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Clinical Chemistry 45: 1248-1254, 1999;
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(Clinical Chemistry. 1999;45:1248-1254.)
© 1999 American Association for Clinical Chemistry, Inc.


Articles

Structural Investigations of a New Familial Dysalbuminemic Hyperthyroxinemia Genotype

Charles E. Petersen1, Chung-Eun Ha1, Krishna Harohalli1, David S. Park1, Jimmy B. Feix2, Osamu Isozaki3 and Nadhipuram V. Bhagavan1,a

1 Department of Biochemistry and Biophysics, University of Hawaii, 1960 East-West Rd., Honolulu, HI 96822.

2 Biophysics Research Institute, Medical College of Wisconsin, 8701 Watertown Plank Rd., P.O. Box 26509, Milwaukee, WI 53226.

3 Department of Medicine, Institute of Clinical Endocrinology, Tokyo Women's Medical College, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162, Japan.
a Author for correspondence. Fax 808-956-9498; e-mail bhagavan{at}jabsom.biomed.hawaii.edu


   Abstract
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Background: In a previous study, we found that the amino acid substitution R218H in human serum albumin (HSA) was the cause of familial dysalbuminemic hyperthyroxinemia (FDH) in several Caucasian patients. Subsequently the substitution R218P was shown to be the cause of FDH in several members of a Japanese family. This study attempts to resolve discrepancies in the only other study of R218P HSA and identifies two new Japanese R218P FDH patients unrelated to those described previously.

Methods and Results: Recombinant R218H, R218P, and wild-type HSA were synthesized in yeast, and the affinities of these HSA species for l- and d-thyroxine were determined using fluorescence spectroscopy. The dissociation constants for the binding of wild-type, R218P, and R218H HSA to l-thyroxine were 1.44 x 10-6, 2.64 x 10-7, and 2.49 x 10-7 mol/L, respectively. The circular dichroism spectra of thyroxine bound to R218H and R218P HSA were markedly different, indicating that the structure of the thyroxine/HSA complex is different for either protein.

Conclusions: The Kd values for l-thyroxine bound to R218P and R218H HSA determined in this study were similar. The extremely high serum total-thyroxine concentrations reported previously for R218P FDH patients (10-fold higher than those reported for R218H FDH patients) are not consistent with the Kd values determined in this study. Possible explanations for these discrepancies are discussed.© 1999 American Association for Clinical Chemistry


   Introduction
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Familial dysalbuminemic hyperthyroxinemia (FDH)1 is a well-documented phenotype (1)(2)(3)(4)(5)(6)(7) that causes increased serum total thyroxine in affected individuals. The increased serum thyroxine is attributable to the presence of an abnormal human serum albumin (HSA) species with enhanced affinity for thyroxine. In FDH patients, the concentration of free thyroxine is within the reference interval; thus, these patients are clinically euthyroid. The euthyroid status of FDH patients can be further verified by the presence of thyroid-stimulating hormone concentrations within the reference interval. One of the major hazards for FDH patients is that they can be misdiagnosed for hyperthyroidism. The presence of FDH HSA in patient serum may lead to spuriously high readings for free thyroxine when free-thyroxine concentrations are measured using a common clinical radioimmunoassay kit (1)(2)(3)(4)(5)(6)(7). These spuriously high readings for free thyroxine coupled with increased total-thyroxine concentrations have led to the misdiagnosis of hyperthyroidism in FDH patients (1)(2)(3)(4)(5)(6)(7). Until our study, which showed that a specific molecular defect in the HSA gene was responsible for FDH in several unrelated Caucasian patients, the specific genotype that caused FDH was unknown (8). In that study, we found that the substitution of adenine for guanine at nucleotide 653 led to the substitution of histidine for arginine at amino acid position 218 (R218H). Other studies have identified the substitution R218H in several unrelated individuals of Caucasian origin (9)(10). In one of our studies published before the discovery of the R218H genotype, we found that 4% of a patient population diagnosed as hyperthyroid were in fact FDH patients (11). The prevalence of FDH in a Venezuelan population has been estimated to be 0.17% (12); however, the incidence may vary in other populations.

