Rapid liquid chromatography tandem mass-spectrometry screening method for urinary metabolites of primary hyperoxaluria.

BACKGROUND: The primary hyperoxalurias are inherited disorders of glyoxylate metabolism that lead to overproduction of oxalate, urolithiasis and renal failure. Delays in diagnosis can be costly in terms of preserving renal function. Here we present a rapid liquid chromatography tandem mass-spectrometry screening method for the analysis of metabolites (primary hyperoxaluria metabolites) produced in excess by primary hyperoxaluria patients that include glycolate, glycerate and 2,4-dihydroxyglutarate. METHODS: Assay performance was compared to our existing gas chromatography-mass spectrometry method and clinical utility established by analysis of urine samples from patients with confirmed primary hyperoxalurias (11 PH1, 12 PH2 and 8 PH3) and controls ( n = 12). An additional 67 urine samples from patients with PH3 were used postvalidation to confirm the derived 2,4-dihydroxyglutarate cut-off. RESULTS: Glycolate, glycerate and 2,4-dihydroxyglutarate showed a mean bias of 3.3, -22.8 and 5.7%, respectively, compared to our previously published gas chromatography-mass spectrometry method. The mean total imprecision for glycolate, glycerate and 2,4-dihydroxyglutarate was shown to be 6.4, 10 and 11%, respectively. Clinical assessment confirmed that mean urinary glycolate, glycerate and 2,4-dihydroxyglutarate excretion were significantly elevated in patients with PH1, PH2 and PH3, respectively. The greatest sensitivity and specificity for PH1, PH2 and PH3 was achieved at cut-offs of 193, 100 and 4.9 µmol/mmol for glycolate, glycerate and 2,4-dihydroxyglutarate, respectively. CONCLUSIONS: A rapid screening method for the identification and differentiation of patients with suspected PH1, PH2 and PH3 is presented that allows focussing of genetic testing, saving time, money and, with earlier treatment, potential preservation of renal function for these patients.

A preliminary account of the properties of recombinant human Glyoxylate reductase (GRHPR), LDHA and LDHB with glyoxylate, and their potential roles in its metabolism.

Human lactate dehydrogenase (LDH) is thought to contribute to the oxidation of glyoxylate to oxalate and thus to the pathogenesis of disorders of endogenous oxalate overproduction. Glyoxylate reductase (GRHPR) has a potentially protective role metabolising glyoxylate to the less reactive glycolate. In this paper, the kinetic parameters of recombinant human LDHA, LDHB and GR have been compared with respect to their affinity for glyoxylate and related substrates. The Km values and specificity constants (Kcat/K(M)) of purified recombinant human LDHA, LDHB and GRHPR were determined for the reduction of glyoxylate and hydroxypyruvate. K(M) values with glyoxylate were 29.3 mM for LDHA, 9.9 mM for LDHB and 1.0 mM for GRHPR. For the oxidation of glyoxylate, K(M) values were 0.18 mM and 0.26 mM for LDHA and LDHB respectively with NAD+ as cofactor. Overall, under the same reaction conditions, the specificity constants suggest there is a fine balance between the reduction and oxidation reactions of these substrates, suggesting that control is most likely dictated by the ambient concentrations of the respective intracellular cofactors. Neither LDHA nor LDHB utilised glycolate as substrate and NADPH was a poor cofactor with a relative activity less than 3% that of NADH. GRHPR had a higher affinity for NADPH than NADH (K(M) 0.011 mM vs. 2.42 mM). The potential roles of LDH isoforms and GRHPR in oxalate synthesis are discussed.

A novel point mutation in P450c17 (CYP17) causing combined 17alpha-hydroxylase/17,20-lyase deficiency.

