Clinical Enzymology

Plasma enzymes
Blood plasma contains many enzymes , which are classified into
functional and non functional enzymes :

Functional enzymes present at all times in the circulation and perform a

physiologic function in the blood , examples of these functional enzymes
include lipoprotein lipase , pseudocholinestrase and enzymes of blood
coagulation .
These enzymes are synthesized and secreted by the liver .

Non functional enzymes : plasma also contains numerous other enzymes

that perform unknown physiologic function in blood . These non
functional plasma enzymes arise from the routine normal destruction of
erythrocytes , leukocytes , and other cells . Tissue damage or necrosis
resulting from injury or disease is generally accompanied by increasing in
the levels of several non functional plasma enzymes . Therefore several
enzymes are used in the diagnosis .

Medical importance of non functional plasma enzymes .

Measurement of non functional enzymes is important for :

1- Diagnosis of diseases as diseases of different organs cause
elevation of different plasma enzymes .
2- Prognosis of the diseases : we can follow up the effect of treatment
by measuring plasma enzymes before and after treatment .
 Functional plasma enzymes Non Functional plasma enzymes
Concentration in Present in plasma in higher Normally , present in plasma in very
plasma enzymes concentration in comparison to low concentrations in comparison to
tissues tissues
Function Have known functions No known functions
Substrate Their substrates are always Their substrate are absent from the
present in the blood . blood .
Site of synthesis Liver Different organs e.g. liver , heart ,
brain , and skeletal muscles .
Effect of diseases Decrease in liver diseases Different enzymes increase in
different organ diseases .
Examples Clotting factors e.g. prothrombin ALT, AST , CK , LDH , alkaline
, lipoprotein lipase , and phosphatase , acid phosphatase , and
pseudocholine esterase . amylase .
Lactate Dehydrogenase ( LDH ) ( LD )

1 – Normal values

Lactate dehdrogenase will convert pyruvate to lactate . The normal value

of LDH in serum is 100 – 200 U/L . Values in upper range are generally
seen in children . Strenuous exercise will slightly increase the value .
LDH level is 100 times more inside the RBC than in plasma , and
therefore minor amount of hemolysis will result in a false positive test .

2 – LDH and heart attack

In myocardial infarction , total LDH activity is increased . The time

course of LDH level after a heart attack is given in the following figure .
The magnitude of the peak value as well as the area under the graph will
be roughly proportional to the size of myocardial infarction .

Creatine kinase ( CK )
1 – Normal values
It is used to convert creatine to creatine phosphate , therefore it was called
creatine phosphokinase in old literature . Normal serum value for CK is
15 – 100 U/L for males and 10 – 80 U/L for females .

2 – CK and heart attack

 CK values in serum is increased in myocardial infarction , the time
course is shown in the former figure . The CK level starts to rise
within 3 – 6 hours of infarction .
 Therefore CK estimation is very useful to detect early cases ,
where ECG changes is ambiguous .
 The CK level is not increased in hemolysis or in conestive cardiac
failure , and therefore CK has an advantage over LDH . The area
 under the peak and slope of initial rise are proportional to the rise
of infarction .

3 – CK and muscle diseases

 The level of CK in serum is very much elevated in muscular
dystrophies ( 500 – 1500 IU/L )
 CK level is highly elevated in crush injury , fracture and acute
cerebrovascular accidents .

Aspartate amino transferase ( AST )

 In old literature it was called as serum glutamate oxaloacetate

transaminase ( SGOT ) . AST needs pyridoxal phosphate ( vit. B6
) as coenzyme .
 Normal serum level of AST is 8 – 20 U/L . The level is
significantly elevated in myocardial infarction . The time course of
AST is shown in in the former figure .
 It is moderately elevated in liver diseases .
Alanine amino transferase ( ALT )

