The deoxyuridine suppression test: a review of its clinical and research applications

Megaloblastic anaemia in vegetarian Asians

Of 27 Asians with a megaloblastic bone marrow, 22 (81%) had nutritional deficiency of vitamin B12 (NMA), while five (19%) had true pernicious anaemia (PA). All the patients were Hindu vegetarians except for a single Muslim who had PA. Dietary intakes of calories, protein, iron, vitamin B12 and folate were below the recommended level in both groups. The PA group had lower levels of serum B12 and higher levels of serum folate than the NMA group. Despite low levels of red cell folate (RCF) in the NMA patients, the abnormality in deoxyuridine (dU) suppression was always corrected by vitamin B12. The dU suppressed value showed a significant inverse relationship to the RCF level. Nutritional deficiency of vitamin B12 is the most common cause of megaloblastic anaemia in Hindu vegetarians but the incidence of true PA is higher than previously thought and may approximate to that of the white population.

Effects of phenytoin sodium on doubling time, deoxyuridine suppression, 3H-methotrexate uptake and 57Co-cyanocobalamin uptake in HL60 cells

Phenytoin sodium (5-50 micrograms/ml) caused a dose-dependent prolongation of the doubling time of the human promyelocytic leukaemia cell line, HL60. This effect was unassociated with any alteration in cell viability. HL60 cells which were pre-incubated with 15 micrograms/ml phenytoin sodium for 1 or 48 h and then incubated with the same concentration of the drug plus either 3H-methotrexate (3H-MTX) or 57Co-cyanocobalamin for 90 min, showed an altered accumulation of both radioactive compounds when compared with control cells. Control cells were not pre-incubated with the drug and were subsequently studied in the absence of the drug. Pre-incubation with the drug for 1 h resulted in a 34% increase, and pre-incubation for 48 h in a 19% reduction in the accumulation of 3H-MTX. Pre-incubation for 1 or 48 h caused a 29% reduction in the accumulation of 57Co-cyanocobalamin. Cells cultured in the presence of 15 micrograms/ml phenytoin sodium for 48 h also gave a slightly increased deoxyuridine-suppressed value; this abnormality was partially corrected by the addition of 50 micrograms/ml folinic acid to the test system but was unaffected by the addition of 1 microgram/ml cyanocobalamin. The data indicate that the effects of phenytoin sodium on the proliferation of HL60 cells may have been slightly mediated via a reduced uptake of folate and possibly also of vitamin B12. They also suggest that one of the mechanisms underlying some of the undesirable effects of long-term therapy with phenytoin may be a drug-related impairment of both folate and vitamin B12 uptake by certain cells, including haemopoietic and neural cells.

Diagnosis of megaloblastic anaemias

There are a large number of causes of megaloblastic anaemia. The most frequent are disorders resulting in vitamin B(12) or folate deficiency. The diagnostic process often consists first of establishing the presence of B(12) or folate deficiency and then of determining the cause of deficiency. The blood count, blood film, serum B(12) assay, and red cell and serum folate assays are the primary investigations. Other useful investigations include serum/plasma methylmalonic acid (MMA), plasma total homocysteine (tHCYS) and serum holo-transcobalamin II assays. All currently used tests have limitations regarding specificity or sensitivity or both and the metabolite assays are not widely available. An understanding of these limitations is essential in formulating any diagnostic strategy. The wide use of serum B(12) and metabolite assays has resulted in the increasingly early diagnosis of B(12) deficiency, often in patients without B(12)-related symptoms (subclinical deficiency). Food cobalamin malabsorption is the most frequent cause of a low serum B(12). At least 25% of low serum B(12) levels are not associated with elevated metabolite levels and may not indicate B(12) deficiency. Some of these are caused by partial deficiency of transcobalamine I.

On the pathogenesis of erythroleukaemia (H0493)

In erythroleukaemia megaloblastic changes can co-exist with leukaemic changes in the marrow. The cause of the disease must therefore be such as can cause megaloblastosis and at the same time be mutagenic. Failure of the thymidylate synthelase reaction, the commonest cause of megaloblastic anaemia, can be eliminated in erythroleukaemia because (a) the dU suppression test is normal in the disease and (b) failure of the thymidylate synthelase reaction is not mutagenic. The deamination of both cytosine and adenine is mutagenic but the deamination of cytosine alone is apparent and the nucleotide of cytosine is the prime mutagenic nucleotide in leukaemia and cancer. Megaloblastic changes can result from an inadequate supply of any one of the four nucleotides that enter into the composition of DNA and it is suggested that an inadequate supply of the mutagenic nucleotide of cytosine, possibly through impaired synthesis, could cause both the megaloblastic and leukaemic changes in erythroleukaemia.

