Enzymatic and molecular strategies to diagnose Pompe disease.

Enzyme replacement therapy for Pompe disease, a neuromuscular disorder characterized by lysosomal glycogen storage due to acid α-glucosidase deficiency, has entered the clinic. There is more than ever a need for early and reliable diagnosis. The objective of this review is to present a critical review of the recent literature on laboratory procedures to diagnose Pompe disease by enzymatic assay and DNA analysis. The methods we used were Compilation and expert interpretation of recent and relevant publications. The introduction of new and the updating of existing laboratory procedures have facilitated the diagnosis of Pompe disease (glycogen storage disease type II; acid maltase deficiency; OMIM 232300). With regard to enzymatic analysis, the application of acarbose as inhibitor of maltase-glucoamylase has enabled the use of mixed leukocyte preparations as diagnostic material. The use of glycogen as a natural substrate in the reaction mixture adds to the selectivity of this procedure. Newborn screening is envisaged and facilitated by the introduction of high-throughput procedures. DNA analysis has become an integral part of the diagnostic procedure for confirmation and completion, for carrier detection, and for genetic counseling.

Erythrocyte creatine as a marker of excessive erythrocyte destruction due to hypersplenism in patients with liver cirrhosis.

OBJECTIVE: Erythrocyte creatine is a sensitive marker of erythrocyte age, and can be used to detect slight and continuous hemolysis. Excessive blood cell destruction caused by increased spleen function is important evidence of hypersplenism. This study evaluates the usefulness of erythrocyte creatine as a sensitive marker of excessive erythrocyte destruction due to hypersplenism in patients with liver cirrhosis. DESIGN AND METHOD: Erythrocyte creatine was determined by an enzymatic method in 50 patients with postnecrotic liver cirrhosis and 50 healthy controls. The spleen size was measured by ultrasonography and expressed as a spleen index. RESULTS: The patients with splenomegaly showed significantly higher erythrocyte creatine than those without splenomegaly (p < 0.005) and healthy controls (p < 0.001), but there was no significant difference in erythrocyte creatine between healthy controls and those without splenomegaly. Fourteen (93%) of the 15 patients with abnormally high erythrocyte creatine (> 1.8 micromol/g hemoglobin) had splenomegaly. There were no significant differences in reticulocyte count between healthy controls and the patients with and without splenomegaly. Erythrocyte creatine showed good correlations with spleen index (r = 0.67; p < 0.001) and reticulocytes (r = 0.63; p < 0.001). CONCLUSIONS: Erythrocyte creatine can be used for predicting erythropoietic status and estimating hypersplenism in patients with liver cirrhosis.

Abnormally decreased HbA1c can be assessed with erythrocyte creatine in patients with a shortened erythrocyte age.

OBJECTIVE: To investigate whether erythrocyte creatine can serve as a corrective index for HbA1c in patients with a shortened mean age of erythrocytes. RESEARCH DESIGN AND METHODS: HbA1c and creatine in density-fractionated erythrocytes from 18 normal subjects were measured. HbA1c and erythrocyte creatine in the whole blood of 43 patients with liver cirrhosis (LC), 14 patients with hemolytic anemia (HA), 38 other patients with high reticulocyte counts (HRC) (>2.2%), and 59 normal subjects were also measured. The patients in this study all had normal blood glucose levels. A correction formula derived from the linear regression equation for the correlation between HbA1c and erythrocyte creatine was used to correct the patients' HbA1c values. RESULTS: Among density-fractionated erythrocytes, the young cells exhibited low HbA1c and high creatine values. With progressively increasing density, HbA1c gradually increased and creatine gradually decreased. In the whole blood samples, the HbA1c values were significantly lower (P < 0.001) in LC, HA, and HRC patients than in normal subjects. By contrast, the erythrocyte creatine values were significantly higher (P < 0.001) in LC, HA, and HRC patients than in normal subjects. A linear correlation between HbA1c (y) and erythrocyte creatine (x) was observed (y=-0.224x + 5.00; n=154; r=-0.70; P < 0.001). Based on the regression equation, a correction formula was obtained. Low HbA1c values (<4.3%) were found in 24 of the 43 LC patients, 12 of the 14 HA patients, and 20 of the 38 HRC patients. After correction of the HbA1c values, 15 of the 24 LC patients, 9 of the 12 HA patients, and 16 of the 20 HRC patients had HbA1c values within the normal range. CONCLUSIONS: HbA1c decreased in inverse proportion to the increase in erythrocyte creatine because of a shortened mean age of erythrocytes. The abnormally decreased HbA1c value could be assessed with erythrocyte creatine.

