Microvascular circulatory dysregulation driven in part by cystathionine gamma-lyase: A new paradigm for cardiovascular compromise in the preterm newborn

OBJECTIVE

H₂ S may explain the dysregulation of microvascular tone associated with poor outcome following preterm birth. In adult vasculature, H₂ S is predominantly produced by CSE. We hypothesized that vascular CSE activity contributes to microvascular tone regulation during circulatory transition.

METHODS

Preterm (GA62) and full-term (GA69) guinea pig fetuses and neonates were studied. Microvascular blood flow was assessed by laser Doppler flowmetry. Thiosulfate, primary urinary metabolite of H₂ S, was determined by high-performance liquid chromatography. Real-time H₂ S production was assessed using a microrespiration system in fetal and postnatal (10, 24 hours) skin and heart samples. CSE contribution was investigated by inhibition via propargylglycine.

RESULTS

In preterm animals, postnatal H₂ S production capacity in peripheral vasculature increased significantly and was significantly reduced by the inhibition of CSE. Urinary thiosulfate correlated with both microvascular blood flow and capacity of the vasculature to produce H₂ S. H₂ S produced via CSE did not correlate directly with microvascular blood flow.

CONCLUSIONS

In preterm neonates, H₂ S production increases during fetal-to-neonatal transition and CSE contribution to total H₂ S increases postnatally. CSE-dependent mechanisms may therefore underpin the increase in H₂ S production over the first 72 hours of life in preterm human neonates, associated with both central and peripheral cardiovascular instability.

Interactions of the gasotransmitters contribute to microvascular tone (dys)regulation in the preterm neonate

BACKGROUND & AIMS

Hydrogen sulphide (H2S), nitric oxide (NO), and carbon monoxide (CO) are involved in transitional microvascular tone dysregulation in the preterm infant; however there is conflicting evidence on the interaction of these gasotransmitters, and their overall contribution to the microcirculation in newborns is not known. The aim of this study was to measure the levels of all 3 gasotransmitters, characterise their interrelationships and elucidate their combined effects on microvascular blood flow.

METHODS

90 preterm neonates were studied at 24h postnatal age. Microvascular studies were performed by laser Doppler. Arterial COHb levels (a measure of CO) were determined through co-oximetry. NO was measured as nitrate and nitrite in urine. H2S was measured as thiosulphate by liquid chromatography. Relationships between levels of the gasotransmitters and microvascular blood flow were assessed through partial correlation controlling for the influence of gestational age. Structural equation modelling was used to examine the combination of these effects on microvascular blood flow and derive a theoretical model of their interactions.

RESULTS

No relationship was observed between NO and CO (p = 0.18, r = 0.18). A positive relationship between NO and H2S (p = 0.008, r = 0.28) and an inverse relationship between CO and H2S (p = 0.01, r = -0.33) exists. Structural equation modelling was used to examine the combination of these effects on microvascular blood flow. The model with the best fit is presented.

CONCLUSIONS

The relationships between NO and H2S, and CO and H2S may be of importance in the preterm newborn, particularly as NO levels in males are associated with higher H2S levels and higher microvascular blood flow and CO in females appears to convey protection against vascular dysregulation. Here we present a theoretical model of these interactions and their overall effects on microvascular flow in the preterm newborn, upon which future mechanistic studies may be based.

Maternal transfer of methimazole and effects on thyroid hormone availability in embryonic tissues

Methimazole (MMI) is an anti-thyroid drug used in the treatment of chronic hyperthyroidism. There is, however, some debate about its use during pregnancy as MMI is known to cross the mammalian placenta and reach the developing foetus. A similar problem occurs in birds, where MMI is deposited in the egg and taken up by the developing embryo. To investigate whether maternally derived MMI can have detrimental effects on embryonic development, we treated laying hens with MMI (0.03% in drinking water) and measured total and reduced MMI contents in the tissues of hens and embryos at different stages of development. In hens, MMI was selectively increased in the thyroid gland, while its levels in the liver and especially brain remained relatively low. Long-term MMI treatment induced a pronounced goitre with a decrease in thyroxine (T₄) content but an increase in thyroidal 3,5,3'-triiodothyronine (T₃) content. This resulted in normal T₃ levels in tissues except in the brain. In chicken embryos, MMI levels were similar in the liver and brain. They gradually decreased during development but always remained above those in the corresponding maternal tissues. Contrary to the situation in hens, T₄ availability was only moderately affected in embryos. Peripheral T₃ levels were reduced in 14-day-old embryos but normal in 18-day-old embryos, while brain T₃ content was decreased at all embryonic stages tested. We conclude that all embryonic tissues are exposed to relatively high doses of MMI and its oxidised metabolites. The effect of maternal MMI treatment on embryonic thyroid hormone availability is most pronounced for brain T₃ content, which is reduced throughout the embryonic development period.