Cobalamin

Cobalamin (vitamin B12) is an essential nutrient derived exclusively from bacterial sources. It is an essential cofactor for three known enzymatic reactions. Untreated deficiency, caused by either the autoimmune disease pernicious anemia or nutritional lack, results in a macrocytic anemia and/or subacute combined degeneration of the spinal cord and is eventually fatal. Cobalamin in serum is bound to two proteins, transcobalamin and haptocorrin. The former is responsible for the essential delivery of cobalamin to most tissues. Inadequate tissue availability of cobalamin results in increased concentration of methylmalonic acid and homocyst(e)ine due to inhibition of methylmalonyl-CoA mutase and methionine synthase, respectively. Strict vegetarians have long been known to be at risk of cobalamin deficiency, which develops insidiously over many years. It is now clear that a significant number of the elderly and HIV-positive individuals are also at increased risk of deficiency. Any individual with reduced ability to split cobalamin from food-protein may also become deficient even though intrinsic factor is present. Diagnosis of cobalamin deficiency has frequently relied on total serum cobalamin and the Schilling test. Newer approaches such as analysis of methylmalonic acid, homocyst(e)ine, holotranscobalamin, anti-intrinsic factor antibodies, and serum gastrin may provide more cost-effective testing, as well as identify those with a covert deficiency.

Deoxyuridine suppression test on isolated rat bone marrow cells and the in vitro effect of bidisomide

The deoxyuridine suppression test was performed on isolated rat bone marrow cells in order to study the effect of bidisomide, a new Class I antiarrhythmic agent, on folate-dependent DNA synthesis. Methotrexate and 5-fluorouracil, two known inhibitors of DNA synthesis, were included in the study to validate the test system. Methotrexate and 5-fluorouracil, at a concentration of 5.5 mum, decreased thymidine incorporation into DNA by way of the de novo pathway (thymidylate synthase activity). The salvage pathway of DNA synthesis (thymidine kinase activity), however, was not affected by these anticancer drugs. Bidisomide up to 1 mm did not affect the folate-dependent thymidylate synthase activity, nor the thymidine kinase activity of isolated rat bone marrow cells.

Cell kinetics of the rat corneal epithelium

In the rat corneal epithelium the mitotic rate (MR) is almost equal throughout the epithelium in the morning (Haaskjold et al. 1988). The labelling index (LI) shows a marked reduction in the central cornea, which could suggest a lack of uptake of tritiated thymidine via the salvage pathway (Haaskjold et al. 1989). In the present study we have used [3H]deoxycytidine, and [3H]thymidine after prior treatment with a methotrexate regimen to elucidate this discrepancy. Deoxycytidine is incorporated into DNA independent of thymidine kinase, while methotrexate, which depletes the cells of reduced folates, makes the cells completely dependent on the salvage pathway. With both techniques the same pattern of labelling was observed, confirming that in the morning the ratio between the MR and the LI differs throughout the cornea. Based on previous observations, an analysis of the MR/LI ratio during 24 h was performed, showing that these parameters were strongly correlated. This suggests that there may be different circadian variations in the cell proliferation parameters throughout the corneal epithelium. The methotrexate regimen may be a useful tool to investigate the salvage pathway.

In vitro DNA synthesis by megaloblastic bone marrow: effect of folates and cobalamins on thymidine incorporation and de novo thymidylate synthesis

