Human serum albumin: from bench to bedside

Human serum albumin (HSA), the most abundant protein in plasma, is a monomeric multi-domain macromolecule, representing the main determinant of plasma oncotic pressure and the main modulator of fluid distribution between body compartments. HSA displays an extraordinary ligand binding capacity, providing a depot and carrier for many endogenous and exogenous compounds. Indeed, HSA represents the main carrier for fatty acids, affects pharmacokinetics of many drugs, provides the metabolic modification of some ligands, renders potential toxins harmless, accounts for most of the anti-oxidant capacity of human plasma, and displays (pseudo-)enzymatic properties. HSA is a valuable biomarker of many diseases, including cancer, rheumatoid arthritis, ischemia, post-menopausal obesity, severe acute graft-versus-host disease, and diseases that need monitoring of the glycemic control. Moreover, HSA is widely used clinically to treat several diseases, including hypovolemia, shock, burns, surgical blood loss, trauma, hemorrhage, cardiopulmonary bypass, acute respiratory distress syndrome, hemodialysis, acute liver failure, chronic liver disease, nutrition support, resuscitation, and hypoalbuminemia. Recently, biotechnological applications of HSA, including implantable biomaterials, surgical adhesives and sealants, biochromatography, ligand trapping, and fusion proteins, have been reported. Here, genetic, biochemical, biomedical, and biotechnological aspects of HSA are reviewed.

Medications that distort in vitro tests of thyroid function, with particular reference to estimates of serum free thyroxine

The combination of serum thyroid-stimulating hormone (TSH) with measurement of circulating thyroid hormones greatly improves sensitivity and specificity of thyroid diagnosis, but these assays are not impeccable. Estimation of serum free T4 conveniently accommodates variations in the concentration of thyroxine-binding globulin (TBG), but no current technique reliably reflects the in vivo free T4 concentration in numerous other situations. The effect of circulating competitors that increase T4 and T3 in vivo, in particular, many medications, is under-estimated by current free hormone estimates that involve sample dilution. Non-esterified fatty acids generated during sample storage and incubation can spuriously increase the measured free T4 estimate, especially after in vivo treatment with heparin. These artefacts are unlikely to be overcome by current assay strategies. Total serum T4, corrected for alterations in TBG concentration, gives a more robust estimate of thyroxine concentration than current methods of free hormone estimation and should now be reintroduced as the 'gold standard'.

The nature of analogue-based free thyroxine estimates

Clinical laboratories often use analogue-based immunoassays to estimate serum free thyroxine (FT(4)) concentrations. These assays yield FT(4) estimates that correlate closely with thyroxine (T(4)) binding protein concentrations. This correlation implies that either T(4) binding proteins or protein bound T(4) contribute to analogue-based FT(4) values. To study the contributions made by T(4) binding proteins to these FT(4) estimates further, four analogue-based FT(4) assays were applied to: (1) FT(4) solutions without T(4) binding proteins, (2) to T(4) binding protein solutions without T(4), and (3) to total T(4) solutions containing T(4) binding protein, FT(4), and protein-bound T(4). The FT(4) estimates obtained with these solutions ranged from 0.2-8.6 ng/dL, when FT(4) concentrations ranged from less than 0.2-12,000 ng/dL. In the FT(4) solutions, gravimetrically determined FT(4) concentrations were 500-12,000 ng/dL (0.5-12.0 microg/dL) without protein-bound T(4), and the FT(4) estimates obtained were 0.3-6.9 ng/dL. In the total T(4) solutions, dialyzable FT(4) concentrations were less than 0.2-59 ng/dL, retained T(4) concentrations were 499.8-11,441 ng/dL, and the analogue-based FT(4) estimates obtained were 0.2-8.6 ng/dL. Similar FT(4) estimates (0.2-8.6 ng/dL and 0.3-6.9 ng/dL) were obtained with similar concentrations of either protein-bound T(4) or FT(4). Similar test results were associated with similar total T(4) concentrations, not similar FT(4) concentrations. Protein-bound T(4) and T(4) binding protein contributed variably to test results. T(4) quantifications included large analytical losses that are unaccounted for. These assays passed tests of correlation with FT(4) concentrations, but they failed tests of specificity for FT(4) and accuracy in T(4) quantification.

An outline of inherited disorders of the thyroid hormone generating system

To date, various genetic defects impairing the biosynthesis of thyroid hormone have been identified. These congenital heterogeneous disorders result from mutations of genes involved in many steps of thyroid hormone synthesis, storage, secretion, delivery, or utilization. In contrast to thyroid dyshormonogenesis, the elucidation of the underlying etiology of most cases of thyroid dysgenesis is much less understood. It is suggested that genetic factors might play a role in some cases of thyroid dysgenesis and the best candidate genes involved are those encoding transcription factors known to play a role in the embryonic development of the thyroid gland. Moreover, discordance for thyroid dysgenesis is the rule for monozygotic twins as recently reported and this may result from epigenetic phenomena, early somatic mutations, or postzygotic events. In the final part of this review the molecular defects involved in proteins that transport thyroid hormone in the circulation are described: thyroxine-binding globulin (TBG), transtiretin and albumin, that may be associated with altered thyroid function tests and other pathologic conditions such as amyloidotic polyneuropathy.