Spectrophotometric method for the determination of total thiols in human urine

Thiols have been of enduring interest for many years because of their role in biological and pharmacological processes. Monitoring of total thiols content is very important in order to understand their function in living organisms. This paper describes the spectrophotometric method for the determination of total thiols concentration in urine. The method is based on derivatization with 1-benzyl-2-chloropyridinium bromide and ultraviolet detection of S-pyridinium derivatives at 316 nm. The analytical recovery and RSD values for precision within the calibration range were from 95.7 to 102.9% and from 2.1 to 8.4%, respectively. The concentration of total thiols normalized against creatinine for 38 apparently healthy subjects (19 women and 19 men) occurred in the range 17.2-73.7 and 25.7-83.6 mmol/mol creatinine, respectively. There was no difference in the urinary excretion of thiols in men and women, but there was a significant statistical correlation between urine total thiols and age in the studied group.

Effect of cystamine on blood pressure and vascular characteristics in spontaneously hypertensive rats

BACKGROUND

Tissue transglutaminase (t-TG) has been implicated in small artery remodelling. The aim of this study was to determine if cystamine, an inhibitor of t-TG, could reduce blood pressure in spontaneously hypertensive rats (SHR) and if so to what extent this is mediated through small arteries.

METHODS

In vitro inhibition of t-TG, with cystamine, was studied in organ culture and wire myograph setups in small mesenteric arteries obtained from SHR. In vivo treatment with cystamine (80 mg/kg/day) or amlodipine (10 mg/kg/day) was performed with osmotic pumps in adult SHR, and hemodynamic parameters determined with telemetry. Plasma concentrations of cystamine were determined with a liquid chromatography setup. Small arteries were harvested following administration of cystamine, and structural as well as functional characteristics were determined.

RESULTS

SHR small arteries showed inward remodelling following in vitro activation. Administration of cystamine caused attenuation of the inward remodelling induced by activation. In vivo administration of cystamine caused a 9 ± 2 mm Hg reduction in blood pressure, but with no detectable alterations in small artery structure.

CONCLUSION

t-TG is potentially involved in vascular remodelling of SHR small arteries and results support a possible role for t-TG in blood pressure control.

[Homocysteine and glutathione metabolism in steroid-treated relapse of idiopathic nephrotic syndrome]

Changes in metabolism of aminothiols may have an influence on endothelial function or change the red-ox balance. The aim of study was designed to assess changes in plasma aminothiols': proatherogenic (homocysteine-HCY) and antiatherogenic (glutathione-GSH) metabolism in nephrotic syndrome in children.

MATERIAL AND METHODS

The study group included 77 nephrotic children (aged 2-18 years) divided into four groups, i.e. in acute phase of the disease (24), during steroid-induced (24), steroid-free (12) and in long-term remission (17). Twenty five healthy children served as controls. GSH and HCY in plasma were assessed by high-performance liquid chromatography. Fraction of protein-bound and free aminothiols was assessed and albumin saturation was calculated.

RESULTS

GSH and its fractions' concentrations were comparable to healthy subject, however in early relapse free fraction was significantly higher than in late remission. The albumin saturation with GSH was significantly higher in early than in late relapse. Total HCY concentration was decreased in early relapse, elevated after 2 week and comparable to controls after 8 week of treatment. HCY free fraction and albumin saturation were elevated within first 2 weeks. Children in long-term remission showed elevated total concentration of HCY and GSH and their protein bound fractions when compared to controls. Albumin saturation with these aminoacids was higher as well.

CONCLUSION

The study showed aminothiol imbalance in children in first weeks of relapse of nephrotic syndrome.

