Efficacy of a glutamine-based oral rehydration solution on the electrolyte and water absorption in a rabbit model of secretory diarrhea induced by cholera toxin

Intervention and Mechanisms of Alanyl-glutamine for Inflammation, Nutrition, and Enteropathy: A Randomized Controlled Trial

OBJECTIVE

Determine the minimum dosage of alanyl-glutamine (Ala-Gln) required to improve gut integrity and growth in children at risk of environmental enteropathy (EE).

METHODS

This was a double-blinded randomized placebo-controlled dose-response trial. We enrolled 140 children residing in a low-income community in Fortaleza, Brazil. Participants were 2 to 60 months old and had weight-for-age (WAZ), height-for-age (HAZ), or weight-for-height (WHZ) z-scores less than -1. We randomized children to 10 days of nutritional supplementation: Ala-Gln at 3 g/day, Ala-Gln at 6 g/day, Ala-Gln at 12 g/day, or an isonitrogenous dose of glycine (Gly) placebo at 12.5 g/day. Our primary outcome was urinary lactulose-mannitol excretion testing. Secondary outcomes were anthropometry, fecal markers of inflammation, urine metabolic profiles, and malabsorption (spot fecal energy).

RESULTS

Of 140 children, 103 completed 120 days of follow-up (24% dropout). In the group receiving the highest dose of Ala-Gln, we detected a modest improvement in urinary lactulose excretion from 0.19% on day 1 to 0.17% on day 10 (P = 0.05). We observed significant but transient improvements in WHZ at day 10 in 2 Ala-Gln groups, and in WHZ and WAZ in all Ala-Gln groups at day 30. We detected no effects on fecal inflammatory markers, diarrheal morbidity, or urine metabolic profiles; but did observe modest reductions in fecal energy and fecal lactoferrin in participants receiving Ala-Gln.

CONCLUSIONS

Intermediate dose Ala-Gln promotes short-term improvement in gut integrity and ponderal growth in children at risk of EE. Lower doses produced improvements in ponderal growth in the absence of enhanced gut integrity.

Mechanisms of Regulation of Transporters of Amino Acid Absorption in Inflammatory Bowel Diseases

Intestinal absorption of dietary amino acids/peptides is essential for protein homeostasis, which in turn is crucial for maintaining health as well as restoration of health from significant diseases. Dietary amino acids/peptides are absorbed by unique transporter processes present in the brush border membrane of absorptive villus cells, which line the entire length of the intestine. To date, the only nutrient absorptive system described in the secretory crypt cells in the mammalian intestine is the one that absorbs the amino acid glutamine. Majority of the amino acid transporters are sodium dependent and therefore require basolateral membrane Na-K-ATPase to maintain an efficient transcellular Na gradient for their activity. These transport processes are tightly regulated by various cellular and molecular mechanisms that facilitate their optimal activity during normal physiological processes. Malabsorption of amino acids, recently described in pathophysiological states such as in inflammatory bowel disease (IBD), is undoubtedly responsible for the debilitating symptoms of IBD such as malnutrition, weight loss and ultimately a failure to thrive. Also recently, in vivo models of IBD and in vitro studies have demonstrated that specific immune-inflammatory mediators/pathways regulate specific amino acid transporters. This provides possibilities to derive novel nutrition and immune-based treatment options for conditions such as IBD. © 2020 American Physiological Society. Compr Physiol 10:673-686, 2020.

Working Dogs Drinking a Nutrient-Enriched Water Maintain Cooler Body Temperature and Improved Pulse Rate Recovery After Exercise

