International Atomic Energy Agency, Vienna.
New York: UNipub hormone-secreting pituitary tumor: biosynthetic characterization
1978:469-504.
22 Cargille CM, RossGT, Yoshimi T. Daily variations in plasma
follicle stimulating hormone, luteinizing hormone and progester-
one in the normal menstrual cycle. J Clin Endocrinol Metab
1969;29:12-9.
23. MacFarlane IA, Beardwell CG, Shalet SM, Ainslie-Green,
Rankin E. Glycoprotein hormone alpha subunit secretion in pa-
tients with pituitary adenomas: influence of TRH, LRH, and
bromocriptine. Acts Endocrinol (Copenhagen) 1982;99:489-92.
24. Klibanski A, Deutsch PJ, Jameson JL, et al. Luteinizing
CLIN. CHEM. 36/2, 344-346 (1990)
Serum Angiotensin-Converting Enzyme in Healthy and Sarcoidotic Children: Comparison
with the Reference Interval for Adults
B. B#{233}nOteau-Burnat,
B. Baudin, G. Morgant, F. Ch. Baumann,t and J. Giboudeau
Angiotensin-converting enzyme (ACE) was measured in
serum of 187 healthy children between the ages six months
and 18 years. Results were pooled for five-year age intervals
and compared with the reference values for adults that we
previously determined [din Chem 1986;32:884-6). Results
for each age group were also studied as a function of sex.
Children had higher ACE activities in serum than did adults
(P <0.001), but these activities were age-related only from
age four to 18 years. Adolescents showed sex-related differ-
ences, with higher serum ACE activities in boys than in girls
(P <0.05). Both sex- and age-related differences may be
related to a steroid hormonal regulation of ACE biosynthesis.
We also verified that children with sarcoidosis (n = 20) had
significantly increased serum ACE activity. Such physiologi-
cal variations in serum ACE activity must be taken into
account for diagnosing sarcoidosis in children, for following
the course of the disease, and for evaluating the accuracy of
therapy.
Additional Keyphrasea: sex- and age-relatedeffects pediatric
chemistry steroids monitoring therapy hypertension
.
enzyme activity
Angiotensin-converting enzyme (ACE; EC 3.4.15.1,
dipeptidyl carboxypeptidase I) catalyzes the conversion of
angiotensin I to angiotensin II, a potent vasopressor, and
inactivates bradykinin, a vasodilator. Thus it is important
in homeostasis of blood pressure. ACE is primarily synthe-
sized by endothelial cells but also by macrophages under
certain conditions of stimulation-e.g., in the course of
sarcoidosis. Determination of ACE activity in serum or
plasma is of particular interest in the diagnosis of clinically
active sarcoidosis and the management of the disease after
corticotherapy or without drug treatment (1,2).Reference
intervals for ACE in serum of human adults have been
Laboratoire de Biochimie A, H#{244}pital
Saint-Antoine, 184, rue du
Fbg. St.-Antoine, 75571 Paris Cedex 12, France.
t DeceasedSeptember 1988.
Received August 9, 1989;accepted October 19, 1989.
344 CLINICAL CHEMISTRY, Vol. 36, No. 2, 1990
and clinical studies. J Clin Endocrinol Metab 1987;64:536-42.
25. Kourides IA, Weintraub BD, Rosen SW, et al. Secretion of
alpha subunit of glycoprotein hormones by pituitary adenomas.
Ibid. 1976;43:97-106.
26. Rosen SW, Weintraub BD. Ectopic production of the isolated
alpha subunit of the glycoprotein hormones. A quantitative
marker in certain cases of cancer.Ibid. 1974;290:1441-7.
27. Quigley MM, Tyrey L, Hammond CB. Utility of assay of alpha
subunit of human choriomcgonadotropinin management of gas-
Downloaded from https://academic.oup.com/clinchem/article-abstract/36/2/344/5648257 by University of Cape Town Libraries user on 13 February 2020
tational trophoblastic malignancies. Am J Obstet Gynecol
1980;138:545-9.
determined for several enzymatic assays (2,3),but little is
known about the reference values for serum of children,
even though sarcoidosis has been widely described in
children and young adults (4, 5). The substrate N-[3-
(2-furyl)acryloyl]-L-phenylalanyl-L-glycyl-L-glycine (FAPGG)
permits kinetic assays of ACE activity. We previously
reported an automated determination of serum ACE activ-
ity based on use of this substrate with a discrete analyzer
and demonstrated the reliability, rapidity, and simplicity
of the assay that makes it suitable for routine use and for
clinical investigations of ACE (6).