Prevention of brain disease from severe 5,10-methylenetetrahydrofolate reductase deficiency

Over a four-year period, we collected clinical and biochemical data from five Amish children who were homozygous for missense mutations in 5,10-methylenetetrahydrofolate reductase (MTHFR c.1129C>T). The four oldest patients had irreversible brain damage prior to diagnosis. The youngest child, diagnosed and started on betaine therapy as a newborn, is healthy at her present age of three years. We compared biochemical data among four groups: 16 control subjects, eight heterozygous parents, and five affected children (for the latter group, both before and during treatment with betaine anhydrous). Plasma amino acid concentrations were used to estimate changes in cerebral methionine uptake resulting from betaine therapy. In all affected children, treatment with betaine (534+/-222 mg/kg/day) increased plasma S-adenosylmethionine, improved markers of tissue methyltransferase activity, and resulted in a threefold increase of calculated brain methionine uptake. Betaine therapy did not normalize plasma total homocysteine, nor did it correct cerebral 5-methyltetrahydrofolate deficiency. We conclude that when the 5-methyltetrahydrofolate content of brain tissue is low, dietary betaine sufficient to increase brain methionine uptake may compensate for impaired cerebral methionine recycling. To effectively support the metabolic requirements of rapid brain growth, a large dose of betaine should be started early in life.

Mutations in methylenetetrahydrofolate reductase or cystathionine beta-synthase gene, or a high-methionine diet, increase homocysteine thiolactone levels in humans and mice

Genetic disorders of homocysteine (Hcy) metabolism or a high-methionine diet lead to elevations of plasma Hcy levels. In humans, severe genetic hyperhomocysteinemia results in premature death from vascular complications whereas dietary hyperhomocysteinemia is often used to induce atherosclerosis in animal models. Hcy is mistakenly selected in place of methionine by methionyl-tRNA synthetase during protein biosynthesis, which results in the formation of Hcy-thiolactone and initiates a pathophysiological pathway that has been implicated in human vascular disease. However, whether genetic deficiencies in Hcy metabolism or a high-methionine diet affect Hcy-thiolactone levels in mammals has been unknown. Here we show that plasma Hcy-thiolactone is elevated 59-fold and 72-fold in human patients with hyperhomocysteinemia secondary to mutations in methylenetetrahydrofolate reductase and cystathionine beta-synthase genes, respectively. We also show that mice, like humans, eliminate Hcy-thiolactone by urinary excretion; in contrast to humans, however, mice also eliminate significant amounts of plasma total Hcy (approximately 38%) by urinary excretion. In mice, hyperhomocysteinemia secondary to a high-methionine diet leads to 3.7-fold and 25-fold increases in plasma and urinary Hcy-thiolactone levels, respectively. Thus, we conclude that hyperhomocysteinemia leads to significant increases in the atherogenic metabolite Hcy-thiolactone in humans and mice.

The effects of modulation of γ-glutamyl transpeptidase activity in HepG2 cells on thiol homeostasis and caspase-3-activity

The present studies aimed to elucidate how the modulation of gamma-glutamyl transpeptidase (gammaGT) activity in human hepatoma (HepG2) cell line influences H(2)O(2) production, caspase 3 activity, protein S-thiolation by glutathione (GSH), cysteinyl-glycine (Cys-Gly) and cysteine (Cys), and the level of other redox forms of these thiols. The experiments showed that 1-h stimulation of gammaGT elevated H(2)O(2) production, leading to prooxidant conditions. After 24-h stimulation, H(2)O(2) concentration was at the control level, while Cys-Gly-, Cys- and GSH-dependent S-thiolation was markedly increased, which was accompanied by a drop in caspase-3 activity. The inhibition of gammaGT activity by acivicin led to H(2)O(2) decrease after 1-h incubation which still persisted after 24 h. The inhibition of gammaGT activity in HepG2 cells was also connected with the lowering of S-thiolation with Cys and Cys-Gly and with increasing of caspase-3 activity. The results of our studies indicate that the modulation of gammaGT activity can be used to change cellular redox status, and can affect Cys- and Cys-Gly-dependent S-thiolation and caspase-3 activity. We suggest that the role of high gammaGT activity in HepG2 cells can be connected with production of reactive oxygen species and with S-thiolation with Cys and Cys-Gly that can influence activity of caspase 3.

Disruption of thiol homeostasis in plasma of terminal renal failure patients

BACKGROUND

The aim of the present studies was to investigate the changes in concentrations of different forms of thiols in plasma of terminal renal failure patients before and after hemodialysis.

