Enzymes are biocatalysts found in various cells and organs. They can be used to know the functioning of an organ and in diagnostic kits and methods.

1. CLINICAL
ENZYMOLOGY
A presentation
by
Ms. Jigisha Pancholi
Head
Department of Biochemistry
Indian Institute of Ayurvedic Pharmaceutical Sciences
Gujarat Ayurved University

2. Introduction
• Enzymes are proteins which catalyze the biological reactions in an
animal.
• They are responsible for supporting almost all the chemical
reactions that maintain the animal’s homeostasis.
• Certain tissue cells contain characteristic enzymes which enter the
blood only when the cells to which they are confined are damaged
or destroyed.
• The presence in the blood of significant quantities of these
specific enzymes indicates the probable site of tissue damage.

3. Types of Enzymes
• Functional plasma enzymes (Plasma derived enzymes)-
Certain enzymes, pro enzymes and their substrates are present at
all times in the circulation of normal individuals and perform a
physiological function in the blood.
• Examples of these functional plasma enzymes include
lipoprotein lipase, pseudo cholinesterase, and the pro
enzymes of blood coagulation and blood clot dissolution.
• The majority of these enzymes are synthesized in and secreted by
the liver.

4. Types of Enzymes
• Nonfunctional plasma enzymes (Cell derived enzymes)-
Plasma also contains numerous other enzymes that perform no
known physiologic function in blood.
• These apparently nonfunctional plasma enzymes arise from the
routine normal destruction of erythrocytes, leukocytes, and other
cells.
• Tissue damage or necrosis resulting from injury or disease is
generally accompanied by increases in the levels of several
nonfunctional plasma enzymes.

5. Increased Release
Increase in non functional plasma enzymes
Necrosis of cell / Cell damage
Eg : Myocardial Infarction, Viral
Hepatitis
Increased permeability of cell
without gross cellular damage as in
hypoxia
Increased production of enzyme
within the cell resulting in increase
in serum by overflow
Eg: Bilirubin increases the rate of
synthesis of alkaline phosphatase
in obstructive liver disease
Increase in tissue source of
enzyme as in malignancy
Increased levels in obstructive
jaundice
Eg: Obstruction of bile duct
increases Alkaline phosphatase
Increased levels in renal failure
Impaired disposition

6. Decrease in non functional plasma enzymes
Decreased Synthesis of
enzymes due to Genetic
or Acquired reasons
Enzyme inhibition
Lack of cofactors

7. Introduction
• Clinical enzymology deals with the application of enzyme
analysis for diagnosing and treating disease.
• It gained importance with the introduction of serum alkaline
phosphatase (ALP) as a diagnostic aid by King and Armstrong in
1927.
• The measurement of serum levels of numerous enzymes in the
plasma is used as an indicator of disease of a particular organ.

8. Diagnostic Applications of Non Plasma
Enzymes
• Helps in making the
diagnosis/differential diagnosis/ early
detection of a disease
• Helps in ascertaining prognosis of a
disease
• Helps in ascertaining the response to
drugs in a disease
• Helps in ascertaining the time course
of disease
Single or
serial assay
of serum
activity of a
selected
enzyme

9. Diagnostic Applications of Non Plasma
Enzymes
• Enzyme estimations are helpful in the diagnosis of –
• Myocardial Infarction
• Liver diseases
• Muscle diseases
• Bone diseases
• Cancers
• GI Tract diseases

10. ENZYMES IN HEART
DISEASE

11. • The diagnosis of AMI is usually predicated on the WHO criteria
of chest pain, ECG changes, and increases in biochemical
markers of myocardial injury.

12. Why Enzyme Diagnosis?
• Half of the patients with "typical" symptoms do
not have myocardial infarction
• The ECG is specific for myocardial infarction, but
lacks sensitivity
• In contrast, biochemical markers have excellent
sensitivity for diagnosing myocardial infarction
• By combining the most sensitive and the most specific
tests, diagnostic accuracy can be enhanced

14. Major Enzyme Markers for AMI
• Creatine Phospho kinase
• Aspartate transaminase
• Lactate dehydrogenase
• Acceptable biochemical markers of ischemic heart disease are
now considered to include myoglobin, CK-MB, total CK and
cardiac troponins T and I.

15. Creatine phosphokinase (CPK or CK)
Normal Concentration in Serum: 4 -60 IU/L
High Concentration
Small Concentration

16. Creatine phosphokinase (CPK or CK)
Not Synthesized by

17. Creatine phosphokinase (CPK or CK)

19. CK – MB Profile in Myocardial Infarction
• CK is a sensitive indicator in
the early stages of myocardial
ischemia.
• No increase in activity is found in
heart failure and coronary
insufficiency.
• In acute MI, CPK usually rises
faster than SGOT and returns
to normal faster than the
SGOT.
• MB accounts for 4.5- 20 % of the
total CK activity in the plasma of
the patients with recent
myocardial infarction and the total
isoenzyme is elevated up to 20-
folds above the normal.