CONTEXT: Combined 17alpha-hydroxylase/17,20-lyase deficiency is a rare cause of congenital adrenal hyperplasia and hypogonadism. Novel single amino acid changes in P450c17 provide potentially important insights into key structural domains for enzyme function. OBJECTIVE, DESIGN, AND SETTING: We report a novel missense mutation in P450c17 in a 17-yr-old female presenting with a malignant mixed germ cell tumor with yolk sac elements who demonstrated clinical and biochemical features of combined 17alpha-hydroxylase/17,20-lyase deficiency. METHODS: Quantitative urinary steroid analysis was performed by high resolution gas chromatography. All eight coding exons of CYP17 were PCR amplified and sequenced. The position of arginine at codon 96 was modeled using the CYP17 structure 2c17 (www.rcsb.org). The CYP17 genes were subcloned into pcDNA3, expressed in HEK-293 cells, and chromatographed. PATIENT AND RESULTS: 17alpha-Hydroxylase deficiency was confirmed by marked reductions in urinary and serum cortisol, androgens, and estradiol. Mutational analysis revealed a novel homozygous R96Q missense mutation in P450c17, affecting an amino acid in a key substrate-binding region of the enzyme, leading to complete inactivity. CONCLUSION: The description of a second missense mutation at codon 96 (R96W and R96Q) in the substrate-binding region of P450c17 provides strong evidence for the key role of this amino acid in 17alpha-hydroxylase/17,20-lyase function. An association between a malignant germ cell tumor and 17alpha-hydroxylase deficiency has not been reported previously, although the presence of gonadoblastoma in the ovary of a patient with this condition has recently been described.

Identification and expression of a cDNA for human glycolate oxidase.

The isolation and expression of a human liver cDNA encoding a 43 kDa protein with glycolate oxidase activity is described. The cDNA (HAO1) is 1128 bp and has a 1113 bp open reading frame. Northern blot analysis detects a 1.8 kb mRNA with expression restricted to the liver. The 370 amino acid protein has 89% sequence similarity to glycolate oxidase from mouse liver and 53% similarity to the spinach and Arabidopsis enzymes. The protein has glycolate oxidase activity in vitro, as measured by the reduction of 2, 6-dichlorophenolindophenol in the presence of flavin mononucleotide and glycolate. The genomic sequence is contained within eight exons and encompasses approximately 57 kb of chromosome 20p12. This paper offers the first full functional description of a gene encoding human glycolate oxidase.

Identification and expression of a cDNA for human hydroxypyruvate/glyoxylate reductase.

The isolation and expression of a human liver cDNA encoding a 40-kDa protein with glyoxylate and hydroxypyruvate reductase activities is described. The cDNA (GLXR) is 1235 bp and consists of a predicted open reading frame of 987 bp with a 225-bp 3'-untranslated region. The 328-amino acid protein has partial sequence similarity to hydroxypyruvate and glyoxylate reductases from a variety of plant and microbial species.

Single strand conformation polymorphism (SSCP) analysis for the detection of mutations in the CYP11B1 gene.

The adrenal 11 beta-hydroxylase is a mitochondrial P450 enzyme encoded by the CYP11B1 gene, which is situated on chromosome 8q22 in tandem with the gene for aldosterone synthase (CYP11B2). Deficiency of 11 beta-hydroxylase results in the inability to convert 11-deoxycortisol to cortisol and accounts for 5-8% of cases of congenital adrenal hyperplasia. In the following study the CYP11B1 genes from eight individuals with 11 beta-hydroxylase deficiency were screened for mutations using single strand conformation polymorphism (SSCP) analysis. Sequence analysis of variant exons revealed a 28 bp deletion and a 5 bp duplication exon 2 and five missense mutations, G267R, G267D, Q356X, R427H and C494F, distributed throughout the gene. One of these mutations, G267R, and a G to A transversion at the third nucleotide position of codon 318 occur at the +1 position of the splice donor sites. Mutations were neither the result of gene conversion nor nonhomologous recombination between the two closely related CYP11B genes.