METHODS

Total concentrations of thiols, their free forms and the level of their mixed disulfides with proteins were determined with HPLC.

RESULTS

In terminal renal failure patients before dialysis, total concentrations of cysteine, homocysteine and cysteinylglycine and their free and protein-bound fractions increased while level of all such forms of glutathione dropped. A single dialysis session caused short-lasting return of concentrations of all forms of thiols to the level equal or close to the control group. The changes observed in non-dialyzed patients were similar to those observed in dialyzed patients before single dialysis procedure.

CONCLUSIONS

The obtained results showed severe disturbance of thiol homeostasis in plasma of terminal renal failure patients. The following changes have to be emphasized: (1) high level of free cysteine (cystine) fraction, (2) strong tendency of homocysteine to form mixed disulfides with proteins, (3) drop of glutathione level. These observations confirm a suggestion that atherogenic action of homocysteine can be a result of S-homocysteinylation and N-homocysteinylation reactions, whereas toxic action of cysteine can result from auto-oxidation reaction.

Peritoneal clearance of homocysteine with icodextrin or standard glucose solution exchange

BACKGROUND

The aim of the study was to assess plasma homocysteine concentration in peritoneal dialysis patients, and to compare the effect of different peritoneal solutions (glucose-based and icodextrin-based) on peritoneal clearance of homocysteine.

METHODS

The study group comprised 10 chronic peritoneal dialysis patients; the control group comprised 15 healthy, age-matched non-obese subjects with normal renal function. Patients with vitamin B(12) or folate deficiency were excluded. In all subjects, plasma homocysteine and dialysis adequacy parameters were assessed at baseline. The clearance study was carried out with 2.27% glucose and 7.5% icodextrin solutions (12-h dwell time).

RESULTS

Mean dialysate concentration of homocysteine was similar for both glucose and icodextrin solutions (8.3 +/- 3.2 and 8.4 +/- 1.9 micromol/L, respectively), but homocysteine clearance was significantly higher for icodextrin than glucose solution (1.82 +/- 0.57 vs 1.39 +/- 0.53 mL/min per 1.73 m(2)P = 0.01). Net ultrafiltration after icodextrin solution was also higher than after glucose solution (599 +/- 136 mL vs 134 +/- 337 mL, P < 0.01). A correlation between total plasma level of homocysteine and its peritoneal clearance was found (r = 0.69; P = 0.03).

CONCLUSION

It appears that peritoneal elimination of homocysteine depends primarily on its plasma concentration. Icodextrin-based solution for peritoneal dialysis seems to be more efficient in homocysteine elimination than a standard glucose-based solution.

The determination of homocysteine-thiolactone in human plasma

The thioester homocysteine-thiolactone, a reactive metabolite of homocysteine, has been implicated in human cardiovascular disease. However, data on the levels of homocysteine-thiolactone in humans are limited, mostly due to a lack of facile and reliable assays. Here we describe a sensitive assay for the determination of plasma homocysteine-thiolactone and demonstrate its utility with a cohort of 60 healthy human subjects. Plasma homocysteine-thiolactone is first separated from macromolecules by ultrafiltration and then selectively extracted with chloroform/methanol. Further purification of plasma homocysteine-thiolactone is achieved by high-performance liquid chromatography on a cation exchange microbore column. The detection and quantification is by monitoring fluorescence after postcolumn derivatization with o-phthaldialdehyde. The limit of detection is 0.36 nM. Using this assay, homocysteine-thiolactone concentrations in plasma from normal healthy human subjects (n=60) were found to vary from zero to 34.8 nM, with an average of 2.82+/-6.13 nM. In 29 of the 60 human plasma samples analyzed, homocysteine-thiolactone levels were below the detection limit. Homocysteine-thiolactone represented from 0 to 0.28%, on average 0.023+/-0.05%, of plasma total homocysteine.

Urinary Excretion of Homocysteine-Thiolactone in Humans

Background: A metabolite of homocysteine (Hcy), the thioester Hcy-thiolactone, has been implicated in coronary heart disease in humans. Because inadvertent reactions of Hcy-thiolactone with proteins can lead to cell and tissue damage, the ability to detoxify or eliminate Hcy-thiolactone is essential for biological integrity. We examined the hypothesis that the human body eliminates Hcy-thiolactone by urinary excretion.

