Elevated gamma-aminobutyric acid, glutamate, and vascular endothelial growth factor levels in the vitreous of patients with proliferative diabetic retinopathy.

OBJECTIVE: To examine the relative levels of gamma-aminobutyric acid (GABA), glutamate, and vascular endothelial growth factor (VEGF) in the vitreous of nondiabetic and diabetic patients. METHODS: Undiluted vitreous samples were obtained from 22 patients with proliferative diabetic retinopathy (PDR) and 28 patients without diabetes who underwent pars plana vitrectomy. Simultaneous venous blood samples also were obtained. Amino acid concentrations were determined using sensitive high-performance liquid chromatography, and VEGF levels by quantitative enzyme-linked immunosorbent assay. Hemoglobin concentrations in the blood and vitreous were determined using spectrophotometry. RESULTS: The level of GABA in the vitreous of patients with PDR, 29.4 +/- 7.8 mumol/L, was significantly higher than in controls (18.4 +/- 5.5 mumol/L) (P = .004). The vitreous concentration of glutamate was higher in patients with PDR (24.7 +/- 14.0 mumol/L) compared with controls (9.1 +/- 5.1 mumol/L) (P < .001). Vitreous VEGF level was significantly higher in patients with PDR (1759 +/- 1721 pg/mL) compared with controls (27 +/- 65 pg/mL) (P < .001). There were moderately strong correlations between GABA and VEGF levels (r = 0.68) and glutamate and VEGF levels (r = 0.43). Elevated GABA, glutamate, and VEGF levels also correlated strongly with the presence of PDR. Correcting for possible introduction of these molecules by vitreous hemorrhage did not significantly alter these findings. CONCLUSIONS: Levels of glutamate potentially toxic to retinal ganglion cells are found in the vitreous of patients with PDR. Elevated vitreous GABA may reflect amacrine cell dysfunction and underlie electroretinographic oscillatory potential abnormalities seen in diabetic retinopathy. The correlations of glutamate and GABA levels with an elevated VEGF level provide biochemical support for ischemia-induced neovascularization in patients with PDR. These findings present opportunities for novel therapeutic modalities in the treatment of PDR.

Serum androstanediol glucuronide in women with facial hirsutism.

BACKGROUND: Measurement of serum 5 alpha-androstane-3 alpha, 17 beta-diol glucuronide (3 alpha-diolG) has been proposed as a useful biochemical marker of peripheral androgen metabolism. Is 3 alpha-diol G a useful biochemical marker of peripheral androgen metabolism and does it correlate with degree of facial hirsutism? OBJECTIVE: Our purpose was to assess possible correlation between serum 3 alpha-diol G and degree of facial hirsutism and to compare serum 3 alpha-diol G levels with levels of other commonly measured serum androgens. METHODS: Twenty-three consecutive women with facial hirsutism were studied, and serum concentrations of 3 alpha-diol G, testosterone (total, free, and biologically active portions), dehydroepiandrosterone sulfate, and androstenedione were measured. RESULTS: There was no correlation between serum 3 alpha-diol G levels and degree of facial hirsutism. There was a correlation between levels of 3 alpha-diol G and dehydroepiandrosterone sulfate (p less than 0.01), biologically active testosterone (p = 0.01), free free testosterone (p less than 0.02), and androstenedione (p less than 0.05). CONCLUSION: Serum 3 alpha-diol G concentrations have no correlation with degree of facial hirsutism and do not provide additional information over the commonly measured androgens.

Heparin free hemodialysis does not cause fibrin consumptive coagulopathy and maintains alternate pathway complement activation.