In the present study, using the same enzymic assay, we
measured ACE in serum of 187 healthy children, ages six
months to 18 years, to determine whether there were age-
and sex-related differences in the normal reference inter-
vaL
Subjects and Methods
Subjects. We obtained serum samples from 187 appar-
ently healthy children (95 girls, 92 boys) during a consul-
tation for routine health control in the Center of Preventive
Medicine of Vandoeuvre-les-Nancy (ages six months to four
years) and the Pediatry Medical Center of Paris 12 (ages
four to 18 years). We arbitrarily grouped the 187 subjects
into five-year age intervals. We also studied the results for
each group according to sex.
We also collected sera from 20 children with active
sarcoidosis confirmed by clinical findings plus a positive
biopsy (Department of Pediatric Pneumology, Trousseau
Hospital, Paris).
Determination oIACE in serum. ACE activity was deter-
mined according to the automated method previously do-
scribed, with FAPGG as the substrate (6). One unit (1 U) of
ACE activity is the amount of enzyme that hydrolyzes 1
lLmol of FAPGG per minute at 37#{176}C.
Data analysis. For statistical comparison we used Stu-
dent’s t-test for non-paired data.
Results
Table 1 summarizes the ACE activity in serum of
 and in those with sarcoidosis, but little is known about
Table 1. Variations of ACE Activity in Serum of physiological sex- and age-related differences for this en-
Healthy Children as a Function of Age and in zyme in children. We previously reported a reference inter-
Comparison with Healthy Adults val for serum ACE activity in normal adults, enzyme
Serum ACE activity being determined by an automated kinetic method
Age group (years) n (mean ± SD), U/I
with FAPGG as the substrate. There was no significant
0.5-2 40 109 ± 33 difference either by age or by sex in adults, but we noticed
2-4 47 100 ± 30 higher values in newborns, premature infants being no

Downloaded from https://academic.oup.com/clinchem/article-abstract/36/2/344/5648257 by University of Cape Town Libraries user on 13 February 2020
4-9 31 124 ± 428 different from full-term infants. Now we show that serum
9-13 38 138 ± 47b ACE activity is returned to the adult value in six-month-
13-18 15 boys 126 ± old infants and is stabilized at this concentration until the
16 girls 102 ± 30 age of four years. Then, serum ACE gradually increases
Children (<18) 187 118 ± 30b until puberty; afterward, it decreases during adolescence to
Adults(>18) 156 100 ± 35C again reach adult values, but ACE activity stays at high
aD Significantlydifferentfrom the adult values: 8 P <0.01; b p <#{216}#{216}values for a longer time in boys than in girls.
CFrom reference 6. Our results are comparable with those reported by Ro-
driguez et al. (5), who found higher values for normal
children than for adults but no age- or sex-related differ-
healthy children as compared with the reference interval in ences. This discrepancy could be explained by the fact that
adults (6). they used another substrate, hippuryl-histidyl-leucine, in a
Overall, the children had higher mean serum ACE less sensitive assay.
activity than did adults: 118 (SD 30) vs 100 (SD 35) UIL. The high ACE activities determined in serum from
A more detailed analysis, however, demonstrated an newborns have been explicated as the consequence of the
age-related dependence. Between six months and four rapid development of lung capillaries after parturition (7),
years we observed no difference; from four years to 13 capillary endothelial cells being the principal source of
years, serum ACE progressively increased; after 13 years, circulating ACE. This phenomenon cannot explain the
serum ACE gradually decreased until it reached values for increased ACE values between four and 18 years. Rather,
adults. Furthermore, between 13 and 18 years, a sex- such an increment may be related to a hormonal regulation
related difference was apparent: serum ACE decreased to of ACE synthesis, because it is well known that hormones
normal adult values faster in girls (102 ± 30 UIL) than in from the renal cortical and thyroid glands can stimulate
boys (126 ± 34 UIL) (P <0.05) (Figure 1). ACE biosynthesis, as shown in in vivo studies (8) as well as
We also verified statistically significant (P <0.01) high in vitro in cultures of endothelial cells (8, 9). On the other
serum ACE activity in subjects with sarcoidosis, both in hand, the difference encountered between boys and girls
adults (n = 15, 220 ± 48 UIL) and in children (n = 20, 200 during puberty may be related more specifically to a steroid
± 30 U/L). However, the difference between the sarcoidotic hormonal regulation of ACE synthesis. Testicular and
adults and the sarcoidotic children was not significant. epididymal ACE are known to develop at puberty and
depend on pituitary function (10). In particular,the devel-
Discussion opment during puberty and the maintenance during adult-
Serum ACE has been widely studied in normal adults hood of testicular ACE require the presence of an intact
pituitary gland, and thus they are under endocrinological
8 8 U) U) UI control (11).
