CLINICAL ENZYMOLOGY

PLASMA ENZYMES

Measurements of the activity of enzymes in plasma are of value in the

diagnosis and management of a wide variety of diseases. Most enzymes
measured in plasma are primarily intracellular, being released into the blood
when there is damage to cell membranes, but many enzymes, for example renin,
complement factors and coagulation factors, are actively secreted into the blood,
where they fulfil their physiological functions.
Small amounts of intracellular enzymes are present in the blood as a result of
normal cell turnover. When damage to cells occurs, increased amounts of
enzymes will be released and their concentrations in the blood will rise.
However, such increases are not always due to tissue damage. Other possible
causes include:
increased cell turnover
cellular proliferation (e.g. neoplasia)
increased enzyme synthesis (enzyme induction)
obstruction to secretion
decreased clearance.
Little is known about the mechanisms by which enzymes are removed from the
circulation. Small molecules, such as amylase, are filtered by the glomeruli but
most enzymes are probably removed by reticuloendothelial cells. Plasma
amylase activity rises in acute renal failure but, in general, changes in clearance
rates are not known to be important as causes of changes in plasma enzyme
levels.

CLINICAL ENZYMOLOGY

Plasma contains many functional enzymes, which a actively secreted into

plasma. For example, enzymes blood coagulation. On the other hand, there are
a few non functional enzymes in plasma, which are coming out from cells of
various tissues due to normal wear and tear. Their normal levels in blood are
very low; but are drastically increased during cell death (necrosis) or disease.
Therefore assays of these enzymes are very useful in diagnosis diseases.
Enzyme Units
Enzyme assays usually depend on the measurement the catalytic activity of the
enzyme, rather than the concentration of the enzyme protein itself. Since each
enzyme molecule can catalyze the reaction of many molecules of substrate,
measurement of activity provides great sensitivity. It is, however, important that
the conditions of the assay are optimized and standardized to give reliable and
reproducible results. Reference ranges for plasma enzymes are dependent on
assay conditions, for example temperature, and may also be subject to
physiological influences. It is thus important to be aware of both the reference
range for the laboratory providing the assay and the physiological circumstances
when interpreting the results of enzyme assays.
One international unit is the amount of enzyme that will convert one
micromole of substrate per minute per litre of sample and is abbreviated as U/L.
The SI Unit (System Internationale) expression is more scientific, where
or Katal (catalytic activity) is defined as the number of mole of substrate
transformed per second per litre of sample. Katal is abbreviated as kat or k (60
U = 1 kat and 1 nk = 0.06 U).

