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\begin{document}

\title{Serum ischemia-modified albumin as an oxidative stress biomarker in lung
tuberculosis patient}



\author[1]{Elif Demir}%
\author[1]{Zeliha Demir Giden}%
\affil[1]{Harran University}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
Aim of Study: The goal of this study was to evaluate ischemia-modified
albumin (IMA) as a novel marker of oxidative stress in tuberculosis
patients and to investigate changes occurring in patients. Methods: Our
study included 50 patients with active lung tuberculosis and 48 healthy
controls. Serum ischemia-modified albumin was measured with automated
spectrometric method and results were compared statistically. Results:
We found that IMA levels were significantly higher in pulmonary
tuberculosis patients than in the control group. Albumin levels were
significantly lower in the patient group than in the control group.
Conclusion: The results of our study showed that we can use this
parameter as a new oxidative stress marker in the pathogenesis of
pulmonary tuberculosis. Evaluation of IMA and albumin parameters in
patients with pulmonary tuberculosis may contribute significantly to the
evaluation of these patients.%
\end{abstract}%



\sloppy


\textbf{Serumischemia-modified albumin as an oxidative stress biomarker}

\textbf{in lung tuberculosis patient}

Elif Demir\textsuperscript{a}, Zeliha Demir Giden\textsuperscript{b}

\textsuperscript{a} Department of Medical Biochemistry, Harran
University, College of Health, Sanl\selectlanguage{polish}ı\selectlanguage{english}urfa, Turkey

\textsuperscript{b} Department of Chest Diseases, Viran\selectlanguage{polish}ş\selectlanguage{english}ehir State
Hospital, Sanliurfa, Turkey

\textbf{Running title :} Ischemia-modified albumin in tuberculosis

\textbf{Original article}

\textbf{Conflict of interest:} No author has a financial or proprietary
interest in any material or method

Mentioned.

*Address for correspondence:

Elif DEM\selectlanguage{polish}İ\selectlanguage{english}R, Ass. Prof.

Department of Medical Biochemistry,

Harran University, Medical School, \selectlanguage{polish}Ş\selectlanguage{english}anliurfa, Turkey

Fax : +90 ~414 3183190

Phone : +90 414 3183000

E-mail:\emph{e.deniz63@hotmail.com}

\textbf{ABSTRACT}

\textbf{Aim of Study} : The goal of this study was to evaluate
ischemia-modified albumin (IMA) as a novel marker of oxidative stress in
tuberculosis patients and to investigate changes occurring in patients.

\textbf{Methods:} Our study included 50 patients with active lung
tuberculosis and 48 healthy controls. Serum ischemia-modified albumin
was measured with automated spectrometric method and results were
compared statistically.

\textbf{Results:} We found that IMA levels were significantly higher in
pulmonary tuberculosis patients than in the control group. Albumin
levels were significantly lower in the patient group than in the control
group.

\textbf{Conclusion:} The results of our study showed that we can use
this parameter as a new oxidative stress marker in the pathogenesis of
pulmonary tuberculosis. Evaluation of IMA and albumin parameters in
patients with pulmonary tuberculosis may contribute significantly to the
evaluation of these patients.

\textbf{Keywords} : Tuberculosis, oxidative stress, ischemia-modified
alb\selectlanguage{ngerman}ümin.

\textbf{What's known}

Tuberculosis is an important public health problem worldwide. It
continues to be one of the most important causes of death until recent
years. For this reason, biomarkers are very important for the effective
and accurate determination of the diagnosis, treatment and outcome of
tuberculosis disease. A lot of information about tuberculosis disease is
not fully clarified. Currently available diagnostic technology for
tuberculosis detection is insufficient.

\textbf{What's new}

New biomarkers are needed in the prognosis and treatment process of the
disease. So far, there are no reports of IMA levels in patients with
pulmonary tuberculosis. To the best of our knowledge, this is the first
study to investigate IMA levels in patients with pulmonary tuberculosis.
For this purpose, it will be important to determine IMA levels in
diseases in which oxidative stress plays an important role in the
pathogenesis.

\textbf{INTRODUCTION}

Mycobacterium tuberculosis (MTB), the etiological agent of tuberculosis
(TB), infects nearly a quarter of the world's population and remains the
leading cause of death by a single pathogen {[}1{]}. The vast majority
of this infection settles in the lungs. Transmission occurs from an
infected person to another person via droplets or with coughing up blood
or contaminated sputum {[}2{]}.