Problems in diagnosis and management of congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

A number of biochemical tests have been utilized to assist the diagnosis of steroid 21-hydroxylase deficiency. The specificity and accuracy of plasma 17-hydroxyprogesterone assays are important. A profile of steroids in urine by gas chromatography and mass spectrometry is the definitive test. Molecular biology is not practical for the diagnosis of a new case. The ACTH stimulation test for detection of heterozygotes is a poor discriminant. Fertility in patients with congenital adrenal hyperplasia may be due to excess of progesterone as well as of androgens. Gene amplification offers the best approach in molecular biology for the prenatal diagnosis of 21-hydroxylase deficiency.

Genetic analysis of the steroid 21-hydroxylase gene following in vitro amplification of genomic DNA.

The 5' end of the steroid 21-hydroxylase B gene encompassing putative control regions and the first 3 exons, has been selectively amplified in vitro from a number of patients with congenital adrenal hyperplasia caused by a deficiency of this enzyme. Sequence analysis has revealed a number of isolated instances of gene conversion to the 21-hydroxylase A sequence. One mutation, a C to G transversion at the 3' end of the second intron, thought to lead to incorrect splicing of the mRNA, was found in 11 subjects all with the classical form of the disease.

Expression of genes on human chromosome 21.

Gene sequences were isolated from a lambda library containing inserts originating from human chromosome 21. One phage, CP21G1, had been selected on the basis of its lack of middle-repetitive sequences and its ability to hybridize with 32P-labeled cDNA synthesized from the cytoplasmic poly A+ RNA of cultured fibroblasts. Further experiments revealed that the human insert in this phage is unique-sequence DNA, maps to the long arm of chromosome 21, and is expressed in fibroblasts and T cells. A panel of 127 "unique-sequence" phage were also selected from the lambda library and were tested for hybridization to 32P-labeled cDNA synthesized from the cytoplasmic poly A+ RNA of CCRF-HSB-2, a T-blast leukemic line. Seventeen recombinants hybridized to the probe. One of these phages, CP8, contains a human unique-sequence DNA expressed in T cells and neuroblastoma cells. One phage (CP5) in the "unique-sequence" panel that had not hybridized to cDNA from T-cell RNA was found to carry a low-repeat sequence and to hybridize specifically to RNA from a neuroblastoma line. This phage appears to carry a brain-specific gene. Many of the genomic sequences related to the low-repeat sequence contained in CP5 map to the short arm of chromosome 21. The cloned genes described here represent new markers for the detailed mapping of human chromosome 21 and may prove valuable in studying tissue-specific gene regulation.

Effect of temperature and sample preparation on performance of ion-moderated partition chromatography of organic acids in biological fluids.

A thorough investigation of the behavior of organic acids on the Bio-Rad Aminex cation exchange resin was prompted by both the limitations of, and a number of inexplicable inconsistencies found in, previously published papers using an identical system. In order to stabilise the elution order of various acids it was necessary to analyse samples at a higher temperature than previously recommended. This temperature (50 degrees C) decreased the retention times of all acids permitting the analysis of both aromatic and aliphatic acids within the same 45-min run. Preparation of an acidic fraction of biological fluids improved specificity, allowed direct comparison of urine and plasma profiles and by control of the conditions interference by urate could be substantially reduced. Retention data are given for more than 90 acidic metabolites including nearly 40 of clinical significance and a number derived from diet and drug therapy.

Experience in prenatal diagnosis of primary hyperoxaluria type 1.

Prenatal diagnosis of primary hyperoxaluria type 1 (PH1) using DNA-based techniques has been performed in 22 pregnancies from 21 families to date. The outcome of these diagnoses were: 2 affected, 14 carriers and 4 normal fetuses. In 2 families, only partially informative at the time of testing, a clear diagnosis could not be made and in one of these cases the presence of disease could not be excluded. The methods, which use a combination of linked polymorphisms and detection of the two most common mutations, have a diagnostic accuracy of > 99% and can be performed in the first trimester of pregnancy.

Identification of new mutations in primary hyperoxaluria type 1 (PH1).