Exercise-related physiological changes were evaluated in hydrated, exercise-conditioned working dogs with free access to tap water (TW) with or without a nutrient-enriched water supplement (NW). Physiological samples and measures were collected before and after work-related field tasks in a warm and moderately humid ambient environment. In a cross-over design study, 12 dogs (age range 8-23 months) were evaluated on 3 separate occasions within each period with exercise bouts up to 30 min, on days -4, 3, and 11. Dogs were offered either ad libitum TW or portion-controlled NW daily plus ad libitum TW. Prior to and serially after exercise, pulse rate (PR), core (BT_core) and ear (BT_ear) temperature were recorded. Urine was collected first thing in the morning, whereas blood samples collected and body weight (BW) recorded pre- and immediately post exercise. Ambient temperature was above 21.7°C (71°F) and relative humidity ranged from 36 to 76%. Activity parameters, AM urine measures, post-exercise percent change of BW, resting PR and resting BT_core did not differ between treatment groups on any exercise day. At the completion of exercise, mean BT_core for all dogs ranged from 104.8 to 105.6°F. Immediate post-exercise BT_ear was always lower compared to BT_core and means ranged from 103.3 to 104.0°F. The effect of time was highly significant (P < 0.001) for both BT measures with both BT_core and BT_ear recovering to resting levels by 60 min post exercise. PR and several blood values showed a significant main effect of time. Over the recovery period, dogs in the NW group had lower mean BT_ear and PR by 0.6°F and 3.4 bpm, respectively. Daily ingestion of a NW in combination with free access to TW can reduce the post-exercise-related BT_core and BT_ear hyperthermia, and improve pulse rate recovery following exercise in this population of working dogs undergoing 30 min bout of exercise.

Whey protein hydrolysates enhance water absorption in the perfused small intestine of anesthetized rats

We evaluated the effect of whey protein hydrolysates (WPH) on the water absorption rate in the small intestine using a rat small intestine perfusion model. The rate was significantly higher with 5 g/L WPH than with 5 g/L soy protein hydrolysates or physiological saline (p < 0.05). WPH dose-dependently increased the water absorption rate in the range of 1.25-10.0 g/L. WPH showed a significantly higher rate than an amino acid mixture whose composition was equal to that of WPH (p < 0.05). The addition of 4-aminomethylbenzoic acid, an inhibitor of PepT1, significantly suppressed WPH's enhancement of water absorption (p < 0.05). The rate of water absorption was significantly correlated with that of peptides/amino acids absorption in WPH (r = 0.82, p < 0.01). These data suggest that WPH have a high water absorption-promoting effect, to which PepT1 contributes.

Inducible nitric oxide regulates intestinal glutamine assimilation during chronic intestinal inflammation

To facilitate assimilation of glutamine, different Na-dependent glutamine absorptive pathways are present in the rabbit small intestine, specifically B0AT1 in villus and SN2 in crypt cell brush border membrane. Further, both are uniquely regulated in the chronically inflamed intestine. B0AT1 is inhibited secondary to reduced number of brush border membrane (BBM) co-transporters while SN2 is stimulated secondary to an increased affinity for glutamine. These unique changes are reversible by treatment with a broad spectrum immune modulator such as glucocorticoids. However, whether inducible nitric oxide (iNO), known to be elevated in the mucosa of the chronically inflamed intestine, may be responsible for these co-transporter alterations is not known. In the present study, treatment of chronically inflamed rabbits with L-NIL, a selective inhibitor of iNO synthase, reversed the inhibition of B0AT1 in villus and the stimulation of SN2 in crypt cells. At the level of the co-transporter in the brush border membrane, inhibition of iNO production reversed the inhibition of villus B0AT1 by restoring the co-transporter numbers while the stimulation of crypt SN2 was reversed back to normal by restoring its affinity for glutamine. Western blot analyses of BBM proteins also confirmed the kinetic studies. Thus, L-NIL treatment restores the uniquely altered Na-glutamine co-transporters in the enterocytes of chronically inflamed intestine. All these data indicate that iNO functions as an upstream immune modulator directly regulating glutamine assimilation during chronic intestinal inflammation.

Intestinal epithelial restitution after TcdB challenge and recovery from Clostridium difficile infection in mice with alanyl-glutamine treatment

BACKGROUND

Clostridium difficile is an anaerobic bacterium that causes antibiotic-associated diarrhea. It produces toxin A and toxin B (TcdB), which cause injury to the gut epithelium. Glutamine is a fundamental fuel for enterocytes, maintaining intestinal mucosal health. Alanyl-glutamine (AQ) is a highly soluble dipeptide derivative of glutamine. We studied whether administration of AQ ameliorates the effects of TcdB in the intestinal cells and improves the outcome of C. difficile infection in mice.

