Development of urea-synthesizing enzymes in human liver

Global metabolomic profiling reveals hepatic biosignatures that reflect the unique metabolic needs of late-term mother and fetus

OBJECTIVE

Gestational disorders including preeclampsia, growth restriction and diabetes are characterized, in part, by altered metabolic interactions between mother and fetus. Understanding their functional relevance requires metabolic characterization under normotypic conditions.

METHODS

We performed untargeted metabolomics on livers of pregnant, late-term C57Bl/6J mice (N = 9 dams) and their fetuses (pooling 4 fetuses/litter), using UPLC-MS/MS.

RESULTS

Multivariate analysis of 730 hepatic metabolites revealed that maternal and fetal metabolite profiles were highly compartmentalized, and were significantly more similar within fetuses (ρ_average = 0.81), or within dams (ρ_average = 0.79), than within each maternal-fetal dyad (ρ_average = - 0.76), suggesting that fetal hepatic metabolism is under distinct and equally tight metabolic control compared with its respective dam. The metabolite profiles were consistent with known differences in maternal-fetal metabolism. The reduced fetal glucose reflected its limited capacity for gluconeogenesis and dependence upon maternal plasma glucose pools. The fetal decreases in essential amino acids and elevations in their alpha-keto acid carnitine conjugates reflects their importance as secondary fuel sources to meet fetal energy demands. Whereas, contrasting elevations in fetal serine, glycine, aspartate, and glutamate reflects their contributions to endogenous nucleotide synthesis and fetal growth. Finally, the elevated maternal hepatic lipids and glycerol were consistent with a catabolic state that spares glucose to meet competing maternal-fetal energy demands.

CONCLUSIONS

The metabolite profile of the late-term mouse dam and fetus is consistent with prior, non-rodent analyses utilizing plasma and urine. These data position mouse as a suitable model for mechanistic investigation into how maternal-fetal metabolism adapts (or not) to gestational stressors.

CPS1: Looking at an ancient enzyme in a modern light

The mammalian urea cycle (UC) is responsible for siphoning catabolic waste nitrogen into urea for excretion. Disruptions of the functions of any of the enzymes or transporters lead to elevated ammonia and neurological injury. Carbamoyl phosphate synthetase 1 (CPS1) is the first and rate-limiting UC enzyme responsible for the direct incorporation of ammonia into UC intermediates. Symptoms in CPS1 deficiency are typically the most severe of all UC disorders, and current clinical management is insufficient to prevent the associated morbidities and high mortality. With recent advances in basic and translational studies of CPS1, appreciation for this enzyme's essential role in the UC has been broadened to include systemic metabolic regulation during homeostasis and disease. Here, we review recent advances in CPS1 biology and contextualize them around the role of CPS1 in health and disease.

Altered metabolites in newborns with persistent pulmonary hypertension

BACKGROUND

There is an emerging evidence that pulmonary hypertension is associated with amino acid, carnitine, and thyroid hormone aberrations. We aimed to characterize metabolic profiles measured by the newborn screen (NBS) in infants with persistent pulmonary hypertension of the newborn (PPHN) METHODS: Nested case-control study from population-based database. Cases were infants with ICD-9 code for PPHN receiving mechanical ventilation. Controls receiving mechanical ventilation were matched 2:1 for gestational age, sex, birth weight, parenteral nutrition administration, and age at NBS collection. Infants were divided into derivation and validation datasets. A multivariable logistic regression model was derived from candidate metabolites, and the area under the receiver operator characteristic curve (AUROC) was generated from the validation dataset.

RESULTS

We identified 1076 cases and 2152 controls. Four metabolites remained in the final model. Ornithine (OR 0.32, CI 0.26-0.41), tyrosine (OR 0.48, CI 0.40-0.58), and TSH 0.50 (0.45-0.55) were associated with decreased odds of PPHN; phenylalanine was associated with increased odds of PPHN (OR 4.74, CI 3.25-6.90). The AUROC was 0.772 (CI 0.737-0.807).

