Amino acid kinetics in patients with sepsis

Ambivalent roles of carboxypeptidase B in the lytic susceptibility of fibrin

BACKGROUND

Removal of C-terminal lysine residues that are continuously exposed in lysing fibrin is an established anti-fibrinolytic mechanism dependent on the plasma carboxypeptidase TAFIa, which also removes arginines that are exposed at the time of fibrinogen clotting by thrombin.

OBJECTIVE

To evaluate the impact of alterations in fibrin structure mediated by constitutive carboxypeptidase activity on the function of fibrin as a template for tissue plasminogen activator-(tPA) induced plasminogen activation and its susceptibility to digestion by plasmin.

METHODS AND RESULTS

We used the stable carboxypeptidase B (CPB), which shows the same substrate specificity as TAFIa. If 1.5 - 6μM fibrinogen was clotted in the presence of 8U/mL CPB, a denser fibrin network was formed with thinner fibers (the median fiber diameter decreased from 138 - 144nm to 89 - 109nm as established with scanning electron microscopy). If clotting was initiated in the presence of 5 - 10μM arginine, a similar decrease in fiber diameter (82 -95nm) was measured. The fine structure of arginine-treated fibrin enhanced plasminogen activation by tPA, but slowed down lysis monitored using fluorescent tPA and confocal laser microscopy. However, if lysis was initiated with plasmin in CPB-treated fibrin, the rate of dissolution increased to a degree corresponding to doubling of the plasmin concentration.

CONCLUSION

The present data evidence that CPB activity generates fine-mesh fibrin which is more difficult to lyse by tPA, but conversely, CPB and plasmin together can stimulate fibrinolysis, possibly by enhancing plasmin diffusion.

Low plasma citrulline levels are associated with acute respiratory distress syndrome in patients with severe sepsis

INTRODUCTION

The role of nitric oxide synthase (NOS) in the pathophysiology of acute respiratory distress syndrome (ARDS) is not well understood. Inducible NOS is upregulated during physiologic stress; however, if NOS substrate is insufficient then NOS can uncouple and switch from NO generation to production of damaging peroxynitrites. We hypothesized that NOS substrate levels are low in patients with severe sepsis and that low levels of the NOS substrate citrulline would be associated with end organ damage including ARDS in severe sepsis.

METHODS

Plasma citrulline, arginine and ornithine levels and nitrate/nitrite were measured at baseline in 135 patients with severe sepsis. ARDS was diagnosed by consensus definitions.

RESULTS

Plasma citrulline levels were below normal in all patients (median 9.2 uM, IQR 5.2 - 14.4) and were significantly lower in ARDS compared to the no ARDS group (6.0 (3.3 - 10.4) vs. 10.1 (6.2 - 16.6), P = 0.002). The rate of ARDS was 50% in the lowest citrulline quartile compared to 15% in the highest citrulline quartile (P = 0.002). In multivariable analyses, citrulline levels were associated with ARDS even after adjustment for covariates including severity of illness.

CONCLUSIONS

In severe sepsis, levels of the NOS substrate citrulline are low and are associated with ARDS. Low NOS substrate levels have been shown in other disease states to lead to NOS uncoupling and oxidative injury suggesting a potential mechanism for the association between low citrulline and ARDS. Further studies are needed to determine whether citrulline supplementation could prevent the development of ARDS in patients with severe sepsis and to determine its role in NOS coupling and function.

Growth and Development Symposium: Impacts of inflammation on cattle growth and carcass merit

Inflammation caused by bovine respiratory disease (BRD) continues to be one of the greatest challenges facing beef cattle producers and feedlot managers. Inflammation decreases DMI, ADG, and G:F in feedlot calves, decreasing growth rate and increasing days on feed, which results in economic losses during the feeding period. During the past decade, marketing of feedlot animals has changed from selling cattle on a live basis to a grid-based marketing system. When cattle are marketed on a live basis, the economic effects of BRD stop at increased health cost and decreased feedlot performance, carcass weight, and death loss. However, when cattle are marketed in a grid-based system, inflammation has the potential to also affect carcass cutability and quality. The effects of inflammation on feedlot cattle in regards to performance are well understood; however, specific effects on cattle growth and ultimately carcass merit are not as well described. Recent studies in feedlot cattle have indicated that the incidence of BRD decreases both HCW and marbling; however, mechanisms are not understood. Research in other species has demonstrated that during the acute phase response, pro-inflammatory cytokines promote skeletal muscle catabolism to supply AA and energy substrates for immune tissues. Further, during this early immune response, the liver changes its metabolic priorities to the production of acute phase proteins for use in host defense. Together these dramatic shifts in systemic metabolism may explain the detrimental effects on performance and carcass traits commonly associated with BRD in feedlot calves. Moreover, recent studies relative to human health have revealed complex multilevel interactions between the metabolic and immune systems, and highlighted inflammation as being a significant contributor to major metabolic diseases. The objective of this paper is to review data to help explain the economical and physiological effects of inflammation on cattle growth and carcass merit.