Disadvantages of enzyme assays

A major disadvantage in the use of enzymes for the diagnosis of tissue damage
is their lack of specificity to a particular tissue or cell type. Many enzymes are
common to more than one tissue, with the result that an increase in the plasma
activity of a particular enzyme could reflect damage to any one of these tissues.
This problem may be obviated to some extent in two ways:
first, different tissues may contain (and thus release when they are damaged)
two or more enzymes in different proportions; thus alanine and aspartate
aminotransferases are both present in cardiac and skeletal muscle and
hepatocytes, but there is only a very little alanine aminotransferase in either
type of muscle;
second, some enzymes exist in different forms (isoforms), colloquially termed
isoenzymes (although, strictly, the term 'isoenzyme' refers only to a genetically
determined isoform). Individual isoforms are often characteristic of a particular
tissue: although they may have similar catalytic activities, they often differ in
some other measurable property, such as heat stability or sensitivity to
inhibitors.
After a single insult to a tissue, the activity of intracellular enzymes in the
plasma rises as they are released from the damaged cells, and then falls as the
enzymes are cleared. It is thus important to consider the time at which the blood
sample is taken in relation to the insult. If taken too soon, there may have been
insufficient time for the enzyme to reach the blood- stream and if too late, it
may have been completely cleared. As with all diagnostic techniques, data
acquired from measurements of enzymes in plasma must always be assessed in
the light of whatever clinical and other information is available, and their
limitations borne in mind.
 LACTATE DEHYDROGENASE (LDH) (LD)
The total LDH is generally tested by reaction of the serum sample with pyruvate
and NADH2. LDH will convert pyruvate to lactate, and in turn NADH is use up
by the reaction.
Normal value of LDH in serum is 100-200 U/L. Values the upper range are
generally seen in children. Strenuous exercise will slightly increase the value.
LDH level is 100 times more inside the RBC than in plasma, and therefore
minor amount of hemolysis will result in a false-positive test.
LDH and Heart Attack
In myocardial infarction, total LDH activity is increased, while H4 iso-enzyme
is increased 5-10 times more.
Differential diagnosis: Increase in total LDH level is seen in hemolytic
anemias, hepatocellular damage, muscular dystrophy, carcinomas, leukemias,
and any condition which causes necrosis of body cells. Since total LDH is
increased in many conditions, the study of isozymes of LDH is of great
importance.
Isoenzymes of LDH
LDH enzyme is a tetramer with four subunits. But the subunit may be either H
(heart) or M (muscle) polypeptide chains. These two are the products of two
different genes.
Although both of them have the same molecular weight (32 kD), there are
minor amino acid variations. So five combinations of H and M chains are
possible; H4, H3M, H2M2, M3H and M4 varieties, forming five iso-enzymes. All
these five forms are seen in all persons. M4 form is seen in skeletal muscles; it is
not inhibited by pyruvate. But H4 form is seen in heart and is inhibited by
pyruvate. Normally LDH-2 (H3M1) concentration in blood is greater than LDH-
1 (H4); but this pattern is reversed in myocardial infarction; this is
called flipped pattern. The iso-enzymes are usual ly separated by cellulose
acetate electrophoresis at pH 8.6. They are then identified by adding the
reactants finally producing a colour reaction. . Lactate dehydrogenase
isoenzymes (as percentage of total):

LDH1 14-26 %
LDH2 29-39 %
LDH3 20-26 %
LDH4 8-16%
LDH5 6-16 %

CREATINE KINASE(CK)
It is used for the reaction shown in Figure:
Creatine Creatine phosphate

It was called as creatine phosphokinase in old literature.

Normal serum value for CK is 15-100 U/L for males and 10-80 U/L for
females.
CK and Heart Attack CK value in serum is increased in myocardial
infarction. The CK level starts to rise within three hours of infarction.
Therefore, CK estimation is very useful to detect early cases, where ECG
changes may be ambiguous. The CK level is not increased in hemolysis or in
congestive cardiac failure; and therefore CK has an advantage over LDH.
CK and Muscle Diseases he level of CK in serum is very much elevated in
muscular dystrophies (500 -1500 IU/L). The level is very high in the early
phases of the disease. In such patients a fall in CK level is indicative of
deteriorating condition, because by that time, all muscle mass is destroyed. In
female carriers of this X-linked disease (genotypically heterozygous), CK is
seen to be moderately raised. CK level is highly elevated in crush injury,
fracture and acute cerebrovascular accidents. Estimation of total CK is
employed in muscular dystrophies and MB iso-enzyme is estimated in
myocardial infarction.
Iso-enzymes of CK CK is a dimer; each subunit has a molecular weight of
40,000. The subunits are called B for brain and M for muscle. They are products
of loci in chromosomes 14 and 19 respectively. Therefore three iso-enzymes are
seen in circulation. Normally CK2 is only 5% of the total activity. Even
doubling the value in CK2 (MB) iso-enzyme may not be detected, if total value
of CK alone is estimated. Hence the detection of MB-iso-enzyme is important
in myocardial infarction. CK-MB < 6 % of total CK in normal conditions.
The above three iso-enzymes are cytosolic. A fourth variety, called CK-
mt is located in mitochondria and constitutes about 15% of total CK activity.
Its gene is located in chromosome 15. CK1 may be complexed with
immunoglobulin; and then termed macroCK. CK1-lgG causes false-positive
diagnosis of myocardial infarction because it has an electrophoretic mobility
close to CK2.
For quantitating MB iso-enzyme, anti-MM antiserum is added to the
patient's serum. This will precipitate MM iso-enzyme. The supernatant serum
is used for the CK estimation. Here it is assumed that BB isoenzyme is
negligible in quantity, which is correct if there is no brain disease. CK iso-
enzymes can also be identified by electrophoresis.
TRANSFERASES
AST present in cytosol and mitochondria
ALT located in cytosol of liver
In the liver, the concentration of ALT per unit weight of the tissue is
more than AST.
These enzymes are more important in assessing and monitoring the
degree of liver cell
inflammation and necrosis.
The highest activities of ALT are found in hepatocytes and muscle cells.
Again the hepatocytes have very high activity of ALT.
Therefore elevations in serum ALT are considered to be relatively
specific for liver disease.
AST may be elevated in other forms of tissue damage, such as
myocardial infarction,
muscle necrosis and renal disorders.
In liver disease, the ALT level is increased markedly compared to AST.
In acute viral hepatitis there is a 100-1000 times increase in both ALT
and AST but ALT
level is increased more than that of AST

