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Isoenzyme Update: Creatine Kinase and Lactate Dehydrogenase

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Isoenzyme Update: Creatine Kinase and Lactate Dehydrogenase Henry Ford Hospital Medical Journal Volume 30 Number 2 Article 11 6-1982 Isoenzyme Update: Creatine kinase and lactate dehydrogenase Craig C. Foreback Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Foreback, Craig C. (1982) "Isoenzyme Update: Creatine kinase and lactate dehydrogenase," Henry Ford Hospital Medical Journal : Vol. 30 : No. 2 , 97-101. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol30/iss2/11 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med J Vol 30, No 2,1982 I I "111 illPlI: ""III, .III' i, 111." Ill :oiiii 1/ Isoenzyme Update Creatine kinase and lactate dehydrogenase Craig C. Foreback, PhD* Creatine kinase (CK)and lactate dehydrogenase f LD j are to determine CK-MB activity in serum. New methods to isoenzymes that have been measured in clinical labora­ quantify CK-MB have also been tested, including an tories for over 20 years; their separation has proved automated column technique, the immunoinhibidon/ valuable in the diagnosis of myocardial infarction and immunoprecipitadon technique, and immunoradiome- other cardiac-related diseases. Although, historically, try. In addition, new immunological techniques have electrophoresis was the preferred method to measure recently been developed to analyze LD isoenzymes; the both isoenzymes, there has been controversy over the assay for LD-1 has already replaced electrophoresis. In best method for separating the CK isoenzyme, lon time, specific assays for CK-MB will also be available. exchange chromatography has been used successfully However, new techniques have not eliminated the need to isolate CK isoenzymes, and the procedure was adapted to order CK-MB and LD-1 as a battery and to employ appropriate timing and serial collection of samples. Elevations of creatine kinase (CK) and lactate dehy­ mobility. The fastest anodally migrating isoenzyme is drogenase (LD) in myocardial infarction are well LD-1 (H4), and the slowest LD-5 (M4). The tissue distribu­ documented, and these enzymes have been measured tion of LD and CK isoenzymes is shown in Tables I and 11, routinely in clinical laboratories for over 20 years. Crea­ respectively. tine kinase is present in striated muscle, brain, smooth muscle, heart muscle, and the prostate. Lactate dehy­ Historically, separation of LD isoenzymes preceded the drogenase is present in the liver, heart, kidney, striated separation of CK isoenzymes as a routine clinical test muscle, red blood cells, and the lung. Because of their (5,6). The classic electrophoretic separation of LD isoen­ widespread tissue distribution, they are also elevated in zymes is effective and relatively accurate. It is still widely other cardiovascular and nonrelated diseases. The obser­ used in most hospital laboratories. Ion exchange chro­ vation that LD and CK existed in isoenzyme forms (1,2) matographic methods have been developed, but these led to speculation that separation and determination of require additional skills and apparatus not always rou­ different isoenzymes in serum might lead to specific tinely available. Therefore, this approach has not achieved markers for various diseases. Indeed, the determination any popularity. After electrophoretic separation, the of CK and LD isoenzymes has proved valuable in diagno­ separation media are "stained" with any substrate spe­ sis and confirmation of acute myocardial infarction (3). cific for LD. The result is five bands of activity corres­ ponding to the five different LD isoenzymes. These Isoenzymes are similar but distinct protein molecules bands are then scanned on a densitometer, and a tracing which catalyze the same chemical reaction. CK is a is produced. Even normal serum contains all five isoen­ dimeric molecule composed of two types of monomers, zymes (Fig. IA). In myocardial infarction, the ratio of the M and B subunits. Varying the combination ofthese LD/LDj becomes > 1, creating the so-called "flipped" subunits results in three isoenzymes, designated the pattern (Fig. IB). The most frequent use of LD isoen- MM (CK-3) skeletal muscle, MB (CK-2) cardiac muscle, and BB (CK-1) brain forms (4). LD exists as a tetramer which is also composed of two types of monomers, the H Submined for publication: May 17, 1982 and M subunits. This results in five different isoenzymes: Accepted for publication: May 24.1982 H4, H3M, H2M2, HM3, and M4. The isoenzymes of LD • Department of Pathology, Division of Cnemistry, Henry Ford Hospital are often referred to in terms of their electrophoretic Address reprint requests to Dr. Foreback, Department of Pathology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202 97 Foreback TABLE I Tissue Localization of LD Isoenzymes Tissue Principal Isoenzymes Heart Kidney LD-1, LD-2 Brain Red