Familial dysalbuminemic hyperthyroxinemia: a rare example of albumin polymorphism and its rapid molecular diagnosis

Familial dysalbuminemic hyperthyroxinemia (FDH) is the most common cause of euthyroid hyperthyroxinemia, although a rare example of albumin polymorphism. FDH is inherited in an autosomal dominant manner and is characterized by enhanced binding of thyroxine to a mutant form of albumin, probably at Site 1, subdomain 11A. Previous laboratory tests of FDH have been cumbersome, rarely available, and required demonstration of anti-albumin precipitable T4, isoelectric focusing of serum for albumin in presence of labeled T4 and, occasionally, comparison of the concentrations of metabolites of T4 that have different binding affinities to the abnormal albumin. Recent studies have shown that the same mutation in the albumin gene that results in FDH has been found in 13 unrelated families. A G-->A transition in codon 218 of the albumin gene resulted in the replacement of arginine with histidine. An intragenic Sac-1 polymorphic site was found in association with the specific FDH mutation, suggesting a founder effect. FDH in our Hispanic family was confirmed by isoelectric focusing of serum. Results of thyroid function tests in our affected patients were typical for the phenotype: high total T4 and normal total T3. Genomic DNA was amplified by PCR using a mismatched oligonucleotide primer that produced a unique restriction site (Dra III) only if the DNA sample contained the mutation in codon 218: CGC (Arg) to CAC (His). In affected individuals of this family expression of the FDH phenotype was associated with the presence of His218 in one of the two alleles. Analysis linking the FDH mutation to the Sac-1 polymorphism in this family was not informative. DNA analysis is a rapid and simple method to diagnose FDH in individuals with euthyroid hyperthyroxinemia.

Direct and Indirect Free Thyroxine Assay Methods: Theory and Practice

Background: For the diagnosis of thyroid disease, measurement of “free hormone” is generally accepted as an appropriate measure. However, valid assays measuring the free fraction of thyroxine (FT4) ideally must perform without bias, despite large variations in the concentrations and affinities of serum T4-binding proteins in the population. Several approaches have been taken to overcome such bias, and these have created considerable controversy in the field over the past decade.

Approach: This review, from both a historical and an analytical standpoint, charts the progress made over more than 30 years in improvements to the performance of assays in common use for the measurement of FT4 in serum or plasma. It reexamines the theory behind early approaches to such assays [for example, the free thyroxine index (FTI) method], that preceded more accurate, two-step immunoassays or one-step analog techniques. It evaluates the continuous refinements to the latter assays that by now have largely supplanted the FTI approach and where the deficiencies that so exercised clinical chemists in the past have been virtually eliminated in the leading assays.

Content: The basic Mass Action theory underpinning all such methods is discussed by assessing how far each particular approach obeys the criteria the theory imposes. In this, it is not the intention of the review to dissect individual commercial or academic assays, but rather to give guidance where appropriate as to how any assay said to measure FT4 can be conveniently evaluated by those intending to use it. Examples are given where inappropriate tests may wrongly imply assay invalidity by misinterpreting how FT4 assays work.

Summary: Detailed knowledge of the underlying theory is essential when devising tests for direct FT4 assays, to ensure that such tests do not overstep the practical limits of assay validity.

Free thyroid hormone measurement. A critical appraisal

The main purpose of free T4 and free T3 assays is to distinguish reliably between thyrotoxicosis, hypothyroidism, and the euthyroid state, an objective that cannot be attained with assays of total T4 and T3 because of hereditary and acquired variations in the concentrations of binding proteins. Effective correction for changes in the serum concentration of TBG can be achieved with numerous types of free hormone estimate, but other changes in binding are not well accommodated. Despite remarkable methodologic ingenuity, no current method reflects the free T4 concentration in undiluted serum under in vivo conditions. Equilibrium dialysis, widely considered the reference method for free T4 measurement, is also subject to error, either preanalytic, owing to generation of NEFA in the sample leading to an overestimate of free T4, or analytic with underestimation of the effect of competitors to increase free T4. Current approaches to free T4 measurement are vulnerable to several method-dependent artifacts: abnormal albumin binding of T4 or of the assay tracer, the inhibition of T4 binding to TBG by medications, and the effects of critical illness, especially in heparin-treated patients, pregnancy, and the abnormalities in sick premature infants. Because of systematic variation between methods (i.e., whether a technique is albumin dependent or prone to incubation or dilution artifacts), it is essential to consider methodologic details in evaluating free T4 estimates in these situations and whenever estimates of free T4 are clinically discordant. False-positive abnormalities are more frequent than false-negative results. When free T4 results are correlated with the serum TSH concentration with attention to the assumptions that define this relationship, the majority of false-positive results can be readily identified. If a free T4 anomaly remains unexplained on repeat sampling, it is appropriate to use an alternative free T4 method that depends on a different assay principle and to correlate the result with an authentic total T4 measurement.

