Serum gamma-glutamyltransferase and alkaline phosphatase in rheumatoid arthritis

Inflammatory arthritis increases the susceptibility to acute immune-mediated hepatitis in mice through enhancing leptin expression in T cells

Liver function abnormalities are common in patients with inflammatory arthritis. However, the precise mechanism is still unclear. In this study, inflammatory arthritis was established in mice by subcutaneous injection of complete Freund's adjuvant, and the intravenous injection of concanavalin A (Con A) was employed to induce acute immune-mediated hepatitis in mice. The result showed that the arthritis mice were more susceptible to ConA-induced hepatitis than the control mice, as evidenced by increased hepatic necrosis, elevated serum alanine aminotransferase activity, and raised inflammatory cytokines. Besides, the in vitro assay demonstrated that the T cells from arthritis mice were more sensitive to the Con A stimulation than those from control mice. Moreover, we determined that the level of leptin, a kind of adipokine, was significantly increased in the serum and hepatic T cells of arthritis mice. Interestingly, the data indicated that the enhanced expression of leptin in hepatic T cells is responsible for the hypersensitivity of arthritis mice-derived T cells to Con A challenge. Collectively, our findings demonstrate an unexpected role of leptin in the connection between inflammatory arthritis and acute immune-mediated hepatitis, thus providing new insight into the clinical therapy of arthritis-related liver dysfunction.

Disease Activity Score in 28 Joints Using GGT Permits a Dual Evaluation of Joint Activity and Cardiovascular Risk

OBJECTIVE

To identify the factors potentially associated with serum gamma-glutamyltransferase (GGT) elevation in patients with rheumatoid arthritis (RA).

METHODS

This is a cross-sectional monocentric study including RA patients over a 12-month period. Data on liver function, RA disease activity, and hepatotoxic and cardiovascular (CV) risk factors were systematically collected. To provide a simple tool to evaluate both joint disease activity and CV risk factors, we constructed the Disease Activity Score in 28 joints (DAS28)-GGT composite index by replacing erythrocyte sedimentation rate (ESR) with GGT.

RESULTS

Among the 129 included patients, 32 (25%) had isolated GGT increase. GGT correlated with age, C-reactive protein (CRP) levels, and body weight and were significantly increased in patients with alcohol intake, type 2 diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome. GGT levels also gradually increased with the number of CV risk factors and correlated with the Framingham CV risk score. The composite index DAS28-GGT remained a reliable marker of RA disease activity and accurately detected patients with CV risk factors. Conversely to the DAS28 and the DAS28-CRP, the DAS28-GGT steadily increased according to the number of CV risk factors and had an increased diagnostic value compared to the DAS28 and DAS28-CRP for the presence of at least 2 CV risk factors and a Framingham CV risk score greater than 10%.

CONCLUSION

GGT may be considered as a marker of systemic inflammation and CV risk in patients with RA. Based on these findings, we herein propose an original index, the DAS28-GGT, which is able to evaluate both joint disease activity and CV risk. This index will deserve further validation in prospective cohorts.

Ratiometric Imaging of γ-Glutamyl Transpeptidase Unperturbed by pH, Polarity, and Viscosity Changes: A Benzocoumarin-Based Two-Photon Fluorescent Probe

γ-Glutamyltransferase (GGT) is involved in maintaining the intracellular glutathione levels and, at its elevated levels, is associated with various diseases including cancer and myocardial infarction. To study this enzyme in biological systems, fluorescent probes have received significant attention recently. As fluorescence signal is sensitive to environmental fluctuations; however, it is challenging to address the signal fluctuation issue. Disclosed is the benzocoumarin-based probe that enables ratiometric imaging of GGT activity levels in cells as well as in tissues, essentially unperturbed by medium pH, viscosity, and polarity changes. Validity of the probe is demonstrated by determining the GGT activity level in HeLa cells directly through ratiometric imaging. Furthermore, the probe and its enzymatic product are two-photon absorbing, extending its applicability to tissue: an 8.5-fold higher level of GGT in cancerous tissue over the normal tissue is determined, and the GGT activity levels between different mouse organ tissues are quantitatively compared with the highest level in the kidney. The probe with practicality holds great promise for studying GGT-associated biological processes directly through ratiometric imaging by two-photon microscopy.

