Serum prealbumin levels in alpha1-antitrypsin deficiency (PiZ)

Serum Prealbumin

Levels In Alpha,-Antitrypsin

Ronald W. Berninger,

Deficiency

(PiZ)

Susan V. Booker, and Richard C. Talamo

The relationship between low serum prealbumin levels and alpha,-antitrypsin deficiency (Pi21 was investigated. Pi typing was done by acid starch gel electrophoresis followed by crossed antigen-antibody electrophoresis and/or immunofixation. Serum prealbumin levels were determined by radial immunodiffusion. While the serum concentration of prealbumin was low in nine of the fifteen Pi2 children, this could be explained by the presence of liver disease in eight of those patients: one patient was asymptomatic. In contrast, only one of the twelve adult PiZ patients exhibited a low prealbumin level, also due to liver disease. We conclude that there is no direct association between PiZ alpha,-antitrypsin deficiency and low serum prealbumin levels in children or adults.

P

REALBUMIN, which binds thyroxine in the blood, is also called thyroxine-binding prealbumin.’ Serum prealbumin levels have been shown to be decreased in patients with liver disease;2 protein calorie maInutrition;3 surgery;4 inflammation associated with acute and chronic disease5-’ as well as benign inflammatory diseases;8,9 cancer;8.9 hyperthyroid’ and thyrotoxicosis;7 infective hepatitis when serum bilirubin was greater than 10 mg/ 100 ml;” chronic active hepatitis;’ acute viral hepatitis;2 nephrotic syndrome;” and cystic fibrosis.” However, prealbumin levels have been reported to be normal in patients with cystic fibrosis.‘2,‘3 Heavy smokers exhibit lower levels of prealbumin;8,9 as do women during pregnancy.14 Prealbumin levels are low in children, and in adults over seventy years, with maximum serum concentration obtained during midlife.‘4-‘9 Recently, it was reported that three alpha,-antitrypsin deficient (PiZ) adults had low serum levels of prealbumim2’ two of these patients had emphysema. Other obvious possible causes of the low prealbumin levels had been eliminated. Another recent report on a larger number of alpha,-antitrypsin deficient (PiZ) plasmas failed to substantiate these findings2’ However, it was noted that one patient with pulmonary emphysema of 19 PiZ patients exhibited an unexplained low plasma concentration of prealbumin. One of the twenty PiMZ subjects also had a low prealbumin plasma level, but the patient showed signs of a severe inflammatory reaction. The purpose of our study is to investigate the frequency of low serum prealbumin levels in PiZ alpha,-antitrypsin deficient patients.

MATERIALS

AND

METHODS

Potato starch was purchased from Fisher Scientific and hydrolyzed as previously described.22 Seakem agarose was obtained from Marine Colloids. Antibody (goat) to human alpha,-antitrypsin was obtained from Kallestad Laboratories. Trypsin was bought from Worthington Biochemicals Corporation. Benzoyl-DL-arginine-pnitroanilide hydrochloride (BAPNA) was obtained from ICN Pharmaceuticals. Radial lmmunodiffusion (RID) Kits for the quantitation of prealbumin by the technique of Mancini et al.23 were bought from Calbiochem-Behring Corporation and stored at 4°C until Metabolism, Vol. 3 1, No. 3, (March), 1982

needed. All other chemicals and reagents used in this study were of the highest purity commercially available.

Sera Blood was drawn into glass tubes and allowed to clot at room temperature. Following centrifugation, separated sera were stored in 12 mm x I7 mm capped polypropylene tubes (Falcon) at - 20°C or -70°C until needed for analyses. Thawed sera were mixed well by gentle inversion of the tube several times prior to removal of a sample.

