Evaluation of a New Skeletal Troponin I Assay in Patients with Idiopathic Inflammatory Myopathies

BACKGROUND

The current biomarkers for diagnosis and monitoring of injured and diseased skeletal muscles, such as creatine kinase (CK), have limited tissue specificity and incapability to differentiate between pathological and physiological changes. Thus, new biomarkers with improved diagnostic accuracy are needed. Our aim was to develop and validate a novel assay for skeletal troponin I (skTnI), and to assess its clinical performance in patients with idiopathic inflammatory myopathies (IIM).

METHODS

A two-step fluoroimmunoassay was used to analyze samples from healthy reference individuals (n = 140), patients with trauma (n = 151), and patients with IIM (n = 61).

RESULTS

The limit of detection was 1.2 ng/mL, and the upper reference limit (90th percentile) was 5.2 ng/mL. The median skTnI concentrations were <limit of detection (LoD), 2.7 ng/mL, and 8.6 ng/mL in reference, trauma, and IIM cohorts, respectively. Differences in measured skTnI levels were statistically significant between all three study cohorts (Kruskal-Wallis P < 0.001; Mann-Whitney P < 0.001 for all). skTnI and CK had a strong positive correlation (Spearman's r = 0.771, P < 0.001), and the longitudinal changes in skTnI mirrored those observed with CK.

CONCLUSIONS

With the skTnI assay, patients with IIM were identified from healthy individuals and from patients with traumatic muscular injuries. When compared to CK, skTnI appeared to be more accurate in managing patients with low-grade IIM disease activities. The developed assay serves as a reliable analytical tool for the assessment of diagnostic accuracy of skTnI in the diagnosis and monitoring of myopathies.

P4420Is exercise-induced cardiac troponin release caused by skeletal muscle injury?

Background

Cardiac troponins (cTn) are highly sensitive and specific markers for cardiac injury and a key element in the diagnosis of acute coronary syndrome. Strenuous exercise is known to induce increases in cTn, but the causative factors remain ambiguous. It is also equivocal whether exercise induced skeletal muscle injury is associated with cTn elevation.

Purpose

The aim of this study was to identify independent predictors for the rise in cardiac troponin T (cTnT) and I (cTnI) concentration and to focus on the relationship between skeletal muscle injury measured by skeletal troponin I (skTnI) and cTn elevations after a marathon race in a large group of male recreational runners.

Methods

A total of 40 recreational runners participating in the marathon in our city were recruited. The study included baseline visit (prerace) and immediate post-race sampling.

Results

The post-marathon cTnT concentration rose above the reference limit in 38 (95%) participants and the detection limit for cTnI was exceeded in 34 (85%) participants. Similarly, a 10-fold increase in skTnI concentration was observed and elevated post-race values were seen in all participants. There was no significant correlation between the post-race cTnT or cTnT change and post-race skTnI (Spearman's rho = 0.249, p=0.122, rho = 0.285, p=0.074). However, post-race cTnI and change in cTnI were associated with post-race skTnI (rho = 0.404, p=0.01, rho = 0.460, p=0.003) and creatine kinase (r=0.368, p=0.019) concentration. Subjective exertion or self-reported muscle symptoms did not correlate with post-race cTnT, cTnI or skTnI levels.

Post-Race cTnT <40 Post-Race cTnT ≥40 p-value n=18 n=22 Age, years 53.3±12.2 44.0±11.9 0.002 Active training, years 12.0 (9.3) 17.0 (15.8) 0.190 Muscle symptoms 7 (38.9) 11 (52.4) 0.523 Creatinine kinase, ug/l 406 (137) 399 (319) 0.163 N-terminal proBNP ng/l 137±168 158±277 0.783 Skeletal Troponin I, ng/ml 28.6 (41) 56.7 (143) 0.199

Figure 1

Conclusions

Cardiac troponin became abnormal in almost all runners after marathon race. The exercise-induced rise in cardiac troponin I is related to simultaneous release of skeletal troponin I. The mechanism of this association remains uncertain, but clinicians should be cautious when interpreting post-exercise troponin levels without clinical symptoms and signs of myocardial ischemia.