CONCLUSIONS

In a large, population-based dataset, infants with PPHN have distinct, early metabolic profiles. These data provide insight into the pathophysiology of PPHN, identifying potential therapeutic targets and novel biomarkers to assess the response.

Effect of cardiopulmonary bypass on urea cycle intermediates and nitric oxide levels after congenital heart surgery

OBJECTIVE

To test the hypothesis that cardiopulmonary bypass used for repair of ventricular septal defects and atrioventricular septal defects would decrease availability of urea cycle intermediates including arginine and subsequent nitric oxide availability.

STUDY DESIGN

Consecutive infants (n = 26) undergoing cardiopulmonary bypass for repair of an unrestrictive ventricular septal defect or atrioventricular septal defect were studied. Blood samples were collected immediately before surgery, immediately after surgery, and 12 hours, 24 hours, and 48 hours after surgery. Urea cycle intermediates, including citrulline, arginine, and ornithine, were measured by amino acid analysis. Nitric oxide metabolites were measured by means of the modified Griess reaction.

RESULTS

Cardiopulmonary bypass caused a significant decrease in the urea cycle intermediates arginine, citrulline, and ornithine at all postoperative time points compared with preoperative levels. The ratio of ornithine to citrulline, a marker of urea cycle function, was elevated at all postoperative time points compared with preoperative values, indicating decreased urea cycle function. Nitric oxide metabolites were significantly decreased at all postoperative time points except for 48 hours, compared with preoperative levels.

CONCLUSIONS

Cardiopulmonary bypass significantly decreases availability of arginine, citrulline, and nitric oxide metabolites in the postoperative period. Decreased availability of nitric oxide precursors may contribute to the increased risk of postoperative pulmonary hypertension.

Neonatal pulmonary hypertension--urea-cycle intermediates, nitric oxide production, and carbamoyl-phosphate synthetase function

BACKGROUND

Endogenous production of nitric oxide is vital for the decrease in pulmonary vascular resistance that normally occurs after birth. The precursor of nitric oxide is arginine, a urea-cycle intermediate. We hypothesized that low concentrations of arginine would correlate with the presence of persistent pulmonary hypertension in newborns and that the supply of this precursor would be affected by a functional polymorphism (the substitution of asparagine for threonine at position 1405 [T1405N]) in carbamoyl-phosphate synthetase, which controls the rate-limiting step of the urea cycle.

METHODS

Plasma concentrations of amino acids and genotypes of the carbamoyl-phosphate synthetase variants were determined in 65 near-term neonates with respiratory distress. Plasma nitric oxide metabolites were measured in a subgroup of 10 patients. The results in infants with pulmonary hypertension, as assessed by echocardiography, were compared with those in infants without pulmonary hypertension. The frequencies of the carbamoyl-phosphate synthetase genotypes in the study population were assessed for Hardy-Weinberg equilibrium.

RESULTS

As compared with infants without pulmonary hypertension, infants with pulmonary hypertension had lower mean (+/-SD) plasma concentrations of arginine (20.2+/-8.8 vs. 39.8+/-17.0 micromol per liter, P<0.001) and nitric oxide metabolites (18.8+/-12.7 vs. 47.2+/-11.2 micromol per liter, P=0.05). As compared with the general population, the infants in the study had a significantly skewed distribution of the genotypes for the carbamoyl-phosphate synthetase variants at position 1405 (P<0.005). None of the infants with pulmonary hypertension were homozygous for the T1405N polymorphism.

CONCLUSIONS

Infants with persistent pulmonary hypertension have low plasma concentrations of arginine and nitric oxide metabolites. The simultaneous presence of diminished concentrations of precursors and breakdown products suggests that inadequate production of nitric oxide is involved in the pathogenesis of neonatal pulmonary hypertension. Our preliminary observations suggest that the genetically predetermined capacity of the urea cycle--in particular, the efficiency of carbamoyl-phosphate synthetase--may contribute to the availability of precursors for nitric oxide synthesis.