Appropriate protein provision in critical illness: a systematic and narrative review

BACKGROUND

Widely varying recommendations have been published with regard to the appropriate amount of protein or amino acids to provide in critical illness.

OBJECTIVE

We carried out a systematic review of clinical trials that compared the metabolic or clinical effects of different protein intakes in adult critical illness and comprehensively reviewed all of the available evidence pertinent to the safe upper limit of protein provision in this setting.

DESIGN

MEDLINE was searched for clinical trials published in English between 1948 and 2012 that provided original data comparing the effects of different levels of protein intake on clinically relevant outcomes and evidence pertinent to the safe upper limit of protein provision to critically ill adults.

RESULTS

The limited amount and poor quality of the evidence preclude conclusions or clinical recommendations but strongly suggest that 2.0-2.5 g protein substrate · kg normal body weight⁻¹ · d⁻¹ is safe and could be optimum for most critically ill patients. At the present time, most critically ill adults receive less than half of the most common current recommendation, 1.5 g protein · kg⁻¹ · d⁻¹, for the first week or longer of their stay in an intensive care unit.

CONCLUSION

There is an urgent need for well-designed clinical trials to identify the appropriate level of protein provision in critical illness.

Effects of lipopolysaccharide infusion on arterial levels and transcerebral exchange kinetics of glutamate and glycine in healthy humans

An imbalance between glutamate and glycine signalling may contribute to sepsis-associated encephalopathy by causing neuronal excitotoxicity. In this study, we therefore investigated the transcerebral exchange kinetics of glutamate and glycine in a human-experimental model of systemic inflammation. Cerebral blood flow (CBF) and arterial to jugular venous concentration differences of glutamate and glycine were determined before and after a 4-h intravenous infusion of Escherichia coli lipopolysaccharide (LPS, total dose of 0.3 ng/kg) in 12 healthy volunteers. The global cerebral net exchange was calculated by multiplying CBF with the arterial to jugular venous differences. LPS induced a systemic inflammatory response with fever, neutrocytosis, and elevated arterial levels of tumour necrosis factor-α. This was associated with a decrease in the arterial levels of both glutamate and glycine; however, their transcerebral exchange kinetics were unaffected. Inflammation-induced alterations of the circulating levels of glutamate and glycine, do not affect the global transcerebral exchange kinetics of these amino acids in healthy humans.

The ratio of arginine to dimethylarginines is reduced and predicts outcomes in patients with severe sepsis

OBJECTIVES

Arginine deficiency may contribute to microvascular dysfunction, but previous studies suggest that arginine supplementation may be harmful in sepsis. Systemic arginine availability can be estimated by measuring the ratio of arginine to its endogenous inhibitors, asymmetric and symmetric dimethylarginine. We hypothesized that the arginine-to-dimethylarginine ratio is reduced in patients with severe sepsis and associated with severity of illness and outcomes.

DESIGN

Case-control and prospective cohort study.

SETTING

Medical and surgical intensive care units of an academic medical center.

PATIENTS AND SUBJECTS

One hundred nine severe sepsis and 50 control subjects.

MEASUREMENTS AND MAIN RESULTS

Plasma and urine were obtained in control subjects and within 48 hrs of diagnosis in severe sepsis patients. The arginine-to-dimethylarginine ratio was higher in control subjects vs. sepsis patients (median, 95; interquartile range, 85-114; vs. median, 34; interquartile range, 24-48; p < .001) and in hospital survivors vs. nonsurvivors (median, 39; interquartile range, 26-52; vs. median, 27; interquartile range, 19-32; p = .004). The arginine-to-dimethylarginine ratio was correlated with Acute Physiology and Chronic Health Evaluation II score (Spearman's correlation coefficient [ρ] = - 0.40; p < .001) and organ-failure free days (ρ = 0.30; p = .001). A declining arginine-to-dimethylarginine ratio was independently associated with hospital mortality (odds ratio, 1.63 per quartile; 95% confidence interval, 1.00-2.65; p = .048) and risk of death over the course of 6 months (hazard ratio, 1.41 per quartile; 95% confidence interval, 1.01-1.98; p = .043). The arginine-to-dimethylarginine ratio was correlated with the urinary nitrate-to-creatinine ratio (ρ = 0.46; p < .001).

