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UMEÅ UNIVERSITY MEDICAL DISSERTATIONS New series No 342 - ISSN 0346-6612 From the Department of Medical Biochemistry and Biophysics University of Umeå, Umeå, Sweden

HUMAN INTESTINAL ALKALINE

Tissue expression and levels

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AKADEMISK AVHANDLING som med vederbörligt tillstånd av Rektorsämbetet vid Umeå Universitet för avläggande av doktorsexamen i medicinsk vetenskap kommer att offentligen försvaras i hörsal E, Humanisthuset, Umeå Universitet fredagen den 22 maj 1992 kl 9.00

av Ulla Domar ABSTRACT HUMAN INTESTINAL ALKALINE PHOSPHATASE. Tissue expression and serum levels. ISBN 91-7174-674-9 ISSN 0346-6612 - New series No 342 Ulla Domar, Department of Medical Biochemistry and Biophysics, University of Umeå, S-90187 Umeå, Sweden. Human alkaline phosphatase (ALP) comprises four , viz // or tissue unspecific (AP), intestinal (LAP), placental (PLAP) and germ cell or PLAP-like alkaline phosphatase, with their main expression in specific tissues as indicated by their names. The isozymes are coded by different , but they are closely related, with more than 50% amino acid sequence homologies. Their biological function is unclear. In certain malignant and benign diseases, serum elevations of one or more of the isozymes occur, which is of diagnostic importance. In this study, the special expression of the intestinal in human tissues and sera, in normal as well as in pathological conditions, has been investigated by use of isozyme specific monoclonal antibodies. Monoclonal antibodies against the AP, IAP and PLAP isozymes were prepared, and specific assays developed, based on these monoclonal antibodies and the catalytic activity of the isozymes. By use of these assays the basal levels of all three isozymes were examined in selected normal organs. The isozymes were found to be expressed in measurable amounts in all the examined organs. IAP was immunohistochemically localized to the epithelial cells of membranes lining the ducts and tubules of the kidney, liver, and small intestine. Normal human serum contained all three isozymes. The AP isozyme constituted about 90% of the total ALP activity, the IAP isozyme less than 10% and the PLAP isozyme about 1%. Considerable interindividual variations of the serum IAP activity were observed. The serum activities of the IAP isozyme were related to the individual ABO blood group and secretor status. Non-secretors had low levels of IAP activity amounting to about one tenth of the activity in sera from blood group B or 0 secretors, while blood group A secretors had serum IAP activities in the same order as non-secretors. High individual day to day variations were observed. Fat absorption caused serum IAP to increase significantly for all persons, but it was rapidly cleared from the blood. We found that the release of IAP into the blood was linked to lipid absorption, but removal from the blood was not linked to lipoprotein clearance. Certain tumors of the testis expressed elevated levels of all three ALP isozymes. The highest activitiy of IAÌP was observed in one yolk sac tumor, in agreement with the endodermal origin of this tumor. In seminoma tissue the AP and PLAP isozymes were significantly, and IAP moderately elevated. of the liver caused significantly increased serum levels of IAP besides the AP isozyme. In inflammatory diseases of the small intestine, normal serum IAP activities were observed. Kev words: Human alkaline phosphatase, intestinal alkaline phosphatase, blood, blood group, lipid, monoclonal antibody, , liver, kidney, pancreas, liver disease, inflammatory bowel disease. UMEÅ UNIVERSITY MEDICAL DISSERTATIONS New series No 342 - ISSN 0346-6612

From the Department of Medical Biochemistry and Biophysics University of Umeå, Umeå, Sweden

HUMAN INTESTINAL ALKALINE PHOSPHATASE Tissue expression and serum levels

Ulla Domar

AIA

University of Umeå Umeå 1992 Copyright 1992 © Ulla Domar ISBN 91-7174-674-9 Printed in Sweden by Solfjädern Printing Office Umeà 1992

CONTENTS

ABSTRACT ORIGINAL PAPERS ABBREVIATIONS INTRODUCTION - The small intestine ■ Microvillar ■ Human alkaline phosphatase isozymes ■ Tissue unspecific alkaline phosphatase ■ Placental alkaline phosphatase - Intestinal alkaline phosphatase - Function of the alkaline phosphatase isozymes - Selective identification of alkaline phosphatase isozymes - Clinical relevance of alkaline phosphatase isozymes • What is a secretori AIMS OF THIS THESIS RESULTS AND DISCUSSION - The assays (I, II) - Immunohistochemical localization of the intestinal alkaline phosphatase (III) • Alkaline phosphatase isozymes in malignancies (IV) - Alkaline phosphatase isozymes in non-malignant gastrointestinal and liver diseases (V) - Serum levels of intestinal alkaline phosphatase in relation to blood groups (VI) • Serum levels of intestinal alkaline phosphatase in fat absorption (VII) CONCLUSIONS ACKNOWLEDGEMENTS REFERENCES PAPERS I-V II ABSTRACT HUMAN INTESTINAL ALKALINE PHOSPHATASE. Tissue expression and serum levels. ISBN 91-7174-674-9 ISSN 0346-6612 - New series No 342 Ulla Domar, Department of Medical Biochemistry and Biophysics, University of Umeå, S-90187 Umeå, Sweden. Human alkaline phosphatase (ALP) comprises four isozymes, viz liver/bone/ kidney or tissue unspecific (AP), intestinal (LAP), placental (PLAP) and germ cell or PLAP-like alkaline phosphatase, with their main expression in specific tissues as indicated by their names. The isozymes are coded by different genes, but they are closely related, with more than 50% amino acid sequence homologies. Their biological function is unclear. In certain malignant and benign diseases, serum elevations of one or more of the isozymes occur, which is of diagnostic importance. In this study, the special expression of the intestinal isozyme in human tissues and sera, in normal as well as in pathological conditions, has been investigated by use of isozyme specific monoclonal antibodies. Monoclonal antibodies against the AP, IAP and PLAP isozymes were prepared, and specific assays developed, based on these monoclonal antibodies and the catalytic activity of the isozymes. By use of these assays the basal levels of all three isozymes were examined in selected normal organs. The isozymes were found to be expressed in measurable amounts in all the examined organs. IAP was immunohistochemically localized to the epithelial cells of membranes lining the ducts and tubules of the kidney, liver, pancreas and small intestine. Normal human serum contained all three isozymes. The AP isozyme constituted about 90% of the total ALP activity, the IAP isozyme less than 10% and the PLAP isozyme about 1%. Considerable interindividual variations of the serum IAP activity were observed. The serum activities of the IAP isozyme were related to the individual ABO blood group and secretor status. Non-secretors had low levels of IAP activity amounting to about one tenth of the activity in sera from blood group B or 0 secretors, while blood group A secretors had serum IAP activities in the same order as non-secretors. High individual day to day variations were observed. Fat absorption caused serum IAP to increase significantly for all persons, but it was rapidly cleared from the blood. We found that the release of IAP into the blood was linked to lipid absorption, but removal from the blood was not linked to lipoprotein clearance. Certain tumors of the testis expressed elevated levels of all three ALP isozymes. The highest activitiy of LAP was observed in one yolk sac tumor, in agreement with the endodermal origin of this tumor. In seminoma tissue the AP and PLAP isozymes were significantly, and IAP moderately elevated. Cirrhosis of the liver caused significantly increased serum levels of IAP besides the AP isozyme. In inflammatory diseases of the small intestine, normal serum IAP activities were observed. Kev words: Human alkaline phosphatase, intestinal alkaline phosphatase, blood, blood group, lipid, monoclonal antibody, immunohistochemistry, liver, kidney, pancreas, liver disease, inflammatory bowel disease. 6

ORIGINAL PAPERS

This thesis is based on the following papers, which will be referred to by their Roman numerals.

