Mutations in CUBN, encoding the intrinsic factor-vitamin B12 receptor, cubilin, cause hereditary megaloblastic anaemia 1.

Megaloblastic anaemia 1 (MGA1, OMIM 261100) is a rare, autosomal recessive disorder characterized by juvenile megaloblastic anaemia, as well as neurological symptoms that may be the only manifestations. At the cellular level, MGA1 is characterized by selective intestinal vitamin B12 (B12, cobalamin) malabsorption. MGA1 occurs worldwide, but its prevalence is higher in several Middle Eastern countries and Norway, and highest in Finland (0.8/100,000). We previously mapped the MGA1 locus by linkage analysis in Finnish and Norwegian families to a 6-cM region on chromosome 10p12.1 (ref. 8). A functional candidate gene encoding the intrinsic factor (IF)-B12 receptor, cubilin, was recently cloned; the human homologue, CUBN, was mapped to the same region. We have now refined the MGA1 region by linkage disequilibrium (LD) mapping, fine-mapped CUBN and identified two independent disease-specific CUBN mutations in 17 Finnish MGA1 families. Our genetic and molecular data indicate that mutations in CUBN cause MGA1.

The role of sialic acid in the binding of calcium ions to intrinsic factor and its intestinal receptor.

The binding of vitamin B-12-intrinsic factor (cobalamin-intrinsic factor) to its intestinal receptor requires Ca2+. Only low concentrations of Ca were shown to be needed; therefore apparently high-affinity Ca-binding sites, such as neuraminic acids, are involved. Accordingly, the Ca-binding properties of purified human intrinsic factor and purified hog intrinsic factor receptor were studied by gel filtration and by isoelectric focusing. Cobalamin-intrinsic factor binds 45Ca2+ as a stable complex and in electrofocusing the 45Ca activity resolves into several peaks corresponding to the acidic isoproteins of cobalamin-intrinsic factor. Digestion with neuraminidase abolishes the Ca-binding capacity of cobalamin-intrinsic factor. This intrinsic factor binds 45Ca2+ via sialic acids. The purified receptor also binds 45Ca2+ but the binding is not lost after neuraminidase treatment. Thus the receptor does not bind Ca2+ with sialic acid residues sterically accessible to neuraminidase. The desialylated receptor still binds both cobalamin-intrinsic factor and desialocobalamin-intrinsic factor.

Isolation of the porcine ileal intrinsic factor receptor by sequential affinity chromatography.

An extract containing solubilised receptor was passed through four columns containing Sepharose to which had been covalently coupled anti-cobalophilin IgG, vitamin B-12-intrinsic factor, vitamin B-12, and free intrinsic factor, respectively. Following a wash the receptor was eluted with EDTA, then residual Triton X-100 micelles and vitamin B-12-intrinsic factor were removed by Sephadex G-200 filtration. The receptor was purified 84 000-fold, sodium dodecyl sulphate electrophoresis indicated two subunits and gel filtration of its vitamin B-12-inttrinsic factor complex resolved it into two molecular species.

Solubilised intrinsic factor receptor from pig ileum and its characteristics.

The vitamin B-12-intrinsic factor receptor was shown to be present in pig ileum and localized on the brush borders of the enterocytes, and to be solubilisable with Triton X-100. At neutral pH and in the presence of Ca2+ it bound the vitamin B-12-intrinsic factor but not the vitamin B-12-cobalophilin complex. The solubilised vitamin B-12-intrinsic factor-receptor complex consisted of two molecular species with clear Stokes radii (13.11 and 33.53 nm), sedimentation coefficients (15.1 and 45.1 S) and molecular weights (1 600 000 and 12 000 000). A third smaller macromolecule possibly also represented the receptor. Some receptor activity was present in extracts prepared with buffers lacking detergent. There was evidence that the receptor is a membrane lipoprotein from which the lipids reversibly dissociate. Free intrinsic factor also bound to the solubilized receptor and its vitamin B-12-binding site seemed not to be involved in the attachment to the receptor. A small portion of the vitamin B-12-intrinsic factor spontaneously dissociated from the receptor and nearly all dissociated in the presence of Na2-EDTA. TheStokes radius of the dissociated vitamin B-12-intrinsic factor complex was 0.17 nm smaller than before binding to the receptor. Intrinsic factor and cobalophilin were present in ileal extract and observations were made on their molecular characteristics. These proteins, polymers of the vitamin B-12-intrinsic factor complex and binding of vitamin B-12 and its protein complexes to detergent micelles may give spurious receptor-like effects which must be properly controlled.

Porcine serum cobalophilin and transcobalamin. Identification, isolation and properties including electrofocusing patterns.