ASPARTATE AMINO TRANSFERASE (AST)

It is also called as serum glutamate-oxaloacetate transaminase (SGOT). AST
needs pyridoxal phosphate as co-enzyme. AST is estimated by taking
aspartate, -ketoglutarate, pyridoxal phosphate (vitamin B6) and patient'
serum as the source of AST. The oxaloacetate formed may be allowed to
react with dinitrophenyl hydrazine to produce a colour which is estimated
colorimetrically at 520 nm.
Normal serum level of AST is 8-40 U/L or (0,1-0,45 mmol/(hourL))
It is significantly elevated in myocardial infarction. It if moderately elevated
in liver diseases. However, a marked increase in AST may be seen in primary
hepatoma. AST has two iso-enzymes; cytoplasmic and mitochondrial. In mile
degree of tissue injury, cytoplasmic form is seen in serum. Mitochondrial type
is seen in severe injury.
Marked increase (10 to 100 times the upper adult reference limit):
Circulatory failure with 'shock' and hypoxia:
Myocardial infarction
Acute viral or toxic hepatitis.
Moderate increase
Cirrhosis (may be normal, but may rise to twice the upper adult reference
limit):
Infectious mononucleosis (due to liver involvement):
Cholestatic jaundice (up to 10 times the upper adult reference limit):
Malignant infiltration of the liver (may be normal, but may rise to twice the
upper reference
limit):
Skeletal muscle disease:
After trauma or surgery (especially after cardiac surgery):
Severe haernolytic episodes (of erythrocyte origin).
ALANINE AMINO TRANSFERASE (ALT)
It is also called as serum glutamate-pyruvate transaminase (SGPT). ALT
needs pyridoxal phosphate as co-enzyme.
Normal serum level of ALT is 5-30 U/L or (0,1-0,68 mmol/(hourL))
Very high values (100 to 1000 U/L) are seen in acute hepatitis, either toxic or
viral in origin. Both ALT and AST are increased in liver diseases, but ALT
>AST. Moderate increase (25 to 100 U/L) may be seen in chronic liver
disease such as cirrhosis, and malignancy in liver. A sudden fall in ALT level
in cases of hepatitis is a very bad prognostic sign.
Ritis coefficient (AST/ALT) in normal conditions is 1,330,42.
Marked increase (10 to 100 times the upper limit of the adult reference
range circulatory failure with 'shock' and hypoxia:
Acute viral or toxic hepatitis.
Moderate increase:
Cirrhosis (may be normal or up to twice the upper adult reference limit):
infectious
 mononucleosis (due to liver involvement):
Liver congestion secondary to congestive cardiac failure:
cholestatic jaundice (up to 10 times the upper reference limit in adults);
surgery or
extensive trauma and skeletal muscle disease (much less affected than
AST)