Accuracy of free thyroxine measurements across natural ranges of thyroxine binding to serum proteins

Systemic inaccuracies, proportional to the concentrations of serum proteins and the thyroxine (T4) they carry, have been reported in direct free T4 immunoassays. However, analytical recoveries of free T4 have not been carefully examined in most current methods, and they have not previously been examined across the pathophysiological range of serum T4 binding. In the present study we investigated ranges of serum T4 binding using free and total T4 measurements from 1359 individuals. Carefully characterized, gravimetrically calibrated, serum-based free T4 test solutions were then prepared with a constant normal free T4 concentration (12 ng/L) and varied serum T4 binding (approximately 300:1 to 24,000:1, ng protein bound T4: ng free T4). These standardized test solutions were analyzed using five T4 analog based free T4 methods. Analytical recoveries were calculated as ratios of actual free T4 measurements to the target value, and expressed as a percent of the target. Analytical recoveries were directly proportional to the extent of serum T4 binding and ranged 2% to 155%, 25% to 131%, 53% to 106%, 37% to 93%, and 37% to 73%, lowest to highest, in different methods. These systemic inaccuracies will confound interpretations of free T4 test results in clinical conditions with altered T4 binding. Future investigations into free T4 status must examine the analytical recovery of the free T4 method(s) used, as they relate to the extent of serum T4 binding in the clinical condition(s) studied.

Simultaneous measurement of free thyroxine and free 3,5,3'-triiodothyronine in undiluted serum by direct equilibrium dialysis/radioimmunoassay: evidence that free triiodothyronine and free thyroxine are normal in many patients with the low triiodothyronine syndrome

We have devised a practical, sensitive and specific method for simultaneous measurement of free thyroxine (FT4) and free triiodothyronine (FT3) in undiluted serum by direct equilibrium dialysis radioimmunoassay (RIA). Two hundred microliters serum sample was dialyzed against buffer (pH 7.4) for 20 hours at 37 degrees C and approximately 800 microL of the dialysate was used for measuring FT4 and FT3 simultaneously. The assay was set up in polystyrene tubes coated with anti-T4 antibody and available commercially for FT4 measurement (Quest-Nichols Institute, San Juan Capistrano, CA). The mean +/- SE (range) FT4 concentration (ng/dL) was 1.2 +/- 0.04 (0.7.0 to 2.30) in 54 normal subjects. It was significantly increased (3.6 +/- 0.4 [1.8 to 9.6], n = 20) in hyperthyroidism and clearly decreased (0.40 +/- 0.04 [1.10 to 0.70], n = 26] in hypothyroidism. All nonthyroid illness (NTI) patients had normal FT4 except 3, 2 of whom were on amiodarone and 1 had received heparin. Serum FT4 concentration was minimally elevated in 18 newborn cord blood serum (1.40 +/- 0.08 [0.90 to 2.2], cf. normal p < .05). The mean serum FT3 concentration (pg/dL) was 285 +/- 10 (134 to 454) in 54 normal sera. It was clearly increased in hyperthyroidism (1033 +/- 98 [593 to 2134], n = 20, p < .001). However, serum FT3 varied widely in hypothyroidism (27 to 597, mean 235 +/- 24, NS) as did serum total T3 (19 to 175). Interestingly, however, the mean serum FT3 concentration was normal (273 +/- 28 [62 to 575, NS]) in 25 NTI patients. All of these patients had low serum total T3 (46 +/- 5.0 [10 to 84], ng/dL; normal 84 to 160, p < 0.001), while FT3 was clearly normal in 21 of 25 patients and low in the remaining 4 patients. Similarly, among 18 newborn cord blood sera serum FT3 concentration was normal in 15 and subnormal only in the remaining 3 while all had clearly subnormal total T3 (28 to 74 ng/dL).

CONCLUSIONS

(1) A practical, sensitive, and specific assay for simultaneous measurement of FT4 and FT3 is described; (2) FT3 is consistently elevated in hyperthyroidism while FT4 is elevated in most (approximately 85%) cases; (3) FT4 is consistently decreased in hypothyroidism but FT3 varies widely; (4). Serum FT3 concentration is normal in approximately 83% of patients with the low T3 syndrome in NTI and newborn cord blood serum. These data suggest that normal FT3 may explain clinical euthyroidism in many patients with the low T3 syndrome.

Direct determination of free triiodothyronine (T3) in undiluted serum by equilibrium dialysis/radioimmunoassay (RIA)

We have devised a practical, sensitive, and reliable assay for measurement of free T3 concentration in serum. The assay employs a convenient and disposable plastic equilibrium dialysis cell and a buffer that resembles the in vivo biochemical environment (Nelson JC, Tomei RT 1988 Clin Chem 34:1737). A 200-microliters aliquot of serum was dialyzed against 2.4 mL buffer at 37 degrees C for 18 +/- 2 h and T3 was quantified by RIA of about 1.0-mL aliquot of the dialysate buffer. The detection threshold of the RIA approximated 2 pg/ml permitting accurate measurement of > 200 pg/dL of free T3 directly. Serum specimens that contained less free T3 were spiked with 200 ng/dL of non-radioactive T3 prior to dialysis. Free T3 in the dialysate of these samples was divided by total T3 in serum (after spiking) to determine percent free T3. Free T3 was calculated by multiplying percent free T3 and serum total T3 (before spiking). Free T3 concentration (pg/dL) did not differ appreciably in a serum pool when tested both with and without spiking with exogenous T3. The between assay coefficient of variation of three specimens tested over an 8-month period averaged 20%. Serum free T3 concentration (pg/dL) was [mean +/- SD (n), range, p] [293 +/- 12 (39), 154-440] in normal subjects. It was significantly increased [742 +/- 87 (13), 525-1700, p < 0.001] in hyperthyroidism and significantly decreased in nonthyroidal illness [NTI, 138 +/- 26 (9), 53-320, p < 0.001], cord blood serum [124 +/- 7.5 (11), 93-353, p < 0.001], and third trimester of pregnancy [214 +/- 26 (8), 93-253, p < 0.02]. Serum free T3 concentration varied widely in hypothyroidism 274 +/- 92 (10), 10-923, NS].