CONCLUSIONS

The arginine-to-dimethylarginine ratio is associated with severe sepsis, severity of illness, and clinical outcomes. The arginine-to-dimethylarginine ratio may be a useful biomarker, and interventions designed to augment systemic arginine availability in severe sepsis may still be worthy of investigation.

Activated protein synthesis and suppressed protein breakdown signaling in skeletal muscle of critically ill patients

Background

Skeletal muscle mass is controlled by myostatin and Akt-dependent signaling on mammalian target of rapamycin (mTOR), glycogen synthase kinase 3β (GSK3β) and forkhead box O (FoxO) pathways, but it is unknown how these pathways are regulated in critically ill human muscle. To describe factors involved in muscle mass regulation, we investigated the phosphorylation and expression of key factors in these protein synthesis and breakdown signaling pathways in thigh skeletal muscle of critically ill intensive care unit (ICU) patients compared with healthy controls.

Methodology/Principal Findings

ICU patients were systemically inflamed, moderately hyperglycemic, received insulin therapy, and showed a tendency to lower plasma branched chain amino acids compared with controls. Using Western blotting we measured Akt, GSK3β, mTOR, ribosomal protein S6 kinase (S6k), eukaryotic translation initiation factor 4E binding protein 1 (4E-BP1), and muscle ring finger protein 1 (MuRF1); and by RT-PCR we determined mRNA expression of, among others, insulin-like growth factor 1 (IGF-1), FoxO 1, 3 and 4, atrogin1, MuRF1, interleukin-6 (IL-6), tumor necrosis factor α (TNF-α) and myostatin. Unexpectedly, in critically ill ICU patients Akt-mTOR-S6k signaling was substantially higher compared with controls. FoxO1 mRNA was higher in patients, whereas FoxO3, atrogin1 and myostatin mRNAs and MuRF1 protein were lower compared with controls. A moderate correlation (r² = 0.36, p<0.05) between insulin infusion dose and phosphorylated Akt was demonstrated.

Conclusions/Significance

We present for the first time muscle protein turnover signaling in critically ill ICU patients, and we show signaling pathway activity towards a stimulation of muscle protein synthesis and a somewhat inhibited proteolysis.

Is plasma arginine concentration decreased in patients with sepsis? A systematic review and meta-analysis

INTRODUCTION

L-arginine is a conditionally essential amino acid that plays an important role in immune and vascular function in sepsis. Plasma concentrations of L-arginine are decreased after trauma or surgery but have been variably reported to be normal or decreased in patients with sepsis.

METHODS

We searched MEDLINE and Embase from database inception until January 2010 for the MESH terms "arginine," "amino acids," and "sepsis" and reviewed all studies that reported plasma arginine concentrations in humans with sepsis. Studies were grouped according to the presence or absence of trauma and surgery. We performed a pooled quantitative analysis on the subset of studies that reported appropriate data.

RESULTS

We identified 285 citations, of which 16 met inclusion criteria and 10 were included in the quantitative analysis. Plasma arginine concentration was lower in sepsis patients compared with concurrent or historical controls in three of four studies of surgical sepsis, one of four of sepsis after trauma, and all eight studies of predominantly medical sepsis. In the quantitative analysis, mean plasma L-arginine concentration was 33.9 μmol/L (95% confidence interval, 41.2-26.6) lower in sepsis patients than in concurrent nonseptic controls (p < .001), which is a relative decrease of 41%.

CONCLUSION

Plasma concentrations of plasma L-arginine are substantially decreased in patients with sepsis in the absence of trauma or surgery. There are not enough studies of sufficient quality to determine whether this is also the case for trauma-associated or surgery-associated sepsis.

