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Physiol. Res. 53: 245-253, 2004
Calprotectin – a Pleiotropic Molecule in Acute and Chronic
I. STŘÍŽ1, I. TREBICHAVSKÝ2
1Department of Immunology, Institute for Clinical and Experimental Medicine, Prague, 2Division of
Immunology and Gnotobiology, Institute of Microbiology, Academy of Sciences of the Czech
Republic, Nový Hrádek, Czech Republic
Received February 25, 2003
Accepted August 8, 2003
Calprotectin (MRP8/14, S100A8/S100A9, 27E10 antigen) is a heterodimer of two calcium-binding proteins present in
the cytoplasm of neutrophils and expressed on the membrane of monocytes. Upon neutrophil activation or endothelial
adhesion of monocytes, calprotectin is released and may be detected in serum or body fluids as potentially useful
clinical inflammatory marker. The soluble form of calprotectin provides both bacteriostatic and cytokine-like effects in
the local environment. When calprotectin metabolism is affected on a systemic level, the zinc-binding properties of
protein may induce severe dysregulation of zinc homeostasis with severe clinical symptoms. The distribution of
membrane form of calprotectin is restricted to monocytes and immature macrophages and the presence of calprotectin-
positive infiltrating cells reflects the influx of mononuclear phagocytes to the site of inflammation. Calprotectin
expression and release seems to be of particular importance in immune and immunopathological reactions.
Calprotectin • MRP8/14 • S100A8 • S100A9 • Inflammation • Neutrophils
“Vestigia terrent” Horatius
Calprotectin was originally discovered as an
antimicrobial protein that was present in the cytoplasm of
neutrophil granulocytes (Dale et al. 1983). Subsequently,
it has been recognized as a promising marker of
inflammation, or rather a trace of the antagonism going
on inside the organism (Sander et al. 1984, Roth et al.
2001). Furthermore, the molecule is involved in the
recruitment of inflammatory cells by interactions with
endothelial cells (Srikrishna et al. 2001) and its zinc-
capturing function may affect physiological homeostasis
(Sampson et al. 2002). The pleiotropic functions of
calprotectin are associated
inflammatory processes including antibacterial defense
mechanisms or with Th1-mediated responses such as
allograft rejection or in autoimmune reactions.
Calprotectin can be found in the literature under
several synonyms (complex of S100A8 and S100A9
proteins, 27E10 antigen, macrophage inhibitory factor-
related protein MRP8/14, L1L and L1H proteins,
mostly with active
246 Stříž and Trebichavský
calgranulin A/B). It is a 24 kD heterodimer composed of
light (MRP8) and heavy (MRP14) chains (8 and 14 kDa)
(Bhardwaj et al. 1992, Hunter and Chazin 1998),
members of the S-100 family (Kligman and Hilt 1988) of
calcium-binding proteins (Steinbakk et al. 1990). The
binding of calcium induces conformational changes, the
calcium-saturated state, which allows binding of other
proteins (Lewit-Bentley and Rety 2000). In the presence
of calcium, MRP8/14 heterodimeric complexes may
Table 1. Essential characteristics of calprotectin
tetramerize into heterotetramers (Strupat et al. 2000).
Calprotectin also contains zinc-binding domains, which
have a zinc-binding capacity higher than other S100
proteins, and are not affected by the binding of calcium.
Both MRP8 and MRP14 contain histidine-based zinc-
binding sequences (His-X-X-X-His motif), which are
involved in the antibacterial activity of calprotectin
(Loomans et al. 1998).
calprotectin, MRP8/14 protein, calgranulin,
L1 protein, 27E10 antigen
(Bhardwaj et al. 1992;
Brandtzaeg et al. 1987;
Gebhardt et al. 2002;
Roth et al. 2001)
(Zwadlo et al. 1986)
24 kD heterodimer (or 48 kD tetramer) of
2 calcium-binding proteins MRP8 and
MRP14 (S100A8 and S100A9)
(Itou et al. 2002;
Roth et al. 1994;
Strupat et al. 2000)
S100 proteins family
(Kerkhoff et al. 1998;
Kligman and Hilt 1988;
Lewit-Bentley and Rety 2000)
(Bhardwaj et al. 1992;
Brandtzaeg et al. 1987;
Doussiere et al. 2002;
Helbert et al. 2001;
Pillay et al. 1998;
Roth et al. 1993)
(Clohessy and Golden 1995;
Eue et al. 2002;
Mahnke et al. 1995;
Newton and Hogg 1998;
Sampson et al. 2002)
macrophages, invariably in endothelial and
monocytes, acute phase
an important role in inflammatory processes
by regulating the adhesion of myeloid cells
to endothelium and extracellular matrix
and, activation of effector cells (e.g.
induction of CD11b), direct antibacterial
effects by zinc- capturing, induction of
Distribution of calprotectin
Calprotectin was originally found in neutrophils
and a subpopulation of mononuclear phagocytes
(Table 1). The reactivity of monoclonal antibody 27E10
showed restricted distribution within the myeloid cell
lineage with a weak variable expression also in
endothelial and epidermal cells (Zwadlo et al. 1986). The
concentration of calprotectin in neutrophils is abundant
and constitutes about half (30-60 % according to various
authors) of total cytosolic protein (Hessian et al. 1993).