Heparin-free hemodialysis allows demonstration of the intradialytic coagulation status not previously possible during standard heparin anticoagulant hemodialysis protocols in patients with end-stage renal disease. No evidence for consumptive coagulopathy was noted in the absence of heparin during hemodialysis with cuprophane hollow fiber dialyzers. Fibrinogen levels, euglobulin lysis time, and platelet counts remained stable throughout 3 hours of heparin-free hemodialysis. Serial thrombin times and platelet aggregation improved during heparin-free hemodialysis. Hemodialyzer volumes and the ultrafiltration coefficient decreased only minimally. The alternate pathway of complement activation associated with hemodialysis blood-membrane interaction is not prevented by heparin-free hemodialysis.

The National Reference System for Cholesterol.

The NRS/CHOL is a reality that is progressively becoming the way in which accuracy of cholesterol results is being ensured. Proof of traceability to NRS/CHOL within each segment of the clinical laboratory, now an expectation, will soon be the norm that makes a sound conceptual reference system into an everyday reality that reaches into the many thousands of working sites that measure cholesterol in serum on patient samples.

Survey of special practices associated with College of American Pathologists proficiency testing in the Commonwealth of Pennsylvania.

A questionnaire concerned with special practices associated with proficiency testing was sent to the Chemistry Supervisor, Hematology Supervisor, and Chief Pathologist of 190 Pennsylvania hospital laboratories. Responses were received from 156 hospitals (82.1%) and included responses from 131 chemistry supervisors, 108 hematology supervisors, and 92 chief pathologists. The vast majority of respondents (85% to 95%) indicated moderate to great pressure to score acceptably. The survey showed a high prevalence of special practices, including analysis of controls just prior to survey specimens (23% to 42%), analysis in duplicate on a single instrument (52% to 88%), analysis on more than one instrument (17% to 31%), analysis on two or more separate days (20% to 39%), and delay of testing until an instrument is "working better" (24% to 34%). Approximately 63% of chemistry results and 72% of hematology results are reported as averages or medians. Pathologists consistently reported a lower prevalence of special practices than did laboratory supervisors. These high prevalences of special practices associated with proficiency testing specimens have important implications for proficiency testing programs.

Review of pyridoxal phosphate and the transaminases in liver disease.

In vitro supplementation with the active form of vitamin B6, pyridoxal-phosphate (PLP), increases measurements of both serum aminotransferase enzymes, L-aspartate: 2-oxoglutarate amino transferase, EC 2.6.1.1 (AST) and L-alanine: 2-oxoglutarate aminotransferase, EC 2.6.1.2 (ALT). The plasma PLP level in normal individuals clearly relates inversely to the degree of stimulation of serum AST and ALT. PLP added in vitro increases the reference values but does not decrease the biological variability of AST measurements in healthy individuals. Since B6 deficiency is observed in alcoholics, in some significant percentage of hospitalized patients and in apparently healthy people over age 64, these individuals will show PLP stimulation of their serum amino-transferase enzymes. Patients with liver disease show lesser activation with PLP of AST activity but not ALT activity than patients with heart disease (myocardial infarction). AST isoenzyme measurements in the form of a mitochondrial AST/total AST ratio may discriminate alcoholic hepatitis from all other hepatic diseases. In renal dialysis patients including transplant patients, it may be desirable to measure the aminotransferases with added PLP in order to reflect better the cytolytic state of the liver. While unconfirmed studies suggest the combination of PLP activation and AST isoenzyme measurements may aid in the diagnosis of hepatoma, PLP activation per se does not provide clear cut improved diagnostic value of AST and ALT in liver diseases. However, in view of PLP incorporation into the IFCC reference methods for AST and ALT, and the National Reference System for the Clinical Laboratory, it is recommended that PLP be included in all AST and ALT measurements.

Measurement of total lactate dehydrogenase activity.