Pooled porcine serum was found to contain cobalophilin (also called transcobalamin I) and transcobalamin (also called transcobalamin II). The two proteins were harvested by batchwise absorption with vitamin B-12 covalently coupled to Sepharose, and then separated from each other either by gel filtration or using an immunoadsorbent. Both proteins were finally isolated as single proteins using a second vitamin B-12-Sepharose chromatography step. Cobalophilin and transcobalamin complexed with vitamin B-12 had molecular weights by gel filtration of 135 000 and 38 000 and by the formula of Svedberg 104 000 and 44 000, Stokes radii 4.97 nm and 2.65 nm, and sedimentation coefficients 5.39 S and 3.75 S, respectively. Electrofocusing resolved the cobalophilin complex into three main isoproteins isoelectric at pH 3.23, 3.42 and 3.69, and transcobalamin into only the main component isoelectric at a value as low as pH 3.47. Neither protein was capable of binding to the ileal intrinsic factor receptor.

Identification and characterization of intrinsic factor and cobalophilin from pig ileal and pyloric mucosa.

Pig ileal mucosa was found to bind about 240 ng vitamin B12/g and to contain two vitamin B12-binding proteins. One was highly active in the Schilling test, behaved immunologically as intrinsic factor and was responsible for about half of the total vitamin B12-binding capacity. The other binder was identified as cobalophilin (R-protein). Immunochemical purification of these proteins from pig ileum and pylorus was performed and the molecular characteristics (sedimentation and diffusion coefficients, Stokes radii, frictional ratios and molecular weights) of their vitamin B12 complexes were estimated. Isoelectric focusing revealed differences between the ileal and pyloric intrinsic factors but not between the cobalophilins. The mean isoelectric points of the pyloric and ileal intrinsic factors were pH 5979 and 5.30, respectively, whereas the corresponding figures for the cobalophilins were 4.13 and 4.10.

Spectral and other studies on the intestinal haem receptor of the pig.

We recently demonstrated the presence of a Triton-solubilized high-affinity haem binder on the pig duodenal brush border membrane. The association of haem to the binding factor was determined using radioactive haem and is now studied by a spectrophotometric technique. The binding alters the Soret absorption band of haem from 395 nm to 413 nm. The dissociation constant for the binding of haem to the solubilized binding factor was estimated to be about 10(-9) M by difference spectroscopy. Human serum albumin could not prevent the solubilized binding factor from binding haem. Trypsin digestion destroyed the binder.

Isolation of vitamin B-12-binding proteins by combined immuno and affinity chromatography. Comparative studies on the isolated and unisolated proteins.

Intrinsic factor or cobalophilin were removed by incubating human gastric juice and pig pyloric extract with purified anti-intrinsic factor and anti-cobalophilin immunoglobulin-G, respectively, covalently coupled to Sepharose. Cobalophilin (transcobalamin I) was also removed from pig serum either by using anti-cobalophilin immunoglobulin-G Sepharose or by Sephadex G-200 chromatography. The one remaining semipurified vitamin B-12-binding protein (intrinsic factor, cobalophilin or transcobalamin II) was then isolated by vitamin B-12-Sepharose affinity chromatography. Intrinsic factors, cobalophilins and transcobalamin II isolated by this two-step procedure were compared by double isotope techniques with the corresponding protein not subjected to affinity chromatography and found to be identical in reaction to antiserum, gel filtration and electrofocusing. The avidity of the isolated and unisolated intrinsic factors for the ileal intrinsic factor receptor was also the same.

Binding assay and physicochemical characteristics of solubilized intrinsic factor receptor in ileal mucosal homogenates using phenyl-Sepharose to separate the saturated receptor from free intrinsic factor.

A radioisotopic assay was set to determine the physicochemical properties of the solubilized intrinsic factor receptor in pig mucosal extracts. In this assay, phenyl-Sepharose was used to separate the receptor-intrinsic factor-labelled cobalamin complex from the free saturated intrinsic factor. The association constant (at pH 7.4) of the receptor-intrinsic factor complex was estimated at 3.4 +/- 0.3 nM-1. Adsorption of the apo-receptor to phenyl-Sepharose allowed its binding site to be made accessible to intrinsic factor with an association constant in order of 6 nM-1. The receptor binding activity obtained with five mucosal extracts was closely correlated with that obtained by gel filtration of the intrinsic factor-receptor complex (r = 0.99). The radioisotope assay was used to detect the unsaturated receptor (apo-receptor) in sucrose density ultracentrifugation and in superose 6 gel filtration. The sedimentation coefficient was 9.5 s. The apo-receptor was eluted in three peaks in gel filtration, corresponding to the formation of oligomers. The peak of the monomer was increased in presence of EDTA. Its molecular mass was estimated at 270 kDa and its Stokes radius at 5.9 nm. It was concluded that calcium is involved in the oligomerisation of the apo-receptor.

