Laboratory Diagnosis of Porphyria

Porphyrias are a group of diseases that are clinically and genetically heterogeneous and originate mostly from inherited dysfunctions of specific enzymes involved in heme biosynthesis. Such dysfunctions result in the excessive production and excretion of the intermediates of the heme biosynthesis pathway in the blood, urine, or feces, and these intermediates are responsible for specific clinical presentations. Porphyrias continue to be underdiagnosed, although laboratory diagnosis based on the measurement of metabolites could be utilized to support clinical suspicion in all symptomatic patients. Moreover, the measurement of enzymatic activities along with a molecular analysis may confirm the diagnosis and are, therefore, crucial for identifying pre-symptomatic carriers. The present review provides an overview of the laboratory assays used most commonly for establishing the diagnosis of porphyria. This would assist the clinicians in prescribing appropriate diagnostic testing and interpreting the testing results.

Heme Determination and Quantification Methods and Their Suitability for Practical Applications and Everyday Use

Many research institutions, clinical diagnostic laboratories, and blood banks are desperately searching for a possibility to identify and quantify heme in different physiological and pathological settings as well as various research applications. The reasons for this are the toxicity of the heme and the fact that it acts as a hemolytic and pro-inflammatory molecule. Heme only exerts these severe and undesired effects when it is not incorporated in hemoproteins. Upon release from the hemoproteins, it enters a biologically available state (labile heme), in which it is loosely associated with proteins, lipids, nucleic acids, or other molecules. While the current methods and procedures for quantitative determination of heme have been used for many years in different settings, their value is limited by the challenging chemical properties of heme. A major cause of inadequate quantification is the separation of labile and permanently bound heme and its high aggregation potential. Thus, none of the current methods are utilized as a generally applicable, standardized approach. The aim of this Feature is to describe and summarize the most common and frequently used chemical, analytical, and biochemical methods for the quantitative determination of heme. Based on this overview, the most promising approaches for future solutions to heme quantification are highlighted.

HPLC methods for analysis of porphyrins in biological media

Changes in porphyrin concentrations in biological media may serve as biological indicators of exposure and toxicity from a wide variety of drugs and chemical agents. This unit describes procedures for quantitative extraction of porphyrins from urine, feces, blood, and biological tissues as well as their separation and analysis by HAPLY spectrofluorometrc techniques.

Arsenic and porphyrins

BACKGROUND

To evaluate the possible effect of inorganic arsenic (iAs) and of its species on the urinary excretion of porphyrin homologues.

METHODS

Total porphyrins and their homologues (copro, penta, hexa, hepta, uroporphyrins) and arsenic species (trivalent and pentavalent As; monomethyl arsonic acid; dimethyl arsenic acid; arsenobetaine) were measured respectively by HPLC and HPLC-ICP MS in urine from 86 art glass workers exposed to iAs and from 54 controls.

RESULTS

A significant increase in the excretion of penta and uroporphyrins was demonstrated for workers exposed to As; As3 was the species best correlated with urinary porphyrin excretion.

CONCLUSIONS

The increase of urinary excretion for some porphyrin homologues appears to be consistent with the inhibition by As of URO-decarboxylase in the heme biosynthesis pathway. The determination of urinary porphyrin homologues could be useful to assess, on a group basis, some early effects of arsenic and to demonstrate possible individual susceptibility to the element.

On accuracy and precision of a HPLC method for measurement of urine porphyrin concentrations

We studied the accuracy and precision of a HPLC method for determination of porphyrins in urine. A commercial standard solution appeared to contain less porphyrins than indicated by the manufacturer, since calibration resulted in lower concentrations of uroporphyrin and coproporphyrin: 16% and 8%, respectively. Coefficients of variation for the measurement of uro-, hepta-, copro I and copro III porphyrins in samples of patients with and without porphyria were often much less than 15%. Comparison of measurements with and without calibrated standards revealed differences for uroporphyrin and coproporphyrin of 27% and 5%, respectively. Recovery of added uroporphyrin and coproporphyrin was 99%. The main cause of the variability in test results was apparently the improperly calibrated standard solutions. The precision of porphyrin measurements was not influenced by the type of porphyria.

Biochemical differentiation of the porphyrias

OBJECTIVES

To differentiate the porphyrias by clinical and biochemical methods.

DESIGN AND METHODS

We describe levels of blood, urine, and fecal porphyrins and their precursors in the porphyrias and present an algorithm for their biochemical differentiation. Diagnoses were established using clinical and biochemical data. Porphyrin analyses were performed by high performance liquid chromatography.