Lactate dehydrogenase (LD: EC 1.1.1.27) is the most important clinically of several dehydrogenases occurring in human serum. Lactate dehydrogenase is cytoplasmic in its cellular location and in any one tissue is composed of one or two of five possible isoenzymes. While many of its clinical applications involve quantification of one or more specific serum isoenzymes, an estimate of total LD is required usually. Lactate dehydrogenase catalyzes the reversible reaction: L-lactate + NAD+ in equilibrium pyruvate + NADH. The bidirectional reaction is monitored spectrophotometrically by measuring either the increase in NADH at 340 nm produced in the lactate-to-pyruvate reaction (L----P) or by the decrease in NADH at 340 nm produced in the pyruvate-to-lactate (P----L) reaction. Kinetic assay systems for the measurement of the reaction system in both directions are comprehensively reviewed as well as the standardization efforts proposed to date.

Urinary enzyme measurements in the diagnosis of renal disorders.

In view of Mattenheimer's comprehensive review of enzymes in renal disease in this journal only four years ago, major emphasis has been placed at the recent Symposium on Diagnostic Significance of Enzymes and Proteins in Urine held at Kanderstag, Switzerland in March of 1978. The pathophysiology of enzyme release in renal disease is presented, the current status of enzyme measurement reviewed, and the laboratory findings in several main types of renal disease summarized. While the measurement of selected urinary enzymes has been found extremely useful in specific situations, most investigators agree that routine screening is not warranted at this time. Newer developments in the measurement of isoenzyme patterns hold promise of introducing increased diagnostic specificity and appear to be the wave of the future.

Effects of temperature on the steady-state kinetics and measurement of aspartate aminotransferases.

We examined the effects of temperature on the activity and steady-state kinetics of aspartate aminotransferase (EC 2.6.1.1), using purified human soluble (s-AspAT) and mitochondrial (m-AspAT) isoenzymes, human serum, and porcine s-AspAT. All enzymes obeyed similar linear Arrhenius relationships over the range 20-40 degrees C. Apparent energies of activation (52.3 kJ.mol-1) and ratios of activity between 30 and 37 degrees C (0.626) were identical for the human s- and m-AspAT. This ratio was 0.623 (SEM 0.004) for human sera; deviation from the predicted ratio by individual sera was within analytical error. Similar activity/temperature relationships were observed for porcine s-AspAT. The use of factors to convert AspAT activities at 30 and 37 degrees C influenced neither precision of measurement of frequency distributions of results. The apparent Michaelis constants for the human isoenzymes increased with temperature. The least-influenced Km was for 2-oxoglutarate and s-AspAT: K2-oxoglutarate was 0.24 mmol.L-1 at 25 degrees C and 0.29 mmol.L-1 at 37 degrees C; apparent enthalpy change for substrate binding (delta HS) was 12.1 kJ.mol-1. The largest variation was for 2-oxoglutarate and m-AspAT: K2-oxoglutarate was 0.46 mmol.L-1 at 25 degrees C and 1.02 mmol.L-1 at 37 degrees C; delta HS was 50.8 kJ.mol-1. Incubation of the human isoenzymes with substrate mixture (without 2-oxoglutarate) at 23 and 37 degrees C did not affect activity during 60 min if tris(hydroxymethyl)aminomethane buffer was used. When the isoenzymes were diluted to 10 nmol-L-1 (about 200 U.L-1) in buffer alone and incubated at 50 degrees C, m-AspAT activity was decreased by 20% after 120 min; the cytoplasmic enzyme was unaffected.

Atomic absorption spectrophotometry of chromium in serum and urine with a modified Perkin-Elmer 603 atomic absorption spectrophotometer.

Modification of a Perkin-Elmer 603 atomic absorption spectrophotometer by adding a high-intensity tungsten-halogen lamp for background correction significantly improved the detection limit for elements that have analytical wavelengths in the near-ultraviolet and visible regions. Chromium in human serum and urine can be measured, with a simplified sample-handling technique, in concentrations of less than 0.1 microgram/liter. For comparison, the mean value for chromium in the serum of eight men was 0.14 microgram/liter.

Quantitative toxicology: interlaboratory and intermethod evaluation in New York State.