Therapeutic effect of Parmotrema tinctorum against complete Freund's adjuvant-induced arthritis in rats and identification of novel Isophthalic ester derivative

The present study reveals the anti-arthritic potential of traditionally used Parmotrema tinctorum (Pt) on experimental rats and purification of novel Isophthalic ester derivative. Arthritis was induced in rats using Freund's complete adjuvant (CFA) and subsequently treated with Pt extract (100 & 200 mg/kg.b.w). Assessment of antiarthritic activity was carried out using paw volume, arthritic score, haematological, biochemical, tissue antioxidant, histopathology and radiological analyses of ankle joints. The results revealed that continuous administration of Pt reduces the complication associated with arthritis by inhibiting the edema formation and arthritic score significantly (P < 0.05). The altered changes in biochemical parameters were brought back with an improvement in free radical scavenging ability after treatment with Pt significantly. Further purification of Pt using conventional column chromatography led to the isolation of four compounds and the structure of these isolated compounds were elucidated on the basis of spectral data's FT-IR, ¹H NMR, ¹³C NMR, DEPT-NMR spectroscopy, COSY & HSQC-NMR spectroscopy and LC-MS. The spectral data revealed that the three compounds were found to be Methyl-γ-Orsellinate, Atranorin, and usnic acid (CI-III) along with a novel secondary metabolite, (C-IV)4-Hydroxy-5-methyl-isophthalicacid3-(3,4-dihydroxy-5-methyl-phenyl)ester (C₁₆H₁₄O₇,318.1amu). The present study reveals that Parmotrema tinctorum reduces complications associated with arthritis and the compounds were isolated for the first time.

Plasma Levels of Cell-Free Apoptotic DNA Ladders and Gamma-Glutamyltranspeptidase (GGT) in Diabetic Children

The plasma levels of apoptotic DNA ladders (i.e., apoptosemia) and γ-glutamyltranspeptidase (GGT) in diabetic outpatients and rats were investigated. Apoptotic DNA ladders were detected in plasma from 26.8% of type 1 (T1) and 18.5% of type 2 (T2) diabetic children 1–20 years of age, 25.7% of hospitalized children and 35.7% of adult RA outpatients, but in only 3.5% of adult pre-op patients. Plasma from 7.7% of young streptozotocin-induced diabetic but not control rats contained apoptotic DNA ladders. Apoptosemia was detected more often in male T1 (31%) and T2 (30.8%) diabetic outpatients than in female T1 (20.8%) and T2 (15.4%) diabetic outpatients. GGT in apoptosemic plasma was significantly higher than in nonapoptosemic plasma from T1 ( P = 0.001) but not T2 diabetic children. The highest amounts of apoptotic DNA were detected most often in diabetic children ≥14 years of age. In vitro study results suggest that cell-free apoptotic DNA ladders appear prior to an increase in GGT activity in serum from human blood incubated at 37°C. The results suggest that 24.7% of plasma samples from diabetic children contained apoptotic DNA ladders, the incidence and amounts of apoptotic DNA ladders were higher in the older diabetic children, and GGT was elevated in apoptosemic T1 diabetic children ( P = 0.01). The results indicate that “silent” apoptosemia occurs in T1 and T2 diabetic children and suggest elevated GGT in diabetic children could be due to release from apoptotic cells.

A study of the effects of saliva stimulation by nizatidine on dry mouth symptoms of primary biliary cirrhosis

AIM

To elucidate the effect of saliva stimulation by nizatidine on oral symptoms of primary biliary cirrhosis (PBC) by administering it to PBC cases.