Purification of intrinsic factor receptor from pig ileum using as affinity medium human intrinsic factor covalently bound to Sepharose.

Intrinsic factor receptor was purified from hog ileum using human intrinsic factor covalently bound to Sepharose. A yield of 49.6% and a specific activity of about 2500 pmol/mg protein were achieved. The purified receptor was very unstable: 24 h of storage or addition of sodium phosphate precipitated it. The association constant of the receptor for the cyano[57Co]cobalamin-intrinsic factor complex was estimated to be 2.1 nM-1. In native polyacrylamide gel electrophoresis it resolved in two 256 and 320 kDa bands; beta-mercaptoethanol treatment cleared it into four bands corresponding to molecular masses of 107, 81.8, 63.5 and 53.2 kDa. An additional 39.3 kDa band was considered to be an artefact due to the presence of Triton X-114. Isoelectric focusing polyacrylamide gel electrophoresis resolved the receptor into two isoproteins isoelectric at pH 4.7 and 5.1. A similar result was obtained in column electrofocusing with the 125I-iodinated receptor. The 125I-labelled receptor did not crossreact with rabbit anti-human intrinsic factor antiserum. The electrophoretic properties of the receptor purified with intrinsic factor covalently bound to Sepharose were compared to those of the receptor purified by the use of the classical cobalamin-affinity medium. It was concluded that a disassembled receptor was produced using the classical method.

Isolation of the haemopexin-haem receptor from pig liver cells.

Isolated pig liver plasma membranes interact specifically with the haemopexin-haem complex (Kd 4.4 X 10(-7) M). Affinity chromatography was used to isolate a membrane component which binds this complex with high affinity. Pig serum haemopexin was first isolated by affinity chromatography on haemin-Sepharose followed by HPLC gel filtration. Liver membranes solubilized with Triton X-100 were incubated with haemin-Sepharose saturated with haemopexin, and as a control, with affinity gel lacking haemopexin. SDS-poly-acrylamide gel electrophoresis of the eluted protein indicated that from the haemin-Sepharose emerglow-molecular-mass haemin-binding proteins whereas the eluate from haemopexin-haemin-Sepharose contained an additional 71 kDa protein, which did not bind free haemin. This protein appears to represent the haemopexin-haem receptor or a part of it. Haem from the haemopexin complex, as also free haemin, was accepted by a binder in the plasma membrane, which in gel filtration behaved like an 80 kDa molecule. This component probably represents a second functional subunit of the haemopexin-haem receptor.

Purification of human intrinsic factor using high-performance ion-exchange chromatography as the final step.

Human intrinsic factor was purified 1430-fold from gastric juice with a yield of 75% using two steps: labile ligand affinity chromatography and high-performance ion-exchange chromatography. Intrinsic factor precipitated in the presence of specific autoantibodies and 15% sodium sulfate, had an estimated Mr of 59 000 in 5% SDS electrophoresis and could bind to the specific ileal receptor in vitro. Its carbohydrate composition could be related to N-lactosaminic and O-glycosidic chains. High-performance ion-exchange chromatography was a mild, rapid and efficient procedure to separate completely intrinsic factor from haptocorrin (another glycoprotein of gastric juice which binds cobalamin) and from other contaminating proteins.

Biochemistry and clinical chemistry of vitamin B12 transport and the related diseases.

This review focusses on research performed by the author and coworkers. The absorption, turnover and excretion of cobalamin and the pathogenesis of cobalamin deficiency states are described and the laboratory tests used to diagnose these states are discussed. Topics dealt with in detail include: overall turnover, daily need, enterohepatic circulation and excretion of cobalamin and other corrins . The soluble proteins mediating cobalamin transport and their cellular receptors are described and their nomenclature, isolation, structure and mode of action, the role of calcium in the membrane transport, the evolution of these systems and the analogies with transport systems for other substrates are discussed together with deficiency states, especially fish tapeworm anemia and familial selective vitamin B12 malabsorption with proteinuria. Folate deficiency is a relatively rare cause of megaloblastic anemia in Scandinavia but common in North America and explanations for this difference are suggested. The methods of assaying cobalamin in serum and plasma and the performance of radiovitamin B12 absorption tests are critically evaluated. The measurement of intrinsic factor in gastric juice, serum, amniotic fluid and urine is described.

Selective cobalamin malabsorption and the cobalamin-intrinsic factor receptor.

