Increased Prothrombin, Apolipoprotein A-IV, and Haptoglobin in the Cerebrospinal Fluid of Patients with Huntington's Disease

Abstract

Huntington's disease (HD) is a progressive neurodegenerative disease caused by an unstable CAG trinucleotide repeat expansion. The need for biomarkers of onset and progression in HD is imperative, since currently reliable outcome measures are lacking. We used two-dimensional electrophoresis and mass spectrometry to analyze the proteome profiles in cerebrospinal fluid (CSF) of 6 pairs of HD patients and controls. Prothrombin, apolipoprotein A-IV (Apo A-IV) and haptoglobin were elevated in CSF of the HD patients in comparison with the controls. We used western blot as a semi-quantified measurement for prothrombin and Apo A-IV, as well as enzyme linked immunosorbent assay (ELISA) for measurement of haptoglobin, in 9 HD patients and 9 controls. The albumin quotient (Qalb), a marker of blood-brain barrier (BBB) function, was not different between the HD patients and the controls. The ratios of CSF prothrombin/albumin (prothrombin/Alb) and Apo A-IV/albumin (Apo A-IV/Alb), and haptoglobin level were significantly elevated in HD. The ratio of CSF prothrombin/Alb significantly correlated with the disease severity assessed by Unified Huntington's Disease Rating Scale (UHDRS). The results implicate that increased CSF prothrombin, Apo A-IV, and haptoglobin may be involved in pathogenesis of HD and may serve as potential biomarkers for HD.

About the Authors:

Yen-Chu Huang

Affiliation: Department of Neurology, Chang Gung Memorial Hospital, Chang-Gung University College of Medicine, Taipei, Taiwan, People's Republic of China

Yih-Ru Wu

Contributed equally to this work with: Yih-Ru Wu, Mu-Yun Tseng

Affiliation: Department of Neurology, Chang Gung Memorial Hospital, Chang-Gung University College of Medicine, Taipei, Taiwan, People's Republic of China

Mu-Yun Tseng

Contributed equally to this work with: Yih-Ru Wu, Mu-Yun Tseng

Affiliation: Department of Neurology, Chang Gung Memorial Hospital, Chang-Gung University College of Medicine, Taipei, Taiwan, People's Republic of China

Yi-Chun Chen

Affiliation: Department of Neurology, Chang Gung Memorial Hospital, Chang-Gung University College of Medicine, Taipei, Taiwan, People's Republic of China

Sen-Yung Hsieh

Affiliation: Clinical Proteomics Center, Chang Gung Memorial Hospital, Taipei, Taiwan, People's Republic of China

Chiung-Mei Chen

* E-mail: [email protected]

Affiliation: Department of Neurology, Chang Gung Memorial Hospital, Chang-Gung University College of Medicine, Taipei, Taiwan, People's Republic of China

Introduction

Huntington's disease (HD) is a progressive neurodegenerative disease with autosomal dominant inheritance, characterized by cognitive decline, movement disorder and different psychiatric manifestations. It is caused by an unstable CAG trinucleotide repeat expansion in the gene encoding huntingtin protein [1] resulting in neuronal dysfunction and death predominantly in the striatum and cortex [2]. Several pathogenic mechanisms have been identified, including neuronal aggregation of the mutated protein [3], transcriptional dysregulation [4], excitotoxicity [5], altered energy metabolism [6], [7], mitochondrial dysfunction [8], [9], impaired axonal transport, and altered synaptic transmission [10], [11].

Therapeutic strategies that prevent HD progression are not available yet. While many potential beneficial treatments have been reported in cell or/and animal models, reliable pre-symptomatic/symptomatic biomarkers that can indicate the disease status and test the therapeutic efficacy are lacking. Because cerebrospinal fluid (CSF) is located around and inside the brain, biomarkers originating from it may provide insights into the disease pathophysiology and severity as well as monitoring responses to the preventive, disease-modifying, and symptomatic therapies.

Fang and colleagues reported an extensive list of proteins identified in HD CSF relative to control using current proteomics technology, supporting the idea of CSF as a rich source of biomarkers [12]. In several reports, plausible evidence supports an increased activity of transglutaminases in HD that generates elevated levels of γ-glutamyl-ε-lysine cross-links and γ-glutamylpolyamine residues in CSF [13], [14]. However, the γ-glutamyl-ε-lysine cross-links are also elevated in Alzheimer's disease (AD) and vascular dementia [15], indicating that increased transglutaminase activity is a common phenomenon in a variety of neurodegenerative disease and not specifically for HD [16]. In another study, F2-isoprostane, a marker of oxidative stress, was increased in CSF from HD patients, but the level was not correlated with disease duration [17]. Cocaine- and amphetamine-regulated transcript (CART) was also elevated in CSF of HD patients, probably reflecting the hypothalamic lesion in regulating energy homeostasis and emotion, but the level was not correlated to CAG repeat length, body mass index, or other clinical features [18]. CSF neurofilament was increased in HD subjects and was correlated with scores on the Unified Huntington's Disease Rating Scale (UHDRS) total functional capacity [19]. Clusterin, inteleukin 6 (IL-6), and interleukin 8 (IL-8) in both serum and CSF were up-regulated and correlated to disease severity, indicating a neuroinflammatory activation in HD [20], [21]. Despite an extensive list of CSF proteins identified in HD by Fang and colleagues [12], a subsequent study has not been conducted yet to further verify the differentially-expressed protein molecules as reliable biomarkers.

Given that valid CSF biomarkers that are specific for HD and correlated with disease severity are imperative, we set out to use clinical proteomics to investigate the CSF protein profile of HD patients, which may be helpful to shed light on the pathophysiology of HD and to identify potential biomarkers.

Materials and Methods

CSF specimen and preparation

CSF and serum samples were collected from 9 HD (5 males, 4 females, Table 1) patients who were recruited from neurological clinic of Chang Gung Memorial Hospital and genetically diagnosed. The UHDRS of each patient was assessed by clinicians (Yih-Ru Wu and Chiung-Mei Chen) in outpatient clinics before the CSF and serum were collected and investigated for proteomic profile. Therefore, the clinicians who assessed the UHDRS did not know the CSF results before scoring. The proteomic studies of CSF samples were subsequently performed by a different person, who was blinded to the identity and the disease severity of each patient. CSF and serum samples from 18 controls (7 males, 11 females, Table 1) were collected from patients with other neurological diseases who were admitted due to migraine, tension headache, spontaneous intracranial hypotension, amyotrophic lateral sclerosis, and degenerative spine diseases. These control patients had no systemic infection; chronic renal, cardiac or liver dysfunction; autoimmune diseases; or malignancies. The 18 controls were divided into 4 groups with one for two-dimensional electrophoresis (2-DE) and the other overlapping three for quantification of prothrombin, Apo-A IV, and haptoglobin. Body mass index (BMI) was calculated by weight in kilograms divided by squared height in meters for each individual. The examination of the control and HD CSF samples also showed an absence of inflammation (no pleocytosis). Venous blood was obtained simultaneously with the CSF sampling for each subject. White blood cell counts, and albumin concentration of the CSF and serum were analyzed automatically using Synchron LX®20 PRO (Beckman Coulter, Brea, California, USA) by the Department of Clinical Pathology, Chang Gung Memorial Hospital. The albumin quotient (Qalb) was derived from CSF albumin/serum albumin, where the CSF or serum albumin was an absolute concentration. This study was performed under a protocol approved by the institutional review boards of Chang Gung Memorial Hospital (ethical license No: 98-0125C) and all examinations were performed after obtaining written informed consents.