20. Serum Glutamate Oxaloacetate Transaminase
(SGOT) / Aspartate Transaminase (AST)
Normal Concentration in Serum: 4 - 17 IU/L

21. SGOT
• GOT1/cAST, the cytosolic isoenzyme derives mainly from red
blood cells and heart.
• GOT2/mAST, the mitochondrial isoenzyme is present
predominantly in liver.

22. Prognostic Significance
• Highest incidence of abnormal levels
occurs on second day of infarction
• > 350 IU/L are due to massive
infarction (Fatal)
• > 150 IU/L are associated with high
mortality
• < 50 IU/L are associated with low
mortality
• Other diseases- The rise in activity is also
observed in muscle and hepatic diseases.
• These can be well differentiated from
simultaneous estimations of other enzyme
activities like SGPT etc, which do not show
and rise in activity in Acute MI.

23. Lactate Dehydrogenase (LDH)
Normal Concentration in Serum: 60 - 250 IU/L
• LDH is synthesized by almost all the body cells
• Values in upper range are generally seen in children
• Strenuous exercise slightly increase the levels
• LDH level is 100 times higher in RBC than plasma, therefore even
a minor hemolysis result in false positive test
• The increased level of LDH in blood is an indicator of general
tissue or cellular damage

24. LDH Isoenzymes

26. ENZYMES IN LIVER
DISEASE

27. Types of Liver Diseases
• Hepatitis- Infectious and Non Infectious
• Alcoholic liver disease
• Non – Alcoholic fatty liver disease
• Hepatocellular carcinoma
• Cirrhosis

28. Enzyme Profile for Liver Diseases
• Amino Transferases/ Serum transaminases (SGOT and
SGPT)
• Alkaline Phosphatase
• Gamma Glutamyl transferase

29. Serum Transaminases
• SGOT (Aspartate transaminase) : 4-17 IU/L
• SGPT (Alanine transaminase) : 3-15 IU/ L
• Heart tissue is rich in SGOT, liver contains both but more of
SGPT.
• Increase in both transaminases are found in liver diseases, with
SGPT much higher than SGOT.
• Useful in differential diagnosis of Infective hepatitis, toxic
hepatitis, obstructive jaundice and serum hepatitis.

30. Serum Transaminases
Disease Changes in ALT and AST levels
Viral, Toxic or Alcoholic
hepatitis
Highly increase in ALT and AST ( Upto
20-50 folds )
In viral hepatitis, ALT is much more
higher than AST
Cirrhosis (Chronic liver
diseases)
Moderate increase (upto 4- 5 folds)
In chronic cases, AST is much elevated
than ALT
Obstructive jaundice Moderate increase in ALT and AST (
upto 3 folds ), but usually do not exceed
200-300 IU/L
After alcohol and drug
intake
Transient slight or moderate increase

31. Alkaline Phosphatase
• Normal Concentration in Serum: 23- 92 IU/L
• It occurs in the cell membrane of osteoblasts, hepatocytes,
leukocytes, the kidneys, spleen, placenta, prostate and the
small intestine.

32. Alkaline Phosphatase
These are group of enzymes that hydrolyze organic phosphates
at high pH ( 9-10.5 )
Alkaline phosphatase in serum consists of 4 structural genotypes:
• the liver-bone-kidney type
• the intestinal type
• the placental type
• and the variant from the germ cells
• The liver-bone-kidney type is particularly important.

33. Increase in Serum Alkaline Phosphatase

34. Alkaline Phosphatase
• Increase in activity of ALP in liver diseases is not due to hepatic cell
disruption nor to a failure of clearance but is due to increased
synthesis of hepatic ALP.
• The stimulus for the increased synthesis in patients with liver diseases
has been due to bile duct obstruction either extra hepatically by
stones and tumors or intra hepatically by space occupying lesions like
abscess, primary carcinoma, metastatic carcinoma etc.
• It is used for many years in differential diagnosis of jaundice.
• It is increased in both viral hepatitis and post hepatic jaundice
(Extra hepatic obstruction) but the rise is much greater in
obstructive jaundice.

