Determinants of ureagenesis, with particular reference to renal failure

Inhibition of urease-mediated ammonia production by 2-octynohydroxamic acid in hepatic encephalopathy

Hepatic encephalopathy is a neuropsychiatric complication of liver disease which is partly associated with elevated ammonemia. Urea hydrolysis by urease-producing bacteria in the colon is often mentioned as one of the main routes of ammonia production in the body, yet research on treatments targeting bacterial ureases in hepatic encephalopathy is limited. Herein we report a hydroxamate-based urease inhibitor, 2-octynohydroxamic acid, exhibiting improved in vitro potency compared to hydroxamic acids that were previously investigated for hepatic encephalopathy. 2-octynohydroxamic acid shows low cytotoxic and mutagenic potential within a micromolar concentration range as well as reduces ammonemia in rodent models of liver disease. Furthermore, 2-octynohydroxamic acid treatment decreases cerebellar glutamine, a product of ammonia metabolism, in male bile duct ligated rats. A prototype colonic formulation enables reduced systemic exposure to 2-octynohydroxamic acid in male dogs. Overall, this work suggests that urease inhibitors delivered to the colon by means of colonic formulations represent a prospective approach for the treatment of hepatic encephalopathy.

Overview of Antibiotic-Induced Nephrotoxicity

Drug-induced nephrotoxicity accounts for up to 60% of cases of acute kidney injury (AKI) in hospitalized patients and is associated with increased morbidity and mortality in both adults and children. Antibiotics are one of the most common causes of drug-induced nephrotoxicity. Mechanisms of antibiotic-induced nephrotoxicity include glomerular injury, tubular injury or dysfunction, distal tubular obstruction from casts, and acute interstitial nephritis (AIN) mediated by a type IV (delayed-type) hypersensitivity response. Clinical manifestations of antibiotic-induced nephrotoxicity include acute tubular necrosis (ATN), AIN, and Fanconi syndrome. Given the potential nephrotoxic effects of antibiotics on critically ill patients, the use of novel biomarkers can provide information to optimize dosing and duration of treatment and can help prevent nephrotoxicity when traditional markers, such as creatinine, are unreliable. Use of novel kidney specific biomarkers, such as cystatin C and urinary kidney injury molecule-1 (KIM-1), may result in earlier detection of AKI, dose adjustment, or discontinuation of antibiotic and development of nonnephrotoxic antibiotics.

Does Monitoring Total and Free Polymyxin B1 Plasma Concentrations Predict Polymyxin B-Induced Nephrotoxicity? A Retrospective Study in Critically Ill Patients

INTRODUCTION

The correlation between total and free polymyxin B (PMB including PMB1 and PMB2) exposure in vivo and acute kidney injury (AKI) remains obscure. This study explores the relationships between plasma exposure of PMB1 and PMB2 and nephrotoxicity, and investigates the risk factors for PMB-induced acute kidney injury (AKI) in critically ill patients.

METHODS

Critically ill patients who used PMB and met the criteria were enrolled. The total plasma concentration and plasma binding of PMB1 and PMB2 were analysed by liquid chromatography-tandem mass spectrometry and equilibrium dialysis.

RESULTS

A total of 89 patients were finally included, and AKI developed in 28.1% of them. The peak concentration of PMB1 (C_max (B1)) (adjusted odds ratio (AOR) = 1.68, 95% CI 1.08-2.62, p = 0.023), baseline BUN level (AOR = 1.08, 95% CI 1.01-1.16, p = 0.039) and hypertension (AOR = 3.73, 95% CI 1.21-11.54, p = 0.022) were independent risk factors for PMB-induced AKI. The area under the ROC curve of the model was 0.799. When C_max (B1) was 5.23 μg/ml or more, the probability of AKI was higher than 50%. The ratio of PMB1/PMB2 decreased after PMB preparation entered into the body. The protein binding rate in critically ill patients indicated significant individual differences. Free C_max (B) and free C_max (B1) levels in the AKI group were significantly (p < 0.05) higher than those in the non-AKI group. Total and free concentrations of PMB in patients showed a positive correlation.