I Hirano K, Matsumoto H, Tanaka T, Hayashi Y, lino S, Domar U, Stigbrand T (1987). Specific assays for human alkaline phosphatase isozymes. Clin Chim Acta 166:265-273.

II Hayashi Y, Mitani T, Kurono M, Hirano K, Hayashi K, lino S, Domar U, Stigbrand T (1991). Improved monoclonal immunocatalytic assays (MICAs) for human alkaline phosphatase isozymes. Jpn J Clin Chem 20:125-132.

III Domar U, Nilsson B, Gerdes U, Stigbrand T (1992). Expression of intestinal alkaline phosphatase in human organs. Submitted.

IV Hirano K, Domar U M, Yamamoto H, Brehmer-Andersson E E, Wahren B E, Stigbrand T I (1987). Levels of alkaline phosphatase isozymes in human seminoma tissue. Cancer Res 47:2543-2546.

V Domar U, Danielsson Å, Hirano K, Stigbrand T (1988). Alkaline phosphatase isozymes in non-malignant intestinal and hepatic diseases. Scand J Gastroenterol 23: 793-800.

VI Domar U, Hirano K, Stigbrand T (1991). Serum levels of human alkaline phosphatase isozymes in relation to blood groups. Clin Chim Acta 203:305-314.

VII Domar U, Karpe F, Hamsten A, Stigbrand T, Olivecrona T (1992). Intestinal alkaline phosphatase - release to the blood is linked to lipid absorption, but removal from the blood is not linked to lipoprotein clearance. Submitted. 7

ABBREVIATIONS

ALP alkaline phosphatase IAP intestinal alkaline phosphatase IAP-like IAP-like phosphatase PLAP placental alkaline phosphatase PLAP-like PLAP-like/germ cell alkaline phosphatase AP tissue unspecific alkaline phosphatase MICA monoclonal immunocatalytic assay mab monoclonal antibody TG RER rough endoplasmatic reticulum SER smooth endoplasmatic reticulum 8

INTRODUCTION

The small intestine

The intestinal alkaline phosphatase belongs to the family of intestinal brush border .

In the small intestine digestion is completed and the formed products are absorbed. The absorptive capacity of the small intestine is significantly enhanced by the villus structure of the mucosa. The villi intrude approximately 1 mm into the intestinal lumen, with the crypts of Lieberkühn in between (Fig 1). The crypts are simple tubes, and in the lower part of the crypts undifferentiated cell proliferation takes place. As the cells differentiate, they move upwards along the villus and mature to absorptive . The life span of the is 3 - 6 days and dead cell fragments are continuously shed from the villi to the intestinal lumen. During maturation the luminal membrane of the enterocyte develop densely packed microvilli with the height of 1 pm, which increase the absorptive capacity of the intestinal mucosa even more (Fig 2). A coat of glycoproteins, the glycocalyx, covers the microvilli (Ito 1969). Together, the microvilli and glycocalyx form the brush border. The basolateral membrane of the enterocyte has no microvilli and is separated from the apical membrane by junctional complexes, which make the intestinal epithelium a very tight one. Thus, digestive products have to pass through the enterocytes at absorption from the lumen and discharge into the portal blood. Important digestive functions such as activation of pancreatic enzymes, final digestion of and oligosaccarides and uptake of nutrients are linked with the mi ero villar membrane, while the basolateral membrane is known to be responsible for the secretion of absorbed products of digestion. 9

Intestinal lumen Glycocalyx Brush border Microvilli

Muscle layers Lysome

Subm ucosa Muscularis mucosae Mitochondrion

Gdgi complex

Lamina propria Nucleus

Endoplasmic reticulum

Intercellular

11 membrane

Fig 1. Schematic drawing of a Fig 2. Schematic drawing of cross section of the small intestine the enterocyte (modified from (modified from Stenling 1986). Stenling 1986).

Microvillar enzymes

The digestive functions of the intestine are carried out by hydrolytic enzymes, which are bound to the microvillar membrane with the functional part of the molecule protruding into the intestinal lumen. The most abundant and thoroughly studied of the brush border hydrolases are the glycosidases and the peptidases, which are responsible for the final digestion of disaccarides to monosaccaride s, and peptides to dipeptides and aminoacids respectively (Hansen et al 1988). Monosaccarides and aminoacids are absorbed by the enterocytes and delivered directly into the portal blood. The (TG), however, are first degraded to free fatty acids or monoglycerides, which can be absorbed by the enterocytes. In the smooth endoplasmic reticulum (SER) of the enterocyte, resynthesis to TG occurs, and in the rough endoplasmic reticulum (RER), the TGs aggregate with phospholipids, and proteins to form chylomicrons (Scott 1989). These particles, 10

about 1 pm in diameter, are transported through the Golgi complex and secreted from the enterocyte by exocytosis at the lateral membrane into the intercellular fluid. Then they move into the lacteals and lymph vessels, and finally into the blood (Fig 3). This pathway is predominantly followed by long chain fatty acids (more than 10 carbons). Medium chain fatty acids can be absorbed directly to the portal blood as free fatty acids bound to albumin.

BILE ACIDS ► LIPIDS

Glycerol Fatty acids Monoglycerides

SER ^ Resynthesis o 0 ° * triglycerides rr ® I "ER y y J J <§> Synthesis^/fOyn I of proteinj Qr Triglyceride + — ►

• s complex

Basal lamina

Lymphatic capillary

Fig 3. Lipid absorption in the small intestine (Junqueira et al 1989). RER: rough endoplasmic reticulum, SER: smooth endoplasmic reticulum. 11

Human alkaline phosphatase isozymes

Human alkaline phosphatase [ALP, ortophosphoric-monoester phospho- (alkaline optimum), EC 3.I.3.I.] comprises four related isozymes, the tissue unspecific (AP), the intestinal (IAP), the placental (PLAP) and the PLAP-like alkaline .

In humans, IAP and PLAP are the major isozymes expressed in intestine and respectively, and have been regarded as organ specific. The AP isozyme is expressed as the major ALP in the bone, liver and kidney. All the ALP isozymes are membrane bound glycoproteins. The active consists of two identical subunits. A tetrameric quartemary structure in the plasma membrane has been suggested (Hawrylak and Stinson 1988).