Structure of the PPARalpha and -gamma ligand binding domain in complex with AZ 242; ligand selectivity and agonist activation in the PPAR family

BACKGROUND

The peroxisome proliferator-activated receptors (PPAR) are ligand-activated transcription factors belonging to the nuclear receptor family. The roles of PPARalpha in fatty acid oxidation and PPARgamma in adipocyte differentiation and lipid storage have been characterized extensively. PPARs are activated by fatty acids and eicosanoids and are also targets for antidyslipidemic drugs, but the molecular interactions governing ligand selectivity for specific subtypes are unclear due to the lack of a PPARalpha ligand binding domain structure.

RESULTS

We have solved the crystal structure of the PPARalpha ligand binding domain (LBD) in complex with the combined PPARalpha and -gamma agonist AZ 242, a novel dihydro cinnamate derivative that is structurally different from thiazolidinediones. In addition, we present the crystal structure of the PPARgamma_LBD/AZ 242 complex and provide a rationale for ligand selectivity toward the PPARalpha and -gamma subtypes. Heteronuclear NMR data on PPARalpha in both the apo form and in complex with AZ 242 shows an overall stabilization of the LBD upon agonist binding. A comparison of the novel PPARalpha/AZ 242 complex with the PPARgamma/AZ 242 complex and previously solved PPARgamma structures reveals a conserved hydrogen bonding network between agonists and the AF2 helix.

CONCLUSIONS

The complex of PPARalpha and PPARgamma with the dual specificity agonist AZ 242 highlights the conserved interactions required for receptor activation. Together with the NMR data, this suggests a general model for ligand activation in the PPAR family. A comparison of the ligand binding sites reveals a molecular explanation for subtype selectivity and provides a basis for rational drug design.

Rosiglitazone (BRL49653), a PPARgamma-selective agonist, causes peroxisome proliferator-like liver effects in obese mice

The PPAR (peroxisome proliferator activated receptor) transcription factors are ligand-activated nuclear receptors that regulate genes involved in lipid metabolism and homeostasis. PPARalpha is preferentially expressed in liver and PPARgamma preferentially in adipose tissue. Activation of PPARalpha leads to peroxisome proliferation and increased beta-oxidation of fatty acids in rodents. PPARgamma-activation leads to adipocyte differentiation and improved insulin signaling of mature adipocytes. Both PPAR receptors are believed to be functional targets for treatment of hyperlipidemia in man. We have treated obese diabetic mice (ob/ob), which have highly elevated levels of plasma triglycerides, glucose and insulin, for 1 week with WY14,643 (180 micromol/kg/day), a selective PPARalpha agonist, or rosiglitazone (BRL49653; 2.5 micromol/kg/day), a selective PPARgamma agonist. The doses used produce a similar therapeutic effect in both treatment groups (lowering of triglycerides and glucose). High resolution two-dimensional gel electrophoresis of livers showed that WY14,643 and rosiglitazone both produced changes in expression pattern of many proteins involved in peroxisomal fatty acid beta-oxidation. However, similar experiments performed in lean mice showed significant up-regulation of these proteins only with WY14,643 treatment. Furthermore, the proteins up-regulated by the drugs in obese mice had a higher basal expression in obese controls compared to the lean littermates. Liver PPARgamma mRNA levels were determined and we observed that PPARgamma2 mRNA levels were elevated in obese mice compared to lean littermates. As PPARalpha and PPARgamma recognize similar DNA response elements, it is likely that the effects of rosiglitazone on PPARalpha responsive genes in livers of the ob/ob mice are mediated by PPARgamma2.

beta-subunit assembly is essential for the correct packing and the stable membrane insertion of the H,K-ATPase alpha-subunit

The alpha-subunits of H,K-ATPase (HKAalpha) and Na,K-ATPase require a beta-subunit for maturation. We investigated the role of the beta-subunit in the membrane insertion and stability of the HKAalpha expressed in Xenopus oocytes. Individual membrane segments M1, M2, M3, M4, and M9 linked to a glycosylation reporter act as signal anchor (SA) motifs, and M10 acts as a partial stop transfer motif. In combined HKAalpha constructs, M2 acts as an efficient stop transfer sequence, and M3 acts as a SA sequence. However, M5 and M9 have only partial SA function, and M7 has no SA function. Consistent with the membrane insertion properties of segments in combined alpha constructs, M1-3 alpha-proteins are resistant to cellular degradation, and M1-5 up to M1-10 alpha-proteins are not resistant to cellular degradation. However, co-expression with beta-subunits increases the membrane insertion of M9 in a M1-9 alpha-protein and completely protects M1-10 alpha-proteins against cellular degradation. Our results indicate that HKAalpha N-terminal (M1-M4) membrane insertion and stabilization are mediated by intrinsic molecular characteristics; however, the C-terminal (M5-M10) membrane insertion and thus the stabilization of the entire alpha-subunit depend on intramolecular and intermolecular beta-subunit interactions that are similar but not identical to data obtained for the Na,K-ATPase alpha-subunit.