Alkaline phosphatase (ALP)

It is a non- specific enzyme which hydrolyses aliphatic, aromatic or
heterocyclic compounds. The pH optimum for the enzyme reaction is between
9 and 10. It is prodused by osteoblasts of bone, and localized in cell
memmbranes (ecto-enzyme).
Normal serum level of ALP is 40-125 U/L or 0,5-1,3 mmol/(hour L).
In children the upper level of normal value may be more, becouse of the
increased osteoblastic activity. Mild increase is noticed during pregnancy, due
to production of placental isoenzyme.
Moderate (2-3 times) increase in ALP level is seen in hepatic diseases such as
hepatitis, alcoholic hepatosis or hepatocellular carcinoma. Very high levels of
ALP (10-12 times of upper limit) may be noticed in extrahepatic obstructions
or cholestasis. ALP is produced by epithelial cells of biliary canaliculi and
obstruction of bile with consequent irritation of epithelial cells leads to
secretion of ALP into serum.
Drastically high levels of ALP (10-25 times of upper limit) are also seen in
bone diseases where osteoblastic activity is enhanced such as Paget's disease,
rickets, osteomalacia, osteoblastoma, metastatic carcinoma of bone and
hyperparathyroidism (Paget's disease or osteitis deformans was described in
1877 by Sir James Paget).
Iso-enzymes of Alkaline Phosphatase
1. -1 ALP moves in -1 position, it is synthesised by epithelial cells of
biliary canaliculi. It is about 10% of total activity and is increased in
obstructive jaundice and to some extent in metastatic carcinoma of liver.
2. -2 heat labile ALP is stable at 56C; but loses its activity when kept
at 65C for 30 minutes. It is produced by hepatic cells. Therefore absence of
-1 with exaggerated -2 band suggests hepatitis. This liver iso-enzyme forms
about 25% of total ALP.
3. -2 heat stable ALP will not be destroyed at 65 C but is inhibited by
phenylalanine. It is of placental origin, which is found in blood in normal
pregnancy. An isoenzyme closely resembling the placental form is
characteristically seen in circulation in about 15% cases of carcinoma of lung,
liver and gut and named as Regan isoenzyme (after the first patient in whom it
was detected or carcinoplacental iso-enzyme. Chronic heavy smoking also
increases Regan iso-enzyme level in blood. Normal level is only 1 % of the
total ALP.
 4. Pre- ALP is of bone origin and elevated levels are seen in bone
diseases. This is the most heat labile (destroyed at 56C, 10 min). Wheat germ
lectin will precipitate bone iso-enzyme. This constitutes about 50% of normal
ALP activity.
5. -ALP is inhibited by phenylalanine and originates from intestinal
cells. It is increased in ulcerative colitis. About 10% of plasma ALP are of
intestinal variety.
6. The leucocyte alkaline phosphatase (LAP) is significantly decreased
in chronic myeloid leukemia. It is increased in lymphomas.
ALP has different isoforms. Although ALP is a monomer, depending on
the number of sialic acid residues, the charged groups differ. Such different
forms are detected in agar gel electrophoresis.

NUCLEOTIDE PHOSPHATASE (NTP)

It is also known as 5' nucleotidase. This enzyme hydrolyses 5' nucleotides to
corresponding nucleosides at an optimum pH of 7.5. It is a marker enzyme for
plasma membranes and is seen as an ecto-enzyme (enzyme present on the cell
membrane).
Usually, AMP is used as substrate, which is hydrolysed to adenosine and
inorganic phosphate. The latter reacts with ammonium molybdate to produce
the yellow ammonium phosphomolybdate, which is estimated
colorimetrically. However, ALP will also catalyse the same reaction. Serum
samples contain both ALP and NTP. These are distinguished by Nickel ions
which inhibit NTP but not ALP.
Normal NTP level in serum is 2-10 U/L. It is moderately increased in hepatitis
and highly elevated in biliary obstruction. Unlike ALP, the level is unrelated
with osteoblastic activity and therefore is unaffected by bone diseases.