Calprotectin is secreted
stimulated neutrophils (Boussac and Garin 2000) and
monocytes (Rammes et al. 1997), or is released as
a result of cell disruption or death (Voganatsi et al. 2001).
After cell death, calprotectin is released into pus or
abscess fluid together with microbicidal nucleohistones.
Immunohistochemical studies confirmed the presence of
calprotectin not only in neutrophils and reactive tissue
macrophages, but also on the membrane of non-
keratinizing squamous epithelia, and, occasionally, in
kidney tubules. Some mucosal epithelial cells express
calprotectin in the cytoplasm constitutively (Brandtzaeg
et al. 1987). The soluble form of calprotectin is found in
plasma (reference range < 2 mg/l in healthy subjects),
urine (its production by kidney cells could prevent
formation of calcium oxalate stones) (Pillay et al. 1998),
body secretions (higher calprotectin levels were found in
saliva of subjects with candidiasis, and the calprotectin
concentration correlated positively with the severity of
candidal infection), intestinal fluid and feces.
Physiological role of membrane calprotectin
The role of calprotectin in cellular adhesion has
been reported as the monoclonal antibody 27E10
inhibited the attachment of monocytes to collagen and
fibronectin. On the other hand, these extracellular matrix
proteins induced the expression of calprotectin in parallel
with the release of inflammatory cytokines tumor
necrosis factor alpha (TNFα) and interleukin-6 (IL-6) and
production of superoxide anions (Mahnke et al. 1995).
The relationship between calprotectin expression and
higher capacity to release TNFα has also been shown in
human alveolar macrophages derived by bronchoalveolar
lavage (Zheng et al. 1995). In vitro studies suggested an
important role of calprotectin in extravasation of
leukocytes by the attachment to endothelial cells via the
MRP-14 subunit interacting mainly with endothelial
heparan sulfate proteoglycans (Robinson et al. 2002). The
molecules CD36 (Kerkhoff et al. 1998) and RAGE
(receptor for advanced glycation end-products) (Hofmann
et al. 2002) are two other putative receptors for
calprotectin. The affinity of calprotectin for carboxylated
glycans has also been demonstrated by another group
(Srikrishna et al. 2001). Calprotectin binding to
microvascular endothelial cells may also be induced by
arachidonic acid (Eue and Sorg 2001). The signaling
pathways of calprotectin are not fully elucidated, but
involve MAP kinase cascade activation (Schaefer et al.
1999). The interaction of monocytic calprotectin with
activated endothelium leads to its release (Frosch et al.
2000), which may account for the high calprotectin
concentrations in the body fluids of patients with acute or
chronic inflammatory diseases. Released calprotectin
may be involved in inflammation by enhancing CD11b
expression in human monocytes and by participating in
the transendothelial migration mechanism (Hogg and
Physiological role of soluble calprotectin
Calprotectin has antimicrobial and apoptosis-
inducing activities, which are reversed by the addition of
zinc. By sequestration of zinc, calprotectin inhibits
MMPs (matrix metalloproteinases), zinc-dependent
enzymes that are important in embryonic development,
angiogenesis, wound healing, inflammation, cancer, and
tissue destruction. In this way, calprotectin is capable of
regulating many important processes in the body.
Calprotectin also inhibits the microbial growth through
competition for zinc. Zinc chelation that is mediated by
histidine-rich regions of calprotectin represents an
important antimicrobial mechanism in host defense
(Clohessy and Golden 1995, Loomans et al. 1998).
Calprotectin concentrations of 50-250 µg/ml were found
to inhibit growth of Escherichia coli, Staphylococcus
aureus, Staphylococcus epidermidis, lower concen-
trations (4-32 µg/ml) are sufficient to inhibit growth of
Candida albicans. Cells expressing calprotectin are able
to resist invasion by Listeria monocytogenes and
Salmonella enterica serovar Typhimurium (Nisapakultorn
et al. 2001). It is likely that calprotectin represents a
defense mechanism by protecting neutrophils and other
calprotectin-expressing cells against microbes that invade
the host’s cell cytoplasm.