Structural aspects of the gastric H,K ATPase

The gastric H,K ATPase is an alpha beta heterodimeric member of the eukaryotic alkali-cation P-type ion-motive ATPase family. The alpha subunit is composed of 1033 amino acids and the beta subunit of 291 amino acids with 6 or 7 potential N-linked glycosylation sites. Much effort has been expended to define the membrane domain of P-type ATPases. A membrane domain of the large subunit consisting of 10 membrane-spanning sequences is suggested by a combination of methods such as (1) tryptic digestion, separation, and sequencing of membrane peptides, (2) labeling with extracytoplasmic reagents, and (3) in vitro translation of hydrophobic segments. The beta subunit has a single transmembrane segment with strong hydrophobic interactions with the alpha subunit. Blue native gel electrophoresis shows that the enzyme is an (alpha-beta)2 dimer. Cross-linking with Cu-phenanthroline provides evidence that association is between the alpha subunits, and the potential SH groups that are Cu sensitive are at cysteine 565 and cysteine 615, in the region of the large cytoplasmic loop between the fourth and fifth transmembrane segments. No cross-linking is observed in the membrane domain. ATP prevents cross-linking because of a conformational change at the surface of the protein induced by ATP or by direct binding of the nucleotide at the site of cross-linking. The WGA binding properties of the beta subunit allow investigation of the region of interaction with the alpha subunit. Thus, digestion of the enzyme by trypsin followed by SDS solubilization and selective elution from a WGA column resulted in coelution of the membrane fragment containing TM7 and TM8. This result demonstrates major hydrophobic interaction between the seventh and eighth transmembrane segments and the beta subunit. An antibody generated against rat parietal cells also recognized shared epitopes in the same region of both the alpha and beta subunits. Biochemical investigation of the arrangement of the transmembrane segments has been hindered by the lack of effective cross-linking reagents probably because of the compact arrangement of this domain, preventing even Cu access. A series of antiulcer drugs has been developed that have a unique chemistry related to their inhibition of the gastric H,K ATPase. They are 2-(substituted pyridyl methylsulfinyl) benzimidazoles, weak bases with a pKa of 4.0. After accumulation in the acidic space generated by the H,K ATPase either in vivo or in vitro, they undergo acid-catalyzed conversion to a tetracyclic sulfenamide which reacts with luminally accessible SH residues to form stable disulfide derivatives. In the particular case of pantoprazole, 2-(3,4-dimethoxy-2-pyridyl-methylsulfinyl)-5-difluoromethoxy benzimidazole, reaction is confined largely to cysteine 813, placed between the fifth and sixth transmembrane segments. The 5 azido analog of pantoprazole provided acid transport-dependent inhibition of the isolated transporting ATPase by this photoactivatable covalent SH reagent. The inhibited enzyme was then photolyzed, cleaved with trypsin, and the membrane fragments compared before and after photolysis. Disappearance of the segment corresponding to TM3,4 and a relative loss of the segment corresponding to TM7,8 suggests close proximity of these two membrane pairs to the loop joining the fifth and sixth transmembrane segments, in particular TM3,4. Use of this type of covalent, photoactivatable site-specific reagent to determine loop proximity can be extended to other acid transporters.

