Detection of vitamin K deficiency by use of an enzyme-linked immunosorbent assay for circulating abnormal prothrombin

Range of protein induced by vitamin K absence or antagonist-II levels in neonates at birth

Protein induced by vitamin K absence or antagonist-II (PIVKA-II) is avitamin K (VK) deficiency indicator in neonates. However, PIVKA-II detection frequency in neonatal blood at birth and the correlation between PIVKA-II and gestational age are unclear. We retrospectively analyzed infants admitted to our institution between June 1, 2018, and March 31, 2022, whose clinical and PIVKA-II data were available, and classified them into preterm and term infant groups. Overall incidence of PIVKA-II-positive cases (≥ 50 mAU/mL) was 42.8%, including 0.6% apparent VK deficiency (≥ 5000 mAU/mL), 3.1% experimental VK deficiency (1000-4999 mAU/mL), and 10.7% latent VK deficiency (200-999 mAU/mL) cases. Incidence of PIVKA-II-positive cases was significantly higher in the term group than in the preterm group (49.4% vs. 29.7%, p < 0.001). Gestational age correlated with PIVKA-II levels (r2 = 0.117, p < 0.0001). Median serum PIVKA-II levels and incidence of PIVKA-II-positive cases (≥ 50 mAU/mL, 16.4%) were lower at 5 days after birth than at birth, possibly reflecting the postnatal VK prophylaxis impact. Only one infant was diagnosed with VK deficiency bleeding (PIVKA-II levels, at birth: 10,567 mAU/mL; at day 5: 2418 mAU/mL). Thus, serum PIVKA-II levels after birth weakly correlated with gestational age. VK deficiency was more common in term infants than in preterm infants.

Are 90K/MAC-2BP Serum Levels Correlated with Poor Prognosis in HCC Patients? Preliminary Results

In this study we assessed the prognostic significance of 90K/MAC-2BP serum levels in a group of 40 hepatocellular carcinoma patients. This glycoprotein is a new, interesting serum marker that reflects the immune reaction of the host against certain viral infections and tumors such as breast, ovarian and pancreatic cancer. Hepatocellular carcinoma (HCC) is one of the most widespread tumors in the world. AFP is currently the most useful marker for HCC, in spite of its poor diagnostic sensitivity. In this study 40 cirrhotic HCC patients were enrolled. The prevalence of viral hepatic infections in this group was 73% for HCV, 8% for HBV, and 8% for both viruses. Thirteen percent of the patients showed non-virus-related liver damage. 90K serum levels were assayed by an ELISA kit and AFP levels by a chemiluminescent enzyme immunometric system. The overall survival curves were estimated by the Kaplan-Meier method, taking into account age, sex, 90K and AFP serum levels. Statistical analysis showed a highly significant influence on overall survival of age below 70 years and 90K serum levels below the cutoff of 14 ng/mL. Serum AFP (≤20 ng/mL) had positive prognostic value only when it was associated with 90K levels (p<0.02, log-rank).

A quantitative analytical method for PIVKA-II using multiple reaction monitoring-mass spectrometry for early diagnosis of hepatocellular carcinoma

Prothrombin induced by vitamin K absence-II (PIVKA-II) is an effective tumor marker for hepatocellular carcinoma (HCC). We have developed a novel targeted mass spectrometric (MS) assay for quantifying PIVKA-II in human serum. The ideal signature peptide was selected to measure PIVKA-II concentrations on a triple quadrupole (QqQ) mass spectrometer, and the chromatography gradient was optimized for the peptide separation to minimize elution interference. Using multiple reaction monitoring-mass spectrometry (MRM-MS), good linearity (R ² = 0.9988) was obtained for PIVKA-II over a range of 3 orders. We achieved a limit of detection (LOD) of 0.45 nM (31.72 ng/mL), a limit of quantification (LOQ) of 0.93 nM (65.31 ng/mL), a lower limit of quantification (LLOQ) of 0.49 nM (34.32 ng/mL), and an upper limit of quantification (ULOQ) of 1000.00 nM (70,037.00 ng/mL). The intra-day and inter-day precisions were within ±14.96%, and the accuracy ranged from 87.66 to 114.29% for QC samples at four concentrations. Compared with an established immunoassay, the correlation (R = 0.8335) was good for the measurements of PIVKA-II concentrations. This method was successfully applied to the analysis of clinical samples for normal control (n = 50), chronic hepatitis (n = 50), liver cirrhosis (n = 50), HCC (n = 50), and recovery (n = 50) serum. Graphical Abstract MRM-MS assay development for determining concentration of PIVKA-II in serum and a comparison between MRM-MS assay and immunoassay with high correlation.

Biological Systems of Vitamin K: A Plasma Nutriproteomics Study of Subclinical Vitamin K Deficiency in 500 Nepalese Children

Vitamin K (VK) is a fat-soluble vitamin whose deficiency disrupts coagulation and may disturb bone and cardiovascular health. However, the scale and systems affected by VK deficiency in pediatric populations remains unclear. We conducted a study of the plasma proteome of 500 Nepalese children 6–8 years of age (male/female ratio = 0.99) to identify proteins associated with VK status. We measured the concentrations of plasma lipids and protein induced by VK absence-II (PIVKA-II) and correlated relative abundance of proteins quantified by mass spectrometry with PIVKA-II. VK deficiency (PIVKA-II >2 μg/L) was associated with a higher abundance of low-density lipoproteins, total cholesterol, and triglyceride concentrations (p < 0.01). Among 978 proteins observed in >10% of the children, five proteins were associated with PIVKA-II and seven proteins were differentially abundant between VK deficient versus sufficient children, including coagulation factor-II, hemoglobin, and vascular endothelial cadherin, passing a false discovery rate (FDR) threshold of 10% (q < 0.10). Among 27 proteins associated with PIVKA-II or VK deficiency at a less stringent FDR (q < 0.20), a network comprised of hemoglobin subunits and erythrocyte anti-oxidative enzymes were highly and positively correlated each other (all r > 0.7). Untargeted proteomics offers a novel systems approach to elucidating biological processes of coagulation, vascularization, and erythrocyte oxidative stress related to VK status. The results may help elucidate subclinical metabolic disturbances related to VK deficiency in populations.

Des-gamma-carboxy prothrombin identified by P-11 and P-16 antibodies reflects prognosis for patients with hepatocellular carcinoma

BACKGROUND AND AIMS

Serum des-γ-carboxy prothrombin (DCP) is an established tumor marker in patients with hepatocellular carcinoma (HCC), which can be identified by using MU-3 antibody. The MU-3 antibody mainly reacts with the 9-10 glutamic acid residues of DCP (conventional DCP). Since other variants of DCP with fewer glutamic acid residues can be detected using P-11 and P-16 antibodies (code name: NX-PVKA), we examined the clinical characteristics associated with NX-PVKA, and whether NX-PVKA is a useful measure in HCC patients.

METHODS

Participants comprised 197 HCC patients admitted to our hospital between 2001 and 2010. NX-PVKA, conventional DCP, alpha-fetoprotein, and L3 fraction of alpha-fetoprotein were measured prior to initiation of HCC treatment.

RESULTS

Of the tumor markers assessed, NX-PVKA was the only significant predictor of prognosis (hazard ratio, 81.32; P < 0.0001). Patients with NX-PVKA level ≥ 100 mAU/mL showed significantly lower survival rates (P < 0.0001). NX-PVKA level was also significantly associated with platelet count, prothrombin time, C-reactive protein, sex, maximum tumor size, number of nodules, and portal venous invasion by HCC. Finally, using NX-PVKA level and other clinical parameters, we established a prognostic model to estimate patient survival time.

CONCLUSIONS

NX-PVKA offers the best marker of tumor prognosis among HCC patients, and is strongly associated with tumor factors and hepatic functional reserve. NX-PVKA could be useful for clinical evaluation of tumor severity, as well as the estimated duration of survival among patients with HCC.

Prevalence of subclinical vitamin K deficiency in cholestatic liver disease

BACKGROUND AND OBJECTIVE

Prothrombin time (PT), a surrogate marker of vitamin K deficiency, may underestimate the prevalence of vitamin K deficiency in cholestatic liver disease. This study investigated the frequency of vitamin K deficiency in children and adults with cholestatic liver disease by determining plasma protein induced in vitamin K absence II (PIVKA-II), and assessed the relation between plasma PIVKA-II levels and markers of cholestasis, measured PT, international normalized ratio (INR), serum undercarboxylated osteocalcin (ucOC), serum vitamins A and E, and serum 25-hydroxyvitamin D levels.