Alpha,-Antitrypsin The trypsin inhibitory capacity (TIC) of serum was measured as previously described.*4 Results are expressed as percent of normal standard pool run in each TIC assay. Pi typing of alpha,-antitrypsin was conducted in starch followed by cross immunoelectrophoresi?’ and/or immunofixation in starch following the method of Arnaud et al.25

Prealbumin Prealbumin was measured supplied by the manufacturer. less than 10%.

in duplicate by RID usmg standards Actual duplicate values differed by

Samples The Pi2 sera samples had been sent to our laboratory for routine Pi typing during 1977-1979. The patients’ physicians were contacted to determine the clinical status of the patient at the time the sample was drawn. PiM children control sera were obtained from relatives of PiZ patients as well as children visiting the pulmonary clinic; none had any complications which would affect serum prealbumin levels. Healthy, normal PiM adult control sera were obtained from laboratory personnel. RESULTS

The prealbumin levels and TIC values as well as the characteristics of the PiZ children are tabulated in

From

the

Department

Receivedfor Supported land Heart,

Johns

Hopkins

of Pediatrics, publication

University,

Baltimore.

of

Medicine,

21205.

June 9. 1981.

in part by the Hospital

(Eudowood)

School

Maryland

and by Grant

MO

for

Consumptives

19157 from

of Mary-

the National

Lung, and Blood Institute.

Address reprint requests to Ronald

W. Berninger,

New England

Medical

I71 Harrison

Avenue, Boston. Massachusetts

(r)I982

Center, Department

by Grune & Stratton,

Ph.D..

of Pediatrics,

Tufts-

Box 208,

021 I I

Inc.

002660495/82/3103-0018$01.00/0

299

300

BERNINGER,

BOOKER,

AND

TALAMO

Table 1. Patients: Pi2 Children TIC, Patlent

Sex

Age

Prealbumin,

% Normal

mg/lOO

Comment

ml

1

6 wk

M

39.8

17.2

(at

Chronic

2

6 wk

PA

21.3

8.4

(a)

Neonatal

3

6 wk

M

38.2

20.5

(a)

Liver disease

4

7 wk

F

20.7

15.2

(a)

Liver disease

5

7wk

M

36.7

17.0

(a)

Liver disease,

6

2mo

M

50.4

9.8

(b)

Prolonged

7

2 mo

F

40.3

11.1

(b)

Liver disease

8

4mo

M

40.1

17.7

(b)

Liver disease,

9

4mo

F

31.3

13.4

lb)

Neonatal

jaundice

M

49.6

9.3

(b)

Enlarged

liver,

10

4.5

mo

liver disease jaundice,

dead

1 yr

malnourished

jaundice,

cholestasis

malnourished

brother

(?I

died of liver

disease 11

1.5 yr

M

45.2

19.0

(c)

Persistent

12

4 v

F

35.7

6.9

(d)

Cirrhosis

13

5

M

37.3

8.3

(e)

Asymptomatic

14

B yr

F

32.6

3 1.2

(f)

Nephrotic

15

9 vr

M

40.7

9.5

(9)

Cirrhosis

a: Ref 19, 6 wk mean

vr

+ SD,

20.7

& 2.5

mg/lOO

jaundice

syndrome

ml

b:Ref19,3momean~SD,18.2i-1.1mg/100ml c: Ref

19,

16 mo mean

d: Ref

19.

4yrmean

* SD,

+ SD,

18.5

17.1

+ 2.1

+ 5.1

mg/lOO

ml

mg/lOOml

e: Ref

19.

5 yr mean

? SD,

17.7

i

3.0

mg/lOO

ml

f: Ref

19,

8 yr mean

+ SD,

18.7

+ 3.5

mg/lOO

ml

10yrmean

*

g: Ref

19,

SD,

21.2

t

2.6

mg/lOOml

Table 1; similar information about the PiZ adults is contained in Table 2. The TIC values and prealbumin levels of both PiM control children and adults are shown in Tables 3 and 4, respectively. The sera of the alpha,-antitrypsin deficient PiZ children had the expected low mean TIC value (n = 15, mean k SD) of 37.3 k 8.5% normal compared to a mean TIC value (n = 12, mean +- SD) of 119.4 k 22.8% normal for the sera of PiM control children. The sera of the PiZ children exhibited a low mean prealbumin level (n = 15, mean f SD) of 14.3 t 6.4 mg/lOO ml with a range of 6.9 to 3 1.2 mg/ 100 ml. The mean prealbumin level (n = 12, mean t SD) of 21.2 k 5.2 mg/lOO ml with a range of 13.0 to 31.3 mg/lOO ml was obtained for the PiM control children. Sera from PiZ adults also had a low mean TIC value (n = 12, mean + SD) of 24.6 +

