Skeletal Alkaline Phosphatase Activity Research Articles

Relationship between fluoride exposure, orthopedic injuries and bone formation markers in patients with coal-burning fluorosis

Chronic exposure to fluoride is a public health problem worldwide. We explored the relationship between fluoride exposure, orthopedic injuries and bone formation markers alkaline phosphatase (ALP), bone Gla protein (BGP) in participants with coal-burning fluorosis in Hehua Village (coal-burning fluorosis endemic area) in Zhijin County of Guizhou Province and Zhangguan Village (non-fluoride contaminated area) in Anshun City of Guizhou Province. Environmental samples were collected and fluoride contents were examined using a fluoride ion-selective electrode. Dental fluorosis and skeletal fluorosis of 295 participants from Hehua Village and 85 participants from Zhangguan Village were diagnosed with informed consent. Urinary samples and peripheral blood samples were collected from the participants to determine urinary fluoride (UF), ALP acti-vity, and BGP content. The results showed that fluoride contents in rice, pepper, corn, drinking water, clay, vegetable-grown soil, coal and indoor and outdoor air were significantly higher than those in the control area, but lower than the previously reported values. With the increases of UF concentration, the ALP activity and BGP content significantly increased, the severity of skeletal fluorosis was greater, but with no significant changes in dental fluorosis. There was positive correlation between the severity of skeletal fluorosis and ALP activity, BGP content. These results indicated that low fluoride exposure could cause orthopedic injuries. ALP and BGP could be used to eva-luate the bone turnover in patients with skeletal fluorosis, which would be useful in the auxiliary diagnosis and therapeutic evaluation of skeletal fluorosis.

Gene expression between a congenic strain that contains a quantitative trait locus of high bone density from CAST/EiJ and its wild-type strain C57BL/6J.

Peak bone density is an important determining factor of future osteoporosis risk. We previously identified a quantitative trait locus (QTL) that contributes significantly to high bone density on mouse chromosome 1 from a cross between C57BL/6J (B6) and CAST/EiJ (CAST) mouse strains. We then generated a congenic strain, B6.CAST-1T, in which the chromosomal fragment containing this QTL had been transferred from CAST to the B6 background. The congenic mice have a significantly higher bone density than the B6 mice. In this study we performed cDNA microarray analysis to evaluate the gene expression profile that might yield insights into the mechanisms controlling the high bone density by this QTL. This study led to several interesting observations. First, approximately 60% of 8,734 gene accessions on GEM I chips were expressed in the femur of B6 mice. The expression and function of two-thirds of these expressed genes and ESTs have not been documented previously. Second, expression levels of genes related to bone formation were lower in congenic than in B6 mice. These data are consistent with a low bone formation in the congenic mice, a possibility that is confirmed by reduced skeletal alkaline phosphatase activity in serum compared with B6 mice. Third, expression levels of genes that might have negative regulatory action on bone resorption were higher in congenic than in B6 mice. Together these findings suggest that the congenic mice might have a lower bone turnover rate than B6 mice and raise the possibility that the high bone density in the congenic mice could be due to reduced bone resorption rather than increased bone formation.

Apoptosis may determine the release of skeletal alkaline phosphatase activity from human osteoblast-line cells.

Although quantitative measurement of skeletal alkaline phosphatase (sALP) activity in serum can provide an index of the rate of bone formation, the metabolic process that determines the release of sALP - from the surface of osteoblasts, into circulation-is unknown. The current studies were intended to examine the hypothesis that the release of sALP from human osteoblasts is a consequence of apoptotic cell death. We measured the release of sALP activity from human osteosarcoma (SaOS-2) cells and normal human bone cells, under basal conditions and in response to agents that increased apoptosis (TNF-a, okadiac acid) and agents that inhibit apoptosis (IGF-I, calpain, and caspase inhibitors). Apoptosis was determined by the presence of nucleosomes (histone-associated DNA) in the cytoplasm of the cells by using a commercial kit. The results of these studies showed that TNF-a and okadiac acid caused dose- and time-dependent increases in apoptosis in the SaOS-2 cells (r = 0.78 for doses of TNF-a and r = 0.93 for doses of okadiac acid, P <0.005 for each), with associated decreases in cell layer protein (P <0.05 for each) and concomitant increases in the release of sALP activity (e.g., r = 0.89 for TNF-a and r = 0.75 for okadiac acid, P <0.001 for each). In contrast, caspase and calpain inhibitors reduced apoptosis, increased cell layer protein, and decreased the release of sALP activity (P <0.05 for each). Exposure to IGF-I also decreased apoptosis, in a time- and dose-dependent manner (e.g., r = 0.93, P <0.001 for IGF-I doses), with associated proportional effects to increase cell layer protein (P <0.001) and decrease the release of sALP activity (P <0.001). IGF-I also inhibited the actions of TNF-a and okadiac acid to increase apoptosis and sALP release. The associations between apoptosis and sALP release were not unique to osteosarcoma (i.e., SaOS-2) cells, but also seen with osteoblast-line cells derived from normal human bone. Together, these data demonstrate that the release of sALP activity from human osteoblast-line cells in vitro is associated with, and may be a consequence of, apoptotic cell death. These findings are consistent with the general hypothesis that the appearance of sALP activity in serum may reflect the turnover of osteoblast-line cells.