The catalytic activity of the ALP isozymes is dependant on metal ions. Each monomer contains one firmly bound zinc ion, essential for structural stability, and a second zinc ion, less firmly bound and involved in the catalytic process. One magnesium ion, essential for catalytic activity, is bound to the on each subunit. Acording to the suggested three dimensional structure of the ALP isozymes (Kim and WyckofF 1989) all three metal sites are simultaneously coordinated by histidine and asparagine residues in the tissue specific ALPs. These metal sites are associated with active site and highly conserved in all the ALP isozymes, and loss of activity occurs if any of the metal ions are removed (Millàn 1990). These facts indicate functional importance. The ALP has been crystallized and a detailed X-ray diffraction structure has been determined (Sowadski et al 1985, WyckofF 1987), which lead to the suggested structure for the human ALPs (Kim and WyckofF 1989).

The proteins of the ALP isozymes are encoded by separate but related genes. The cDNAs encoding the AP, IAP, PLAP and PLAP-like isozymes have been cloned and sequenced (Kam et al 1985, Millân 1986, Weiss et al 1986, Berger et al 1987, Henthom et al 1988 a, Millân and Mânes 1988). The deduced amino acid sequencies show that PLAP and the PLAP-like isozymes comprise each 513 amino acids with an identity of 98%, and the intestinal isozyme 509 amino acids with 87% identity with PLAP and the PLAP-like isozymes. The tissue 12

unspecific ALP, the most divergent isozyme, comprises 507 amino acids presenting an identity of 50-60% with the three other ALPs (Harris 1989). The IAP, PLAP and PLAP-like loci are closely linked and located on , while the AP gene locus is found on (Griffin et al 1987, Smith et al 1988). The IAP, PLAP and PLAP-like genes are similar in size with eleven exons and small introns. However, they vary in their regulatory sequences and are highly tissue specific in their normal expression. The AP gene is about five times longer than the other genes with 12 coding exons and long introns. The AP gene is not tissue specific in its normal expression. The close homology of the ALP isozymes supports the concept that they have descended from a common ancestral gene (Fig 4) and that in the course of evolution, duplications and mutations have developed this complex multiple enzyme system (Harris 1982, Fishman et al 1990).

Ancestral gene

Tissue unspecific precursor gene

Intermediate intestinal ALP gene

Tissue unspecific Intestinal Germ cell ______ALP gene ALP gene ALP gene | I I I PLAP gene Tissue unspecific* Intestinal ▼ PLAP-like * " * " ALP ALP ALP Allelic variants ( liver.bone.kidney ) of PLAP AP IAP PLAP-like PLAP

Fig 4. Current view of the evolution of the alkaline phosphatase isozymes. (Modified from Fishman 1990).

The ALP isozymes are bound to the lipid bilayers by a phosphatidyl inositol glycan (GPI) moiety (Fig 5), which is covalently attached to the C-terminal amino add of the protein (Low et al 1986, Low 13

1987, Cross 1987, Howard et al 1987) . The action of GPI specific D (PLD), abundant in plasma, and of an intracellular GPI specific phospho- lipase C (PLC) may detach the enzyme from the membrane ( Malik and Low 1986, Davitz et al 1987, Low and Prasad 1988). The ÅLP isozymes are released from the tissues into serum at various physiological and pathological conditions. It was therefore suggested that the ALP isozymes might be released in vivo from the tissues into the serum by activation of endogenous GPI-PLC (Low and Zilversmit 1980). Recently, Low suggested that inositol acylation of the GPI anchor could profoundly affect the extent of ALP release from tissues as well as the molecular properties of the released ALP in plasma (personal communication at Symposium on "Recent Development in ALP Research", March 1992, Antwerp, Belgium).

protein

C-terminal amino acid ethanolamine glycan glucosamine nitrous acid

> phospho- PI-PLD inositoi (Pi)

membrane 2 diacyl- glycerol

Fig 5. Membrane anchoring of the ALP isozymes. (Modified from Low 1987). 14

Tissue unspecific alkaline phosphatase

The AP isozyme is synthesized mainly in the human liver, kidney and bone. The active enzyme is a homodimer with the apparent subunit Mr 68-85 kDa (Stigbrand 1984). The catalytic activity of AP is inhibited by L-homoarginine (Kellen and Lustig 1971) and (Van Belle 1976 a). Liver, kidney and bone derived isoforms can be distinguished electrophoretically, but have identical immunochemical and catalytic properties. The electrophoretic differences are due to glycosylation differences in a tissue specific manner. The AP isoforms can be separated on Concanavalin-A and Lentil lectin (Lehman 1980).

In sera from healthy individuals, the AP isozyme is the predominant ALP. The liver and bone derived ALPs are almost invariably present in the normal human serum, but the liver ALP isozyme is the main component (Smith et al 1968, Sussman et al 1968, Moss 1982). Prepuberty children normally have high serum activity of the bone ALP isozyme due to significant bone growth (Moss and Whitby 1975).

Placental alkaline phophatase

PLAP is expressed in the syncytiotrophoblasts of the term placenta (Fishman et al 1972) and in trace amounts in the normal lung (Hirano et al 1989 a) and the ovaries (Kellen et al 1976). PLAP is a membrane associated homodimer enzyme with a subunit of 58-63 kDa. The catalytic activity of PLAP is inhibited by L-phenylalanine and L-phenylalanylglycyl-glydne (Stigbrand 1984). The isozyme is characteristically heat stable, resisting treatment up to 65°C. PLAP shows a unique rate of allelic polymorphism, being the most polymorphic enzyme in the human body. Three common alleles and several rare alleles have been inferred at the placental gene locus (Beckman et al 1966, Harris 1982, Stigbrand et al 1982, Henthom et al 1986).

The germ cell or PLAP-like ALP differs from the PLAP isozyme by only 12 amino acids. Despite the high identity (98%), the PLAP-like isozyme is 15

uniquely inhibited by L-leucin (Nakayama et al 1970). Recently, transgenic mice with the human germ cell isozyme gene were generated. This human transgene was found to be expressed at high levels in the mouse intestine besides the mouse intestinal ALP. Furthermore, germ cell ALP was also detected in the sera of the mice (Millàn 1990).

Trace amounts of the placental isozyme can be detected in the normal human serum. During , PLAP is produced by the placenta and released into the maternal circulation in increasing amounts from the 12th week of pregnancy. PLAP disappears from the blood within 3 to 6 days after delivery (Fishman et al 1972, Fishman et al 1973, Holmgren et al 1978). Smoking causes elevated serum levels of PLAP (Maslow et al 1983, Tonik et al 1983, McLaughlin et al 1984, Koshida et al 1990).