METHODS

From among 73 cases that had been definitively diagnosed as PBC at our hospital by February 2010, we selected 27 cases of PBC, 4 males and 23 females, as subjects. We obtained subjects' consent after giving them a full explanation of the administration of nizatidine. Nizatidine 150 mg was administered internally twice daily, after morning and evening meals. To observe changes in the quantity of saliva secreted, chewing gum tests were carried out four times: before the initial dose, and after 6 mo, 12 mo and 24 mo of administration. For subjective dry mouth symptoms, a visual analog scale (VAS) method was used to assess their feelings of oral dryness and eating difficulty, five times: before the initial dose, and after 1, 6, 12 and 24 mo of administration in 8 cases. The nutritional condition and the hepatic functional reserve were compared between before and after the nizatidine treatment.

RESULTS

The result of a chewing gum test on the subjects before the administration of nizatidine showed that 50% produced less than 10 mL of saliva, i.e., the standard under which cases are considered to have hyposalivation. The results of these tests showed that the quantity of saliva secreted was 10.5 ± 6.8 mL before administration of nizatidine, 10.9 ± 6.0 mL after 6 mo, 10.6 ± 4.9 mL after 12 mo, and 11.8 ± 6.8 mL after 24 mo administration. Thus, there was a slowly increasing trend in the quantity of saliva in the whole group. The percentage of subjects with saliva production above 10 mL was 45.8% after 6 mo administration of nizatidine, that is, only a slight change from before its administration, but it was 64.3% after 12 mo, that is, a significant increase. The saliva secretion by subject patients was examined before the beginning of administration of nizatidine, 12 mo later, and 24 mo later, and Fisher's combined probability test was used to examine the results for increases in saliva secretion. The analysis yielded P values of 0.51 and 0.53 for 12 mo later and 24 mo later, respectively. Thus, although there was no statistically significant increase, it was confirmed that saliva secretion tended to increase. A VAS method was employed to study the intensities of subjective symptoms of oral dryness and eating difficulty. Almost every case indicated some improvement of subjective oral dryness on the VAS early in the administration, i.e., one month after. We also studied the effects of the administration of nizatidine on nutritional condition, hepatic functional reserve, and long-term prognosis of PBC. No significant improvements in cholinesterase (ChE) level, albumin (Alb) level, or Child-Pugh score were found during the period of observation from the beginning to the end of administration of nizatidine, nor in comparison with the non-administration group. A comparative analysis between before administration and 24 mo later yielded P values of 0.41 for Alb, 0.56 for ChE, and 0.59 for the Child-Pugh scores.

CONCLUSION

It was confirmed that administering nizatidine to cases of PBC with dry mouth increased the secretion of saliva and improved the symptoms.

Primary biliary cirrhosis in a rheumatoid arthritis patient treated with rituximab, a case-based review

Primary biliary cirrhosis (PBC) is an autoimmune disease in which intrahepatic bile ducts are targeted by an immune-mediated injury. This disease tends to progress to fibrosis and cirrhosis with hepatic failure. The authors report a case of a 50-year-old rheumatoid arthritis (RA) patient, with erosions and seropositive for rheumatoid factor and anti-citrullinated peptide antibodies, with 18 years disease duration refractory to prednisolone and several disease-modifying antirheumatic drugs, either conventional or biological (adalimumab and etanercept). In April 2007, she started therapy with rituximab (RTX) with good European League Against Rheumatism response achieved 9 months later. In June 2008, she was admitted with intrahepatic cholestasis, steatorrhea, and spontaneous fractures of various ribs. After excluding cholelitiasis, as well as infectious and neoplastic diseases a liver biopsy was performed that was compatible with the diagnosis of PBC. The antinuclear antibodies (1/160) were positive as well as the antimitochondrial antibodies (1/640). Other antibodies were negative such as anti-SSA and anti-SSB. Afterwards, the patient started ursodesoxycholic acid 15 mg kg(-1) day(-1) with progressive improvement of cholestatic markers. A labial salivary gland biopsy was performed and showed findings compatible with the concomitant diagnosis of Sjögren's syndrome. Based on this clinical report, a detailed review of the clinical aspects of PBC is presented as well as its association with other immune-mediated inflammatory diseases, particularly, with RA.