In vitro translation analysis of integral membrane proteins

A method of in vitro translation scanning was applied to a variety of polytopic integral membrane proteins, a transition metal P type ATPase from Helicobacter pylori, the SERCA 2 ATPase, the gastric H+,K+ ATPase, the CCK-A receptor and the human ileal bile acid transporter. This method used vectors containing the N terminal region of the gastric H+,K+ ATPase or the N terminal region of the CCK-A receptor, coupled via a linker region to the last 177 amino acids of the beta-subunit of the gastric H+,K+ ATPase. The latter contains 5 potential N-linked glycosylation sites. Translation of vectors containing the cDNA encoding one, two or more putative transmembrane domains in the absence or presence of microsomes allowed determination of signal anchor or stop transfer properties of the putative transmembrane domains by the molecular weight shift on SDS PAGE. The P type ATPase from Helicobacter pylori showed the presence of 8 transmembrane segments with this method. The SERCA 2 Ca2+ ATPase with this method had 9 transmembrane co-translational insertion domains and coupled with other evidence these data resulted in a 11 transmembrane segment model. Translation of segments of the gastric H+,K+ ATPase provided evidence for only 7 transmembrane segments but coupled with other data established a 10 membrane segment model. The G7 protein, the CCK-A receptor showed the presence of 6 of the 7 transmembrane segments postulated for this protein. Translation of segments of the human ileal bile acid transporter showed the presence of 8 membrane insertion domains. However, translation of the intact protein provided evidence for an odd number of transmembrane segments, resulting in a tentative model containing 7 or 9 transmembrane segments. Neither G7 type protein appeared to have an arrangement of sequential topogenic signals consistent with the final assembled protein. This method provides a useful addition to methods of determining membrane domains of integral membrane proteins but must in general be utilized with other methods to establish the number of transmembrane alpha-helices.

Localization of mRNA for the muscarinic M1 receptor in rat stomach

Cholinergic stimulation of receptors in the oxyntic mucosa results in secretion of mucus, pepsinogen and hydrochloric acid. There has been speculation as to the cellular localization of these receptors in the mucosa and as to which subtype is present in the different cell types. In the present study, utilizing radioactive riboprobes for the M1 muscarinic receptor subtype, we carried out in situ hybridization to determine which cells of the gastric corpus transcribe mRNA for this receptor. The antisense M1 probe hybridized strongly on the zymogen cells and, to a lesser extent, on the surface mucous cells and the muscle layers. Control sections from brain also displayed specific hybridization.

The expression of pepsinogen c mRNA in normal gastroduodenal mucosa and the gastric ulcer margin of the rat

During the healing of experimental gastric ulcers in the oxyntic mucosa, there is a dedifferentiation of the glands in the ulcer margin: previous studies have shown that the parietal cells lose their capacity to produce HCl, and mucous cells replace the zymogen cells. Primarily, we wished to investigate whether or not the glands of the ulcer margin transcribe mRNA for pepsinogen; secondly we also wanted to locate such transcription in other parts of the gastroduodenal epithelium. For this purpose, we first established the baseline for distribution of pepsinogen mRNA in normal rats. We then studied its location in the margin of ulcers in the corpus region after 1-15 days of healing. Formaldehyde-fixed paraffin sections were used for in situ hybridization of mRNA for pepsinogen C, utilizing radioactive riboprobes. The normal gastroduodenal mucosa showed widespread hybridization: the signal was particularly strong in the zymogen cells; weaker signals were obtained from the mucous neck cells, and the cells of the cardiac, antral, and Brunner glands. Specific hybridization was weak or absent in the ulcer margin during the entire period studied. It is concluded that the capacity to produce pepsinogen C is significantly reduced or absent in the gastric ulcer margin during the first 15 days of healing; this should reduce the risks of peptic attack on the delicate scar and margin tissues during ulcer healing.