PATIENTS AND METHODS

Blood was collected from patients with cholestatic liver disease for liver biochemistries, PT, INR, bile acids, 25-hydroxyvitamin D, vitamin A, vitamin E, ucOC, and PIVKA-II.

RESULTS

Thirty-one patients were enrolled (age range 0.5-54 years, median age 5.7 years, 17 females). Nine patients (29%) had increased INRs, whereas 21 (68%) had elevated plasma PIVKA-II levels. All patients with increased INRs had increased plasma PIVKA-II. Fifteen of 21 patients with increased plasma PIVKA-II were receiving supplemental vitamin K therapy (range 7.8-700 mug/kg/day). Plasma PIVKA-II levels were positively correlated with serum conjugated bilirubin, bile acids, aspartate aminotransferase, alanine aminotransferase, PT, INR, and serum ucOC (P <or= 0.02) and negatively correlated with serum 25-hydroxyvitamin D levels (P = 0.01). Twenty-two patients (71%) had vitamin D deficiency, 9 patients (29%) had vitamin A deficiency, and 2 patients (6%) had vitamin E deficiency.

CONCLUSIONS

Despite vitamin K supplementation, elevation of plasma PIVKA-II suggesting ongoing vitamin K deficiency is common in cholestatic liver disease. Better strategies for vitamin K supplementation and dosing guidelines are needed.

Lens culinaris agglutinin-reactive alpha-fetoprotein and protein induced by vitamin K absence II are potential indicators of a poor prognosis: a histopathological study of surgically resected hepatocellular carcinoma

BACKGROUND

We histopathologically examined Lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3)-positive hepatocellular carcinoma (HCC) and protein induced by vitamin K absence (PIVKA) II-positive HCC to clarify the efficacy of these markers for predicting a poor prognosis.

METHODS

Serum AFP-L3 and PIVKA II was measured in 110 HCC patients. AFP-L3 was measured by lectin-affinity electrophoresis coupled with antibody-affinity blotting, and PIVKA II by using a high-sensitivity kit. The growth type, capsule formation, capsule infiltration, portal vein invasion, intrahepatic metastasis and histological tumor grade were evaluated pathologically.

RESULTS

Thirty-eight (35%) HCC patients were AFP-L3-positive, and 63 (57%) were PIVKA II-positive. In AFP-L3-positive HCC, the frequencies of an infiltrative growth type (positive : negative = 66% : 42%, P = 0.027) and a poorly differentiated type (positive : negative = 32% : 6%, P < 0.001) were significantly higher than in AFP-L3-negative HCC. In PIVKA II-positive HCC, the frequencies of an infiltrative growth type (positive : negative = 62% : 28%, P < 0.001), vascular invasion (positive : negative = 63% : 26%, P < 0.001), and intrahepatic metastasis (positive : negative = 38% : 4%, P < 0.001) were significantly higher than in PIVKA II-negative HCC. In both AFP-L3- and PIVKA II-positive HCC, the frequency of a poorly differentiated growth type was significantly higher than in HCC positive for either AFP-L3 or PIVKA II or HCC negative for both AFP-L3 and PIVKA II (both positive : either positive : both negative = 37% : 12% : 0%; P = 0.014, P < 0.001, respectively).

CONCLUSIONS

AFP-L3 was related to progression from moderately differentiated to poorly differentiated HCC, whereas PIVKA II was more specific to vascular invasion. PIVKA II is therefore likely to be a useful indicator of vascular invasion.

Vitamin K deficiency in children pre-bone marrow transplantation

This study examined the prevalence of vitamin K deficiency in children pre-bone marrow transplantation (BMT). Vitamin K status was measured by the PIVKA-II assay and prothrombin times. Blood samples were obtained before vitamin-containing TPN was infused. Results indicated that eight of 26 patients (31%) were vitamin K deficient; four cases were attributed to drug antagonism (phenytoin) and four were due to inadequate vitamin K intake, synthesis or malabsorption. Only one patient had a prolonged prothrombin time. Prothrombin time, in our study, is shown to be an ineffective screening tool to determine vitamin K status. All patients receiving phenytoin and chemotherapy are at increased risk of vitamin K deficiency.

Prevalence of vitamin K deficiency in children with mild to moderate chronic liver disease

OBJECTIVES

Children with chronic liver disease are at risk for vitamin K deficiency because of fat malabsorption and inadequate dietary intake. The objective of this study was to determine the prevalence of vitamin K deficiency in children with mild to moderate chronic cholestatic and noncholestatic liver disease.

METHODS

Vitamin K status was examined in 43 children (0.25-15.9 years) with mild to moderate chronic cholestatic liver disease, 29 children (0.9-16.9 years) with chronic mild to moderate noncholestatic liver disease, and in 44 healthy children (1-18 years). Vitamin K status was assessed by the plasma PIVKA-II (protein induced in vitamin K absence) assay (enzyme-linked immunosorbent assay). Plasma PIVKA-II values greater than 3 ng/mL are indicative of vitamin K deficiency.

RESULTS

The mean plasma PIVKA-II (+/-SD) in cholestatic, noncholestatic, and healthy children was 61.9 +/-144, 1.2 +/- 3, and 2.1 +/- ng/mL, respectively (P < 0.002). Fifty-four percent of the children supplemented with vitamin K had plasma PIVKA-II greater than 3 ng/mL. Plasma conjugated bilirubin, total bile acids, and severity of liver disease were positively correlated with plasma PIVKA-II levels (P < 0.05).

CONCLUSIONS

Vitamin K deficiency is prevalent in children with mild to moderate chronic cholestatic liver disease, even with vitamin K supplementation. Elevated PIVKA-II levels occurred in children with a normal prothrombin, indicating that more sensitive markers of vitamin K status should be used in children with chronic liver disease. Vitamin K deficiency was related to degree of cholestasis and severity of liver disease in children. Children without cholestasis did not exhibit vitamin K deficiency.

Clinicopathologic features of patients with primary malignant hepatic tumors seropositive for alpha-fetoprotein-L3 alone in comparison with other patients seropositive for alpha-fetoprotein-L3

BACKGROUND

Patients with hepatocellular carcinoma (HCC) seropositive for lectin-reactive alpha-fetoprotein (AFP-L3) have a poor prognosis. However, there have been no studies of the clinicopathologic features of patients seronegative for both AFP and des-gamma-carboxy prothrombin (DCP), and seropositive for AFP-L3 alone in comparison with other patients seropositive for AFP-L3.

METHODS

Patients with primary malignant hepatic tumors seropositive for AFP-L3 who underwent hepatectomy (n = 84) were divided into four groups, and their clinicopathologic features were compared: (i) group A, seronegative for AFP <100 ng/mL and DCP <40 mAU/mL; (ii) group B, seropositive for AFP > or =100 ng/mL and seronegative for DCP; (iii) group C, seronegative for AFP and seropositive for DCP > or =40 mAU/mL; and (iv) group D, seropositive for AFP and DCP.

RESULTS

Among the 14 group A patients seropositive for AFP-L3 alone with low AFP concentrations, three had intrahepatic cholangiocarcinoma (ICC), one had a cholangiolocellular carcinoma, one had combined HCC and ICC, and one had undifferentiated hepatic sarcoma. Group A had a higher incidence of non-HCC tumors (P < 0.001) and tumors derived from cholangiocytes (P < 0.001) than the other three groups. They also had a high frequency of poorly differentiated tumors and sarcomatous changes, and showed a poor prognosis.

CONCLUSIONS

Patients with primary malignant hepatic tumors seropositive for AFP-L3 alone with low AFP concentrations have unique clinicopathologic features. Thus, we should be aware of these patients and should measure AFP-L3 levels, at least once, even in those seronegative for both AFP and DCP.

Immunohistochemical study of protein induced by vitamin K absence or antagonist II in hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

Protein induced by vitamin K absence or antagonist II (PIVKA-II) has been used as a tumor marker of hepatocellular carcinoma (HCC). In this study, we examined the expressions of PIVKA-II in HCC tissues.

METHODS

Expression of PIVKA-II in HCC was evaluated with the avidin-biotin-peroxidase complex method. Paraffin-embedded HCC tissues obtained from 48 patients were subjected to immunohistochemical staining using the anti-PIVKA-II antibody monoclonal antibody (MU-3) (Eisai, Tokyo, Japan).