Effects of zinc on human skeletal alkaline phosphatase activity in vitro.

Inorganic phosphate (Pi) can regulate the level of skeletal alkaline phosphatase (ALP) activity in human osteoblast-like cells by stabilizing the enzyme (without affecting transcription, ALP release from the cell surface, or the amount of ALP protein). These observations suggest that Pi determines the level of ALP activity by modulating a process of irreversible inactivation. The current studies were intended to examine the hypothesis that this inactivation of ALP activity is caused by the dissociation of an active center Zn and that Pi inhibits that dissociation. Initial studies showed that Zn, like Pi, could increase ALP specific activity in human osteosarcoma SaOS-2 cells in a time- and dose-dependent manner (e.g., a 50% increase at 0.2 micromol/liter Zn, P < 0.005). This effect was specific for Zn (i.e., no similar effect was seen with Ca, Fe, Co, Mg, Mn, or Cu), but not for SaOS-2 cells. Zn also increased ALP specific activity in (human osteosarcoma) MG-63 cells and in cells derived from normal human vertebrae (P < 0.001 for each). The effect of Zn to increase ALP activity was not associated with parallel increases in total protein synthesis, collagen production, or tartrate-resistant acid phosphatase activity (no change in any of these indices), net IGF-2 synthesis (a Zn-dependent decrease, P < 0.005), or PTH-dependent synthesis of cAMP (a biphasic increase, P < 0.02). Kinetic studies of Pi and Zn as co-effectors of ALP activity showed that Zn was a mixed-type effector with respect to Pi, whereas Pi was competitive with respect to Zn. Mechanistic studies showed that (1) Zn reversed the effect of Pi withdrawal to decrease ALP activity, but not by reactivating inactive ALP protein (the process required protein synthesis, without increases in ALP mRNA or the level of ALP immunoreactive protein); (2) Zn increased the half-life of ALP activity in intact cells and after a partial purification; and (3) Pi inhibited the process of ALP inactivation by EDTA (which chelates active center Zn). All these findings are consistent with the general hypothesis that Pi increases the half-life of skeletal ALP by preventing the dissociation of active center Zn and with a mechanistic model of skeletal ALP activity in which active center Zn participates in Pi-ester binding and/or hydrolysis.

Alkaline phosphatase levels and osteoprogenitor cell numbers suggest bone formation may contribute to peak bone density differences between two inbred strains of mice

