Effect of carnitine and essential fatty acid supplementation on the uptake of 11C-carnitine in muscle of a myopathic carnitine-deficient patient using positron emission scintigraphy

The aim of this study was to demonstrate the pattern of 11C-carnitine uptake after various treatment regimens in a myopathic carnitine-deficient patient and two normal volunteers, using a whole body counter specially adapted for positron emission. One carnitine-deficient patient and two normal volunteers were scanned after an intravenous injection of 11C-carnitine, both while on carnitine therapy and after discontinuation thereof. The third scan was done on the patient following carnitine and fatty acid therapy for 7 days. Both the carnitine-deficient patient and the normal volunteers showed improved 11C-carnitine uptake by thigh muscles after carnitine supplementation, and the carnitine-deficient patient even more so after carnitine and fatty acid supplementation. It is therefore concluded that the scintigraphic findings support the clinical impression that carnitine deficient patients improve after carnitine and essential fatty acid supplementation.

Propionyl-L-carnitine

Propionyl-L-carnitine stimulates energy production in ischaemic muscles by increasing citric acid cycle flux and stimulating pyruvate dehydrogenase activity. The free radical scavenging activity of the drug may also be beneficial. Propionyl-L-carnitine improves coagulative fibrinolytic homeostasis in vasal endothelium and positively affects blood viscosity. Improvements in maximum walking distance (MWD) correlated positively with increased mitochondrial oxidative adenosine triphosphate (ATP) synthesis in a study in patients with peripheral arterial disease. Oral propionyl-L-carnitine 1 to 3 g/day significantly improved mean MWD compared with placebo in patients with peripheral arterial obstructive disease (Fontaine Leriche stage II) in double-blind multicentre phase III studies (mean improvements ranged from 21 to 50% with placebo and from 33 to 73% with propionyl-L-carnitine). In one phase III study, propionyl-L-carnitine 1 to 3 g/day significantly improved mean MWD (measured by treadmill) compared with placebo (by 73 vs 46% after 24 weeks) in patients with intermittent claudication. Oral propionyl-L-carnitine therapy was associated with significant improvements in quality of life compared with placebo in patients with a baseline MWD < 250m. Propionyl-L-carnitine appears to be well tolerated, showing a similar incidence of adverse events to that reported in placebo recipients.

Evidence for an asymmetrical uptake of L-carnitine in the blood-brain barrier in vitro

The transport of L-carnitine (4-N-trimethylammonium-3-hydroxybutyric acid) was studied with a primary culture of porcine brain capillary endothelial cells (BCEC) as an in vitro model of the blood-brain barrier. The measurements with suspended cells and cell monolayers allowed to distinguish a polarized transport phenomena. The part of the BCEC cells exposed to the medium (apical membrane) accumulated carnitine by a sodium-independent, saturable (Km=28 microM) system, with k=0.018 min-1. Exposure of the basolateral part revealed a presence of a facilitated diffusion process. Carnitine uptake through the saturable system was inhibited by butyrobetaine. Acylcarnitines and choline have no effect on the carnitine accumulation in suspended cells, a process diminished by phenylalanine, leucine, and L system inhibitor. This points to the possibility that carnitine enters through the basolateral membrane using amino acid transporting systems. A different, novel system is postulated to operate in the apical part of the plasma membrane of BCEC.

Carnitine and its derivatives in cardiovascular disease

Carnitine and its derivative propionyl-L-carnitine are endogenous cofactors which enhance carbohydrate metabolism and reduce the intracellular buildup of toxic metabolites in ischemic conditions. The carnitines have been, and are being used in a spectrum of diseases including multiple cardiovascular conditions. These include angina, acute myocardial infarction, postmyocardial infarction, congestive heart failure, peripheral vascular disease, dyslipidemia, and diabetes. Most published data on carnitine, propionyl-L-carnitine, and other carnitine congeners are favorable but the clinical trials have been relatively small. In currently used doses, these substances are virtually devoid of significant side effects.