8.9% normal compared to a mean TIC value (n = 14, mean f SD) of 137.4 + 35.2% normal for sera from PiM control adults. The sera of the PiZ adults had a mean prealbumin level (n = 1 1, adult patient #12 in Table 2 not included; mean k SD) of 23.8 rt 7.6 mg/ 100 ml with a range of 15.6 to 36.8 mg/ 100 ml compared to a mean prealbumin level (n = 14, mean + SD) of 32.6 r 9.1 mg/ 100 ml with a range of 21.6 to 56.0 mg/lOO ml for the sera of PiM control adults. DISCUSSION

Our study of sera from alpha,-antitrypsin (PiZ) patients sent to our laboratory for included fifteen children and twelve adults. viduals may have liver disease26 which is also be associated with low prealbumin plasma

deficient Pi typing PiZ indiknown to levels’ as

Table 2. Patients: Pi2 Adults TIC. Patient

Age

1

23 yr

Prealbumln,

Sex

% Normal

F

35.9

mg/lOO 18.5

Comment

ml Healthy.

son jaundiced

2

30

yr

F

21.5

36.8

Healthy

3

30 yr

F

34.7

20.7

Pregnant

4

32

yr

F

25.3

15.7

Emphysema

5

35 yr

M

13.8

29.5

Severe

6

36 yr

M

24.5

31.3

Lung

COPD disease

7

36 yr

M

32.0

19.2

COPD,

8

39

yr

M

23.7

33.6

Lung disease

upper

9

42

yr

M

12.7

18.5

COPD

10

44

yr

M

37.7

22.6

Severe

11

63

yr

M

13.7

15.6

Emphysema,

12

69

yr

F

19.7

5.0

respiratory

infection

emphysema

Cirrhosis, bile duct

malnourished lung disease,

carcinoma

of

PREALBIJMIN; ALPHA,-ANTITRYPSIN

301

DEFICIENCY

Table 3. PiM Children Controls Range. Sex

F

M M+F

N

TIC. % Normal

Age. v

Prealbumw

mg/lOO

ml

Mean + SD (range) 126.0 +_ 17.2(107.7-145.4)

20.2

rt 5.3 (13.0-25.2)

2-17

116.1

+ 25.6 (90.9-171.3)

21.5

+ 5.4(15.5-31.3)

1-17

119.4

+ 22.8 (90.9-171.3)

21.2

k 5.2 (13.0-31.3)

4

1-9

8 12

well as malnutrition or inflammation which can result in low prealbumin plasma levels.‘~5-7 As shown in Table I, 13 out of 15 PiZ children had clinical signs of liver disease or malfunction and might therefore be expected to exhibit low serum levels of prealbumin. Indeed, of the 13 PiZ children patients with liver disease, only five (#I. #3, #5, #8, and fll in Table 1) had serum prealbumin levels near normal for their age as determined by RID by Vahlquist et al.,19 whereas the other eight PiZ children with liver disease had low or very low serum levels of prealbumin. Sveger2’ has reported that 7% of the PiZ infant patients had severe obstructive jaundice and another 9%) had clinical evidence of liver disease. By two yr of age, 47% of the rest of the PiZ children exhibited increased liver enzymes suggestive of some liver impairment. After 4 yr, 2.5%) of the PiZ children had died and 45% of the PiZ children still had increased liver enzymes.28 This situation could result in low prealbumin levels. The PiZ children as a group in our study have a low mean serum prealbumin level when compared to the mean serum prealbumin level of our PiM children controls. However, serum prealbumin levels have been shown to increase during childhood through mid-life followed by a decrease to childhood levels during old age. I4 I9 Therefore, this comparison cannot be made in this or other studies. We cannot compare our prealbumin concentrations for PiZ children and PiZ adults to those of Felding et al.” since they used a mean of 18 PiZ patients with a mean age of 39 and an age range of twelve to seventy-two years. Furthermore, no clinical symptoms were tabulated for the alpha,-antitrypsin deficient (PiZ) patients. Two of the PiZ children in our study are clearly different. One patient (#14 Table I) has nephrotic syndrome with an elevated prealbumin level and the other patient (#13, Table 1) is asymptomatic with a very low level of serum prealbumin. Nephrotic syndrome has been associated with low levels of prealbumin.‘” However, Smith and Goodman’

