Mechanisms of cell damage and enzyme release.

Release of intracellular enzymes to the extracellular space is a marker of cell damage in various diseases, e.g. liver, heart and muscle diseases. In the normal state the plasma membrane is impermeable to enzymes, and enzyme release, therefore, indicates a severe change of the membrane integrity. This review deals with the present knowledge about cellular changes leading to enzyme release, which may be caused either by energy depletion, e.g. in ischemia or shock, or by a direct membrane damage as caused by various toxins and inflammatory products. Inhibition of the energy metabolism results in ATP depletion leading to fluxes of Na+, K+ and Cl- down their gradients across the membrane and swelling of the cell. Subsequently Ca2+ leak into the cell activating phospholipases and the formation of eicosanoids, affecting the cytoskeleton and, perhaps, activating the formation of oxidants. The exact "point of no return" is not known but an uncontrolled Ca2+ activity in the cell probably has an important role in initiating the irreversible changes. The result of these reactions and probably other unknown reactions as well is damage to the membrane. This is evident morphologically at first by the formation of blebs that appears in the reversible phase, and later on by rupturing of the membrane, a sign of irreversible damage. A very small part of the enzyme release may occur in the reversible phase when blebs detach with resealing of the membrane, but the substantial part of enzyme release occurs as a result of irreversible cell damage when ATP has decreased to a low level and a serious disruption of the membrane integrity has taken place. All the secondary affections of the membrane during energy depletion may also occur as a primary direct membrane damage that more or less may affect the energy metabolism secondarily. The cell damage and enzyme release after some types of direct membrane damage is almost independent of the cellular energy metabolism whereas other types of direct membrane damage are counteracted by the cell by energy consuming reactions and, therefore, the final cell damage is a concerted action of the direct membrane damage and the energy depletion. This also means that a direct membrane damage may be more severe for the cell in energy depleted states than in the normal state. As in energy dependent cell damage the substantial part of enzyme release after a direct membrane damage is due to irreversible cellular changes. It appears that although the knowledge of the molecular basis of cell damage and enzyme release has grown there are still many questions to be answered about these complex processes.