METHODS

WST-1 proliferation and cell-wounding-migration assays were assessed in IEC-6 cells exposed to TcdB, with or without AQ. Apoptosis and necrosis were assessed using Annexin V and flow cytometry. C57BL/6 mice were infected with VPI 10463 and treated with either vancomycin, AQ, or vancomycin with AQ. Intestinal tissues were collected for histopathologic analysis, apoptosis staining, and determination of myeloperoxidase activity.

RESULTS

AQ increased proliferation in intestinal cells exposed to TcdB, improved migration at 24 and 48 hours, and reduced apoptosis in intestinal cells challenged with TcdB. Infected mice treated with vancomycin and AQ had better survival and histopathologic findings than mice treated with vancomycin alone.

CONCLUSIONS

AQ may reduce intestinal mucosal injury in C. difficile-infected mice by partially reversing the effects of TcdB on enterocyte proliferation, migration, and apoptosis, thereby improving survival from C. difficile infection.

Protective effects of alanyl-glutamine supplementation against nelfinavir-induced epithelial impairment in IEC-6 cells and in mouse intestinal mucosa

PURPOSE

Human Immunodeficiency Virus (HIV) protease inhibitors (PI) remain a crucial component of highly active therapy (HAART) and recently have been demonstrated to have potent antitumor effect on a wide variety of tumor cell lines. However, discontinuation of therapy is an important issue, which may be related to various side-effects, especially diarrhea. The aim of this study was to evaluate the effects of nelfinavir (NFV), an HIV PI, and of alanyl-glutamine (AQ) supplementation, on intestinal cell migration, proliferation, apoptosis and necrosis, using IEC-6 cells and on intestinal crypt depth, villus length, villus area, mitotic index and apoptosis in Swiss mice.

METHODS

Migration was evaluated at 12 and 24 h after injury using a wound healing assay. Cellular proliferation was measured indirectly at 24 and 48 h using tetrazolium salt WST-1. Apoptosis and necrosis were measured by flow cytometry using the Annexin V assay. Intestinal morphometry and mitotic index in vivo were assessed following a seven-day treatment with 100 mg/kg of NFV, given orally. In vivo proliferation and apoptosis were evaluated by intestinal crypt mitotic index and immunohistochemistry, respectively.

RESULTS

In vitro, AQ supplementation enhanced IEC-6 cell migration and proliferation, following challenge with NFV. In vivo, AQ increased intestinal villus length, villus area, crypt depth and cell proliferation and cell migration, following treatment with NFV. AQ did not decrease cell death induced by NFV both in vivo and in vitro.

CONCLUSIONS

AQ supplementation is potentially beneficial in preventing the effects of PIs, such as NFV, in the intestinal tract.

L-alanyl-L-glutamine ingestion maintains performance during a competitive basketball game

Background

The purpose of this study was to examine the efficacy of L-alanyl-L-glutamine (AG) ingestion on basketball performance, including jump power, reaction time, shooting accuracy and fatigue.

Methods

Ten women (21.2 ± 1.6 years; height: 177.8 ± 8.7 cm; body mass: 73.5 ± 8.0 kg), all scholarship NCAA Division I basketball players, volunteered for this study. Subjects participated in four trials, each consisting of a 40-min basketball game with controlled time-outs for rehydration. During the first trial (DHY) subjects were not allowed to rehydrate, and the total weight lost during the contest was used to determine fluid replenishment during the subsequent three trials. During one trial subjects consumed only water (W), while during the other two trials subjects consumed the AG supplement mixed in water using either a low dose (1 g per 500 ml) (AG1) or high dose (2 g per 500 ml) (AG2) concentration. All data assessed prior to and following each game were converted into a Δ score (Post results - Pre results). All performance data were then analyzed using a one-way repeated measures analysis of variance.

Results

During DHY subjects lost 1.72 ± 0.42 kg (2.3%) of their body mass. No differences in fluid intake (1.55 ± 0.43 L) were seen between rehydration trials. A 12.5% (p = 0.016) difference in basketball shooting performance was noted between DHY and AG1 and an 11.1% (p = 0.029) difference was seen between AG1 and W. Visual reaction time was significantly greater following AG1 (p = 0.014) compared to DHY. Differences (p = 0.045) in fatigue, as determined by player loads, were seen only between AG2 and DHY. No differences were seen in peak or mean vertical jump power during any trial.