Gastrointestinal and hepatic manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA), characterized by inflammation of the synovium and surrounding structures, has a prevalence of 0.5-1%. Rheumatoid vasculitis (RV) is an inflammatory condition of the small- and medium-sized vessels that affects up to 5% of patients with RA with intestinal involvement in 10-38% of these cases. Clinically apparent RV of the gastrointestinal (GI) tract, while rare, is often catastrophic, resulting in ischemic ulcers and bowel infarction. Vasculitis of the colon may present as pancolitis clinically similar to ulcerative colitis. Rectal biopsies that include submucosal vessels are positive for vasculitis in up to 40% of cases. Abnormal esophageal motility in RA may result in heartburn and dysphagia. Chronic atrophic gastritis may be associated with hypergastrinemia and hypo- or achlorhydria, promoting small bowel bacterial overgrowth. RA is the most common cause of secondary amyloidosis with GI symptoms in 22% of affected patients. Although amyloid is usually found in the liver, it is rarely evident clinically. Felty's syndrome occurs in less than 1% of patients with RA and is characterized by neutropenia and splenomegaly. The liver may be involved with portal fibrosis or nodular regenerative hyperplasia. Liver histology is abnormal in 92% of RA patients at autopsy, although the changes are usually mild without associated hepatomegaly. Drug-induced liver disease may occur with aspirin, sulfasalazine, and methotrexate. Significant liver damage is rare if the drug is discontinued or the patient is properly monitored. RA can affect both the GI tract and the liver; changes are usually mild except with RV.

Bone alkaline phosphatase in rheumatic diseases

A double monoclonal immunoradiometric assay specific for bone alkaline phosphatase (BAP) was used to determine whether the raised total alkaline phosphatase (TAP) often found in patients with active rheumatoid arthritis (RA) and ankylosing spondylitis (AS) is derived from bone or liver. Fifty-eight patients with RA were compared to 14 with AS and 14 with non-inflammatory rheumatic diseases (NI). None had clinical liver disease and only one had a slightly elevated aspartate transaminase activity. Elevated BAP concentrations were found in seven patients (5 RA, 1 AS, 1 NI), only two of whom also had abnormal TAP. Abnormal TAP activities were found in only three patients (all RA). BAP did not correlate with disease activity in RA or AS. In contrast, TAP correlated with disease activity (assessed by plasma viscosity) in RA (P < 0.002) and gamma-glutamyl transferase (GGT) also correlated with plasma viscosity in RA (P < 0.01). Both TAP and BAP were significantly correlated with GGT in RA (P < 0.001 and P < 0.02, respectively). These findings are discussed, together with possible reasons for the conflicting nature of some of the observations.

Alkaline phosphatase isoenzyme activities in rheumatoid arthritis: hepatobiliary enzyme dissociation and relation to disease activity

OBJECTIVES

Hyperphosphatasaemia has been observed occasionally in patients with rheumatoid arthritis (RA), and it has been suggested that the serum alkaline phosphatase (ALP) level is related to the activity of the disease. Therefore, the relationship between serum ALP and RA was studied.

METHODS

The serum activities of hepatobiliary enzymes (ALP isoenzymes, gamma-glutamyltranspeptidase (GTP), leucine aminopeptidase (LAP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT)), immunoglobulins, RA haemagglutinin test (RAHA), C reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were observed in 288 patients with rheumatoid arthritis.