Because of our initial finding that the amino acid substitution R218H produces FDH, we thought that all cases of FDH resulted from this specific genotype. Recently, a new genotype that also causes FDH was identified in several Japanese patients (13). This newly identified genotype results from the substitution of cytidine for guanine at nucleotide 653, which gives rise to a substitution of proline for arginine at amino acid position 218 (R218P). We have identified two new Japanese FDH patients unrelated to those described previously who also have the R218P genotype.

Because both the R218H and R218P genotypes can be responsible for FDH, it becomes important to determine whether there are any clinically significant differences between the FDH HSA species resulting from these two distinct genotypes. Our new R218P cases findings were identified by analyzing archived DNA samples supplied by O. Isozaki. Unfortunately, the natural R218P HSA from these patients was not available for this study. R218H HSA from patients identified previously was also unavailable. To obtain R218P and R218H HSA for this study, these proteins were expressed in the yeast species Pichia pastoris. Recombinant wild-type HSA was also produced as a control. Because all FDH patients that have been identified are heterozygous, their serum contains a mixture of wild-type and either R218H or R218P HSA. A method has not been developed to separate wild-type from FDH HSA; therefore, all previous studies on natural FDH HSA had used a mixture of the two proteins. One advantage of expressing the recombinant proteins is that it allowed us to use homogeneous preparations of R218H and R218P HSA in these studies.

The affinity of l- and d-thyroxine for R218H and R218P HSA was measured using fluorescence spectroscopy. Circular dichroism (CD) was used to examine the structure of thyroxine bound to R218P and R218H HSA.


   Materials and Methods
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
sequencing of fdh patient dna
The total genomic DNA from two Japanese FDH patients identified by O. Isozaki and that of a healthy volunteer was isolated using standard techniques. The genomic DNA was used as template to amplify exon 7 from each individual by PCR as described previously (8). The PCR product was purified with a PCR purification Spin Kit (Qiagen). The purified exon 7-containing DNA fragments generated by PCR were sequenced using a kit, Taq cycle sequencing kit (Promega), which contained fluorescently labeled dideoxynucleotides.

synthesis and purification of recombinant hsa
Introduction of mutations into the HSA-coding region.
Specific mutations were introduced into the HSA-coding region in a plasmid vector containing the entire HSA-coding region (pHiL-D2 HSA), using standard techniques as described previously (14).

Expression of recombinant HSA.
Each pHiL-D2 HSA expression cassette coding for a particular HSA mutant was introduced into the yeast species P. pastoris by electroporation. A yeast clone that contained the expression cassette stably integrated into the chromosomal DNA was isolated in each case.

Verification of the DNA sequence of HSA clones.
The DNA sequence of the HSA-coding region was verified as described previously (14).

Purification of recombinant HSA.
The secreted HSA was isolated from growth medium as follows. The medium was brought to 50% saturation with ammonium sulfate at room temperature. The temperature was then lowered to 4 °C, and the pH was adjusted to 4.4, the isoelectric point of HSA in a solution 50% saturated with ammonium sulfate. The precipitated protein was collected by centrifugation and resuspended in distilled water. Dialysis was carried out for 72 h against 100 volumes of phosphate-buffered saline (PBS; 137 mmol/L NaCl, 2.7 mmol/L KCl, 4.3 mmol/L Na2HPO4, 1.4 mmol/L KH2PO4, pH 7.4) with one change of buffer. The solution was loaded onto a column of cibacron blue immobilized on Sepharose 6B (Sigma). After the column was washed with 10 bed volumes of PBS, HSA was eluted with 3 mol/L NaCl. The eluent was dialyzed against PBS and passed over a column of Lipidx-1000 (Packard Instruments) to remove hydrophobic ligands possibly bound to the HSA (15). The resulting protein exhibited only one band on sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

thyroxine binding studies
Background.
As shown previously, the fluorescence emission spectrum of HSA overlaps substantially with the absorption spectrum of thyroxine (16). It has been shown that the quenching of the fluorescent emission of tryptophan 214 (located in the subdomain 2A binding site) on serial additions of thyroxine is primarily a result of the binding of thyroxine to this site (16). To determine the dissociation constant for the thyroxine/HSA equilibrium, two separate experiments are required. A high concentration of HSA is first titrated with ligand to approximate, as near as possible, stoichiometric binding. In this case, a plot of fluorescence vs the ligand/HSA molar ratio shows an initial monotonic decrease in fluorescence, which then plateaus at a minimum value that reflects the fraction of fluorescence not quenched by bound ligand. A lower concentration of HSA is then titrated with ligand, and the fraction of ligand-bound HSA can be calculated on the basis of the quenching efficiency determined from the stoichiometric titration described above. The free concentration of thyroxine can then be calculated on the basis of the number of ligand-bound HSA molecules and the amount of thyroxine added to the cuvette at each point along the titration.

