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The Interpretation of the Serum Protein-Bound Iodine: a Review

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The Interpretation of the Serum Protein-Bound Iodine: a Review J Clin Pathol: first published as 10.1136/jcp.24.3.187 on 1 April 1971. Downloaded from J. clin. Path., 1971, 24, 187-218 The interpretation of the serum protein-bound iodine: A review J. D. ACLAND' From the Department of Pathology, Central Middlesex Hospital, Park Royal, London SYNOPSIS The effects of physiological and environmental factors, of thyroid and non-thyroid diseases, and of drugs on the serum protein-bound iodine are described and discussed. The blood iodine consists of several fractions, not that the regression line of one method on the other all of which are clinically important (Acland, 1958). did not differ significantly from the line of agree- The serum protein-bound iodine (PBI) is defined as ment. Contamination by iodine drugs is a serious that part of the total serum iodine which cannot be problem in all methods for determining protein- dialysed and is precipitated with the serum proteins. bound iodine. Physiological and pathological factors which may affect the serum PBI have been extensively reviewed lodothyronines in Serum (eg, Rall, Robbins, and Lewallen, 1964; Davis, 1966; Sandier and McGowan, 1967). The present review Thyroxine (TJ makes up the greater part of the is concerned with the interpretation of the serum serum protein-bound iodine. The normal range for PBI in routine diagnosis. serum T4 by column chromatography followed by alkaline ashing is quoted as 3-2-6-4 /tg of T4-I/100 ml Determination of the Serum PBI (Henry, 1964, p. 950). Interference by some, but not all, iodine drugs is eliminated by this method (Henry, The methods for determining serum PBI have been 1964, p. 950). Direct determination of T4 in the http://jcp.bmj.com/ fully reviewed (Acland, 1958; Chaney, 1958; Henry, column eluate after bromination (Pileggi and 1964, ch. 28; Robbins and Rall, 1967). The tradi- Kessler, 1968) gives results for T4-I which are tional normal range for the serum PBI in healthy 0-13 /tg/100 ml higher on average than the alkaline adults is 4-8 ,ug/100 ml (Henry, 1964, p. 932). ashing technique. Priodax and Telepaque were found Investigators who use alkaline ashing techniques for to interfere with the bromination method, but most determining serum PBI have reported lower limiting radioopaque iodine drugs did not (Pileggi and values, eg, 3 4-7-3 ,ug/100 ml (95 % limits calculated Kessler, 1968). The normal 95 % range for serum T4 on October 2, 2021 by guest. Protected copyright. from the data of Radcliff, Baker, Croydon, Hart, by the competitive protein-binding technique, con- and Hales, 1964) and 3 5-7 5 .tg/100ml (Sisson, 1965). verted to the same units, has been quoted as 2-6-7-2 Workers using acid digestion techniques have ,ug of T4-I/100 ml (Murphy and Pattee, 1966), 2-0- reported wider normal ranges, eg, 3-6-8-8 ,ug/100 ml 7-4 ,tg of T4-I/100 ml (Cassidy, Benotti, and Peno, (Bodansky, Benua, and Penacchia, 1958) and 3 0- 1968), 2-6-6-9 ,tg of T4-I/100 ml (Lucis, Cummings, 7-5 ug/100 ml (Wayne, Koutras, and Alexander, Matthews, and Burry, 1969), and 2-9-7 5 ,ug of T4- 1964-method of Farrell and Richmond, 1961). 1/100 ml (Ekins, Williams, and Ellis, 1969). The use Michell (1966) reported that he had analysed 'about of competitive protein-binding methods avoids 500' sera with PBI values in the range 0-3-20-0 interference by iodine drugs (Murphy, 1969) but ,ug/100 ml both by the alkaline incineration method necessitates extraction of T4 from serum with of Acland (1957) and by the Technicon PBI Auto- organic solvents, which may cause artefacts unless Analyzer (Technicon Instruments Ltd), which the solvent is evaporated above pH 9 (Bellabarba uses an acid digestion technique, and had found and Sterling, 1969). The normal range (95% limits) for total serum 'Present address: Department of Chemical Pathology, Royal Post- 3:5 :3'-tri-iodothyronine (T3), calculated from the graduate Medical School, Ducane Road, London, W12. data of Nauman, Nauman, and Werner (1967), who Received for publication 20 August 1970. used a competitive pretein-binding technique, is 187 J Clin Pathol: first published as 10.1136/jcp.24.3.187 on 1 April 1971. Downloaded from 188 J. D. Acland 011-0-28 ,ug of T3-I/100 ml. The technique of Non-hormonal Iodine in the PBI Nauman et al (1967) has been criticized on the grounds that esterification artefacts could have been The PBI may contain iodoproteins, iodotyrosines, formed during extraction (Sterling, Bellabarba, or inorganic iodide in addition to hormonal iodine. Newman, and Brenner, 1969). A normal 95 % range Contamination by iodine