The disease is characterised by cobalamin (Cbl) deficiency in children 0-5 years old, causing failure to thrive, infections, megaloblastic anaemia, neuropathy, and mild general malabsorption; slight proteinuria is common. Cbl injections produce remission, but Cbl malabsorption and proteinuria persist. About 250 cases have been reported. Dogs also have it. The heredity is autosomal and recessive. The physiological and pathological absorption mechanisms are described: Cbl liberated from food by digestion is first bound to haptocorrin, but in the intestine it is transferred to intrinsic factor. In the ileum the complex attaches to a receptor on the enterocytes; this requires neutral pH and Ca2+. The receptor is a membrane-bound glycoprotein consisting of multiple subunits. The receptor-ligand complex is endocytosed and degraded in lysosomes, and the vitamin is transferred to transcobalamin which carries it to tissues. The same receptor is strongly expressed in the kidneys, but urine also contains its activity which can be assayed for diagnosis. The basic lesion is an error in the ileal receptor. In the affected dogs the synthesised receptor is retained intracellularly. Urine and ileal biopsies from human cases contained little receptor but it had conserved affinity for the ligand. Recently examined Arab patients did not excrete reduced amounts of the receptor. Apparently, the disease has subsets, such as different structural errors in the receptor and possibly faulty transport inside the enterocyte. The cause of the proteinuria is unknown but kidney damage due to severe Cbl deficiency and an error in a multiligand renal receptor are among the possibilities.

The driving license examination as a stress model: effects on blood picture, serum cortisol and the production of interleukins in man.

We have studied the following stress model: the tension caused by sitting for the theoretical part of the driving license examination. Volunteers were investigated twice, after their driving license examination and after a (stress-free) control session. The effects of the stress were investigated by studying the blood picture (differential counts), serum concentration of cortisol, and cytokine production in stimulated blood cells. Relationships between the subjective perception of stress and the physiological reaction were also investigated. This stress induced significant increase in the concentrations of cortisol and hemoglobin, and in the values of hematocrit and MCV, and in the lipopolysaccharide-induced release of IL-1beta and -6. The subjective feelings of irritability and wakefulness were also significantly higher after the exam. A significant relationship was found between the changes in the stimulated production of IL-1beta and irritability. The responsiveness to psychological stress might be influenced by the temporary mood of the subjects.

Reference values, why and how.

A review describing the fallacies of the concept of normal values and the reasons for its substitution with reference values. The "reference value philosophy", its terminology and recommended practical procedures are presented and it is warned not to use incorrect terms such as "normal reference range". The concepts of health and disease are discussed from the point of view of the laboratory. Reference values are not always derived from "healthy" persons. In order to be comparable, reference values and observed (i.e. patient) values should be produced in the same way, using the same analytical procedure, quality control, etc. The influence of preanalytical factors such as food intake, posture, use of tourniquet and freezing and storing samples is great and necessitates standardisation of specimen collection. Strategies for the selection of reference individuals are presented and the reasons and methods for subdivision of the data are described. Descriptions are also given of the individual reference values and the statistical treatment of collected data including multivariate analysis. Finally, the reporting of observed values in relation to reference values is discussed. There is a trend to avoid the use of the reference interval because of the temptation to regard the values falling outside it as pathological.

How to diagnose cobalamin deficiency.

Cobalamin deficiency must be suspected in all patients with unexplained neuropsychiatric symptoms or unexplained anemia. Special attention should be paid to patients at risk of developing cobalamin deficiency such as elderly people, vegetarians, HIV-infected patients, patients with gastrointestinal diseases and patients with autoimmunity or a family history of pernicious anemia. The assays aimed to answer the question: does this patient suffer from cobalamin deficiency, include analysis of P--cobalamins and analyses of the metabolites that accumulate upon cellular cobalamin deficiency, P--methylmalonate and P--homocysteine. P--cobalamins or especially a fraction of P--cobalamins, P--TC cobalamins are markers for latent cobalamin deficiency. An increased concentration of P--methylmalonate that decreases upon injection of cobalamin indicates overt metabolic cobalamin deficiency. The same holds for P--homocysteine but this analysis is less specific than P--methylmalonate. We suggest that either assay of P--cobalamins or P--methylmalonate is employed as screening test for cobalamin deficiency, and that further tests are performed only if the initial test in combination with the clinical picture gives an unclear answer. Once cobalamin deficiency has been diagnosed, the cause for the deficiency should be sought and the patient should be treated for life. Cobalamin absorption tests such as the Schilling test are considered of limited use. Gastric atrophy is likely to be present in patients with increased P--gastrin or decreased P--pepsinogen A. However, this condition can be diagnosed also by upper gastrointestinal endoscopy.