Experimental conditions.
Fluorescence intensity measurements were made on a QM-1 spectrafluorometer (Photon Technologies). Samples were excited at 295 nm with a 2.0 nm bandpass, and the emission intensity was collected through a monochromator from 330 to 360 nm. The fluorescence emission intensity was the integrated area under the emission spectrum from 330 to 360 nm. All samples were suspended in PBS. The fluorescence of a buffer blank was subtracted from all measurements. For all titrations, 800 µL of a HSA solution was placed in a dual-pathlength fluorescence cuvette (10 x 2 mm) with the short pathlength oriented toward the emission side, and the temperature of the cuvette was maintained at 37 °C by a constant temperature circulator. All thyroxine stock solutions were prepared by dissolving the ligand at a concentration of 1 mmol/L in 10 mmol/L sodium hydroxide. Dilutions of the stock were prepared by diluting the stock with distilled water. For stoichiometric titrations 10 µmol/L HSA was titrated to a thyroxine/HSA molar ratio of 4. For Kd determinations, 0.4 µmol/L HSA was titrated with thyroxine.

Analysis of data.
The data for each Kd determination were fit to the equation shown below by nonlinear regression (least-squares method), using the computer program Prism (Graphpad):

The variable H is the Hill coefficient and is a measure of the degree to which the relationship between the number of molecules bound and the log of the free ligand concentration deviates from simple binding. For simple binding with no positive or negative cooperativity, the Hill coefficient is 1. In this case, the Hill coefficient is a measure of the degree to which the curve that best fits the data deviates from an ideal shape.

cd measurements on bound thyroxine
Background.
It had been shown that although pure solutions of either D- or L-thyroxine exhibit no CD at 255–400 nm, each of these enantiomers exhibits a distinct induced CD spectrum in the presence of HSA (17)(18). Previous work with commercial HSA has attributed this induced CD spectrum to an asymmetric orientation of the outer and inner rings of thyroxine when thyroxine is bound to its high affinity binding site on HSA. In this study, we compared the induced CD spectra of the D and L enantiomers of thyroxine when bound to wild-type, R218H, and R218P HSA to determine whether the spectra differed significantly among these HSA species.

Experimental conditions.
Measurements were made on a J-700 spectrapolarimeter (Jasco) at room temperature. All samples were suspended in PBS. A pockel cell with a pathlength of 1 mm containing 330 µL of sample was scanned from 190 to 255 nm and from 255 to 400 nm at a scan speed of 0.5 nm/s at sensitivities of 1000 and 2 millidegrees, respectively. Each wavelength range was scanned three times, and the scans were averaged automatically by the instrument software.

For all HSA species, a 40 µmol/L solution of HSA in PBS was scanned before the addition of thyroxine. The sample was titrated with either L- or D-thyroxine to the following thyroxine/HSA molar ratios, 0.25, 0.50, 0.75, 1.00, 1.50, 2.00, and 2.50. After each addition, the sample was mixed and scanned. The expectation of the experiment was that the CD spectral changes resulting from the binding of thyroxine to its high affinity binding site would reach a plateau at a molar ratio near 1.00 and that the spectrum would change only very slightly as the molar ratio was increased from 1.00 to 2.50 because binding to the high affinity site should be nearly saturated in the region of the titration in which the molar ratio is adjusted from 1.00 to 2.50.

The induced CD spectrum for each enantiomer of thyroxine was calculated as the difference spectrum equal to the CD spectrum of a thyroxine/HSA solution at a molar ratio of 2 (corrected for dilution) minus the CD spectrum of HSA without thyroxine. Thyroxine in the absence of HSA does not exhibit a measurable CD spectrum in the wavelength range examined. The CD difference spectra were smoothed using a noise reduction feature of the Standard Analysis program (Jasco), which is included in the software package provided with the instrument.


   Results
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Previous reports suggested that the R218H genotype is a common cause of FDH in Caucasians (8)(9)(10). In this study, we found two Japanese FDH patients who were heterozygous for the R218P genotype reported previously in six other Japanese FDH patients.