CONCLUSIONS

We have described a practical method and initial results of direct measurements of free T3 concentration in health and disease.

Study of binding of thyroxin-conjugates to the thyroxin-binding proteins

In this work we studied the effects of the molecular weight (M.W.) of thyroxin (T4)-conjugates and the sample dilution factor on the binding potential (C) of serum T4-binding proteins for these T4-conjugates. We prepared six T4-conjugates with great difference in molecular weight with proteins such as IgG, apoferritin, ferritin, transferrin, and thyroglobulin using p-benzoquinone as bifunctional reagent. The conjugates prepared were characterized in terms of their M.W., the molar ratio of T4 to the carrier protein, and their affinity to bind with the anti-Tr antibody. The binding potential values of serum T4-binding proteins for the T4-conjugates were determined, following appropriate mathematical interpretation of the results, obtained through an assay system containing 125I-labeled conjugated tracers, anti-T4 antibody in great excess compared with the concentration of the tracers, and increasing concentration of T4-binding proteins. We conclude that the M.W. of the conjugates is a parameter which significantly influences the binding of a conjugate to the T4-binding proteins. Additionally, for conjugates of very high M.W. (> 650,000), zero C values were obtained using 20-fold sample dilution in the final incubation mixture.

Radioimmunoassay of free thyroxine (T4) using 125I-labeled T4-IgG complex with very large molecular weight

We describe a double-antibody radioimmunoassay for the determination of free thyroxine (FT4) in serum using a 125I-labeled T4-IgG conjugate of very large molecular weight (approximately 1,000,000) as tracer. The binding of this conjugate to the anti-T4 antibody was found to be satisfactory and independent of the T4-binding protein concentration. The T4 sequestration by the antibody was limited and the sample dilution used in the final assay mixture was low. The results determined by the assay developed for samples from hypo-, hyper-, euthyroid subjects and from non-thyroidal-illness patients were well correlated with those obtained by a free T4-equilibrium dialysis kit (Nichols). The detection limit of the assay was 0.41 pmol/l and the range covered by assay standard solutions was 2.4-121 pmol/l. The FT4 concentrations in serum as determined by this assay were 9.6-31 pmol/l (mean 21 pmol/l) for 46 euthyroid serum samples; 6.7-47 pmol/l (mean 23.5 pmol/l) for 27 non-thyroidal illness; and 4.2-25.8 pmol/l (mean 11.6 pmol/l) for 19 pregnant women.

The clinical utility of a non-isotopic two-step assay (DELFIA) and an analogue radioimmunoassay (SimulTRAC) for free thyroxine compared

The analytical and diagnostic performance of a new non-isotopic, two-step immunoassay (DELFIA) for the measurement of free thyroxine (free T4) in plasma or serum has been compared with an established second generation analogue radioimmunoassay (SimulTRAC). Both methods had a good diagnostic specificity in pregnancy, thyroid clinic patients, and patients taking anticonvulsant drugs. In patients presenting to a general medical ward the diagnostic specificity of both methods was poor. Two samples appeared to contain substances which produced assay interference by DELFIA but not by SimulTRAC assays. When free T4 was measured by equilibrium dialysis a clear association between sample dilution and free T4 concentration was demonstrated in sick euthyroid patients. In contrast, using samples obtained from patients with known thyroid disease, free T4 was little influenced by sample dilution. The effects of sample dilution on free T4 measured by DELFIA were similar to those found using equilibrium dialysis. It would appear that free T4 measurements have a relatively poor diagnostic specificity in non-thyroidal illness irrespective of the method used.

Effective laboratory evaluation of thyroid status

This article focuses on recent developments in thyroid-related laboratory tests, including analytical methods, clinical utility, and limitations of TSH, FT4, T4, FT3/T3, thyroglobulin, and thyroid autoantibodies and the effective use of these tests in the diagnosis of various forms of hypothyroidism or hyperthyroidism, and the management of patients undergoing T4 replacement, T4 suppression, or antithyroid drug therapy.