RESULTS

The tissue PIVKA-II positivity rate of 12/23 (52.2%) in HCC with vascular infiltration was significantly higher than the rate of 4/25 (16.0%) in HCC without such infiltration. Further, the tissue PIVKA-II positivity rate of 13/28 (46.4%) in HCC of tumor stage III or IV was significantly higher than the rate of 3/20 (6.0%) in HCC of tumor stage I or II. Overall survival rate tended to be lower in the tissue-PIVKA-II-positive than -negative patients.

CONCLUSIONS

PIVKA-II may play an important role in progression of HCC and is useful not only as a tumor marker but also as a prognostic factor.

Assessment of vitamin K deficiency in CF—how much sophistication is useful?

BACKGROUND

Due to maldigestion of dietary lipids, fat soluble vitamins are prone to malabsorption in cystic fibrosis (CF) patients with pancreatic insufficiency (PICF). Routine supplementation of vitamin K(1) in PICF is presently subject of discussion.

METHODS

Serum vitamin K, prothrombin time, PIVKA-II ('liver marker', by two different ELISAs), hydroxyapatite binding capacity (HBC, 'bone marker') and ApoE genotypes were measured in 32 PICF patients (age: 7 months to 25 years) with (PICFK) or without (PICFN) oral vitamin K(1) supplementation, all receiving lipase supplementation, and in 18 healthy controls (C).

RESULTS

PIVKA-II was positive only in 4/7 PICFN. HBC medians of all groups were 57-60%. HBC values of PIVKA-II positive patients were below HBC median of their group. There was no correlation between HBC and PIVKA-II. There was no correlation between prothrombin time and other measurements. HBC medians with regard to ApoE were ApoE2/3 (62.9%)>ApoE3/3 (57.6%)>ApoE3/4+ApoE4/4=(56.65%).

CONCLUSIONS

Vitamin K deficiency of liver or bone may occur independently. Prothrombin time is an insensitive marker. Individuals with ApoE4 allels might be more susceptible to osteopenia. As high expenditures are necessary to detect patients at risk, routine vitamin K supplementation for all PICF patients appears appropriate.

Des-gamma-carboxy prothrombin (DCP) ratio, a novel parameter measured by monoclonal antibodies MU-3 and 19B7, as a new prognostic indicator for hepatocellular carcinoma

BACKGROUND/AIM

Recently, a novel des-gamma-carboxy prothrombin (DCP) antibody named 19B7 has been developed. It has been reported that the DCP ratio defined by DCP measured by MU-3 antibody/DCP measured by 19B7 antibody demonstrated differences between hepatocellular carcinoma and vitamin K deficiency. The aim of this study was to clarify the relationship between the DCP ratio and tumour malignancy, as well as the prognostic significance of the DCP ratio after hepatectomy for hepatocellular carcinoma.

METHODS

From January 1996 to December 1999, 79 patients diagnosed with hepatocellular carcinoma underwent hepatectomy. To detect DCP in the plasma before surgery, we used a new EIA kit, Eitest PIVKA-II kit (Eisai, Tokyo, Japan) with both MU-3 and 19B7 antibody. The DCP ratio was calculated using the formula: DCP ratio = DCP level measured by MU-3 antibody (mAU/ml)/DCP level measured by 19B7 antibody (mAU/ml). Pathologic findings using resected specimens were classified according to the Japanese General Rules for Primary Liver Cancer.

RESULTS

Among DCP-positive patients, the DCP ratio was significantly higher in those with tumour thrombus in the portal vein (vp) or with a moderately or poorly differentiated hepatocellular carcinoma than in those without vp or with a well-differentiated carcinoma (P = 0.0162, 0.0109, respectively). Patients with DCP ratio > 3 had a significantly higher incidence of vp than those with DCP ratio < or = 3 (P = 0.0027). The survival rate was significantly higher in patients with DCP ratio < or = 3 than in those with DCP ratio > 3 (P = 0.0002). This result was the same as in DCP positive cases (P = 0.0027).

CONCLUSIONS

The DCP ratio can distinguish DCP produced by hepatoma cells from DCP produced by normal hepatocytes in vitamin K deficiency. The DCP ratio is a useful prognostic indicator that can be assessed before hepatectomy.

Clinicopathologic features of patients with hepatocellular carcinoma seropositive for alpha-fetoprotein-L3 and seronegative for des-gamma-carboxy prothrombin in comparison with those seropositive for des-gamma-carboxy prothrombin alone

BACKGROUND

There has been no study of the clinicopathologic features of patients with hepatocellular carcinoma (HCC) who are seropositive for lectin-reactive alpha-fetoprotein (AFP-L3) alone, or seropositive for AFP-L3 and seronegative for des-gamma-carboxy prothrombin (DCP) in comparison with those who are seropositive for DCP alone. Thus, the present comparative study was performed.

METHODS

The clinicopathologic features of HCC patients with either one or two tumors who underwent a hepatectomy (n = 88) were compared among the following five groups according to the seropositivity of AFP, AFP-L3 and DCP: (i) group A, seropositive for AFP above 100 ng/mL, AFP-L3 above 15% and DCP above 100 mAU/mL; (ii) group B, seropositive for AFP-L3 and seronegative for DCP below 40 mAU/mL; (iii) group C, seronegative for AFP below 20 ng/mL, AFP-L3 below 15% and seropositive for DCP; (iv) group D, seropositive for AFP and seronegative for AFP-L3 and DCP; and (v) group E, seronegative for AFP, AFP-L3 and DCP.

RESULTS

Group B patients showed a higher incidence of infiltrative-type HCC with an irregular margin (P < 0.05) and a higher frequency of poorly differentiated HCC (P < 0.01) compared with group C patients. Group A patients had larger tumors and more massive-type tumors than group B patients. Our HCC cases showed that advanced clinicopathologic features were demonstrated in the order of group B, group C and group D. Group A and B patients and group D and E patients showed similar characteristics.

CONCLUSIONS

Hepatocellular carcinoma patients who were seropositive for AFP-L3 and seronegative for DCP demonstrated clinicopathologic features of more advanced HCC compared with those who were seropositive for DCP alone.

Are breast-fed infants vitamin K deficient?

Hemorrhagic disease of the newborn is a disease of breast-fed infants. We have followed 119 exclusively breast-fed infants for up to 6 months of age, who received 1 mg of vitamin K, intramuscularly at birth. As vitamin K is undetectable in cord blood, the only other source in breast-fed infants is human milk. We found persistently low vitamin K1 plasma concentrations in these infants by 4 weeks, and vitamin K concentrations at 2, 4, 6, 8, 12, and 26 weeks averaged 1.18+/-0.99, 0.50+/-0.70, 0.16 +/-0.07, 0.20+/-0.20, 0.25+/-0.34, and 0.24+/-0.23 ng/mL, respectively (lower limit of adult normal = 0.5ng/mL). Vitamin K, in breast milk at 2, 6, 12, and 26 weeks was also very low, averaging 1.17+/-0.70, 0.95+/-0.50, 1.15+/-0.62, and 0.87+/-0.50 mg/mL, respectively. This may be secondary to low maternal vitamin K1 intakes or inability of vitamin K1 to penetrate human milk. We had previously reported a relatively high mean vitamin K intake of 316+/-548 microg in 20 lactating women during the first 6 months of lactation (mean of 60, 3-day dietary recalls) which greatly exceeded the recommended daily allowance of 1 microg/kg/day. The vitamin K content of foods was recently revised downward utilizing newer analytical methods (Booth et al. 1995). Recalculating maternal vitamin K intakes in this original cohort resulted in a dramatic decrease in intake to 74+/-57 microg/day, an amount closely approximating 1 microg/kg/day. We have completed 69 new dietary recalls in 23 lactating women and, combining these data with the previous study, determined a maternal vitamin K1 mean intake of 65+/-48 microg/day (0.8-1.3 microg/kg/day). Other than plasma vitamin K1 concentrations, PIVKA (undercarboxylated prothrombin produced in the absence of vitamin K) is a marker of vitamin K deficiency. We measured PIVKA in 156 cord bloods of full-term infants. Seventy-five (48%) had a significantly elevated PIVKA (> or =0.1 absorption units per milliliter). Seventy-seven of these infants who were exclusively breast-fed subsequently had no detectable PIVKA at 4 weeks, but by 8 weeks, 3 were again positive for PIVKA (prothrombin times were normal). Breast-fed infants may benefit from increased maternal vitamin K intakes (>1 microg/kg/day) during pregnancy and lactation. A supplement of 5 mg of vitamin K to lactating mothers will increase the concentration in human milk to 80.0+/-37.7 ng/mL and significantly increase infant plasma vitamin K (Greer et al. 1997).