The de novo pathway of thymidylate synthesis (i.e., methylation of dUMP to dTMP) is directly folate dependent and indirectly vitamin B12 (cobalamins) dependent. In deficiency of these vitamins, this pathway is impaired, and exogenous deoxyuridine (dU) fails to suppress adequately in vitro incorporation of [3H]thymidine (3H-TdR) into DNA via the salvage pathway (i.e., abnormal dU suppression). This abnormality is corrected by the addition of folate compounds (analogues) and/or vitamin B12 depending on the nature of the underlying deficiency. We studied the effects of addition of PteGlu, 5-methyl THF (5-CH3-FH4), 5-formyl-THF (5-CHO-FH4), and hydroxy-cobalamin (OH-cbl) on 3H-TdR incorporation into DNA and thymidine kinase activity (salvage pathway), and on [3H]deoxyuridine (3H-dU) incorporation and dU suppression values (de novo pathway) in cultures of normal and megaloblastic bone marrows. The results showed that 3H-TdR incorporation into DNA and the salvage enzyme, thymidine kinase, activity were greater and 3H-dU incorporation into DNA less in megaloblastic cells as compared with normal cells. The addition of folates significantly reduced 3H-TdR incorporation and thymidine kinase activity and enhanced 3H-dU incorporation in folate and vitamin B12-deficient cells except that 5-CH3-FH4 had no effect on vitamin B12-deficient cells. None of these additives had any significant effect on normal cells. This study also showed that the addition of the deficient vitamin(s) to the "control tubes" in the dU suppression test is inappropriate, as these vitamins may at least partially correct the defect in cellular DNA synthesis caused by the deficiencies of these vitamins and may mask these deficiencies in the results of the in vitro correction of the dU suppression abnormalities in mild cases of megaloblastic anemia.

Deoxyuridine suppression: biochemical basis and diagnostic applications

The deoxyuridine (dU) suppression test evolved out of investigations into the biochemical basis of the megaloblastic changes seen in vitamin B12 and folate deficiency. Although the abnormality in dU suppression which occurs in vitamin B12- or folate-deficient states is assumed to reflect impaired methylation of deoxyuridylate, there is still no direct demonstration that this is so. Furthermore, there is evidence that reactions other than the methylation of deoxyuridylate are involved in the phenomenon of dU suppression. Nevertheless, in clinical practice abnormal dU suppression serves as a sensitive index of the presence of megaloblastosis due to vitamin B12 or folate deficiency. dU suppression is also abnormal in a number of conditions other than vitamin B12 or folate deficiency, but its overall specificity in detecting tissue dysfunction due to these two deficiency states is considerably higher than that of the serum vitamin B12 or red cell folate levels. Consequently, the test enables us simply and rapidly to define those patients in whom macrocytosis is unrelated to a deficiency of vitamin B12 or folate. For these reasons, the dU suppression test has been adopted by several laboratories across the world for investigating patients with (a) possible vitamin B12 or folate deficiency, (b) macrocytosis, and (c) megaloblastic erythropoiesis. Since the dU suppression test is abnormal in transcobalamin II deficiency and in some congenital disorders of vitamin B12 and folate metabolism, it is very useful in the investigation of obscure anaemias in infancy and childhood. In addition, it has contributed to our understanding of the mechanisms underlying the myelotoxicity of certain drugs, and particularly of nitrous oxide.

Enhanced therapeutic effect of methotrexate in experimental rat leukemia after inactivation of cobalamin (vitamin B12) by nitrous oxide

Exposure to nitrous oxide interferes selectively with the coenzyme function of vitamin B12 and causes inactivation of methionine synthetase, with subsequent impairment of folate metabolism and reduction of cellular proliferation. In a rat leukemia model (BNML) we investigated the combined administration of nitrous oxide, inactivating vitamin B12, and methotrexate (MTX), a folate antagonist inhibiting the enzyme dihydrofolate reductase. Through different mechanisms, both agents decrease the availability of tetrahydrofolate, and subsequently of other reduced folates, with increased impairment of folate-dependent synthesis of thymidylate. Effects on leukemic growth and on hematological values in rats demonstrated enhancement of the therapeutic effect of MTX by exposure to nitrous oxide. With several treatment schedules, the results of combined treatment were seen to be better than additive when compared with the effects of single agents. In particular, pretreatment of leukemic rats with nitrous oxide for 3 days before administration of MTX appeared effective. With higher doses of MTX, concomitant exposure to nitrous oxide even resulted in toxic effects. These findings were in accordance with the results of some metabolic studies performed in leukemic rats.(ABSTRACT TRUNCATED AT 250 WORDS)

A method for performing deoxyuridine suppression tests on microtitre plates

A method of performing deoxyuridine suppression tests on bone marrow cells using microtitre plates is described. The geometric mean and 95% reference interval derived from 19 patients with normoblastic erythropoiesis and normal levels of serum B12 and folate were, respectively, 5.1 and 2.0-12.8%. In 70 deoxyuridine suppression tests on 60 patients, the correlation between the results from the conventional tube test and the plate method was good, r = 0.9, P less than 0.001, and replicate tests with both techniques showed equal degrees of precision. The microtitre plate method uses fewer cells and is easier to perform than the tube method: thus each test may be performed in triplicate, and additional investigations carried out on cells obtained from a single marrow aspiration. We conclude that the microtitre plate method of performing a deoxyuridine suppression test is useful for both diagnostic and research purposes.