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Table 1. Clinical characteristics of the Huntington's disease (HD) patients and the controls.

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CSF samples were centrifuged immediately after collecting to eliminate cells and other insoluble material, aliquoted and stored at −80°C until analysis. Blood samples were kept at 4°C for 1 h and then centrifuged. The serum was aliquoted and stored at −80°C until analysis.

UHDRS

UHDRS [22] including motor score, independence scale, and functional capacity, was used to assess the severity of HD (Table 1). Worse severity of HD scores higher in motor score and lower in independence scale and functional score.

2-DE

CSF samples were cleaned up by ReadyPrep 2-DE Clean-Up Kit (Bio-Rad, Herculus, CA) following the manufacturer's instruction. Briefly, each CSF sample was first mixed with 3-fold volume of precipitation agent 1 and kept on ice for 15 min, and then 3-fold sample volume of precipitation agent 2 was added. The mixture was centrifuged at 19,000×g for 5 min. The pellet was washed by wash reagent 1 and centrifuged again. After the pellet was re-suspended with distilled water, pre-chilled wash reagent 2 and wash reagent 2 additive were added. The mixture was incubated at −20°C for 30 min and vortexed every 10 min followed by a centrifugation at 19,000×g for 5 min. The protein pellets were solubilized in rehydration buffer (85 mM DTT, 1.4% biolyte pH 3–10, 4.4 M urea, 1.8 M thiourea, 3.5% CHAPS).

Each sample containing 350 µg of protein was diluted to 330 µl with rehydration buffer and kept at room temperature for 2 h. The isoelectric focusing electrophoresis (IEF) was performed with pH 3–10 nonlinear immobilized pH gradient (IPG) strips (Bio-Rad, Herculus, CA) at 18°C as the following steps: active rehydration at 50 V for 16 h, then fast to 300 V for 1h, slow to 3500 V for 3h, kept at 3500 V for 3h, finally fast to 8000 V until achieved 63000 Vh. After IEF, the strip was equilibrated with equilibration buffer (6 M urea, 30% glycerol, 2% SDS) containing 2% DTT for 15 min at room temperature, and then incubated with 2.5% IAA in equilibration buffer for another 15 min. The secondary dimensional separation was performed using 11.5% SDS polyacrylamide gel electrophoresis (SDS-PAGE).

Protein visualization and image analysis

The 2-DE gels were fixed with 7% acetic acid and 10% methanol for 60 min followed by staining in a SYPRO Ruby solution (Molecular Probes, Eugene, OR) for 6 h. After that, gels were washed for 10 h with 7% acetic acid and 10% methanol to remove the background, and then stored in distilled water at 4°C. Gels were scanned by a ProXPRESS 2D Proteomic Imaging System (PerkinElmer, MA, USA) at excitation/emission values of 460 nm/650 nm and resolution of 100 µm. Gel images were analyzed by Progenesis software (Nonlinear Dynamics, Durham, NC) and a cut-off value 1.5-fold change of spot normalized volume was used to be an estimation of significant difference.

In-gel digestion

The interesting spots were cut from 2-DE gel. The gel particles were incubated in 25 mM NH4HCO3 buffer containing 55 mM DTT, pH 8.5, for 1 h at 37°C and then incubated in 25 mM NH4HCO3 containing 100 mM IAA, pH 8.5, for 1 h at 37°C in dark. After washing twice with 25 mM NH4HCO3/50% acetonitrile for 15 min, gel particles were dehydrated with acetonitrile followed by rehydration with trypsin solution (5 µl of 25 mM NH4HCO3, pH 8.5, containing 20 ng trypsin) and then incubated at 37°C for 16 h. The peptides were extracted by 5% TFA in 50% acetonitrile and analysis by mass spectrometry.

Mass spectrometry (MS) analysis and protein identification

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) analyses were performed using an Ultraflex MALDI-TOF MS instrument (Bruker Daltonics). Samples were premixed with matrix solution (1 mg/ml α-Cyano-4-hydroxycinnamic acid (CHCA) in 70% acetonitrile, 0.1% v/v TFA) at 1∶1 ratio and spotted onto the AnchorChip. A nitrogen laser (wave length, 337 nm) operating at 20 Hz was used for ionization. For matrix suppression, a gating factor with signal suppression up to 800 Da was performed. A calibration mixture of known peptides/proteins in a mass range of 1,000∼25,000 Da was set for mass calibration. To increase detection sensitivity, excess matrix was removed with ten shots at a laser power of 60% before data acquisition. Fifty laser shots at three different spot positions were acquired in each spectrum. All of the peaks with S/N>5 in a mass range of 1,000∼25,000 Da were recorded using the AutoXecute tool of the flexControl acquisition software (Version 2.0, Bruker Daltonics).

Matrix-assisted laser desorption/ionization time-of-flight tandem mass spectrometry (MALDI-TOF MS/MS) analyses were performed by a dedicated Q-Tof Ultima™ MALDI instrument (Micromass, Manchester, UK) and the systems were operated under MassLynx 4.0 and raw MS data were processed for database searching using ProteinLynx Global Server 2.0. Each sample was premixed 1∶1 with matrix solution (5 mg/ml CHCA in 50% acetonitrile, 0.1% v/v TFA and 2% w/v ammonium citrate) and spotted onto the 96 well formats MALDI sample stage. Within each well, peaks of parent ions which were within the m/z 800∼3,000 range with intensity above 10 counts ± include/exclude list will be selected automatically for collision-induced dissociation (CID) MS/MS using argon as collision gas and a mass dependent ±5V rolling collision energy until end of probe pattern was reached, starting from the most intense peak. The low mass and high mass resolution of the quadrupole were both set at 10 to give a precursor selection window of about 4 Da wide. The instrument was externally calibrated to less than 5 ppm accuracy over the mass range of m/z 800∼3,000. At a laser firing rate of 10 Hz, individual spectra from 5 second integration period acquired for each of the MS survey and MS/MS performed were combined, smoothed, deisotoped (fast option), and centroided using the Micromass ProteinLynx™ Global Server (PGS) 2.0 data processing software. The combined PMF and MS/MS ion meta data were searched against the specified protein database within the PGS 2.0 workflow.