R218H and R218P HSA have similar and significantly higher affinities for L-thyroxine than does wild-type HSA. The Kd values for L-thyroxine binding to R218P and R218H were 2.64 x 10-7 and 2.93 x 10-7 mol/L, respectively (Table 1 and Fig. 1 ). The Kd values determined for D-thyroxine binding to R218P and R218H HSA were 2.49 x 10-7 and 4.12 x 10-7 mol/L, respectively, similar to the values for L-thyroxine binding. For binding to wild-type HSA, the values for L- and D-thyroxine (1.44 x 10-6 and 1.28 x 10-6 mol/L, respectively) were nearly identical.


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Table 1. Kd values for thyroxine binding and serum total-thyroxine concentrations.



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Figure 1. Thyroxine binding.

Binding curves derived from fluorescence quenching experiments with L-thyroxine (A) and D-thyroxine (B). y-axis, log of the free ligand concentration (µmol/L); x-axis, ratio bound thyroxine molecules/HSA molecules. The curves represent the theoretical curves corresponding to the mean Hill coefficients and mean Kd values for three identical titrations. The values corresponding to these curves are shown in Table 1Up . The data set corresponding to each theoretical curve was derived by averaging the three values for the number of bound thyroxine molecules and the free ligand concentration for each data point in the three identical titrations. •, wild type; {square}, R218H; {blacktriangledown}, R218P.

Other researchers have shown that although L-thyroxine exhibits no measurable CD spectrum from 255 to 400 nm, when L-thyroxine binds to wild-type HSA (commercial), negative peaks in an induced CD spectrum occur at positions near peaks observed in the thyroxine absorption spectrum. These peaks in the absorption spectrum occur at 292 and 325 nm (18)(19). The peaks in the CD spectrum near 325 and 292 nm may be attributable to the outer and the inner rings of thyroxine, respectively (17)(18). For D-thyroxine, previous researchers found that the magnitude of the peak in the CD spectrum associated with aromatic ring A was reduced in magnitude but was still negative, whereas the peak associated with aromatic ring B was reduced in magnitude and became positive, indicating an altered orientation of aromatic ring B for D-thyroxine bound to wild-type HSA (commercial). We found spectra similar to those described above for D- and L-thyroxine bound to commercial and recombinant wild-type HSA (Fig. 2 ). At 190–255 nm, the CD spectrum arises from the secondary structure of the protein. In this region, thyroxine binding did not cause any measurable changes in the CD spectra for all HSA species.



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Figure 2. Induced CD spectra of thyroxine bound to HSA.

(A), L-thyroxine bound to recombinant wild-type, R218H, and R218P HSA; (B), D-thyroxine bound to recombinant wild-type, R218H, and R218P HSA. Each spectrum is a difference spectrum equal to the spectrum of 40 µmol/L of each HSA species in the presence of 80 µmol/L L- or D-thyroxine minus the spectrum of 40 µmol/L of the same HSA species in the absence of thyroxine. Curve I, wild-type HSA; curve II, Rs218P HSA; curve III, R218H HSA; y-axis, molar ellipticity; x-axis, light wavelength. The molar ellipticity is the ellipticity/mole bound thyroxine and is determined by assuming that at a thyroxine/HSA molar ratio of 2, one-half of the added thyroxine is bound to HSA at its high affinity site. This assumption is based on experiments described in the text.

For all HSA samples at a concentration of 40 µmol/L, the magnitude of the induced CD spectra at 255–400 nm changed most dramatically as the concentration of thyroxine was increased from a thyroxine/HSA molar ratio of 0.00 to 1.00. For all HSA species, the magnitude of the induced CD spectra increased only slightly as the thyroxine/HSA molar ratio was increased from 1.00 to 1.50. When the ratio was increased from 1.5 to 2.5, there was no detectable change. There were no detectable changes in the shapes of the spectra for any HSA species as the molar ratio was increased from 1.00 to 2.5. The changes in the CD spectra as a function of the thyroxine/HSA molar ratio described above suggest that the induced CD spectra for the range of thyroxine concentrations studied arise mainly from thyroxine binding to its high affinity binding site on HSA. Based on the above observations, we determined that the induced CD spectrum of thyroxine bound to its high affinity site was the difference spectrum equal to the spectrum of a thyroxine/HSA mixture at a molar ratio of 2.00 minus the spectrum of HSA alone. The approximate molar ellipticity of bound thyroxine was calculated by assuming that under these conditions one-half of the thyroxine added was bound to HSA.