Previous studies have shown that C3 H HeJ (C3H) mice have higher peak bone density than C57 BL 6 J (B6) mice, at least in part because of differences in rates of bone resorption. The current studies were intended to examine the alternative, additional hypothesis that the greater bone density in C3H mice might also be a consequence of increased bone formation. To that end, we measured two presumptive, indirect indices of bone formation and osteoblast number in these inbred strains of mice: alkaline phosphatase (ALP) activity in serum, bones, and bone cells; and the number of ALP-positive colony-forming units (CFU) in bone marrow stromal cell cultures. We found that C3H mice had higher serum levels of ALP activity than B6 mice at 6 (118 vs. 100 U/L, p < 0.03) and 32 weeks of age (22.2 vs. 17.2 U/L, p < 0.001). Tibiae from C3H mice also contained higher levels of ALP activity than tibiae from B6 mice at 6 (417 vs. 254 mU/mg protein, p < 0.02) and 14 weeks of age (132 vs. 79 mU/mg protein, p < 0.001), as did monolayer cultures of bone-derived cells from explants of 7.5-week-old C3H calvariae and femora (8.2 times more, p < 0.02, and 4.6 times more, p < 0.001, respectively). Monolayer cell cultures prepared by collagenase digestion of calvariae from newborn and 6-week-old mice also showed similar strain-dependent differences in ALP-specific activity ( p < 0.001 for each). Our studies also showed more ALP-positive CFU in bone marrow stromal cell cultures from 8-week-old C3H mice, compared with B6 mice (72.3 vs. 26.1 ALP-positive CFU/culture dish, p < 0.001). A similar result was seen for ALP-positive CFU production at 6 and 14 weeks of age, and the difference was greatest for the CFU that contained the greatest numbers of ALP-positive cells. Because skeletal ALP activity is a product of osteoblasts and has been shown to correlate with rates of bone formation, and because the number of ALP-positive CFU is believed to reflect the number of osteoprogenitor cells, the current data are consistent with the general hypothesis that bone formation may be greater in C3H than B6 mice because of a difference in osteoblast number. Our data further suggest that peak bone density may be greater in C3H mice than B6 mice due to a combination of decreased bone resorption and increased bone formation.

Phosphate regulates the stability of skeletal alkaline phosphatase activity in human osteosarcoma (SaOS-2) cells without equivalent effects on the level of skeletal alkaline phosphatase immunoreactive protein.

Inorganic phosphate (P(i)) can regulate the level of skeletal alkaline phosphatase (ALP) activity in human osteoblast-like cells, but not by means of changes in transcription or release from the cell surface. The current studies were intended to determine whether (1) P(i) affected the inactivation of ALP activity in human osteosarcoma (SaOS-2) cells; and (2) P(i)-dependent changes in ALP-specific activity were associated with equal, concomitant changes in the level of ALP immunoreactive protein. The results of these studies revealed that P(i) increased the stability of skeletal ALP activity without equivalent effects on the level of ALP immunoreactive protein. An increase in P(i) (from 0 to 1.8 mmol/liter) caused a time-dependent increase in the amount of skeletal ALP activity in the SaOS-2 cells, without a parallel increase in the amount of skeletal ALP immunoreactive protein, and a decrease in P(i) (from 1.8 to 0 mmol/liter) caused a time-dependent decrease in the amount of ALP activity, without a significant decrease in the total cellular content of ALP immunoreactive protein. Together, these observations suggest that P(i) may alter the level of skeletal ALP activity in SaOS-2 cells by inhibiting a process of irreversible inactivation that does not effect equal, concomitant changes in the level of skeletal ALP immunoreactive protein.

Skeletal alkaline phosphatase activity in serum

Skeletal alkaline phosphatase activity in serum

Paradoxical effects of phosphate to directly regulate the level of skeletal alkaline phosphatase activity in human osteosarcoma (SaOS-2) cells and inversely regulate the level of skeletal alkaline phosphatase mRNA

Recent studies indicate that the amount of alkaline phosphatase (ALP) activity in human osteoblast-line cells is proportional to the concentration of phosphate in the culture medium. The current studies were intended to extend those observations and to determine whether the effects of phosphate (and phosphate esters and analogs) to alter the cellular level of ALP activity, in human osteosarcoma SaOS-2 cells, reflected regulation at the level of transcription. Consistent with previous findings, we found direct, time- and dose-dependent correlations between the concentration of phosphate and the amount of ALP activity/mg cell protein (P < 0.05). Surprisingly, we also found a negative correlation between the phosphate concentration in the medium and the level of skeletal ALP mRNA (e.g., r = -0.98, P < 0.01 at 24 hours). As the highest cellular levels of skeletal ALP activity were associated with the lowest levels of ALP mRNA, these data indicated that the phosphate-dependent increase in ALP activity was not mediated by an increase in transcription and, conversely, that the effect of phosphate withdrawal to decrease ALP activity was not mediated by a decrease in transcription.(ABSTRACT TRUNCATED AT 250 WORDS)

Reference standards for quantification of skeletal alkaline phosphatase activity in serum by heat inactivation and lectin precipitation