Deficient muscle carnitine transport in primary carnitine deficiency

Primary carnitine deficiency is associated with deficient blood and tissue carnitine concentrations. The clinical syndrome is dominated by heart and skeletal muscle symptoms, and the clinical response to oral carnitine supplementation is life-saving. Carnitine uptake has been shown to be defective in cultured skin fibroblasts and leukocytes obtained from patients with this condition. We report a new case of primary carnitine deficiency and offer direct evidence consistent with an impairment of carnitine uptake in differentiating muscle culture. The patient presented with severe and progressive cardiomyopathy and moderate proximal limb weakness. Plasma and muscle carnitine levels were very low, and the maximal rate of carnitine transport in cultured fibroblasts was deficient. An asymptomatic sister with intermediate levels of carnitine in plasma showed partially deficient carnitine uptake in fibroblasts, indicating heterozygosity. The patient's condition improved dramatically with oral carnitine therapy. Further studies were performed in cultured muscle cells at different stages of maturation, which demonstrated deficient maximal rates of carnitine uptake. Our findings are consistent with the concept that primary carnitine deficiency is the result of a generalized defect involving carnitine transport across tissue membranes.

Betaine and L-carnitine transport by Listeria monocytogenes Scott A in response to osmotic signals

The naturally occurring compatible solutes betaine and L-carnitine allow the food-borne pathogen Listeria monocytogenes to adjust to environments of high osmotic strength. Previously, it was demonstrated that L. monocytogenes possesses an ATP-dependent L-carnitine transporter (A. Verheul, F. M. Rombouts, R. R. Beumer, and T. Abee, J. Bacteriol. 177:3205-3212, 1995). The present study reveals that betaine and L-carnitine are taken up by separate highly specific transport systems and support a secondary transport mechanism for betaine uptake in L. monocytogenes. The initial uptake rates of betaine and L-carnitine are not influenced by an osmotic upshock, but the duration of transport of both osmolytes is directly related to the osmotic strength of the medium. Regulation of uptake of both betaine and L-carnitine is subject to inhibition by preaccumulated solute. Internal betaine inhibits not only transport of external betaine but also that of L-carnitine and, similarly, internal L-carnitine inhibits transport of both betaine and L-carnitine. The inhibition is alleviated upon osmotic upshock, which suggests that alterations in membrane structure are transmitted to the allosteric binding sites for betaine and L-carnitine of both transporters at the inner surface of the membrane. Upon osmotic downshock, betaine and L-carnitine are rapidly released by L. monocytogenes as a consequence of activation of a channel-like activity. The osmolyte-sensing mechanism described is new and is consistent with various unexplained observations of osmoregulation in other bacteria.

Synthesis of O-[11C]Acetyl CoA, O-[11C]Acetyl-L-carnitine, and L-[11C]carnitine labelled in specific positions, applied in PET studies on rhesus monkey

The syntheses of L-carnitine, O-acetyl CoA, and O-acetyl-L-carnitine labelled with 11C at the 1- or 2-position of the acetyl group or the N-methyl position of carnitine, using the enzymes acetyl CoA synthetase and carnitine acetyltransferase, are described. With a total synthesis time of 45 min, O-[1-11C]acetyl CoA and O-[2[11C]acetyl CoA was obtained in 60-70% decay-corrected radiochemical yield, and O-[1-11C]acetyl-L-carnitine and O-[2-11C] acetyl-L-carnitine in 70-80% yield, based on [1-11C]acetate or [2-11C]acetate, respectively. By an N-methylation reaction with [11C]methyl iodide, L-[methyl-11C]carnitine was obtained within 30 min, and O-acetyl-L-[methyl-11C]carnitine within 40 min, giving a decay-corrected radiochemical yield of 60% and 40-50%, respectively, based on [11C]methyl iodide. Initial data of the kinetics of the different 11C-labelled L-carnitine and acetyl-L-carnitines in renal cortex of anaesthetized monkey (Macaca mulatta) are presented.