A comparison of the induced CD spectra resulting from the binding of L-thyroxine to the various HSA species in this study shows several important trends. For wild-type, R218H, and R218P HSA bound to L-thyroxine, the peak CD signal near 325 nm was negative, with peak molar ellipticities of -12 340, -28 520, and -16 800, respectively (Fig. 2Up ). The peak in the CD spectrum near 292 nm was negative for L-thyroxine bound to wild-type and R218H HSA, with peak molar ellipticities of -6260 and -12 640, respectively. For L-thyroxine bound to R218P HSA, the peak in the CD spectrum near 292 nm was positive and substantially blue shifted, with a peak molar ellipticity of 12 580. A comparison of the induced CD spectra resulting from the binding of D-thyroxine to R218H HSA and R218P HSA showed them to be similar to those obtained for L-thyroxine (Fig. 2Up ).


   Discussion
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Our results indicate that the binding affinities of R218H and R218P HSA for thyroxine are similar (Table 1Up ). The Kd value determined in this study for L-thyroxine binding to R218P was 2.64 x 10-7 mol/L, which is similar to the Kd of 1.11 x 10-7 mol/L determined in a previous study using the natural protein (13). The Kd values determined for R218H binding to L-thyroxine in this study and two previous studies were 2.93 x 10-7, 2.22 x 10-7 (9), and 1.70 x 10-7 mol/L (19), respectively. Despite these similarities, a case was made in the only study other than this one in which the binding of R218P to L-thyroxine was measured (13) that R218P HSA has a much greater affinity for L-thyroxine than does R218H HSA. The argument in that study was as follows. The Kd values for the binding of L-thyroxine to wild-type and R218P HSA were 9.09 x 10-6 and 1.11 x 10-7 mol/L (13), respectively, an 80-fold difference (Table 1Up ). The magnitude of this difference between the Kd values was compared with a previous study in which Kd values of 2.22 x 10-6 and 2.22 x 10-7 mol/L were reported for wild-type and R218H HSA, respectively (9). The 10-fold difference between these previously reported values was then compared to the 80-fold difference described above. The conclusion of authors of the study was that R218P HSA had an affinity eightfold greater than R218H HSA for L-thyroxine, although the absolute Kd values of R218P and R218H HSA were similar. The analysis described above is seriously flawed. The major flaw is that the conclusion critically depends on the Kd value determined for the binding of L-thyroxine to wild-type HSA. This Kd value for wild-type HSA determined for comparison to R218P HSA in the study described above was much greater than that determined in our study and many other studies of R218H HSA (Table 1Up ). The binding of L-thyroxine to wild-type HSA has been well studied by a variety of methods, with values ranging from 6.25 x 10-7 to 3.64 x 10-6 mol/L (20)(21)(22)(23)(24). The large value for the wild-type Kd used in the comparative analysis described above, 9.09 x 10-6 mol/L, would magnify the difference between the affinities of R218P and wild-type HSA, creating a systematic error in the comparative analysis.

If we assume that the Kd values for L-thyroxine binding to purified R218H and R218P HSA are similar, as this study indicates, we are left with a major paradox. In two previous studies of FDH patients with the R218H genotype, the mean serum total-thyroxine concentrations were 151.6 (11) and 240 (10), and the reference values were 92.8 and 140 nmol/L, respectively (Table 1Up ). In the study of six FDH patients with the R218P genotype described above, the mean serum total-thyroxine concentration was 2293.7 nmol/L (13) compared with 111.3 nmol/L for healthy controls. On the basis of these serum total-thyroxine concentrations, we would expect the affinity of R218P HSA for L-thyroxine to be increased at least 20-fold over that of R218H HSA.