L I. L
8 18 (8 18 (5
dl U) 8 8 8,

In
In conclusion, the high ACE activities frequently en-
countered in serum from boys four years to 18 years old and
I,,
from girls four years to 13 years old must be taken into
d fd C, account for diagnosing sarcoidosis and monitoring therapy
200
in this disease.

References
1. Lieberman J. Elevation of serum angiotensin-converting en-
150 - zyme (ACE) level in sarcoidosis. Am J Med 1975;59:365-72.
2. Lieberman J. The specificity and nature of serum angiotensin-
converting enzyme (serum ACE) elevation in sarcoidosis. Ann NY
Acad Sci 1976;278:488-90.
100 - 3. Ronca-TestoniS.Direct spectrophotometric assay for angioten-
sin-converting enzyme in serum. Clin Chem 1983;29:1093-6.
4. Fiselier TJW, Lijnen P, Monnens PV, Jansen M, Peer P. Levels
of renin, angiotensin I and II, angiotensin-converting enzyme and
50 - NS NS NS NS p.O5 aldosterone in infancy and childhood. Eur J Pediatr 1983;141:3-7.
5. Rodriguez GE, Shimb C, Abernaty RS, Kending EL. Serum
angiotensin-converting enzyme activity in normal children and in
those with sarcoidosis. J Pediatr 1981;99:68-72.
6. B#{233}n#{233}teau
B, Baudin B, Morgant C, Giboudeau J, Baumann
- Boys
FCh. Automated kinetic assay of angiotensin-converting enzyme
in serum. Clin Chem 1986;32:884-6.
- - Ciris 7. Pitt B, Lister G, Davies P, Reid L. Correlation of pulmonary
Fig. 1. Comparison of serum ACE actMty (U/L, y.axis) between the ACE activity and capillary surface area during postnatal develop-
different age-groups, by sex ment. Am J Physiol 1987;161:2031-41.

CLINICAL CHEMISTRY, Vol. 36, No. 2, 1990 345

8. Mendelsohn FAO, Lloyd CJ, Kachel C, Funder JW. Glucocor-
ticoid induction of angiotensin-converting enzyme production from
bovine endothelial cells in culture and rat lung in vivo. Clin Exp
Pharmacol Physiol 1982;Suppl 7:57-62.
9. Krulewitz AH, Baur WE, Fanburg BL. Hormonal influence on
endothelial cell angiotensin-converting enzyme activity. Am J
Physiol1984;247:C163-8.
CL1N.CHEM. 36/2, 346-348 (1990)
Aminotransferase as a Prognostic Index in Infants with Liver Disease
Philip Rosenthal’ and Michael Haight
To assess the utility of the serum aspartate aminotrans-
ferase/alanine aminotransferase (AST/ALT) ratio in a group
of infants with liver disorders, we retrospectively analyzed the
charts of 73 infants with chronic liver disorders. Patients were
considered as having either a good outcome (n = 40) or a
poor outcome (n = 33), based upon the clinical course. AST
and ALT in serum were measured simultaneously at the time
of initial presentation and at various follow-up visits during
the first 13 months after birth. At presentation (mean age
1.65 months), there was no difference in the AST/ALT ratios
between the good (1.61 ± 0.62; mean ± SD) and poor (1.65
± 0.78) outcome groups (P = 0.81). However, over time, the
AST/ALT ratio increased in patients in the poor-outcome
group and decreased in patients in the good-outcome group.