drugs is considered in a for total serum T3 calculated from the data of later section. The serum PBI is usually separated Sterling et al (1969) is 0 10-0'166g of T3-1/100 ml. from free serum iodide by protein precipitation or 3:3' :5' :-Tri-iodothyronine and 3 :3'-di-iodo- by means of an anion-exchange resin. Thyroglobulin thyronine, although present in thyroid hydrolysates, and iodoalbumin secreted by the thyroid gland are not normal serum constituents (Stanbury and (Robbins and Rall, 1960) and iodoalbumin secreted Morris, 1957; Dunn and Stanbury, 1958). by the liver (Surks and Oppenheimer, 1969) remain in the protein fraction and are estimated as protein- bound iodine. Thyroglobulin is present only in Serum Proteins which Bind Thyroid Hormones minute traces in normal serum (Roitt and Torni- T4) giani, 1967). lodoalbumin from the liver could Nearly all the serum hormonal iodine (T3 and contribute up to 10 to 15% of the normal PBI (see in serum is bound to protein (Robbins and Rall, Surks and Oppenheimer, 1969). 1960). T4 is attached under in-vitro conditions to Free iodotyrosines are precipitated from serum in several proteins, the most important of which are a zinc hydroxide precipitate but not to any signi- an 0x2-glycoprotein, thyroxine-binding globulin ficant extent in a trichloroacetic acid precipitate (TBG), and a thyroxine-binding prealbumin (TBPA). (O'Halloran and Wellby, 1966). If an anion exchange In physiological conditions about 15 % of the serum resin is used to remove inorganic iodide from serum, T4 is bound to TBPA (Woeber and Ingbar, 1968). as in the case of the method used for the Technicon The remainder is largely bound to TBG with smaller PBI AutoAnalyzer, iodotyrosines are included in the amounts attached to albumin and certain lipo- iodine remaining in the serum, which constitutes the proteins (Robbins and Rall, 1952; Miyai, Itoh, Abe, 'total serum organic iodine', or TSOI (Austin and and Kumahara, 1968). T3 is bound more weakly Koepke, 1966). Thus any iodotyrosines in serum are than T4 by TBG and is not bound at all by TBPA estimated as PBI if zinc hydroxide precipitation is (Ingbar, 1960). used and as TSOI if iodide is removed from the The unbound, or 'free', T3 or T4 may be estimated serum by an anion exchange resin. Iodotyrosines by determining the fraction of the serum T3 or T4 in sera which has passed into the diffusate after dialysing are not found in the free state normal (Wellby and O'Halloran, 1969) but are detectable in the http://jcp.bmj.com/ the serum until equilibrium is attained (Oppen- serum in some thyroid diseases (see below). An heimer, Squef, Surks, and Hauer, 1963; Ingbar, exhaustive review of iodotyrosines in serum has Braverman, Dawber, and Lee, 1965). In normal been published (Rhodes, 1968). The evidence for sera, on the average, 99-954% of the total T4 is the presence in serum of 'bound iodotyrosines', protein-bound (Sterling and Brenner, 1966) and which may be identical with the serum iodoalbumin 99 54% of the total T3 is protein-bound (Nauman fraction of Surks and Oppenheimer (1969), has been et al, 1967). These authors give normal ranges of Radichevich, and summarized by Weinert, Masui, on October 2, 2021 by guest. Protected copyright. 0-036-0-056% for the free T4 fraction and 0-18- Werner (1967). 0 74% for the free T3 fraction. It is important that Inorganic iodide is present in the PBI in signi- the [13'I] T4 or [131I] T3 used in the determination ficant quantities only if large doses of some organic should not be contaminated by other iodothyronines iodine preparations (Chaney, 1958) or at least 1 g (Volpert, Martinez, and Oppenheimer, 1967). of inorganic iodide per day (Fisher, Oddie, and Epperson, 1965) have been administered. Serum Free T3 and Free T4 Investigation of Anomalous Serum PBI Results The normal range (95 % limits) for the concentration of free T4 in serum is 1 76-3-76 ng of T4-I/100 ml or Serum PBI results which are at variance with the 35-74 pmoles/l (calculated from the data of Sterling clinical assessment of thyroid state may be observed and Brenner, 1966) and the normal range (95% in any of the following situations: (1) if the serum limits) for serum free T3 is 0-42-1 35 ng of T3-I/100 TBG capacity is abnormal; (2) if iodinated drugs ml or 11-35 pmoles/l (calculated from the data of (including T3 and TO), or drugs which interfere with Nauman et al, 1967). The upper limit of normal for the analysis, have been administered; (3) if the the serum absolute T3 level may be as low as 20 thyroid gland is secreting a product of abnormal pmoles/l (Sterling et al, 1969). composition; and (4) if the peripheral metabolism J Clin Pathol: first published as 10.1136/jcp.24.3.187 on 1 April 1971.
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