Non-isotopic, two-step free thyroxine immunoassay: a better measure of free thyroxine than analogue radioimmunoassay

Plasma or serum free thyroxine (T4) was measured by a novel non-isotopic, two-step immunoassay in 373 consecutive patients attending a thyroid clinic, in whom thyroid status was categorized according to clinical findings, supported by routine thyroid function tests. The 95% confidence limit of free T4 in the euthyroid patients (n = 112) was 7-20 pmol/L. Free T4 concentrations within the reference range were found in six of 40 patients with primary hypothyroidism and nine of 182 patients with overt thyrotoxicosis, six of whom had T3 toxicosis. Serum or plasma free T4 measured by the two-step method showed improved diagnostic specificity over an analogue RIA in selected groups of euthyroid patients in whom abnormal binding of analogue T4 can affect the validity of the result. Free T4 results found by analogue RIA and the two-step method in 58 patients who were receiving thyroxine replacement therapy were similar. The between-assay precision of the two-step method was poor ranging from a coefficient of variation of 9.7% to 19.3% over a free T4 concentration range of 5.0 to 46.0 pmol/L. We conclude that the two-step methodology offers diagnostic advantages for a laboratory which receives specimens from such patients for exclusion of thyroid disease but that improved assay precision is required before it could be used in a routine situation.

Use of sensitive immunoradiometric assay for thyrotropin in clinical practice

Although measurement of thyrotropin (thyroid-stimulating hormone; TSH) by radioimmunoassay was a major advance in the laboratory diagnosis of thyroid failure--replacing the time-consuming TSH stimulation test--it was not sufficiently sensitive to discriminate reliably between euthyroid and hyperthyroid patients. Measurement of the TSH response to thyrotropin releasing hormone (TRH) served this purpose, however. The recent development of TSH assays that are severalfold more sensitive and more specific than conventional radioimmunoassays has allowed distinction of euthyroid from hyperthyroid patients and eliminated the need for the TRH test. Although undetectable levels of TSH, compatible with hyperthyroidism, are occasionally noted in euthyroid patients with severe nonthyroidal illness and during the first trimester of pregnancy, false-positive results are less often recorded for TSH than for free or total thyroid hormone measurements. Measurement of TSH by sensitive immunoradiometric assay is currently the most useful first-line test of thyroid function in patients with suspected thyroid disease and, in addition, has a valuable role in monitoring the dose of thyroxine replacement therapy.

Functional properties of human thyroid follicles cultured within collagen gel

Cultures of human thyroid follicles embedded in collagen gel were performed to investigate certain functional properties under bovine thyrotropin (TSH) stimulation. Follicles obtained from normal glands responded to increasing concentrations of TSH administered on day 4 in culture and for 3 days by increased amounts of cyclic AMP (cAMP), thyroglobulin (Tg) and triiodothyronine (T3) and by decreased levels of thyroxine (T4). Effect was maximal at 2000 microU/ml TSH (cAMP) or 200 microU/ml (Tg, T3, T4). When methimazole or propylthiouracil (PTU) were added, the T3 levels decreased. Follicle lumens contained a periodic acid-Schiff substance which was identified by immunoreaction as Tg. Thyroid follicles obtained from Graves' disease glands gave modified results with an earlier and intensified T3 response and no increase in Tg. These data show that (1) Tg and T3 are secretory products of functional follicles giving a cAMP-mediated response to TSH. (2) The detected T3 also derives from T4 5'-deiodination inhibited by PTU. (3) Intensified T3 response in Graves' follicles is probably due to enhanced conversion of T4 to T3.

A new radioimmunoassay of free thyroxine using 125I-labelled thyroxine-protein complex uninfluenced by albumin and thyroxine-binding globulin

We describe a double-antibody solid phase radioimmunoassay for free thyroxine (FT4) in serum with use of 125I-labelled thyroxine-human chorionic gonadotropin conjugate. Since the labelled conjugate does not bind to thyroxine binding globulin (TBG) and albumin because of its large molecular weight, the method is uninfluenced by TBG or albumin. The measurable range of FT4 in serum was 2.0 to 128 ng/l. The mean coefficients of variation within and between assays were 4.6-8.6% and 6.3-11.6%, respectively. The FT4 values determined by the proposed method correlated well with those determined by commercial radioimmunoassay in subjects with normal albumin concentration (r = 0.98). The FT4 concentrations in serum as determined by this method were 9 to 17 ng/l for healthy adult subjects; high for patients with hyperthyroidism; low for patients with hypothyroidism; and within normal limits for pregnant women, and patients with high or low concentrations of thyroxine-binding globulin.

Serum free thyroxine and free triiodothyronine concentrations in healthy fullterm, preterm and sick preterm neonates

There are few data available on free thyroid hormone concentrations in the early neonatal period. With the widespread application of screening procedures for detecting congenital hypothyroidism there is a need for reference ranges in neonates. In this study we have evaluated thyroid function in healthy fullterm and preterm neonates, and sick neonates all within one to 10 days postnatal age. Our data indicates that free thyroxine but not free triiodothyronine is higher in fullterm neonates than the adult reference range and that both free thyroid hormone concentrations are reduced in healthy and sick preterm neonates as compared to fullterm neonates. Assessment of thyroid function in the early neonatal period needs to take into account these changes particularly in preterm and sick preterm neonates.