Calculating the AST/ALT ratio appears to be an easy, early,
and reliable prognostic indicator for infants with hepatic
disease, and may be a useful measure for evaluating liver-
disease patients.
Advances in the diagnosis and treatment of pediatric
liver disorders have markedly improved survival rates for
children with liver disease (1).Unfortunately, a substan-
tial number of children continue to die from complications
of their primary hepatic pathology while awaiting liver
transplantation. Given the limited number of donor organs,
identification of the infants at greatest risk who might
benefit from earlier hepatic transplantation could be of
considerable utility.
The ratio between aspartate aminotransferase (AST, EC
2.6.1.1) and alanine aminotransferase (ALT, EC 2.6.1.2),
AST/ALT, has been found to be a useful indicator of hepatic
disease in adults (2).In adult patients with nonalcoholic
liver disease, an AST/ALT ratio increasing to >1.0 sug-
gests cirrhosis, whereas a ratio <1.0 is usually seen in
patients with chronic hepatitis, survivors of acute viral
hepatitis, and patients with chronic cholestatic syndromes
(2-5). An AST/ALT activity concentration ratio >2.0 has
Division of Gastroenterology and Nutrition, Department of
Pediatrics, Childrens Hospital of Los Angeles, University of South-
ern California School of Medicine,Los Angeles,CA 90027.
‘Address correspondence: Department of Pediatrics, Cedars-
Sinai Medical Center, 8700 Beverly Blvd., Suite 4310, Los Ange-
les, CA 90048-1869.
Received September 15, 1989; accepted October 24, 1989.
346 CLINICAL CHEMISTRY, Vol. 36, No. 2, 1990
10. Strittmatter SM, Thiele EA, De Souza EB, Snyder SH. An-
giotensin-converting enzyme in the testis and epididymis: differ-
ential development and pituitary regulation of isozymes. Endocri-
nology 1985;117:1374-9.
11. Velletri PA, Aquilano DR, Bruckwick E, Tsai-Morris CH,
Dufau ML, Lovenberg W. Endocrinological control and cellular
localization of rat testicular angiotensin-converting enzyme (EC
3.4.15.1). Endocrinology 1985;116:2516-22.
Downloaded from https://academic.oup.com/clinchem/article-abstract/36/2/344/5648257 by University of Cape Town Libraries user on 13 February 2020
been reported in adult patients with alcoholic liver disease
(5, 6).
In an attempt to identify an easily measured and reliable
index that would assist in the early evaluation of infants
with liver disorders and offer a prognostic guide to their
outcome, we assessed the utility of the AST/ALT ratio in
the serum of a group of such infants.
Patients and Methods
We retrospectively analyzed the charts of 73 infants with
chronic liver disorders, who had been referred to our
division for evaluation and treatment between October
1976 and September 1988. Diagnoses were confirmed on
the basis of appropriate clinical, microbiological, radiolog-
ical, biochemical, and histological criteria. The study pop-
ulation included 42 infants with extrahepatic biliary
atresia, 12 infants with cytomegalovirus (CMV) hepatitis,
11 with idiopathic neonatal hepatitis, six with alpha-
1-antitrypsin deficiency liver disease, and two with arterio-
hepatic dysplasia (Alagille’s syndrome). There were 39
boys and 34 girls.
Patients were assigned to either a good-outcome (n = 40)
or poor-outcome (n = 33) group, based on their clinical
course. Poor outcome was defined as evidence of cirrhosis,
portal hypertension, esophageal varices, ascites, liver
transplantation, or death. Patients in the good-outcome
group had no signs of chronic liver disease or any of the
findings used to define a poor outcome. Follow-up assess-
ments were made from three months to 10 years later
(mean 23 months).
AST and ALT activity concentrations were measured
simultaneously in serum of each patient at the time of
initial presentation and at various intervals at follow-up
visits with an automated procedure (Abbott Bichromatic
Analyzer, ABA-100; Abbott Labs., Abbott Park, IL) in our
clinical chemistry laboratory under standard laboratory
conditions (7). The serum AST/ALT ratios during the first
13 postnatal months were calculated from these serial
values. We used Student’s t-test (two-tailed) to compare
values obtained for the two groups.
This study was approved by the Committee on Clinical
Investigations and Publications of the Childrens Hospital
of Los Angeles.
Results
For the good-outcome group, serum AST values ranged