Mean

f

SD (range)

reported that patients with chronic renal disease had normal plasma prealbumin levels. It has been estimated that as many as 80% of the PiZ patients get emphysema by the fourth decade of life.29 About 10% of the PiZ adults have cirrhosis.26 One PiZ adult patient (#12, Table 2) in our study of 12 PiZ adults, clearly has a low serum level of prealbumin. However, this patient also has cirrhosis and carcinoma of the bile duct, conditions which could account for the low level of prealbumin. Premachandra and Yuzo reported that three adult PiZ patients, two with emphysema, had unexplained low prealbumin levels. Felding et al.” found that one PiZ adult patient with emphysema out of 19 PiZ patients studied had an unexplained low prealbumin level. In our study of 12 PiZ adult patients, a few had borderline serum levels of prealbumin (#l, #4, #9, and #I 1’) although the overall adult group mean prealbumin level of 23.8 + 7.6 mg/ 100 ml is comparable to other reported adult serum levels of 25 t 6 mg/ 100 ml for 79 adults, ages 2 l-63 yr14 and other investigators.‘9,30 The mean serum prealbumin level of our PiM adult controls in Table 4 is slightly high compared to these reported adult values, perhaps due to the fact that all except one PiM adult controls are non-smokers. Again, these mean prealbumin concentrations may not be valid since prealbumin levels do change with age.14 I9 We conclude that alpha,-antitrypsin deficient adults (PiZ) do not have very low unexplained prealbumin levels in general. However, there are a few PiZ adult patients who may exhibit these very low levels as reported by Premachandra and Yu” and Felding et al.” but they are the exception rather than the rule. The alpha,-antitrypsin deficient children (PiZ) do indeed exhibit somewhat low serum prealbumin levels, probably as a result of liver disease. In addition, there may be a few PiZ children with very low unexplained prealbumin levels who may become the few PiZ adults with low prealbumin levels.

Table 4. PiM Adult Controls Range SW

N

TIC. % Normal

Age. yr Mean

+ SD (range)

Prealbumln mgJlO0

ml

Mean + SD (range)

F

7

21-37

148.3

k 45.4 (107.6-234.9)

33.4

+ 12.1 (21.6-56.0)

M

7

23-50

126.5

k 18.8 (106.0-153.5)

31.8

+ 5.5 (26.6.-41.5)

14

21-50

137.4

k 35.2 (106.0-234.9)

32.6

+ 9.1 (21.6.-56.0)

M+F

302

BERNINGER, BOOKER, AND TALAMO

REFERENCES I. Putnam FW: Alpha, Beta, Gamma, Omega-The Roster of the Plasma Proteins, in Putnam FW (ed): The Plasma ProteinsStructure, Function, and Genetic Control, vol. I. New York, Academic Press, 1975, pp 57-131 2. Smith FR, Goodman DS: The effects of diseases of the liver, thyroid, and kidneys on the transport of vitamin A in human plasma. J Clin Invest 50:2426-2436, 197 1 3. Ingenbleek Y, de Visscher M, De Nayer Ph: Measurement of prealbumin as index of protein-calorie malnutrition. Lancet 2: 106109, 1972 4. Surks MI, Oppenheimer JH: Postoperative changes in the concentration of thyroxine-binding prealbumin and serum-free thyroxine. J Clin Endocrinol 24:794-801, 1964 5. Socolow EL, Woeber KA, Purdy RH, et al: Preparation of I”‘-labeled human serum prealbumin and its metabolism in normal and sick patients. J Clin Invest 44:160%1609, 1965 6, Oppenheimer JH, Surks MI, Bernstein G, et al: Metabolism of iodine-13 l-labeled thyroxine-binding prealbumin in man. Science 149:748-751, 1965 7. Ingbar SH, Braverman LE, Dawber NA, et al: A new method for measuring the free thyroid hormone in human serum and an analysis of the factors that influence its concentration. J Clin Invest 44: 1679-I 689, 1965 8. Rostenberg I, Rico R, Perialoza R: Cc globulin and prealbumin serum levels in patients with cancer and benign inflammatory diseases and in asymptomatic smokers. J Natl Cancer Inst 62:299300, 1979 9. Hollinshead AC, Chuang C-Y: Evaluation of the relationships of prealbumin components in sera of patients with cancer. Natl Cancer Inst Mongr 49:187-192, 1978 10. Helen PL, Rajagopal G, Prasanna CV, et al: A study of prealbumin in health and diseases by polyacrylamide gel disc electrophoresis. Indian J Med Res 63:2733277, 1975 11, Smith FR, Underwood BA, Denning CR, et al: Depressed plasma retinol-binding protein levels in cystic fibrosis. J Lab Clin Med 80:423-433, 1972 12. Knijpfle G, Rotthauwe HW, Odenthal A: Vitamin A, carotin, retinolbindendes protein and prlalbumin in serum von patienten mit cystischer fibrose. 2 Kinderheilk 119:279929 1, 1975 13. Weeke B, Flensborg EW, Jacobsen L, et al: Immunochemical quantitation of I8 proteins in sera from patients with cystic fibrosis: Concentrations correlated to class of fibroblast metachromasia, clinical and radiological lung symptoms. Dan. Med Bull 23:155-160, 1976 14. Rossi T, Hirvonen T, Toivanen P: The concentration of prealbumin in human fetal and infant sera. Stand J Clin Lab Invest 26135-36, 1970 15. Braverman LE, Dawber NA, Ingbar SH: Observations concerning the binding of thyroid hormones in sera of normal subjects of varying ages. J Clin Invest 45: 1273-l 279, 1966