36. Gamma Glutamyl Transferase
• The elevated levels do not necessarily indicate liver cell disruption
but may be due to enzyme induction by drugs such as
Phenobarbitone, Phenytoin, Warfarin and Alcohol.
• In biliary obstruction, like in obstructive jaundice, GGT is
markedly increased (5 -30 folds). Increase is earlier (more
sensitive) than ALP and persists longer than ALP.
• In viral, alcoholic or toxic hepatitis, increase is only 2 -5 folds
(less sensitive than AST and ALT).
• In liver tumors, GGT is elevated earlier than other enzymes.

38. ENZYMES AS TUMOUR
MARKERS

39. Enzymes As Tumour Markers
Enzyme Disease
Serum acid phosphatase Prostrate Cancer
Serum alkaline phosphatase Metastasis in liver, jaundice due to
carcinoma head of pancreas, osteoblastic
metastasis in bones
Serum LDH Advanced malignancies, Breast cancer
and Leukemias
Β- Glucuronidase Cancer of urinary bladder
Leucine Amino Peptidase (LAP) Liver cell carcinoma
Neuron specific Enolase Malignancies of nervous tissue and brain
Glucose 6 phosphate
dehydrogenase
Gastric Cancer

40. ENZYMES AS
DIAGNOSTIC REAGENTS

41. Enzymes As Diagnostic Reagents
Enzyme Used for testing
Urease Urea
Uricase Uric acid
Glucose oxidase Glucose
Cholesterol oxidase Cholesterol
Lipase Triglycerides
Alkaline phosphatase ELISA
Horse radish Peroxidase ELISA
Restriction endonuclease Recombinant DNA technology
Reverse transcriptase Polymerase chain reaction

42. Enzymes in Biosensors

43. ENZYMOTHERAPY

44. Enzymotherapy
• The uses of enzymes as diagnostic tools, as prognosis tools and as
disease markers is known to medicine for quite some time.
• More recently, enzymes have found the applications as a new class
of therapeutic agents.
• This new emerging field is named as enzymotherapy.
• More than 200 enzyme deficiencies related to genetic dysfunction
have been reported in humans.

45. Maggot Therapy – Collagenase

48. Ayurveda

50. Asparginase
• Asparginase is employed for the treatment of acute
lymphocytic leukemia.
• Tumor cells lack aspartate-ammonia ligase activity, which stops the
synthesis of nonessential amino acid L-asparagine.
• The activity of asparginase is based on this fact.
• The asparginase does not affect the normal cells which have the
capability to synthesize L-asparagine for their own need, but they
cause a decline in the free exogenous concentration, which causes
a state of fatal starvation in the tumor cells.
• The enzyme can be administered intravenously and is effective
only when the asparagine levels within the bloodstream are
extremely low.

51. Chitinase
• Chitinase has antimicrobial property.
• Chitin is the component of cell wall of many pathogenic
organisms, including fungi, protozoa, and helminthes and is a
good target for antimicrobials.
• The cell walls of Streptococcus pneumonia, Bacillus anthracis, and
Clostridium perfringens are targeted using lytic enzyme derived from
bacteriophage.
• These lytic enzymes derived from bacteriophages can be used for
the treatment of several infections and also shows activity
against new drug-resistant bacterial strains.
• Proteolytic enzymes have anti-inflammatory actions.
• Huge number of these proteolytic enzymes of bacterial origin can
also be employed in the removal of dead skin of burns

52. Collagenase
• Collagenase helps in the healing of burns and skin ulcers.
• It helps to break up and remove dead skin and tissue and thus
help in repair mechanism.
• This in turn helps antibiotics to work better and speed up an
individual s body s natural healing process.

53. Lipase
• Lipase is used as digestive aids.
• It is also used in the treatment of malignant tumors as they have
the ability to activate tumor necrosis factor.
• Lipases were used in the treatment of dyspepsia,
gastrointestinal disturbances, cutaneous manifestations of
digestive allergies, and many more such infections in the past.

54. Nattokinase
• Nattokinase is a serine proteinase obtained from Bacillus subtilis.
• It can reduce some factors of blood clotting and lipids that are
associated with an increased risk for cardiovascular disease
(CVD).
• Oral administration of nattokinase could be considered as a CVD
neutraceutical.
• It decreases the plasma levels of fibrinogen, factor VII and factor
VIII.
• Nattokinase shows prolonged action of preventing coagulation of
blood and dissolving existing thrombus

55. Serratiopeptidase
• Serratiopeptidase is useful in the treatment of pain and inflammation.
• It has three mechanisms to reduce inflammation.
• It breaks down fibrin, the insoluble protein byproducts of blood
coagulation and thins the fluids formed from inflammation and
injury.
• It also facilitates their drainage which increases the speed of the
tissue repair process.
• It also alleviates pain as it inhibits the release of bradykinin, a
specific pain inducing peptide.

56. Thank You !