Putative standards of skeletal alkaline phosphatase (ALP) (from bone, bone cells, osteosarcoma cells, and Pagetic serum) and hepatic ALP (from cholestatic serum and bile) were used to compare three methods for quantifying skeletal ALP activity in serum: heat inactivation, precipitation with wheat germ agglutinin (WGA), and precipitation with concanavalin A (Con A). All the skeletal ALP standards were similarly sensitive to heat inactivation, as were the hepatic ALP standards. Heat inactivation separated skeletal from hepatic ALP by a 50% difference in remaining ALP activities (e.g., 23% and 74% remaining skeletal and hepatic ALP activities after 30 min at 52 degrees C). Differential precipitations with WGA and with Con A were less efficient at separating skeletal from hepatic ALP (maximum differences of < 30% remaining ALP activity). Although both types of hepatic ALP standard (cholestatic serum and bile) were precipitated with similar efficiencies by WGA and Con A, the skeletal ALP standards were not (e.g., at 2.7 g/L, WGA precipitated 78-86% of the ALP activity in Pagetic serum, but only 49% of the ALP activity in extracts of human bone). These data suggest that heat inactivation is preferable to precipitation with WGA or Con A for quantifying skeletal ALP activity in serum: it better separates skeletal from hepatic ALP activity and is not sensitive to glycosyl heterogeneity.

Calcitonin acutely increases net 45Ca uptake and alters alkaline phosphatase specific activity in human osteosarcoma cells

Altnough the primary skeletal action of exogenous calcitonin is to inhibit bone resorption, calcitonin also has effects on bone formation. In-vitro data indicate that the latter may include direct effects on bone cells of osteoblastic lineage. In the current studies, we examined the effects of calcitonin on cyclic adenosine monophosphate (cAMP) and PGE 2 synthesis and 45Ca uptake in human osteosarcoma cells, specifically, TE-85 cells and subpopulations of SaOS-2 cells with low-, intermediate-, and high-steady-state levels of skeletal alkaline phosphatase (ALP) activity. Since previous in-vivo studies had shown that calcitonin could acutely decrease skeletal ALP activity in rat periosteal osteoblasts, we also measured the effects of calcitonin treatment on ALP specific activity. Neither salmon nor human calcitonin altered the net synthesis of cAMP or PGE 2 by SaOS-2 cells, but human calcitonin gene-related peptide increased both ( P < .001 and P < .005, respectively). Both salmon and human calcitonin had short-term effects to alter ALP activity in TE-85 and SaOS-2 cells. The effects were different in SaOS-2 subpopulations with different pretreatment ALP levels. Four hours of exposure to salmon calcitonin had dose-dependent, biphasic effects on ALP levels in SaOS-2 cells with intermediate pretreatment ALP levels, increasing ALP at doses between 0.16 and 1.6 nmol/L ( P < .005) and decreasing ALP at higher concentrations ( P < .05). Both salmon and human calcitonin, but not human calcitonin gene-related peptide, also had short-term effects to increase net 45Ca uptake by SaOS-2 cells; these effects were dose-dependent and long-lasting. Salmon calcitonin (8 pmol/L) increased net 45Ca uptake within 10 minutes (242% of control, P < .001), and the effect was still apparent after 4 hours of continuous exposure (151% of control, P < .01); similar effects were seen with TE-8t cells. The effect of calcitonin to increase net 45Ca uptake by SaOS-2 cells could be obeserved in (Fitton-Jackson-modified) Biggers-Gwatkin-Jones culture medium (BGJ b) containing 1.5 or 2.0 mmol/L Ca, but not in medium containing 0.5 or 1.0 mmol/L Ca, or in the presence of 10 μmol/L verapamil.

Two biochemical indices of mouse bone formation are increased, in vivo, in response to calcitonin.

In a series of four studies, adult female Swiss-Webster mice were used to measure the effects of salmon calcitonin on two biochemical indices of local and systematic bone formation: (1) skeletal alkaline phosphatase activity--in serum and in extracts of calvaria and tibiae, and (2) calvarial collagenase-digestible protein synthesis--measured, acutely, in vitro. Subcutaneous calcitonin doses ranged from 50 to 400 mU/mouse/day (0.95-18.1 U/kg/day), and treatment schedules were continuous (daily) for 2-14 days, acute, or intermittent (2 days/week for 6 weeks). The effects of calcitonin on these bone formation indices (skeletal alkaline phosphatase and collagenase-digestible protein synthesis) were biphasic with respect to dose and treatment time, being increased in response to short-term, low-dose treatment, but not long-term, continuous treatment. The effects of long-term intermittent calcitonin treatment were dose-dependent increases in skeletal alkaline phosphatase in calvaria and serum (r = 0.948, P less than 0.02, and r = 0.960, P less than 0.01, respectively).