CONCLUSIONS

Both the ROC curve and logistic regression model showed that C_max (B1) was a good predictor for the probability of PMB-induced AKI. Early therapeutic drug monitoring (TDM) of PMB should be considered in critically ill patients. Compared with C_min (B), C_max (B) and C_max (B1) may be helpful for the early prediction of PMB-induced AKI in critically ill patients.

Effects of blood urea nitrogen independent of the estimated glomerular filtration rate on the development of anemia in non-dialysis chronic kidney disease: The results of the KNOW-CKD study

BACKGROUND

Anemia is a common complication of chronic kidney disease (CKD). Blood urea nitrogen (BUN) in CKD represents nitrogenous uremic toxin accumulation which could be involved in anemia of CKD. We investigated the effects of BUN independent of estimated glomerular filtration rate (eGFR) on anemia in non-dialysis CKD (NDCKD).

METHODS

This prospective study included 2,196 subjects enrolled in the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD) cohort with BUN and hemoglobin level data. Initially, we investigated the association between BUN and hemoglobin level. To examine the impact of baseline BUN on the incident anemia, a longitudinal study was performed on 1,169 patients without anemia at study enrollment. BUN residuals were obtained from the fitted curve between BUN and eGFR. Anemia was defined as a hemoglobin level of <13.0 g/dL for men and <12.0 g/dL for women.

RESULTS

BUN residuals were not related to eGFR but to daily protein intake (DPI), while BUN was related to both eGFR and DPI. BUN was inversely associated with hemoglobin level (β -0.03; 95% confidence interval [CI] -0.04, -0.03; P <0.001) in the multivariable linear regression analysis adjusted for multiple confounders including eGFR, and BUN residual used instead of BUN was also inversely associated with hemoglobin level (β -0.03; 95% CI -0.04, -0.02; P <0.001). Among the 1,169 subjects without anemia at baseline, 414 (35.4%) subjects newly developed anemia during the follow-up period of 37.5 ± 22.1 months. In the multivariable Cox regression analysis with adjustment, both high BUN level (Hazard ratio [HR] 1.02; 95% CI 1.01, 1.04; P = 0.002) and BUN residual used instead of BUN (HR 1.02; 95% CI 1.00, 1.04; P = 0.031) increased the risk of anemia development. Moreover, BUN, rather than eGFR, increased the risk of anemia development in patients with CKD stage 3 in the multivariable Cox regression.

CONCLUSION

Higher BUN levels derived from inappropriately high protein intake relative to renal function were associated with low hemoglobin levels and the increased risk of anemia independent of eGFR in NDCKD patients.

A Quantitative Approach to the CAPD Prescription

The CAPD prescription, expressed as daily drainage volume, can be formulated as a function of the recommended dietary protein intake and the average BUN level. This process is greatly simplified because urea nitrogen reaches a state of equilibrium on CAPD. The ratio of the actual drainage volume to this prescribed drainage volume -a dialysis index (Dl), reflects the fraction of urea nitrogen clearance achieved. Used with the average BUN level, the dialysis index provides an estimate of the protein catabolic rate (PCR), in gm/kg/day. When integrated these three factors -BUN, Dl and PCR, can be applied to optimize diet and dialysis and may provide a basis for comparing treatment results between patients and between centers.

As continuous ambulatory peritoneal dialysis (CAPD) approaches its ninth anniversary, it continues to grow and to enjoy wide acceptance. Only a small minority continue to question its role in the care of end-stage renal disease patients. However, they ask fundamental questions which deserve our attention. Why is rate of hospitalization higher -peritonitis and access-related difficulties are only partially responsible (I). Does this technique's low urea nitrogen clearance provide adequate dialysis? Why do nearly 30% of patients leave CAPD programs within one year (2)? Are some CAPD patients under-dialyzed or malnourished? After nearly a decade of experience we have not answered these nagging questions and perhaps they cannot be answered. However, it is clear that they cannot be avoided. As Huxley cautioned, “Facts do not cease to exist because they are ignored.” An objective analysis of these issues raises the fundamental question, namely, the adequacy of dialysis -and adequacy compared to what?