Methods: We used a sensitive HPLC method with postcolumn derivatization and fluorescence detection to examine Hcy-thiolactone concentrations in human urine and plasma.

Results: We discovered a previously unknown pool of Hcy-thiolactone in human urine. Urinary concentrations of Hcy-thiolactone (11–485 nmol/L; n = 19) were ∼100-fold higher than those in plasma (&lt;0.1–22.6 nmol/L; n = 20). Urinary Hcy-thiolactone accounted for 2.5–28.3% of urinary total Hcy, whereas plasma Hcy-thiolactone accounted for &lt;0.002–0.29% of plasma total Hcy. Urinary concentrations of Hcy-thiolactone, but not of total Hcy, were negatively correlated with urinary pH. Clearance of Hcy-thiolactone, relative to creatinine, was 0.21–6.96. In contrast, relative clearance of Hcy was 0.001–0.003.

Conclusions: The analytical methods described here can be used to quantify Hcy-thiolactone in biological fluids. Using these methods we showed that the human body eliminates Hcy-thiolactone by urinary excretion. Our data also suggest that the protonation status of its amino group affects Hcy-thiolactone excretion.

Plasma levels of total, free and protein bound thiols as well as sulfane sulfur in different age groups of rats

The redox status of plasma thiols can be a diagnostic indicator of different pathological states. The aim of this study was to identify the age dependent changes in the plasma levels of total, free and protein bound glutathione, cysteine and homocysteine. The determination was conducted in plasma of three groups of rats: 1) young (3-month-old), 2) middle aged (19-month-old), and 3) old (31-month-old). Total levels of glutathione, cysteine and homocysteine and their respective free and protein-bound fractions decreased with age. The only exception was a rise in free homocysteine concentration in the middle group, which indicates a different pattern of transformations of this thiol in plasma. The drop in the level of protein-bound thiols suggests that the antioxidant capacity of plasma diminishes with age, which, consequently, leads to impaired protection of -SH groups through irreversible oxidation. The plasma sulfane sulfur level also declines with age, which means that aging is accompanied by inhibition of anaerobic sulfur metabolism.

Analysis of plasma thiols by high-performance liquid chromatography with ultraviolet detection

The procedure for measurement of different forms of four plasma thiols cysteine, cysteinylglycine, glutathione and homocysteine is proposed. The analytes are derivatized with thiol-specific ultraviolet labeling reagent, 2-chloro-1-methylquinolinium tetrafluoroborate, and separated from each other, reagent excess and plasma matrix constituents by reversed-phase high performance liquid chromatography with detection at 355 nm. Oxidized forms are converted to their thiol counterparts by reductive cleavage with sodium borohydride prior to derivatization step. In order to circumvent the loss of reduced fraction of thiols due to oxidation during sample preparation, the derivatization reagent is added to whole blood immediately after collection and before separation of plasma from erythrocytes. The method measures total thiols, total free thiols, protein-bound thiols and reduced thiols. The method is linear within the physiological and pathological ranges of thiols and is applied for plasma samples donated by apparently healthy volunteers.

Plasma levels of total, free and protein bound thiols as well as sulfane sulfur in different age groups of rats

The redox status of plasma thiols can be a diagnostic indicator of different pathological states. The aim of this study was to identify the age dependent changes in the plasma levels of total, free and protein bound glutathione, cysteine and homocysteine. The determination was conducted in plasma of three groups of rats: 1) young (3-month-old), 2) middle aged (19-month-old), and 3) old (31-month-old). Total levels of glutathione, cysteine and homocysteine and their respective free and protein-bound fractions decreased with age. The only exception was a rise in free homocysteine concentration in the middle group, which indicates a different pattern of transformations of this thiol in plasma. The drop in the level of protein-bound thiols suggests that the antioxidant capacity of plasma diminishes with age, which, consequently, leads to impaired protection of -SH groups through irreversible oxidation. The plasma sulfane sulfur level also declines with age, which means that aging is accompanied by inhibition of anaerobic sulfur metabolism.