Efficacy and safety of Privigen, a novel liquid intravenous immunoglobulin formulation, in adolescent and adult patients with chronic immune thrombocytopenic purpura

Intravenous immunoglobulin (IVIG) has become a mainstay of treatment for acute and chronic immune thrombocytopenic purpura (ITP). The efficacy and safety of Privigen, a new, ready-to-use, 10% liquid human IgG formulation, was evaluated in this open-label, multicentre study. Privigen infusions (1 g/kg per day for 2 consecutive days, days 1 and 2) were given to 57 adolescent and adult patients with chronic ITP and platelet counts < or =20 x 10(9)/l. By day 7, 80.7% of patients (95% CI, 69.2, 89.3) achieved platelet counts of > or =50 x 10(9)/l. Correspondingly, haemorrhage number and severity were significantly reduced. Adverse events were generally mild or moderate and typical of underlying disease and IVIG treatment. Privigen was well tolerated - 104 of 114 infusions were performed at the maximum permitted infusion rate (4 mg/kg/min). Thus, in patients with chronic ITP, a two-day regimen of Privigen was effective in increasing platelet count, reducing bleeding events and was well tolerated.

Sepsis-associated microvascular dysfunction measured by peripheral arterial tonometry: an observational study

Introduction

Sepsis has a high mortality despite advances in management. Microcirculatory and endothelial dysfunction contribute to organ failure, and better tools are needed to assess microcirculatory responses to adjunctive therapies. We hypothesised that peripheral arterial tonometry (PAT), a novel user-independent measure of endothelium-dependent microvascular reactivity, would be impaired in proportion to sepsis severity and related to endothelial activation and plasma arginine concentrations.

Methods

Observational cohort study in a 350-bed teaching hospital in tropical Australia. Bedside microvascular reactivity was measured in 85 adults with sepsis and 45 controls at baseline and 2-4 days later by peripheral arterial tonometry. Microvascular reactivity was related to measures of disease severity, plasma concentrations of L-arginine (the substrate for nitric oxide synthase), and biomarkers of endothelial activation.

Results

Baseline reactive hyperaemia index (RH-PAT index), measuring endothelium-dependent microvascular reactivity; (mean [95% CI]) was lowest in severe sepsis (1.57 [1.43-1.70]), intermediate in sepsis without organ failure (1.85 [1.67-2.03]) and highest in controls (2.05 [1.91-2.19]); P < 0.00001. Independent predictors of baseline RH-PAT index in sepsis were APACHE II score and mean arterial pressure, but not plasma L-arginine or markers of endothelial activation. Low baseline RH-PAT index was significantly correlated with an increase in SOFA score over the first 2-4 days (r = -0.37, P = 0.02).

Conclusions

Endothelium-dependent microvascular reactivity is impaired in proportion to sepsis severity and suggests decreased endothelial nitric oxide bioavailability in sepsis. Peripheral arterial tonometry may have a role as a user-independent method of monitoring responses to novel adjunctive therapies targeting endothelial dysfunction in sepsis.

Arginine, citrulline and nitric oxide metabolism in sepsis

Arginine has vasodilatory effects, via its conversion by NO synthase into NO, and immunomodulatory actions which play important roles in sepsis. Protein breakdown affects arginine availability and the release of asymmetric dimethylarginine, an inhibitor of NO synthase, may therefore affect NO synthesis in patients with sepsis. The objective of the present study was to investigate whole-body in vivo arginine and citrulline metabolism and NO synthesis rates, and their relationship to protein breakdown in patients with sepsis or septic shock and in healthy volunteers. Endogenous leucine flux, an index of whole-body protein breakdown rate, was measured in 13 critically ill patients with sepsis or septic shock and seven healthy controls using an intravenous infusion of [1-13C]leucine. Arginine flux, citrulline flux and the rate of conversion of arginine into citrulline (an index of NO synthesis) were measured with intravenous infusions of [15N2]guanidino-arginine and [5,5-2H2]citrulline. Plasma concentrations of nitrite plus nitrate, arginine, citrulline and asymmetric dimethylarginine were measured. Compared with controls, patients had a higher leucine flux and higher NO metabolites, but arginine flux, plasma asymmetric dimethylarginine concentration and the rate of NO synthesis were not different. Citrulline flux and plasma arginine and citrulline were lower in patients than in controls. Arginine production was positively correlated with the protein breakdown rate. Whole-body arginine production and NO synthesis were similar in patients with sepsis and septic shock and healthy controls. Despite increased proteolysis in sepsis, there is a decreased arginine plasma concentration, suggesting inadequate de novo synthesis secondary to decreased citrulline production.

Reduced citrulline production in sepsis is related to diminished de novo arginine and nitric oxide production

BACKGROUND

L-Arginine is an important precursor of nitric oxide (NO) and protein synthesis. Arginine is produced in the body (mainly kidney) by de novo production from citrulline and by protein breakdown. Arginine availability appears to be limited in sepsis.

OBJECTIVE

The objective was to compare arginine and citrulline metabolism in septic patients and nonseptic control patients in an intensive care unit (ICU) and in healthy control subjects.