Automated chemoenzymatic synthesis of no-carrier-added [carbonyl-11C]propionyl L-carnitine for pharmacokinetic studies

Propionyl-L-carnitine (PLC) is under development as a therapeutic for the treatment of peripheral artery disease, coronary heart disease and chronic heart failure. Three methods were examined for labelling PLC in its propionyl group with positron-emitting carbon-11 (t12 = 20.3 min), one chemical and two chemoenzymatic. The former was based on the preparation of [11C]propionyl chloride as labelling agent via 11C-carboxylation of ethylmagnesium bromide with cyclotron-produced [11C]carbon dioxide and subsequent chlorination. Reaction of carrier-added [11C]propionyl chloride with L-carnitine in trifluoroacetic acid gave [11C]PLC in 12% radiochemical yield (decay-corrected) from cyclotron-produced [11C]carbon dioxide. However, the radiosynthesis was unsuccessful at the no-carrier-added (NCA) level of specific radioactivity. [11C]Propionate, as a radioactive precursor for chemoenzymatic routes, was prepared via carboxylation of ethylmagnesium bromide with [11C]carbon dioxide and hydrolysis. NCA [11C]PLC was prepared in 68 min in 14% radiochemical yield (decay-corrected) from [11C]propionate via sequential conversions catalysed by acetate kinase, phosphotransacetylase and carnitine acetyltransferase. A superior chemoenzymatic synthesis of NCA [11C]PLC was developed, based on the use of a novel supported Grignard reagent for the synthesis of [11C]propionate and conversions by S-acetyl-CoA synthetase and carnitine acetyltransferase. This gave an overall radiochemical yield of 30-48% (decay-corrected). This synthesis was automated for radiation safety and provides pure NCA [11C]PLC in high radioactivities ready for intravenous administration within 25 min from radionuclide production. The [11C]PLC is suitable for pharmacokinetic studies in human subjects with PET and the elucidation of the fate of the propionyl group of PLC in vivo.

Excretion and metabolism of propionyl-L-carnitine in the isolated perfused rat kidney

Propionyl-L-carnitine (PLC) is an ester of L-carnitine (LC) under evaluation for the treatment of cardiovascular disorders. The renal disposition of PLC was studied in the isolated perfused rat kidney with deuterium-labeled derivative (PLC-CD3). Kidneys of male Sprague-Dawley rats were perfused at initial PLC-CD3 concentrations of 10 (n = 4) and 200 microM (n = 5). High-performance liquid chromatography/mass spectrometry was used to quantify PLC-CD3, deuterated L-carnitine (LC-CD3) and acetyl-L-carnitine (ALC-CD3) in perfusate and urine. PLC-CD3 in perfusate decreased in a monoexponential manner with a half-life of 90 +/- 24 min (S.D.) (10 microM) and 94 +/- 11 min (200 microM). The renal excretory clearance of PLC-CD3 was significantly lower (P < .05, unpaired t test) at an initial concentration of 10 microM (45 +/- 23 microl/min) than at 200 microM (85 +/- 28 microl/min), but in both cases it was substantially less than the glomerular filtration rate, which indicates extensive tubular reabsorption. The renal excretory clearance of PLC-CD3 represented less than 6% of the total clearance, which suggests that metabolism is the major renal elimination route for this compound. The appearance in perfusate and urine of LC-CD3 and ALC-CD3 provided additional evidence for a metabolic role of the kidney. The apparent renal excretory clearance values for these metabolites were always significantly higher than the values obtained for the corresponding endogenous compounds, which suggests that LC-CD3 and ALC-CD3, as formed metabolites, underwent passive or carrier-mediated movement directly into urine.