RESULTS AND CONCLUSIONS

Plasma and urine porphyrin patterns were useful for diagnosis of porphyria cutanea tarda, but not the acute porphyrias. Erythropoietic protoporphyria was confirmed by erythrocyte protoporphyrin assay and erythrocyte fluorescence. Acute intermittent porphyria was diagnosed by increases in urine delta-aminolevulinic acid and porphobilinogen and confirmed by reduced erythrocyte porphobilinogen deaminase activity and normal or near-normal stool porphyrins. Variegate porphyria and hereditary coproporphyria were diagnosed by their characteristic stool porphyrin patterns. This appears to be the most convenient diagnostic approach until molecular abnormalities become more extensively defined and more widely available.

Quantitation of a novel metalloporphyrin drug in plasma by atomic absorption spectroscopy

A bioanalytical method to quantify cobalt mesoporphyrin (CoMP), a novel therapeutic agent, in plasma has been developed and validated. The approach involves atomic absorption spectroscopy to determine total cobalt in a sample and a back-calculation of the amount of compound present. Endogenous plasma cobalt concentrations were small ( <0.2 ng/ml(-1) Co in rat plasma) in comparison to the quantitation limit (4.5 ng/ml(-1) Co). The inter-day imprecision of the method was 10.0% relative standard deviation (RSD) and the inter-day bias was +/- 8.0% relative error (RE) over a standard curve range of 4.5- 45.0 ng/ml(-1) Co. Because it quantifies total cobalt, the method cannot differentiate between parent drug and metabolites, but negligible metabolism allows reliable estimates of the actual parent drug concentration. A correlation study between the atomic absorption method and 14C-radiometry demonstrated excellent agreement (r = 0.9868, slope = 1.041 +/- 0.028, intercept = 223.7 +/- 190.0) and further substantiated the accuracy of the methods. Methodology was successfully applied to a pharmacokinetic study of CoMP in rat, with pharmacokinetic parameter estimation. The elimination half-lives, after intra-muscular and subcutaneous administration, were 7.7 and 8.8 days, respectively.

Alterations in the heme biosynthetic pathway from the III-V semiconductor metal, indium arsenide (InAs)

The effects of indium and arsenic on the heme biosynthetic pathway have been well documented but the effects of indium arsenide (InAs), the next possible generation of the III-V semiconductors, are unknown. Male Syrian golden hamsters were given s.c. injections of sodium arsenite (As3+), indium chloride (In3+) or indium arsenide (InAs). Erythrocyte delta-aminolevulinic acid dehydratase (ALAD) activity was inhibited in all exposure groups, while hepatic ALAD activity was not significantly changed. In contrast, the activity of renal ALAD was found to be statistically decreased by As3+ at 10 days, but increased at 30 days, while In3+ and InAs inhibited this enzyme activity at all time points. In vitro studies showed that hepatic ALAD activity was more sensitive to In3+ than As3+, suggesting that the effects of InAs in vivo on this enzyme are due primarily to the In rather than the As moiety. Studies of urinary porphyrin excretion patterns in animals treated with InAs showed marked, early 2-4-fold increase in the excretion of the penta-, hexa- and heptacarboxyl porphyrin at 1-5 days which continued through day 30 of the study. In contrast, there was a slow and steady rise in the excretion of coproporphyrin I and III which reached a maximum at day 30. The results of these studies indicate that both the In and As moieties of InAs are biologically active following InAs exposure and that the enzymes in the heme pathway, such as ALAD, may have great utility as markers of exposure/toxicity for these agents.

Urinary porphyrin profiles as biomarkers of trace metal exposure and toxicity: studies on urinary porphyrin excretion patterns in rats during prolonged exposure to methyl mercury

Studies were conducted to define the specific changes in the urinary porphyrin excretion pattern (porphyrin profile) and the time course of those changes in rats exposed to mercury as methyl mercury hydroxide (MMH) at 5 or 10 ppm in the drinking water for up to 30 weeks. The urinary porphyrin profile elicited by MMH is uniquely characterized by highly elevated levels of 4- and 5-carboxyl porphyrins, and of a third atypical porphyrin with as yet undetermined chemical characteristics. Changes in the porphyrin profile were observed as early as 1 or 2 weeks following initiation of exposure to MMH at 10 or 5 ppm, respectively, and were sustained as long as 40 weeks following cessation of MMH treatment. The magnitude of the urinary porphyrin profile at either MMH dose level increased progressively during the course of mercury treatment and was highly correlated with the renal mercury concentration. A subsequent decline in the magnitude of the urinary porphyrin profile in animals exposed to 10 ppm MMH for more than 10 weeks was associated with the accumulation of high levels of Hg2+ in kidney cells and loss of renal functional status. These findings demonstrate that mercury elicits a unique change in the urinary porphyrin excretion pattern which is related to the dose and duration of mercury treatment. The association of urinary porphyrin excretion rates with renal mercury content and functional status suggests that urinary porphyrin profiles may serve as a useful biomarker of mercury accumulation and nephrotoxicity during prolonged mercury exposure.