The New York State Department of Health has conducted a proficiency evaluation program in quantitative toxicology since 1974. Serum samples containing a barbiturate and phenytoin, together with either glutethimide, procainamide, or theophylline, are sent to participating laboratories quarterly. Within the first two years of the program the percentage of laboratories able to quantitate 75% of the test samples to within 25% of the gravimetric values increased from 25 (1974-1975) to 40% (1975-1976). This improvement was partly due to licensure requirements, improved technology for sample preparation and analysis, and the availability of better quality-control practice. An obstacle to obtaining uniform accuracy is the lack of adequate calibration or testing materials. To overcome these obstacles, pure drugs are weighed into a bovine serum matrix, and the weights are confirmed by reference laboratories and used as the target values in the testing program. Comparison of the methods used by participants in this program for barbiturate and phenytoin yielded equations different from those found in other method evaluations.

The effect of temperature on the kinetic constants of human lactate dehydrogenase 1 and 5.

The kinetic constants of human lactate dehydrogenase 1 and 5 (L-lactate: NAD+ oxidoreductase, EC 1.1.1.27), assayed lactate-to-pyruvate increase with temperature. The reaction mechanism is ordered sequential as has been found with lactate dehydrogenase from other sources. The KM values for each substrate are larger for isoenzyme 5 than for 1. For lactate dehydrogenase 1 the KM(lactate) increases from 1.07 mM at 25 degrees C to 3.95 mM at 37 degrees C and for lactate dehydrogenase 5 it increases from 5.37 mM at 25 degrees C to 6.88 mM at 37 degrees C. The KM(NAD+) for lactate dehydrogenase 5 is 0.14 mM at 25 degrees C and 0.29 mM at 37 degrees C. The increase in the KM for each substrate with increasing temperature confirms that additional substrate is required for optimal reaction conditions at higher temperatures.

Optimal conditions for assaying human lactate dehydrogenase by the lactate-to-pyruvate reaction: Arrhenium relationships for lactate dehydrogenase isoenzymes 1 and 5.

Optimal reaction conditions to sassay human lactate dehydrogenase (lactate-to-pyruvate) were established for isoenzymes 1 and 5 at 25, 30, and 37 degrees C in diethanolamine and 2-amino-2-methyl-1,3-propanediol. Different substrate concentrations are required at each temperature. The conditions permit measurement of lactate dehydrogenase 1 and 5 with the lowest substrate concentrations that allow for the highest equal sustainable efficiency in measuring both isoenzymes. About 95% of each isoenzyme activity is measured if the assay is performed within the first minute after the reaction is initiated even for activities as high as triple the upper limit of normal. The Arrhenius relationship is different for each isoenzyme, but results obtained for each at one temperature can be compared with results at another temperature by use of simple conversion equations. Assays at 25 and 30 degrees C are more economical and less variable than assays at 37 degrees C.

Proficiency testing: purification of lactate dehydrogenase 1 and results of its use as a reference material in the New York State program.

Highly purified human lactate dehydrogenase 1 has been used in an interlaboratory evaluation and improvement progran in clinical chemistry in New York State since 1971. Although there are difficulties in determining and assigning the most nearly accurate values for test samples in the absence of a reference method and a reference material, we have minimized these difficulties by using human lactate dehydrogenase preparations purified as we describe here and suspended in the same matrix, and by utilizing "reference laboratories" that routinely are doing multiple assays to determine the most nearly accurate value. The lactate dehydrogenase used in the program is stable for longer than 1.5 years. Conversion factors were used to convert all results to U/liter at 30 degrees C. Review of the data for 1972-75 shows a marked improvement in the accuracy of virtually all methods used to determine this enzyme.

Interconverting measurements of human lactate dehydrogenase activities in three buffers.