Sensitive enzymatic assay for erythrocyte creatine with production of methylene blue.

We developed a new, highly sensitive enzymatic method for quantifying creatine in erythrocytes, which comprises creatine amidinohydrolase, sarcosine oxidase, and peroxidase. In the present method, an N-methylcarbamoyl derivative of methylene blue, 10-N-methylcarbamoyl-3,7-bis(dimethylamino)phenothiazine (MCDP), was used as a sensitive chromogenic compound. Potassium ferrocyanide was used to prevent nonspecific oxidation of MCDP. The enzymatic method exhibited good analytical performance: precision, within-run CVs <1.0% and between-day CVs <2.0%; average analytical recovery, 99.3% +/- 1.8%; detection limit, 1.0 micromol/L in hemolysate; and linearity, at least up to 500 micromol/L as creatine concentration in hemolysate. Excellent agreement was observed between the present method (y) and HPLC (x), y = 1.029x - 0.002 micromol/g hemoglobin, r = 0.9998, S(y/x) = 0.053 micromol/g hemoglobin (n = 110). No significant interference was produced by various compounds, including guanidino compounds, amino acids, and reducing materials. The reference intervals (mean +/- 2 SD) for erythrocyte creatine obtained from 60 males and 60 females were (in micromol/g hemoglobin) 1.18 +/- 0.52 (0.66-1.70) for males and 1.35 +/- 0.49 (0.86-1.84) for females. Using this method, we documented changes in erythrocyte creatine in patients with various hemolytic conditions, including hemolytic anemia, liver cirrhosis, renal insufficiency, and chronic renal failure treated with hemodialysis with or without the administration of erythropoietin. We conclude that the use of MCDP allows sensitive measurement of erythrocyte creatine and that MCDP with potassium ferrocyanide can improve the sensitivity of assays that use peroxidase for detection of H2O2.

An enzymatic assay for erythrocyte creatine as an index of the erythrocyte life time.

OBJECTIVES: To establish and estimate an enzymatic measurement of creatine in erythrocytes as an index of the erythrocyte life time. DESIGN AND METHOD: The measurement of creatine in erythrocytes was performed using an enzymatic assay kit that was developed for serum and urine creatine. An erythrocyte sample was subjected to creatine measurement after hemolysis and deproteinization. Performance of the method for creatine measurement in erythrocytes was estimated. Effects of age and gender on the creatine content of erythrocytes were also estimated in 305 normal subjects. RESULTS: The method showed within-run CVs varying from 0.7 to 1.0% (n = 20), and between-day CVs from 1.3 to 1.7% (15 days). Good linearity was observed at least up to 1000 mumol/L as creatine value in hemolyzed sample. The analytical recovery was calculated to be 98.1 +/- 1.3% on average. No considerable interference by various substances, including guanidino compounds and amino acids, with the assay was observed. Excellent correlation was observed between the present method and high performance liquid chromatography. With the unit of mumol/g Hb: slope, 1.034 +/- 0.003 (mean +/- SD); intercept, -0.059 +/- 0.012 (mean +/- SD); correlation coefficient, 0.9996; and Sy.x, 0.069. With the unit of mumol/L RBC: slope, 1.033 +/- 0.003 (mean +/- SD); intercept, -18.23 +/- 3.55 (mean +/- SD); correlation coefficient 0.9996; and Sy.x, 20.40. A significant increase in erythrocyte creatine was observed in females aged 11- to 50 years old as compared with males in the corresponding age bracket, however, a gender difference was not observed in other age bracket. This finding suggests the possibility of a slight decrease in the erythrocyte life time due to menstruation in females. CONCLUSION: This study showed that the present method is favorable for quantifying erythrocyte creatine, and has analytical characteristics suitable for routine work in clinical laboratories.

Alpha-galactosidase transgenic mouse: heterogeneous gene expression and posttranslational glycosylation in tissues.