Biomarkers of Drug-Induced Kidney Toxicity

Blood urea nitrogen and serum creatinine are imperfect markers of kidney function because they are influenced by many renal and nonrenal factors independent of kidney function. A biomarker that is released directly into the blood or urine by the kidney in response to injury may be a better early marker of drug-induced kidney toxicity than blood urea nitrogen and serum creatinine. Urine albumin and urine protein, as well as urinary markers kidney injury molecule-1 (KIM-1), β2-microglobulin (B2M), cystatin C, clusterin, and trefoil factor-3 (TFF-3) have been accepted by the Food and Drug Administration and European Medicines Agency as highly sensitive and specific urinary biomarkers to monitor drug-induced kidney injury in preclinical studies and on a case-by-case basis in clinical trials. Other biomarkers of drug-induced kidney toxicity that have been detected in the urine of rodents or patients include IL-18, neutrophil gelatinase-associated lipocalin, netrin-1, liver-type fatty acid-binding protein (L-FABP), urinary exosomes, and TIMP2 (insulin-like growth factor-binding protein 7)/IGFBP7 (insulin-like growth factor-binding protein 7), also known as NephroCheck, the first Food and Drug Administration-approved biomarker testing platform to detect acute kidney injury in patients. In the future, a combined use of functional and damage markers may advance the field of biomarkers of drug-induced kidney toxicity. Earlier detection of drug-induced kidney toxicity with a kidney-specific biomarker may result in the avoidance of nephrotoxic agents in clinical studies and may allow for earlier intervention to repair damaged kidneys.

Measurement and Estimation of Residual Kidney Function in Patients on Dialysis

Residual kidney function (RKF) in patients on dialysis is strongly associated with survival and better quality of life. Assessment of kidney function underlies the management of patients with chronic kidney disease before dialysis initiation. However, methods to assess RKF after dialysis initiation are just now being refined. In this review, we discuss the definition of RKF and methods for measurement and estimation of RKF, highlighting the unique aspects of dialysis that impact these assessments.

Urea and Ammonia Metabolism and the Control of Renal Nitrogen Excretion

Renal nitrogen metabolism primarily involves urea and ammonia metabolism, and is essential to normal health. Urea is the largest circulating pool of nitrogen, excluding nitrogen in circulating proteins, and its production changes in parallel to the degradation of dietary and endogenous proteins. In addition to serving as a way to excrete nitrogen, urea transport, mediated through specific urea transport proteins, mediates a central role in the urine concentrating mechanism. Renal ammonia excretion, although often considered only in the context of acid-base homeostasis, accounts for approximately 10% of total renal nitrogen excretion under basal conditions, but can increase substantially in a variety of clinical conditions. Because renal ammonia metabolism requires intrarenal ammoniagenesis from glutamine, changes in factors regulating renal ammonia metabolism can have important effects on glutamine in addition to nitrogen balance. This review covers aspects of protein metabolism and the control of the two major molecules involved in renal nitrogen excretion: urea and ammonia. Both urea and ammonia transport can be altered by glucocorticoids and hypokalemia, two conditions that also affect protein metabolism. Clinical conditions associated with altered urine concentrating ability or water homeostasis can result in changes in urea excretion and urea transporters. Clinical conditions associated with altered ammonia excretion can have important effects on nitrogen balance.

The Saga of Two Centuries of Urea: Nontoxic Toxin or Vice Versa?

In the early 1700s, a substance ultimately identified as urea was reported for the first time in urine. About a century later, in 1828, synthesis of this organic compound was achieved, thus giving rise to modern organic chemistry. In parallel, physicians showed that urine comes from the kidneys and contains large amounts of urea, which is produced outside of the kidneys, establishing the humoral approach of renal physiology. Urea was the first uremic retention solute to be identified and it has been used as a marker of renal disease ever since. However, progress in the knowledge of urea metabolism has shown that it is susceptible to many extrarenal variations and, therefore, it cannot be a reliable marker of renal function. It reflects protein intake in the stable patient and has been used to assess nutrition and dialysis efficacy in renal patients. Although it has been studied for almost 200 years, its toxicity has been largely debated. An indirect toxicity occurring through carbamylation of lysine residues is now well established and some evidence from recent work also supports direct toxicity of urea, offering additional rationale for interventional prevention of uremic complications.