GAMMA GLUTAMYL TRANSFERASE (GGT)

The old name was gamma glutamyl transpeptidase. It can transfer -glutamyl
residues to substrate. In the body it is used in the synthesis of glutathione.
GGT has 11 iso-enzymes. It is seen in liver, kidney, pancreas, intestinal cells
and prostate gland.
Normal serum value of GGT is 6-45 U/L in male and 5-30 U/L in
female. It is slightly higher in normal males, due to the presence of prostate
gland. This value is moderately increased in infective hepatitis and prostate
cancers. The GGT level is highly elevated in alcoholism, obstructive jaundice
and neoplasm's of liver. GGT-2 is positive for 90% of hepatocellular
carcinomas. It is not elevated in cardiac or skeletal diseases.
GGT is a microsomal enzyme. Its activity is induced by alcohol,
phenobarbitone and rifampicin. GGT is clinically important because of its
sensitivity to detect alcohol abuse. GGT is increased in alcoholics even when
other liver function tests are within normal limits. GGT level is rapidly
decreased within a few days when the person stops to take alcohol. Increase in
GGT level is generally proportional to the amount of alcohol intake.

ACID PHOSPHATASE (ACP)

It hydrolyses phosphoric acid ester at pH between 4 and 6. Methods for assay
are the same as described for ALP; but the pH of the medium is kept at 5 to
5.4.
Normal serum value for ACP is 2.5-12 U/L or 0,025-
0,12 mmol/(hour L).
ACP is secreted by prostate cells, RBC, platelets and WBC. Isoenzymes
of ACP are described. Erythrocyte ACP gene is located in chromosome 2;
osteoclast ACP gene is on chromosome 19; lysosomal gene is on 11 and
prostate ACP gene is on 13. The prostate iso-enzyme is inactivated by tartaric
acid. Cupric ions inhibit erythrocyte ACP. Normal level of tartrate labile
fraction of ACP is 1 U/L.
ACP total value is increased in prostate cancer and highly elevated in bone
metastasis of prostate cancer. In these conditions, the tartrate labile iso-enzyme
is elevated. This assay is very helpful in follow up of treatment of prostate
cancers. ACP is therefore an important tumour marker.
Since blood cells contain excess quantity of ACP, must be taken to
prevent hemolysis while taking blood from the patient. Prostate massage may
also increase to value. So blood may be collected for ACP estimation before
per rectal examination of patient. ACP is present in high concentration in
semen, a finding which is used in forensic medicine in investigation of rape.
The main indications for estimation are to help diagnose prostatic carcinoma
and to monitor its treatment. The estimation is gradually being replaced by the
measurement of plasma prostate specific antigen (PSA) a protein derived from
the prostate. This test is more specific and sensitive for diagnosis and
monitoring treatment. However, it may be raised in similar circumstances to
those affecting prostatic ACP and is more expensive to estimate. ACP is more
useful for monitoring the treatment of a known case of disseminated prostatic
carcinoma than for making the diagnosis.

PROSTATE SPECIFIC ANTIGEN (PSA)