L-carnitine and acetyl-L-carnitine status during hemodialysis with acetate in humans: a kinetic analysis

The effects of the acetate content of hemodialysis fluids on the relation between L-carnitine (free carnitine, cr FC) and acetyl-L-carnitine (AC) have not previously been examined in detail. The net fluxes of FC, AC, and acetate between intra- and extracellular pools during hemodialysis were calculated using a kinetic model with dialysates containing three concentrations of FC (0, 40, and 80 mumol/L) and either 40 or 3 mmol acetate/L. Radioenzymatic assays of FC and AC were optimized for use with samples taken during hemodialysis. Acetate stimulated a tissue uptake of FC (P < 0.05) that could exceed the rate of FC delivery and was related to the dialysate FC composition (P < 0.02). There were associated changes in tissue AC output. With dialysate containing 40 mmol acetate/L, AC tissue output was directly related to the dialysate FC composition (P < 0.05). The AC tissue output was less with dialysate containing 3 mmol acetate/L (P < 0.05) but the significant increase with the provision of FC in the dialysate was retained (P < 0.05). Hemodialysis may therefore represent an acute period of relative carnitine deficiency when regeneration of free coenzyme A from acetyl coenzyme A consequent to metabolism of acetate is limited.

Long-term 1-carnitine treatment prolongs the survival in rats with adriamycin-induced heart failure

BACKGROUND

The most serious consequence of heart failure is the shortened life expectancy, which may be associated with myocardial energy starvation.

METHODS AND RESULTS

Eight-week-old male Sprague-Dawley rats received 6 intraperitoneal injections of adriamycin (group A: total dose; 15 mg/kg body weight) or vehicle (group C) over 2 weeks. Rats then received either 272 mg/kg daily of oral 1-carnitine (A-LC and C-LC groups) or saline (A-S and C-S groups) for 6 weeks. The cumulative mortality rate in the A-LC group was significantly lower than in the A-S group (13 vs 42%, P = .028). Myocardial levels of high-energy phosphate compounds (ATP and creatine phosphate) and fatty acid metabolites (free carnitine, short-chain and long-chain acylcarnitine, and long-chain acyl CoA) in the left ventricle were measured the day after the last dose of drug or vehicle was administered. ATP was decreased by 73%, creatine phosphate by 61%, free carnitine by 52%, short-chain acylcarnitine by 48%, and long-chain acylcarnitine by 56% in the A-S group compared to the C-S group. Long-chain CoA was increased by 168% in the A-S group. Levels of myocardial high-energy phosphate compounds and fatty acid metabolites were near normal in adriamycin- and 1-carnitine-treated rats.

CONCLUSIONS

Preservation of the myocardial level of carnitine by 1-carnitine treatment prolonged survival of rats with adriamycin-induced failure by improving the myocardial metabolism of fatty acids.

[Influence of multiple-dose administration of cefetamet pivoxil on blood and urinary concentrations of carnitine and effects of simultaneous administration of carnitine with cefetamet pivoxil]

Cefetamet pivoxil (CEMT-PI), a drug of pivaloyloxymethyl group, was investigated for its impact on the carnitine blood homeostasis and renal excretion upon administering CEMT-PI alone, and CEMT-PI simultaneously with carnitine. 500 mg of CEMT-PI (group A) and 500 mg of CEMT-PI and an equimolar amount (200 mg of carnitine) of levocarnitine chloride (group B) were administered twice a day for 7 and 1/2 consecutive days to 5 healthy volunteers (group A) and 3 healthy volunteers (group B). No serious side effects nor abnormal values in physical and laboratory tests were observed throughout the study in both groups. During the treatment period, plasma total carnitine decreased slowly down to 25.5 microM (group A) and 38.8 microM (group B) and plasma free carnitine reached steady state levels at 17.7 microM (group A) and 29.2 microM (group B) on day 5. These concentrations represent 45 and 37% in group A, 66 and 58% in group B of the average pre-treatment baseline levels. Plasma pivaloylcarnitine quickly reached plateau levels of 6.12 microM (group A) and 4.05 microM (group B) on day 4. After treatment stop, plasma total and free carnitine returned to the pretreatment baseline level within 5 days (group A) and 3 days (group B), and plasma pivaloylcarnitine was detectable until day 7 of the treatment-free follow up in both groups. Although carnitine was given concurrently at a dose equimolar to the ingested amount of pivalic acid in group B, the plasma total and free carnitine exhibited a decrease. This was considered attributable to the fact that the bioavailability of carnitine is as low as 16% when administered orally, which is considerably less compared to the 55% bioavailability of cefetamet pivoxil.