Biomarkers of acute kidney injury

The diagnosis of acute kidney injury (AKI) is usually based on measurements of blood urea nitrogen (BUN) and serum creatinine. BUN and serum creatinine are not very sensitive or specific for the diagnosis of AKI because they are affected by many renal and nonrenal factors that are independent of kidney injury or kidney function. Biomarkers of AKI that are made predominantly by the injured kidney have been discovered in preclinical studies. In clinical studies of patients with AKI, some of these biomarkers (eg, interleukin-18, neutrophil gelatinase-associated lipocalin, and kidney injury molecule-1) have been shown to increase in the urine before the increase in serum creatinine. These early biomarkers of AKI are being tested in different types of AKI and in larger clinical studies. Biomarkers of AKI may also predict long-term kidney outcomes and mortality.

In Vitro and In Vivo Assessment of Intraintestinal Bacteriotherapy in Chronic Kidney Disease

Chronic kidney disease may progress to end-stage renal disease, which requires dialysis or kidney transplantation. No generally applicable therapies to slow progression of renal disease are available. Bacteriotherapy affords a promising approach to mitigate uremic intoxication by ingestion of live microbes able to catabolize uremic solutes in the gut. The present study evaluates the nonpathogenic soil-borne alkalophilic urease-positive bacterium Sporosarcina pasteurii (Sp) as a potential urea-targeted component for such "enteric dialysis" formulation. Data presented herein suggest that Sp survives through exposure to gastric juice retaining the ability to hydrolyze urea. In vitro, 10 cfu (colony forming units) of Sp removed from 21 +/- 4.7 mg to 228 +/- 6.7 mg urea per hour, depending on pH, urea concentration, and nutrient availability. Beneficial effects of Sp on fermentation parameters in the intestine were demonstrated in vitro in the Simulator of the Human Intestinal Microbial Ecosystem (SHIME) inoculated with fecal microbiota. Enumeration of marker organisms suggested that presence of Sp does not disturb microbial community of the SHIME. Additionally, a pilot study in 5/6th nephrectomized rats fed 10 cfu of live Sp daily throughout the study demonstrated that the tested regimen reduced blood urea-nitrogen levels and significantly prolonged the lifespan of uremic animals.

Sulfate production depicts fed-state adaptation to protein restriction in humans

One feature of the adaptation to dietary protein restriction is reduced urea production over the hours after consumption of a test meal of fixed composition. This adaptation is impaired in conventionally treated insulin-dependent diabetes mellitus (Hoffer LJ, Taveroff A, and Schiffrin A. Am J Physiol Endocrinol Metab 272: E59--E67, 1997). We have now tested the response to a test meal containing less protein and included as a main outcome variable the production of sulfate, a specific indicator of sulfur amino acid catabolism. Six normal men consumed a mixed test meal containing 0.25 g protein/kg and 10 kcal/kg while adapted to high (1.5 g x kg(-1) x day(-1)) and low (0.3 g. kg(-1) x day(-1)) protein intakes. They followed the identical protocol twice. Six subjects with insulin-dependent diabetes consumed the test meal while adapted to their customary high-protein diet. Adaptation to protein restriction reproducibly reduced 9-h cumulative postmeal urea N and S production by 22--29% and 49--52%, respectively (both P < 0.05). Similar results were obtained for a postmeal collection period of 6 h. The response of the diabetic subjects was normal. We conclude that reductions in postmeal urea and sulfate production after protein restriction are reproducible and are evident using a postmeal collection period as short as 6 h. Sulfate production effectively depicts fed-state adaptation to protein restriction.