Comparison of total body urea production potential with total body carbamoyl phosphate synthetase (CPS-1) activity in newborn piglets infused with alanine at 50% of resting energy expenditure for 36 hours

The calculated rate of urea production [U(p); mmol urea/(h. kg(0. 75))], based on urinary urea-N (UUN) excretion and changes in total body urea-N, was compared with the calculated total body V(max) of carbamoyl phosphate synthetase (CPS-1) of 24 neonatal piglets from four treatments as follows: 6 h baseline control (n = 8), 18 h of alanine intravenously (IV) at 50% of resting energy expenditure (REE; n = 4), 36 h of alanine IV at 50% of REE (n = 6), or 36 h of glucose IV at 50% of REE (n = 6). The following significant increases from baseline were seen in piglets infused with alanine for 36 h: 1) UUN excretion [10.6 +/- 5.9 mg N/(h. kg(0.75)) to 53.2 +/- 11.1]; 2) BUN concentrations (9.1 +/- 3.0 mmol urea N/L to 51.2 +/- 7.0); 3) calculated urea production [0.34 +/- 0.21 mmol urea/(h. kg(0.75)) to 2.39 +/- 0.53]; and 4) CPS-1 V(max) [2.0 +/- 0.81 mmol citrulline/(h. kg (0.75)) to 4.4 +/- 1.5], (P < 0.05). With the exception of CPS-1 activity, significant decreases from baseline were seen in these values in piglets infused with glucose for 36 h (P < 0.05). Comparison of calculated urea production with calculated total body CPS-1 V(max) at baseline, 18 or 36 h after the start of infusion of alanine or glucose revealed a positive relationship (slope = 0.263; P < 0.002). At all enzyme activities, infusion of alanine resulted in a significant increase in the rate of urea production compared with controls (P < 0.001). Total body CPS-1 activity varied from 1.8 to 5.8 times that of urea production, suggesting that CPS-1 did not limit urea production.

Urea production is increased in neonatal piglets infused with alanine at 25, 50, and 75% of resting energy needs

To study the ability of neonatal piglets to metabolize a nitrogen load and excrete it as urea, 12 newborn piglets, 6 small (0.99 +/- 0. 16 kg; expt. 1) and 6 large (1.86 +/- 0.16 kg; expt. 2), were infused intravenously with alanine (n = 8; 4 large, 4 small; treatment) or glucose (n = 4; 2 large, 2 small; control) at equal ATP equivalents, supplying 25-75% of the resting energy requirements of the piglet over 18 h. To adjust for differences in the baseline urinary urea nitrogen excretion, blood urea nitrogen (BUN) and estimated urea production between groups, the absolute changes from baseline to maximum value for piglets infused with alanine, and from baseline to the 24-h value for piglets infused with glucose were evaluated statistically. There were no differences (0.1 < P < 0.3) in the absolute changes from baseline to maximum values of urinary urea nitrogen, BUN or estimated urea production between small [18.6 +/- 3.8 mg N/(h. kg(0.75)); 19.1 +/- 2.2 mmol N/L; 2.7 +/- 1.2 mmol N/(h. kg(0.75)), respectively] and large [23.6 +/- 7.6 mg N/(h. kg(0. 75)); 21.6 +/- 3.3 mmol N/L; 3.7 +/- 1.5 mmol N/(h. kg(0.75)), respectively] piglets infused with alanine. Differences in the changes from baseline were detected between alanine and glucose (P = 0.001) infusions. Small piglets required more time (P < 0.005) for BUN to maximize after initiation of the alanine infusion, suggesting that small piglets require more time to process a nitrogen load. Infusion of alanine resulted in at least a threefold increase from baseline in the rate of calculated urea production, suggesting that neonatal piglets, small or large, have reserve capacity to metabolize nitrogen and excrete it as urea.