We produced six transgenic mouse lines expressing human alpha-galactosidase (alpha-Gal) in order to evaluate its posttranslational modification. Among them, serum alpha-Gal activity increased 3000-fold in two transgenic mouse lines (TgN2 and TgN51), as compared to that in non-transgenic lines. The heart and liver of the TgN2 mouse expressed a high amount of transcript as well as high alpha-Gal activity. Its gene products in the heart and kidney were sensitive to endoglycosidase H digestion, but those in the spleen and liver were largely resistant. Glycopeptidase F treatment confirmed an identical molecular mass for the peptide moiety of the enzyme. We concluded that heterogeneous molecular mass of the gene products was caused by different degrees of posttranslational glycosylation in murine tissues.

High incidence of thrombosis in Fabry's disease.

Although a high incidence of thrombotic accidents in Fabry's disease has been postulated, few investigations have been performed. To clarify the incidence of thrombosis in Fabry's disease, we undertook a systematic study on thrombosis in patients with Fabry's disease including hemizygous males and heterozygous females. Sixty patients with Fabry's disease (45 hemizygotes and 15 heterozygotes) from 36 Japanese families were subjected to clinical, biochemical and genetic investigations. We found that seven patients with Fabry's disease (4 hemizygous males and 3 heterozygous females) had experienced thrombotic accidents. Six of these thrombotic patients developed brain infarctions, including one man who had the complication of recurrent thrombophlebitis. The remaining woman showed central retinal artery occlusion and thrombophlebitis. We demonstrated a high incidence of thrombosis in Fabry's disease. Thrombotic accidents occurred not only in hemizygous males but also in heterozygous females. The complication of thrombotic accidents should be taken into account in patients with Fabry's disease.

Screening and detection of gene mutations in Japanese patients with Fabry disease by non-radioactive single-stranded conformation polymorphism analysis.

We have applied non-radioactive polymerase chain reaction (PCR)-single-stranded conformation polymorphism (SSCP) to the detection of gene mutations causing Fabry disease. Nineteen of 22 known mutations were detected as electrophoretic mobility shifts on PCR-SSCP analysis. Then, DNA from newly diagnosed Japanese patients with the classical form of Fabry disease was subjected to PCR-SSCP analysis, and 4 novel mutations (1 small deletion, 1 nonsense mutation and 2 missense mutations) and 1 neutral polymorphism were identified. Furthermore, identification of an asymptomatic heterozygote and a hemizygote with moderate clinical manifestations was successfully achieved by application of this method to a family with the variant form of Fabry disease. PCR-SSCP is useful for the gene diagnosis of etiologically heterogeneous Fabry disease.

[alpha-Galactosidase gene mutation and its expression product in Fabry disease (alpha-galactosidase deficiency)].

Fabry disease is characterized by a deficiency of lysosomal alpha-galactosidase (alpha-Gal) and the accumulation of glycosphingolipid (e.g. predominantly globotriaosylceramide) in various tissues, mainly in lysosomes of the vascular endothelium. This disorder is currently classified into two clinical phenotypes; classical severe type and atypical variant type. Classical form patients, with clinical manifestations of generalized angiopathy of early onset, usually show no detectable alpha-Gal activity. Recently, there are also atypical form patients with residual alpha-Gal activity and late-onset cardiomyopathy without other systemic manifestations. So far, we identified a number of alpha-Gal gene mutations including partial gene deletions, splicing mutations, nonsense mutations and missense mutations. They were heterogeneous and more than half of them were missense mutations. To clarify the molecular mechanism causing the enzyme defect in the patient, various missense mutations were expressed in COS-1 cells. At least, two groups have been identified; one expressing a mutant enzyme without catalytic activity (non-functional type), and the other expressing catalytically active but unstable mutant enzyme (fragile type). The fragile type mutants were widely present in the different clinical phenotypes from classical severe type to atypical milder type including subclinical Fabry hemizygote, and the mutant enzymes were posttranslationally inactivated and degraded in the cells. The inactivation and degradation were prevented by the addition of substrate analogue; galactose or melibiose. These findings provided us with significant informations on the molecular pathology of the enzyme defect in Fabry disease, and suggested the possibility of a new therapeutic approach for this disease.

Two novel mutations in the alpha-galactosidase gene in Japanese classical hemizygotes with Fabry disease.