Blood Cells Thyroid Adrenal Gland LD-3 Lymph Nodes Pancreas Thymus Spleen Leukocytes ^ H A A Liver Skeletal Muscle LD-4, LD-5 Fig. 2 Electrophoresis of LD isoenzymes showing treatment of serum wilh anii M, anii-anti M precipitation agenl. LD is al lop of picture. N= TABLE II normal palieni; A= abnormal palieni (myocardial infarction). Tissue Localization of CK Isoenzymes TABLE III Tissue Isoenzyme LD Isoenzyme Pallerns in Various Diseases Brain Disease Paltern Smooth Muscle Thyroid BB Lung Myocardial Infarct* LD-1, LD-2 elevated Prostate Pernicious Anemia Acute Renal Damage Cardiac Muscle Hemolysis Tongue MB Diaphragm Liver Damage LD-5 elevated Skeletal Muscle (Trace Amounts) Myocardial Infarction with LD(1>2) ± LD-5 4^ Skeletal Muscle MM Liver Congestion Cardiac Muscle Lymphoproliferative Disorders LD-2, LD-3 elevated Pulmonary Infarct Heart Failure All isoenzymes elevated Crush Syndrome LDH ISOENZYMES MYOCARDIAL-INFARCT Neoplastic Disease NORMAL LDH ISOENZYMES •Generally LD-1/LD-2 greater than 1.0 zymes is in the diagnosis or confirmation of myocardial infarction. The presence of the "flipped" pattern in clin­ ically diagnosed myocardial infarction is highly specific. Although elevations of the other LD isoenzymes (LD-3- LD-5) have been reported in various diseases (Table 111), their value in diagnosing or confirming these diseases is doubtful. There has been considerably more controversy over the preferred method of separating CK isoenzymes. Like LD isoenzymes, CK isoenzymes were first separated by elec­ Fig.1 trophoresis. Of particular interest was the CK-2 or MB 98 Isoenzyme Update Comparison of LD-1 by Roche Isomune Cy) procedure was adapted to accurately determine CK-MB to LD-1 by Electrophoresis (x) activity in serum. There was intense interest in this procedure because it could provide an accurate, quan­ titative assessment of CK-MB in serum. 200- Originally CK-MB was thought to be specific for myocardial infarction based upon the generally accepted tissue dis­ tribution of the CK isoenzymes. However, elevated CK- 150H MB has been reported in other cardiac-related diseases, such as severe angina, congestive heart failure, and car­ y(IU/L) diomyopathy. CK-MB has also been reported in Reye's tOO-t syndrome, carbon monoxide poisoning, and various skeletal muscular myopathies. This in part accounts for the demand by clinicians for a quantitative CK-MB / r = 0 994l %^ y- 1 008x- 1 34 method. Varat and Mercer have suggested that the rela­ 50- / • tive percent of CK-MB compared to the total CK activity is more specific for myocardial infarction (9); over 5-8 units of MB activity greater than 2% ofthe total is indica­ llll 1 1 1 p 1 20 40 60 80 100 120 140 160 ISO tive of myocardial necrosis. Other workers have quanti­ X (lU/L) tated CK-MB and attempted to relate it to histological infarct size. Progress in this area has recently been Fig. 3 reviewed (10,11). Quantitation of CK-MB may also be useful in evaluating the effectiveness of streptokinase in myocardial infarction (LeeTG, personal communication). Comparison of LD-1 by Roche Isomune to LD-1/LD-2 by Electrophoresis Other quantitative methods are immunoinhibition (12) and radioimmune assay (RIA) for the CK-B subunit (13). Key: t. MB band (+) In terms of efficiency of diagnosing or confirming • Specimen later tlipped • Specimen * Flipped on earlier specimen myocardial infarction, none ofthe methods are superior to electrophoresis, which directly detects the presence of the CK-MB isoenzyme visually. The immunoinhibition techniques are insensitive, while the CK-B subunit RIA techniques require long incubation times and can be tolal 2673 run economically only in batches. Both suffer from BB I LD3, LD4, LD5 dilution (5:1) interference. Although oncethought to be uncommon, CK-BB is found in about 1% of all CK isoenzymes requested at Henry Ford Hospital. 1?0 160 200 240 lsomune-LD-1 In our laboratory, we have been evaluating several new Value lU/L CK-MB proced ures. The first is an automated column technique which can easily be performed 24 hoursa day, Fig.4 seven days a week (14). The method works quite well to analyze serum, providing at least three samples are col­ lected serially. Specimens should be collected at 8, 16, band, because its presence in human serum was reported 24, and 36 hours following suspected infarction. In many to have a high degree of specificity in the diagnosis of cases, the method is not sensitive enough to be diagnos­ myocardial infarction (7). tically accurate on a single specimen. The procedure may not be useful on patients who have recently under­ The development of ion exchange chromatography to gone cardiac surgery such as coronary artery bypass. successfully isolate and purify tissue isoenzymes of CK led to clinical applications in the diagnosis of myocardial Another approach currently being tested is the im- infarction, as reported to Mercer (8).
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