Effect of L-carnitine supplementation on acute valproate intoxication

We analyzed urinary valproate (VPA) metabolites and carnitine concentrations in a child who accidentally ingested 400 mg/kg VPA. The concentration of 4-en VPA, the presumed major factor in VPA-induced hepatotoxicity, was markedly increased, without liver dysfunction or hyperammonemia. The other major abnormality was decreased beta-oxidation and markedly increased omega-oxidation. After L-carnitine supplementation, VPA metabolism returned to normal. The level of valproylcarnitine was not increased and therefore was not affected by L-carnitine. L-Carnitine may be useful in treating patients with coma after VPA overdose.

Uptake of [N-methyl-11C]propionyl-L-carnitine (PLC) in human myocardium

We studied the uptake of propionyl-L-carnitine from plasma by the myocardium in 10 human subjects using positron emission tomography. Propionyl-L-carnitine was labeled in the N-methyl position with carbon-11 (T1/2 = 20.4 min) and administered i.v. in trace amounts. The uptake of the radiolabel by the myocardium was then scanned over a period of 1 1/2 h. The activity-time course of the tracer in blood and plasma and the exchange of the label in plasma between propionyl carnitine, acetyl carnitine and free carnitine was followed during the scans. Myocardial blood flow was also measured in the same subjects. The results show an exchange of the tracer between the myocardium and plasma, and they show an apparently irreversible component of uptake, a result consistent with the incorporation of the label into relatively large intracellular carnitine pools.

Effect of short- and long-term treatments by a low level of dietary L-carnitine on parameters related to fatty acid oxidation in Wistar rat

This study was designed to examine whether short- and long-term treatments by a low level of dietary L-carnitine are capable of altering enzyme activities related to fatty acid oxidation in normal Wistar rats. Under controlled feeding, ten days of treatment changed neither body weights nor liver and gastrocnemius weights, but succeeded in reducing the weight of peri-epididymal adipose tissues. Triacylglycerol contents were lowered in liver and ketone body concentrations were found slightly more elevated in blood. In the liver, mitochondrial carnitine palmitoyltransferase I (CPT I) exhibited a slightly higher specific activity and a lower sensitivity to malonyl-CoA inhibition, while peroxisomal fatty acid oxidizing system (PFAOS) was found to be less active. Carnitine supplied for one month reduced the mass of the periepididymal fat tissue, but not those of the other studied organs, and produced a slight but non-significant gain in body weight after ten days of treatment. In the liver, CPTI characteristics were comparable in control and treated groups, while PFAOS activity was less in rats receiving carnitine. Data show that L-carnitine at a low level in the diet exerted two paradoxical effects before and after ten days of treatment. Results are discussed in regard to fatty acid oxidation in mitochondria and peroxisomes, and to the possible altered acyl-CoA/acylcarnitine ratio with increased concentrations of L-carnitine in the liver.

Transport of carnitine in neuroblastoma NB-2a cells

Carnitine accumulation was measured in cultured neuroblastoma NB-2a cells. This process was found partially sodium dependent and its kinetics to be a sum of a saturable transport (Km = 123 +/- 13 microM) and diffusion (D = 63 +/- 7 pmol/mg protein/min/mM). On the contrary to previous reports on neural cells, the accumulation of carnitine was found insensitive to gamma-aminobutyric acid (GABA). Measurements of carnitine accumulation in the presence of different compounds resulted in the conclusion that carnitine transport does not occur through the known systems specific toward choline and/or amino acids. For instance, an observed inhibition of carnitine transport by serine and cysteine, without any effect of alanine, excluded a possible role of ASC amino acid transport system. An involvement of a new transporter is thus postulated, specific toward compounds with a polar group in the beta position with respect to the carboxylic group.