Relationship between effects of added albumin, initial free thyroxine value and endogenous serum-binding protein concentrations on Amerlex free thyroxine estimations

We studied the effect of adding purified human albumin to sera on free thyroxine (FT4) values obtained with Amerlex radioimmunoassays. Apparent FT4 values increased with progressive addition of albumin in vitro. The effect was smallest with low and greatest with high initial FT4 concentrations, which were also linearly correlated with the incremental increase in FT4 values per g/l albumin added. Wide variations in either endogenous thyroxine binding globulin (TBG) or albumin concentrations in patient serum had little effect on the rate of increase in FT4 values when albumin was added in vitro. From Mass Action theory, calculations of the binding affinity of the endogenous albumin for the analog (2.1 X 10(5) l/mol) gave values nearly half that of the added albumin (3.94 X 10(5) l/mol). Distortions in Amerlex FT4 values caused by adding albumin in vitro may exaggerate its importance as a tracer binder and such results may be unrepresentative of patient samples.

A new type of albumin with predominantly increased binding affinity for 3,3',5-triiodothyronine in a patient with Graves' disease

A new type of serum albumin, that shows a markedly enhanced binding activity for 3,3', 5-triiodothyronine (T3), a somewhat increased activity for thyroxine (T4), and a normal activity for 3,3', 5-triiodothyronine (rT3) is described. This albumin was found in a patient with Graves' disease. After successful subtotal thyroidectomy, the existence of abnormal binding activity for T3 was suspected in this patient because of persistently increased total T3 concentrations in spite of elevated thyrotropin levels. Although free T3 and T4 concentrations measured by radioimmunoassay using commercial tracer analogue kits were markedly increased, those measured by equilibrium dialysis were within normal ranges. Electrophoretic studies revealed that these abnormalities were due to the markedly increased T3 binding activity by the serum albumin; that for T4 was also slightly increased. Scatchard plot analysis revealed that the association constant (Ka) for T3 of the patient's albumin was 5.1 X 10(6)/M (normal pooled albumin; 6.2 X 10(5)/M), and those for T4 and rT3 were 5.2 X 10(6)/M and 2.7 X 10(6)/M, respectively (normal pooled albumin; 2.1 X 10(6)/M for both T4 and rT3). The increased binding of albumin to T3 and T4 was markedly inhibited by barbitone, and 8-anilino-1-naphthalene-sulfonic acid. These characteristic features, and erroneously high values of free T3 and T4 concentrations measured by tracer analogue kits were similar to those seen in patients with familial dysalbuminemic hyperthyroxinemia, which have been previously reported. These findings strongly suggest that this albumin is a new variant in various dysalbuminemic syndromes, and the abnormal binding of iodothyronines moieties in these syndromes are not biochemically identical.

Ultrafiltration method for direct radioimmunoassay measurement of free thyroxine and free tri-iodothyronine in serum

Ultrafiltration at physiological pH and temperature of undiluted serum followed by direct radioimmunological determination of T3 and T4 in the protein-free ultrafiltrate offers the best possible approach towards estimation of in vitro plasma levels of free T3 and free T4. The major technical difficulties in meeting this apparently simple proposition are: establishing adequately sensitive radioimmunoassays; avoidance of adhesion to ultrafilters and glassware; removal from the ultrafilters of compounds which would cross-react or interfere in the radioimmunoassays; and avoidance of co-filtration of thyroid hormone binding proteins in serum, which would obviously imply spurious data. This methodological study describes the magnitude and significance of each of these obstacles and how to circumvent them. Practically all other available methods, including equilibrium dialysis, imply dilution of serum samples with buffer often leading to alterations in ionic composition to which thyroid hormone binding to proteins is peculiarly sensitive. Dilution itself alters the fraction of free thyroid hormones in serum especially when pharmaca or compounds are present which compete for the binding sites. These pitfalls are avoided in ultrafiltration of undiluted serum. This is illustrated through measurements on serum containing therapeutic concentrations of Fenclofenac which was found to displace 120% more T4 in undiluted than in diluted (1:28) serum. Using the described technique FT3 was 8.8 +/- 1.7 pmol/l and FT4 30.8 +/- 8.2 (SD) pmol/l in serum from 29 normal subjects. Pregnant women in their third trimester had lower levels: FT3 7.1 +/- 2.1 and FT4 17.6 +/- 5.8 pmol/l (SD, n = 24).

Fatty acid induced changes in circulating total and free thyroid hormones: in vivo effects and methodological artefacts

Elevated levels of nonesterified fatty acids (NEFA) are frequently found in acute illnesses, and they may contribute to changes in serum thyroid hormone concentrations in nonthyroidal illnesses (NTI) by displacing protein bound hormones. We therefore examined the effects of low and raised plasma NEFA levels on circulating total and free thyroxine (TT4 and FT4) and triiodothyronine (TT3 and FT3) concentrations, the Free T4 Index (FT4I) and TSH, in a randomized crossover study in 10 normal subjects. Subjects ate either a high carbohydrate breakfast (low NEFA protocol) or a high fat breakfast followed by an iv injection of 1000 u heparin (high NEFA protocol). Possible biological effects of changes in FT4 and FT3 were evaluated by a 200 micrograms iv TRH test. Free T4 and T3 were measured by a direct analogue method (AFT4 and AFT3). In a similar high NEFA study, but without TRH, FT4 was also measured by equilibrium dialysis (DFT4) and a 2-step RIA method (2-step FT4). Acute elevations of plasma NEFA from 0.67 +/- 0.08 mmol/L to a peak of 2.6 +/- 0.54 mmol/L resulted in a prompt reciprocal fall of mean TT4 (-8.7%, p less than 0.01), AFT4 (-30%, p less than 0.005) and TT3 (-11.5%, p less than 0.01) and AFT3 (-16%, p less than 0.005); DFT4 rose significantly from 23.7 +/- 1.9 pmol/L to 33.0 +/- 3.7 pmol/L (+39%, p less than 0.025) and 2-step FT4 rose by 16% (p less than 0.05). TSH levels declined consistently from 3.3 +/- 0.5 mIU/L to 2.6 +/- 0.4 mIU/L (p less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Recent advances in routine thyroid function testing