Conclusion

Rehydration with AG appears to maintain basketball skill performance and visual reaction time to a greater extent than water only.

Glutamine supplementation in sick children: is it beneficial?

The purpose of this review is to provide a critical appraisal of the literature on Glutamine (Gln) supplementation in various conditions or illnesses that affect children, from neonates to adolescents. First, a general overview of the proposed mechanisms for the beneficial effects of Gln is provided, and subsequently clinical studies are discussed. Despite safety, studies are conflicting, partly due to different effects of enteral and parenteral Gln supplementation. Further insufficient evidence is available on the benefits of Gln supplementation in pediatric patients. This includes premature infants, infants with gastrointestinal disease, children with Crohn's disease, short bowel syndrome, malnutrition/diarrhea, cancer, severe burns/trauma, Duchenne muscular dystrophy, sickle cell anemia, cystic fibrosis, and type 1 diabetes. Moreover, methodological issues have been noted in some studies. Further mechanistic data is needed along with large randomized controlled trials in select populations of sick children, who may eventually benefit from supplemental Gln.

Glutamine supplementation improves intestinal barrier function in a weaned piglet model of Escherichia coli infection

The weaning period is associated with an increased prevalence of gastrointestinal infection in many species. Glutamine (Gln) has been shown to improve intestinal barrier function and immune function in both in vivo and in vitro models. The objective of the present study was to determine the effect of dietary Gln supplementation on intestinal barrier function and intestinal cytokines in a model of Escherichia coli infection. We randomised 21-d-old piglets (n 20) to nutritionally complete isonitrogenous diets with or without Gln (4·4 %, w/w) for 2 weeks. Intestinal loops were isolated from anaesthetised pigs and inoculated with either saline or one of the two E. coli (K88AC or K88 wild-type)-containing solutions. Intestinal tissue was studied for permeability, cytokine expression, fluid secretion and tight-junction protein expression. Animals receiving Gln supplementation had decreased potential difference (PD) and short-circuit current (I(sc)) in E. coli-inoculated intestinal loops (PD 0·628 (SEM 0·151) mV; I(sc) 13·0 (SEM 3·07) μA/cm(2)) compared with control-fed animals (PD 1·36 (SEM 0·227) mV; I(sc) 22·4 (SEM 2·24) μA/cm(2)). Intestinal tissue from control, but not from Gln-supplemented, animals responded to E. coli with a significant increase in mucosal cytokine mRNA (IL-1β, IL-6, transforming growth factor-β and IL-10). Tight-junction protein expression (claudin-1 and occludin) was reduced with exposure to E. coli in control-fed animals and was not influenced in Gln-supplemented piglets. Gln supplementation may be useful in reducing the severity of weaning-related gastrointestinal infections, by reducing the mucosal cytokine response and altering intestinal barrier function.

Examination of the efficacy of acute L-alanyl-L-glutamine ingestion during hydration stress in endurance exercise

BACKGROUND

The effect of acute L-alanyl-L-glutamine (AG; Sustamine) ingestion on performance changes and markers of fluid regulation, immune, inflammatory, oxidative stress, and recovery was examined in response to exhaustive endurance exercise, during and in the absence of dehydration.

METHODS

Ten physically active males (20.8 +/- 0.6 y; 176.8 +/- 7.2 cm; 77.4 +/- 10.5 kg; 12.3 +/- 4.6% body fat) volunteered to participate in this study. During the first visit (T1) subjects reported to the laboratory in a euhydrated state to provide a baseline (BL) blood draw and perform a maximal exercise test. In the four subsequent randomly ordered trials, subjects dehydrated to -2.5% of their baseline body mass. For T2, subjects achieved their goal weight and were not rehydrated. During T3 - T5, subjects reached their goal weight and then rehydrated to 1.5% of their baseline body mass by drinking either water (T3) or two different doses (T4 and T5) of the AG supplement (0.05 g.kg-1 and 0.2 g.kg-1, respectively). Subjects then exercised at a workload that elicited 75% of their VO2 max on a cycle ergometer. During T2 - T5 blood draws occurred once goal body mass was achieved (DHY), immediately prior to the exercise stress (RHY), and immediately following the exercise protocol (IP). Resting 24 hour (24P) blood samples were also obtained. Blood samples were analyzed for glutamine, potassium, sodium, aldosterone, arginine vasopressin (AVP), C-reactive protein (CRP), interleukin-6 (IL-6), malondialdehyde (MDA), testosterone, cortisol, ACTH, growth hormone and creatine kinase. Statistical evaluation of performance, hormonal and biochemical changes was accomplished using a repeated measures analysis of variance.