Intestinal alkaline phosphatase

IAP is synthesized by the epithelial cells of the small intestine, the enterocytes. The active enzyme is a dimer with an apparent subunit molecular weight of 70-85 kDa. The catalytic activity of IAP is inhibited by L-phenylalanine (Stigbrand 1984). IAPs purified from fetal and adult intestinal mucosa have similar properties (Sugiura et al 1981), but IAP obtained before the 25th week of gestation (fetal IAP) can clearly be distinguished from adult IAP by electrophoresis. The switch from the fetal form to the adult form occurs between the 28th and 32nd week of gestation (Mulivor et al 1978 a). Fetal as well as adult IAP are glycoproteins, but the adult form lacks the terminal sialic acids. Neuraminidase treatment is usually considered to eliminate the differences between the two forms (Komoda et al 1981, Verpooten et al 1989 a). However, after neuraminidase digestion some molecular differences still remain. Whether this reflects other differences in glycosylation pattern or differences at the protein level remains unclear. Peptide map analysis and different immunochemical reactivity patterns (Vockley et al 1984 a and b) indicate putative differences also at the protein level. This may be a consequence of the possible existence of separate gene loci (Mueller et al 1985). 16

Small amounts of IAP are present in some normal human sera, but not in all (Moss 1982). Several reports from the 1960s (Keiding 1964, Blomstrand et al 1965, Langman et al 1966, Beckman et al 1970, Denborough et al 1971, Reynoso et al 1971) confirm that IAP enters the blood via the thoracic duct lymph in large amounts after fat ingestion. IAP is, however, rapidly cleared from the circulation (Komoda et al 1981). IAP lacks the terminal sialic acid and can thus be cleared by galactosyl-glycoprotein receptors on the hepatocytes (Ashwell and Morell 1974, Meijer et al 1982). The IAP levels in the serum seem to be a function of input from the gut and elimination by the liver. It is, however, unclear if the gut is the only source of serum IAP. Furthermore, the IAP activity in the blood has been assumed to be under genetic control. IAP is more frequently found in the sera from subjects with blood groups B or 0, who are also secretors of red blood cell antigens, than in non-secretors and blood group A individuals ( Arfors et al 1963, Beckman 1964, Komoda et al 1978). It has has been suggested the IAP molecule carries blood group antigens (Komoda et al 1978 and 1981, Bayer et al 1980).

Knowledge of the mode of biosynthesis and the mode of anchoring in the membrane for the IAP isozyme is limited. Low (1987) have suggested that in general, the alkaline phosphatases are anchored in the plasma membrane by a GPI moiety. Recently, it was suggested that the IAP isozyme is attached that way to the enterocytes of calf intestine (Hoffinan-Blume et al 1991). If this is the case also in humans, IAP would be different from the other microvillar enzymes, since they are all, as far as is presently known intrinsic membrane proteins. These proteins are found to be synthesized in the RER as proproteins and then processed, glycosylated and transported through the Golgi membranes, from where they reach their final position in the brush border. They are inserted in the microvillar membrane by a short hydrophobic N-terminal amino acid sequence and with a small segment forming a connecting piece, "a stalk", between the membrane anchor and the bulk of the extracellular protein (Sjöström et al 1983, Danielsen et al 1984, Semenza 1986). 17

Function of the alkaline phosphatase isozymes

Despite the detailed information of sequence data and gene organisation for the ALP isozymes, the question of their in vivo function has still not been answered. Their presence in all species, from to humans, indicates that the ALP isozymes are involved in fundamental biological processes (McComb et al 1979).

However, some biological processes with the involvement of the ALP isozymes are known. It is, for example, clear that the presence of the AP isozyme on the cell membrane of is necessary for bone mineralisation (Rodan and Rodan 1983). Furthermore, it has recently been suggested that the PLAP isozyme can bind IgG molecules and transport them through the placenta from the mother to the faetus (Makia et al 1992 a and b). This proposes a protein binding function in addition to the catalytical function of the PLAP isozyme.

There is high concentration of the IAP isozyme in the small intestinal brush border membrane. Since IAP activity is elevated in the blood after fat rich meals, IAP may be involved in fat absorption. The mechanism for this is, however unclear. Another possible function is that IAP catalyzes the hydrolysis of esters, normally not absorbed in the gut, so that the inorganic phosphate and the non-phosphorylated moiety can be absorbed separately. A third possibility is that, in analogy with PLAP, IAP interacts with some protein component in the intestinal content for its transport through the mucosal cells of the intestine.

Selective identification of alkaline phosphatase isozymes

The close relationship between the ALP proteins has made their selective determination difficult in the serum and tissue homogenates. Differential properties such as electrophoretic mobility, kinetics of heat and urea inactivation, uncompetitive inhibition by amino acids, neuraminidase sensitivity, differences in lectin binding and catalytic and immunochemical differences have been used individually or in combination to quantify each IS

isozyme (Fishman 1974, Moss 1982). The PLAP and PLAP-like isozymes can for example be heated at 65°C for one hour without loss of activity, whereas the IAP and AP isozymes are rapidly inactivated under these conditions (Moss and Whitby 1975, Mullivor et al 1978 a, Chang et al 1980, Goldstein et al 1982). The IAP, PLAP and PLAP-like isozymes are all inhibited by L-phenylalanine, whereas the AP isozyme is not. In contrast the AP isozyme is more sensitive to L-homoarginine than the IAP, PLAP and PLAP-like isozymes (Stigbrand 1984). Levamisole is a potent inhibitor of the AP isozyme, but has little inhibitory effect on the other ALP isozymes (Van Belle 1976 a). L-leucine characteristically gives much stronger inhibition of the PLAP-like isozyme than the other ALPs (Nakayama et al 1970).

Electrophoretic resolution of the ALP isozymes has been used on different supporting media, e g starch, polyacrylamide, agarose. AP displays fast, PLAP medium, and IAP slow anodal migration (Moss 1982). However, since different forms of each isozymes have almost the same electrophoretic mobility, combinations with heat inactivation, neuraminidase treatment and antisera are still necessary to fully discriminate all the different forms of the ALP isozymes.

Antisera raised in rabbits against purified ALP isozymes are discriminative, but cross reactions occur between the IAP, PLAP and PLAP-like isozymes. Some but not all of the antigenic determinants detected on the PLAP molecule are also present on the IAP molecule. The hybridoma technology (Köhler and Milstein 1975) for producing monoclonal antibodies (mabs) has offered new discriminatory tools for selective determinations of closely related molecules. Accurate quantifications of the different ALP isozymes in biological fluids, e g serum, urine, ascites, have a great impact on their informative value in diagnostic considerations. Liver and bone ALPs in the human serum are the most relevant for diagnostic purposes, e g in , cirrhosis, extrahepatic obstruction, malignant tumors (Moss 1987). For identification and quantification of the almost identical liver and bone ALPs great efforts are currently made to produce monoclonal antibodies specific for each of these isozymes (Lawson et al 1985, Hill and Wolfert 1989). They only differ in posttranslational glycosylation patterns, and most attempts to produce non-cross reacting mabs have failed. A number of mabs raised 19

against each of the four ALP isozymes and recognizing different determinants on the molecules have provided new detailed information about the different ALP isozymes (Wahren et al 1986).

Clinical relevance of alkaline phosphatase isozymes

The clinical usefulness of ALP activity determinations in the serum is evident by the fact that this is one of the most frequently used parameters in . Elevations of serum ALP activity occur in a wide variety of pathological conditions.