Regulation of calprotectin synthesis
In addition to local regulation of calprotectin
expression by proinflammatory cytokines, genetic factors
might also be of vital importance. A previously non-
described inborn error of zinc metabolism was identified
by Sampson et al. (1997). These authors reported
a child with hyperzincemia (> 200 µmol/l, reference
range 11-18 µmol/l) associated paradoxically with
symptoms of zinc deficiency (severe growth failure,
hepatosplenomegaly, rashes, anemia, and impaired
immune functions) due to zinc capturing of upregulated
calprotectin (6.5 g/l, i.e. >1000 times normal). The fecal
and urinary calprotectin content was within the normal
range. It was suggested that this patient had a defect in
the control of calprotectin synthesis or in calprotectin
Hypercalprotectinemia led to zinc deficiency and
generalized inflammatory disease. New patients with
calprotectin dysregulation accompanied by recurrent
infections, hepatosplenomegaly, anemia and systemic
inflammation have recently been reported (Sampson et al.
248 Stříž and Trebichavský
2002), creating a new disease entity or syndrome.
Calprotectin as an inflammatory marker in
The upregulation of serum calprotectin levels
may occur in different immune and immunopathological
reactions, especially in acute inflammation or Th1-
mediated responses. In some respects, the sensitivity and
dynamics of calprotectin seem to overcome traditional
inflammatory markers such as C-reactive protein (CRP).
Our recent data showed a rapid increase in the
serum levels of calprotectin in response to bacterial
infection in kidney or heart allograft recipients but, also,
during the course of acute rejection (Stříž et al. 2001a).
Calprotectin may be a very sensitive marker of
complications in organ transplantation, especially in
combination with other inflammatory markers such as
procalcitonin, extremely specific for bacterial systemic
infections (Jarešová et al. 1999). Calprotectin usefulness
in kidney allograft transplantation has also been
confirmed by others (Burkhardt et al. 2001).
Calprotectin is a valuable marker at the very
early stage of inflammatory reactions in human lungs
(Stockley et al. 1984). It seems to be comparable to CRP
in distinguishing between bacterial and viral infections.
Plasma levels of 40 to 130 times the normal values were
frequently seen during life-threatening infections such as
septicemia, meningitis, or pneumonia (Sander et al.
1984). Patients with active tuberculosis had significantly
increased plasma levels of calprotectin compared with
pulmonary sarcoidosis and healthy controls. Human
growth in a dose- and time-dependent manner
(Pechkovsky et al. 2000).
It has been suggested
inflammation is mediated preferentially by activated pro-
inflammatory Th1 cells (Hitchon and El-Gabalawy 2002).
The concentrations of plasma calprotectin have been
shown to be a convenient marker of disease activity and
joint inflammation but not predictive of the outcome of
patients with rheumatoid arthritis (Madland et al. 2002).
In juvenile rheumatoid arthritis, calprotectin seems to be
superior to conventional markers for monitoring
pathological activity (Frosch et al. 2000).
Only a small proportion of patients with
abdominal discomfort have organic disease, but a correct
diagnosis can seldom be made by simple clinical
examination. Additional diagnostic procedures must be
employed, but these are expensive and involve a certain
risk. Assessment of fecal calprotectin can be used as a
screening test for selecting patients for further
examination (Fagerhol 2000). The test can be performed
on 1-2 g of random stool samples that are sent to the
laboratory by regular mail, since the protein is
remarkably stable in stools. This test has a high
sensitivity and specificity for gastrointestinal cancers and
IBD (inflammatory bowel disease). Fecal calprotectin
levels reflect disease activity in IBD and can be used to
monitor the response to treatment and detect relapses
(Aadland and Fagerhol 2002). Upper gastrointestinal
disorders showed a small difference in calprotectin levels
compared to median calprotectin levels in normal adult
subjects (4.5 mg/ml). Median fecal calprotectin was
elevated significantly in esophageal and gastric
carcinoma (30 mg/ml), colorectal carcinoma (53 mg/ml)
and IBD (Crohn's disease, 31 mg/ml, ulcerative colitis,
116 mg/ml) (Summerton et al. 2002). Serum calprotectin
discriminates well between active and inactive Crohn
disease and may have considerable potential in the
analysis of clinical disease activity in these patients
(Lugering et al. 1995).
Cell expression of calprotectin in inflamed
In addition to serum or fecal values of
calprotectin which can easily be determined by
commercial ELISA kits, its local membrane expression
provides another important piece of information. In the
lungs, calprotectin can serve as a marker of freshly
expressed in 84 % of peripheral blood mononuclear cells
but only in 10 % of alveolar macrophages of healthy
human subjects (Stříž et al. 2001b). The percentage of
calprotectin-positive macrophage correlates with the
proportion of bronchoalveolar neutrophils (Stříž et al.