The resulting peptide data from both mass and tandem mass were searched against SWISS-PROT database using MASCOT software on the matrixscience website (www.matrixscience.com). Matching peptides with one missed cleavage were considered as adequacy. For MS data searching, a mass deviation of 50 and 75 ppm was allowed. For MS/MS ion searching, a 50 ppm peptide mass tolerance and 0.6 Da ms/ms tolerance was applied.

Western blot analysis

Equal amount protein of each CSF or serum sample from 9 HD patients and 9 controls was mixed with sample buffer (Invitrogen, Carlsbad, CA) and reducing agent (Invitrogen, Carlsbad, CA). Each sample was heated at 70°C for 10 min, and then separated by NuPAGE Novex Bis-Tris 4–12% gel (Invitrogen, Carlsbad, CA) and transferred to polyvinylidene fluoride (PVDF) membranes (Millipore, Billerica, MA). After overnight blocking, the membranes were incubated with 1 µg/ml anti-prothrombin rabbit polyclonal antibody (Abnova, Taipei, Taiwan) or anti-prothrombin mouse polyclonal antibody (Abnova, Taipei, Taiwan) at 1∶ 1000 dilution, anti-apolipoprotein A-IV (Apo-A IV) polyclonal antibody (Abnova, Taipei, Taiwan) at 1∶2000 dilution in Tris buffer saline containing 0.05% Tween 20 (1× TBST) for 3 h, and anti-albumin antibody (Sigma, Saint Louis, MO) at 1∶200,000 dilution in 1× TBST for 2 h. The membranes were washed and incubated in 1× TBST containing horseradish peroxidase conjugated goat anti-mouse IgG secondary antibody or donkey anti-rabbit IgG secondary antibody (Pierce, Rockford, IL) for 2 h. For membranes stained with mouse anti-prothrombin and anti-Apo A-IV primary antibody, 0.04 µg/ml secondary antibody was applied; for membranes stained with rabbit anti-prothrombin primary antibody, 0.013 µg/ml secondary antibody was applied; for membranes stained with anti-albumin primary antibody, 0.002 µg/ml secondary antibody was added. Immuno-reactive bands were visualized with SuperSignal West Pico Chemiluminescent Substrate (Pierce, Rockford, IL) and detected with Kodak BioMax light film. The resulting bands were scanned and measured for density using Image Pro software (Image Pro Plus 5.0, Media Cybernetics, MD). Western blot experiments for both Apo A-IV and prothrombin were performed in triplicate to reduce experimental error and the mean was used in statistical analysis. The level of prothrombin and Apo A-IV in CSF or serum was expressed as the ratio of prothrombin and Apo A-IV over albumin density in each sample on the western blot (prothrombin/Alb and Apo A-IV/Alb, respectively).

Enzyme linked immunosorbent assay (ELISA) for haptoglobin

CSF and serum haptoglobin levels were assessed by AssayMax ELISA Kit (Assaypro, Winfield, MO, USA) according to the manufacturer's instruction.

Statistical analysis

All statistical analyses were performed using Statistical Program for Social Sciences (SPSS) statistical software (version 16, Chicago, IL, USA). For each set of values, data were expressed as mean ± standard error (SE) or median (interquartile range) where appropriate. Differences in spot intensities in 2-DE gels between HD patients and controls were analyzed by the paired Student's t-test. Mann-Whitney U test was used to examine the differences between HD patients and controls in BMI, prothrombin/Alb, Apo A-IV/Alb, and haptoglobin concentration in CSF and serum. Spearman correlation was used to test if the examined protein levels were correlated with age. Mann-Whitney U test was used to examine if the protein levels were affected by gender. Linear regression analysis was applied to evaluate the correlation of each subscale in UHDRS to Apo A-IV/Alb, prothrombin/Alb, and haptoglobin concentration in CSF, respectively. The correlation of BMI with Apo A-IV/Alb in CSF of HD patients was also analyzed by linear regression. A p<0.05 was considered statistically significant. The present sample sizes achieve a power of 71%, 94%, and 80% for haptoglobin, Apo A-IV/Alb, and prothrombin/Alb, respectively, to detect differences between the mean of control group and that of case group with the estimated standard deviations at the level of 0.05.

Results

CSF proteome profile in HD patients and controls

We investigated the proteome profile in CSF of 6 HD patients (age, 42±4.8) and 6 age-matched controls (age, 44.4±3.21) using gel-based proteomics technology. The disease and control samples were aligned randomly to get pairs for 2-DE gel analysis. A representative pair of resulting 2-DE gels was shown in figure 1. There were at least three protein spots (spots 1–3) expressed at higher level on the gel of CSF from the HD patient (Fig. 1A) compared to the corresponding control (Fig. 1B). Although some other protein spots expressed at differential level between HD and control CSF, we only showed the protein spots whose volume after normalization (spot volume over total spots volume on the gel, analyzed by Progenesis software) have at least 1.5-fold change in at least four pairs of specimens, or P<0.05 analyzed by paired t-test. MALDI-TOF MS and MALDI-TOF MS/MS were applied to identify the proteins corresponding to these three spots (Table 2). The three up-regulated proteins in HD CSF were prothrombin, Apo A-IV, and haptoglobin. The cropped images of these three spots from 2-DE maps of six sample pairs are shown in Figure 1C.

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Figure 1. 2-DE maps of CSF proteomes.

Representative 2-DE maps of CSF proteome from a patient with HD (A) and a control (B) are shown. Spots 1–3 indicate proteins with up-regulation in HD. Cropped images containing spots corresponding to prothrombin (spot 1), apolipoprotein A-IV (Apo A-IV, spots 2) and haptoglobin (spot 3) (indicated by arrowheads) derived from 2-DE maps of six CSF samples of patients with HD and paired control samples (C).

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Table 2. Differentially-expressed protein molecules in CSF of Huntington's disease (HD) patients.

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The expression level of prothrombin, spot 1 in Fig. 1, was 1.66-fold higher in HD versus control samples, which was found in five of six comparisons (p = 0.003). Another up-regulated protein, Apo A-IV (spot 2 in Fig. 1) was 1.67-fold increased in CSF of the HD patients, and the Apo A-IV level was higher in four HD samples compared with the controls (p = 0.004). The haptoglobin (spot 3 in Fig. 1) level revealed a 1.96-fold increase in HD group compared with the controls, which was found in five of six comparisons (p = 0.007).