16. Guidetti LM: Prealbumina (TBPA) e protidogramma sierico di soggetti ultranovantenni. Boll Sot It Biol Sper 54:848-850, 1978 17. Weeke B, Krasilnikoff PA: The concentration of 21 serum proteins in normal children and adults. Acta Med Stand 192: 149155, 1972 18. Stabilini R, Vergani C, Agostoni A, et al: Influence of age and sex on prealbumin levels. Clin Chim Acta 20:358-359, 1968 19. Vahlquist A, Rask L, Peterson of retinol-binding protein, prealbumin, newly delivered mothers and children Lab Invest 35:569-575, 1975

PA, et al: The concentrations and transferrin in the sera of of various ages. Stand J Clin

20. Premachandra BN, Yu SY: Association of prealbumin deficiency with alpha,-antitrypsin deficiency. Metabolism 28:89&894, I979 2 I. Felding P, Fex G, Jeppsson J-O: Plasma prealbumin concentration in alpha,-antitrypsin deficiency (PiZ). Metabolism 29:12033 1205, 1980 22. Talamo RC, Bruce RM, Langley CE, et al: Alpha,-antitrypsin Laboratory Manual. National Heart, Lung, and Blood Institute. U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, DHEW Publication No. (NIH) 78-1420, 1978, pp 37-64 23. Mancini G, Carbonara AO, Heremans JF: Immunochemical quantitation of antigens by single radial immunodiffusion. Immunothem 2:235-254, 1965 24. Talamo RC, Bruce RM, Langley CE, et al: Alpha,-antitrypsin Laboratory Manual. National Heart, Lung, and Blood Institute. U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, DHEW Publication No. (NIH) 7881420, 1978, pp 15-36 25. Arnaud P, Wilson GB, Koistinen J, et al: Immunofixation after electrofocusing: Improved method for specific detection of serum proteins with determination of isoelectric points I. Immunofixation print technique for detection of alpha,-antitrypsin-protease inhibitor. J lmmunol Methods 16:221-231, 1977 26. Sharp HL: protease inhibitor, 70:61 l-621, 1976

The current status of alpha,-antitrypsin, in gastrointestinal disease. Gastroenterology

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a

in alpha,-antitrypsin deficiency infants. N Engl J Med 294: I3 16-

28. Sveger T, Thelin T: Four-year-old children antitrypsin deficiency. Acta Pediatr Stand 70:171l177,

with alpha,1981

29. Norum RA, Bearn AC, Briscoe WA, et al: Alpha,-antitrypsin and disease. Mount Sinai J Med 44:82 l-828, 1977 30. Storiko K: Normal values for 23 different human plasma proteins determined by single radial immunodiffusion. Blut 16:20& 208, 1968