Persistent protoporphyrinemia in hereditary porphobilinogen synthase (delta-aminolevulinic acid dehydrase) deficiency under low lead exposure. A new molecular basis for the pathogenesis of lead intoxication

Urinary 5-aminolevulinic acid in lead-exposed children

Lead intoxication can interfere with haem synthesis and alter the concentration of haem precursors, such as the neurotoxin 5-aminolevulinic acid, in plasma and urine. The relationship between blood lead concentration (PbB), a biomarker of lead exposure, and 5-aminolevulinic acid concentration in urine (ALAU), a biomarker of the early biological effect of lead, was examined in lead-exposed children. ALAU was assayed by chemical derivatization and high performance liquid chromatography with fluorescence detection. The study subjects were 79 children with moderate to high lead exposure recruited from a lead-poisoning prevention clinic. Their urine had been previously analysed for creatinine (CR) concentration and the benzene metabolite trans,trans- muconic acid, and their blood had been analysed for lead. We found that ALAU was not correlated with PbB (Spearman r=0.088, p=0.44), but the ratio ALAU/CR was correlated with PbB (Spearman r=0.22, p=0.054). Creatinine and ALAU concentrations were higher in urine samples collected in the afternoon than those collected in the morning, a finding that is consistent with known diurnal variation. However the ratio ALAU/CR was not different in morning and afternoon urines, supporting the use of creatinine adjustment of ALAU analysis of spot urine samples. In view of the neurotoxic properties of ALA, future validation studies of biomarkers of lead exposure and effect in children should include ALAU or ALAU/CR as potential markers of lead effect.

Plasma 5-aminolevulinic acid concentration and lead exposure in children

The relationship between concentration of 5-aminolevulinic acid in plasma (ALAP) and other biomarkers of lead exposure and effect was investigated in lead-exposed children. We measured ALAP by chemical derivatization and high-performance liquid chromatography with fluorescence detection. The study population consisted of 103 children: 78 from a referral clinic for children with lead poisoning and 25 from a general pediatric clinic. Blood lead concentration (PbB), age, and ALAP were higher in lead clinic subjects than in general clinic subjects. ALAP was significantly correlated with PbB (Spearman r=0.38, P=0.0007) and free erythrocyte protoporphyrin concentration (r=0.41, P=0.0002) in lead clinic subjects. PbB was a significant predictor of ALAP (P=0.0001) by multiple linear regression in all subjects. The average PbB in the 3- to 12-month period prior to blood collection correlated with ALAP to the same degree that current PbB correlated with ALAP. Possible associations between ALAP and adverse health outcomes, particularly neurobehavioral effects, should be investigated in children to assess the predictive value of ALAP for these endpoints.

Studies of hybrid hematopoietic growth factor receptors

To gain further insight into the mechanisms by which both granulocyte-macrophage-colony stimulating factor (GM-CSF) and erythropoietin receptors function, we have utilized a GM-CSF erythropoietin hybrid receptor with GM-CSF as the external domain and erythropoietin as the intracellular domain. Results show that the beta common GM-CSF receptor both enhances the affinity binding of GM-CSF to the receptor and plays an important role in signaling through the receptor. A truncated form of the beta common receptor actually acts as a dominant negative regulatory factor.

Porphyric neuropathy and hereditary delta-aminolevulinic acid dehydratase deficiency in an adult

A man without a history of porphyric attacks developed a subacute motor neuropathy at the age of 63. At the same time the first signs of a myeloproliferative disorder were found. He had a homozygous deficiency of erythrocyte delta-aminolevulinic acid dehydratase (ALA-D) with autosomal recessive inheritance. Treatment with parenteral glucose and with hematin had a beneficial influence on the plasma ALA levels. The finding of a motor neuropathy with increased plasma levels of ALA but not of porphobilinogen (PBG) supports the potential role of ALA in the pathogenesis of porphyric neuropathy.

delta-Aminolevulinic acid dehydratase isozymes and lead toxicity

ALAD is a zinc metalloenzyme whose inhibition by lead is the first and most sensitive indicator of lead exposure and whose decreased activity has been implicated in the pathogenesis of lead poisoning. This heme biosynthetic enzyme is encoded by a gene located at chromosome 9q34, which has two codominant alleles, ALAD1 and ALAD2. The occurrence of two frequent alleles for ALAD stimulated an investigation into the possible pharmacogenetic role of the enzyme polymorphism in lead poisoning. In a New York City population at high risk for lead exposure, individuals heterozygous or homozygous for the less common allele, ALAD2, had blood lead levels greater than or equal to 30 micrograms/dl more frequently than expected. These findings suggest a potential genetic susceptibility to lead poisoning in individuals with the ALAD 1-2 and 2-2 phenotypes.