Increased prothrombin, Apo A-IV and haptoglobin levels in CSF of HD patients

The increased levels of CSF prothrombin, Apo A-IV, and haptoglobin were further examined in 9 HD patients compared with 9 age-matched controls using western blot analysis or ELISA. The levels of prothrombin in CSF and serum from 9 HD patients (age, 43.4±3.4) and 9 age-matched controls (age, 41.7±4.3) are shown in Fig. 2. Age did not has an effect on CSF prothrombin/Alb (p = 0.90), Apo A-IV/Alb (p = 0.30), and haptoglobin (p = 0.65) levels. The CSF prothrombin/Alb ratio (male, 0.30 [0.24 to 0.40]; female, 0.21 [0.17 to 0.27], p = 0.05), Apo A-IV/Alb ratio (male, 0.12 [0.05 to 0.17]; female, 0.07 [0.06 to 0.10], p = 0.16), and haptoglobin levels (male, 0.9 [0.24 to 2.67]; female, 0.42 [0.23 to 0.82], p = 0.18) showed no significant difference between male and female group. The prothrombin/Alb ratio in CSF of HD patients (0.30 [0.21 to 0.40]) was increased compared with the controls (0.22 [0.16 to 0.26]) (p = 0.048). The ratio of prothrombin/Alb in serum of HD patients (0.30 [0.24 to 0.45]) was not different from those of controls (0.35 [0.30 to 0.43]). Albumin quotient (Qalb, CSF albumin/serum albumin), a marker of blood-brain barrier (BBB) function revealed no significant difference when comparing the HD patients (4.7 [4.1 to 6.6] *10−3) with the controls (4.0 [3.4 to 6.3]*10−3).

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Figure 2. Representative Western blots of prothrombin (72 kD) and albumin (64 kD) in CSF and serum of HD patients and their corresponding controls (C).

The resulting data are illustrated in scatter plots with median and interquartile range. The prothrombin/Alb ratio in CSF of HD patients (n = 9) is higher than that in controls (n = 9). *p<0.05, Mann-Whitney U test.

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The Apo A-IV/Alb ratios in CSF and serum from 9 HD patients (age, 43.4±3.4) and 9 age-matched controls (age, 45.7±4.7) are shown in Fig. 3. The ratio of Apo A-IV/Alb in CSF of HD patients (0.12 [0.08 to 0.15]) was significantly higher than that of controls (0.06 [0.03 to 0.09]) (p = 0.005), while ratio of Apo A-IV/Alb in serum of HD patients (0.23 [0.19 to 0.29]) was not different from those of controls (0.31 [0.23 to 0.39]). The Qalb were not different between HD patients (4.7 [4.1 to 6.6]*10−3) and controls (3.4 [2.6 to 6.6]*10−3). CSF Apo A-IV/Alb ratio was not correlated to BMI in HD patients. In order to know if the elevated CSF Apo A-IV is specific to HD, we compared CSF Apo A-IV/Alb ratios between 5 controls (0.058 [0.013 to 0.154]) and 5 patients with Guillain–Barré syndrome (0.095 [0.055 to 0.126]) and there was no difference between them.

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Figure 3. Representative Western blots of Apo A-IV (46 kD) and albumin (64 kD) in CSF and serum, respectively, of HD patients and their corresponding controls (C).

The Apo A-IV/Alb ratios in CSF and serum in comparison with their corresponding control groups are illustrated in scatter plots with median and interquartile rang, respectively. The Apo A-IV/Alb ratio in CSF of HD patients (n = 9) is significantly higher when compared with the controls (n = 9). *p<0.01, Mann-Whitney U test.

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The haptoglobin levels in CSF and serum from 9 HD patients (age, 43.4±3.4) and 9 age-matched controls (age, 41.1±4.1) are shown in Fig. 4. CSF haptoglobin concentration of HD patients (0.9 [0.48 to 2.50] µg/ml) was significantly higher than those of controls (0.38 [0.22 to 0.53] µg/ml) (p = 0.014), whereas haptoglobin concentration in serum of HD patients (876 [799 to 2338] µg/ml) was not different from those of controls (902 [612 to 1846] µg/ml). The Qalb was not different between HD patients (4.7 [4.1 to 6.8]*10−3) and controls (4.0 [3.4 to 6.3]*10−3).

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Figure 4. Qalb, CSF haptoglobin, and serum haptoglobin concentration in HD patients.

Data are illustrated in scatter plots with median and interquartile rang. Either the Qalb or serum haptoglobin concentration was not different between HD (n = 9) and the controls (n = 9), whereas the CSF haptoglobin was significantly increased in HD. *p<0.05, Mann-Whitney U test.

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The correlation of prothrombin/Alb, Apo A-IV/Alb, and haptoglobin concentration in CSF to UHDRS subscales, respectively

The ratio of CSF prothrombin/Alb was significantly correlated to subscales of UHDRS, with a positive correlation to motor score (r = 0.810, p = 0.008) and a negative correlation to independence scale (r = −0.908, p<0.001) and functional capacity (r = −0.891, p = 0.001), respectively (Fig. 5). However, there was no significant correlation of the CSF Apo A-IV/Alb ratio to motor score (r = 0.394, p = 0.294), independence scale (r = −0.447, p = 0.228) and functional capacity (r = −0.521, p = 0. 151), as well as the CSF haptoglobin concentration to motor score (r = −0.047, p = 0. 905), independence scale (r = 0.067, p = 0.864) and functional capacity (r = 0.002, p = 0.995). There was no significant correlation of the CAG repeat numbers to CSF Apo A-IV/Alb ratio (r = 0.539, p = 0.134), CSF prothrombin/Alb (r = 0.644, p = 0.061) and CSF haptoglobin concentration (r = 0.008, p = 0.944).

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Figure 5. Linear regression of prothrombin/Alb to motor score, independence scale, and function capacity of UHDRS, respectively.

The ratio of prothrombin/Alb was significantly correlated to subscales of UHDRS, with a positive correlation to motor score (A, r = 0.810, p = 0.008) and a negative correlation to independence scale (B, r = −0.908, p<0.001) and functional capacity (C, r = −0.891, p = 0.001).

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Discussion

In this study, using 2-DE and MS analysis we have identified three up-regulated protein molecules, prothrombin, Apo A-IV, and haptoglobin, in CSF of HD patients in comparison with controls. We have further used western blot analysis to measure prothrombin and Apo A-IV levels and ELISA to measure haptoglobin levels. The CSF prothrombin/Alb and Apo A-IV/Alb ratios and haptoglobin concentration in HD patients were increased, respectively, when compared with the controls. Importantly, the CSF prothrombin/Alb ratio was significantly correlated to the disease severity indicated by motor, independence, and functional score of UHDRS.