gamma-Carboxyglutamic acid content of hepatocellular carcinoma-associated des-gamma-carboxy prothrombin

Serum des-gamma-carboxy prothrombin (DCP) is a useful marker for the diagnosis of hepatocellular carcinoma (HCC), but the exact mechanism of its synthesis and its structural properties in liver diseases are unknown. DCP is measured by the monoclonal antibody MU-3. The purpose of this study was to examine the epitope of MU-3 and to characterize the differences in DCP between HCC and benign liver diseases. The epitope of MU-3 was examined by ELISA using prothrombin Gla domain polypeptides and was determined to be amino acid residues 17-27 of the prothrombin Gla domain, which has four gamma-carboxyglutamic acid residues (Gla) at positions 19, 20, 25 and 26. Peptides having a glutamic acid residue (Glu) at these positions reacted strongly to MU-3 but lost reactivity when Glu 19 or 20 was changed to Gla. In the order of gamma-carboxylation, MU-3 reacted strongly to DCP containing 0-1 Gla, weakly to 2-4 Gla and not at all to DCP containing more than five Gla. After adsorbing normal prothrombin with barium carbonate, DCP reaction to MU-3 was measured by determining the amount of DCP that was adsorbed by MU-3-coated beads. The proportion of DCP reacting to MU-3 in HCC was 41.0-76.8%, whereas in patients with benign liver diseases, only 0-42.1% reacted to MU-3. These results indicate that DCP variants preferentially synthesized in HCC have less than four Gla, which are restricted to positions 16, 25, 26 and 29, whereas DCP variants in benign liver diseases have more than five Gla.

Comparison of clinicopathological features of patients with hepatocellular carcinoma seropositive for alpha-fetoprotein alone and those seropositive for des-gamma-carboxy prothrombin alone

BACKGROUND

There has been no comparative study of the clinicopathological features of HCC patients who are seropositive for alpha-fetoprotein (AFP) alone and those who are seropositive for des-gamma-carboxy prothrombin (DCP) alone. The authors, thus, performed this comparative study.

METHODS

The clinicopathological features of patients with solitary hepatocellular carcinoma (HCC), who underwent a hepatectomy were compared among the four below groups according to the seropositivity of AFP and DCP: group A, seronegative for both AFP below 20 ng/mL and DCP below 40 mAU/mL; group B, seropositive for AFP above 100 ng/mL and seronegative for DCP; group C, seronegative for AFP and seropositive for DCP above 100 mAU/mL; and group D, seropositive for both AFP and DCP.

RESULTS

Group B patients showed a higher incidence of HCC with an indistinct margin, and a somewhat higher incidence of small HCC less than 2 cm in greatest dimension compared with group C patients. By contrast, group C patients had a higher frequency of HCC with a distinct margin compared with that of an indistinct margin, large tumors more than 3 cm compared with that of small tumors less than 2 cm, and a somewhat higher frequency of moderately to poorly differentiated HCC compared with that of well-differentiated HCC. Our HCC cases showed advanced clinicopathological features in the order of group C, group B and group A. Groups C and D patients showed similar characteristics.

CONCLUSIONS

Hepatocellular carcinoma patients who were seropositive for AFP alone demonstrated clinicopathological features of less advanced HCC compared with those who were seropositive for DCP alone.

Possible effects of one week vitamin K (menaquinone-4) tablets intake on glucose tolerance in healthy young male volunteers with different descarboxy prothrombin levels

To clarify the roles of vitamin K (VK) in the pancreas, twice oral, glucose tolerance tests were examined in 12 healthy young male volunteers before and after 1 week of VK tablet intake. Blood were collected by venipucture at 0, 30 and 120 min after 75 g oral glucose loading. They then took VK tablets (90 mg/d of menaquinone-4) for 1 week, and the second glucose tolerance test was examined. The subjects were divided into three groups by serum descarboxy prothrombin (DP) levels; four of lowest DP (L-DP), middle of DP (M-DP) and highest DP (H-DP) levels. They were compared by one-factor analysis of variance and Scheffè's F (group differences) and paired t -test (the effects of 1 week of VK intake). Age, body mass index and glucose status [plasma glucose (PG) and immunoreactive insulin (IRI), hemoglobin-Alc, fructosamine] of all groups were almost the same, but the IRI of the H-DP group was higher than that of the other groups at 120 min after the glucose loading (mean+/-SEM; L; 10.6+/-0.9, M-; 17.5+/-4.2, H-; 40.4+/-6.0 microU/ml). One week of VK intake tended to decrease the plasma DP levels of all groups and significantly reduced IRI of the H-DP at 120 min by half (before; 40.4+/-6.0 vs after: 18.4+/-4.6 microU/ml). The IRI/pG ratio in areas under the curve (AUC) of H-DP from 0 to 120 min after the loading was significantly decreased by 1 week of VK tablet intake (before: 31.0+/-7.4 vs after: 20/1+/-3.8 microU/g). These results suggested that there may be some relationship between pharmacological dose of vitamin K and insulin response.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is increasing in many countries as a result of an increase in hepatitis C virus (HCV) infection since World War II. The epidemiology of HCC varies with the global region. There have been conflicting observations from different parts of the world concerning the frequency of HCC in patients who in the distant past had post-transfusion non-A, non-B hepatitis. The genetic basis of hepatocarcinogenesis is still poorly understood. In hepatitis B virus (HVB) associated HCC, codon 249 mutation in the p 53 gene seems more related to exposure to aflatoxin B1 than to hepatocarcinogenesis itself. HCC that occurs in children in high HBV endemic regions could be associated with germ-line mutations, but little information is available; not much is known about chemical hepatocarcinogens in the environment other than aflatoxins. The X gene of HBV seems to play an important role in HBV-associated hepatocarcinogenesis. There are preliminary observations on the molecular mechanism of HCV-associated HCC, such as HCV core protein inducing HCC in transgenic mice and the NS3 genome transforming NIH 3T3 cells. Pathological distinction between preneoplastic and very early transformed lesions still depends on classical morphology, and a more genetically oriented differential diagnosis is required. Clinical diagnosis based on modern imaging has improved greatly, but is still unsatisfactory in the differential diagnosis of preneoplastic and early transformed nodules, because the vasculature changes that occur within the nodule are not accurately discerned with the current imaging. Use of sensitive des-gamma-carboxy prothrombin (PIVKA II) assay, and lectin affinity chromatography separating HCC specific subspecies of AFP molecules with a more practical biochemical technique will further improve diagnosis. Early diagnosis and transplantation are the best treatment at the moment, but transplantation is not widely available because of the donor shortage. Despite successful resection, the remnant cirrhotic liver frequently develops new HCC lesions, seriously curtailing long-term survival. All-out efforts should be directed to the prevention of HCC, through prevention of viral hepatitis, prevention of acute hepatitis from becoming chronic, prevention of chronic hepatitis from progressing to cirrhosis, and prevention of the cirrhotic liver from developing HCC (chemoprevention). At the moment, very few such studies exist.

Serum levels of des-gamma-carboxy prothrombin measured using the revised enzyme immunoassay kit with increased sensitivity in relation to clinicopathologic features of solitary hepatocellular carcinoma

BACKGROUND

Des-gamma-carboxy prothrombin (DCP) is an established marker for hepatocellular carcinoma (HCC), but the conventional enzyme immunoassay (EIA) kit lacks adequate sensitivity. Thus, a revised EIA kit with increased sensitivity has been developed. In this kit, the sensitivity has increased while high specificity to HCC has been maintained. The authors have already reported the clinical usefulness of this revised EIA kit. In this study, they examined the serum levels of DCP measured by this revised EIA kit in relation to the clinicopathologic features of solitary HCC.

METHODS

Fifty-six patients with solitary HCC who underwent hepatectomy were studied. The relation between the greatest dimension and the histologic differentiation of HCC was investigated in these 56 patients, as were the serum levels of DCP measured by the revised EIA kit (Sensitive DCP), alpha-fetoprotein (AFP), and DCP measured by the conventional EIA kit (DCP). The cutoff value for Sensitive DCP was set at 40 mAU/mL, and the values for AFP and DCP were 20 ng/mL and 100 mAU/mL (0.1 AU/mL), respectively.