RESULTS

Glutamine concentrations for T5 were significantly higher at RHY and IP than T2 - T4. When examining performance changes (difference between T2 - T5 and T1), significantly greater times to exhaustion occurred during T4 (130.2 +/- 340.2 sec) and T5 (157.4 +/- 263.1 sec) compared to T2 (455.6 +/- 245.0 sec). Plasma sodium concentrations were greater (p < 0.05) at RHY and IP for T2 than all other trials. Aldosterone concentrations at RHY and IP were significantly lower than that at BL and DHY. AVP was significantly elevated at DHY, RHY and IP compared to BL measures. No significant differences were observed between trials in CRP, IL-6, MDA, or in any of the other hormonal or biochemical measures.

CONCLUSION

Results demonstrate that AG supplementation provided a significant ergogenic benefit by increasing time to exhaustion during a mild hydration stress. This ergogenic effect was likely mediated by an enhanced fluid and electrolyte uptake.

Gastroenterology in developing countries: issues and advances

Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas: diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those setting up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of "cascades" are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.

Malnutrition as an enteric infectious disease with long-term effects on child development

Malnutrition is a major contributor to mortality and is increasingly recognized as a cause of potentially lifelong functional disability. Yet, a rate-limiting step in achieving normal nutrition may be impaired absorptive function due to multiple repeated enteric infections. This is especially problematic in children whose diets are marginal. In malnourished individuals, the infections are even more devastating. This review documents the evidence that intestinal infections lead to malnutrition and that malnutrition worsens intestinal infections. The clinical data presented here derive largely from long-term cohort studies that are supported by controlled animal studies. Also reviewed are the mechanisms by which enteric infections lead to undernutrition and by which malnutrition worsens enteric infections, with implications for potential novel interventions. Further intervention studies are needed to document the relevance of these mechanisms and, most importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their full potential.

Dosing and efficacy of glutamine supplementation in human exercise and sport training

Some athletes can have high intakes of l-glutamine because of their high energy and protein intakes and also because they consume protein supplements, protein hydrolysates, and free amino acids. Prolonged exercise and periods of heavy training are associated with a decrease in the plasma glutamine concentration and this has been suggested to be a potential cause of the exercise-induced immune impairment and increased susceptibility to infection in athletes. However, several recent glutamine feeding intervention studies indicate that although the plasma glutamine concentration can be kept constant during and after prolonged strenuous exercise, the glutamine supplementation does not prevent the postexercise changes in several aspects of immune function. Although glutamine is essential for lymphocyte proliferation, the plasma glutamine concentration does not fall sufficiently low after exercise to compromise the rate of proliferation. Acute intakes of glutamine of approximately 20-30 g seem to be without ill effect in healthy adult humans and no harm was reported in 1 study in which athletes consumed 28 g glutamine every day for 14 d. Doses of up to 0.65 g/kg body mass of glutamine (in solution or as a suspension) have been reported to be tolerated by patients and did not result in abnormal plasma ammonia levels. However, the suggested reasons for taking glutamine supplements (support for immune system, increased glycogen synthesis, anticatabolic effect) have received little support from well-controlled scientific studies in healthy, well-nourished humans.

Wasting and intestinal barrier function in children taking alanyl-glutamine-supplemented enteral formula

OBJECTIVE

We examined the effect of a diet supplemented with alanyl-glutamine (AG) or placebo glycine (G) on intestinal barrier function and growth in children in northeastern Brazil.

PATIENTS AND METHODS

One hundred seven children ages 7.9 to 82.2 months with a weight-for-age (WAZ), height-for-age (HAZ), or weight-for-height (WHZ) z-score less than -1 were studied. From July 2003 to November 2004, 51 study patients received AG (24 g/d) and 56 received G (25 g/d; isonitrogenic concentration) control for 10 days. Lactulose/mannitol excretion ratio was used as a measure of intestinal permeability and was performed on days 1 and 10 of nutritional supplementation. Weight and height were measured on days 1, 10, 30, and 120 of the protocol.