Disposition of L-carnitine and acetyl-L-carnitine in the isolated perfused rat kidney

The isolated perfused rat kidney was used to investigate the regulation, specificity and concentration-dependence of the renal tubular disposition of L-carnitine (LC) and its ester, acetyl-L-carnitine (ALC). Tritiated markers were used to study the renal disposition of LC and ALC and HPLC was used to purify 3H-LC and 3H-ALC before radiochemical analysis. At perfusate concentrations comparable to those found in plasma in vivo (50 microM for LC and 5 microM for ALC), the renal clearance of both analogues was substantially less than GFR (P < .05) which, in view of their negligible binding to perfusate proteins, is indicative of extensive reabsorption. During the first 20 min of perfusion, the percent tubular reabsorption (%TR) of LC and ALC was 94 +/- (SD) 2.6% and 97 +/- 0.6%, respectively. The extent of 3H-ALC and 3H-LC enrichment of perfusate in experiments with 3H-LC and 3H-ALC, respectively, provided evidence for the capability of the rat kidney to acetylate LC and deacetylate ALC. In addition, a portion of renally generated 3H-ALC and 3H-LC was found to undergo leakage into renal tubules and escape subsequent reabsorption. It was also found that the %TR of both compounds decreased substantially when the perfusate concentration was increased above endogenous levels; each compound was capable of decreasing the %TR of the other; and trimethylamine-N-oxide, a metabolite of LC, had no significant effect on the renal handling of the carnitine derivatives.

Propionyl-L-carnitine: labelling in the N-methyl position with carbon-11 and pharmacokinetic studies in rats

The prospective therapeutic, propionyl-L-carnitine, was labelled in the N-methyl position with the positron-emitter, carbon-11 (t1/2 = 20.4 min), with a view to studying its pharmacokinetics in humans using PET. Labelling was achieved by methylating nor-propionyl-L-carnitine hydrochloride with no-carrier-added [11C]iodomethane (produced from cyclotron-produced [11C]carbon dioxide) in ethanol in the presence of 1,2,2,6,6-pentamethylpiperidine. HPLC of the reaction mixture on a strong cation exchange column provided high purity [N-methyl-11C]propionyl-L-carnitine in 62% radiochemical yield (decay-corrected from [11C]iodomethane), ready for intravenous administration within 35 min from the end of radionuclide production. [N-methyl-11C]Propionyl-L-carnitine, given intravenously to rats, cleared rapidly from plasma. A slow uptake of radioactivity into myocardium and striated muscle was observed. In plasma, unchanged tracer represented 84% of the radioactivity at 2.5 min and 2.5% of the radioactivity at 60 min. In heart, unchanged tracer represented 18% of radioactivity at 2.5 min and 2.4% at 15 min. The remainder of radioactivity detected in plasma and heart was identified as [N-methyl-11C]L-carnitine and [N-methyl-11C]acetyl-L-carnitine.

Comparison of L-carnitine pharmacokinetics with and without baseline correction following administration of single 20-mg/kg intravenous dose

L-Carnitine, a naturally occurring compound, is indicated in the treatment of primary systemic carnitine deficiency. To assess the differences in pharmacokinetic parameters calculated from data corrected for baseline versus those from "uncorrected" data, compartmental fitting was carried out for baseline corrected and original plasma concentration data obtained following a single intravenous (iv) dose of 20 mg/kg. For free L-carnitine, mean volumes of distribution at steady state (Vdss) of the central compartment were similar using either approach (9.86 versus 11.2 L). However, Vdss (54.0 versus 29.0 L) and apparent elimination half-life (17.4 versus 5.0 h) were significantly different between the two data bases. Similar observations were noted for pharmacokinetic parameters based on plasma concentrations of total L-carnitine. Although the pharmacokinetic parameters obtained after baseline correction may represent the kinetics of a bolus dose, the pharmacokinetic parameters from uncorrected plasma data probably represent the clinical settings for patients. Baseline correction also probably has its greatest value in attempting to determine and/or define the biological half-life and Vdss for the "exogenously" administered dose and uncorrected data best describes the pharmacokinetics of composite endogenous and exogenous L-carnitine levels.