RESULTS

The positivity rates for Sensitive DCP, AFP, and DCP (n = 56) were 53.6%, 53.6%, and 35.7%, respectively, and the rate was 73.2% when Sensitive DCP was used in combination with AFP (Sensitive DCP + AFP). The positivity rates for these markers were as follows: 1) When the greatest dimension of HCC was more than 3 cm (n = 16) and less than 2 cm (n = 23), the rates were 81.3% and 30.4% for Sensitive DCP, 68. 8% and 39.1% for AFP, 56.3% and 13.0% for DCP, and 93.8% and 56.5% for Sensitive DCP + AFP. 2) When HCC was moderately to poorly differentiated (n = 41) and well differentiated (n = 15), the rates were 68.3% and 13.3% for Sensitive DCP, 61.0% and 33.3% for AFP, 48. 8% and 0% for DCP, and 85.4% and 40% for Sensitive DCP + AFP. 3) When HCC was either more than 3 cm or moderately to poorly differentiated (n = 42) and either less than 2 cm or well differentiated (n = 27), the rates were 69.0% and 29.6% for Sensitive DCP, 61.9% and 37.0% for AFP, 47.6% and 11.1% for DCP, and 85.7% and 51.9% for Sensitive DCP + AFP.

CONCLUSIONS

DCP measured by the revised EIA kit with increased sensitivity has a stronger correlation than AFP with size and histologic differentiation of HCC. This Sensitive DCP is a very useful marker for HCC and should be used in combination with AFP.

Vitamin K contents in liver tissue of hepatocellular carcinoma patients

Serum protein induced in vitamin K absence-II (PIVKA-II) is used as a tumor marker because it increases at a notably higher rate in patients with hepatocellular carcinoma. To clarify the mechanism causing the elevation of serum PIVKA-II, we measured the contents of vitamins K1 (phylloquinone, PK) and K2 (menaquinone, MK) (MK-4, MK-5, MK-6, MK-7, MK-8, MK-9, MK-10) in liver tissue resected from 21 hepatic cancer patients (12 patients with hepatocellular carcinoma and 9 patients with metastatic hepatic cancer), using HPLC combined with coulometric reduction and fluorometric detection. In the cancerous tissue of hepatocellular carcinoma patients, PK, MK-7, MK-8, and MK-10 were significantly lower than that found in the noncancerous tissue. Furthermore, MK-6, MK-7, MK-8, and MK-10 in the cancerous tissue of hepatocellular carcinoma patients were significantly lower than that in the cancerous tissue of metastatic hepatic cancer patients. These data suggested that one of the mechanisms of the elevation of serum PIVKA-II levels in hepatocellular carcinoma patients is a vitamin K deficiency in the local cancerous tissue.

Prevalence of vitamin K deficiency in cystic fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) are at risk of developing vitamin K deficiency because of pancreatic insufficiency, hepatobiliary disease, or both.

OBJECTIVE

Our objective was to determine the prevalence of vitamin K deficiency in unsupplemented patients with CF and to identify risk factors that might be associated with the deficiency.

DESIGN

Ninety-eight patients with CF-83 who were pancreatic insufficient (age: 15.2 +/- 10.7 y; range: 0.6-45.8 y), 15 who were pancreatic sufficient (age: 26.2 +/- 11.6 y; range: 6.5-45.3 y), and 62 healthy individuals (age: 16.2 +/- 12. 8 y; range: 1-45 y)-were studied prospectively. None had taken vitamin K supplements. Eight pancreatic-insufficient patients had advanced CF-associated liver disease. Plasma prothrombin in vitamin K absence (PIVKA-II) was measured by immunoassay. All control subjects had PIVKA-II concentrations <3 microg/L.

RESULTS

Seventy-eight percent of pancreatic-insufficient patients had PIVKA-II concentrations >/=3 microg/L (22.8 +/- 35.7 microg/L). All patients with CF-associated liver disease had abnormal PIVKA-II concentrations. The mean PIVKA-II concentration of pancreatic-insufficient patients with liver disease was greater than that of those without liver disease (46.6 +/- 65.3 compared with 15. 3 +/- 26.1 microg/L; P < 0.05). Five pancreatic-sufficient patients had mildly elevated PIVKA-II concentrations. Six (7%) pancreatic insufficient patients (3 with CF-associated liver disease) had mildly prolonged prothrombin time but no clinical bleeding. There was no correlation between PIVKA-II concentrations and severity of fat malabsorption or antibiotic use.

CONCLUSIONS

Vitamin K deficiency is common in unsupplemented patients with CF and pancreatic insufficiency and routine supplementation should be considered in all of these patients.

Prothrombin and PIVKA-II levels in cord blood from newborn exposed to anticonvulsants during pregnancy

PURPOSE

To determine whether anticonvulsant exposure during human pregnancy caused an increase of the abnormal form of prothrombin, known as PIVKA-II (prothrombin induced by vitamin K absence for factor II), and a decrease in total prothrombin, in the blood of the newborn.

METHODS

Cord blood was collected from the placenta at the time of parturition from 12 women who had received anticonvulsant therapy during pregnancy and from 11 control women.

RESULTS

PIVKA-II was present in cord blood from control mothers at low or nondetectable levels. In the same samples, total prothrombin concentrations were approximately 50% of adult levels, but there was wide variation between individuals. Exposure to carbamazepine (CBZ) alone during pregnancy was associated with markedly increased PIVKA-II levels in four of six samples and decreased total prothrombin levels for the whole group. High PIVKA-II levels also were recorded in one cord blood sample from a mother who received phenytoin (PHT) and vigabatrin (VGB). Two cases of PHT alone and one of valproic acid (VPA) alone were not associated with increased PIVKA-II levels.

CONCLUSIONS

These results are consistent with the hypothesis that some anticonvulsants (particularly CBZ) interfere with vitamin K metabolism during pregnancy and may result in hematologic signs of vitamin K deficiency in the newborn.

Serum des-gamma-carboxy prothrombin levels determined by a new generation of sensitive immunoassays in patients with small-sized hepatocellular carcinoma

OBJECTIVE

Des-gamma-carboxy prothrombin (DCP), also called protein induced by vitamin K absence or antagonist II (PIVKA-II), is a tumor marker complementary to AFP for the diagnosis of hepatocellular carcinoma (HCC). Currently available immunoassays for DCP are not sensitive enough to detect HCC at an early stage. Recently, two new immunoassays with enhanced sensitivity were developed. The aim of this study was to assess the diagnostic values of the new methods in patients with small-sized HCC.

METHODS

Coded serum samples obtained from 36 patients with small-sized and single-nodular HCC (< or = 3 cm in diameter) and 49 patients with posthepatitic cirrhosis not carrying HCC were analyzed. DCP levels were determined in three different ways: 1) conventional EIA; 2) a new immunoassay using the electrochemiluminescence (ECLIA) detection system; and 3) a new immunoradiometric assay (IRMA). Lectin-reactive profiles of AFP (AFP-L3) were also determined.

RESULTS

In 36 patients with small-sized HCC, the rates of abnormal values obtained by the conventional, ECLIA, and IRMA methods were 2.7%, 27.8%, and 16.7%, respectively. An ROC analysis of the two new methods (ECLIA vs IRMA) revealed a better performance by the ECLIA method (p < 0.05). The true positive rate of AFP-L3 was 22.2%, whereas a combination assay of ECLIA for DCP and AFP-L3 resulted in a 41.7% sensitivity with a specificity of 90%.

CONCLUSIONS

Compared with the conventional method, the sensitivity in detecting small-sized HCC was increased in the two new DCP immunoassays (ECLIA and IRMA). The overall performance as evaluated by an ROC analysis was significantly better in ECLIA than in IRMA.

Clinical utility of Lens culinaris agglutinin-reactive alpha-fetoprotein in small hepatocellular carcinoma: special reference to imaging diagnosis

BACKGROUND/AIMS

Blood concentration levels of alpha-fetoprotein like the Lens culinaris agglutinin-reactive fraction (AFP-L3) are a useful marker for predicting the long-term prognosis of hepatocellular carcinoma. This study investigated the relationship between serum AFP-L3 and various imaging modalities.