Thyroid function tests are one of the most common of endocrine laboratory investigations requested by general clinicians. The tests used therefore have to be efficient at identifying thyroid disease, monitoring treatment, and handling large numbers of tests. Recent advances in methodology have expanded both the range of in vitro thyroid function tests available and the techniques by which the well-established tests may be performed. This article reviews the methods and analytical and clinical performance of the routine tests currently available, concentrating particularly on the relatively new ones, and speculating on their role in strategies for the laboratory investigation of thyroid function.

Thyroid function tests in patients with familial dysalbuminaemic hyperthyroxinaemia (FDH)

Two patients with familial dysalbuminaemic hyperthyroxinaemia (FDH) are described in whom the albumin variant resulted in raised total T4 levels, and artefactually raised free T4 using a 'single-step' technique employing an analogue of T4 as tracer. The first patient was clinically euthyroid and presented with relapse of schizophrenia and abnormal thyroid function tests (total T4 336 nmol/L, total T3 4.2 nmol/L, TSH 1.8 mU/L, free T4 73 pmol/L). These results led to diagnostic confusion and the patient was treated with a short course of anti-thyroid drugs. The second patient had signs and symptoms of thyrotoxicosis at her first visit but was clinically euthyroid 5 months later when she was 10 weeks pregnant. Thyroid function tests were total T4 259 nmol/L, total T3 3.6 nmol/L, TSH 3.8 mU/L, free T4 46 pmol/L. Further studies showed both patients to be biochemically euthyroid. A variant albumin was confirmed in both patients by a screening test for FDH and by reverse-flow electrophoresis. Family studies on 10 relatives of the first patient identified eight with FDH. A simple screening procedure for the indentification of FDH is described and the use of laboratory tests in suspected cases is discussed.

Comparison of a new ultrafiltration method for serum free T4 and free T3 with two RIA kits in eight groups of patients

We measured serum free thyroxine (FT4) and free T3 (FT3) concentrations by a newly developed ultrafiltration (UF) method and by the Diagnostic Products Corporation (DPC) and Amersham Corporation (Amerlex) RIA methods in 173 patients divided into eight groups: 1) normal controls, II) normal elderly subjects, III) hyperthyroidism, IV) hypothyroidism, V) pregnancy, VI) critically ill, VII) chronic renal failure, and VIII) heparin therapy. The results were also compared with the free T4 index and free T3 index. FT4 (UF) and FT3 (UF) were generally normal in the elderly subjects. All methods showed elevated values in hyperthyroid patients. FT4 was normal in 7-23% of hypothyroid patients (depending on the method), and FT3 was normal in 15-27% of hypothyroid patients. Mean FT4 (UF) and FT3 (UF) were increased in pregnancy; in contrast the Amerlex RIA results were reduced in pregnancy. In critically ill patients, mean FT4 and FT3 were reduced by all methods. In heparinized patients, FT4 (UF) and FT3 (UF) were normal, but the RIA kits, especially Amerlex, gave very low values. Although the various methods gave considerably different absolute values of FT4 and FT3, there was a high degree of correlation between the ultrafiltration FT4 and FT3 and the results by the other methods.

Amerlex free triiodothyronine and free thyroxine levels in normal pregnancy

Free triiodothyronine (FT3) and free thyroxine (FT4) were measured in 159 women during normal pregnancy and compared with non-pregnancy reference ranges for these hormones. FT3 values fell from the reference level of 6.34 (SD 1.06) pmol/l to 3.87 (SD 0.54) pmol/l in the 3rd trimester; corresponding figures for FT4 were: reference 16.92 (SD 2.97) pmol/l, 3rd trimester 11.29 (SD 2.01) pmol/l. There were no significant changes in the 1st trimester; 4% and 69% of FT3 results in the 2nd and 3rd trimesters respectively fell below the reference range of mean +/- 2 SD. The corresponding findings for FT4 were 4% and 42%. FT3 correlated reasonably well with total T3 (r = 0.90) and was acceptably precise (within-batch CV 2.1% at 5.6 pmol/l, between-batch CV between 3.1% and 4.7% at six levels).