Effect of protein restriction on (15)N transfer from dietary [(15)N]alanine and [(15)N]Spirulina platensis into urea

Six normal men consumed a mixed test meal while adapted to high (1.5 g. kg(-1) x day(-1)) and low (0.3 g. kg(-1) x day(-1)) protein intakes. They completed this protocol twice: when the test meals included 3 mg/kg of [(15)N]alanine ([(15)N]Ala) and when they included 30 mg/kg of intrinsically labeled [(15)N]Spirulina platensis ([(15)N]SPI). Six subjects with insulin-dependent diabetes mellitus (IDDM) receiving conventional insulin therapy consumed the test meal with added [(15)N]Ala while adapted to their customary high-protein diet. Protein restriction increased serum alanine, glycine, glutamine, and methionine concentrations and reduced those of leucine. Whether the previous diet was high or low in protein, there was a similar increase in serum alanine, methionine, and branched-chain amino acid concentrations after the test meal and a similar pattern of (15)N enrichment in serum amino acids for a given tracer. When [(15)N]Ala was included in the test meal, (15)N appeared rapidly in serum alanine and glutamine, to a minor degree in leucine and isoleucine, and not at all in other circulating amino acids. With [(15)N]SPI, there was a slow appearance of the label in all serum amino acids analyzed. Despite the different serum amino acid labeling, protein restriction reduced the postmeal transfer of dietary (15)N in [(15)N]Ala or [(15)N]SPI into [(15)N]urea by similar amounts (38 and 43%, respectively, not significant). The response of the subjects with IDDM was similar to that of the normal subjects. Information about adaptive reductions in dietary amino acid catabolism obtained by adding [(15)N]Ala to a test meal appears to be equivalent to that obtained using an intrinsically labeled protein tracer.

Arteriovenous difference of blood ammonia in uremic patients under hemodialysis

In this study the ammonia concentration was determined in arterial and venous blood samples pre- and posthemodialysis (HD) in 18 uremic patients and in 18 health subjects (controls). The mean values (+/- SD) of ammonia in the arterial blood of uremic patients pre-HD were 98.32 +/- 26.55; post-HD, 63.18 +/- 17.09; and in control group patients, 72.37 +/- 10.09 micrograms/dl. In venous blood they were pre-HD, 71.70 +/- 20.68; post-HD, 58.05 +/- 16.73; and in control patients, 74.46 +/- 12.0 micrograms/dl. According to our findings, the ammonia concentration in the arterial blood of uremic patients pre-HD exceeds the normal limits and is significantly higher (p < 0.001) than that post-HD and that of control patients. The ammonia contents of venous blood pre- and post-HD ranges were within normal values, but the post-HD range was significantly lower than the pre-HD range (p < 0.05) and the control range (p < 0.01). Comparison between ammonia levels from arterial and venous blood showed significant and positive arteriovenous differences pre-HD (p < 0.001), which disappeared post-HD and were not observed in the control patients. In conclusion, uremic patients under HD present pre-HD high levels of ammonia in arterial blood with a significantly positive arteriovenous difference. In contrast, the post-HD ammonia levels in arterial and venous blood are decreased, and the arteriovenous difference is not significant.

Urea inhibits inducible nitric oxide synthase in macrophage cell line

Macrophage dysfunction is considered an important contributory factor for increased propensity of infections in uremia. Because nitric oxide (NO) is believed to be an effector molecule of macrophage cytotoxicity, we propose that the dysfunction may be related to impaired NO synthesis. To verify this hypothesis, we evaluated macrophage NO synthesis in the presence of urea, a compound that accumulates in renal failure and is believed by some to be a uremic toxin. Macrophages (RAW 264.7 cells) were incubated with bacterial lipopolysaccharide to induce NO synthesis, whereas the test groups had various concentrations of urea in addition. NO synthesis was measured by assaying the supernatant for nitrites and nitrates by chemiluminescence. We observed that urea consistently produced a dose-dependent reversible inhibition of inducible NO production in macrophages, whereas parathormone, another toxin retained in uremia, had no such inhibitory effects. Further studies revealed that mRNA for inducible NO synthase was not inhibited by urea. We thus conclude that urea inhibits inducible NO synthesis in macrophages by a posttranscriptional mechanism and that this may be important in macrophage dysfunction of uremia.

