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Tsuneshige A, Tokoro T. Cooperative oxygen binding in beta-semihemoglobins caused by a chemical modification in the alpha1beta1 interface. J Inorg Biochem 2023; 246:112264. [PMID: 37290360 DOI: 10.1016/j.jinorgbio.2023.112264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/25/2023] [Accepted: 05/20/2023] [Indexed: 06/10/2023]
Abstract
A beta-semihemoglobin is an alpha-beta dimer of hemoglobin (Hb) in which the beta-subunit carries heme, while the alpha-subunit is heme-less, in apo form. It is characterised by displaying a high affinity for oxygen, and absence of cooperative binding of oxygen. We have modified chemically the residue beta112Cys (G14), located adjacent to the alpha1beta1 interface, and studied the impact of such a modification on the oligomeric state and oxygenation properties of the derivatives. We also studied the impact of modifying beta93Cys (F9) since its modification was unavoidable. For this, we used N-Ethyl maleimide and iodoacetamide. For the alkylation of beta112Cys (G14) in isolated subunits, we used N-Ethyl maleimide, iodoacetamide, or additionally, 4,4'-Dithiopyridine. Seven native and chemically modified beta-subunit derivatives were prepared and analysed. Only those derivatives treated with iodoacetamide showed oxygenation properties that were indistinguishable from those of native beta-subunits. These derivatives were then converted into their respective semihemoglobin forms, and four additional derivatives were prepared and analysed .in terms of ligation-linked oligomeric state, and oxygenation function, and contrasted against native Hb and unmodified beta-subunits. Strikingly, beta-semiHbs with modifications in beta112Cys showed indications of cooperative oxygen binding in various degrees, which suggested the possibility of assembly of two beta-semiHbs. The derivative modified with 4-Thiopyridine in beta112Cys showed a highly cooperative binding of oxygen (nmax = 1.67). A plausible allosteric scheme that could explain allostery in beta-semiHb system is suggested.
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Affiliation(s)
- Antonio Tsuneshige
- Department of Frontier Bioscience, Faculty of Bioscience and Applied Chemistry, Hosei University, Tokyo 184-8584, Japan; Research Center for Micro-Nano Technology, Hosei University, Tokyo 184-0003, Japan.
| | - Tatsunori Tokoro
- Department of Frontier Bioscience, Faculty of Bioscience and Applied Chemistry, Hosei University, Tokyo 184-8584, Japan
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2
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Cooper CE, Bird M, Sheng X, Choi JW, Silkstone GGA, Simons M, Syrett N, Piano R, Ronda L, Bettati S, Paredi G, Mozzarelli A, Reeder BJ. Stability of Maleimide-PEG and Mono-Sulfone-PEG Conjugation to a Novel Engineered Cysteine in the Human Hemoglobin Alpha Subunit. Front Chem 2021; 9:707797. [PMID: 34381760 PMCID: PMC8350135 DOI: 10.3389/fchem.2021.707797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/07/2021] [Indexed: 12/14/2022] Open
Abstract
In order to use a Hemoglobin Based Oxygen Carrier as an oxygen therapeutic or blood substitute, it is necessary to increase the size of the hemoglobin molecule to prevent rapid renal clearance. A common method uses maleimide PEGylation of sulfhydryls created by the reaction of 2-iminothiolane at surface lysines. However, this creates highly heterogenous mixtures of molecules. We recently engineered a hemoglobin with a single novel, reactive cysteine residue on the surface of the alpha subunit creating a single PEGylation site (βCys93Ala/αAla19Cys). This enabled homogenous PEGylation by maleimide-PEG with >80% efficiency and no discernible effect on protein function. However, maleimide-PEG adducts are subject to deconjugation via retro-Michael reactions and cross-conjugation to endogenous thiol species in vivo. We therefore compared our maleimide-PEG adduct with one created using a mono-sulfone-PEG less susceptible to deconjugation. Mono-sulfone-PEG underwent reaction at αAla19Cys hemoglobin with > 80% efficiency, although some side reactions were observed at higher PEG:hemoglobin ratios; the adduct bound oxygen with similar affinity and cooperativity as wild type hemoglobin. When directly compared to maleimide-PEG, the mono-sulfone-PEG adduct was significantly more stable when incubated at 37°C for seven days in the presence of 1 mM reduced glutathione. Hemoglobin treated with mono-sulfone-PEG retained > 90% of its conjugation, whereas for maleimide-PEG < 70% of the maleimide-PEG conjugate remained intact. Although maleimide-PEGylation is certainly stable enough for acute therapeutic use as an oxygen therapeutic, for pharmaceuticals intended for longer vascular retention (weeks-months), reagents such as mono-sulfone-PEG may be more appropriate.