Four alpha-galactosidase gene mutations were identified in Japanese male patients with Fabry disease who had no detectable alpha-galactosidase activity. Two of them were novel mutations, an 11-bp deletion in exon 2 and a g-1 to t substitution at the 3' end of the splice acceptor site in intron 1. The former caused a frameshift and led to the creation of a new stop codon at codon 118. The latter was predicted to provoke aberrant mRNA splicing followed by accelerated degradation of the mRNA. A nonsense mutation, R301X, and a 2-bp deletion starting at nucleotide position 718, which were reported previously, were also identified in unrelated patients.

Aggregation of the inactive form of human alpha-galactosidase in the endoplasmic reticulum.

35S-Labeled mutant alpha-galactosidases (Q279E and R301Q) expressed in COS1 cells were detected as two forms (46-kDa protein and gel-top aggregate) on SDS-polyacrylamide gel electrophoresis under nonreducing conditions. The 46-kDa protein disappeared rapidly, but the aggregate decreased slowly. The accumulation of aggregate was observed in COS1 cells expressing either Q279E or R301Q on Western blot analysis. The aggregate was mainly recovered in the fraction extracted with 1% Triton X-100 and had no catalytic activity. The COS1 cells expressing Q279E were treated with 10 microgram/ml brefeldin A or 5 microM monensin. Treatment with brefeldin A caused a decrease in the alpha-galactosidase activity and an increase in the amount of aggregate, but the amount of aggregate did not change on monensin treatment.

[Fabry disease (alpha-galactosidase deficiency)].

Fabry disease is an X-linked glycosphingolipid storage disorder resulting from a deficiency of lysosomal alpha-galactosidase (alpha-Gal; EC 3.2.1.22). Classical form patients, with clinical manifestations of generalized angiopathy of early onset, usually show no detectable alpha-Gal activity. There are also atypical form patients with residual alpha-Gal activity and late onset cardiomyopathy without other systemic manifestations. We identified a number of alpha-Gal gene mutations including partial deletions and point mutations. They were heterogeneous and more than half of them were missense mutations. Various missense mutants were expressed in COS-1 cells. Two groups have been identified; one expressing a mutant enzyme without catalytic activity, and the other expressing a catalytically active but unstable mutant enzyme. The latter was restored in patient cells by the addition of substrate analogues. The molecular genetic and biochemical analysis for Fabry disease will provide us with significant informations on the pathogenesis and the possibility of the therapeutic approach for this disease.

Galactose stabilizes various missense mutants of alpha-galactosidase in Fabry disease.

The effect of galactose on alpha-galactosidase missense mutants causing Fabry disease was investigated in the COS-1 cell expression system and lymphoblasts. Three mutant enzymes, A156V, L166V and Q279E, showed increases in activity and amount in COS-1 cells cultured with galactose. Another mutant without catalytic activity, C142Y, did not show any changes. In lymphoblasts cultured with galactose, the enzyme activity increased significantly in four classical Fabry patients with the respective mutations, A156V, L166V, G260A and G373S, and in three atypical Fabry patients with the respective mutations, Q279E, R301Q and M296I. Such an increase was not observed in the other four classical Fabry patients, with C142Y, E66Q/R112C, G328R and N320K, respectively. This suggests that many missense mutations in the alpha-galactosidase gene causing Fabry disease allow the expression of catalytically active mutant enzymes regardless of the clinical phenotype, which are rapidly degraded under physiological conditions and stabilized by galactose.

Alpha-galactosidase gene mutations in Fabry disease: heterogeneous expressions of mutant enzyme proteins.

Five point mutations were identified in unrelated Japanese Fabry disease hemizygotes: three new missense mutations, C142Y (425 G-->A), A156V (467 C-->T), and L166V (496 C-->G) in exon 3; one new splice site mutation at the 3' end of the consensus sequence in exon 4; one previously reported nonsense mutation, W44X (131 G-->A). C142Y expressed 50% of the normal enzyme protein in COS-1 cells, but catalytic activity was not detected. Both A156V and L166V expressed significant amounts of residual enzyme activity (6.7% and 9.8%) and enzyme proteins (10% each), the latter were more thermolabile at neutral pH than at acid pH, in vitro.