DESIGN

Ten patients with septic shock, 7 critically ill control patients, and 16 healthy elderly subjects were studied. Metabolism was measured by using a primed continuous (2 h) stable-isotope infusion protocol. NO production was calculated as the conversion rate of arginine to citrulline; de novo arginine production was calculated as the conversion rate of citrulline to arginine. Arterial blood (arterialized venous blood in healthy subjects) was collected for the measurement of amino acid enrichment and concentrations. Data are reported as means +/- SDs.

RESULTS

Whole-body citrulline production was significantly lower in septic patients (4.5 +/- 2.1 micromol . kg(-1) . h(-1)) than in ICU control patients (10.1 +/- 2.9 micromol . kg(-1) . h(-1); P < 0.01) and in healthy control subjects (13.7 +/- 4.1 micromol . kg(-1) . h(-1); P < 0.001). Accordingly, de novo arginine production was lower in patients with sepsis (3.3 +/- 3.7 micromol . kg(-1) . h(-1)) than in healthy controls (11.9 +/- 6.6 micromol . kg(-1) . h(-1); P < 0.01) and tended to be lower in septic patients than in ICU control patients (10.9 +/- 9.4 micromol . kg(-1) . h(-1); P = 0.05). NO production was lower in septic patients than in healthy control subjects (P < 0.01), whereas a larger part of arginine was converted to urea in sepsis.

CONCLUSIONS

Citrulline production is severely low in patients with sepsis and is related to diminished de novo arginine and NO production. These metabolic alterations contribute to reduced citrulline and arginine availability, and these findings warrant further studies of therapeutic nutritional interventions to restore arginine metabolism in sepsis.

Methionine metabolism in an animal model of sepsis

BACKGROUND

Sepsis is a disease with high incidence and lethality and is accompanied by profound metabolic disturbances. In mammalian methionine metabolism, S-adenosylmethionine (SAM) is produced, which is important in the synthesis of neurotransmitters and glutathione and as an anti-inflammatory agent. The degradation product and antagonist of SAM is S-adenosylhomocysteine (SAH). In this study, we investigated changes in methionine metabolism in a rodent model of sepsis.

METHODS

Sepsis was induced in male Wistar rats (n=21) by intraperitoneal injection of bacterial lipopolysaccharide (10 mg/kg). Controls (n=18) received vehicle only. Blood was collected by cardiac puncture 24 h later. Puncture of the suboccipital fossa was performed to collect cerebrospinal fluid (CSF). Methionine metabolites were measured using stable isotope dilution tandem mass spectrometry. Plasma total homocysteine and cysteine were measured by HPLC using fluorescence detection. Glutathione was assayed using a modified enzymatic microtiter plate assay.

RESULTS

We observed significantly higher plasma levels of SAM (p<0.001) and SAM/SAH ratio (p=0.004) in septic animals. In CSF, there was also a trend for higher levels of SAM in septic animals (p=0.067). Oxidative stress was reflected by an increase in the ratio of oxidized/reduced glutathione in septic animals (p=0.001).

CONCLUSIONS

Sepsis is associated with an increase in SAM/SAH ratio in plasma and CSF in rodents. This indicates an altered methylation potential during sepsis, which may be relevant for sepsis-associated impairment of transmethylation reactions, circulation and defense against oxidative stress. If verified in humans, such findings could lead to novel strategies for supportive treatment of sepsis, as methionine metabolism can easily be manipulated by dietary strategies.

Safety and efficacy of Privigen, a novel 10% liquid immunoglobulin preparation for intravenous use, in patients with primary immunodeficiencies

PURPOSE

The present study was designed to evaluate the efficacy and safety of a novel, 10% liquid formulation of intravenous immunoglobulin, stabilized with 250 mmol/L L-proline (Privigen), in patients with primary immunodeficiency disease.

MATERIALS AND METHODS

Eighty adults and children diagnosed with common variable immunodeficiency or X-linked agammaglobulinemia received intravenous Privigen infusions (200-888 mg/kg) at 3- or 4-week intervals over a 12-month period, according to their previously established maintenance dose. The primary endpoint was the annual rate of acute serious bacterial infections.

RESULTS

There were six episodes of acute serious bacterial infections, corresponding to an annual rate of 0.08; the annual rate for all infections was 3.55. Mean serum IgG trough levels were between 8.84 and 10.27 g/L. A total of 1,038 infusions were administered, most of them at the maximum rate permitted (8.0 mg kg(-1) min(-1)). Temporally associated adverse events, possibly or probably related to study drug, occurred in 9% of infusions, either during or within 72 h after infusion end.