Diseases with an obstructed bile flow cause high serum AP (Sebesta et al 1964). The AP elevations in these conditions are suggested to be due to increased enzyme synthesis and are of significant diagnostic importance. High levels of ALP activity due to the AP isozyme are also detected in patients with bone disorders (Rodan and Rodan 1983). is an "inborn error of ", characterized by gross deficiency of the AP isozyme in all tissues and in the serum (Warshaw et al 1971). This deficiency is due to a mutation in the coding region of the AP gene (Weiss et al 1988), and leads to defective osteogenesis due to failure in bone mineralization (Fraser 1957, Mulivor et al 1978 b).

Besides during pregnancy, the PLAP isozyme is elevated in serum at certain malignant conditions. PLAP as a tumor associated enzyme was first discovered by Fishman in a patient with oat cell carcinoma of the lung. This enzyme was called the Regan enzyme (Fishman et al 1968). The Nagao enzyme, another PLAP-like enzyme (Nakayama et al 1970), is released into the circulation from seminomas and ovarian cancers, and is a clinically useful marker for these two malignancies (Lange et al 1982, Jeppson et al 1984, Stigbrand et al 1985, Stigbrand and Wahren 1992).

An increased incidence of the LAP isozyme in the serum has been reported in diseases of the digestive tract (Dent et al 1968) in patients with end stage renal failure (De Broe et al 1974), and in diseases which lead to cirrhosis of the liver (Stolbach et al 1967). Some tumors appear to ectopically express IAP. In the 20

sera from both primary hepatoma patients (Higashino et al 1975) and a lung cancer patient (Moss et al 1986), IAP-like isozymes have been described. These "Kasahara" isozymes have been found in two electrophoretically different forms (Hada et al 1984).

The ÂP and PLAP/PLAP-like isozymes are thus used as diagnostic tools, AP in the diagnosis of liver and bone diseases and PLÀP as a marker for certain malignancies (Stigbrand and Wahren 1992). However, raised serum levels of IAP have so far been of little diagnostic value.

What is a secretori

Secretors with blood groups B or 0 have higher frequencies of high serum IAP activity than non-secretors and blood group A individuals (Beckman 1964, Arfors et al 1963, Komoda et al 1978). Therefore, the clinical usefulness of serum IAP level determinations is complicated.

The A, B, H and Lewis (Le) antigens are carbohydrate structures, which occur on the surface of the erytrocytes and epithelial cells (Marcus 1969, Oriol et al 1986). If these antigens occur in body fluids, e g plasma and saliva, the individual will be classified as a secretor; if not, as a non-secretor. It is also known that A, B, H and Le substances are present on the absorptive cells of the small intestine and on hydrolytic enzymes bound to the microvilli (Triadou et al 1983, Mollicone et al 1986, Green et al 1988). Komoda et al (1981) have presented evidence that bloodgroup substances are present on IAP molecules. This expression is suggested to be controlled by the Le and Se gene loci (Triadou et al 1983).

The secretor status of an individual is determined by the type of Le-antigen on the erytrocytes (Fig 6). Two main antigens, Lea and Le^, have been identified. The fucosyltranferase coded by the active Le gene adds a fucose residue to the subterminal N-acetylglucosamin of a precursor oligosaccaride, resulting in the non-secretor phenotype with Lea antigen on red blood cells. If also the Se gene is active, an additional fucose is added to the terminal galactose on the precursor substance, resulting in the secretor phenotype with Le^ antigen on 21

the red blood cells, and with A, B, H and Leb substances in the body fluids and on the intestinal mucosal hydrolases (Marcus 1969, Oriol et al 1986).

Lewis system Le a antigen Gic Gal NAc Gal vGICy non-secretor

Fuc

L e b antigen Glc vGIC/ Gal NAc Gal secretor

Fuc Fuc

A B H system

i Glc Gal — î NAc Gal

Fuc

[ Glc Gal — Ï NAc Gal

Fuc

Gal Gal i NAc i Gal

Fuc

Fig 6. Illustration of the A, B, H and Lewis antigens. (GlcNAc = N-acetylglucosamine, GalNAc = N-acetylgalactosamine, Gal = galactose, Glc = glucose, Fuc = fucose) 22

AIMS OF THIS THESIS

- To develop assays for selective determinations of the ALP isozymes. - To immunochemically quantify the expression of the ALP isozymes in normal human tissues. - To immunohistochemically localize the expression of IAP in selected organs. - To investigate a possible relation of the IAP isozyme to clinical disorders of the . - To determine the influence of ABO blood groups and secretor status on the circulating IAP levels. - To study the relationship between IAP and fat absorption. 23

RESULTS AND DISCUSSION

The assays (Papers I and II)

A prerequisite for this study was the availability of selective and sensitive assays for each of the ALP isozymes. One mqjor problem in the development of such assays has been the extensive similarity between the IAP and PLAP isozymes. Conventional techniques and polyclonal antisera do not discriminate well enough between the isozymes to allow their quantitative determination in samples, where they occur together and in small amounts. Monoclonal antibodies (mabs) recognize single epitopes on proteins and are thus capable to discriminate between closely related molecules. Therefore, highly specific monoclonal antibodies were raised against each of the AP, PLAP and IAP isozymes, by immunizing mice with purified liver ALP, PLAP and IAP respectively. After fusion and cloning, a battery of positive clones was obtained. By characterization of the different monoclonal antibodies, those that had high affinity and high specificity for the respective antigen were chosen for the assays. The anti-PLAP antibody, HPMS-1, had high affinity for all phenotypes of the PLAP and PLAP-like isozymes. The anti-liver ALP antibody, HLMS-1, had high affinity for the AP isozyme (from bone, liver and kidney), and the anti-IAP antibodies 2HIMS-1 and 2HIMS-2, had high affinities for both the adult and fetal forms of IAP. No cross reactivity was observed for the chosen antibodies (Table 1). The developed assays are called MICAs (monoclonal immunocatalytic assays).

Table 1. Characteristics of the antibodies used in the MICAs

Antigen Monoclonal Immuno- Affinity constant antibody globulin AP IAP PLAP

AP HLMS-1 IgGi (k) 4.07x1010

IAP 2HIMS-1 IgG2b (k) 5.75x109

IAP 2HIMS-2 IgG2a (k) 3.16x1Q10 *

PLAP HPMS-1 IgGi (k) * * 4.17x109

*) below the detection limit 24

IAP MICA Substrate Product —► A 495 nm

Fig 7. Monoclonal immunocatalytic assay (MICA) for determinations of immunoreactive and enzymatically active IAP.

In the original MICAs the mabs were covalently coupled to cyanogen bromide activated paper discs. These discs were then used to trap the isozymes in serum or tissue homogenate, and the catalytic activity of the bound ALP was directly used to quantify the isozyme (Paper I and Hirano et al 1986). This version of the MICAs was used for the measurements described in papers I, IV and V.

