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Fecal Elastase-1 As a Test for Pancreatic Function: a Review

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Fecal Elastase-1 As a Test for Pancreatic Function: a Review Clin Chem Lab Med 2002; 40(4):325–332 © 2002 by Walter de Gruyter · Berlin · New York Review Fecal Elastase-1 as a Test for Pancreatic Function: a Review Roberto Dominici1 and Carlo Franzini1, 2* matostatin (δ-cells) and pancreatic polypeptide (PP- cells) organized into islets scattered throughout the ex- 1 Istituto di Scienze Biomediche, 2 Università degli Studi di Milano, ocrine pancreas. The endocrine and exocrine compart- Ospedale Luigi Sacco, Milano, Italy ments are structurally and functionally integrated through an islet-acinar portal blood system that facili- tates the regulation of acinar cell funtions directly by islet peptide hormones. Historically, any proteinases Pancreatic elastase-1 is a specific human protease syn- that hydrolyze elastin, the major structural fibrous pro- thetized by the acinar cells. Immunoreactive elastase-1 tein in connective tissues, and especially elastic fibers, cannot be detected in either porcine or bovine pancre- were named elastases. This name is now applied to a atic enzyme preparations. It is very stable and, in con- group of enzymes that vary in their specificity. The trast to fecal chymotrypsin, elastase is unaffected by genes coding for the elastases are clustered on chro- exogenous pancreatic enzyme treatment, and corre- mosome 19, and three main types of enzymes are lates well with exocrine pancreatic function tests. The known: a) pancreatic elastase-1 (E1), or pancreatopep- measurement of this proteolytic enzyme in stool by tidase EC 3.4.21.36; b) pancreatic elastase-2 EC means of an enzyme-linked immunosorbent assay 3.4.21.71; c) pancreatic endopeptidase-3 EC 3.4.21.70, (ELISA) is a sensitive, specific, and relatively inexpen- also called cholesterol-binding proteinase. These sive non-invasive test. It is an accurate function test for forms of proteases with elastolytic activity differ in re- patients with chronic pancreatitis confirmed by endo- spect to their catalytic properties. The proteases, scopic retrograde cholangiopancreatography and named elastase-1 and elastase-2, have been isolated computerized axial tomography. It shows higher sen- from activated extracts of human pancreatic tissue: the sitivity and specificity for exocrine pancreatic insuffi- purification procedure used for both elastases included ciency than fecal chymotrypsin determination and is ammonium sulfate fractionation followed by ion-ex- comparable to oral pancreatic function tests such as change chromatography on CM Sephadex C-50. E1, the pancreolauryl test. Clin Chem Lab Med 2002; which is very similar to another human protease, pro- 40(4):325–332 tease E, which lacks elastolytic activity, was further pu- Key words: Proteases; Elastase-1; Pancreatic function rified by chromatography on DEAE-Sephadex A-50. tests; ELISA. Feinstein et al. (1) also reported differentiation of these two pancreatic elastases on the basis of esterase activ- Abbreviations: AP, acute pancreatitis; BMI, body mass ities and kinetic parameters using the synthetic sub- index; CAT, computerized axial tomography; CF, cystic strates, [Ac(Ala) OMe] N-acetyl-L-alanyl methyl ester fibrosis; CFTR, cystic fibrosis transmembrane conduc- 3 [Ac(Ala) OCH ] and benzoylalanine methyl ester; the tance regulator; CP, chronic pancreatitis; E1, elastase-1; 3 3 latter has been shown to be a specific substrate for the ERPC, endoscopic retrograde cholangiopancreatogra- porcine enzyme (2, 3). A comparison of human pro- phy; IBD, inflammatory bowel diseases; NBT-PABA, N- tease E with porcine elastase revealed a high degree of benzoyl-L-tyrosyl-p-aminobenzoic acid; PI, pancreatic similarity between the two proteases with respect to insufficiency; PS, pancreatic sufficiency. the following: inhibition by the active-site directed pep- tide chloromethyl ketones; stability; reduced suscepti- bility to naturally occurring proteinase inhibitors; Introduction specificity for synthetic substrates and several other physical properties. Degradation of other proteins by Biochemistry of elastases pancreatic elastases has been reported to be due to Mammalian pancreas is a compound gland of en- contamination by chymotrypsin or trypsin. Enzymes docrine and exocrine tissue derived from the embry- mimicking pancreatic elastases occur in microorgan- onic endoderm. Approximately 90% of the pancreas is isms such as Flavobacterium elastolyticum, Clostrid- exocrine tissue, comprising acinar cells that synthetize ium histolyticum and Staphylococcus epidermis. The and secrete digestive enzymes, and ductal cells that se- enzyme is synthetized in porcine pancreas as a pre-pro- crete and channel the fluids that transport the acinar elastase. After processing to proelastase, it