Protein metabolism in the extremely low-birth weight infant

Although extensive data are available on the impact of nutrient and protein administration on growth, plasma amino acids, and nitrogen balance in the newborn and growing infants, relatively few studies have carefully examined the dynamic aspects of protein metabolism in vivo and particularly in the micropremie or ELBW infant. These studies show that the very preterm infants, either because of immaturity or because of the intercurrent illness, have high rates of protein turnover and protein breakdown. This high rate of proteolysis is not as responsive to nutrient administration. Intervention strategies aimed at promoting nitrogen accretion, such as insulin, human growth hormone, or glutamine, have not thus far resulted in enhanced protein accretion and growth. This may be, in part, due to limitations in delivery of adequate calorie and nitrogen.

Molecular genetic research into carbamoyl-phosphate synthase I: molecular defects and linkage markers

Deficiency of the hepatic enzyme carbamoyl-phosphate synthase I (CPSI), results in lethal or near-lethal hyperammonaemia. As part of our work on CPSI deficiency we have explored the development of markers for prenatal diagnosis, and the determination of molecular defects resulting in CPSI deficiency. We have determined a set of highly informative microsatellite markers flanking the CPSI gene. We have found 14 mutations in individuals with CPSI deficiency. During our mutation studies, we have made extensive use of cell lines not normally expressing CPSI through amplification of 'illegitimate' transcripts. We summarize these findings and review our current understanding of this important enzyme.

Plasma ammonia levels in very low birth weight preterm infants

The mean plasma ammonia level at birth of 36 very low birth weight infants (< or = 32 weeks of gestation) was 71 +/- 26 mumol/L (121 +/- 45 micrograms/dl), which is similar to the mean level in preterm infants born at > or = 32 weeks of gestational age. Plasma ammonia levels declined to 42 +/- 14 mumol/L (72 +/- 24 micrograms/dl) at 7 days of age; mean ammonia levels at 14, 21, and 28 days of age were similar to that at 7 days of age and to the mean plasma ammonia level of 14 healthy term infants at birth (45 +/- 9 mumol/L (77 +/- 16 micrograms/dl)).

Complication of parenteral nutrition composed of essential amino acids and histidine in adults with renal failure

This is a case report on six patients with hyperammonemia that developed while they were receiving total parenteral nutrition (TPN) as a component of renal failure therapy. Clinically, the hyperammonemia presented as mental status changes in all six cases. Four of the six patients with renal failure initially received 400 mL Amiyu in 1400 mL 17% glucose (total = 1800 mL TPN-A) administered over each 24-hour period. Two patients had been placed on 400 mL complete amino acid in 1400 mL 17% glucose (total = 1800 mL TPN-C over each 24-hour period) prior to therapy with TPN-A. Approximately 3 weeks after initiation of TPN therapy with TPN-A, episodes of mental status changes of increasing duration and paroxysms were documented in five of the six patients. In one of the patients receiving TPN-C prior to TPN-A therapy, toxicity was clinically evident only 4 days after initiation of TPN-A. Serum ammonia levels were obtained and found to be elevated in the acute (ie, presenting) stage in all patients. With the discontinuance of TPN-A, ammonia levels normalized uniformly. Mental status also improved in all cases except for the patient with rapid clinical presentation who died 2 weeks after first evidence of clinical toxicity. In cases 1, 2, and 6, serum amino acid analysis in the acute phase showed reduced levels of ornithine and citrulline, the substrate and product, respectively, of condensation with carbamyl phosphate at its entry into the urea cycle. Moreover, levels of arginine, precursor to ornithine, were found to be elevated.(ABSTRACT TRUNCATED AT 250 WORDS)

Localization of ammonia-metabolizing enzymes in human liver: ontogenesis of heterogeneity