RESULTS

Serum biliary ALP (ALP1) activity was detected in 31.6% of the patients. In patients positive for ALP1 the respective values of total ALP (ALPt) (p < 0.001), liver ALP (ALP2) (p < 0.001), bone ALP (ALP3) (p < 0.05), gamma-GTP (p < 0.001), LAP (p < 0.001), immunoglobulins IgG (p < 0.01), IgA (p < 0.01), and IgM (p < 0.01), RAHA (p < 0.001), CRP (p < 0.001), ESR (p < 0.001), and articular index (p < 0.001) were significantly higher than in patients who did not have ALP1. Significant Spearman's rank correlations (rs) were demonstrated between serum ALP2 level and the respective values of ALPt (rs = 0.9128, p < 0.001), ALP1 (rs = 0.4443, p < 0.001), ALP3 (rs = 0.5898, p < 0.001), gamma-GTP (rs = 0.2903, p < 0.001), LAP (rs = 0.3093, p < 0.001), IgA (rs = 0.2299, p < 0.01), IgM (rs = 0.1773, p < 0.05), RAHA (rs = 0.2420, p < 0.01), CRP (rs = 0.3532, p < 0.001), ESR (rs = 0.4006, p < 0.001). the articular index (rs = 0.4006, p < 0.001). However, no significant difference or correlation was noted for either AST or ALT. In many patients who showed abnormal hyperphosphatasaemia, hepatobiliary enzyme dissociation was observed: levels of ALPt (in 12.8%), ALP1 (in 31.6%), ALP2 (18.8%), gamma-GTP (in 4.3%), and LAP (in 19.3%) were abnormally high, but both AST and ALT were within normal limits.

CONCLUSION

These findings are considered to be characteristic of RA, and suggest the existence of latent or subclinical hepatobiliary involvement and an association between the expansion of hepatobiliary involvement and the mechanism of disease activation. Thus measurement of the serum levels of ALP and its isoenzymes in RA is considered to be important.

Electrophoretic separation of alkaline phosphatase isoenzymes in synovial fluid and serum from patients with rheumatoid arthritis

The alkaline phosphatase enzyme in both serum and synovial fluid from 28 cases of rheumatoid arthritis and from the serum of 30 controls was measured. The enzyme was further studied by separating its isoenzymes to clarify their origin in both synovial fluid and serum of 10 patients with elevated level of the enzyme in their sera. The level of the enzyme in serum was elevated in 37% of patients confirming previous reports on that point. The most abundant isoenzyme in the synovial fluid (66.9%) was found to be bone in origin while in serum the most abundant isoenzyme was found to be hepatic (60.5%). This may be responsible for increased bone turn-over in rheumatoid joints whether in formation or resorption.

Alkaline phosphatase isoenzymes in rheumatic diseases

Serum alkaline phosphatase isoenzymes were determined quantitatively by electrophoresis on cellulose acetate in 168 patients with rheumatic diseases subgrouped for disease activity. Median values of total alkaline phosphatase and bone isoenzyme activity, as well as frequency of patients showing pathological values, increased gradually and significantly corresponding to disease activity in rheumatoid arthritis and ankylosing spondylitis, from 0% in inactive to 90% in very active forms. Bone isoenzyme was much more sensitive than total alkaline phosphatase in moderate disease activity and was also correlated to the number of involved extravertebral joints and pain in ankylosing spondylitis. No correlation was found with stage or duration of disease, age, sex, and erythrocyte sedimentation rate. Additional to bone isoenzyme, liver isoenzymes were elevated in some patients, but with only a weak correlation with disease activity. The intestinal isoenzymes were always normal. We conclude that quantitative determination of serum alkaline phosphatase bone isoenzyme activity is a major indicator for the assessment of disease activity and therapeutic monitoring in rheumatoid arthritis and ankylosing spondylitis.

Idiopathic retroperitoneal fibrosis--is serum alkaline phosphatase a marker of disease activity?

Two patients are presented in whom extensive investigations were carried out to determine the cause of a raised serum alkaline phosphatase. Idiopathic retroperitoneal fibrosis was diagnosed in both cases and the serum alkaline phosphatase returned to normal following treatment with corticosteroids and coincident with resolution of the patients' symptoms.