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Affiliation(s)
- Chris E Cooper
- School of Life Sciences, University of Essex, Colchester, United Kingdom
| | | | | | | | - Gary G A Silkstone
- School of Life Sciences, University of Essex, Colchester, United Kingdom
| | - Michelle Simons
- School of Life Sciences, University of Essex, Colchester, United Kingdom
| | - Natalie Syrett
- School of Life Sciences, University of Essex, Colchester, United Kingdom
| | - Riccardo Piano
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Ronda
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Institute of Biophysics, National Research Council, Pisa, Italy
| | - Stefano Bettati
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Institute of Biophysics, National Research Council, Pisa, Italy
| | | | - Andrea Mozzarelli
- Institute of Biophysics, National Research Council, Pisa, Italy.,Department of Food and Drug, University of Parma, Parma, Italy
| | - Brandon J Reeder
- School of Life Sciences, University of Essex, Colchester, United Kingdom
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3
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Crystal structure of the ferric homotetrameric β 4 human hemoglobin. Biophys Chem 2018; 240:9-14. [DOI: 10.1016/j.bpc.2018.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/21/2022]
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4
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Proteomic Analysis of Thiol Modifications and Assessment of Structural Changes in Hemoglobin Induced by the Aniline Metabolites N-Phenylhydroxylamine and Nitrosobenzene. Sci Rep 2017; 7:14794. [PMID: 29093547 PMCID: PMC5665987 DOI: 10.1038/s41598-017-14653-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/13/2017] [Indexed: 11/19/2022] Open
Abstract
MS-based proteomic analysis was combined with in silico quantum mechanical calculations to improve understanding of protein adduction by N-phenylhydroxylamine (PhNHOH) and nitrosobenzene (NOB), metabolic products of aniline. In vitro adduction of model peptides containing nucleophilic sidechains (Cys, His, and Lys) and selected proteins (bovine and human hemoglobin and β-lactoglobulin-A) were characterized. Peptide studies identified the Cys thiolate as the most reactive nucleophile for these metabolites, a result consistent with in silico calculations of reactivity parameters. For PhNHOH, sulfinamides were identified as the primary adduction products, which were stable following tryptic digestion. Conversely, reactions with NOB yielded an additional oxidized adduct, the sulfonamide. In vitro exposure of human whole blood to PhNHOH and NOB demonstrated that only sulfinamides were formed. In addition to previously reported adduction of β93Cys of human Hb, two novel sites of adduction were found; α104Cys and β112Cys. We also report CD and UV-Vis spectroscopy studies of adducted human Hb that revealed loss of α-helical content and deoxygenation. The results provide additional understanding of the covalent interaction of aromatic amine metabolites with protein nucleophiles.
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Kan HI, Chen IY, Zulfajri M, Wang CC. Subunit disassembly pathway of human hemoglobin revealing the site-specific role of its cysteine residues. J Phys Chem B 2013; 117:9831-9. [PMID: 23902424 DOI: 10.1021/jp402292b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cysteine residues play a unique role in human hemoglobin (Hb) by affecting its cooperative oxygen binding behavior and the stability of its tetrameric structure. However, how these cysteine residues fulfill their biophysical functions from the molecular level is yet unclear. Here we study the subunit disassembly pathway of human hemoglobin using the sulfhydryl reagent, p-hydroxymercuribenzoate (PMB) and investigate the functional roles of cysteine residues in human hemoglobin. We show evidence from the matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry that all three types of cysteine residues, including the surface-exposed βCys93 and the shielded αCys104 and βCys112 are reactive to PMB, resolving an issue long under debate. It is demonstrated that all three types of cysteine residues must be blocked by PMB to accomplish the subunit disassembly, and the PMB-cysteine reactions proceed in a stepwise manner with an order of βCys93, αCys104, and βCys112. The PMB reactions with the three different cysteine residues demonstrate strong site-specificity. The possible influence of PMB-cysteine reactions to the stability of various intersubunit salt bridges has been discussed based on the crystallographic structure of hemoglobin, providing insights in understanding the hemoglobin subunit disassembly pathway and the site-specific functional role of each cysteine residue in hemoglobin.