Primary hyperoxaluria type 1 (PH1) is caused by deficiency of the hepatic peroxisomal enzyme alanine:glyoxylate aminotransferase (AGT). The AGXT gene, which codes for the 392 amino acid protein, has been mapped to chromosome 2q37.3. In order to identify new mutations in the AGXT gene we studied 79 PH1 patients using single strand conformation polymorphism analysis. In addition to a cluster of new mutations in exon 7 we report five novel mutations in exons 2, 4, 5, 9 and 10. These are T444C, G640A, G690A, 1008-1010delGCG and G1171A. These five new mutations contribute to our knowledge of the AGXT gene. Their possible consequences for PH1 phenotype and enzyme activity are discussed.

Primary hyperoxaluria type 2: enzymology.

Deficiency of the enzyme D-glycerate dehydrogenase (D-GDH) which also has glyoxylate reductase (GR) activity, is believed to be the underlying cause of primary hyperoxaluria type 2 (PH2). We have established the reaction kinetics of this enzyme in human liver and using these parameters have developed a microassay for the measurement of D-GDH and GR on needle liver biopsies obtained from patients with suspected primary hyperoxaluria. Tissue distribution studies of the two enzyme activities suggest that more than one enzyme with D-GDH activity is present in human tissues and the one with associated GR activity is mainly confined to the liver. The clinical significance of these findings for diagnosis and treatment is discussed.

Kinetic analysis and tissue distribution of human D-glycerate dehydrogenase/glyoxylate reductase and its relevance to the diagnosis of primary hyperoxaluria type 2.

The enzyme D-glycerate dehydrogenase (D-GDH; EC 1.1.1.29), which is also believed to have glyoxylate reductase (GR; EC 1.1.1.26/79) activity, plays a role in serine catabolism and glyoxylate metabolism and deficiency of this enzyme is believed to be the cause of primary hyperoxaluria type 2 (PH2). The pH optima and kinetic parameters of D-GDH and GR in human liver have been determined and assays developed for their measurement. Maximal activities were observed at pH 6.0, 8.0 and 7.6 for the D-GDH forward, D-GDH reverse and GR reactions, respectively. The apparent Km values for the substrates in these reactions were as follows: D-GDH forward reaction, 0.5 mmol/L hydroxypyruvate and 0.08 mmol/L NADPH; D-GDH reverse reaction, 20 mmol/L D-glycerate and 0.03 mmol/L NADP and for the GR reaction 1.25 mmol/L glyoxylate and 0.33 mmol/L NADPH. The forward D-GDH and GR assays were adopted for routine use, the low activity of the reverse D-GDH reaction being of little use for routine analyses. D-GDH and GR activity in 13 normal livers ranged from 350-940 nmol per min per mg protein (median 547) and 129-209 nmol per min per mg protein (median 145), respectively. D-GDH activity in kidney, lymphocytes and fibroblasts fell within the range of values seen in the liver but GR activity was approximately 30% in the kidney and barely detectable in lymphocytes and fibroblasts. Analysis of liver and lymphocyte samples from patients with PH2 showed that GR activity was either very low or undetectable while D-GDH activity was reduced in liver but within the normal range in lymphocytes. These results suggest that there is more than one enzyme with D-GDH activity in human tissues but only one of these has significant GR activity. We conclude that a definitive diagnosis of PH2 requires measurement of GR and D-GDH in a liver biopsy.

A semiautomated alanine:glyoxylate aminotransferase assay for the tissue diagnosis of primary hyperoxaluria type 1.

We have developed a sensitive assay for the measurement of alanine:glyoxylate aminotransferase (EC 2.6.1.44) activity in human liver. The assay is partly automated, and takes into consideration the sensitivity of the reaction to pH and to glyoxylate concentration. It is less subject to interference from other enzymes utilizing glyoxylate and to chemical interference from glyoxylate itself and can therefore be used without correction for cross-over by glutamate:glyoxylate aminotranferase (EC 2.6.1.4). The assay allows clear discrimination between normal and affected livers and is sufficiently sensitive to measure enzyme activity in fetal liver samples. Enzyme activity ranged from 17.9 to 38.5 mumol/h/mg protein in control livers (n = 9) and 0.8 to 9.5 mumol/h/mg protein in 30 of 39 hyperoxaluric patients studied. Normal alanine:glyoxylate aminotransferase activity (from 22.8 to 45.5 mumol/h/mg protein) allowed exclusion of primary hyperoxaluria type 1 in the other nine hyperoxaluric patients.