In inherited porphyrias, lead intoxication is a toxogenetic disorder

1. delta-Aminolevulinic acid dehydratase (ALA-D), blood lead and several enzymes and metabolites of the heme biosynthetic pathway were measured in a number of symptomatic porphyric patients, 22 with acute intermittent porphyria, three with hereditary hepatic coproporphyria, 10 with hereditary porphyria cutanea tarda, two with erythropoietic protoporphyria and two with congenital erythropoietic porphyria and in 84 lead intoxicated persons. 2. In the 39 individuals suffering from the inherited porphyrias and in 32 lead poisoned patients with a 30-50% reduced deaminase, blood lead content was not sufficiently increased (average 28 micrograms%) to account for the greatly decreased activity of ALA-D (average 36% of controls). 3. After a relatively trifling lead exposure they developed the signs of acute lead intoxication. 4. A second group of lead intoxicated patients showing low ALA-D activity and corresponding high concentration of lead in blood, exhibited no other physiologic deviation in the enzymes and metabolites of porphyrin biosynthesis. 5. Individuals with inherited porphyrias are ultrasensitive to low level lead exposure and that lead would also act as a triggering factor. In these patients, lead intoxication can be considered a toxogenetic disorder. 6. An inversely linear correlation between ALA-D activity and blood lead content was obtained for both groups of lead intoxicated patients, however, a different constant (k) for each was obtained, which we have taken as a measure of lead toxogeneticity: k = 10 +/- 1 for lead intoxicated individuals with otherwise normal heme metabolism and k = 5 +/- 0.5 for lead intoxicated symptomatic porphyric patients. 7. Determination of erythrocytic ALA-D, besides blood lead, will be a valuable indicator for preventive medical care for these patients, when they are expected to be exposed to lead either environmentally or in their professional life.

delta-Aminolevulinic acid dehydrase (porphobilinogen synthase) in two families with inherited enzyme deficiency

The inheritance of a deficient delta-aminolevulinic acid dehydrase (ALA-D; synonym: porphobilinogen synthase; EC 4.2.1.24) was studied in blood samples of two families over three generations. The propositus in each family was a young male acute hepatic porphyria patient with an almost complete ALA-D deficiency in the homozygous state (ALA-D activity less than 2% of controls). Heterozygotes are clinically non-affected (mean ALA-D 36% of controls). The mode of transmission could be traced by enzyme activity and electrophoretic polymorphism studies. Heterozygotes are detected by the demonstration of enzyme activity in the gel. The notation D was used for the gene expressing the defective enzyme. The "phenotype" D-1 was observed in six, the "phenotype" D-2 in three of all heterozygotes studied. These results are compatible with a single normal allele in heterozygotes responsible for enzyme activity. Quantitative assays and the segregation pattern in both families suggest a 3-allele-system for the inheritance of ALA-D deficiency.

Association of amino levulinate dehydratase levels and ferrochelatase inhibition in childhood lead exposure

The basis for the clinical variation in response to lead exposure in children is not well understood. We studied selected children from a large lead screening program in whom elevation of red cell protoporphyrin concentration (a measure of inhibition of the enzyme ferrochelatase) was markedly above or below average for a given blood lead level. We then measured the activity of the enzyme amino levulinate dehydratase in 306 of these children, and found that ALA-d activity was lower in children with higher protoporphyrin elevation, independent of the effects of lead. This observation, coupled with reports in the literature of families with ALA-d deficiencies and elevated red cell protoporphyrin values, makes likely a genetic basis for some of the variation in susceptibility to lead. The mechanism by which the two effects are associated remains unknown.

Delta aminolevulinic acid dehydratase amounts in lead-exposed subjects: description of a method correlated with the immunoturbidimetric assay

The measurement of delta-aminolevulinic acid dehydratase (ALA.D) activity is a good index of lead exposure. Recently, we proposed an immunoturbidimetric assay which allows determination of the amount of the enzyme. This last test is particularly interesting for workers presenting high blood-lead levels. We then studied the effects of different agents (dithiothreitol, heat and zinc ions) in restoring the activity of lead-inhibited ALA.D. The individual or combined effects of these three agents showed an additive restoration of activity. The combination of zinc ions with heat and/or DTT gave the best activations, which correlated perfectly with ALA.D amounts. Consequently, the catalytic assay using zinc ions and DTT may be used in routine testing as an indirect measurement of ALA.D amount.