Later, the MICAs were improved by the use of microtiter plates instead of paper discs as a solid phase (Fig 7). The substrate, phenylphosphate, was also changed for p-nitrophenylphosphate, and in the IAP-MICA the mab 2HIMS-1 was changed to 2HIMS-2, which has higher affinity for IAP. Several advantages were gained by using the new MICAs. These assays were more rapid and simpler to use than the original ones, and a smaller amount of mab was needed. Furthermore, the final measuring of the absorbance was quickly and conveniently carried out by an automatic multiscanner. The improved MICAs were used in the measurements presented in papers II, VI and VII.

Both the old and new MICAs were used to quantify each ALP isozyme in tissue homogenates from the liver, lung, kidney, placenta, small intestine, colon and testis with similar results (I, II). 25

The total ALP activity was normally low in most organs, except in the small intestine and term placenta, which both expressed high activities. In the small intestine more than 95% of the ALP activity was of the IAP type, and in colon about 90% (Table 2). The ALP activity was highest in the duodenum (38.9 IU/g tissue) and decreased distally with low total activity in the colon (2.5 IU/g tissue). The term placenta expressed the PLAP isozyme by more than 99%. In the liver, kidney and lung the total ALP activity was low, about 2 IU/g tissue in each organ, and the main isozyme expressed was AP (about 90%). In the kidney as much as about 9 % of the ALP activity was of the IAP type. This kidney derived IAP has later been purified and characterized by Hirano et al (1989 b). The relatively high expression (1.4%) of PLAP in normal lung is of interest, because high levels of PLAP have been observed in sera from smokers (Maslow et al 1983, Tonik et al 1983, McLaughlin et al 1984, Koshida et al 1990). Later Hirano et al (1989 a) have purified a PLAP-like ALP from lung tissue.

Table 2. Relative activities of the ALP isozymes in different organs.

Relative activity (%) Organ of No. of Total activity origin samples AP IAP PLAP IU/g tissue Small intestine

• duodenum 4 1.5 97.7 0.8 38.9 - jejunum 4 2.2 96.9 0.9 22.7 - ileum 4 1.4 98.1 0.5 14.3 Colon 4 7.9 90.9 1.2 2.5 Liver 6 97.7 1.8 0.5 2.7 Kidney 4 91.1 8.7 0.2 2.3 Lung 5 98.1 0.5 1.4 2.1 Term placenta 3 0.3 0.1 99.6 69.3 Testis 4 86.2 6.9 6.9 0.6 26

The normal testis expressed extremely low total ALP activity (0.6 IU/g tissue). In normal testis tissue both IAP and PLAP were demonstrated to contribute to the total activity in similar amounts, about 7% each.

With the sensitive MICAs it was found that the ALP isozymes are not restricted to single and defined organs, as previously assumed, but widely distributed and present together in most organs in varying proportions .

Immunohistochemical localization of the intestinal alkaline phosphatase (Paper III)

The widespread expression of the ALP isozymes, described in paper I and II, called for a further examination of their cellular localization. The kidney, and organs connected to the gastrointestinal tract, viz the liver, pancreas, and common , were selected for immunohistochemistry. There are very few reports on the localization of the ALP isozymes within these organs (McComb et al 1979); those available are mainly based on histochemical staining of total catalytic ALP activity and do not reflect the selective patterns of ALP isozyme expression in the tissues.

Attempts to use the previously prepared mabs, used in the MICAs, were not sucessful in the immunohistochemistry. Therefore, we produced mabs specific for the IAP isozyme. One of them, the IAP4 mab, was used for the immunohistochemical examination of the specific tissue localization of the IAP isozyme. The chosen organs were known to express trace amounts of IAP, if at all. Therefore, highly sensitive techniques had to be used for the . An amplified biotin streptavidin alkaline phophatase staining method (Shi et al 1991) and the use of the IAP4 mab, which was of IgM isotype, resulted in a distinct pattern of the IAP distribution in electron microscopy as well as in light microscopy.

IAP was found in sections of the liver, kidney and pancreas and was localized in the epithelial cells of the bile ducts of the liver, the distal tubules and collecting ducts of the kidney and the exocrine acinar cells of the pancreas (Paper III, Fig 4). Contrary to our results, the kidney IAP has been 27

localized to the proximal convoluted tubules by others using different antibodies (Pfleiderer et al 1980, Verpooten et al 1989 b). In agreement with us Alpers et al (1988) localized the enzyme to the apical membranes of the collecting tubules. This contradiction may indicate that different types of IAP are expressed in the kidney.

IAP has been reported to be secreted into the bile by liver cells (Warnes et al 1981). We did not notice IAP in the hepatocytes, but rather in the epithelium of the liver bile ducts, and in Kupffer cells, which are involved to a small extent in the protein export from the liver. These results may indicate that IAP is not synthesized in the liver but metabolized in an enterohepatic circulation as suggested by Warnes et al (1981). The endothelium was stained in some but not in all capillaries in the liver as well as the kidney.

By immunelectron microscopy using the mab IAP4, the main localization of IAP in the microvillar region of the small intestinal mucosa was confirmed (Paper III, Fig 2a). The extensive lumenal layer of membrane fragments overlaying the microvilli was also rich in IAP activity. These lumenal membrane bodies have been described and visualized in the rat intestine by others (De Broe et al 1977, Misch et al 1980, DeSchryver-Kecskemeti et al 1989 and 1991). These morphologically dominating structures are probably budding from the microvilli and may contain other microvillar enzymes as well, thereby amplifying the final digestion in close connection with the absorptive enterocyte (Eliakim et al 1989). The basolateral membrane of the enterocyte and the capillary endothelium in the small intestinal submucosa were shown to express IAP (Paper III, Fig 3). IAP was also found in small pinocytotic vesicles in the endothelial cell wall, which may indicate its involvement in transport across the membrane.

The general localization of IAP in membranes intensely involved in transport suggests that IAP participates in the active transport of some metabolites across the membranes, where it is frequently expressed. However, the in vivo substrate(s) and the mechanisms for this transport are unclear and a matter of discussion. 28

Alkaline phosphatase isozymes in malignancies (Paper IV)

One of the basic concepts of oncodevelopmental biology has been the similarities in the enhancement of specific gene expression during normal embryogenesis as well as malignant transformation causing rapid growth (Abelev et al 1963). This process generates an increased synthesis of growth-promoting cell components, which are all typical and often identical in both tumors and fetal cells. Furthermore, oncofetal or carcinoembryonic antigens have been described (Abelev et al 1963, Gold et al 1965 and 1970). One of these is the placental alkaline phosphatase, PLAP, which has been shown to be present in both the serum and tumor tissue from patients with active disease (Fishman et al 1968, Wahren et al 1979, Harmenberg et al 1989). Both PLAP and IAP are known to be expressed in the course of normal embryogenesis (Fishman et al 1976, Mulivor et al 1978 a), PLAP also following malignant transformation (Fishman et al 1968).

In seminomas, testicular germ cell tumors, increased levels of all three ALP isozymes were demonstrated (Paper IV, Table 1). The relative increase in tumor tissue content was the same for AP as for PLAP (10- to 100-fold), while the IAP increase was only moderate (2- to 10-fold). In testis tumors derived from the primitive endoderm, elevated levels of the IAP isozyme were expected, and this was indeed confirmed. The highest level of IAP activity in the examined testicular tumors was seen in one of the yolk sac tumors (Paper IV, Table 1).