It derived most of the radicals formed in the human body from oxygen
{[}3{]}. The formation of highly reactive oxygen containing molecular
species is a normal consequence of a variety of essential biochemical
reactions. In healthy conditions at the cellular level, there is a
critical balance exists between the free radical generation and the
antioxidant defense {[}4{]}. Oxidative stress (OS) arises because of an
imbalance between the free reactive oxygen species (ROS) and the
antioxidant mechanisms {[}5,6{]}. Lung is the organ most affected by
oxidants because it is under the influence of air pollution and
blood-borne oxidants. It is also the organ that meets the most oxygen.
There is a higher risk of OS in the lung compared to other organs
{[}7,8{]}. Excess formation of ROS can start a series of chemical
reactions and cause damage to cellular components, including proteins,
lipids, and nucleic acids {[}5,9{]}. Many studies have linked OS to
various lung disorders, including asthma, chronic obstructive pulmonary
disease (COPD), acute pulmonary distress syndrome, and TB {[}10,11{]}.
The oxidative environment normally helps to kill pathogenic
microorganisms. However, in the intracellular pathogen of MTB, the
opposite can grow well in macrophages in environments with high oxygen
concentrations {[}12{]}. As an immune response, the infected macrophage
starts a respiratory burst and produces high levels of ROS to counteract
and kill the mycobacteria {[}13{]} MTB infection can induce oxidative
stres {[}14{]}.

There are various biochemical markers used to identify OS and
inflammation. One of these markers is ischemia-modified albumin. Albumin
plays a major role in regulating oncotic pressure with antioxidant,
anti-inflammatory, and antithrombotic effects {[}15{]}. In case of
oxidative stress, certain alterations occur in the N terminal portion of
albumin, leading to reduced binding to heavy metals such as copper and
cobalt. This new chemical structure of albumin is termed as ischemia
modified albumin (IMA) {[}16{]}. The IMA was first identified in the
early 1990s and has since been widely studied in patients presenting
with myocardial ischemia IMA is one of the earliest predictors of
ischemia {[}17,18{]}. However, new studies have shown that IMA, which is
evaluated as a cardiac ischemia marker, may also increase in different
pathologies and affect other organs {[}19{]}. Studies on patients with
acute mesenteric ischemia, pulmonary embolism, cardiopulmonary
resuscitation, end-stage renal failure cerebrovascular ischemia,
systemic sclerosis, arthroscopic knee surgery, post-exercise skeletal
ischemia and diabetes mellitus have reported increased serum IMA level
{[}20{]}.

The goal of this study was to evaluate IMA as a novel marker of OS in TB
patients and to investigate changes occurring in patients.

\textbf{METHODS}

This study was performed regarding the recommendations put forward via
the Declaration of Helsinki. The study protocol was approved by the
Ethical Committee and each participant gave written, informed consent.
50 patients with active lung tuberculosis referred to the Sanliurfa
Tuberculosis Dispensary (29 male, 21 female) and 48 healthy controls (28
male, 20 female) were included in the study. Most of our patients were
young adults and had no additional diseases other than tuberculosis.

Venous blood samples from the patients, and healthy controls in the
study were collected. Plasma blood samples were centrifuged at 1500 rpm
for 10 min and serum was got. The separated serum was immediately placed
in eppendorf tubes and these samples were stored at \selectlanguage{english}-80degC until used.

For measurement of serum IMA levels, the albumin cobalt binding test was
used. This involved the addition of 50 mL 0.1\% cobalt (II) chloride
(CoClv, 6 H\textsubscript{2}O) to the patient serum. After mixing,
followed by 10-min incubation for albumin cobalt binding, 50 mL 1.5
mg/mL dithiothreitol was added. After mixing followed by 2 min of
incubation, 1.0 mL of 0.9\% sodium chloride solution was added in order
to reduce the binding capacity. The absorbance of samples was measured
at 470 nm using a spectrophotometer. The results were expressed as
absorbance units (ABSUs) {[}18{]}.

\textbf{Statistical Analysis}

Statistical analysis was completed using IBM SPSS 25.0 (SPSS for
Windows, SPSS Inc., Chicago, IL, USA). The Shapiro--Wilks test was used
for normality testing of IMA and albumin ratios. The groups displayed
normal distribution. The independent samples t\selectlanguage{english}-test, among parametric
tests, was used to investigate whether there were considerable
differences between the groups. P\textless{}0.05 was accepted as
statistically significant.

\textbf{RESULTS}

It included 50 patients with lung tuberculosis and 48 healthy volunteers
in the study. 29 patients with lung tuberculosis (58\%) were male and 21
patients with lung tuberculosis (42\%) were female. 28 control group
(58,33\%) were male and 20 control group (41,67\%) were female. The mean
age of the patient group diagnosed with lung tuberculosis was 33.84 +-
12.40 years, and the mean age of the control group was 34.58 +- 11.86
years. There was no significant difference between the groups in terms
of age. There was no significant difference between the groups in terms
of gender.