Limitations of new thyroid function tests in pregnancy

Sensitive immunoradiometric assays (IRMA) for TSH and radioimmunoassay (RIA) kits for free thyroid hormones (fT4, fT3) are becoming increasingly used for routine thyroid investigations. We have assessed these tests in 93 euthyroid pregnant women. Mean fT4 and fT3 values decreased with gestation by 24-27% and 14-35%, respectively, using several analogue RIA kits. Some patients had free hormone values which fell below the reference range derived from non-pregnant euthyroid patients. By contrast, the fT4 concentrations measured by direct equilibrium dialysis fell by only 16% with all values within the reference range. Serum non-esterified fatty acid (NEFA) levels (non-fasting) did not correlate with fT4 and fT3 but a spurious effect of serum albumin levels on the free hormone kits was suggested. TSH results showed that the majority of subjects had lower values measured by IRMA than by RIA. Three patients had basal TSH (IRMA) below the mean detection limit of the assay; this could have been falsely interpreted as indicating hyperthyroidism. We conclude that, as with longer established thyroid function tests, special care must be taken in interpreting results of these new thyroid function tests in pregnancy.

Abnormalities of thyroid function tests in hospital inpatients

Results of thyroid function tests were analysed in 199 clinically euthyroid inpatients with normal serum thyroid stimulating hormone values. Serum total triiodothyronine was less than 1.25 nmol/l in 61.8% of samples, free triiodothyronine less than 3.9 pmol/l in 57.8%, total thyroxine less than 63 nmol/l in 21.1% and free thyroxine less than 9.5 pmol/l in 17.6%. In contrast, thyroxine binding globulin ratio was below normal (less than 5) in only 5 samples. A significant positive correlation (P less than 0.001) of serum free thyroxine with total thyroxine, thyroxine/thyroxine binding globulin ratio and free triiodothyronine was present as well as a significant negative correlation (P less than 0.001) with serum thyroid stimulating hormone. There was no correlation of free thyroxine measurements with serum albumin or non-esterified fatty acid concentrations. Although serum free thyroxine is low in a number of patients with non-thyroidal illnesses, this does not appear to be due to a rise in non-esterified fatty acids or a fall in albumin as has been proposed. Serum thyroid stimulating hormone measurements are essential to confirm the diagnosis of hypothyroidism in such subjects.

Serum thyroglobulin levels in hypofunctioning nodules before and after surgery

Serum thyroglobulin (Tg) level was determined in 34 biologically euthyroid patients having benign hypofunctioning nodule, before and after surgery. Based on the results of thyroid scanning with radioiodine, 2 groups of patients were considered. Group 1 (n = 18) had solitary hypofunctioning nodule with an otherwise normal thyroid gland and group 2 (n = 16) had hypofunctioning nodule inside an enlarged and/or heterogeneous thyroid. Results were compared to a group of 30 control subjects. Mean Tg level was significantly elevated in both groups 1 and 2 before surgery. No significant difference was found between group 1 and group 2. After surgical removal of the hypofunctioning nodule (follicular adenoma), mean Tg level was normalized in group 1 and decreased but still remained elevated in group 2. It is concluded that the observed elevated serum Tg level is due to the presence of hypofunctioning nodule and/or heterogeneous thyroid tissue. Thus, Tg determination may be useful in the follow-up of operated hypofunctioning nodules in order to detect abnormality in the remaining thyroid tissue.

Diagnosis of hyperthyroidism: the newer biochemical tests

Investigation of suspected hyperthyroidism is conventionally based on measurement of total or free T4 as the initial test, followed in equivocal cases by total or free T3, and the TRH test. Recent developments in techniques for measuring free hormones and TSH promise to change this approach. Free T4 and free T3 can now be rapidly and simply quantitated in whole serum using labelled analogue radioimmunoassays. Specific and highly sensitive assays using labelled monoclonal antibodies are now available for serum TSH that permit the suppressed levels found in most cases of hyperthyroidism to be distinguished from euthyroid levels. These newer assays are available at a cost per test that is often similar to that of the more established tests. Available evidence indicates that measurement of basal serum TSH by a sensitive labelled antibody method can serve as a first line test, at least in uncomplicated cases of suspected hyperthyroidism. In patients with a suppressed TSH, a serum free T4, and in equivocal cases free T3, will distinguish the clinical and subclinical forms of hyperthyroidism. Such an approach would obviate the need for the TRH test. It must be emphasized, however, that experience with this new approach is limited. Caution is advised in the interpretation of low TSH and free hormone levels when there are associated complicating features, such as severe non-thyroidal illness, or pregnancy. These developments mark a trend in thyroid function testing away from measurement of circulating total hormone levels. The newer tests provide an assessment of end organ (thyrotroph) response, and an assessment of biologically active (free) hormone to which the tissues are exposed. These complementary approaches have the potential to identify relatively minor degrees of thyroid dysfunction.

Familial dysalbuminemic hyperthyroxinemia (FDH): inadequacy of the "analog" methods for assaying free-T4 levels

Free-T4 levels were determined in familial dysalbuminemic hyperthyroxinemia (FDH) subjects. In agreement with their euthyroid status free-T4 levels were within the normal range when tested by equilibrium dialysis and by the FT4 Immophase method (Corning Medical). However, when using the recently introduced "analog" methods, either Amerlex FT4 or Becton-Dickinson FT4, Free-T4 values were markedly higher than the control values. This discrepancy is probably due to artifactual binding of the labeled analog to the fraction of albumin exhibiting an excessive affinity for T4.