Topological analysis of H+,K(+)-ATPase using in vitro translation

The membrane topology of the alpha subunit of the H+,K(+)-ATPase was investigated by using in vitro transcription/translation of DNA sequences encoding fusion proteins that contained possible membrane-spanning segments. The vectors consisted of DNA sequences encoding (a) either the first 101 (M0 vectors) or the first 139 (M1 vectors) amino acids of the N-terminal region of the alpha subunit of the ATPase, (b) a variable region, and then (c) the C-terminal 177 amino acids of the C-terminal region of the beta subunit, with five N-linked glycosylation sites. The variable region of the fusion protein contained the cDNA sequences representing the possible eight or 10 membrane-spanning segments either alone or in various combinations. Transcription/translation was performed in the presence of [35S]methionine using a coupled reticulocyte lysate in the absence and presence of microsomes. The fusion protein was identified by autoradiography following separation using SDS-polyacrylamide gel electrophoresis. Glycosylation of a translated sequence corresponded to membrane insertion and translocation of the C-terminal beta sequence. This method allowed analysis of signal anchor sequences using the M0 vector. The presence of a stop transfer sequence in the variable segment of the M1 vector resulted in inhibition of translocation of the C-terminal beta sequence. The sequences for the first four membrane segments could act as either signal anchor or stop transfer sequences. Therefore, this region of the alpha subunit has four membrane-spanning segments that are co-inserted with translation. The sequence corresponding to membrane segment M8 acted as a stop transfer sequence. The sequence corresponding to membrane segment M9 acted as a signal anchor sequence, and that corresponding to membrane segment M10 acted as a stop transfer sequence. The sequences representing the fifth, sixth, and seventh (M5, M6, and M7) membrane segments were unable to co-insert into the membrane. These data verify the first four and the eight membrane-spanning segments of the alpha subunit of the gastric H+,K(+)-ATPase and provide evidence for translational insertion of an additional pair of membrane-spanning segments, M9 and M10. It appears that insertion of membrane segments M5, M6, and M7 is determined differently from the other membrane-spanning segments. In combination with other methods, this in vitro transcription/translation method is useful for defining the membrane topology of the P type ATPases.

In situ hybridization of mRNA for the gastric H+,K(+)-ATPase in rat oxyntic mucosa

The H+,K(+)-ATPase member of the phosphorylating ion motive ATPases is composed of two subunits, a large alpha-subunit composed of about 1030 amino acids and a smaller beta-subunit consisting of about 290 amino acids. By biochemical and immunological methods both subunits have been found in high abundance in the gastric parietal cell. In the present study in situ hybridization was used for localizing and comparing concentrations of the mRNA for the two subunits in the gastric epithelium. For this purpose 3H-labelled probes were preferred. Hybridization was detected only in the parietal cells. The older parietal cells in the bottom of the mucosa gave a weaker hybridization signal than the younger parietal cells closer to the surface. The margin of experimental ulcers, where the parietal cells are of low differentiation, showed very weak, if any, hybridization. The differences observed in hybridization densities may reflect differences in mRNA synthesis or stability. It is conceivable that older parietal cells, as well as parietal cells of low differentiation, produce relatively small amounts of H+,K(+)-ATPase.

Gastric acid secretion: activation and inhibition

Peripheral regulation of gastric acid secretion is initiated by the release of gastrin from the G cell. Gastrin then stimulates the cholecystokinin-B receptor on the enterochromaffin-like cell beginning a calcium signaling cascade. An exocytotic release of histamine follows with concomitant activation of a C1- current. The released histamine begins the H2-receptor mediated sequence of events in the parietal cell, which results in activation of the gastric H+/K+ - ATPase. This enzyme is the final common pathway of acid secretion. The H+/K+ - ATPase is composed of two subunits: the larger alpha-subunit couples ion transport to hydrolysis of ATP, the smaller beta-subunit is required for appropriate assembly of the holoenzyme. Both the membrane and extracytoplasmic domain contain the ion transport pathway, and therefore, this region is the target for the antisecretory drugs of the post-H2 era. The 100 kDa alpha-subunit has probably 10 membrane spanning segments with, therefore, five extracytoplasmic loops. The 35 kDA beta-subunit has a single membrane spanning segment, and most of this protein is extracytoplasmic with the six or seven N glycosylation consensus sequences occupied. Omeprazole is an acid-accumulated, acid-activated, prodrug that binds covalently to two cysteine residues at positions 813 (or 822) and 892, accessible from the acidic face of the pump. Lansoprazole binds to cys321, 813 (or 822) and 892; pantoprazole binds to cys813 and 822. The common binding site for these drugs (cys813 or 822) is responsible for the inhibition of acid transport. Covalent inhibition of the acid pump improves control of acid secretion, but since the effective half life of the inhibition in man is about 48 hr, full inhibition of acid secretion, perhaps necessary for eradication of Helicobacter pylori in combination with a single antibiotic, will require prolongation of the effect of this class of drug.