Hereditary hepatic porphyria with delta aminolevulinate dehydrase deficiency: immunologic characterization of the non-catalytic enzyme

Immunoreactive delta-aminolevulinate dehydrase (ALA-D) was measured in lysates from two porphyric patients with ALA-D deficiency (enzyme activities were below 2% of the normal level). By using two different immunologic methods, we found a cross-reactive immunologic material (CRIM+) which corresponded to 20% and 33% of the control level. Therefore the molecular basis that accounts for the deficiency of ALA-D in these patients is a structurally modified enzyme. The methods used to determine the molecular weight (by Western blotting) and the isoelectric point (by chromatofocusing) of the mutants did not show any difference by comparison with the normal enzyme.

Lead poisoning as a toxogenetic disease

In two non-related patients suffering from acute lead intoxication a persistent decrease in red cell delta-aminolevulinic acid dehydratase (synonym: porphobilinogen synthase) activity of 30%-60% of controls was noted after treatment and normalisation of lead levels and heme precursors in urine and blood. An inherited enzyme deficiency was suggested and confirmed by a subnormal activity in the mothers of both patients. These four persons are considered as heterozygotes with an increased sensitivity to lead exposure.

Lead poisoning in inherited delta-aminolevulinic acid dehydratase deficiency

delta-Aminolevulinic acid dehydratase (ALA-D), respectively porphobilinogen synthase, EC 4.2.1.24) activity can be lowered by toxic, metabolic and hereditary factors. A 30-year-old painter was suffering from lead poisoning with an acute abdominal-neurologic syndrome and anemia. Blood lead was measured at 414 micrograms/l. Urinary ALA and coproporphyrin excretion as well as erythrocyte protoporphyrin had increased extremely, whereas ALA-D activity in erythrocytes had decreased extremely to 8% of controls. Excretion parameters, protoporphyrin, hemoglobin and lead returned to normal after treatment, but four years later ALA-D activity still remained diminished (30% of controls). An inherited enzyme deficiency was assumed and found in the mother, analogous to the subnormal ALA-D activity in heterozygotes of four other families. The inherited enzyme deficiency sensitized the patient to lead exposure and intoxication, which is a toxogenetic disease in this case.

Porphobilinogen-synthase (delta-aminolevulinic acid dehydratase) deficiency in bone marrow cells of two patients with porphobilinogen-synthase defect acute porphyria

Two male patients aged 23 and 25 years with intermittent acute, frequently repeated porphyria syndromes presented an almost total deficiency of porphobilinogen-synthase [(PBG-S); synonym: delta-aminolevulinic acid dehydratase] in peripheral erythrocytes. PBG-S was investigated in bone marrow cells obtained by sternal puncture. A minimal enzyme activity of less than 3% of controls was established. Specific activity and protoporphyrin concentration decreased considerably during the course of erythropoiesis. Both patients are homozygous gene carriers; their parents (father and mother) as well as most of their brothers and sisters are heterozygotes with a PBG-S deficiency of approximately 50% of controls. All people with PBG-S deficiency are especially endangered by alcohol intake and lead exposure, because alcohol and lead toxically inhibit PBG-S.

Acute lead poisoning in inherited porphobilinogen synthase (delta-aminolevulinic acid dehydrase) deficiency

The second enzyme of the porphyrin and heme synthesis pathway, porphobilinogen synthase (EC 4.2.1.24), can be lowered due to a hereditary defect or toxic damage. Lead is the most common cause for a toxically lowered activity. We report on a 48-year-old patient with an acute abdominal syndrome, anemia and a grave toxic disorder of porphyrin metabolism which was diagnosed as acute lead intoxication. Although the hematologic findings and porphyrins in the blood, as well as porphyrin precursors and porphyrin excretion in the urine, returned to normal within five months after exacerbation of the acute symptoms the activity of porphobilinogen synthase showed only 50% physiologic activity of healthy subjects six years after the acute syndrome with complete normalization of prophyrin metabolites and lead levels in blood and urine. The influence of alcohol was excluded. Enzyme activation by zinc and reactivation by dithiothreitol lies within the normal range and thus contradicts an increased body burden of lead. In connection with findings of a familiar porphobilinogen synthase defect we are most likely dealing with a hereditarily determined enzyme deficiency in this patient which sensitizes him to a lead intoxication.