RESULTS

The patients were similar on admission with regard to age, sex, birth weight, nutritional status, lactulose/mannitol ratio, and serum concentrations of glutamine and arginine. The percentage of lactulose urinary excretion significantly improved (decreased) in children receiving AG for 10 days but not in those receiving glycine controls. AG significantly increased cumulative change over 120 days in WHZ and WAZ scores but not HAZ scores after adjustment for age and season in comparison with the placebo glycine group.

CONCLUSIONS

Children tolerated AG-supplemented enteral formula well, and it significantly improved cumulative WHZ and WAZ over 120 days in comparison with children in the placebo glycine group. The data also suggested a beneficial effect of AG in the barrier function paracellular pathway, albeit with reduced mannitol excretion. Thus, although the effect of AG on reduced mannitol concentration requires clarification, AG appears to improve nutrition and barrier function.

Caspase and bid involvement in Clostridium difficile toxin A-induced apoptosis and modulation of toxin A effects by glutamine and alanyl-glutamine in vivo and in vitro

Clostridium difficile is the leading cause of nosocomial bacterial diarrhea. Glutamine and its stable and highly soluble derivative alanyl-glutamine, have been beneficial in models of intestinal injury. In this study, we extend our work on the mechanisms of Clostridium difficile toxin A (TxA)-induced apoptosis in human intestinal epithelial T84 cells and evaluate the effects of glutamine and alanyl-glutamine on TxA-induced apoptosis in vitro and disruption of ileal mucosa in vivo. T84 cells were incubated with TxA (100 ng/ml) in medium with or without glutamine or alanyl-glutamine (3 to 100 mM). Apoptosis was evaluated by DNA fragmentation in vitro and the terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end-labeling method in vivo. Caspase and Bid involvement were investigated by Western blotting. Ligated rabbit ileal loops were used for the evaluation of intestinal secretion, mucosal disruption, and apoptosis. TxA induced caspases 6, 8, and 9 prior to caspase 3 activation in T84 cells and induced Bid cleavage by a caspase-independent mechanism. Glutamine or alanyl-glutamine significantly reduced TxA-induced apoptosis of T84 cells by 47% and inhibited activation of caspase 8. Both glutamine and alanyl-glutamine reduced TxA-induced ileal mucosal disruption and secretion. Altogether, we further delineated the apoptosis-signaling cascade induced by TxA in T84 cells and demonstrated the protective effects of glutamine and alanyl-glutamine. Glutamine and alanyl-glutamine inhibited the apoptosis of T84 cells by preventing caspase 8 activation and reduced TxA-induced intestinal secretion and disruption.

Effect of glutamine on water and sodium absorption in human jejunum at baseline and during PGE1-induced secretion

Glutamine, a major fuel for enterocytes, stimulates water and sodium absorption in animal models of secretory diarrhea, but data in humans are still limited. The aim of this study was to investigate the effect of glutamine on jejunal absorption during hypersecretion in humans. In six healthy adults, the effects of glutamine on jejunal absorption were assessed with a triple-lumen tube on two occasions, at baseline and during PGE1-induced hypersecretion (0.1 μg·kg−1·min−1) in a random order. Isoosmolar solutions containing polyethylene glycol 4000 as nonabsorbable marker were infused in the jejunum at 10 ml/min over 1-h periods: saline (sodium chloride 308 mmol/l), glucose-mannitol 45:45 mM, glucose 90 mM, alanine-glucose 45:45 mM, glutamine-glucose 45:45 mM, and glutamine 90 mM. Net absorptive and secretory fluxes were measured at steady state. At baseline, glutamine- and alanine-containing solutions induced a threefold increase of water and sodium absorption ( P < 0.05); 90 mM glutamine stimulated water absorption more than 90 mM glucose (3.6 ± 0.6 vs. 1.9 ± 0.3 ml·min−1·30 cm−1, P < 0.05). PGE1-induced hypersecretion was reduced ( P < 0.05) by solutions of alanine-glucose, glutamine-glucose, and glutamine 90 mM ( P < 0.05) and reversed to absorption by alanine-glucose and glutamine-glucose. Glutamine and alanine absorption was nearly complete and was not influenced by PGE1. In conclusion, glutamine stimulates water and electrolyte absorption in human jejunum, even during experimental hypersecretion. In addition to the metabolic effects of glutamine, these results support the evaluation of glutamine-containing solutions for the rehydration and the nutritional support of patients with secretory diarrhea.

