CLINICAL

ENZYMOLOGY

Measurements of the activity of

enzymes in plasma are of
value in the diagnosis and
management of a wide variety
of diseases.

 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

Enzyme activity
Enzyme assays usually depend
on the measurement the catalytic
activity of the enzyme, rather than
the concentration of the enzyme
protein itself.

 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.
Katal (catalytic activity) is
defined as the number of mole
of substrate transformed per
second per litre of sample.

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 .

 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

 S econd, some enzymes exist

in different forms (isoforms)
Individual isoforms are often
characteristic of a particular
tissue: although they may
have similar catalytic
activities

Alkaline phosphatase
(ALP)
Normal serum level of ALP is 40-125 U/L or 0.5-1.3
mmol/(hour L).

This enzyme present in high concentrations in the

liver
bone (osteoblasts)
placenta
intestinal epithelium.

 The causes of an increase in

plasma ALP activity

Physiological increases are been

in pregnancy, due to the placental
isoenzyme, and in childhood (when
bones are growing), due to the
bone isoenzyme.

 Pathological: often >5 x ULN

Paget's disease or bone osteomalacia
rickets
cholestasis (intra- and extrahepatic)
cirrhosis
usually <5 x ULN
bone tumours (primary and secondary),
primary hyperparathyroidism with bone
involvement, healing fractures,
Osteomyelitis
hepatic space-occupying lesions (tumour,
abscess)

ACID PHOSPHATASE (ACP)

It hydrolyses phosphoric acid
ester at pH between 4 and 6.
ACP is secreted by prostate cells,
RBC, platelets and WBC.
Normal serum value for ACP is
2.5-12 U/L or 0.025-0.12 mmol/
(hour L).

 ACP total value is increased in prostate

cancer and highly elevated in bone
metastasis of prostate cancer.
ACP is therefore an important tumour
marker.
ACP is present in high concentration in
semen, a finding which is used in
forensic medicine in investigation of
rape.

Aminotransferases
Two aminotransferases are
used in diagnosis and
management: aspartate
aminotransferase (AST)
and
alanine aminotransferase (ALT).

ASPARTATE AMINO
TRANSFERASE (AST)
It is also called as serum glutamateoxaloacetate transaminase (SGOT).
Normal serum level of AST is 8- 40 U/L or (0.10.45 mmol/(hour L))
It is significantly elevated in myocardial
infarction. It if moderately elevated in liver
diseases.

Measurement of cardiac
enzyme levels
Measure cardiac enzyme levels at regular
intervals, starting on admission and
continuing until the peak is reached or
until 3 sets of results are negative.
Biochemical biomarkers are useful for
both diagnosis and prognostication

Laboratory Diagnosis of
Myocardial Infarction

ALANINE AMINO
TRANSFERASE (ALT)
It is also called as serum
glutamate-pyruvate transaminase
(SGPT).
Normal serum level of ALT is 5-30
U/L or (0.1- 0.68 mmol/(hour L))

 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.

 Ritis coefficient (AST/ALT) in

normal conditions is
1.33 0,42.

LACTATE DEHYDROGENASE
(LDH) (LD)
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.

 This enzyme exists in body

tissues as a tetramer. Two
monomers, H and M, can
combine in various proportions
with the result that five
isoenymes of LD are known.
So five combinations of H and
M chains are possible; H4,
H3M, H2M2, M3H and M4

 The iso-enzymes are usually separated

by cellulose acetate electrophoresis at
pH 8.6.
Lactate dehydrogenase isoenzymes (as
percentage of total):
LDH1
14-26 %
LDH2
29-39 %
LDH3
20-26 %
LDH4
8-16%
LDH5
6-16 %

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.

Creatine kinase (CK)

Normal serum value for CK is 15-100 U/L for
males and 10-80 U/L for females.
CK is a dimer; each subunit has a
molecular weight of 40,000. The subunits
are called B for brain and M for muscle.
Three isoenzymes, BB, MM and MB, occur.
Normally CK2 (MB) iso-enzyme is only 5%
of the total activity.

Causes of an increased plasma creatine kinase activity.

often >10 x ULN
polymyositis
rhabdomyolysis (e.g. trauma, malignant hyperpyrexia)
Duchenne muscular dystrophy
myocardial infarction
5-10 x ULN
following surgery
skeletal muscle trauma
severe exercise
myositis
carriers of Duchenne muscular dystrophy
usually <5 x ULN
physiological (Afro-Caribbeans)
hypothyroidism
drug (statin) treatment

NUCLEOTIDE
PHOSPHATASE (NTP)
It is a marker enzyme for plasma
membranes and is seen as an ectoenzyme (enzyme present on the cell
membrane).
Normal NTP level in serum is 2-10
U/L. It is moderately increased in
hepatitis and highly elevated in biliary
obstruction.

GAMMA GLUTAMYL
TRANSFERASE (GGT)
It is seen in liver, kidney, pancreas,
intestinal cells and prostate gland.
In the body it is used in the synthesis
of glutathione.
Normal serum value of GGT is 645 U/L in male and 5-30 U/L in
female.

 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.

PROSTATE SPECIFIC
ANTIGEN (PSA)
It is produced from the secretory
epithelium of prostal gland. It is
normally secreted into seminal fluid
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)
This enzyme is secreted by the liver
into the blood- stream and low plasma
activities occur in chronic hepatic
dysfunction. Low activities occur
physiologically during pregnancy.

 Interest in this enzyme derives largely

from the fact that it hydrolyzes a musclerelaxant drug, widely used in
anaesthesia, called succinylcholine
(scoline). Occasionally, patients are
found in whom the effect of this drug,
which paralyzes respiration, persists for
several hours after it has been
administered (scoline apnoea). Many of
these patients have an abnormal
cholinesterase activity.

CHOLINESTERASE (ChE)
Acetyl cholinesterase or true ChE or Type 1 ChE
can act mainly on acetyl choline.
Normal serum range is 2-12 U/ml
It is present in nerve endings and in RBCs.
Plasma cholinesterase activity also falls in
organophosphate poisoning.
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.

GLUCOSE-6-PHOSPHATE
DEHYDROGENASE
This is an important enzyme in the
hexose monophosphate shunt pathway of
glucose.
Normal value of GPD in RBC is 125250 U/1012 cells.
It is mainly used for production of
NADPH. It has a special role in the RBC
metabolism.

AMYLASE
This splits starch to maltose. It is
activated by calcium, chloride and
fluoride ions.
It is produced by pancreas and
salivary glands
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.
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.
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.

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.

Enolase
It is a glycolytic enzyme. Neuronspecific 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,pheochromocyto
m, medullary carcinoma of thyroid, etc.
Upper limit of NSE is 12 g/ml.