Multiple-dose pharmacokinetics and bioequivalence of L-carnitine 330-mg tablet versus 1-g chewable tablet versus enteral solution in healthy adult male volunteers

The bioavailability and bioequivalence of three oral dosage forms of L-carnitine were studied in 15 healthy volunteers. Recently, an intravenous (iv) dosage form of L-carnitine has been approved to be marketed in the United States. The purpose of this study was to determine after multiple dose administration of the three oral dosage forms (marketed solution, chewable tablet, and marketed tablet) the pharmacokinetics and absolute bioavailability of each of the dosage forms at steady state and compare them with those following administration of a single iv dose. The relative bioavailability and bioequivalence of the chewable and marketed tablet relative to the marketed solution at steady-state replicate design conditions were also studied. Bioavailability based on data that was not corrected for the baseline (uncorrected data) was compared with bioavailability determined from data corrected for baseline. Steady-state conditions, based on free or total L-carnitine plasma concentrations, were achieved by Day 3, and products were bioequivalent based on the analysis of variance and comparisons by the two one-sided t test. Pharmacokinetic evaluations were found to be powerful tools for bioequivalence determinations; the power to detect 20% differences in AUC, Cmax tmax, and Cmin0 was > 80%. Mean absolute bioavailabilities (based on free or total L-carnitine plasma concentrations) on Day 4 (fraction of the dose absorbed) of Carnitor (levocarnitine) tablet, Carnitor (levocarnitine) oral solution, and levocarnitine chewable tablet relative to the first iv dose were approximately 18%. Similarly, absolute bioavailability compared with the last iv dose was approximately 18% for all three oral formulations.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic considerations for the therapeutic use of carnitine in hemodialysis patients

Clinical observations have suggested that carnitine supplementation may be beneficial to a subset of patients receiving chronic hemodialysis. In the absence of definitive clinical trials, the clinician must decide for an individual patient whether a trial of carnitine therapy is justified. The institution of carnitine therapy is further complicated by the availability of oral and intravenous dosing forms and by the compound's complex pharmacokinetics. The oral systemic bioavailability of carnitine in normal subjects is 5% to 16%, with peak plasma carnitine concentrations reached 2 to 6 hours after dosing. Carnitine is initially distributed into extracellular water and then more slowly enters tissue compartments with complex kinetics. Elimination of carnitine is through the urine or dialysate. Intravenous carnitine administration results in large peak plasma concentrations and assures systemic bioavailability. Orally administered carnitine has been reported to have clinical efficacy in hemodialysis patients in doses of 2 to 4 g per day in divided doses. Intravenous carnitine has also been widely used in clinical trials in attempts to demonstrate efficacy in the hemodialysis population; however, the available data do not establish the superiority of the intravenous formulation over the oral form. Intravenous carnitine may have theoretical advantages in initiating treatment when high peak concentrations are required to facilitate carnitine reaching nonhepatic tissue sites or when oral carnitine therapy is not feasible due to poor tolerance or compliance. Although comparative trials are lacking, it is probable that oral therapy can be used for long-term maintenance, regardless of which formulation was used to initiate therapy. The decision to use carnitine therapy, as well as the dose and route of administration, requires individualization based on the clinical status of the patient and the goals of therapy.

Carnitine supplementation: effect on muscle carnitine and glycogen content during exercise

This study investigated the effects of L-carnitine supplementation on muscle carnitine and glycogen content during submaximal exercise (EX). Triglycerides were evaluated by a fat feeding (90 g fat) and 3 h later subjects cycled for 60 min at 70% VO2max (CON). Muscle biopsies were obtained preexercise and after 30 and 60 min of EX. Blood samples were taken prior to and every 15 min of exercise. Subjects randomly completed two additional trials following 7 and 14 d of carnitine supplementation (6 g.d-1). During one of the two trials, subjects received 2000 units of heparin 15 min prior to EX to elevate FFA (CNhep); no heparin was administered during the other trial (CN). There were no differences in VO2, respiratory exchange ratio, heart rate, or g.min-1 of CHO and fat oxidized among the three trials. At rest serum total acid soluble (TASC) and free (FC) carnitine increased with supplementation (TASC; CON, 71.3 +/- 2.9; CN, 92.8 +/- 5.4; CNhep, 109.8 +/- 3.5 mumol.l-1) (FC; CON, 44.1 +/- 2.7; CN, 66.1 +/- 5.3; CNhep, 77.1 +/- 4.1 mumol.l-1). During EX, TASC remained stable, while FC decreased and short-chain acylcarnitine (SCAC) increased (P < 0.05). Muscle carnitine concentration at rest was unaffected by supplementation. During EX, muscle TASC did not change, FC decreased, and SCAC increased significantly in all three trials. Pre-EX and post-EX muscle glycogens were not different. Increased availability of serum carnitine does not result in an increase in muscle carnitine content nor does it alter lipid oxidation. It appears that there is an adequate amount of carnitine present within the mitochondria to support lipid oxidation.