 In old literature it was called as serum glutamate pyruvate

transaminase ( SGPT ) . The enzyme needs pyridoxal phosphate as
coenzyme .
 Normal serum level of ALT for male is 13 – 35 U/L . Very high
values ( 300 – 1000 U/L ) in acute hepatitis , either toxic or viral
in origin .
 Both ALT and AST levels are increased in liver diseases , but
ALT > AST .
Alkaline phosphatase ( ALP )

 This enzyme is produced by osteoblasts of bone , and is associated

with the calcification process . It ia activated by magnesium and
manganese . Zinc is a constituent ion of ALP .
 Normal serum value of ALP is 40 – 125 U/L . In children the upper
level of normal value may be more , because of the increased
osteoblastic activity in children .
 Moderate increase ( 2-3 times ) in ALP level is seen in hepatic
diseases such as infective hepatitis , alcoholic hepatitis or
hepatocellular carcinoma .
 Very high level ( 10 – 12 times of upper limit ) may be noticed in
extrahepatic obstruction ( obstructive jaundice ) caused by
gallstone or by pressure on bile duct by carcinoma of head of
pancreas .
 ALP is produced by epithelial cells of biliary canaliculi and
obstruction of bile with consequent irritation of epithelial cells
leads to secretion of ALP into serum .
 Drastically high levels of ALP ( 10 – 25 times of upper limit ) are
seen also in bone diseases where osteoblastic activity is enhanced
such as Paget's disease , rickets osteomalacia , osteoblastoma ,
metastatic carcinoma of bone and hyperparathyroidism .

Nucleotide phosphate ( NTP )

 It is also known as 5 nucleotidase , this enzyme hydrolyses 5

nucleotides to corresponding nucleosides at an optimum pH of 7.5 .
Nickel ions inhibit NTP .
 Normal NTP level in serum is 2 – 10 IU/L . It is moderately
elevated in hepatitis and highly elevated in biliary obstruction .
Gamma Glutamyl Transferase ( GGT )

 In the body it is used in the synthesis of glutathione . It is seen in

liver , kidney , pancreas , intestinal cells and prostate gland .
 Normal serum value of GGT is 10 – 30 U/L . It is moderately
increased in infective hepatitis and prostate cancer .
 GGT is clinically important because of its sensitivity to detect
alcohol abuse . GGT is increased in alcoholics even where other
liver function tests are within normal limits .
 GGT level is rapidly decreased within a few days when the person
stops to take alcohol . Increase in GGT level is generally
proportional to the amount of alcohol intake .

Enzyme Profile in Liver Diseases .

Enzymes commonly studied for diagnosis of liver diseases are :

1. ALT
2. ALP
3. NTP
4. GGT

Acid Phosphatase ( ACP )

 Normal serum value of ACP is 2.5 – 12 U/L .

 ACP is secreted by prostate cells , RBC , platelets and WBC .
 ACP total value is increased in prostate cancer and highly elevated
in bone metastasis of prostate cancer
 ACP is an important tumor marker
 Since blood cells contains excess quantity of ACP , care must be
taken to prevent hemolysis while taking blood from the patient .
prostate massage may also increase the value . So blood may be
collected for ACP estimation before rectal examination of patient .
Amylase

 This splits starch to maltose . It is activated by calcium and

chloride ions . It is produced by pancreas and salivary glands .
 Normal serum value is 50 – 120 IU/L the value is increased 1000
times in acute pancreatitis which is a life threatening conditions .
The peak values are seen between 5 – 12 hours after the onset of
disease and returns to normal levels within 2 – 4 days after the
acute phase .
 Moderate increase in serum levels are seen in chronic pancreatitis ,
mumps ( parotitis ) and obstruction of pancreatic duct .

Lipase

 It will hydrolyse triglycerides to beta monoglyceride and fatty

acid . The enzyme is present in the pancreatic secretion .
 The level in blood is highly elevated in acute pancreatitis and this
persists for 7 – 14 days . Thus lipase remains elevated longer than
amylase .
 Moreover , lipase is not increased in mumps . Therefore , lipase
estimation has advantage over amylase . It is moderately increased
in carcinoma of pancreas , biliary diseases , perforating peptic
ulcer .