The use of oral rehydration solutions in children and adults

The observation that the intestinal Na(+)-glucose cotransporter remains intact in most diarrheal illnesses led to development of the life-saving, low-cost technology of oral rehydration salt (ORS) solutions. The primary therapeutic role of ORS solutions is in prevention and treatment of dehydration during management of acute gastroenteritis. Successful oral rehydration therapy involves early use of ORS with maintenance or timely resumption of regular feeding. Since the inception of the oral rehydration approach more than three decades ago, the widespread use of ORS solutions has revolutionized the management and outcomes of acute gastroenteritis in children and adults. The efficacy of the World Health Organization ORS solution and of commercial ORS formulations has been enhanced by reducing osmolarity. Newer formulations of ORS are under active investigation, with promise of added benefits, including promotion of intestinal healing. This article reviews fluid and electrolyte transport in the gastrointestinal tract, the pathophysiologic mechanisms of acute diarrhea, and the basis and formulation of current and newer ORS solutions. Guidelines for efficacious use of ORS in the management of acute gastroenteritis and short gut syndrome are also provided.

Effect of glutamine supplementation on diarrhea, interleukin-8 and secretory immunoglobulin A in children with acute diarrhea

OBJECTIVE

Glutamine is an important fuel for rapidly dividing cells such as enterocytes and lymphocytes. Exogenous glutamine supplementation in catabolic states preserves intestinal mucosal structure and function, decreases bacterial translocation, and supports normal immunologic responses. This study was planned to assess the effect of glutamine supplementation on duration and severity of diarrhea and to assess its immunomodulatory effect by measuring serum interleukin-8 (IL-8) and salivary immunoglobulin A (sIgA) in children with acute diarrhea.

METHODS

In this placebo-controlled, double-blind and randomized trial, 6- to 24-month-old otherwise healthy children admitted to the Diarrheal Diseases Training and Treatment Center with acute diarrhea received either 0.3 g/kg/day of glutamine (n = 63) or placebo (n = 65) for 7 days. Serum IL-8 and sIgA levels were determined on admission and 7 days later. All cases were followed until the diarrheal episode ended. Anthropometric measurements and history of subsequent infectious diseases were monitored monthly for 3 months after treatment.

RESULTS

Mean duration of diarrhea in the glutamine treated group was significantly shorter than that of the placebo group (3.40 +/- 1.96 days, 4.57 +/- 2.48 days, respectively; P = 0.004). No differences in serum IL-8 and sIgA were found between groups on admission or 1 week later. During 3 month follow-up, mean weight gain and incidence of infectious diseases were similar in both groups.

CONCLUSION

Duration of diarrhea was shorter in children supplemented with glutamine. The beneficial impact of glutamine supplementation seems to be through effects on gastrointestinal mucosa rather than the host immune response.

Cholera, diarrhea, and oral rehydration therapy: triumph and indictment

Cholera drove the sanitary revolution in the industrialized world in the 19th century and now is driving the development of oral rehydration therapy (ORT) in the developing world. Despite the long history of cholera, only in the 1960s and 1970s was ORT fully developed. Scientists described this treatment after the discovery of the intact sodium-glucose intestinal cotransport in patients with cholera. This new understanding sparked clinical studies that revealed the ability of ORT to reduce the mortality associated with acute diarrheal disease. Despite the steady reductions in mortality due to acute dehydrating diarrheal diseases achieved by ORT, the costly morbidity due to these diseases remains, the result of a failure to globalize sanitation and to control the developmental impact of diarrheal diseases and their associated malnutrition. New advances in oral rehydration and nutrition therapy and new methods to recognize its costs are discussed in this review.