Isolated rat hepatocyte metabolism is affected by chronic renal failure

Metabolic changes due to chronic renal failure (CRF) were studied in isolated liver cells. In 14 CRF and 14 sham-operated rats, liver cells were isolated by the Berry and Friend method and incubated with various substrates in order to study gluconeogenesis, ureagenesis, ketogenesis, oxygen consumption as well as cytosolic and mitochondrial adenine nucleotide content. CRF rat hepatocytes exhibited a 25% to 45% decrease in gluconeogenesis and ureagenesis (P < 0.05) from all the tested substrates (lactate plus pyruvate, fructose, glycerol, dihydroxyacetone, alanine and glutamine for gluconeogenesis and alanine, glutamine, ammonia and ammonia plus ornithine for ureagenesis), while endogenous rates were unaffected. CRF did not alter ketone body production (acetoacetate and beta-hydroxybutyrate) from oleate or octanoate. In the presence of either oleate, lactate plus pyruvate or ammonia, oxygen uptake as well as cytosolic and mitochondrial total adenine nucleotides were unaffected by CRF, while the mitochondrial ATP/ADP ratio decreased (P < 0.001). Thus, this study of hepatocyte intermediary metabolism during CRF showed an alteration of only gluconeogenesis and ureagenesis pathways. Moreover, the association of normal oxygen uptake together with decreased mitochondrial ATP/ADP ratio suggest a possible increase in hepatocyte ATP demand during uremia.

The Modification of Diet in Renal Disease Study: design, methods, and results from the feasibility study

The Modification of Diet in Renal Disease (MDRD) Study is a multicenter clinical trial designed to assess acceptance, safety, and efficacy of restricted protein and phosphorus diets in patients with progressive renal disease. The Feasibility Study was designed to test procedures and recruitment strategies and to estimate sample size for the Full-Scale Trial. The Feasibility Study was not designed to compare rates of progression of renal disease among diet groups. Patients aged 18 to 75 years, with a glomerular filtration rate (GFR; measured by 125I-iothalamate clearance) between 7.5 and 80 mL/min/1.73 m2, and a previous progressive increase in serum creatinine, were eligible for enrollment. Compliance with prescribed dietary protein intake was calculated from urea nitrogen appearance (UNA). Nutritional status was monitored by anthropometry and serum proteins. Progression of renal disease was calculated as the rate of decline of GFR. Ninety-six patients met all of the eligibility requirements and were randomized to study diets. Follow-up was conducted for a mean duration of 14 months (range, 2 to 22 months). Although most patients did not achieve the prescribed protein intake, marked changes in intake were observed among patients assigned to the low-protein diets, and mean estimated protein intake differed significantly among diet groups. No patients became malnourished. Mean rates of decline in GFR were relatively slow, and variability among individuals was high. As expected, the number of patients enrolled was too small to determine if the rate of decline in GFR was significantly slower among patients assigned to the restricted protein and phosphorus diets. The rate of decline in GFR was significantly inversely correlated with long-term average mean arterial blood pressure (MAP), even among patients whose blood pressure was controlled to levels within the normal range. However, because patients were not randomly assigned blood pressure goals, it was not possible to determine whether a causal relationship exists. Based on the experience gained during the Feasibility Study, the design for the Full-Scale Study includes two studies of defined by patients' baseline levels of renal function. Within each study, patients will be assigned randomly to one of two diets, and within each diet group, to one of two levels of blood pressure control. Based on variability of rates of decline in GFR slopes observed during the Feasibility Study, 800 patients with follow-up periods of up to 4 years will be required for the Full-Scale Trial.