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Affiliation(s)
- Heng-I Kan
- Department of Chemistry, National Sun Yat-sen University, Kaohsiung, Taiwan, R.O.C. 80424
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6
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Abstract
The role of electrostatics in protein-protein interactions and binding is reviewed in this paper. A brief outline of the computational modeling, in the framework of continuum electrostatics, is presented and the basic electrostatic effects occurring upon the formation of the complex are discussed. The effect of the salt concentration and pH of the water phase on protein-protein binding free energy is demonstrated which indicates that the increase of the salt concentration tends to weaken the binding, an observation that is attributed to the optimization of the charge-charge interactions across the interface. It is pointed out that the pH-optimum (pH of optimal binding affinity) varies among the protein-protein complexes, and perhaps is a result of their adaptation to particular subcellular compartments. The similarities and differences between hetero- and homo-complexes are outlined and discussed with respect to the binding mode and charge complementarity.
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Affiliation(s)
- Zhe Zhang
- Computational Biophysics and Bioinformatics, Department of Physics, Clemson University, Clemson,SC 29634, USA
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Arisaka F, Nagai Y, Nagai M. Dimer–tetramer association equilibria of human adult hemoglobin and its mutants as observed by analytical ultracentrifugation. Methods 2011; 54:175-80. [DOI: 10.1016/j.ymeth.2011.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/10/2011] [Accepted: 01/13/2011] [Indexed: 10/18/2022] Open
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Vasseur-Godbillon C, Hamdane D, Marden MC, Baudin-Creuza V. High-yield expression in Escherichia coli of soluble human α-hemoglobin complexed with its molecular chaperone. Protein Eng Des Sel 2006; 19:91-7. [PMID: 16390839 DOI: 10.1093/protein/gzj006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The alpha-subunits of human hemoglobin (Hb) have been more difficult to express than beta-chains owing to the high instability of alpha-chains. Here, we describe the production in Escherichia coli of a soluble recombinant alpha-Hb with human alpha-hemoglobin-stabilizing protein (AHSP), its molecular chaperone. To succeed in this expression, we have constructed a vector pGEX-alpha-AHSP which contains two cassettes arranged in tandem in the same orientation permitting to express alpha-hemoglobin and human AHSP. While the GST-alpha-Hb alone was expressed in E.coli as insoluble protein, even after adding lysate containing recombinant AHSP, the expression vector pGEX-alpha-AHSP permits the co-expression of soluble GST-alpha-Hb and GST-AHSP. The alpha-Hb, produced at a high yield of 12 to 20 mg per liter of culture, was then purified as a complex with its chaperone. Biochemical and biophysical properties of recombinant AHSP/recombinant alpha-Hb complex were similar to those of recombinant AHSP/native alpha-Hb complex as assessed by UV/visible and CO or O(2) binding properties. This co-expression technique can be use to study the interaction between a molecular chaperone and its target protein and, more generally, this system would be particularly interesting for the study of partner proteins when one or both proteins are individually unstable.
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Yamaguchi T, Adachi K. Hemoglobin equilibrium analysis by the multiangle laser light-scattering method. Biochem Biophys Res Commun 2002; 290:1382-7. [PMID: 11820774 DOI: 10.1006/bbrc.2002.6362] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Dimer-tetramer and monomer-dimer-tetramer equilibria of tetrameric hemoglobins and their single chains in the CO form, respectively, were evaluated using the microbatch multiangle light-scattering (MALS) analysis system. The molecular weights of human Hb A and Hb F in the CO form were dependent on concentration. The dissociation constants to dimers of Hb A and Hb F were 2.58 x 10(-6) and 0.66 x 10(-6), respectively. Equilibration of single globin chains, including alpha, beta, and gamma chains, was also evaluated by the same method. The dissociation constants of alpha-chain dimers to monomers, of beta-chain tetramers to monomers, and of gamma-chain tetramers to dimers were 14 x 10(-6), 25 x 10(-17), and 6.86 x 10(-6) M, respectively. These results indicate that the MALS analysis system can not only determine molecular weight but also characterize protein-protein interactions of multi-subunit proteins.