Elevations of the AP and the PLAP-like isozymes have previously been related mainly to tumors of germinal origin (Millàn and Manes 1988). A recent investigation of colorectal adenocarcinomas, however, presented increased levels of both the AP and PLAP-like isozymes in the tumor tissue. On the contrary, the IAP activity decreased in these tumors (Harmenberg et al 1991). An IAP-like isozyme, the "Kasahara" isozyme, has been demonstrated in the sera from patients with primary hepatoma as well as in hepatoma tissues (Higashino et al 1975, Hada et al 1984). Moss et al (1986) demonstrated the presence of an IAP-like isozyme in the serum from one patient with lung cancer. 29

This may indicate that elevated levels of AP and PLAP is a general phenomenon following malignant transformation. The role of 1AP in malignant transformation is however still unclear and has to be further investigated.

Alkaline phosphatase isozymes in non-malignant gastrointestinal and liver diseases (Paper V)

In most organs inflammatory conditions are accompanied by a significantly increased release of tissue specific enzymes into the . IAP activity in the small intestine is very high, and therefore it is possible that this isozyme could be secreted into serum and thus be a marker of inflammatory gastrointestinal diseases.

Sera from patients with inflammatory gastrointestinal diseases, such as active Crohn's disease and active ulcerative colitis, were assayed for the levels of the AP, IAP and PLAP isozymes. None of the ALP isozymes displayed any elevation of serum activity, neither in Crohn's disease nor in ulcerative colitis. On the contrary, a slight decrease of mean serum activity was observed for the IAP isozyme (Paper V, Table II). Both in Crohn's disease and in ulcerative colitis the intestinal mucosa is degraded. The resulting impaired digestive function of the intestine may explain the slight decrease in serum IAP, which is derived from the intestine and known to enter the circulation in large amounts in fat absorption (See Paper VII). When the small intestine is affected the mucosal cells and consequently the microvillar enzymes are probably shed into the intestinal lumen rather than into the blood (Norén et al 1986).

Diseases of the liver are known to cause high serum levels of ALP activity, mainly due to an increased production of the AP isozyme by thehepatocytes (Moss 1987). Sera from patients with cirrhosis of the liver, and primary biliary cirrhosis (PBC) were assayed by the MICAs. Significantly elevated serum levels of IAP activity were found in cirrhotics. Also in PBC, sera were significantly high in IAP activity, but not in cholestasis (Paper V, Table IV). The cirrhotic condition is characterized by impaired liver function 30

due to destruction of the liver parenchyme. It is most likely that the high serum LAP in this condition is due to inhibition of the clearing of the enzyme by the liver. A complex pattern of IAP activities in different stages of PBC was noted. The highest mean elevation was observed for the group diagnosed as moderate PBC, while the severe PBC group with the most impaired liver function had lower serum IAP levels (Paper V, Table IV). This may be explained by the variability in serum IAP with ABO blood groups and secretor status, which was not considered in this study (See Paper VI). The proposed mechanism of inhibited clearing agrees with the fact that normal serum IAP activity was found in cholestasis. In this condition the liver parenchyme is unaffected. Variations of IAP activities in the serum have so far not been used for diagnostic purposes. In patients with cirrhosis of the liver, however, IAP determinations could be informative.

The AP isozyme was found to be elevated in all the investigated liver diseases. This agrees with what is well known. Elevated serum levels of AP in diseases of the liver is predominantly due to an increased enzyme production, and this matter is of great diagnostic importance in hepatobiliary diseases (Moss 1987). Low, but significant, elevations of serum PLAP were noted in all the investigated liver diseases (Paper V, Table IV). This may interfere with the use of PLAP as a serum marker for seminomas.

Serum levels of intestinal alkaline phosphatase in relation to blood groups (Paper VI)

IAP activity in the blood of healthy individuals has been reported to be related to bloodgroups (Arfors et al 1963, Beckman 1964). To what extent was the divergent pattern of serum IAP activity in PBC (Paper V) influenced by bloodgroups? To evaluate this, serum IAP activitiesof healthy blood donors were quantified and related to ABO blood groups and secretor status. The main result was that non-secretors, regardless of ABO blood groups, had low serum levels of IAP activity. Group B and 0 secretors had high mean activities of serum IAP but individual variations from about 2 IXJ/1 to more than 40 IU/1 (Paper VI, Fig 1 and Table 1). Group A secretors had low mean IAP activities, which were in the same magnitude as those of non-secretors, 31

although some A secretors displayed high IAP activities. Group AB secretors were intermediate to the B and A secretors in mean IAP activity. These quantitative results confirm observations of Arfors et al (1963) and Beckman et al (1964) based on electrophoretic separations.

The varying IAP levels may be due to different clearance rates of IAP by the liver. In contrast to the other ALP isozymes, IAP lacks terminal sialic acids. Therefore possible terminal galactose residues on the carbohydrate chains of the IAP molecule are exposed and can bind to receptors at the liver. Human small intestinal mucosa and brush border hydrolases carry large amounts of A, B, H and Le^ substances in secretors (Fig 6). However, in non-secretors abundant Lea substance but no A,B, H or Le^ substances are expressed in the mucosa (Triadou et al 1983, Mollicone et al 1985 and 1986, Green et al 1988). The terminal galactose residue in the Lea antigen is readily recognized by galactosyl receptors of the liver (Sholtens et al 1982 a and b, Ashwell and Morell 1974) and the non-secretor IAP would swiftly be cleared from the circulation. Thus the high levels of serum IAP in patients with severe cirrhosis of the liver may in part be explained by the inability of the liver to clear the enzyme. If so, it would also be of great importance to know the secretor status of a patient, when IAP is used as a diagnostic tool.

The delivery of IAP to the blood may also be a factor of importance for the serum levels. IAP is known to enter the blood stream in large amounts after fat feeding. This aspect is dealt with in paper VII. There may also exist other possibilities of enzyme release to the blood from the intestine or other organs. This is unclear as well as the way other ALP isozymes enter the blood.

The serum levels of AP and PLAP did not display any significant differences with regard to blood groups (Paper VI, Figs 2 and 3, Tables II and III).

Serum levels of intestinal alkaline phosphatase in fat feeding (Paper VII)

It is known that IAP enters the lymph and subsequently the blood after a fat rich meal (Keiding et al 1964, Blomstrand et al 1965, Langman et al 1966, Beckman et al 1970, Reynoso et al 1971, Denborough et al 1971). We wanted to 32

study the quantitative variations in IAP activity following both fat rich and fat free meals and also to investigate the relationship to bloodgroups. For this purpose we quantified both IAP activity and TG concentration in plasma of 28 male subjects after a standardized oral fat load. We also quantified the serum IAP activity in 8 healthy volunteers after fasting for six consecutive days and finally after a fat free meal.