Prothrombin is synthesized in the liver as a precursor of thrombin. It is cleaved into kringle-1 and kringle-2 domain and active thrombin by prothrombinase [23], which is a crucial step in the coagulation cascade [24]. Both prothrombin and thrombin have been detected locally in the brain and may exert physiological and pathological functions [25], [26]. Thrombin can signal via G protein-coupled protease-activated receptors (PARs) [27] and has been considered as a potent mitogenic and proinflammatory agent to microglia and astrocytes [28], [29], thereby regulating neuronal function. Prothrombin kringle-2 domain participates in cortical neuron death through microglial NADPH oxidase-mediated oxidative stress [30]. Prothrombin and thrombin probably play important roles in the inflammatory process through the activation of PAR and microglia. Some neurodegerative diseases are characterized by increased levels of both active thrombin and PAR-1. Parkinson's disease (PD) is characterized by the selective loss of dopaminergic neurons in the substantia nigra as well as the activation of microglia [31]. The selected dopaminergic neuronal death has been shown as a result of microglia activation by thrombin [32], [33]. In AD, thrombin and prothrombin are expressed in neurons and glial cells and accumulated in senile plaques, reactive microglial cells, and neurofibrillary tangles in brains [26]. In HD, aggregates of mutant huntingtin exist in neurons, astrocytes, and microglia, resulting in the altered neuronal-glial interactions [34]. The mutant huntingtin may enhance the ability of microglia to produce proinflammatory mediators (including IL-6, IL-8, and TNF-α) and contribute to neurodegeneration in HD [20], [34]. Since prothrombin was thought to be involved in the inflammatory process through the activation of PAR and microglia in the central nervous system (CNS), the increased CSF prothrombin hints the inflammatory process in HD. However, the mechanism of how prothrombin is increased in CSF and how it is involved in the pathogenesis of HD remain to be determined. It is worth to note that ratio of CSF prothrombin/Alb was significantly proportional to the disease severity, which may provide a potential biomarker indicating the disease status. Since we did not examine if CSF prothrombin/Alb ratio of other diseases are increased, whether the elevated prothrombin is specific to HD remains to be clarified.

Apo A-IV is a glycoprotein synthesized mainly by the human intestine and also in hypothalamus. Dense Apo A-IV staining has been shown in the arcuate (ARC) hypothalamic nuclei, where Apo A-IV was co-localized with pro-opiomelanocortin (POMC, a body weight decreasing peptide), suggesting that the brain Apo A-IV suppresses food intake probably by stimulating the ARC POMC system [35]. Its intestinal and hypothalamic syntheses are markedly stimulated by fat absorption. Apo A-IV could be up-regulated in hypothalamus by leptin that acts tonically as an afferent signal from adipose tissue to the brain, as part of a negative feedback loop to regulate energy balance [36]. The elevated level of Apo A-IV in CNS subsequently inhibits food intake and regulates the long-term balance of body weight [37], [38]. Increased Apo A-IV has been found in CSF of HD patients by Fang et al. and its origin speculated by the authors may be from peripheral blood [12]. However, a recent study suggested that the circulating Apo A-IV in blood is unable to cross the blood brain barrier (BBB) [36]. In contrast to the proposal presented by Fang et al., our study shows that serum Apo A-IV is not increased and Qalb in HD is not different from that in control, indicating intact BBB, both of which suggest that the increased CSF Apo A-IV may largely originate from the CNS rather than from peripheral blood, although some proteins may be delivered into CNS by specific transporters. In HD, weight loss is a characteristic feature in advanced as well as early stage [7], but the mechanism is not clearly known. A serum metabolic profile indicative of a pro-catabolic phenotype in early HD preceding symptom onset has been shown in both HD patients and transgenic mice [6]. Increased CART, a strong anorectic peptide involved in regulating satiety and body weight, has been shown in CSF of HD patients, also indicating a negative energy balance in HD [18]. The pro-catabolic state in HD patients may account for the cachexia-like features seen in the late disease stage and may also account for the lower than expected weight of patients in the early disease stage. Since Apo A-IV produced in CNS may exert its anorectic action, the finding of increased CSF Apo A-IV in present study may implicate an altered energy metabolism, which may be related with the weight loss in HD patients. It is worth to note that the BMI of HD patient is lower than that of the controls, although it did not reach a statistical significance. The CSF Apo A-IV level, however, was not correlated with BMI in HD patients, which suggests that BMI may be affected by other factors than CNS Apo A-IV only. Further HD animal studies are warranted to explore the mechanism of how CSF Apo A-IV is increased and if it correlates to weight loss in HD. Although the increased CSF Apo A-IV was not found in patients with Guillain–Barré syndrome, since the number of the patients is small, further studies of a large series of samples with other neurological diseases will be warranted to verify whether the elevated Apo A-IV is specific to HD.

Haptoglobin, synthesized primarily by hepatocytes, is stimulated by infection or inflammation. It can bind irreversibly to oxygenated and free hemoglobin (Hb) and thereby plays an antioxidative activity [39]. The antioxidative effect is also observed in CNS. It was found to be produced by oligodendrocytes and play a protective role against Hb-mediated toxicity in intracerebral hemorrhage [40]. Furthermore, haptoglobin was found to be synthesized in reactive astrocytes in response to ischemic-reperfusion injury in rats [41]. Additionally, elevated CSF haptoglobin levels have be seen in idiopathic normal pressure hydrocephalus, traumatic brain injury, Alzheimer's disease, multiple sclerosis, neuromyelitis optica, and Guillain-Barré syndrome [42], [43], [44], [45], [46], and therefore may not be specific to HD. In our study, CSF haptoglobin of HD patients was elevated but the serum haptoglobin was not when compared with the controls, which hints the increased intrathecal synthesis of haptoglobin in HD. However, the CSF haptoglobin was not correlated to the disease severity. Although the exact function of haptoglobin in HD is unclear, the elevated haptoglobin may represent the compensatory response to a serial inflammatory cascade in CNS.

Compared with the findings of proteome analyses in HD CSF published previously by Fang and colleagues where several neuronal proteins were found to be reduced [12], our results identified only three up-regulated protein molecules, which may, in part, due to that we did not deplete CSF abundant protein before 2-DE analysis, which could mask the small differences in low abundant protein and thus the sensitivity of proteomic techniques to identify proteins of biological interest could be reduced. However, many proteins, no matter large or small, are binding to or associated with high abundant protein such as albumin. Therefore, depletion of high abundant protein may also deplete some biologically important proteins. In this regard, we chose not to deplete the high abundant protein before 2-DE analysis [47]. Furthermore, our results are robust, because the three proteins were further confirmed to be elevated in HD CSF using western analysis or ELISA assay. Interestingly, the elevated Apo A-IV, prothrombin, and haptoglobin were speculated to be produced in central nervous system (CNS), based on intact BBB in HD patients shown for the first time by the present study, although it is possible that the increased proteins may be carried into CNS by their transporters. Intact BBB in HD also supports that mutant huntingtin induces parallel cell dysfunction in both CNS and peripheral system. Future studies of BBB integrity in HD mice are warranted to confirm our finding.