METHODS

Sixty-three patients with small hepatocellular carcinomas < or = 2 cm in diameter were studied. Serum AFP-L3 concentrations were measured by lectin-affinity electrophoresis coupled with antibody-affinity blotting and expressed as % AFP-L3 (the percent of AFP-L3 as total AFP). A clinical "cutoff level" of 10% was used in this study to indicate the presence of hepatocellular carcinoma. Selective hepatic intraarterial digital subtraction angiography (DSA), ultrasonographic angiography with carbon dioxide microbubbles (USAG), and computed tomography during arterial portography (CTAP) were performed to evaluate the hemodynamics of hepatic nodules.

RESULTS

Fourteen (22.2%) of the 63 patients were positive for % AFP-L3. The % AFP-L3 levels (n=45, 4.4%) of patients with hypervascular tumors were significantly higher than those (n=15, 0.0%) of patients with isovascular or hypovascular tumors as determined by USAG (p=0.0061). The % AFP-L3 levels (n=53, 4.4%) of patients with a negative portal blood supply were significantly higher than the % AFP-L3 levels (n=7, 0.0%) of patients with a positive portal blood supply as determined by CTAP (p=0.0140). The % AFP-L3 levels of patients with tumors with a long doubling time (DT) were significantly lower than for patients with tumors with a short DT (p=0.0176).

CONCLUSION

AFP-L3 is a positive indicator which may be more specific for small advanced hepatocellular carcinoma.

Comparison of plasma prothrombin and factor VII and urine prothrombin F1 concentrations in patients on long-term warfarin therapy and those in the initial phase

Control of warfarin anticoagulation during the initial phase of therapy is difficult and empirically based. Plasma and urine samples were obtained from normal controls, patients under stable anticoagulation, and patients in the initial phase of anticoagulation. Total plasma prothrombin, des-carboxy (non-adsorbable with barium chloride) prothrombin, and native (total minus non-adsorbable) prothrombin were quantitated using Echis carinatus venom activation. Functional plasma factor VII (VII) was measured using a one-stage clotting assay. Total and des-carboxy urine prothrombin F1 (F1) were measured by ELISA. All urine F1 in normals and both anticoagulated groups was adsorbed by barium chloride. Plasma des-carboxy prothrombin concentration was similar for the two anticoagulated groups and did not correlate with 1/INR. Native prothrombin correlated with 1/INR in both the stable (r = 0.76) and initial phase (r = 0.74) groups. For any given INR, the subjects on stable anticoagulation had lower native prothrombin concentrations than the initial phase patients. Functional factor VII concentration also correlated significantly with 1/INR in both the stable (r = 0.64) and initial phase (r = 0.76) patients. Unlike native prothrombin, VII concentrations did not vary between the two cohorts for any given INR. Previous studies indicate that native prothrombin is a superior predictor of both hemorrhagic and thromboembolic complications during warfarin therapy. Our findings indicate that VII, and not prothrombin, may be the predominant factor monitored by the INR. This further supports the need to reevaluate the usefulness of the INR in the monitoring of warfarin therapy during the initial phase.

Usefulness of ED036 kit for measuring serum PIVKA-II levels in small hepatocellular carcinoma

As a tumor marker for hepatocellular carcinoma (HCC), serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) has high specificity, yet its sensitivity is relatively low, marking it less suitable to serve as an adjunct in the diagnosis of small HCC. Recently, the ED036 kit (Eisai, Tokyo, Japan), whose detection limit is approximately ten times superior to that of a conventional kit (Eitest MONOP II, Eisai) has been developed. In this study, serum PIVKA-II levels in serum samples from 83 patients with benign chronic liver diseases (CLD) and 129 patients with HCC were measured with those two kits. With the ED036 kit, the cut-off value was set at 40 mAU/ml. For PIVKA-II measured with the ED036 kit, sensitivity was 45.0%, specificity 92.8%, and accuracy 63.7%, when we discriminated patients with HCC from those with CLD without HCC. While maintaining a high specificity, of 92.8%, the ED036 kit showed a significantly higher sensitivity than the conventional kit (45.0% versus 27.9%; P < 0.0001). With patients who had HCC consisting of a single nodule 30 mm or less in diameter, the positivity rate for serum PIVKA-II with the ED036 kit was significantly greater than the rate with the conventional kit (21.4% versus 9.5%; P < 0.005). Thus, the ED036 kit was thought to be more useful than the conventional kit as a tumor marker for small HCC.

Plasma vitamin K1 and PIVKA-II after oral administration of mixed-micellar or cremophor EL-solubilized preparations of vitamin K1 to normal breast-fed newborns

BACKGROUND

Vitamin K1 prophylaxis in neonates is required for prevention of vitamin K1 deficiency bleeding. Although intramuscular administration of vitamin K1 is safe, this invasive method is not generally accepted. We therefore examined the pharmacokinetics of two orally administered vitamin K1 preparations in normal, fully breast-fed newborns.

METHODS

Within 1 hour of birth, each baby was randomized to a 2 mg dose of either a conventional Cremophor EL-solubilized preparation of vitamin K1 (Konakion drops, F. Hoffmann-La Roche, n = 16), or a new mixed-micellar preparation of vitamin K1 (Konakion MM, F. Hoffmann-La Roche, n = 14). The concentrations of vitamin K1, des-gamma-carboxyprothrombin (PIVKA-II), and total bound bilirubin were measured in plasma samples taken at 24 hours, 4 days, and 24 days after birth.

RESULTS

The median concentration of plasma vitamin K1 was higher at all three time points in the group that received the mixed-micellar preparation, but the difference was only significant (p < 0.05) at 4 days. At 24 hours and 4 days, PIVKA-II was detectable in a significantly lower proportions of infants receiving the new mixed-micellar preparation than those receiving the Cremophor EL preparation (21% vs. 75% at 24 hours, p < 0.05 and 14% vs. 50% at 4 days, p < 0.05). None of the infants in the study had detectable PIVKA-II levels 24 days after birth.

CONCLUSIONS

Our results suggest that when given orally, the mixed-micellar preparation is superior to the conventional formulation because it increases plasma vitamin K1 concentrations to higher levels, suggesting superior bioavailability, and decreases PIVKA-II concentrations more efficiently, suggesting a faster pharmacodynamic response.

The relevance of developmental hemostasis to hemorrhagic disorders of newborns

The hemostatic system is a dynamic evolving process that is age-dependent. Components of the hemostatic system are synthesized in early fetal life and do not cross the placenta from mother to fetus. However, plasma concentrations of proteins involved in hemostasis significantly differ from adults. Physiological reference ranges are available for premature infants, full-term infants and children from ages 1 to 16 years. In the coagulation system, plasma concentrations of the vitamin K-dependent and contact factors are decreased at birth, whereas other factors such as fibrinogen, FV, FVIII, and FXIII are similar or increased compared with adults at birth. In the fibrinolytic system, plasma concentrations of plasminogen are decreased at birth, whereas tissue plasminogen activator and plasminogen activator inhibitor are increased. Clinically, the hemostatic system of the young is effective and healthy infants do not suffer from spontaneous hemorrhagic complications. However, infants are more vulnerable, compared with older patients, for bleeding in the presence of either congenital or acquired haemostatic defects. Severe congenital bleeding disorders, although rare, frequently present in the newborn period. The most common acquired causes of bleeding newborns include disseminated intravascular coagulation, vitamin K deficiency, and liver disease. A description of these disorders and treatment guidelines are provided.

Specific measurement of hypocarboxylated prothrombin in plasma or serum and application to the diagnosis of hepatocellular carcinoma

An enzyme-linked immunosorbent assay (ELISA) was developed for measuring human hypocarboxyprothrombin, a protein induced by vitamin K antagonists (PIV KA-II). A specific monoclonal antibody (P1-2-B9) was prepared and used for coating a microELISA plate, and revelation proceeded with a rabbit polyclonal anti-human prothrombin antibody-peroxidase conjugate. This assay allowed the measurement of PIVKA-II at concentrations ranging from 2 to 200 ng/ml, with an intraassay coefficient of variation of less than 5.2% and an interassay coefficient of variation of less than 7.4%. This assay permits the direct evaluation of PIVKA-II in citrated plasma as well as in serum. The concentration of PIVKA-II is expressed in nanograms per milliliter. It offers specific measurement of PIVKA-II without any cross-reactivity from native prothrombin: the specificity for PIVKA-II respective to prothrombin is > 10(5). No reactivity was observed with other vitamin K-dependent proteins, whether fully active or decarboxylated. Complementary studies have demonstrated that the monoclonal antibody used was preferentially directed to 3 to 6 Gla hypocarboxylated prothrombin. PIVKA-II concentration was below 2.4 ng/ml in normal individuals (n = 59). In 61 patients given dicoumarol for more than 90 days (receiving a stable therapy), the measured concentrations of PIVKA-II ranged from 750 to 13,400 ng/ml. Combined with the assay of alpha-fetoprotein (AFP), measurement of PIVKA-II in patients with liver diseases introduces a complementary exploration for hepatocellular carcinoma (HCC). In a study in 59 patients with HCC, the assay sensitivity was 49.1% for PIVKA-II, 47.5% for AFP, and 71% for both markers combined.