Importance of low serum vitamin B12 and red cell folate concentrations in elderly hospital inpatients

To determine the functional importance of the low B12 and red cell folate concentrations repeatedly observed in the elderly 200 consecutive patients admitted to a geriatric unit were studied. Forty six of the patients had low serum concentrations of B12 (15), red cell folate (26), or both (five). Serum B12 and red cell folate concentrations correlated with mean cell volume, and serum B12 correlated with the neutrophil lobe count. Bone marrow deoxyuridine suppression was abnormal in 35% of the patients with low vitamin concentrations, but 55% of those with abnormal deoxyuridine suppression had morphologically normal bone marrow, and 73% had a normal mean cell volume. In patients with low vitamin values the deoxyuridine suppressed value correlated with the haemoglobin concentration and neutrophil lobe count. Thus synthesis of thymidylate was impaired by vitamin B12 or folate deficiency in at least 8% of newly admitted elderly patients, many of whom had normal blood counts despite the biochemical disturbance affecting haemopoiesis. A nutritionally depleted diet may have been responsible for many of the low vitamin values.

Malabsorption of protein bound vitamin B12

Patients with subnormal serum vitamin B12 concentrations were tested for absorption of protein bound vitamin B12 and compared with controls. Absorption of the protein bound vitamin appeared to decrease with increasing age in healthy subjects. Differences between the result of this test and the result of the Schilling test in patients who had undergone gastric surgery were confirmed; such differences were also seen in some patients who had iron deficiency anaemia, an excessive alcohol intake, or folate deficiency. Defective absorption was also found in six patients with an adequate dietary intake of vitamin B12, normal Schilling test results, low serum vitamin concentrations, and tissue changes responding to treatment with vitamin B12. Malabsorption of the vitamin from protein bound sources, which is not detected by the Schilling test, may produce vitamin B12 deficiency of clinical importance.

The deoxyuridine suppression test

The deoxyuridine suppression (dU) test, first described in 1964, has gained an important place both in the diagnosis of megaloblastic anemias and in the study of vitamin B12 folate interrelationships in the pathogenesis of megaloblastic anemia. The test measures the integrity of the de novo synthetic pathway of DNA synthesis, in which vitamin B12 and folate play an essential role. The exact mechanism of the test is still largely unknown. However, it is probably the most sensitive and specific functional test for the establishment of vitamin B12 and/or folate deficiency. As such, it is an important diagnostic tool in the investigation of patients suspected of suffering from deficiency of either or both of these vitamins. The test may also have applications towards the study of other factors required for the de novo synthesis of DNA.

The deoxyuridine suppression test in severe anaemia following Plasmodium falciparum malaria

Haematological studies in a group of Gambian children with severe anaemia due to Plasmodium falciparum malaria revealed marked dyserythropoietic changes in erythroblasts and evidence of increased ineffective erythropoiesis. In some cases, the bone marrow also showed a few giant metamyelocytes and ring sideroblasts. The results of deoxyuridine suppression tests indicated that these haematological disturbances were not a consequence of vitamin B12 or folate deficiency within marrow cells.

Regulation of cobalamin and folate metabolism by methionine in human bone marrow cultures

In cobalamin deficiency folate metabolism is disturbed. In the liver this deranged metabolism can be overcome by methionine, however, methionine failed to overcome this abnormality in bone marrow cultures from cobalamin deficient patients. In cobalamin deficient E. coli mutant bacteria, methionine under different conditions could either inhibit or potentiate the growth of the organism. This study was therefore initiated to test the effect of methionine, under different conditions, on bone marrow cultures. The defective DNA synthesis in megaloblastic bone marrow due to cobalamin deficiency could be corrected by the in vitro addition of low 0.27 mumol (40 micrograms) but not high 6.7 mumol (1 mg) amounts of methionine. This was measured by the ability of deoxyuridine to suppress the 3H-thymidine incorporation into DNA. The effect of methionine in facilitating de novo DNA synthesis is probably due to the catalytic action of SAM which activates cobalamin dependent methyltransferase enzyme thus potentiating the effect of cobalamin. In contrast high concentrations of methionine may inhibit this enzyme.