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Affiliation(s)
- Takamasa Yamaguchi
- Division of Hematology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Adachi K, Yang Y, Joshi AA, Vasudevan G, Morris A, McDonald MJ. Consequence of beta 16 and beta 112 replacements on the kinetics of hemoglobin assembly. Biochem Biophys Res Commun 2001; 289:75-9. [PMID: 11708779 DOI: 10.1006/bbrc.2001.5962] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The rates of alpha/beta monomer combination of four beta(A) variants (beta 112C --> S, beta 112C --> D, beta 112C --> T, and beta 112C --> V) in the presence and absence of beta 16G --> D (beta(J)) were measured in an attempt to assess the consequences of amino acid substitution at both a surface (beta 16) and an alpha(1)beta(1) interface (beta 112) residue on oxyhemoglobin assembly. Rates of alpha/beta monomer combination determined spectrally in 0.1 M Tris-HCl, 0.1 M NaCl, 1 mM EDTA, pH 7.4, at 21.5 degrees C differed by over 40-fold (22 +/- 2.0 to 0.49 +/- 0.1 x 10(5) M(-1) s(-1)), and were in the order: HbA beta 112S = HbJ beta 16D, beta 112S > HbA beta 112D = HbJ beta 16D, beta 112D > HbA > Hb J > HbA beta 112T = HbJ beta 16D, beta 112T > HbJ beta 16D, beta 112V > HbA beta 112V. This extensive kinetic investigation of single/double amino acid-substituted recombinant hemoglobin molecules, in conjunction with molecular modeling studies, has allowed examination of an array of unique alpha/beta subunit interactions and assembly processes.
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Affiliation(s)
- K Adachi
- Children's Hospital of Philadelphia, Division of Hematology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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11
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Gattoni M, Piro MC, Boffi A, Brinigar WS, Fronticelli C, Chiancone E. The Heme–Globin and Dimerization Equilibria of Recombinant Human Hemoglobins Carrying Site-Specific β Chains Mutations. Arch Biochem Biophys 2001; 386:172-8. [PMID: 11368339 DOI: 10.1006/abbi.2000.2185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The heme-globin and dimer-tetramer equilibria of ferric recombinant human hemoglobins with site-specific beta chain mutations at the heme pocket or at either the a1beta1 or the alpha1beta2 interfaces have been determined. The heme pocket mutation V67T leads to a marked stabilization of the beta chain heme and does not affect the dimer-tetramer association constant, K2,4. In the C112 mutants, the intrinsic rate of beta chain heme loss with respect to recombinant HbA (HbA-wt) is significantly increased only in C112G with some heme released also from the alpha chains. Gel filtration experiments indicate that the K2,4 value is essentially unaltered in C112G and C112L, but is increased in C112V and decreased in C112N. Substitution of cysteine 93 with A or M leads to a slight decrease of the rate of beta chain heme release, whereas the obvserved K2,4 value is similar to that obtained for HbA-wt. Modifications in oxygen affinity were observed in all the mutant hemoglobins with the exception of V67T, C93A, and C112G. The data indicate that there is no correlation between tetramer stability, beta chain heme affinity, and hemoglobin functionality and therefore point to a separate regulation of these properties.
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Affiliation(s)
- M Gattoni
- CNR Center of Molecular Biology, Department of Biochemical Sciences, University La Sapienza, Rome, Italy
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Adachi K, Yamaguchi T, Yang Y, Konitzer PT, Pang J, Reddy KS, Ivanova M, Ferrone F, Surrey S. Expression of functional soluble human alpha-globin chains of hemoglobin in bacteria. Protein Expr Purif 2000; 20:37-44. [PMID: 11035948 DOI: 10.1006/prep.2000.1277] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Individual, soluble human alpha-globin chains were expressed in bacteria with exogenous heme and methionine aminopeptidase. The yields of soluble alpha chains in bacteria were comparable to those of recombinant non-alpha chains expressed under the same conditions. Molecular mass and gel-filtration properties of purified recombinant alpha chains were the same as those of authentic human alpha chains. Biochemical and biophysical properties of isolated alpha chains were identical to those of native human alpha chains as assessed by UV/vis, circular dichroism (CD), and nuclear magnetic resonance (NMR) spectroscopy which contrasts with previous results of refolded precipitated alpha chains made in the presence of heme in vitro (M. T. Sanna et al., J. Biol. Chem. 272, 3478-3486, 1997). Mixtures of purified, soluble recombinant alpha-globin and native beta-globin chains formed heterotetramers in vitro, and oxygen- and CO-binding properties as well as the heme environment of the assembled tetramers were experimentally indistinguishable from those of native human Hb A. UV/vis, CD, and NMR spectra of assembled Hb A were also the same as those of human Hb A. These results indicate that individual expressed alpha chains are stable in bacteria and fold properly in vivo and that they then can assemble with free beta chains to form hemoglobin heterotetramers in vivo as well as in vitro.