Usefulness of simultaneous determination of alpha-fetoprotein and des-gamma-carboxy prothrombin in hepatocellular carcinoma

Serum gamma-fetoprotein (AFP) and plasma des-gamma-carboxy prothrombin (DCP), a protein induced by vitamin K absence or antagonist II (PIVKA-II) levels, were measured in 197 patients with primary hepatocellular carcinoma (HCC). DCP levels were determined by conventional enzyme immunoassay kit (E-1023) and a newly developed high-sensitivity kit using the avidin-biotin complex method. Cut-off levels of AFP and DCP by the E-1023 kit and of DCP by the high-sensitivity kit were put at 100 ng/ml, 0.1 arbitrary unit (AU)/ml, and 0.004 AU/ml, respectively. Positive rate of AFP and DCP by the E-1023 kit and the high-sensitivity kit for HCC was 48%, 44%, and 57%, respectively. The positive rate by combination assay with AFP and DCP by the high-sensitivity kit increased up to 73%. There was no correlation between serum levels of AFP and those of plasma DCP. A significant correlation between tumor size and DCP levels was observed, but not with AFP. The postoperative disease-free survival rates of patients in the group with elevated levels of AFP and DCP were lower than those with normal levels of AFP and DCP. There were various patterns of change in the AFP and DCP levels at the time of recurrence compared with preoperative patterns. The combination assay of AFP and DCP levels is useful for the diagnosis, prognosis, and postoperative monitoring for recurrence of HCC.

Normotest and abnormal prothrombin in liver transplantation

Postoperative changes in coagulation parameters, including the abnormal plasma prothrombin level, were studied in 95 patients who underwent liver transplantation, and the results were compared with the clinical outcome. The patients were classified into four groups: Group I had a satisfactory postoperative course, (n = 76), Group II suffered graft failure or death at 31 days or more after transplantation (n = 9); Group III suffered graft failure or death from 8 to 30 days after transplantation (n = 4); and Group IV suffered graft failure or death within 7 days of transplantation (n = 6). The Normotest, which closely reflected liver graft function, showed an increase immediately after transplantation in Group I, II, and III, but showed a marked decrease in Group IV. In patients with severe acute cellular rejection, the plasma level of abnormal prothrombin (des-gamma-carboxy prothrombin) was compared with the histology of the liver biopsy specimen. When liver graft function was good after orthotopic transplantation, the Normotest value recovered to the normal range of 70% or more. Subsequently, graft function remained good when the des-gamma-carboxy prothrombin level stayed low, whereas acute cellular rejection was indicated by an elevation of des-gamma-carboxy prothrombin was not produced by graft with early failure, the des-gamma-carboxy prothrombin level also remained low. Thus, the Normotest value and the des-gamma-carboxy prothrombin level were both useful parameters for assessing hepatic function and rejection after transplantation.

Production of a new monoclonal antibody specific to human des-gamma-carboxyprothrombin in the presence of calcium ions. Application to the development of a sensitive ELISA-test

In order to explore pathologies possibly associated with vitamin K deficiency, several monoclonal antibodies (mAbs) were produced against human Desgamma-Carboxy-Prothrombin (DCP). One of these mAbs, designated C4B6, detected DCP forms in the presence of Calcium ions, confirmed by comparison with the patterns of two electrophoretic techniques: Affino-Immuno-Electrophoresis (CAIE) and Polyacrylamide Gel Electrophoresis followed by Electro-blotting (PAGE-Blot). An Enzyme-Linked-Imunosorbent Assay (ELISA) using mAb C4B6 has been developed, optimized and standardized. It has proven to be specific for DCP forms and has a minimum sensitivity of 0.156 A.U/ml.

Levels of vitamin K, immunoreactive prothrombin, des-gamma-carboxy prothrombin and gamma-glutamyl carboxylase activity in hepatocellular carcinoma tissue

To clarify the mechanism of production of des-gamma-carboxy (abnormal) prothrombin (DCP) by hepatocellular carcinoma (HCC), we measured the levels of vitamin K, DCP, immunoreactive prothrombin and the activity of gamma-glutamyl carboxylase in liver tissues from HCC patients and in the medium of cultured human hepatoma cells. There was no significant difference in vitamin K (K1, MK-4) contents between HCC and non-HCC cirrhotic liver tissues. The activity of gamma-glutamyl carboxylase per unit amount of endogenous microsomal prothrombin precursor was decreased in HCC tissue compared with non-HCC liver tissue (positive plasma DCP: 335 +/- 72 vs 372 +/- 67, negative plasma DCP: 370 +/- 84 vs 393 +/- 56 nmol/min per mg prothrombin precursor, P > 0.05), although the total incorporation of 14COOH into microsomal precursor protein was higher in the former. By contrast, levels of DCP and immunoreactive prothrombin in HCC tissue were greater (P < 0.05) than those in non-HCC cirrhotic liver tissue. Furthermore, production of large amounts of immunoreactive prothrombin was observed in human hepatoma cells huH-1 and huH-2, which produced large amounts of DCP. These results suggest that there was excessive synthesis of prothrombin precursors by human HCC tissue and hepatoma cell lines huH-1 and huH-2. Thus, excessive synthesis of prothrombin precursors seems to be the main mechanism of DCP production by HCC.

Serum des-gamma-carboxyprothrombin concentration determined by the avidin-biotin complex method in small hepatocellular carcinomas

BACKGROUND

Des-gamma-carboxyprothrombin (DCP) is a useful tumor marker for hepatocellular carcinoma (HCC). The present method for measurement of DCP concentration, however, does not have adequate sensitivity to detect small HCCs.

METHODS

The serum DCP concentration was investigated by the avidin-biotin complex (ABC) method in patients with an HCC smaller than 20 mm in maximum dimension. A serum DCP concentration greater than 4.0 arbitrary units per liter using the ABC method was considered abnormal.

RESULTS

Of 115 patients with small HCC, 45 (39.1%) had an abnormal DCP concentration. Ten of 141 patients with chronic hepatitis (7.1%), 18 of 115 (15.7%) with cirrhosis, and 0 of 30 normal control patients had abnormal DCP concentrations. This method yielded a sensitivity of 39.1%, a specificity of 89.1%, a positive predictive value of 61.6%, and a negative predictive value of 76.5% for detection of small HCC. The detectability of HCC increased to 56.5% when alpha-fetoprotein (AFP) was was measured (> 40 ng/ml). Abnormal DCP concentrations were seen in 8 of 34 (23.5%), 24 of 42 (57.1%), and 5 of 7 (71.4%) patients with Edmondson's Grade I, II, and III tumors, respectively. There was a significant relationship between DCP concentrations and histologic grade (P = 0.0017), but there was no association between DCP concentration and other patient characteristics. Elevation of serum AFP concentrations in patients with hepatitis B surface antigen positivity, however, was more frequent than that in patients who were antihepatitis C virus (HCV) positive. Therefore, the measurement of serum DCP concentrations may be more useful than that of serum AFP concentrations in patients with anti-HCV positivity.

CONCLUSIONS

The measurement of serum DCP concentrations by the ABC method is a useful diagnostic tool for the monitoring of small HCC.