The lactate-to-pyruvate reaction for serum lactate dehydrogenase (LD) is most frequently assayed in one of three buffers, pyrophosphate (PPi), tris(hydroxymethyl)amino-methane (Tris), or 2-amino-2-methyl-1-propanol (AMP). We described interconverting results for serum samples and for highly purified LD isoenzymes I (dissolved in one of these matrixes) assayed in these buffers under optimized reaction conditions. The equation for converting results obtained for sera in Tris (x) to those in PPi(y) (both at 30 degrees C) is y = 0.74x+10 (n = 98). Since AMP is used extensively in Technicon procedures, we determined the LD activity of sera with an SMA 12/60, at 37 degrees C. The equation for convering these AMP results to results obtained in PPi at 30 degrees C is y = 0.45x-16 (n = 90). Very different equations were obtained with highly purified LD isoenzyme I maintained in two different matrixes and with both isoenzymes assayed in the same matrix. The matrix in which LD is dissolved and the proportion of various LD isoenzymes affect the magnitude of difference in observed LD activity under various conditions. Therefore, in clinical laboratories that use more than one analytical method or when conversion equations are used in the comparison of interlaboratory results, it is important to define the LD source, isoenzyme content, and the matrix, as well as the reaction conditions, and to use many samples with a wide range of activities when determining the conversion equations. For any changes in reagent source, substrate concentration, or alteration in procedure, a new normal range and new conversion equations should be determined.

A search for the best buffer to use in assaying human lactate dehydrogenase with the lactate-to-pyruvate reaction.

Highly purified human lactate dehydrogenases I and V were assayed in 17 different buffers, at a variety of reaction pH's. Diethanolamine and 2-amino-2-methyl-1,3-propanediol provided the best measurements of the enzyme, assayed lactate-to-pyruvate. However, the commercial preparation of 2-amino-2-methyl-1,3-propanediol contained insoluble matter and was relatively expensive. All of the four buffers nowmost commonly used were found to present difficulties. Glycine and pyrophosphate were inhibotory tolactate dehydrogenase activity with increasing buffer concentration. 2-Amino-2-methyl-1-propanol had three major disadvantages: it is chemically unstable during reagent preparation; activity is dependent on buffer concentration; and the pH optima for isoenzymes I and V are vastly different. The pKa of tris(hydroxymethyl)aminomethane is 8.0 at 30 degrees C, whereas to measure total activity the reaction pH should be greater than 8.5; thus tris(hydroxymethyl)aminomethane has limited buffering capacity at the reaction pH.

Effect of reaction initiator on human lactate dehydrogenase assay.

Human lactate dehydrogenase isoenzymes I and V have decreased activities when the reaction is initiated with lactate. No loss in lactate dehydrogenase I activity was found when the reaction was initiated with enzyme or NAD+. For lactate dehydrogenase V an NAD+-initiated reaction, as compared to an enzyme-initiated reaction, yields lower activity in sodium pyrophosphate buffer but higher activity in tris(hydroxymethyl)aminomethane buffer. Both isoenzymes have higher lactate-to-pyruvate activity when assayed in the latter buffer than when assayed in the former. Human lactate dehydrogenase V (but not I) exhibited different activities when assayed with lactate from two different commercial sources. Human lactate dehydrogenase assayed by the pyruvate-to-lactate reaction is not affected by the choice of reaction initiator.

Effects of buffers on aspartate aminotransferase activity and association of the enzyme with pyridoxal phosphate.