There are four plausible explanations for the paradox created by the findings of this study. Natural R218P HSA could be substantially different from recombinant R218P HSA such that the binding values presented in this report for recombinant R218P HSA do not reflect the true values that would be obtained with the natural protein. This seems unlikely because the Kd values obtained in this study and previous studies with recombinant R218H HSA are similar to those obtained for natural R218H HSA. Second, the binding methodology used in this study to determine the Kd value for L-thyroxine binding to R218P could be inaccurate. The technique we used in this study to measure the binding of L-thyroxine to R218P HSA is a well-validated (19)(20)(25) and generally accepted technique; therefore, it is hard to imagine a scenario in which this technique could yield a Kd value that is inaccurate by a factor of 10. Third, the presence of R218P HSA in FDH patient serum samples could interfere with the method used in the previous study to measure total thyroxine in such a way as to give spuriously high values. It is noteworthy in this regard that the initial discovery of the FDH phenotype was because FDH HSA interfered with a standard clinical assay of free thyroxine in patient serum samples, producing spuriously high values for free thyroxine (1)(2)(3)(4)(5)(6)(7). Finally, there may be some serum component that greatly increases the affinity of R218P HSA, but not R218H HSA, for L-thyroxine. Comparison of the CD spectra of L-thyroxine bound to R218P and R218H HSA revealed quite dramatic differences in the structure of the protein/thyroxine complex for either protein. The portion of the CD spectrum shown in previous studies of wild-type HSA to be attributable to the inner aromatic ring of thyroxine (17)(18)(Fig. 2Up ) was the region that was primarily different when the spectra of L-thyroxine/R218H HSA and L-thyroxine/R218P HSA were compared. Our previous mutagenesis/thyroxine analog studies on R218H HSA indicated that amino acid position 218 is next to the inner aromatic ring of thyroxine when thyroxine is bound to wild-type and R218H HSA (25). The finding that the structure of the thyroxine/HSA complex for either R218P or R218H HSA may be different suggests that these two protein/ligand complexes may respond differently to allosteric effectors.

Free-thyroxine concentrations are within the reference interval in R218P FDH patients; thus, they are clinically euthyroid (13). However, release of a substantial portion of the huge reservoir of HSA-bound thyroxine proposed for R218P patients, [estimated to be ~2200 nmol/L) (13)] could cause a sudden and severe thyrotoxicosis. The concentration of free thyroxine-binding globulin sites (~300 nmol/L) could serve as a buffer against a small release of thyroxine, but these sites could easily be saturated by a large release of the huge R218P HSA-bound reservoir. If an as yet unidentified allosteric effector for R218P HSA exists, fluctuations in the concentration of this effector could profoundly influence the thyroid status of R218P FDH patients. In addition, if the previously reported total-thyroxine concentrations for R218P FDH patients are correct, these patients may be especially susceptible to a drug-induced thyrotoxicosis caused by administration of many therapeutics, such as warfarin, aspirin, and furosemide, that bind to subdomain 2A of HSA, the location of the thyroxine binding site. A compendium of subdomain 2A ligands and an explanation of HSA binding sites the reader is presented in Ref. (26).

Our preliminary study of R218P HSA leaves many unanswered questions that will need to be resolved by future studies. Preferably, future studies would be conducted using natural R218P HSA obtained from FDH patients and the serum total-thyroxine concentrations would be measured by a variety of independent methods to eliminate the possibility of erroneous readings.


   Acknowledgments
 
This work was supported by a grant-in-aid from the American Heart Association, Hawaii affiliate, and with funding from the Hawaii Community Foundation under the auspices of the Pacific Health Research Foundation.


   Footnotes
 
1 Nonstandard abbreviations: FDH, familial dysalbuminemic hyperthyroxinemia; HSA, human serum albumin; PBS, phosphate-buffered saline; and CD, circular dichroism.


   References
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 

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The following articles in journals at HighWire Press have cited this article:


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Proc. Natl. Acad. Sci. USAHome page
I. Petitpas, C. E. Petersen, C.-E. Ha, A. A. Bhattacharya, P. A. Zunszain, J. Ghuman, N. V. Bhagavan, and S. Curry
Structural basis of albumin-thyroxine interactions and familial dysalbuminemic hyperthyroxinemia
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J. Clin. Endocrinol. Metab.Home page
S. Pannain, M. Feldman, U. Eiholzer, R. E. Weiss, N. H. Scherberg, and S. Refetoff
Familial Dysalbuminemic Hyperthyroxinemia in a Swiss Family Caused by a Mutant Albumin (R218P) Shows an Apparent Discrepancy between Serum Concentration and Affinity for Thyroxine
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