Alkaline phosphatase activity from human osteosarcoma cell line SaOS-2: an isoenzyme standard for quantifying skeletal alkaline phosphatase activity in serum.

Earlier we described a kinetic assay for quantifying skeletal alkaline phosphatase (ALP) isoenzyme activity in serum. The precision of the assay depends on including ALP standards for the skeletal, hepatic, intestinal, and placental isoenzymes. We wondered whether human osteosarcoma cells could provide an efficient alternative to human bone or Pagetic serum as a source of the skeletal ALP standard. ALP activities prepared from five human osteosarcoma cell lines were compared with a bone-derived ALP standard with respect to heat stability and sensitivity to chemical effectors. Two of the cell lines (SaOS-2 and TE-85) contained ALP activities that resembled the bone-derived standard. We selected SaOS-2 cells for additional evaluation (as a potential source of isoenzyme standard), because they contained 40-50 times more ALP activity than did the TE-85 cells. To include the SaOS-2 cell-derived ALP activity in the quantitative isoenzyme assay, we diluted the enzyme in a solution containing heat-inactivated (i.e., ALP-negative) human serum. Surprisingly, this dilution caused a 60-125% increase in maximum enzyme activity. In the quantitative assay of ALP isoenzyme in serum, the SaOS-2 derived ALP was indistinguishable from the serum skeletal ALP standard, with respect to the above criteria and assay variations. Evidently ALP from SaOS-2 cells is suited as a standard for measuring skeletal ALP activity in this assay.

Skeletal alkaline phosphatase activity as a bone formation index in vitro

These studies were intended to examine the relationship between skeletal collagen formation and skeletal alkaline phosphatase (ALP) activity in vitro. Embryonic chick calvaria were exposed to skeletal effectors (including high and low pH, a range of [p i] and [Ca], PTH, NaF, etc), and collagen formation was assessed by the incorporation of 3[H]-proline as 3[H]-hydroxyproline ( 3[H]-hyp). ALP activity was measured in the serum-free conditioned medium and in 20% butanol extracts of the bones. We found that ALP activity and 3[H]-hyp incorporation were coordinately increased from pH 5.5 to pH 7.2 ( r = .99, P < 0.001). Calvarial ALP was not increased in response to low [P i], but low [Ca] increased ALP and coordinately decreased collagen formation ( r = −.81, P < 0.05). Although calvarial ALP and 3[H]-hyp incorporation were coordinately increased by NaF, vanadate, PGE 2, calcitonin, and insulin, the slopes of the correlations were not the same for all effectors (eg, NaF: r = .97, P < 0.01, slope = 0.90; vanadate, r = .95, P < 0.005, slope = 0.20), indicating differential actions on ALP and 3[H]-hyp incorporation. When a variety of effectors, including low [Ca], were used to treat different groups of calvaria, ALP activity was not correlated with 3[H]-hyp incorporation ( r = .35), but when the exposure to effectors was limited to a preincubation, or when the low [Ca] data were excluded, a correlation was observed ( r = .87, P < 0.001, and r = .64, P < 0.02, respectively). Although ALP activity in the serum-free medium generally reflected the amount of ALP activity in the bones, that correlation was less significant in the presence of effectors ( r = .60, P < 0.05) than in their absence ( r = .89, P < 0.01). Together, these data indicate that (1) skeletal ALP is generally useful as an index of in vitro 3[H]-hyp incorporation and (2) even under conditions in which that correlation is disrupted (ie, in the presence of specific skeletal effectors), skeletal ALP is still useful as a predictive index of the capacity for in vitro calvarial collagen synthesis (ie, the predicted rate of 3[H]-hyp incorporation if the effectors were removed).