It is produced from the secretory epithelium of prostal gland. It is normally
secreted into seminal fluid, where it is necessary for the liquefaction of seminal
coagulum. It is a serine protease, and is a 32 kD glycoprotein; encoded in
chromosome number 19. In blood it is bound to alpha-2
macroglobulin and alpha-1-antitrypsin; a very smal fraction is in the free
from also.
Normal value is 1 -5 g/L. It is very specific for prostate activity. Values
between 4-10 g/L is seen in benign prostate enlargement; but values above 10
g/L is indicative of prostate cancer.
 CHOLINESTERASE (ChE)
Acetyl cholinesterase or true ChE or Type 1 ChE can act mainly on acetyl
choline. It is present in nerve endings and in RBCs. About 25 allelic forms are
reported. Normal serum range is 2-12 U/ml. Newly formed RBC will contain
good quantity of ChE which is slowly reduced according to the age of the cell.
Therefore, ChE level in RBCs will be proportional to the reticulocyte count.
Organophosphorus insecticides (Parathione) irreversibly inhibit ChE in RBCs.
Measurement of ChE level in RBCs is useful to determine the amount of
exposure in persons working with these
insecticides.
Pseudocholinesterase or type II ChE is non-specific and can hydrolyse acyl
esters. It is produced mainly by liver cells. Normal serum level is 8-18
U/ml. Succinyl choline is a widely used as muscle relaxant. It is a structural
analogue of ACh, and so competitively fix on post-synaptic receptors of
ACh. Succinyl choline is hydrolysed by the liver ChE within 2-4 minutes. But
in certain persons the ChE activity may be absent; this is a genetically
transmitted condition. In such individuals when succinyl choline is given
during surgery, it may take hours to get the drug metabolised. Very prolonged
scoline apnoea may result in 'nightmare of anaesthetist'. The
pseudocholinesterase level in serum is reduced in viral hepatitis, cirrhosis,
hepatocellular carcinoma, metastatic cancer of liver and in malnutrition.
Causes of decreased plasma cholinesterase activity
Hepatic parenchymal disease (reduced synthesis).
Ingestion or absorption through the skin, of such anticholinesterases as
organophosphates.
Inherited abnormal cholinesterase variants, with low biological activity.
Causes of increased plasma cholinesterase activity
a. Recovery from liver damage (actively growing hepatocytes)
b. Nephrotic syndrome

GLUCOSE-6-PHOSPHATE DEHYDROGENASE
GPD is a dimer with identical subunits. This is an important enzyme in the
hexose monophosphate shunt pathway of glucose. It is mainly used
for production of NADPH . It has a special role in the RBC metabolism. Due to
the presence of oxygen, hydrogen peroxide is continuously formed inside the
RBC. Peroxide will destroy biomembranes, and RBCs are lysed. Normal value
of GPD in RBC is 125-250 U/1012 cells. Nearly 400 variants (isoforms) of
GPD are described.

AMYLASE
This splits starch to maltose. It is activated by calcium, chloride and fluoride
ions. There are 18 phenotypes. It is produced by pancreas and salivary glands;
they are products of different genes located in chromosome 1.
Normal serum value is 50-120 U/L, (12-32 g/(hour L)).
The value is increased about 1000 times in acute pancreatitis which is a life-
threatening condition. The peak values are seen between 5-12 hours after the
onset of disease and returns to normal levels within 2-4 days after the acute
phase has subsided. Moderate increase in serum levels are seen in chronic
pancreatitis, mumps (parotitis), obstruction of pancreatic duct and in renal
disease. In the last condition, the enzyme is not excreted through urine properly
and hence serum value is raised. Normal urine value is 20-160 g/(hour
L) or (less than 375 U/L).It is increased in acute pancreatitis. It is increased on
the 1 st day and remains to be elevated for 7-10 days.

LIPASE
It will hydrolyse triglyceride to -monoglyceride and fatty acid. Molecular
weight is 54,000. The gene is in chromosome 10. The enzyme is present in
pancreatic secretion. Normal serum range is 0.2-1.5 U/L. It is highly elevated
in acute pancreatitis and this persists for 7-14 days. Thus, lipase remains
elevated longer than amylase. Moreover, lipase is not increased in mumps.
Therefore, lipase estimation has advantage over amylase. It is moderately
increased in carcinoma of pancreas, biliary diseases and perforating peptic
ulcers.

Aldolase (ALD)
It is a tetrameric enzyme with A and B subunits; so there are 5 iso-enzymes. It
is a glycolytic enzyme. Normal range of serum is 1.5-7 U/L.It is drastically
elevated in muscle damages such as progressive muscular dystrophy,
poliomyelitis, myasthenia gravis and multiple sclerosis. It is a very sensitive
early index in muscle wasting diseases.