Glutamine Analogues As Adjunctive Therapy for Infectious Diarrhea

Glutamine is the major fuel for the gut as well as for many cells in the immune system that becomes conditionally essential during catabolic states. Glutamine supplementation improves intestinal mucosal repair and function. Glutamine, even at high doses, is without side effects and is well tolerated. Though unstable in solution, this is overcome by creating stable dipeptides such as alanyl-glutamine. In HIV-positive patients with wasting, glutamine enhances intestinal absorptive function and weight gain. Glutamine enhances sodium and water absorption in a rabbit model of cholera and Cryptosporidium-infected piglet intestine. Both glutamine and alanyl-glutamine have recently proven effective in a bovine model of Cryptosporidium as well. Finally, a rat model of cholera toxin-induced diarrhea also showed that alanyl-glutamine enhanced water and electrolyte intestinal absorption even better than the traditional glucose solutions. Clearly glutamine and its stabler derivatives hold promise for enhancing repair of mucosal injury by a wide range of infections or toxic agents, and hence have great potential as a new oral rehydration and nutrition therapy for patients with enteric infection, malnutrition, or chemotherapy- or radiation-induced enteritis.

Effects of an alanyl-glutamine-based oral rehydration and nutrition therapy solution on electrolyte and water absorption in a rat model of secretory diarrhea induced by cholera toxin

OBJECTIVES

Recurring diarrhea and persistent diarrhea are commonly associated with malnutrition and long-term functional deficits. A beneficial approach would be to develop an alanyl-glutamine (AlaGln)-based oral rehydration and nutrition therapy (ORNT). We investigated the effect of an AlaGln-ORNT solution on electrolyte and water absorption in a rat model of secretory diarrhea induced by cholera toxin.

METHODS

Phenolsulfonphthalein (50 microg/mL) was used as a non-absorbable marker for calculation of net water and electrolyte transport. Solutions tested were Ringer's solution, a glutamine-based ORNT (Gln-ORNT) solution, and an AlaGln-ORNT solution. Cholera toxin (1 microg/mL) was injected into lumen of rat small intestinal segments and incubated for 18 h before the initiation of the perfusion.

RESULTS

Cholera toxin induced significant secretion of electrolyte and water in the control Ringer's solution. AlaGln-ORNT and Gln-ORNT solutions reduced the sodium secretory effect of cholera toxin by 128% and 36%, respectively. The net water secretion also was reduced by 95% and 60%, respectively, with the AlaGln-ORNT and Gln-ORTN solutions.

CONCLUSIONS

These results showed that AlaGln-ORNT solution can enhance water and electrolyte intestinal absorption even better than glutamine or glucose and thus provide a potential novel approach for ORNT to break the vicious cycle of diarrhea and malnutrition. Clinical trials are now needed in children and adults with diarrhea and malnutrition.

Focused gut-mucosal nutrition for diarrhoeal disease: improved nutrient therapy

The main substrates fuelling ion absorption in the mucosa of the small intestine and large intestine are respectively glutamine and short-chain fatty acids. Measurements now reported showed that derivation of both glutamine and fibre for short-chain fatty acid production can be achieved from a single foodstuff--macerated groundnuts. Macerated groundnuts may be more suitable as an additive in oral rehydration solutions for promoting ion absorption than other agents that are low either in glutamine or fibre, such as rice water or resistant starch.

Glutamine signaling in intestinal cells

Glutamine (Gln) is a "competence factor" necessary for intestinal cell proliferation, intestinal fluid/electrolyte absorption, and mitogenic response to growth factors. Gln deprivation produces apoptosis. Gln stimulation of quiescent cells produces immediate-early gene expression and MAP kinase activation. However, EGF signals more powerfully through MAPKs than Gln. Interestingly, EGF-stimulated mitogenesis is ineffective in the absence of Gln. In the intact intestinal epithelia in vivo, Gln has powerful effects on absorption of sodium and chloride. Gln-stimulated absorption is greater than and additive to glucose-stimulated absorption in cryptosporidial enteritis. In the piglet ileum, Gln metabolism stimulates apical amiloride-inhibitable Na+/H+ exchange. Although one might predict powerful effects of oral Gln on absorption in babies with diarrhea, 3 clinical trials to date (one published) have not shown an advantage of Gln-supplemented oral rehydration solutions (ORS) compared to standard glucose ORS. Severely dehydrated subjects have not been studied. More important effects of Gln treatment may be seen with (1) co-administration with a growth factor and (2) in patients with severe intestinal damage, such as protracted diarrhea of infancy or AIDS enteropathy.