Organomegaly in chronic alcoholics

Comparison of ethyl glucuronide and carbohydrate-deficient transferrin in different body fluids for post-mortem identification of alcohol use

AIMS

Alcohol abuse is a major risk factor for premature death. Confirming the role of alcohol consumption in cause-of-death investigations has, however, remained difficult, due to lack of reliable biomarkers.

METHODS

We compared ethyl glucuronide (EtG) and carbohydrate-deficient transferrin (CDT) assays from serum, urine, cerebrospinal fluid and vitreous humor in a forensic autopsy population with either a positive (n = 38) or negative (n = 22) history of alcohol abuse based on detailed medical and police records and forensic toxicological investigations.

RESULTS

A positive blood alcohol concentration (median 1.15‰, range 0-3.3‰) was found in 26/38 (68%) of the cases with a documented history of alcohol abuse. EtG concentrations (mean ± SD) in urine (339 ± 389 mg/l, P < 0.001), vitreous humor (4.2 ± 4.8 mg/l, P < 0.001), serum (6.9 ± 8.9 mg/l, P < 0.01) and cerebrospinal fluid (1.7 ± 2.7 mg/l, P < 0.01) were significantly higher among the cases with a positive history of alcohol use than those in the alcohol-history negative group, whereas in corresponding comparisons CDT was significantly different only in cerebrospinal fluid (4.3 ± 2.1 vs. 2.3 ± 0.6%, P < 0.05). The highest sensitivities (92%) in detecting ante-mortem alcohol use were obtained for urine and vitreous humor EtG assays.

CONCLUSION

Our data indicate that measurements of EtG in urine or vitreous humor show the highest diagnostic accuracies in post-mortem investigations of excessive alcohol consumption and can be recommended for routine applications.

Analysis of carbohydrate-deficient transferrin (CDT) in vitreous humour as a forensic tool for detection of alcohol misuse

Analysis of carbohydrate-deficient transferrin concentration in vitreous humour (VH-CDT) has recently been demonstrated to be useful for diagnosis of pre-mortal alcohol misuse, but more knowledge considering possible methodological problems is warranted. In a forensic sample we examined the stability of VH-CDT during laboratory handling as well as the possible affection of time-dependent changes of total transferrin concentrations in vitreous humour (VH-Transferrin) in the dead body on VH-CDT as indicator of alcohol misuse. By use of a commercial assay designed for serum analysis (CDTect) it was possible to measure VH-CDT with high precision, and detectable amounts were found in 20 of 21 alcoholics and in two of seven controls. The compound was demonstrated to be stable in vitreous humour during laboratory handling, since the results of the first analysis were well reproducible after 4 months storage of the specimens (rs=0.86, P=0.0002). Transferrin concentrations in vitreous humour (VH-Transferrin) correlated to the estimated time since the individual last time had been alive before the forensic examination (rs=0.57, P<0.005). However, in this small sample the discriminating property of VH-CDT as indicator of alcohol misuse was not decisively affected, whether or not the variables "VH-Transferrin" and "estimated time since the individual last time had been alive" were considered in a multivariate logistic regression analysis (minor change in the beta-coefficient from 0.57 to 0.52, P=0.086). We conclude that CDT is stable in vitreous humour during proper laboratory handling and that detection of VH-CDT is primarily a marker of alcohol misuse before death. However, the results of this study do not exclude that time-dependent changes of VH-Transferrin, possibly affecting VH-CDT, may occur in the dead body. VH-CDT analysis should thus, at present, be restricted to cases with rather short post-mortal time interval.

Persistent alterations of vasopressin and N-terminal proatrial natriuretic peptide plasma levels in long-term abstinent alcoholics

BACKGROUND

During alcohol withdrawal and early abstinence, severe alterations of electrolyte and water homeostasis and their regulating hormones are well recognized. Almost nothing is known about regeneration of these functions with long-term abstinence. This cohort study was designed to monitor determinants of electrolyte and water balance over 280 days of abstinence in alcohol-dependent men compared with healthy controls.

METHODS

Vasopressin (AVP), N-terminal proatrial natriuretic peptide, aldosterone, angiotensin II, and electrolytes, together with major parameters of kidney and liver function, were monitored in 35 male alcoholics aged 44 +/- 8 years. Of these, 21 could be followed up to 280 days of strictly controlled abstinence due to their participation in the Outpatient Long-Term Intensive Therapy for Alcoholics. The control group comprised 20 healthy male volunteers aged 39 +/- 7 years.

RESULTS

Basal AVP levels were found to be suppressed over the whole study period. In contrast, N-terminal proatrial natriuretic peptide remained increased over all 280 days. No persistent alterations were found for aldosterone or angiotensin II. Sodium and potassium in plasma and urine returned to normal within a few weeks. Creatinine clearance, urea nitrogen in plasma and urine, urinary osmolality, hematocrit, and hemoglobin remained low as compared with controls over the entire study.

CONCLUSIONS

Chronic alcohol abuse causes severe and persistent alterations in the hormonal regulatory systems of electrolyte and water balance. The suppressed basal secretion of AVP may reflect a dysregulation in the brain that influences the hypothalamic-pituitary-adrenal axis function, mood, memory, addiction behavior, and craving during alcohol abstinence. These findings may provide a ground for future therapeutic approaches to stable abstinence.

Post mortem markers of chronic alcoholism

We compared the post mortem diagnostic value of gamma-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT), alcoholic liver disease (ALD), blood alcohol concentration (BAC), the presence of multiple bruises and poor hygiene of the feet as markers of chronic alcoholism (heavy continuous drinking) in 32 alcoholics with 32 age-sex matched controls drawn from a forensic autopsy population. Alcoholics and controls were selected on the basis of positive and negative medical history but controls were excluded if BAC exceeded 70 mg%. Femoral venous blood, urine and vitreous humour alcohol concentrations were determined by headspace gas chromatography (GC). BAC was positive in 19 alcoholics (mean 234 mg%, range 2-570 mg%) and six controls (mean 32 mg%, range 2-52 mg%). Serum GGT was measured by a kinetic photometric method, and CDT by both isoelectric focusing/laser densitometry and by a commercial radioimmunoassay kit (CDTect). Features of alcoholic liver disease were graded histologically using two weighted scoring systems. Eleven alcoholics tested positive for GGT, CDTq and ALD, nine were positive for two tests, five for one test and three were negative for all three tests. No controls were positive for all three tests but six were positive for two tests and nine for only one test; 17 were negative for all three tests. Using the normal clinical cut-off values GGT, CDTq and CDTect gave poor specificity which was improved at moderate cost to sensitivity by raising cut off values for each test. Comparison of receiver operating characteristic curves, likelihood ratios and post-test odds showed CDT to be the best individual test, followed by ALD and GGT. Quantitation of CDT by IEF/laser densitometry performed slightly better than MAEC/RIA by CDTect. CDT shows considerable promise as a post mortem marker of chronic alcoholism.