Determination of different species of homocysteine in human plasma by high-performance liquid chromatography with ultraviolet detection

This assay measures reduced, free oxidized, protein-bound, and total homocysteine in human plasma. Oxidized species of homocysteine are converted to reduced form by sodium borohydride, and, after precolumn derivatization with 2-chloro-1-methylquinolinium tetrafluoroborate, homocysteine 2-S-quinolinium derivative is separated from those of other plasma thiol derivatives, and quantitated by ion-paired reversed-phase high-performance liquid chromatography with ultraviolet detection. The reduced homocysteine sulfhydryl groups are trapped with minimal oxidation by derivatizing blood samples at the time of collection. With the use of this precise and sensitive HPLC method utilizing popular ultraviolet detection, homocysteine in plasma can be detected and quantitated at the level of 0.1 and 0.2 for reduced fraction, and 0.3 and 0.5 nmol/ml for total homocysteine, respectively. The method is applied for determination of different fractions of homocysteine in plasma of apparently healthy men and women.

Hyperhomocysteinemia in poorly controlled type 2 diabetes patients

Elevated blood level of homocysteine is strongly related to an increased risk for atherosclerosis and cardiovascular disease. The role of homocysteine in Type 2 diabetes vascular complications remains unclear. Our objective was to investigate homocysteine levels in poorly controlled Type 2 diabetic patients, who are at increased risk of vascular complications development. Forty-four Type 2 diabetic patients with no symptoms of any cardiovascular disease were divided into 2 groups: 26 patients with poor metabolic control treated with oral agents (aged 66.8 +/- 5.4 yr, diabetes duration 11.9 +/- 4.1 yr, fasting plasma glucose 13.9 +/- 4.6 mmol/l, HbA1C 9.8 +/- 1.6%), 18 well-matched diabetic patients well-controlled with oral agents (aged 65.8 +/- 4.7 yr, diabetes duration 10.9 +/- 4.2 yr, fasting plasma glucose 7.3 +/- 2.4 mmol/l, HbA1c 6.6 +/- 0.7%). The controls were 12 healthy subjects. Fasting total plasma homocysteine and plasma insulin concentrations were measured. Plasma total homocysteine concentrations were significantly higher in poorly controlled than in well-controlled diabetic patients and controls (17.1 +/- 4.5 vs 8.2 +/- 3.9 and 6.5 +/- 4.9 micromol/l respectively, p < 0.001). Insulinemia showed an inverse correlation with homocysteine levels (8.3 +/- 5.2 vs 14.6 +/- 5.2 and 9.3 +/- 6.1 microlU/ml, p < 0.001; r = -0.32, p < 0.05). HbA1c values correlated positively with homocysteine concentrations in poorly controlled subjects (r = 0.41; p < 0.05). In conclusion, chronic poor metabolic control of Type 2 diabetes is characterized by elevation of plasma homocysteine concentration, which also inversely correlates with endogenous insulin levels. These results may add to the understanding of the increased frequency and mechanisms of vascular damage in diabetes mellitus.

Urinary excretion measurement of cysteine and homocysteine in the form of their S-pyridinium derivatives by high-performance liquid chromatography with ultraviolet detection

Several human diseases, in particular metabolic disorders, often lead to the accumulation of characteristic metabolites in plasma, urine and cells. The selected diseases of this type include cystinuria and homocystinuria. In the typical laboratory diagnosis of these two diseases, a positive nitroprusside test is followed by quantitative analysis of urine cysteine and homocysteine in order to differentiate between cystinuria and homocystinuria. A sensitive and reproducible assay for total urine cysteine and homocysteine has been developed. The essential steps in the assay include conversion of disulphides to free thiols with tributylphosphine, conjugation of the thiols with 2-chloro-1-methyl pyridinium iodide, separation of S-pyridinium derivatives of cysteine and homocysteine from other endogenous urine thiol derivatives by reversed-phase high-performance liquid chromatography, and detection and quantitation by spectrophotometry. The method has a sensitivity of 4 pmol and is reproducible, intra- and inter-day coefficients of variation are from 1.37 to 4.14% and from 2.38 to 5.01%, respectively. The mean concentration of total urine cysteine and homocysteine in healthy donors (7 men and 7 women) were for women. 92.0 +/- 45.8 and 16.4 +/- 4.8 respectively, and for men 120.9 +/- 46.6 and 21.5 +/- 7.4 nmol/ml, respectively. Total urine homocysteine represents approximately 17.7% of cysteine in the urine of normal individuals.