The role of urea kinetic modeling, TACurea, and Kt/V in achieving optimal dialysis: a critical reappraisal

The National Cooperative Dialysis Study (NCDS) established the importance of the time-averaged concentration of blood urea nitrogen (BUN) (TACurea) as a determinant of morbidity among patients maintained on hemodialysis. Although urea is not itself toxic, it serves as a surrogate for those low-molecular weight products of protein catabolism that do contribute to uremic toxicity. The NCDS also reported an association between low protein catabolic rates (a measure of dietary protein intake) and increased morbidity, but the validity of this result has been questioned. On the basis of a retrospective re-analysis of the data, Gotch and Sargent have proposed following the normalized whole-body urea clearance, Kt/V, as a more fundamental index of the level of dialytic therapy. In this review, a comparison is made between these two measures of adequate dialysis, namely, midweek predialysis urea concentration and Kt/V. At least for the cellulosic membranes used in the NCDS, they seem to be equivalent. Furthermore, each prescription defines adequate nutrition as a dietary protein intake (DPI) of 1.0 g/kg/d. At this DPI, a time-averaged concentration of BUN of 17.9 mmol/L (50 mg/dL) (corresponding roughly to a midweek predialysis BUN of 21.4 to 28.6 mmol/L (60 to 80 mg/dL), as recommended by the NCDS, is equivalent to a Kt/V of 1.0, as recommended by Gotch and Sargent. Based on ease and accuracy of measurement, TACurea would seem the more reliable marker for monitoring the adequacy of dialysis. Extrapolation of the utility of TACurea and/or Kt/V to noncellulosic membranes remains to be established. Urea kinetic modeling constitutes a powerful mathematical tool for implementing these recommendations. Urea kinetic modeling may also be used as a means of monitoring DPI and thereby ensuring adequate nutrition.

Amino acid metabolism in uremia

The uremic syndrome is multifactorial, and affects most tissues and organs. Disturbances in protein and amino acid metabolism may play important roles, especially in chronic uremia, either directly or by production of toxic metabolites, with resultant negative nitrogen (N) balance, muscle wasting, reduced protein synthesis, and characteristically abnormal intracellular free amino acid concentrations. There are also grossly abnormal amino acid levels in the plasma of uremic patients, e.g., increases in conjugated amino acids, high levels of several nonessential and low levels of essential amino acids. The ratios of tyrosine/phenylalanine and of valine/glycine are decreased. The low tryptophan levels may contribute to encephalopathy as a result of an imbalance in neurotransmitter synthesis. Citrulline is found in excess; the explanation is unresolved. There are elevated concentrations of the sulfur-containing amino acids: cystine, taurine, cystathionine, and homocysteine. Excess of the latter is implicated in the atherogenesis of renal failure. Disturbed metabolism and interorgan exchange of amino acids in the uremic state explains some of the abnormalities in tissue and plasma concentrations of individual amino acids. Enzymatic defects are involved in the disturbed metabolism of branched chain amino acids (BCAA), with possible antagonism among them, which impairs growth and amino acid utilization. Carbohydrate intolerance, associated with insensitivity of peripheral tissues to insulin and hyperinsulinemia, elicits decreased plasma BCAA. Protein synthesis rates in normal and pathological conditions are more closely related to the intracellular amino acid pool than to plasma amino acid levels. Concentrations of individual amino acids in the plasma pool are poor indicators of their intracellular concentrations. Muscle contains the largest pool of protein and free amino acids in the body. In chronic renal failure patients, the intracellular concentrations of valine, threonine, lysine, and carnosine are low. With low protein diets and in hemodialysis, serine, tyrosine, and taurine often are also low. The low taurine may be related to fatigue and to uremic cardiomyopathies. The commonly used amino acid supplements generally fail to correct the intracellular amino acid deficits. A "New Formula" has been developed to correct these intracellular amino acid abnormalities, and to supplement a low protein diet. It provides more valine than leucine, increased tyrosine and threonine, and less histidine, leucine, isoleucine, lysine, methionine, and phenylalanine than in formulas customarily used for patients with chronic renal failure. It is uncertain whether other ap

Metabolic acidosis stimulates protein degradation in rat muscle by a glucocorticoid-dependent mechanism