Determination of individual porphyrins in rodent urine using high-performance liquid chromatography following clean-up by anion-exchange chromatography

We describe a method for the rapid clean-up of rodent urine samples prior to the analysis of porphyrin carboxylic acids by reversed-phase high-performance liquid chromatography (HPLC) with fluorescence detection. A simple pretreatment step using chromatography on a Dowex 1X8 anion-exchange resin effectively removes fluorescent substances that are present in rodent urine and would otherwise interfere with the detection and quantitation of urinary porphyrins by HPLC. Recovery of porphyrins with four to eight carboxyl groups (coproporphyrin to uroporphyrin) averaged 93% using this procedure. The use of this method to determine the amount of individual porphyrins present in the urine of hexachlorobenzene-treated mice is illustrated.

An improved method for quantitative determination of urinary porphyrins by use of second-derivative spectroscopy

An improved assay for quantification of urinary porphyrins by use of second-derivative spectroscopy is described. A new method for calculation of the porphyrin concentration is developed and the whole procedure is computerized. Acidified urine samples can be assayed within a few minutes by using this method. Precision and recoveries for both uro- and coproporphyrin are good. The method is presented as a very fast and accurate assay for the screening and quantification of urinary porphyrins.

Studies on the etiology of trace metal-induced porphyria: effects of porphyrinogenic metals on coproporphyrinogen oxidase in rat liver and kidney

Studies were conducted on the etiology of trace metal-induced porphyria in rats, with particular emphasis on the action of metals on hepatic and renal coproporphyrinogen oxidase. Prolonged exposure of rats to methyl mercury hydroxide or sodium arsenate at subtoxic dose levels in drinking water resulted in a progressive coproporphyrinuria, reaching highest rates of coproporphyrin excretion 5 weeks after initiation of exposure. The development of coproporphyrinuria was accompanied by substantial metal accumulation in the kidney and a significant decrease in renal, but not hepatic, coproporphyrinogen oxidase activity. During prolonged exposure to either metal, the rates of coproporphyrin excretion and metal accumulation by the kidney continued to increase for 2 to 3 weeks following maximal inhibition of renal coproporphyrinogen oxidase. Acute treatment studies and studies in vitro support the conclusion that the kidney is the principal source of excess urinary coproporphyrin during metal exposure. These observations demonstrate that metal-induced coproporphyrinuria is predominantly of renal etiology and that impairment of renal coproporphyrinogen oxidase is a principal cause of this effect.

High-performance liquid chromatography of porphyrins

Techniques for the analysis of porphyrins in the biomedical fields are reviewed. The emphasis is on high-performance liquid chromatography and its aspplications in: (1) the quantitative analysis of porphyrins in blood, urine and faeces; (2) qualitative porphyrin profiles in normal subjects and in the porphyrias; (3) assay of haem biosynthetic enzyme activities and (4) resolution of type isomers of porphyrins and porphyrinogens. Detection systems, quantitation methods, peak identification and sample preparation procedures are discussed.

Solid-phase purification and analysis of dicarboxylic porphyrins extracted from cultured tumor cells

We describe here a sensitive method for the purification and analysis of porphyrins present in hematoporphyrin derivative. Hematoporphyrin derivative is a solution containing a complex mixture of dicarboxylic porphyrins such as hematoporphyrin IX, monohydroxyethyl monovinyl deuteroporphyrin isomers, and protoporphyrin IX in addition to porphyrin aggregates of variable molecular sizes. This mixture is known for its ability to be selectively retained by tumor cells and for its cytotoxicity in the presence of light. In order to study the mechanisms of hematoporphyrin derivative uptake and its cellular metabolism, extraction methods are required that combine high recoveries with minimum changes of very labile components. Extraction with perchloric acid: methanol mixtures recovered only some 60% of the porphyrins taken up by tumor cells and artifactual fluorescent spots were seen on thin-layer chromatograms. Improved yields were obtained upon extraction with dimethyl sulfoxide or Triton X-100:4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (Hepes) buffer mixture, but the extracts were not suitable for reverse-phase thin-layer chromatography (RTLC). The procedure described here consists of extracting porphyrins from cultured tumor cells with a buffered detergent followed by sequential chromatography on DEAE-cellulose columns and on reverse-phase octadecylsilyl cartridges. Identification of the isolated free dicarboxylic porphyrins is conveniently done by RTLC.

Improved separation and detection of free porphyrins by high-performance liquid chromatography

Porphyrins were separated using ion-pair reversed-phase high-performance liquid chromatography. The eluents were aqueous potassium phosphate buffer and tetrabutylammonium phosphate in methanol. The influences of pH value and ionic strength of the phosphate buffer and molarity of the ion-pair reagent in methanol were investigated to improve separation and detection. A linear response curve was obtained from 0.38 to 7.64 pmol for coproporphyrin I. The detection limits were determined to be 0.12 pmol for coproporphyrin I and 0.22 pmol for uroporphyrin I.