Enolase
It is a glycolytic enzyme. Neuron-specific enolase (NSE) is an iso-enzyme seen
in neural tissues and Apudomas. NSE is a tumour marker for cancers
associated with neuro-endocrine origin, small cell lung cancer, neuroblastoma,
pheochromocytoma, medullary carcinoma of thyroid, etc. It is measured by
RIA or ELISA. Upper limit of NSE is 12 g/ml.
 Enzymes in Malignancy
Plasma total enzyme activities may be raised or an abnormal isoenzyme
detected, in several neoplastic disorders.
Serum prostatic (tartrate-labile) acid phosphatase activity rises in some cases
of malignancy of the prostate gland.
Any malignancy may be associated with a non-specific increase in plasma
LD1 (HBD) and occasionally, transaminase activity.
Plasma transaminase and alkaline phosphatase estimations may be of value to
monitor treatment of malignant disease. Raised levels may indicate secondary
deposits in liver or of alkaline phosphatase, in bone. Liver deposits may also
cause an increase in plasma LD or GGT.
Tumors occasionally produce a number of enzymes, such as the 'Regan' ALP
isoenzyme.'
LD (HBD) or CK-BB. assays of which may be used as an aid to diagnosis or for
monitoring treatment.
Other Clinical correlations
1. Niemann-Pick disease: Acid Sphingomyelinase Deficiency
Sphingomyelin, a ubiquitous component of cell membranes, especially
neuronal membranes, is normally degraded within lysosomes by the enzyme
sphingomyelinase.
In patients with Niemann-Pick disease, inherited deficiency of this enzyme
causes spingomyelin to accumulate in lysosomes of the brain, bone marrow, and
other organs.
Enlargement of the lysosomes interferes with their normal function, leading to
cell death and consequent neuropathy.
 Symptoms include failure to thrive and death in early childhood as well as
learning disorders in those who survive the postnatal period.
2. Homocysteinuria: Cystathionine -synthase Deficiency
1. Cystathionine -synthase catalyzes conversion of homocysteine to
cystathionine, a critical precursor of cysteine.
2. Deficiency of this enzyme leads to the most common form of
homocystinuria, a pediatric disorder characterized by accumulation of
homocysteine and reduced activity of several sulfotransferase reactions that
require this compound or its derivatives as substrate.
3. Accumulation of homocysteine and reduced transsulfation of various
compounds leads to abnormalities in connective tissue structures that cause
altered blood vessel wall structure, loss of skeletal bone density (osteoporosis),
dislocated optic lens (ectopia lentis), and increased risk of blood clots.
3. Enzyme Replacement Therapy for Inborn Errors of Metabolism
Lysosomal enzyme deficiencies, which frequently result in disease due to
accumulation of the substrate for the missing enzyme, are suitable targets for
enzyme replacement therapy (ERT).
In ERT, intravenously administered enzymes are taken up directly by the
affected cells through a receptor-mediated mechanism.
ERT provides temporary relief of symptoms but must be given repeatedly and
is not a permanent cure.

Summary
1. Enzyme concentrations are high in cells. Natural decay of these cells releases
enzymes into the plasma. Plasma activities are usually low but measurable.
2. Plasma enzyme assays are most useful in the detection of raised levels due to
cell damage.
3. Assays of selected enzymes may help to identify the damaged tissues and
isoenzyme studies may increase the specificity. In general, knowledge of the
patterns of enzyme changes, together with the clinical and other findings, are
needed if a useful interpretation is to be made.
4. Non-specific causes of raised enzyme activities include peripheral circulatory
insufficiency, trauma, malignancy and surgery.
5. Artefactual increases may occur in haemolysed samples.
6. Enzyme estimations may be of value in the diagnosis and monitoring of:
a. Myocardial infarction (CK. LD and its isoenzymes and sometimes AST);
b. Liver disease (transaminases. ALP and sometimes GGT):
c. Bone disease (ALP):
d. Prosratic carcinoma (tartrate-labile ACP);
e. Acute pancreatitis (-amylase):
f. Muscle disorders (CK)