CONCLUSION

Privigen is well tolerated and effective for the treatment of primary immunodeficiency.

Exogenous arginine in sepsis

Sepsis is a severe condition in critically ill patients and is considered an arginine deficiency state. The rationale for arginine deficiency in sepsis is mainly based on the reduced arginine levels in sepsis that are associated with the specific changes in arginine metabolism related to endothelial dysfunction, severe catabolism, and worse outcome. Exogenous arginine supplementation in sepsis shows controversial results with only limited data in humans and variable results in animal models of sepsis. Since in these studies the severity of sepsis varies but also the route, timing, and dose of arginine, it is difficult to draw a definitive conclusion for sepsis in general without considering the influence of these factors. Enhanced nitric oxide production in sepsis is related to suggested detrimental effects on hemodynamic instability and enhanced oxidative stress. Potential mechanisms for beneficial effects of exogenous arginine in sepsis include enhanced (protein) metabolism, improved microcirculation and organ function, effects on immune function and antibacterial effects, improved gut function, and an antioxidant role of arginine. We recently performed a study indicating that arginine can be given to septic patients without major effects on hemodynamics, suggesting that more studies can be conducted on the effects of arginine supplementation in septic patients.

Amino acids augment muscle protein synthesis in neonatal pigs during acute endotoxemia by stimulating mTOR-dependent translation initiation

In skeletal muscle of adults, sepsis reduces protein synthesis by depressing translation initiation and induces resistance to branched-chain amino acid stimulation. Normal neonates maintain a high basal muscle protein synthesis rate that is sensitive to amino acid stimulation. In the present study, we determined the effect of amino acids on protein synthesis in skeletal muscle and other tissues in septic neonates. Overnight-fasted neonatal pigs were infused with endotoxin (LPS, 0 and 10 microg.kg(-1).h(-1)), whereas glucose and insulin were maintained at fasting levels; amino acids were clamped at fasting or fed levels. In the presence of fasting insulin and amino acids, LPS reduced protein synthesis in longissimus dorsi (LD) and gastrocnemius muscles and increased protein synthesis in the diaphragm, but had no effect in masseter and heart muscles. Increasing amino acids to fed levels accelerated muscle protein synthesis in LD, gastrocnemius, masseter, and diaphragm. LPS stimulated protein synthesis in liver, lung, spleen, pancreas, and kidney in fasted animals. Raising amino acids to fed levels increased protein synthesis in liver of controls, but not LPS-treated animals. The increase in muscle protein synthesis in response to amino acids was associated with increased mTOR, 4E-BP1, and S6K1 phosphorylation and eIF4G-eIF4E association in control and LPS-infused animals. These findings suggest that amino acids stimulate skeletal muscle protein synthesis during acute endotoxemia via mTOR-dependent ribosomal assembly despite reduced basal protein synthesis rates in neonatal pigs. However, provision of amino acids does not further enhance the LPS-induced increase in liver protein synthesis.

Biomarkers of arginine and lysine excess

Arginine supplementation is used in several disease states. In arginine-deficient states, supplementation is a logical choice of therapy. However, the definition of an arginine-deficient state is complex. For example, plasma arginine levels could be within normal range but intracellular arginine levels could be reduced because of membrane transport problems. Lysine competes with arginine for transport into the cell. In these situations, arginine supplementation of higher than required levels is proposed. Arginine has several important functions in metabolism as it is a precursor of metabolically active components such as nitric oxide (NO), ornithine, creatine, and polyamines. Supplementing arginine in excess could potentially overstimulate metabolism via enhanced production of NO. NO is a reactive component that, via production of radicals, will inactivate proteins. NO is also a powerful vasodilator, which could lead to severe hemodynamic instability. A good marker for excess supplementation of arginine or lysine could be an increased or reduced production rate of NO. However, NO production is difficult to measure because NO is a very labile component and is rapidly oxidized in blood. Stable isotope-labeled arginine and citrulline are used to trace the arginine-NO route. During supplementation of arginine in septic pigs or patients in septic shock, NO production, measured with stable isotope technology, is enhanced.

High-dose amino acid infusion preserves diuresis and improves nitrogen balance in non-oliguric acute renal failure

INTRODUCTION

The effects of protein-enriched diets on glomerular filtration have been described in normal subjects and in patients with chronic renal failure. In acute renal failure, the effects of administration of high rates of protein on renal function and nitrogen balance have not been studied in critically ill patients. The present study examines the effects of large doses of amino acids on the glomerular filtration rate and nitrogen balance in critically ill patients with acute renal failure.