Comparison of flow cytometric analysis and [3H]thymidine incorporation for measurement of the effects of drug toxicity on lymphocyte stimulation

Human mononuclear cells were exposed to three antiviral agents, stimulated with phytohemagglutinin, and assayed for DNA synthesis with [3H]thymidine uptake and flow cytometric analysis. Cytosine-arabinoside demonstrated inhibition of blastogenic reactivity by both [3H]thymidine uptake and flow cytometric analysis, whereas acyclovir showed no significant suppression. In contrast, (E)-5-(2-bromovinyl)-2'-deoxyuridine, a thymidine analog, demonstrated a lack of correlation between the two methods. The competitive inhibition of some compounds with [3H]thymidine incorporation necessitates the use of other methods to measure DNA synthesis.

Folate levels and deoxyuridine suppression tests in protein-energy malnutrition

A group of 39 Nigerian infants and pre-school children with protein-energy malnutrition (PEM) have been studied. Red cell folate levels were within the range observed in 19 age-matched healthy Nigerian children. Serum vitamin B12 levels were either normal or raised. Deoxyuridine (dU) suppression tests were performed on the bone marrow cells of 30 of the patients and were abnormal in 13. It is proposed that the abnormal dU-suppressed values were not caused by vitamin B12 or folate deficiency and were probably a consequence of the protein deficiency. A few megaloblasts and several giant metamyelocytes were found in four of the cases of PEM; the remaining 35 cases had normoblastic erythropoiesis, sometimes with small to moderate numbers of giant metamyelocytes. All four marrow samples containing megaloblasts gave abnormal dU-suppressed values. However, in the marrows showing normoblastic erythropoiesis there was no correlation between the presence or absence of giant metamyelocytes and the dU-suppressed value.

Erythrocyte aging changes evaluated by the deoxyuridine suppression test

Many hematologic studies have shown that the erythrocyte count decreases while the size of the individual cell increases in the aged. This study was performed in order to (1) evaluate changes in the blood erythrocyte level and mean erythrocyte size in the elderly and (2) evaluate use of the deoxyuridine (dU) supression test to determine whether deficiency of vitamin B12 or folate plays any role in age-related changes of hematopoiesis. Selected for study were 102 healthy men whose ages ranged from 20 to 79 years. The erythrocyte count and hemoglobin level decreased significantly, whereas the mean corpuscular volume and mean corpuscular hemoglobin increased after 70 years of age. Fresh bone-marrow cells were obtained from 10 young (20-38 yr) and 10 aged (70-82 yr) men. Wickramasinghe's dU suppression test was modified by application of an automatic cell harvester. The results were normal in both groups. Thus, the route of dU to dTMP in a DNA synthetic pathway appeared intact, and there was no evidence of B12 or folate deficiency in the aged to explain the observed macrocytosis. However, 3H-thymidine uptake by nucleated bone-marrow cells was significantly decreased, and the ratio of 3H-uridine to 3H-thymidine uptake was greater in the old group than in the young group. These results could be explained by altered nucleic acid metabolism (unbalanced cell growth) or by a change in the proportion of the different fractions of nucleated cells.

DNA chain elongation rates in marrow cells from vitamin B12-deficient patients and methotrexate-treated mice

The DNA synthesized by marrow cells from patients with vitamin B12 deficiency and mice previously given methotrexate (MTX), has been investigated. Suspensions of bone marrow cells were pulse-labelled with [methyl-3H]thymidine or deoxy [5-3H]cytidine for 30 s and the radioactivity in the DNA was chased thereafter in the presence of 10 microM non-radioactive nucleoside for periods up to 60 min. The rates of elongation of new daughter strands were then assessed by hydroxyapatite chromatography of alkali-denatured DNA samples. No significant differences were found between the average rates of elongation of daughter strands from control marrow cells on the one hand and the vitamin B12-deficient or the methotrexate-affected cells on the other. This is to be contrasted with the results of previous studies which have shown a retardation in the rates of movement of replication forks in stimulated, cultured lymphocytes obtained from vitamin B12- or folate-deficient patients.