is stored in enzymes to the duodenum. About 1% of the pancreas the zymogen granules and later it is activated to elas- is endocrine tissue, comprising four principal cell types tase by trypsin in the duodenum. The NH2-terminal synthetizing insulin (β-cells), glucagon (α-cells), so- amino acid sequences of both human elastase-1 and elastase-2 were shown to be valine-leucine, while *E-mail of the corresponding author: [email protected] those of porcine elastase were valine-valine. Porcine 326 Dominici and Franzini: Pancreatic elastase-1, pancreatic diseases elastase is thought to be derived from proelastase by sured immunochemically by means of quantitative tryptic activation of the proenzyme. Bovine trypsin, methods such as radial immunodiffusion and rocket chymotrypsin, thrombin and porcine elastase have immunoelectrophoresis. Using these techniques it was been shown to possess a similar activation site, and all possible to show that elastase-1 and chymotrypsin B as four enzymes possess N-terminal sequences begin- well were not significantly degraded during intestinal ning with two hydrophobic aliphatic amino acid passage. Therefore, the amount of concentration of residues. The fact that human elastase-1 and elastase- this enzyme in feces with special reference to E1 may 2 possess two aliphatic residues at their respective N- represent a good indicator of pancreatic function (5–7). terminals suggests that they are activated by a me- chanism similar to that of the previously studied serine-proteases. Of the plasma proteinase inhibitors, Elastase-1: Its Role as a Diagnostic Test α α only 1-proteinase inhibitor and 2-macroglobulin in- hibited human elastase-1 or elastase-2 or porcine elas- Pancreatic diseases may be classified as inflammatory, tase to an approximately equal extent. neoplastic, traumatic or genetic; inflammatory dis- eases may be subdivided into acute pancreatitis, re- lapsing acute pancreatitis, relapsing chronic pancreati- Human Elastase-1 tis and chronic pancreatitis (CP) (8–10). AP is an inflammatory disease of pancreas charac- Human elastase-1 (EC 3.4.21.36) is an anionic protease terized by abdominal pain and increase of pancreatic belonging to the family of serine-proteases, together enzymes in the blood and urine. The criteria used for with digestive enzymes such as chymotrypsin, trypsin diagnosis are: and some proteases of the enzyme cascade of blood 1) Increase > 5-fold in pancreatic enzymes’ activity in coagulation and of the complement system; these serum (amylase and lipase); proteases share more than 40% of homology for the 2) Evidence of inflammation by imaging methods primary and tertiary structure. Pancreatic E1, first de- (computerized axial tomography (CAT), echotomo- scribed by Balo and Banga in 1950 (4), is a carboxyen- graphy) and by laparotomy or autopsy. The incidence dopeptidase, which catalyzes hydrolysis of native of AP is 11–35 per 100,000 per year in the countries elastin, with preferential cleavage at Ala-Xaa > Val-Xaa where the consumption of alcohol is higher. site, but not native collagen and keratin. Cleavage of hemoglobin, casein and fibrin has also been reported. The chronic form of pancreatitis is a progressive in- The elastin digestion capability of E1 is a function flammatory process of pancreas characterized by pain unique to this enzyme. Because of its unique specificity and morphological, irreversible alterations of the func- to degrade elastin, pancreatic elastase has been in- tion of exocrine and endocrine components of the volved in the pathogenesis of emphysema and athero- gland. The criteria used for diagnosis are: sclerosis as well as in aging; this protease has also 1) Pancreatic function tests which indicate reduced ex- been shown to produce the vascular injury observed in ocrine function of pancreas; acute pancreatitis (AP). Human E1 is synthetized by the 2) Morphological alterations evidenced by CAT, acinar cells of the pancreas along with the other diges- wirsungraphy or histology (biopsy). tive enzymes, and is composed of 240 amino acids, with a molecular weight of about 26 kDa and a special The incidence of CP is relatively low: in the Western affinity for the carboxyl group (COOH) of alanine, va- countries it is 3.5–4.0 per 100,000 per year, and the line and leucine. This acidic endoprotease with proper- mean cause (85–90%) of CP is excessive alcohol con- ties of sterol-binding protein (5, 6) was described in sumption. During an acute inflammatory process of the 1975 by Mallory and Travis (3) as protease E, and fur- pancreas many enzymes are released into the blood, ther characterized as an elastolytic pancreatic enzyme so that their quantification in serum allows confirma- by Largmann et al. (2). Quantitative studies using im- tion or exclusion of AP (9–11). On the other hand, the munoelectrophoresis have shown that this enzyme,
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