METHODS

Fourteen critically ill patients with a creatinine clearance below 50 ml/min and conserved diuresis above 2,000 ml/day received 2000 non-protein kcal/day and either 75 g (Group 1) or 150 g (Group 2) of amino acids parenterally. Renal function tests, fluid balance, sodium and nitrogen balances, and furosemide administration were assessed on day 1 (baseline day when dextrose 5% was administered) and days 2, 3 and 4.

RESULTS

The two groups were comparable in terms of severity indices, sex and creatinine clearance. Group 2 was significantly older (p < 0.05). Blood urea nitrogen increased significantly in Group 1 but not in Group 2; creatinine clearance remained unchanged in the two groups. Group 2 patients had a significantly more positive cumulative nitrogen balance (-10.5 +/- 17 g/day vs. 9 +/- 8.3 g/day) (p < 0.01), less positive fluid balance (2003 +/- 1336 ml vs. -2407 +/- 1990 ml) and lower furosemide requirement (1003 +/- 288 mg vs. 649 +/- 293 mg) (p < 0.05).

CONCLUSION

A high amino acid regimen administered as a part of parenteral nutrition improves nitrogen balance, reduces furosemide requirements and ameliorates water balance in acute renal failure patients with conserved diuresis.

Elevated plasma phenylalanine in severe malaria and implications for pathophysiology of neurological complications

Cerebral malaria is associated with decreased production of nitric oxide and decreased levels of its precursor, l-arginine. Abnormal amino acid metabolism may thus be an important factor in malaria pathogenesis. We sought to determine if other amino acid abnormalities are associated with disease severity in falciparum malaria. Subjects were enrolled in Dar es Salaam, Tanzania (children) (n = 126), and Papua, Indonesia (adults) (n = 156), in two separate studies. Plasma samples were collected from subjects with WHO-defined cerebral malaria (children), all forms of severe malaria (adults), and uncomplicated malaria (children and adults). Healthy children and adults without fever or illness served as controls. Plasma amino acids were measured using reverse-phase high-performance liquid chromatography with fluorescence detection. Several plasma amino acids were significantly lower in the clinical malaria groups than in healthy controls. Despite the differences, phenylalanine was the only amino acid with mean levels outside the normal range (40 to 84 microM) and was markedly elevated in children with cerebral malaria (median [95% confidence interval], 163 [134 to 193] microM; P < 0.0001) and adults with all forms of severe malaria (median [95% confidence interval], 129 [111 to 155] microM; P < 0.0001). In adults who survived severe malaria, phenylalanine levels returned to normal, with clinical improvement (P = 0.0002). Maintenance of plasma phenylalanine homeostasis is disrupted in severe malaria, leading to significant hyperphenylalaninemia. This is likely a result of an acquired abnormality in the function of the liver enzyme phenylalanine hydroxylase. Determination of the mechanism of this abnormality may contribute to the understanding of neurological complications in malaria.

Relationship of taurine and other amino acids in plasma and in neutrophils of septic trauma patients

Recently, an interdependency of plasma taurine and other amino acids as well as metabolic and clinical variables implicating therapeutic options was reported. This result may be an indication that plasma taurine levels are directly related to intracellular levels. Therefore, the aim of this study was to analyse the possible relationship between taurine levels in plasma and in neutrophils, the relationship to other amino acids, and variables quantifying metabolic impairment and severity of sepsis in multiple trauma patients developing sepsis. After multiple trauma taurine decreased significantly in plasma in thirty-two patients as well as within the neutrophil and does not recover in sepsis. Lower individual levels in the neutrophil did not follow lower individual levels in plasma and no correlation of taurine in plasma and in the neutrophils could be observed. In sepsis, only plasma showed an interdependency of taurine, aspartate, and glutamate. No association between taurine plasma or intracellular levels and SOFA score as indicator for severity of sepsis or metabolic variables was observed. After multiple trauma and in sepsis, taurine uptake in cells (which is regulated in different ways), and intracellular taurine (which serves e.g. as an osmolyte) can be influenced. Therefore a prediction of the neutrophil taurine pool seems not fully possible from taurine plasma levels. Intracellular taurine has some unique properties explaining the missing interdependency despite some similarities in osmoregulation and metabolic interactions to other amino acids. The association of taurine, aspartate, and glutamate in plasma cannot be simply transferred to the neutrophils intracellular level. The clinical meaning of the plasma correlation remains unclear. A dependency of plasma and neutrophil taurine to severity of sepsis and to metabolic variables seems not possible because of the multifactorial pathophysiology of sepsis.