Using purified enzymes of human origin and patients' sera, we examined factors influencing the in vitro association of pyridoxal phosphate with aspartate aminotransferase (EC 2.6.1.1). The rate of association was markedly retarded by phosphate buffer in comparison with tris(hydroxymethyl)aminomethane or six other buffers. Pyridoxal phosphate at an incubation concentration of 130 mumol/liter reactivated the entire apoenzyme portion of an apoenzyme/holoenzyme mixture within 5 min in tris(hydroxymethyl)aminomethane; in contrast, less than 20% was associated during 15 min in phosphate. Activity measured in tris(hydroxymethyl)aminomethane-buffer without exogenous pyridoxal phosphate was 4% greater than that in phosphate and was slightly increased by increasing the pH of the assay mixture from 7.5 to 8.0. Aspartate in the incubation medium did not retard the stimulation in tris(hydroxymethyl)aminomethane buffer. While the magnitude of stimulation varied greatly among sera, a consistent mean stimulation of 30% for groups of sera with normal activities was found when asparate at 125 mmol/liter, 2-oxoglutarate at 6.7 mmol/liter and tris(hydroxymethyl)aminomethane at 90 mmol/liter were used, an increase over the 16% with phosphate buffer [Clin. Chem. 19, 92 (1973)]. Absorbance spectra suggest pyridoxal phosphate exists as the Schiff base of tris(hydroxymethyl)aminomethane or aspartate, or both, under conditions of assay incubation (without addition of 2-oxoglutarate). Nonenzymatic catalysis of the reaction by pyridoxal phosphate alone or a formation of a protein/pyridoxal phosphate adduct was discounted with use of a D-asparate substrates.

Interlaboratory proficiency, intermethod comparison, and calibrator suitability in assay of serum aspartate aminotransferase activity.

Sources of variation in assays of aspartate aminotransferase (EC 2.6.1.1) activity were examined in an interlaboratory survey and through an examination of materials used as calibration materials in these assays. Four highly stable lyophilized specimens containing human cytoplasmic enzyme, with activities of 0, 22, 46, and 96 U/liter at 30 degrees C and optimal substrate concentrations, were assayed by 319 laboratories. Mean values obtained on these specimens by laboratories using 2,4-dinitrophenylhydrazine kits varied among manufacturers and deviated from values expected from this procedure. The average coefficient of variation (CV) with these kits was greater than 20%. Automated continuous-flow procedures with use of diazonium salt showed the best precision (av CV, less than 10%). However, the automated continuous-flow malate dehydrogenase/NADH coupled method produced an average CV greater than 20%. Results from each of the automated methods were related to a reference malate dehydrogenase/NADH coupled continuous kinetic assay method by temperature relationships alone. Mean values from manual diazonium salt procedures were 1.7-fold greater than similar reference values (av CV was 18%). The higher results were attributed to the use of poorly-defined units and to an artifact caused by chromophore stabilizers in this procedure when aqueous samples are used. The average CV in continuous kinetic methods varied among kit manufacturers, ranging from 6 to 28% for the specimen of highest activity. Variations in results were much larger at 366 nm than at 340 nm than at 340ity. Variations in results were much larger at 366 nm than at 340 nm. Interassay relationships of these methods are presented. Concentrations of pyruvate in commercially available calibration materials differed between manufacturers, varied in stability, and deviated from the expected concentration. For some colorimetric assays the precision attained on reported absorbance values for the enzyme specimens was of the same order of magnitude as that for pyruvate standards. Other sources of error are revealed by the interlaboratory survey. The value of commercially available sources of enzyme activity as calibration or control materials was assessed by evaluating the following properties: activity at suboptimal concentrations of L-aspartate or 2-oxoglutarate, temperature effects, preincubation lability owing to aspartate and phosphate, pyridoxal phosphate saturation, contamination with glutamate dehydrogenase, and manufacturer's rated activity. These properties are compared to those of human cytoplasmic enzyme in a human serum matrix.

Linearity and accuracy of ultraviolet and visible wavelength photometer: an interlaboratory survey.

A survey was made to determine the linearity and accuracy of ultraviolet and visible wavelength photometers used by laboratories in New York State. Two solutions each of high-purity potassium dichromate and cobalt ammonium sulfate were submitted for photometric performance studies. The majority of the participant spectrophotometer results showed good correlation with reference data. Broad half-band width (greater than 10 nm) photometers showed little deviation from linearity. Coefficients of variation for the models surveyed were 5-10%.