Metabolic acidosis is associated with enhanced renal ammonia-genesis which is regulated, in part, by glucocorticoids. The interaction between glucocorticoids and chronic metabolic acidosis on nitrogen utilization and muscle protein metabolism is unknown. In rats pair-fed by gavage, we found that chronic acidosis stunted growth and caused a 43% increase in urinary nitrogen and an 87% increase in urinary corticosterone. Net protein degradation in incubated epitrochlearis muscles from chronically acidotic rats was stimulated at all concentrations of insulin from 0 to 10(4) microU/ml. This effect of acidosis persisted despite supplementation of the media with amino acids with or without insulin, indomethacin, and inhibitors of lysosomal thiol cathepsins. Acidosis did not change protein synthesis; hence, the increase in net protein degradation was caused by stimulation of proteolysis. Acidosis did not increase glutamine production in muscle. The protein catabolic effect of acidosis required glucocorticoids; protein degradation was stimulated in muscle of acidotic, adrenalectomized rats only if they were treated with dexamethasone. Moreover, when nonacidotic animals were given 3 micrograms/100 g of body weight dexamethasone twice a day, muscle protein degradation was increased if the muscles were simply incubated in acidified media. We conclude that chronic metabolic acidosis depresses nitrogen utilization and increases glucocorticoid production. The combination of increased glucocorticoids and acidosis stimulates muscle proteolysis but does not affect protein synthesis. These changes in muscle protein metabolism may play a role in the defense against acidosis by providing amino acid nitrogen to support the glutamine production necessary for renal ammoniagenesis.

Investigation of protein metabolism with respect to amino acid administration

A comparative study of the protein metabolism of two groups of patients having suffered major trauma (group I, n = 26, and group II, n = 16) and of two groups having undergone major surgery (group III, n = 10, and group IV, n = 9) was performed from the 2nd to the 11th day of treatment. All of the patients received approximately 35 kcal/kg body weight/day. In addition the patients in groups I and III received a 10% amino acid solution containing 0.24 g N/kg body weight/day whereas groups II and IV were administered a 5% solution containing only essential and semiessential amino acids amounting to 0, 12 g N/kg body weight/day. The 24-hr nitrogen output in urine, the serum free amino acid concentration as well as the serum protein fractions of transferrin and the C3c and C4 complements were contrasted. Significant differences between traumatised patients and those having had major surgery with respect to nitrogen balance and serum free amino acid concentrations were observed regardless of the pattern of nutrition. However, only slight differences in the concentrations of serum protein fractions of the two groups of patients were noted. Following amino acid solution the polytraumatized patients exhibited an average N balance of -11.9 g N/day, which is indicative of a severely catabolic metabolism. The average nitrogen loss observed in the postsurgical patients amounted to only half this amount. Following administration of the semiessential amino acid solution an appreciable difference in the nitrogen balance between comparable groups was not observed. However, the blood urea nitrogen was lower.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrogen and urea metabolism during continuous ambulatory peritoneal dialysis

During continuous ambulatory peritoneal dialysis (CAPD), concentrations of serum urea nitrogen (SUN) have been reported that are lower than what would be predicted from estimated dietary protein intake and the calculated urea clearance by dialysis. Net urea generation (urea nitrogen appearance) and losses of various nitrogenous constituents were measured during 12 metabolic studies in patients undergoing CAPD. Patients ingested constant diets containing either 1.0 or 1.4 g or protein per kilogram of body wt per day; total daily urea "clearance" from peritoneal dialysis plus renal clearance averaged 10.8 +/- 0.3 liters/day. Urea nitrogen appearance was only 55 and 68% of total nitrogen output with the low and high protein diets, respectively, values that are substantially lower than those reported in normal subjects, patients with chronic renal failure, and those undergoing hemodialysis. The reduction fraction of nitrogen appearing as urea was largely accounted for by the loss of protein and free amino acids into the dialysate. These respective constituents accounted fro 11.5 and 4.4% of total nitrogen output. Urea nitrogen appearance correlated closely (r = 0.96) with total nitrogen output in the patients undergoing CAPD.