Hepatotoxicity associated with low-dose, long-term methotrexate treatment of rheumatoid arthritis

Liver biopsies were performed in 17 patients with therapy-refractory rheumatoid arthritis who were treated successfully with 5-15 mg/week methotrexate (mtx). The average duration of exposure to mtx therapy for each patient was 2.8 years (range 1.5-5 years). Total cumulative mtx doses ranged between 633 and 1,655 mg (mean 1,060 mg). The biopsies revealed 16 cases of normal histology, of which 3 showed nuclear variability in the hepatocytes; 4 with mild fatty infiltration, 2 with mild fatty infiltration and portal round cell infiltration. Portal fibrosis was found in one patient who had psoriasis in addition to clinical RA.

The Tromsø Heart Study: distribution of, and determinants for, gamma-glutamyltransferase in a free-living population

Gamma-glutamyltransferase (GGT) was measured in 1579 men, aged 20-54 years, and 1654 women, aged 20-49 years, screened for coronary risk factors. The distribution was right-skewed with medians 15 and 10 U/l for men and women, respectively. Less than 3.8% of the men and 0.8% of the women had GGT greater than or equal to 50 U/l. The low level of GGT matched well with the low mortality of cirrhosis and the modest use of alcohol in Norway. Multiple regression analysis for each sex showed a strong positive association with body mass index, use of alcohol and, unexpectedly, a negative association with coffee consumption, whereas serum triglycerides and the time since the last meal showed a weaker positive association. In women, use of oral contraceptives was positively associated with GGT.

Alcohol consumption in arthritic patients: clinical and laboratory studies

In popular belief patients with chronic arthritis take alcohol for its analgesic effect. To test this we studied by validated questionnaire the past and present alcohol consumption of 103 patients with primary osteoarthritis of the hip (OA), 95 patients with rheumatoid arthritis (RA), and 90 orthopaedic non-arthritic controls. OA men were most likely and RA men least likely to have been heavy drinkers at any time of their lives. Mean red corpuscular volume (MCV), gamma-glutamyltransferase (GGT), and serum uric acid (SUA) levels did not correlate with reported alcohol consumption. Two of 93 OA femoral heads examined had avascular change; both were from heavy drinkers. The abstemiousness of RA men compared with their OA counterparts was due to a striking increase in joint pain after drinking alcohol (p = 0.004), fear of adverse drug reactions with alcohol, and a widespread belief not expressed by OA men that 'alcohol and arthritis do not mix'.

Circadian variation in biochemical assessments used to monitor rheumatoid arthritis

Circadian variation has been demonstrated in several clinical parameters used to assess disease activity in rheumatoid arthritis, but circadian variation in modern laboratory assessments has not been studied in depth. We therefore made 2-hourly measurements of plasma viscosity, C-reactive protein, total serum sulphydryl, and serum histidine on samples obtained over a 24-hour period from 6 patients with classical or definite rheumatoid arthritis. Hourly control samples were also taken from 6 normal volunteers, 3 of whom starved from 2200 h the previous night and 3 of whom ate normally. There was no significant variation in any of these laboratory measurements between 0900 and 1800 h either in patients or controls. These findings enable us to eliminate circadian variation as a source of error when using these laboratory tests in clinical trials of slow-acting anti-rheumatoid drugs.

Increased serum alkaline phosphatase activity in ankylosing spondylitis

Raised serum alkaline phosphatase (AP) levels were found in 13 of 76 patients (17%) with ankylosing spondylitis (AS), and 11 of these 13 underwent further investigation to determine the origin of the increased enzyme activity. Three had levels within the normal reference range on re-estimation, and, of the remaining 8, AP isoenzyme studies indicated an increased liver fraction in 6. Serum gamma-glutamyl transpeptidase (GGT) was raised in only 3 patients. Increased AP activity did not appear to be directly related to disease activity or to drug therapy. These findings confirm the occurrence of increased serum AP activity in AS but challenge a previously reported suggestion that bone is the source of the increased enzyme.