Location of the cytoplasmic epitope for a K(+)-competitive antibody of the (H+,K+)-ATPase

The monoclonal antibody (mAb) 95-111 binds the alpha subunit of (H+,K+)-ATPase and inhibits the K(+)-ATPase activity. To map the epitope, all of the partial sequences of the alpha subunit were expressed in Escherichia coli HB101 using rabbit alpha subunit cDNA restriction fragments ligated into PuEx vector. Bacterial recombinant lysates were separated by sodium dodecyl sulfate-gel electrophoresis, and the epitope was detected by Western blotting. The antibody site was mapped between Cys529 and Glu561. This is close to the Lys517 that binds fluorescein isothiocyanate (FITC) and is considered to be between M4 and M5 close to the ATP binding domain. However, the mAb inhibition of ATPase is not ATP-competitive but is K(+)-competitive with a KI of 2 x 10(-9) M. The mAb also inhibits K+ quench of FITC fluorescence competitively with a KI of 8 x 10(-9) M. The K+ activation of ATPase activity and quench of FITC fluorescence are dependent on K+ binding to an E2 form of the enzyme from the extracytoplasmic surface. The mAb epitope is cytoplasmic since the K(+)-ATPase activity of ion-tight gastric vesicles is inhibited. The 125I-mAb 95-111 binds to a single class of sites with an apparent KD of 2.3 +/- 0.8 x 10(-9) M and K+ does not displace bound mAb. Hence, antibody binding to a cytoplasmic Cys529-Glu561 epitope allosterically competes with K(+)-dependent reactions at extracytoplasmic sites.

cDNA cloning and membrane topology of the rabbit gastric H+/K(+)-ATPase alpha-subunit

We have cloned and sequenced a cDNA for the rabbit gastric proton-potassium pump (H+/K(+)-ATPase) alpha-subunit. The deduced peptide contains 1035 amino acids (Mr 114,201) and shows 97% sequence identity with the respective rat and hog proteins. A monoclonal antibody 146-14 has been shown previously to react with the extracytoplasmic side of the catalytic H+/K(+)-ATPase subunit and here we show that the epitope is in the region between amino acids 855 and 902 (the numbering of the H+/K(+)-ATPase catalytic subunit throughout the paper refers to the rabbit sequence). The localization of this epitope in conjunction with previously observed trypsin cleavage sites in the C-terminal one third of the enzyme and the hydrophobicity plot of the deduced peptide sequence are evidence for a structural model for the alpha-subunit of the H+/K(+)-ATPase which contains at least ten membrane spanning segments, similar to that deduced for the Ca(2+)-ATPase of sarcoplasmic reticulum.

Acid secretion and the H,K ATPase of stomach

The regulation of acid secretion was clarified by the development of H2-receptor antagonists in the 1970s. It appears that gastrin and acetylcholine exert their effects on acid secretion mainly by stimulation of histamine release from the enterochromaffin-like (ECL) cell of the fundic gastric mucosa. The isolated ECL cell of rat gastric mucosa responds to gastrin/cholecystokinin (CCK), acetylcholine, and epinephrine with histamine release and to somatostatin and R-alpha-methyl histamine by inhibition of histamine release. Histamine and acetylcholine stimulate the parietal cell by elevation of cAMP or [Ca]i by activation of H2 or M3 receptors, respectively. These independent pathways converge to activate the gastric acid pump, the H+,K+ ATPase. Activation is a function of the association of the ATPase with a potassium chloride transport pathway that occurs in the membrane of the secretory canaliculus of the parietal cell. Hence the secretory canaliculus is the site of acid secretion, the acid being pumped into the lumen of the canaliculus. The pump is composed of two subunits, a large catalytic and a smaller glycosylated protein. This final step of acid secretion has become the target of drugs also designed to inhibit acid secretion. The target domain of the benzimidazole class of acid pump inhibitors is the extracytoplasmic domain of the pump that is secreting acid, and the target amino acids are the cysteines present in this domain. The secondary structure of the pump can be analyzed by determining trypsin-sensitive bonds in intact, cytoplasmic-side-out vesicles of the ATPase, and it has been shown that the alpha subunit has at least eight membrane-spanning segments. Omeprazole, the first acid pump inhibitor, forms a disulfide bond with cysteines in the extracytoplasmic loop between the fifth and sixth membrane-spanning segment and to a cysteine in the extracytoplasmic loop between the seventh and eight segments, preventing phosphorylation of the pump by ATP. As a result of the effective and long-lasting inhibition of acid secretion by the acid pump inhibitor, superior clinical results have been found in all forms of acid-related disease.