Potentiation by amino acid of the therapeutic effect of highly purified vitamin B2 in mice with lipopolysaccharide-induced shock

The aim of this experiment was to clarify whether an amino acid supplement could enhance the therapeutic effect of vitamin B2 (riboflavin 5'-sodium phosphate; purity > 97%) in mice with lipopolysaccharide-induced shock. Six hours after injection of a lethal dose of lipopolysaccharide, treatment (6-h i.v. infusion) was commenced. All mice died in the groups treated with saline or aminolevane (an amino acids mixture used to treat hepatopathy); however, the survival rates in the vitamin B2 (10 mg/kg/6 h) and vitamin B2 plus aminolevane groups were 45% (P < 0.05) and 80% (P < 0.05), respectively. Valine (200 mg/kg/6 h) alone had little effect on the survival rate (10%), but the combination of vitamin B2 (10 mg/k/g/6 h) and valine was highly effective (80%, P < 0.05). Clinical trials of vitamin B2 plus amino acids for the treatment of patients with sepsis would appear to be warranted.

Time course of nitric oxide production after endotoxin challenge in mice

Nitric oxide (NO) regulates numerous processes during endotoxemia and inflammation. However, the sequential changes in whole body (Wb) nitric oxide (NO) production during endotoxemia in vivo remain to be clarified. Male Swiss mice were injected intraperitoneally with saline (control group) or lipopolysaccharide (LPS group). After 0, 2, 4, 6, 9, 12, and 24 h, animals received a primed constant infusion of L-[guanidino-(15)N(2)-(2)H(2)]arginine, L-[ureido-(15)N]citrulline, L-[5-(15)N]glutamine, and L-[ring-(2)H(5)]phenylalanine in the jugular vein. Arterial blood was collected for plasma arginine (Arg), citrulline (Cit), glutamine (Gln), and phenylalanine (Phe) concentrations and tracer-to-tracee ratios. NO production was calculated as plasma Arg-to-Cit flux, Wb de novo Arg synthesis as plasma Cit-to-Arg flux, and Wb protein breakdown as plasma Phe flux. LPS reduced plasma Arg and Cit and increased Gln and Phe concentrations. Two peaks of NO production were observed at 4 and 12 h after LPS. Although LPS did not affect total Arg production, de novo Arg production decreased after 12 h. The second peak of NO production coincided with increased Wb Cit, Gln, and Phe production. In conclusion, the curve of NO production in both early and late phases of endotoxemia is not related to plasma Arg kinetics. However, because Wb Cit, Gln, and Phe fluxes increased concomitantly with the second peak of NO production, NO production is probably related to the catabolic phase of endotoxemia.

Malnutrition, infection, and sepsis in acute and chronic illness

Optimal nutritional status contributes to health maintenance and the prevention of infection. The function of healthy cells is maintained by the provision of adequate nutrition. When nutrient availability is disrupted, primary and secondary malnutrition develop. Malnutrition contributes to a cascade of adverse metabolic events that compromise the immune system and impair the body's ability to adapt, recover, and survive. Malnutrition is treated by the early delivery of essential nutrients in an effective and comprehensive manner. Nurses are challenged to understand the importance of adequate nutritional support in the prevention of infection, multiple organ failure, and sepsis.

Effects of sorbent suspension dialysis on plasma amino acid levels in cirrhotic patients with refractory hepatic encephalopathy

In cirrhotic patients, plasma amino acid levels are severely deranged. A decreased ratio of branched-chain to aromatic amino acids (Fischer ratio) has been implicated in the pathogenesis of hepatic encephalopathy. In this prospective study, we investigated the effects of extracorporeal detoxification on amino acid levels using a sorbent suspension dialysis system. Twenty patients with documented cirrhosis and hepatic encephalopathy grade II-III not responding to standard treatment were randomized to receive either six hours of sorbent dialysis and standardized conventional medical treatment or ongoing medical treatment alone. In contrast to previous uncontrolled studies, no significant effect on amino acid levels, Fischer ratio or clinical grade of hepatic encephalopathy was detected in either treatment group. In conclusion, a 6-hour treatment with sorbent dialysis did not significantly influence plasma levels of amino acids and did not ameliorate the clinical grade of hepatic encephalopathy.