The effect of L-carnitine on myocardial protection in cold cardioplegia followed by reperfusion

We studied the effect of exogenous L-carnitine on myocardial viability and carnitine uptake following ischemia-reperfusion in isolated rat hearts. Hearts were subjected to hypothermic cardioplegia at 26 degrees C for 80 minutes with and without carnitine 10 mmol/L added to the perfusate and cardioplegic solution [Groups I (n = 9) and II (n = 14), respectively]. Additionally, to study myocardial carnitine uptake, hearts were subjected to global ischemia at 20 degrees C [Group III (n = 6) and IV (n = 6)] and at 37 degrees C [Group V (n = 6) and VI (n = 6)] with and without carnitine 10 mmol/L added to the perfusate. All hearts received normothermic reperfusion, and Krebs-Henseleit solution was used as the perfusate in all groups. Postischemic aortic flow, expressed as the percentage of pre-ischemic flow, morphometric scores of myocardial mitochondria, and the myocardial concentration of adenosine triphosphate at the end of reperfusion were significantly higher in Group I than in Group II. In hearts treated with L-carnitine both at 20 degrees C and 37 degrees C the myocardial concentrations of carnitine fractions (free, short-acyl, and long-acyl) increased significantly compared to those in hearts without L-carnitine treatment. The myocardial concentration of free carnitine at the end of reperfusion was significantly higher in Group III than at pre-ischemia. These results suggest that exogenous L-carnitine is incorporated into cellular metabolism, even in hypothermic cardioplegia, improving cardiac function and preserving the myocardial adenosine triphosphate concentration.

Intravenous L-carnitine and acetyl-L-carnitine in medium-chain acyl-coenzyme A dehydrogenase deficiency and isovaleric acidemia

The purpose of this study was to determine whether treatment with L-carnitine or acetyl-L-carnitine enhances the turnover of lipid or branched-chain amino acid oxidation in patients with inborn errors of metabolism. Increasing i.v. doses of L-carnitine and acetyl-L-carnitine were given to one patient with medium-chain acyl-CoA dehydrogenase deficiency and to another with isovaleric acidemia. Both patients were in stable condition and receiving oral L-carnitine supplements. The excretion of carnitine and disease-specific metabolites was measured. The incorporation of L-carnitine in the intracellular pool was demonstrated using stable isotopes and mass spectrometry. Increasing doses of either i.v. L-carnitine or acetyl-L-carnitine did not stimulate the excretion of octanoylcarnitine in the patient with medium-chain acyl-CoA dehydrogenase deficiency, nor did it raise the plasma levels of either cis-4-decenoate or octanoylcarnitine. Similarly, increasing doses of either i.v. L-carnitine or acetyl-L-carnitine did not enhance the excretion of isovalerylcarnitine in a patient with isovaleric acidemia. The excretion of isovalerylglycine actually decreased. We conclude that there was no evidence of enhanced fatty acid beta-oxidation or enhanced branched-chain amino acid oxidation in vivo by the administration of high doses of L-carnitine or acetyl-L-carnitine in these two patients. Because only one individual with each disorder was studied, the data are only indicative and may not necessarily be representative of all individuals with these disorders. Definite settlement of this issue will require further studies in additional subjects.