Our study results have provided insights into the pathogenesis of HD and identified a few potential biomarkers for HD. However, there are still some limitations. Our HD patients received variable medications including tetrabenazine, amantadine, ubidecarenone, neuroleptics (risperidone, haloperidol, and quetiapine), anticonvulsants (phenytoin, valproate and clonazepam), and antidepressants (paroxetine and mirtazapine). Although there were no previous studies exploring the interactions of medications to prothrombin, Apo A-IV or haptoglobin, the possibility that the medications could be a confounding variable can not be completely excluded. Since our study enrolled a small number of symptomatic patients, whether or not the results could be seen in pre-symptomatic HD carriers remains to be clarified. Like most of studies on CSF, it is difficult to obtain the CSF from healthy individuals due to the ethical issue, which may add a confounding factor to our results. In addition, there is no systematically comparison of the changes in CSF of HD with other diseases, and thus the specificity of the elevated protein in HD is not clear. Hence, further studies with a large series of cases including pre-symptomatic HD carriers are necessary to predict disease onset and disease progression of HD.

Author Contributions

Conceived and designed the experiments: CMC. Performed the experiments: MYT. Analyzed the data: YCC CMC. Contributed reagents/materials/analysis tools: YRW SYH. Wrote the paper: YCH.

Citation: Huang Y-C, Wu Y-R, Tseng M-Y, Chen Y-C, Hsieh S-Y, Chen C-M (2011) Increased Prothrombin, Apolipoprotein A-IV, and Haptoglobin in the Cerebrospinal Fluid of Patients with Huntington's Disease. PLoS ONE6(1): e15809. https://doi.org/10.1371/journal.pone.0015809

References

1. MacDonald ME, Ambrose CM, Duyao MP, Myers RH, Lin C, et al. (1993) A novel gene containing a trinucleotide repeat that is expanded and unstable on Huntington's disease chromosomes. The Huntington's Disease Collaborative Research Group. Cell 72: 971–983.ME MacDonaldCM AmbroseMP DuyaoRH MyersC. Lin1993A novel gene containing a trinucleotide repeat that is expanded and unstable on Huntington's disease chromosomes. The Huntington's Disease Collaborative Research Group.Cell72971983

2. DiFiglia M, Sapp E, Chase KO, Davies SW, Bates GP, et al. (1997) Aggregation of huntingtin in neuronal intranuclear inclusions and dystrophic neurites in brain. Science 277: 1990–1993.M. DiFigliaE. SappKO ChaseSW DaviesGP Bates1997Aggregation of huntingtin in neuronal intranuclear inclusions and dystrophic neurites in brain.Science27719901993

3. Bennett EJ, Shaler TA, Woodman B, Ryu KY, Zaitseva TS, et al. (2007) Global changes to the ubiquitin system in Huntington's disease. Nature 448: 704–708.EJ BennettTA ShalerB. WoodmanKY RyuTS Zaitseva2007Global changes to the ubiquitin system in Huntington's disease.Nature448704708

4. Anderson AN, Roncaroli F, Hodges A, Deprez M, Turkheimer FE (2008) Chromosomal profiles of gene expression in Huntington's disease. Brain 131: 381–388.AN AndersonF. RoncaroliA. HodgesM. DeprezFE Turkheimer2008Chromosomal profiles of gene expression in Huntington's disease.Brain131381388

5. Tang TS, Chen X, Liu J, Bezprozvanny I (2007) Dopaminergic signaling and striatal neurodegeneration in Huntington's disease. J Neurosci 27: 7899–7910.TS TangX. ChenJ. LiuI. Bezprozvanny2007Dopaminergic signaling and striatal neurodegeneration in Huntington's disease.J Neurosci2778997910

6. Underwood BR, Broadhurst D, Dunn WB, Ellis DI, Michell AW, et al. (2006) Huntington disease patients and transgenic mice have similar pro-catabolic serum metabolite profiles. Brain 129: 877–886.BR UnderwoodD. BroadhurstWB DunnDI EllisAW Michell2006Huntington disease patients and transgenic mice have similar pro-catabolic serum metabolite profiles.Brain129877886

7. Djoussé L, Knowlton B, Cupples LA, Marder K, Shoulson I, et al. (2002) Weight loss in early stage of Huntington's disease. Neurology 59: 1325–1330.L. DjousséB. KnowltonLA CupplesK. MarderI. Shoulson2002Weight loss in early stage of Huntington's disease.Neurology5913251330

8. Chen CM, Wu YR, Cheng ML, Liu JL, Lee YM, et al. (2007) Increased oxidative damage and mitochondrial abnormalities in the peripheral blood of Huntington's disease patients. Biochem Biophys Res Commun 359: 335–340.CM ChenYR WuML ChengJL LiuYM Lee2007Increased oxidative damage and mitochondrial abnormalities in the peripheral blood of Huntington's disease patients.Biochem Biophys Res Commun359335340

9. Saft C, Zange J, Andrich , Müller K, Lindenberg K, et al. (2005) Mitochondrial impairment in patients and asymptomatic mutation carriers of Huntington's disease. Mov Disord 20: 674–679.C. SaftJ. ZangeAndrichK. MüllerK. Lindenberg2005Mitochondrial impairment in patients and asymptomatic mutation carriers of Huntington's disease.Mov Disord20674679

10. Roze E, Saudou F, Caboche J (2008) Pathophysiology of Huntington's disease: from huntingtin functions to potential treatments. Curr Opin Neurol 21: 497–503.E. RozeF. SaudouJ. Caboche2008Pathophysiology of Huntington's disease: from huntingtin functions to potential treatments.Curr Opin Neurol21497503

11. Strehlow AN, Li JZ, Myers RM (2007) Wild-type huntingtin participates in protein trafficking between the Golgi and the extracellular space. Hum Mol Genet 16: 391–409.AN StrehlowJZ LiRM Myers2007Wild-type huntingtin participates in protein trafficking between the Golgi and the extracellular space.Hum Mol Genet16391409

12. Fang Q, Strand A, Law W, Faca VM, Fitzgibbon MP, et al. (2009) Brain-specific proteins decline in the cerebrospinal fluid of humans with Huntington disease. Mol Cell Proteomics 8: 451–466.Q. FangA. StrandW. LawVM FacaMP Fitzgibbon2009Brain-specific proteins decline in the cerebrospinal fluid of humans with Huntington disease.Mol Cell Proteomics8451466

13. Jeitner TM, Bogdanov MB, Matson WR, Daikhin Y, Yudkoff M, et al. (2001) N(epsilon)-(gamma-L-glutamyl)-L-lysine (GGEL) is increased in cerebrospinal fluid of patients with Huntington's disease. J Neurochem 79: 1109–1112.TM JeitnerMB BogdanovWR MatsonY. DaikhinM. Yudkoff2001N(epsilon)-(gamma-L-glutamyl)-L-lysine (GGEL) is increased in cerebrospinal fluid of patients with Huntington's disease.J Neurochem7911091112

14. Jeitner TM, Matson WR, Folk JE, Blass JP, Cooper AJ (2008) Increased levels of gamma-glutamylamines in Huntington disease CSF. J Neurochem 106: 37–44.TM JeitnerWR MatsonJE FolkJP BlassAJ Cooper2008Increased levels of gamma-glutamylamines in Huntington disease CSF.J Neurochem1063744