1993). A rapid influx of macrophages that expressed
calprotectin was observed in fetal pig lungs a few hours
after the translocation of Escherichia coli from an
experimentally infected amniotic cavity (Šplíchal et al.
2002). A similar influx was observed in young
gnotobiotic piglets after the oral infection with E. coli and
translocation of bacteria into the lungs. The ratio of lung
cells containing calprotectin was higher after infection
with the virulent O55 strain than after infection with non-
pathogenic O86 strain that was also capable to translocate
into the lungs of gnotobiotic piglets, and was much
higher than the number of these cells in the lungs of
germ-free animals (unpublished results). Not only in
respiratory infections but also in lung transplantations do
calprotectin-positive macrophages expand during acute
rejection (Frachon et al. 1994).
In kidney allograft transplantations, calprotectin-
positive macrophages have been found to be an early
acute cellular rejection marker together with increased
(Burkhardt et al. 1995, Goebeler et al. 1994).
Calprotectin-positive macrophages may likewise play an
important role in ANCA-positive renal vasculitis
(Rastaldi et al. 2000). The expression of calprotectin in
the kidney is not restricted only to mononuclear
phagocytes (Rugtveit et al. 1996), but can also be
detected in the tubular epithelium (Brandtzaeg et al.
1987) and collecting ducts (Helbert et al. 2001).
Calprotectin is strongly expressed in infiltrating
inflammatory cells, but may also be involved in skin
carcinogenesis (Gebhardt et al. 2002). Calprotectin can
be found in almost all dermatoses associated with
hyperproliferation of epithelial cells (Kelly et al. 1989)
and during wound healing (Thorey et al. 2001).
calprotectin can be found in suprabasal layers and
throughout the epidermis of bullous skin (Paquet and
Pierard 2002). Calprotectin binding to the endothelium
may also occur in the dermis. Calprotectin-positive
macrophages were found to be associated with urticaria
(Czarnetzki et al. 1990), contact dermatitis (Roth et al.
1992), or in local progression of melanoma (Brocker et
Oral cavity and bowels
Calprotectin is constitutively expressed in
gingival keratinocytes. In periodontitis, higher levels are
of adhesion molecules
found in the gingival cervical fluid and tissue specimens.
It confers resistance to infection by Porphyromonas
gingivalis (Nisapakultorn et al. 2001). In Crohn’s disease,
a strong calprotectin immunoreactivity is present in
epithelial cells adjacent to ulcerative and fissuring lesions
in the bowels (Lugering et al. 1995).
Calprotectin is a marker present exclusively on
infiltrating tissue macrophages but not on resident tissue
macrophages; therefore, it is expressed in the rheumatoid
arthritis synovial membrane by macrophages on the
lining layer adjacent to the cartilage-pannus junction
(Youssef et al. 1999).
Conclusions and prospects
Calprotectin represents a cytosolic antibacterial
protein present in neutrophils, which may also be
expressed on the membrane of monocytes and is involved
in their recruitment to inflammation site by adhesive
interactions with the endothelium. Upon neutrophil
activation or monocyte adhesion to the endothelium,
calprotectin is released and may provide not only
bacteriostatic but also cytokine-like effects in the local
environment. When calprotectin metabolism is affected at
the systemic level, the zinc-binding properties of the
protein may induce severe dysregulation of zinc
homeostasis with severe clinical symptoms. In any case,
there are several lines of evidence showing the
importance of calprotectin in defense mechanisms and
physiological functions of the immune system. The
clinical usefulness of calprotectin as an inflammatory
marker has been shown not only in gastroenterology,
where determination of the protein in feces is a non-
invasive parameter reflecting pathological processes
going on in the mucosa. The serum level of calprotectin
may be a very sensitive non-specific inflammatory
marker in various clinical settings. On the other hand, our
experience suggests the importance of being aware that in
neutropenic patients the results may often be falsely
negative. In this respect, the data should be either
evaluated by monitoring the dynamics of serum
calprotectin levels or in combination with other
monocytes/macrophages in a tissue is another clinically
relevant issue and may be useful for assessing the influx
of mononuclear phagocytes to affected tissue or organ.
250 Stříž and Trebichavský
On the other hand, the invasive nature of the biopsy
procedure represents a limitation. Theoretically, a new
area might emerge in the future in the field of
recombinant calprotectin or calprotectin-like drug
administration, but the pleiotropic effects of this protein
should always be taken into account and a large body of
evidence regarding calprotectin metabolism, signaling
and function will have to be accumulated before starting
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