The evaluation of patient and control group in terms of IMA and albumin
levels are shown in table 1. Albumin measurements were 5.14 +- 0.09 in
the control group and 4.61 +- 0.41 in the patient group. Albumin level is
lower in the patient group when compared to the control group and this
difference was statistically significant (p =0.000). IMA level was
higher in the patient group than in the control group, and this
difference was statistically significant (0.72 +- 0.09, 0.53 +- 0.04,
p=0.000).

\selectlanguage{polish}\textbf{DİSCUSSİON}\selectlanguage{english}

It is estimated that about a third of the world's population lives with
latent TB. Continuing to be one of the most important causes of death
until recent years, TB is an important public health problem worldwide
{[}21{]}. Therefore, biomarkers are very important in the diagnosis of
tuberculosis disease, in the follow-up of treatment and in determining
the outcome effectively and accurately. We need new biomarkers in the
prognosis and treatment process of the disease.

Degenerative lung diseases such as tuberculosis are associated with lung
oxidant-antioxidant imbalance {[}22{]}. Mycobacterium tuberculosis is an
intracellular pathogen, which grows and replicates in the host
macrophages. It is well known that macrophages undergo respiratory burst
after contact with this microorganism. Increased amounts of ROS are
produced as a result of respiratory burst {[}23{]}.

Under physiological conditions, antioxidant production also increases to
neutralize the harmful effects of increased ROS in tissues. However, the
delicate balance between antioxidants and oxidants is key to tissue
homeostasis, and when disrupted, it causes irreversible cell damage with
pathological consequences {[}24{]}. There are many studies showing that
oxidant parameters increase and antioxidant parameters decrease in
tuberculosis disease. One study showed that thiol/disulfide homeostasis
is impaired in TB diseases {[}25{]}. In other studies, serum SOD
activities were significantly reduced and serum MDA levels increased in
tuberculosis patients compared to healthy controls {[}26-28{]}. This
result shows that oxidative stress is increased in patients with
pulmonary tuberculosis. Most of the thiols in plasma are associated with
albumin, and SH groups are oxidized in the presence of oxidative stress,
thus causing structural changes in albumin {[}29{]}.

The production mechanism of ischemia modified albumin is unclear.
However with OS, some changes occur in the N-terminal part of albumin,
resulting in reduced binding to heavy metals such as copper and cobalt
{[}16{]}. OS may promote an increase in IMA levels as it affects
albumin's ability to associate with metals such as cobalt {[}30{]}. It
has been shown that increased IMA concentrations are associated with
inflammation, oxidative stress and endothelial dysfunction {[}18{]}.
Elevated IMA levels were detected in patients with COPD {[}31{]} and
inflammatory bowel disease {[}32{]}. In another study, significantly
higher IMA values were found in pulmonary embolism patients compared to
the control group {[}33{]}. In a study, it was shown that there is an
inverse relationship between IMA and albumin levels {[}34{]}. In another
study, serum IMA levels were significantly increased in
community-acquired pneumonia patients {[}35{]}. Albumin, which has an
antioxidant effect, constitutes 70\% of the total antioxidant capacity
of the serum {[}14{]}. Therefore, albumin modification can be
informative about the body's response to OS.

Limited data is available on the relationship between IMA and lung
diseases. Determination of IMA levels in diseases where oxidative stress
plays a major role in pathogenesis would be important. In our study, IMA
levels in the patient group were significantly higher than in the
control group. Albumin levels were significantly lower in the patient
group than in the control group. In this study, we can say that the
increase in ROS released from macrophages in patients with pulmonary
tuberculosis disrupts the structure of albumin, which makes up most of
the serum proteins, causing an increase in serum IMA levels and a
decrease in serum albumin levels.

\textbf{CONCLUSION}

According to the results of our study, it can be clearly said that serum
IMA levels increase significantly, while serum albumin levels decrease
significantly in pulmonary tuberculosis. This may play a role in the
disease's pathogenesis, and measuring these parameters can provide
insight into the disease process. To our knowledge, our study is the
first to evaluate IMA levels in the serum of patients with pulmonary
tuberculosis. The results of our study showed that we can use this
parameter as a new oxidative stress marker in the pathogenesis of
pulmonary tuberculosis. Evaluation of IMA and albumin parameters in
patients with pulmonary tuberculosis may contribute significantly to the
evaluation of these patients. We need new and large-scale studies to
show the potential effects of oxidative stress on the pathogenesis of
pulmonary tuberculosis.

Financing

The authors disclosed they did not receive any grant during conduction
or writing of this study.

Author contribution

All authors have participated in article preparation.

Declaration of competing interest

The authors declare no competing interests.

Acknowledgements

This study was performed Sanliurfa Tuberculosis Dispensary and at the
biochemistry laboratory. Authors are thankful to these institutions.

\textbf{REFERENCES}

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