Differential effects of phospholipids on skeletal alkaline phosphatase activity in extracts, in situ and in circulation

Human skeletal alkaline phosphatase (ALP) purified from human bone was subject to competitive inhibitions by phospholipids including cephalins, lecithins, and phosphatidylinositol. K i values ranged from 0.7 to 1.5 m m, at pH 9.5. As previously shown, the enzyme was subject to uncompetitive inhibition by imidazole. The inhibitory phospholipids potentiated this effect, and altered the nature of the imidazole inhibition, from uncompetitive to mixed type, suggesting that imidazole was bound more efficiently to the enzyme-phospholipid complex than to the enzyme-substrate complex. No interactions were observed between phospholipids and other uncompetitive inhibitors of ALP. The skeletal ALP activity of cultured chick calvarial cells was assayed both in situ and in extracts. Like the extracted human isoenzyme, the extracted chick ALP was subject to competitive inhibition by cephalin ( K i = 0.3 mM at pH 9.3) and an inhibitory interaction between cephalin and imidazole, but the same isoenzyme showed neither effect in situ. The value of K m,PNPP at pH 9.5 for chick skeletal ALP was 1.5 m m in extracts and 7.1 m m in situ. When embryonic chick bones were cultured in vitro, skeletal ALP activity was released into the serum-free medium. Unlike the same isoenzyme extracted from the bones, the ALP activity in the medium was not inhibited by cephalin and showed no inhibitory interaction between cephalin and imidazole. Similarly, human serum ALP activities were not as sensitive to phospholipid inhibition as the same isoenzymes extracted from tissues. Human skeletal ALP extracted from bone was inhibited by cephalin, but the skeletal isoenzyme in Pagetic serum was not, suggesting that the potential for phospholipid interaction was altered during or after release from osteoblast cell membranes. The observation that extracted human skeletal ALP lost its potential for inhibition by phospholipids after treatment with phospholipase C further suggests that ALP activity may be released from cells during membrane turnover.

Improved method for quantitative determination in serum of alkaline phosphatase of skeletal origin.

In this quantitative method for detection of skeletal alkaline phosphatase (EC 3.1.3.1) activity in human serum, intestinal and placental alkaline phosphatase activities are recognized by their susceptibility to inhibition by L-phenylalanine, and skeletal and hepatic alkaline phosphatases are distinguished by their different sensitivities to inactivation by heat. Alkaline phosphatase isoenzymes prepared from organ sources may behave differently from the corresponding isoenzymes in serum. Our procedure allows us to include organ-derived internal standards of skeletal, intestinal, and biliary alkaline phosphatase to minimize between-assay variation. In preliminary applications, we have found that (a) total serum alkaline phosphatase activity is extremely variable in post-menopausal osteoporotic subjects and is not a reliable index of skeletal alkaline phosphatase activity; (b) seven osteoporotic patients responding to therapy with sodium fluoride with increased bone formation showed increased skeletal alkaline phosphatase activity in their serum as compared with age-matched controls (p less than 0.005); and (c) 10 post-menopausal osteoporotic patients responding to therapy with stanozolol with increased total body calcium showed an increase in circulating skeletal alkaline phosphatase activity (p less than 0.001).

Alkaline phosphatase activity in chronic streptozotocin-induced insulin deficiency in the rat: Effect of insulin replacement

Alterations in circulating alkaline phosphatase have been described in both man and the experimental animal with chronic insulin deficiency. We evaluated plasma and tissue alkaline phosphatase levels in freely-fed control, streptozotocin-induced diabetic and insulin-treated diabetic rats, seven weeks after the induction of diabetes. Circulating alkaline phosphatase activity was markedly elevated in the insulin deficient animal ( p < 0.001) and completely normalized following insulin administration. The elevated plasma alkaline phosphatase activity observed in the insulin deficient animals was heat-resistant and phenylalanine-sensitive, a pattern typical of the intestinal isoenzyme. Small intestinal alkaline phosphatase activity was significantly higher ( p < 0.01) in the diabetic animals, but comparable in the insulin-replaced and control rats. The intestinal isoenzyme activity was found to be strikingly insulin-sensitive; withholding insulin therapy for 36 hr prior to sacrifice resulted in an abrupt rise in both plasma and intestinal alkaline phosphatase values comparable to those observed in the insulin-deficient state. In contrast to these observations, skeletal alkaline phosphatase activity was decreased in the insulin deficient animal ( p < 0.01) and this abnormality was corrected by insulin replacement. Neither insulin deficiency nor insulin replacement resulted in any significant changes in the hepatic alkaline phosphatase isoenzyme.