Clinical evaluation of plasma des-gamma-carboxy prothrombin as a marker protein of hepatocellular carcinoma in patients with tumors of various sizes

We measured des-gamma-carboxyprothrombin (DCP) (prothrombin induced by vitamin K absence or antagonist-II, abbreviated as PIVKA-II) by a newly developed enzyme immunoassay using an anti-DCP monoclonal antibody in 665 human subjects, of which 112 were patients with hepatocellular carcinoma (HCC). PIVKA-II was elevated to more than 0.1 AU/ml in 54 of the 112 patients (48.2%) with HCC, while it was positive only in 7.1% of those with liver cirrhosis and 3.1% of those with chronic hepatitis. Three patients with elevated PIVKA-II greater than 0.1 AU/ml who had been diagnosed as having liver cirrhosis by ultrasonography and computed tomography at the start of this study developed a diffuse type of HCC three or six months later, which was detected by angiography. No obvious correlation was observed between plasma PIVKA-II concentration and serum alpha-fetoprotein (AFP) level in HCC patients. Of the 112 HCC patients, 40.2% showed an increase in AFP to above 200 ng/ml. In the remaining patients, 32.8% had a PIVKA-II concentration greater than 0.1 AU/ml. In these patients with a negative or low serum AFP concentration, PIVKA-II proved to be a valuable tumor marker for laboratory diagnosis of HCC. Among them, 59.8% tested positive for PIVKA-II and/or AFP. Thus, combination assay with PIVKA-II and AFP seems useful for increasing the accuracy of laboratory diagnosis of HCC. None of patients with a solitary tumor smaller than 2 cm had elevated PIVKA-II. In patients with larger-sized and multiple HCC, positive results of elevated PIVKA-II were more frequent than those of increased AFP.(ABSTRACT TRUNCATED AT 250 WORDS)

Des-gamma-carboxy (abnormal) prothrombin and hepatocellular carcinoma: a critical review

Des-gamma-carboxyprothrombin (DCP) appears to be a useful tumor marker for the evaluation of patients with HCC. DCP is produced by the malignant hepatocyte and appears to result from an acquired posttranslational defect in the vitamin K-dependent carboxylase system. DCP production is independent of vitamin K deficiency, although pharmacological doses of vitamin K can transiently suppress DCP production in some tumors. DCP levels greater than 0.1 AU/ml (100 ng/ml) on ELISA are highly suggestive of HCC or tumor recurrence. Normalization of DCP levels correlates well with successful tumor resection and appears to be an excellent marker of tumor activity. Plasma DCP does not correlate with AFP levels. However, when used together, DCP and AFP assays increase the sensitivity to HCC in more than 85% of patients. The specificity of the DCP assay appears to be superior to that of AFP; fewer than 5% of patients with nonmalignant liver disorders have DCP levels in excess of 100 ng/ml. In patients with medium to large HCC, DCP levels do correlate with tumor size. In tumors of less than 3 cm, DCP levels are increased in only 20% of patients. However, the diagnostic threshold for the DCP assay may be improved by newer assays that can detect partially carboxylated DCP species not measured by the monoclonal antibody-based ELISA.

Prevention of vitamin K deficiency in infancy by weekly administration of vitamin K

Vitamin K prophylaxis has been developed to prevent classic haemorrhagic disease of the newborn. Single vitamin K administration after birth has been reported to fail, resulting in late haemorrhagic disease of the newborn. The preventive effect of oral administration of vitamin K1 1 mg, repeated weekly during the first three months of life, was studied in 48 healthy breast-fed infants, by determination of thrombotest, PIVKA-II and vitamin K1 concentrations at the age of 4, 8 and 12 weeks. All infants showed normal thrombotest values and PIVKA-II was not detectable. Vitamin K1 concentrations were negatively correlated with the number of days elapsed since the most recent vitamin K administration. Six to seven days after the latest application, mean levels were 1223, 927 and 748 pg/ml at ages 4, 8 and 12 weeks, respectively. In conclusion, weekly administration of vitamin K1 1 mg offers complete protection against vitamin K deficiency and does not result in an accumulation of vitamin K1 in the blood.

Serum alpha-fetoprotein and lens culinaris agglutinin-reactive fraction of alpha-fetoprotein in patients with hepatocellular carcinoma

A fraction of serum alpha-fetoprotein (AFP) reactive with lens culinaris agglutinin (LCA) was measured by affinity chromatography in serum samples from 102 patients with hepatocellular carcinoma (HCC) and 48 patients with chronic liver diseases without HCC. Its usefulness as a marker of HCC was evaluated. The mean +/- SD percentage of this fraction in total AFP was 3.10 +/- 3.17% in 48 patients with chronic liver diseases without HCC. When the cut-off level was set at 12.6% (mean + 3 SD), the sensitivity was 36.3%, the specificity was 100%, and the accuracy was 56.7% in the 102 patients with HCC. This lentil lectin-reactive AFP was positive in 7 of 25 patients (28%) who had single small liver cancer (phi < 20 mm), suggesting its clinical usefulness as a tumor marker. The lentil lectin-reactive AFP showed no correlation with the serum concentration of AFP or des-gamma-carboxy prothrombin (DCP). In patients with HCC showing an AFP level of 20 ng/ml or above, the lentil lectin-reactive fraction is a highly specific tumor marker. We consider it to be useful as an adjunct in the diagnosis of HCC.

Abnormal prothrombin: evaluation as a tumour marker and localization in tissues of patients with hepatocellular carcinoma

In this study, the diagnostic significance of PIVKA-II concentrations in various liver diseases was evaluated, and the use of PIVKA-II as a tumour marker for hepatocellular carcinoma (HCC) was discussed. Also, the location of abnormal prothrombin (PIVKA-II) production in HCC by indirect immunoperoxidase staining was examined. There was a good correlation between plasma and serum PIVKA-II concentrations, indicating that serum samples are adequate for PIVKA-II measurements. Fifty-four of 97 (55.7%) patients with HCC, one of 10 (10%) patients with metastatic liver cancer and two of 47 (4.3%) patients with liver cirrhosis had positive serum PIVKA-II concentrations. Positive serum PIVKA-II concentrations were found more frequently in patients with HCC than in any other liver disease (P < 0.01). Of the 97 patients with HCC, 54 (55.7%) were PIVKA-II positive, 76.3% had serum concentrations of either PIVKA-II or alpha-fetoprotein, indicating the usefulness of both tumour markers in the diagnosis of HCC. Using frozen sections of tissue specimens obtained at autopsy or during surgery, the localization of PIVKA-II was examined by indirect immunoperoxidase staining with specific anti-PIVKA-II antibodies. Tissues from 12 of 22 patients with HCC had positive PIVKA-II indirect immunoperoxidase staining only in the cancer cells. Cells with greater atypia tended to have stronger cytoplasmic staining. No specific staining was observed in non-cancerous cells. These findings suggest that PIVKA-II is synthesized specifically in hepatic cancer cells.

Supplementation of vitamin K in pregnant women receiving anticonvulsant therapy prevents neonatal vitamin K deficiency

OBJECTIVE

The null hypothesis of this study is that extra vitamin K administered to pregnant women on a regimen of enzyme-inducing anticonvulsant therapy will not decrease the frequency of symptoms of vitamin K deficiency in their neonates.

STUDY DESIGN

A multicenter case-control study was performed on 16 pregnant women on anticonvulsant therapy who received 10 mg of vitamin K1 daily from 36 weeks of pregnancy onward. Concentrations of PIVKA-II (protein induced by vitamin K absence for factor II) and of vitamin K1 were determined in cord blood and compared with those in 20 controls.

RESULTS

In none of 17 cord samples was PIVKA-II detectable, compared with 13 of 20 in controls (chi 2, p < 0.001). Median cord vitamin K1 level was 530 pg/ml compared with below detection limit in most controls.

CONCLUSIONS

Antenatal vitamin K1 treatment decreases the frequency of vitamin K deficiency in neonates of mothers on anticonvulsant therapy.

Increased incidence of neonatal vitamin K deficiency resulting from maternal anticonvulsant therapy

OBJECTIVE

The null hypothesis of our study is that the incidence of vitamin K deficiency in mother-infant pairs exposed to anticonvulsant drugs is not higher than in controls.

STUDY DESIGN

In this multicenter observational case-control study, 25 pregnant women receiving anticonvulsant therapy and 25 pregnant controls were studied for PIVKA-II (protein induced by vitamin K absence of factor II) and vitamin K1 concentrations at 32 weeks' gestation and at delivery.

RESULTS

PIVKA-II was detectable in 54% of cord samples of the anticonvulsant group and in 20% of controls (chi 2, p = 0.01). In both groups vitamin K1 cord blood levels were predominantly below the detection limit. Maternal vitamin K1 concentrations were lower in women with epilepsy than in controls (Wilcoxon's rank sum test, p < 0.05), but PIVKA-II was rarely present.

CONCLUSIONS

The incidence of vitamin K deficiency is increased in neonates exposed to anticonvulsant drugs prenatally. Their mothers, however, are rarely vitamin K deficient.