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Affiliation(s)
- K Adachi
- Division of Hematology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Adachi K, Zhao Y, Yamaguchi T, Surrey S. Assembly of gamma- with alpha-globin chains to form human fetal hemoglobin in vitro and in vivo. J Biol Chem 2000; 275:12424-9. [PMID: 10777526 DOI: 10.1074/jbc.c000137200] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Soluble gamma-globin chains were expressed in bacteria and purified to assess the mechanism of gamma- and alpha-chain assembly to form Hb F. Formation of Hb F in vitro following incubation of equimolar mixtures of gamma and alpha chains was about 4 x 10(5)-fold slower than assembly of alpha and beta chains to form Hb A in vitro. Results of assembly for gamma(116Ile-->His) and gamma(112Thr-->Asp) chains with alpha chains were similar to that of beta chains, whereas assembly of gamma(112Thr-->Cys) and alpha chains was similar to wild type gamma chains, indicating that amino acid differences at alpha1beta1 and alpha1gamma1 interaction sites between gamma116 Ile and beta116 His are responsible for the different assembly rates in vitro in the formation of Hb F and Hb A. Homoassembly in vitro of individual gamma chains as assessed by size-exclusion chromatography shows that gamma and gamma(112Thr-->Cys) chains form stable dimers like alphabeta and alphagamma that do not dissociate readily into monomers like beta chains. In contrast, gamma(116Ile-->His) chains form monomers and dimers upon dilution. These results are consistent with the slower assembly rate in vitro of gamma and gamma(112Thr-->Cys) with alpha chains, whereas the faster rate of assembly of gamma(116Ile-->His) and gamma(112Thr-->Asp) chains with alpha chains, like beta chains, may be caused by dissociation to monomers. These results suggest that dissociation of gamma(2) dimers to monomers limits formation of Hb F in vitro. However, yields of soluble Hb F expressed in bacteria were similar to Hb A, and no unassembled alpha and gamma chains were detected. These results indicate that gamma chains assemble in vivo with alpha chains prior to forming stable gamma(2) dimers, possibly binding to alpha chains as partially folded nascent gamma-globin chains prior to release from polyribosomes.
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Affiliation(s)
- K Adachi
- The Children's Hospital of Philadelphia, Division of Hematology and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Yamaguchi T, Yang Y, McDonald MJ, Adachi K. Surface and interface beta-chain residues synergistically affect hemoglobin assembly. Biochem Biophys Res Commun 2000; 270:683-7. [PMID: 10772884 DOI: 10.1006/bbrc.2000.2504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Homo- and heterotetramer formations of beta112 variants (beta(112Cys-->Asp), beta(112Cys-->Ser), beta(112Cys-->Thr), and beta(112Cys-->Val)) of hemoglobin were characterized in the presence and absence of beta(16Gly-->Asp) in vitro. In all cases an alteration in overall surface charge (beta(16Gly-->Asp)) decreased the beta(4) homotetramer stability (association constants as determined by gel-permeation chromatography) albeit to differing extents. In contrast, competition experiments of hemoglobin subunits showed that heterotetramer formation was promoted by this substitution. Order of increase in tetramer formation by the additional negative surface charge in the beta112 variants was as follows: Hb betaG16D, C112D > Hb betaG16D, C112S > Hb betaG16D > Hb G16D, C112T > Hb betaG16D, C112V. Thus, the overall surface charge of the beta chain and its contribution to electrostatic interaction in these instances appear to act in synergy with alpha(1)beta(1) interface residues to affect the assembly of hemoglobin molecules.
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Affiliation(s)
- T Yamaguchi
- The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, 19104, USA
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