein are discussed.

Copper and zinc levels in "healthy" and "sick" elderly.

Healthy elderly as a group have a wider range for serum copper, ceruloplasmin, and serum zinc than the adjusted ranges for the laboratory. In disease serum copper and/or ceruloplasmin act as acute-phase reactants in vascular disease, inflammation, and malignancy. Serum zinc values likewise are affected by the presence of inflammation and malignancy. The reported low level of copper in patients with osteoporosis was not confirmed by the present study. Neither was there any evidence found for zinc deficiency in patients with dementia.

An assessment of efficiency in potential screening for Wilson's disease.

The efficiency of screening for Wilson's disease by serum caeruloplasmin determination was assessed by analysing the epidemiologic data of 289 affected families in Japan. The estimated gene frequency was 5.2 x 10(-3). The sensitivity of the screening test was 93% at a proposed cut-off level of 120 mg/l and the specificity was 99.83%. In Japan 1 500 000 children are born every year of whom 50 would be expected to have Wilson's disease. The present analysis of potential screening for all children would grade three of them as false-negatives and identify 2621 as false-positives. An analysis for children only from consanguineous marriages produced a more efficient result, with a much higher predictive value of the positive and case-finding rate. Although the number of patients identified in this latter high-risk screening group was small, it is worth considering as a pilot study.

An unusual neurological disorder of copper metabolism clinically resembling Wilson's disease but biochemically a distinct entity.

A patient with progressive neurological disease resembling Wilson's disease but in whom Kayser-Fleischer rings were absent, was given 67Cu and 64Cu, orally and intravenously, to measure the rate of absorption of copper using a convolution integral. The data show an abnormal distribution of body copper resulting in low copper concentrations in plasma, urine and liver but with an accumulation in the lower bowel probably due to a defect in mucosal transport. The importance of differentiating this condition from Wilson's disease is stressed.

Plasma antioxidants and lipid peroxidation products in Duchenne muscular dystrophy.

Lipid peroxidation (LPX) products in plasma were elevated in Duchenne muscular dystrophy (DMD) patients (n = 9) compared with an age- and sex-matched group of controls (n = 10). Trichloroacetic acid-precipitable thiobarbituric acid-reactive substances (TBARS) were increased by 35% (p less than 0.01), conjugated dienes by 77% (p less than 0.02) and fluorescent pigments (FP) by 70% (p less than 0.001). Plasma alpha-tocopherol was significantly decreased, by 50%, in DMD compared with healthy subjects (p less than 0.002). In conjunction with the finding of others of a deficiency in DMD of the plasma lipoproteins which normally transport vitamin E to the tissues, this may contribute to the increased LPX seen in the disease especially if muscle damage also liberates free Fe2+. The major circulating antioxidant protein, caeruloplasmin (CP), was significantly increased (p less than 0.001) by 25-30% in DMD patients compared with both adult and young male controls. In DMD patients only, this increase is correlated with the concentration of TBARS and FP suggesting that increased LPX may be a trigger for CP synthesis.

ELISA of ceruloplasmin and alpha-2-macroglobulin in paired bronchoalveolar lavage fluid and serum samples.

Bronchoalveolar lavage fluid (BALF) was analysed to obtain information on leakage of proteins from the blood into the respiratory lumen and on local synthesis. Albumin, ceruloplasmin and alpha-2-macroglobulin were measured in paired BALF and serum samples from patients with acute pneumonitis or asthma. Ceruloplasmin (CP) and alpha-2-macroglobulin (A2M) were measured by ELISAs thereby avoiding concentration of BALF. The quotients 10(3) ([protein]BALF)/(protein]serum), Qprotein, were calculated as well as the relative coefficients of excretion, RCE: Qprotein/Qalbumin. The QCP and QA2M increased parallel to Qalbumin in patients with pneumonitis and QCP increased parallel with Qalbumin in the asthma patients. This indicates that abnormal leakage of proteins from the blood rather than local synthesis cause the increased concentrations of these proteins in the BALF. Increased values for the RCE of CP and A2M were observed at normal Qalbumin. We therefore conclude that the determination of CP and A2M yields more detailed information on leakage of proteins from the blood into the airway compartment than that of albumin.

Serum pseudocholinesterase and ceruloplasmin in various types of hyperlipoproteinemia.

Starting from previous observations emphasizing an increased pseudocholinesterase (PCE) activity in obese and hyperlipemic subjects, the behaviour of this enzyme and of ceruloplasmin was studied in connection with changes of serum lipids and lipoproteins in various types of hyperlipoproteinemia. When compared to values detected in 67 middle-aged normal weight normolipemic subjects, PCE activity was found to be significantly greater (smaller than 0.001) in the 49 overweight subjects without obvious hyperlipemia but presenting a moderate increase of the prebeta electrophoretic fraction. PCE activity was much higher in lean or overweight subjects with endogenous hypertriglyceridemia (68 patients with type IV and 86 patients with mixed hyperlipemia). The slight increase of mean values of PCE activity in the 53 subjects with type II-a was due mainly to overweight subjects, while this enzyme's activity was not significantly changed in lean subjects with pure hypercholesterolemia. PCE activity was positively correlated with serum triglyceride (r equals 0.540; p smaller than 0.001) and the prebeta electrophoretic fraction (r equals 610; p smaller than 0.001). The correlation with beta-lipoproteins was not significant. Ceruloplasmin levels were not significantly changed. It is suggested that elevation of PCE activity could be connected to mechanisms leading to an increased secretion rate of lipoproteins.