15. Nemes Z, Fésüs L, Égerházi A, Keszthelyi A, Degrell IM (2001) N(epsilon)(gamma-glutamyl)lysine in cerebrospinal fluid marks Alzheimer type and vascular dementia. Neurobiol Aging 22: 403–406.Z. NemesL. FésüsA. ÉgerháziA. KeszthelyiIM Degrell2001N(epsilon)(gamma-glutamyl)lysine in cerebrospinal fluid marks Alzheimer type and vascular dementia.Neurobiol Aging22403406

16. Sárvári M, Fésüs L, Nemes Z (2002) Transglutaminase-mediated crosslinking of neural proteins in Alzheimer's disease and other primary dementias. Drug Develop Res 56: 458–472.M. SárváriL. FésüsZ. Nemes2002Transglutaminase-mediated crosslinking of neural proteins in Alzheimer's disease and other primary dementias.Drug Develop Res56458472

17. Montine TJ, Beal MF, Robertson D, Cudkowicz ME, Biaggioni I, et al. (1999) Cerebrospinal fluid F2-isoprostanes are elevated in Huntington's disease. Neurology 52: 1104–1105.TJ MontineMF BealD. RobertsonME CudkowiczI. Biaggioni1999Cerebrospinal fluid F2-isoprostanes are elevated in Huntington's disease.Neurology5211041105

18. Björkqvist M, Leavitt BR, Nielsen JE, Landwehrmeyer B, Ecker D, et al. (2007) Cocaine- and amphetamine-regulated transcript is increased in Huntington disease. Mov Disord 22: 1952–1954.M. BjörkqvistBR LeavittJE NielsenB. LandwehrmeyerD. Ecker2007Cocaine- and amphetamine-regulated transcript is increased in Huntington disease.Mov Disord2219521954

19. Constantinescu R, Romer M, Oakes D, Rosengren L, Kieburtz K (2009) Levels of the light subunit of neurofilament triplet protein in cerebrospinal fluid in Huntington's disease. Parkinsonism Relat Disord 15: 245–8.R. ConstantinescuM. RomerD. OakesL. RosengrenK. Kieburtz2009Levels of the light subunit of neurofilament triplet protein in cerebrospinal fluid in Huntington's disease.Parkinsonism Relat Disord152458

20. Björkqvist M, Wild EJ, Thiele J, Silvestroni A, Andre R, et al. (2008) A novel pathogenic pathway of immune activation detectable before clinical onset in Huntington's disease. J Exp Med 205: 1869–1877.M. BjörkqvistEJ WildJ. ThieleA. SilvestroniR. Andre2008A novel pathogenic pathway of immune activation detectable before clinical onset in Huntington's disease.J Exp Med20518691877

21. Dalrymple A, Wild EJ, Joubert R, Sathasivam K, Björkqvist M, et al. (2007) Proteomic profiling of plasma in Huntington's disease reveals neuroinflammatory activation and biomarker candidates. J Proteome Res 6: 2833–2840.A. DalrympleEJ WildR. JoubertK. SathasivamM. Björkqvist2007Proteomic profiling of plasma in Huntington's disease reveals neuroinflammatory activation and biomarker candidates.J Proteome Res628332840

22. Huntington Study Group (1996) Unified Huntington's Disease Rating Scale: reliability and consistency. Mov Disord 11: 136–142.Huntington Study Group1996Unified Huntington's Disease Rating Scale: reliability and consistency.Mov Disord11136142

23. Taneda H, Andoh K, Nishioka J, Takeya H, Suzuki K (1994) Blood coagulation factor Xa interacts with a linear sequence of the kringle 2 domain of prothrombin. J Biochem 116: 589–597.H. TanedaK. AndohJ. NishiokaH. TakeyaK. Suzuki1994Blood coagulation factor Xa interacts with a linear sequence of the kringle 2 domain of prothrombin.J Biochem116589597

24. Mann KG (1999) Biochemistry and physiology of blood coagulation. Thromb Haemost 82: 165–174.KG Mann1999Biochemistry and physiology of blood coagulation.Thromb Haemost82165174

25. Sokolova E, Reiser G (2008) Prothrombin/thrombin and the thrombin receptors PAR-1 and PAR-4 in the brain: localization, expression and participation in neurodegenerative diseases. Thromb Haemost 100: 576–581.E. SokolovaG. Reiser2008Prothrombin/thrombin and the thrombin receptors PAR-1 and PAR-4 in the brain: localization, expression and participation in neurodegenerative diseases.Thromb Haemost100576581

26. Arai T, Miklossy J, Klegeris A, Guo JP, McGeer PL (2006) Thrombin and prothrombin are expressed by neurons and glial cells and accumulate in neurofibrillary tangles in Alzheimer disease brain. J Neuropathol Exp Neurol 65: 19–25.T. AraiJ. MiklossyA. KlegerisJP GuoPL McGeer2006Thrombin and prothrombin are expressed by neurons and glial cells and accumulate in neurofibrillary tangles in Alzheimer disease brain.J Neuropathol Exp Neurol651925

27. Luo W, Wang Y, Reiser G (2007) Protease-activated receptors in the brain: receptor expression, activation, and functions in neurodegeneration and neuroprotection. Brain Res Rev 56: 331–345.W. LuoY. WangG. Reiser2007Protease-activated receptors in the brain: receptor expression, activation, and functions in neurodegeneration and neuroprotection.Brain Res Rev56331345

28. Suo Z, Wu M, Ameenuddin S, Anderson HE, Zoloty JE, et al. (2002) Participation of protease-activated receptor-1 in thrombin-induced microglial activation. J Neurochem 80: 655–666.Z. SuoM. WuS. AmeenuddinHE AndersonJE Zoloty2002Participation of protease-activated receptor-1 in thrombin-induced microglial activation.J Neurochem80655666

29. Wang H, Ubl JJ, Stricker R, Reiser G (2002) Thrombin (PAR-1)-induced proliferation in astrocytes via MAPK involves multiple signaling pathways. Am J Physiol Cell Physiol 283: C1351–C1364.H. WangJJ UblR. StrickerG. Reiser2002Thrombin (PAR-1)-induced proliferation in astrocytes via MAPK involves multiple signaling pathways.Am J Physiol Cell Physiol283C1351C1364

30. Won SY, Choi SH, Jin BK (2009) Prothrombin kringle-2-induced oxidative stress contributes to the death of cortical neurons in vivo and in vitro: role of microglial NADPH oxidase. J Neuroimmunol 214: 83–92.SY WonSH ChoiBK Jin2009Prothrombin kringle-2-induced oxidative stress contributes to the death of cortical neurons in vivo and in vitro: role of microglial NADPH oxidase.J Neuroimmunol2148392