Biochemical and genetic diagnosis of the primary hyperoxalurias: a review.

BACKGROUND AND PURPOSE: The primary hyperoxalurias are a group of inherited disorders of endogenous oxalate overproduction. Diagnosis of the two best-characterized disorders, primary hyperoxaluria (PH) Types 1 and 2, is achieved by sequential measurement of alanine:glyoxylate aminotransferase and glyoxylate reductase enzyme activity in a single needle liver biopsy. While genetic analysis of PH2 is still at a relatively early stage, the AGXT gene defective in the Type 1 disorder is well characterized, and a number of mutations have been identified. METHODS: To determine whether mutation analysis could replace enzymatic analysis for the diagnosis of PH1, DNA samples from 127 consecutive unrelated patients in whom there was a high clinical suspicion of primary hyperoxaluria were analyzed for the presence of the G630A and T853C mutations, which together account for approximately 34% of the mutant alleles in our patient cohort. RESULTS AND CONCLUSIONS: The sensitivity of mutation detection was 47% in those patients with enzymologically confirmed Type 1 disease, showing that mutation analysis cannot effectively replace enzymology at the present time. However, there is little doubt of the value of genetic methods (mutation and linkage analysis) for diagnosing PH1 (and eventually PH2) in other family members and for prenatal diagnosis and carrier testing.

Primary hyperoxaluria type 1: a cluster of new mutations in exon 7 of the AGXT gene.

Primary hyperoxaluria type 1 (PH1) is a severe autosomal recessive inborn error of glyoxylate metabolism caused by deficiency of the hepatic peroxisomal enzyme alanine:glyoxylate aminotransferase. This enzyme is encoded by the AGXT gene on chromosome 2q37.3. DNA samples from 79 PH1 patients were studied using single strand conformation polymorphism analysis to detect sequence variants, which were then characterised by direct sequencing and confirmed by restriction enzyme digestion. Four novel mutations were identified in exon 7 of AGXT: a point mutation T853C, which leads to a predicted Ile244Thr amino acid substitution, occurred in nine patients. Two other mutations in adjacent nucleotides, C819T and G820A, mutated the same codon at residue 233 from arginine to cysteine and histidine, respectively. The fourth mutation, G860A, introduced a stop codon at amino acid residue 246. Enzyme studies in these patients showed that AGT catalytic activity was either very low or absent and that little or no immunoreactive protein was present. Together with a new polymorphism in exon 11 (C1342A) these findings underline the genetic heterogeneity of the AGXT gene. The novel mutation T853C is the second most common mutation found to date with an allelic frequency of 9% and will therefore be of clinical importance for the diagnosis of PH1.

Strategies for the prenatal diagnosis of primary hyperoxaluria type 1.

Primary hyperoxaluria type 1 (PH1) is a potentially lethal autosomal recessive disorder of glyoxylate metabolism caused by a deficiency of the liver-specific peroxisomal enzyme alanine:glyoxylate aminotransferase (AGT). Over the past 13 years, various strategies have been adopted for its prenatal diagnosis, including (1) glyoxylate metabolite analysis of amniotic fluid in the second trimester; (2) AGT enzyme assay, immunoassay, and immuno-electron microscopy of fetal liver biopsies also in the second trimester; and (3) linkage and mutation analysis of DNA isolated from chorionic villus samples in the first trimester. These methods have evolved in parallel with our increased understanding of the molecular aetiology and pathogenesis of the disease. Although the usefulness of metabolite analysis remains unproven, all the other methods have been successfully applied to the prenatal diagnosis of PH1. In this review, examples of the use of the available methodologies are provided, and their pros and cons are discussed with reference to specific cases.