After the fat rich meal the triglyceride (TG) concentration and the IAP activity rose sharply and simultanously in the blood and peaked at about the same time. IAP was found to be cleared from the blood differently from the TGs. The TGs were completely cleared 12 hours after the meal, while IAP activity was not. Individual differences in the clearing rate of IAP activity were observed, and it seems likely that this rate is dependant on the secretor status of the subject. Fat free meals did not induce IAP release into the blood. It was questioned whether IAP was transported to the blood bound to the chylomicrons. This is a conceivable possibility, since the GPI tail of the IAP molecule enables the incorporation of IAP into the chylomicrons during their synthesis in the enterocyte (Scott 1989, Hoffman-Blume et al 1991). See Fig 3. If transported by the chylomicrons, when in the lymph, the IAP molecule would immediately be cleft off by the action of GPI specific , which is abundant in the lymph (Low and Prasad 1988, Eliakim et al 1990). This would be in accordance with our finding that IAP was not bound to chylomicrons or any other lipoproteins in the blood. The fact that IAP activity was not elevated in the serum after a meal of only carbohydrates and proteins supports the suggestion of a chylomicron dependent transport. Another transport mechanism has been suggested, in which the IAP molecule is bound to lamellar membraneous particles, which are secreted into the serum and into the lumen of the intestine (Alpers et al 1989, DeSchryver- Kecskemeti 1991).

When studying day to day variations of serum IAP, our results in paper VI were confirmed. Secretors displayed high fasting levels of serum IAP, while non-secretors presented low serum IAP levels (Paper VII, Fig 1 and Paper VI, Fig 2). The secretors also displayed wide day to day variations, while the non-secretors varied only a little (Paper VII, Fig 1). Again, these differences may depend on the rapid clearing of non-secretor IAP by galactosyl receptors 33

on the liver (Meijer et al 1982). Non-secretor IAP presumably carries a large amount of Lea antigens with terminal galactose residues (Triadou et al 1983, Oriol et al 1986). That the secretor IAP is cleared more slowly and that the secretor levels of IAP vary a lot may depend on possible différencies in A, B and H antigens on the IAP molecule.

The probable presence of blood group antigens on the IAP molecule in the intestinal mucosa may also impact the release of the enzyme into the blood. No differences between secretors and non-secretors with regard to mucosal IAP activity have been observed, however (Schreffler 1966). Nor have any differences been observed in lymph IAP activity related to secretor status after fat ingestion (Reynoso et al 1971). 34

CONCLUSIONS

Specific monoclonal antibodies were generated for each of the ALP isozymes and used in sensitive and discriminative assays, MICAs, for the AP, PLAP and IAP isozymes. With the MICAs, quantitative determinations of these isozymes in tissue homogenates and sera were carried out. The results support the following conclusions.

- The ALP isozymes were found to be simultaneously expressed in several tissues. The AP as well as the PLAP isozyme were identified besides IAP in the small intestine. IAP was identified in the liver, kidney, lung and testis besides the main AP isozyme. Thus the ALP isozymes are not restricted to single and defined organs, as previously assumed, but widely distributed and present in varying proportions and together in most organs.

- In the small intestine, liver, kidney and pancreas the IAP isozyme was immunohistochemically localized to the epithelial cells of membranes lining ducts, tubules and vessels. This general localization of IAP in membranes intensely involved in transport suggests that IAP participates in the active transport of metabolites across the membranes.

- The IAP isozyme constitutes less than 10%, AP 90% and PLAP about 1% of the total ALP activity in the normal serum. Serum IAP activity varies genetically. Non-secretors have low IAP activities compared with secretors. Blood group B or 0 secretors more often have high serum IAP activity than blood group A secretors. In the group with high IAP activities, considerable interindividual variations were observed, as well as high individual day to day variations. These varying serum levels of IAP may in part be due to different rates of clearing of this asialoglycoprotein by the liver. 35

- The IAP release to the blood from the enterocytes is significantly stimulated by fat absorption. This may indicate a transport of IAP bound to chylomicrons. However, in the blood IAP was not associated with any lipid fraction. IAP was also cleared from the blood at a rate that was different from that of the TG. We propose that in blood, the turnover of IAP is not influenced by the turnover of lipoproteins.

- In testis tumor tissue, the highest levels of IAP were observed in one yolk sac tumor. This agrees with the endodermal origin of these tumors. All ALP isozymes, including IAP, displayed increased activity in seminoma tissue. The role of IAP in malignant transformation is, however, unclear and has to be further investigated.

- Cirrhosis of the liver causes elevated serum levels of the IAP isozyme, probably due to impaired clearing of the isozyme. This is the only pathological condition found to implicate elevated serum IAP activities. It should be noted that inflammatory conditions of the small intestine showed normal serum IAP activities. 36

ACKNOWLEDGEMENTS

This study was carried out at the Department of Biochemistry and Biophysics, University of Umeå. I am deeply grateful to all those within the department as well as outside, who have helped me throughout the years to go through with this work. Those who have been more closely involved in this study and to whom I wish to express my most sincere gratitude are:

Professor Torgny Stigbrand, my supervisor, for accepting me as a research student and for introducing me into the field of alkaline phosphatases. His extensive knowledge, never failing optimism and enthusiasm, and great capacity have made this study possible.

Professor Kazuyuki Hirano, for his excellent help and guidance during the first years of this work and for continued collaboration and support.

Professor Thomas Olivecrona, for his scientific guidance of one part of this thesis and for kindly spending time with me in rewarding discussions.

Bo Appelberg, Director of the College of Health and Caring Sciences in Umeå, for encouragement and support throughout the years.

Sven Carlsson, for useful and valuable scientific and technical advice.

Åke Danielsson, Ulf Gerdes, Anders Lindgren and Vladimir Baranov for excellent collaboration.

Present and former members of the "Stigbrand group", Ricardo Makia, Poul-Erik Jensen, Luis Arbelaez, Ann-Sofie Larsson, Lena Bostedt, Annika Jeppson, José Millân and Erik Berglund for sharing lab space and for convivial exchange of viewpoints on life and science. 37

Berith Nilsson, for friendly collaboration with the monoclonals and for giving me daily encouragement and support.

Helene Genberg, Lisbeth Ärlestig, Elisabeth Näslund and Kerstin Falk for competent technical assistance.

Ingrid Råberg, Marianne Lundberg and Terry Persson for readily helping with secreterial work.

Christina Borg and Anders Fredlander for collegial and personal contributions.

Professor Anna-Karin Holm for being my friend and for substantial support throughout this study.

Inger Henrysson for correcting my English in a friendly way.

All my friends and colleagues for support and sympathy.

Last but not least my beloved husband, Torgny, for his ever present empathy and congenial assistance with scientific as well as practical things. Without his support this thesis would not have been realized.

This study was subsidized by grants from the Swedish Cancer Society (No 1387), Lions" foundation in Umeå, the Medical Faculty, University of Umeå, Västerbottens Läns Landsting, Svenska Sällskapet för Medicinsk Forskning, and J C Kempes Akademiska Fond. 38

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