31. Choi SH, Joe EH, Kim SU, Jin BK (2003) Thrombin-induced microglial activation produces degeneration of nigral dopaminergic neurons in vivo. J Neurosci 23: 5877–5886.SH ChoiEH JoeSU KimBK Jin2003Thrombin-induced microglial activation produces degeneration of nigral dopaminergic neurons in vivo.J Neurosci2358775886

32. Choi SH, Lee DY, Chung ES, Hong YB, Kim SU, et al. (2005) Inhibition of thrombin-induced microglial activation and NADPH oxidase by minocycline protects dopaminergic neurons in the substantia nigra in vivo. J Neurochem 95: 1755–1765.SH ChoiDY LeeES ChungYB HongSU Kim2005Inhibition of thrombin-induced microglial activation and NADPH oxidase by minocycline protects dopaminergic neurons in the substantia nigra in vivo.J Neurochem9517551765

33. Choi SH, Lee DY, Ryu JK, Kim J, Joe EH, et al. (2003) Thrombin induces nigral dopaminergic neurodegeneration in vivo by altering expression of death-related proteins. Neurobiol Dis 14: 181–193.SH ChoiDY LeeJK RyuJ. KimEH Joe2003Thrombin induces nigral dopaminergic neurodegeneration in vivo by altering expression of death-related proteins.Neurobiol Dis14181193

34. Hsiao HY, Chern Y (2010) Targeting Glial Cells to Elucidate the Pathogenesis of Huntington's Disease. Mol Neurobiol 14: 248–255.HY HsiaoY. Chern2010Targeting Glial Cells to Elucidate the Pathogenesis of Huntington's Disease.Mol Neurobiol14248255

35. Shen L, Pearson KJ, Xiong Y, Lo CM, Tso P, et al. (2008) Characterization of apolipoprotein A-IV in brain areas involved in energy homeostasis. Physiol Behav 95: 161–167.L. ShenKJ PearsonY. XiongCM LoP. Tso2008Characterization of apolipoprotein A-IV in brain areas involved in energy homeostasis.Physiol Behav95161167

36. Shen L, Tso P, Woods SC, Sakai RR, Davidson WS, et al. (2007) Hypothalamic apolipoprotein A-IV is regulated by leptin. Endocrinology 148: 2681–2689.L. ShenP. TsoSC WoodsRR SakaiWS Davidson2007Hypothalamic apolipoprotein A-IV is regulated by leptin.Endocrinology14826812689

37. Tso P, Liu M, Kalogeris TJ, Thomson AB (2001) The role of apolipoprotein A-IV in the regulation of food intake. Annu Rev Nutr 21: 231–254.P. TsoM. LiuTJ KalogerisAB Thomson2001The role of apolipoprotein A-IV in the regulation of food intake.Annu Rev Nutr21231254

38. Fujimoto K, Fukagawa K, Sakata T, Tso P (1993) Suppression of food intake by apolipoprotein A-IV is mediated through the central nervous system in rats. J Clin Invest 91: 1830–1833.K. FujimotoK. FukagawaT. SakataP. Tso1993Suppression of food intake by apolipoprotein A-IV is mediated through the central nervous system in rats.J Clin Invest9118301833

39. Carter K, Worwood M (2007) Haptoglobin: a review of the major allele frequencies worldwide and their association with diseases. Int J Lab Hematol 29: 92–110.K. CarterM. Worwood2007Haptoglobin: a review of the major allele frequencies worldwide and their association with diseases.Int J Lab Hematol2992110

40. Zhao X, Song S, Sun G, Strong R, Zhang J, et al. (2009) Neuroprotective role of haptoglobin after intracerebral hemorrhage. J Neurosci 29: 15819–15827.X. ZhaoS. SongG. SunR. StrongJ. Zhang2009Neuroprotective role of haptoglobin after intracerebral hemorrhage.J Neurosci291581915827

41. Lee MY, Kim SY, Choi JS, Lee IH, Choi YS, et al. (2002) Upregulation of haptoglobin in reactive astrocytes after transient forebrain ischemia in rats. J Cereb Blood Flow Metab 22: 1176–1180.MY LeeSY KimJS ChoiIH LeeYS Choi2002Upregulation of haptoglobin in reactive astrocytes after transient forebrain ischemia in rats.J Cereb Blood Flow Metab2211761180

42. Conti A, Sanchez-Ruiz Y, Bachi A, Beretta L, Grandi E, et al. (2004) Proteome study of human cerebrospinal fluid following traumatic brain injury indicates fibrin(ogen) degradation products as trauma-associated markers. J Neurotraum 21: 854–863.A. ContiY. Sanchez-RuizA. BachiL. BerettaE. Grandi2004Proteome study of human cerebrospinal fluid following traumatic brain injury indicates fibrin(ogen) degradation products as trauma-associated markers.J Neurotraum21854863

43. Chang KH, Lyu RK, Tseng MY, Ro LS, Wu YR, et al. (2007) Elevated haptoglobin level of cerebrospinal fluid in Guillain-Barre Syndrome revealed by proteomics analysis. Proteomics - Clin Appl 1: 467–475.KH ChangRK LyuMY TsengLS RoYR Wu2007Elevated haptoglobin level of cerebrospinal fluid in Guillain-Barre Syndrome revealed by proteomics analysis.Proteomics - Clin Appl1467475

44. Pantoni L, Inzitari D (1995) Abnormal penetration of haptoglobin through the blood-brain-barrier (BBB) into the cerebro-spinal fluid (CSF) in Alzheimer's disease patients. Acta Neurol Scand 91: 225.L. PantoniD. Inzitari1995Abnormal penetration of haptoglobin through the blood-brain-barrier (BBB) into the cerebro-spinal fluid (CSF) in Alzheimer's disease patients.Acta Neurol Scand91225

45. Li X, Miyajima M, Mineki R, Taka H, Murayama K, et al. (2006) Analysis of potential diagnostic biomarkers in cerebrospinal fluid of idiopathic normal pressure hydrocephalus by proteomics. Acta Neurochir (Wien) 148: 859–864.X. LiM. MiyajimaR. MinekiH. TakaK. Murayama2006Analysis of potential diagnostic biomarkers in cerebrospinal fluid of idiopathic normal pressure hydrocephalus by proteomics.Acta Neurochir (Wien)148859864

46. Bai S, Liu S, Guo X, Qin Z, Wang B, et al. (2010) Proteome analysis of haptoglobin in cerebrospinal fluid of neuromyelitis optica. Mol Biol Rep 37: 1619–1625.S. BaiS. LiuX. GuoZ. QinB. Wang2010Proteome analysis of haptoglobin in cerebrospinal fluid of neuromyelitis optica.Mol Biol Rep3716191625

47. Zhou M, Lucas DA, Chan KC, Issaq HJ, Petricoin EFr, et al. (2004) An investigation into the human serum “interactome”. Electrophoresis 25: 1289–1298.M. ZhouDA LucasKC ChanHJ IssaqEFr Petricoin2004An investigation into the human serum “interactome”.Electrophoresis2512891298