Immunohistochemical analysis of human liver (8 to 94 years) shows a compartmentation of ammonia-metabolizing enzymes across the acinus. The highest concentration of carbamoylphosphate synthetase (ammonia) is found in the parenchymal cells around the terminal portal venules. Glutamine synthetase is found in a small pericentral compartment two to three cells thick. In contrast to observations in rat liver, in human liver a well-recognizable intermediate zone can be distinguished in which neither enzyme can be detected. This intermediate zone is not yet established at the age of 8 years but can be recognized in livers from 25 years onward. Carbamoylphosphate synthetase can already be detected in the liver of human fetuses at 5 weeks of development. The enzyme distribution reveals a random heterogeneity among the hepatocytes, suggesting that not all hepatocytes start to accumulate carbamoylphosphate synthetase at the same time. From 9 weeks of development onward, the enzyme becomes homogeneously distributed throughout the liver parenchyma until at least 2 days after birth. Glutamine synthetase cannot be detected during this period. In addition, the definitive architecture of the acinus is not yet completed at birth. These results therefore support the idea that in human liver, metabolic zonation with respect to NH3 metabolism exists as it does in rat liver. Furthermore, the data show that this functional compartmentation becomes established concomitant with the development of the acinar architecture.(ABSTRACT TRUNCATED AT 250 WORDS)

Phenylalanine hydroxylase expression in liver of a fetus with phenylketonuria

The expression and activity of phenylalanine hydroxylase was studied in the liver of a fetus aborted after prenatal diagnosis of phenylketonuria. No phenylalanine hydroxylase enzymatic activity or immunoreactive protein was detectable in the PKU liver specimen, though both enzymatic activity and immunoreactive protein were detectable in control specimens of similar gestational age. Phenylalanine hydroxylase messenger RNA of normal size was present in the PKU fetal liver at normal abundance. These results confirm the genetic diagnosis of PKU in this fetus and indicate that the mutations in this fetus affect translation or stability of the phenylalanine hydroxylase protein.

Protein intake during weaning. II. Metabolic responses

Metabolic responses to different feeding regimens during the weaning period have not previously been studied. In this study 30 healthy infants aged 4-6 months were divided into three feeding regimens with 10 infants in each. The regimens were: Human milk (HM-group), formula F1 with 1.9 g protein/100 ml (F1-group) or formula F2 with 2.7 g protein/100 ml (F2-group). All infants received the same supplementary food and were fed ad libitum. Concentrations of serum urea were significantly higher (p less than 0.001) in the formula groups as compared to the breast-fed infants throughout the entire study period. Serum albumin concentrations were within normal limits in the breast-fed infants indicating adequate protein nutritional status. There were no differences in the concentrations of creatinine and total nitrogen in urine between the artificially fed and the breast-fed infants at the beginning of the study (4 months), but at 6 months these concentrations were significantly higher in the formula-fed (infants (p less than 0.001). The results suggest that formulas now in common use during weaning provide amounts of protein which produce metabolic manifestations implying excessive protein intakes.

Differentiation of transient hyperammonemia of the newborn and urea cycle enzyme defects by clinical presentation

We reviewed clinical data in 33 patients with transient hyperammonemia of the newborn (THAN): six previously unreported cases and 27 from the literature. Thirteen neonates with urea cycle enzyme deficiencies (UCED) served for comparison. No differences were found in the incidence of perinatal complications, route of delivery, Apgar scores, sex, or incidence or time of onset of seizures. On the other hand, neonates with THAN had significantly lower birth weights (mean +/- SEM 2282 +/- 78 gm vs 3336 +/- 222 gm, P less than 0.001) and gestational ages (35.1 +/- 0.5 weeks vs 39.6 +/- 0.5 weeks, P less than 0.001). Mean time of onset of respiratory distress (3.9 +/- 1.4 hours vs 71.5 +/- 26.1 hours, P less than 0.001), ventilatory support (P less than 0.001), lethargy (P less than 0.005), and coma (P less than 0.005) occurred earlier in THAN. Distinctive laboratory findings in patients with THAN included abnormal chest radiographic findings and plasma ammonium concentrations that were higher (1871 +/- 209 microM vs 973 +/- 169 microM, P less than 0.02) at an earlier age. Respiratory distress occurred in all but one patient with THAN before 24 hours; in contrast, only 62% of infants with UCED had respiratory symptoms, and none before 30 hours. In this retrospective study, the clinical presentation alone differentiated THAN from UCED.

Stable isotope dilution analysis of orotic acid and uracil in amniotic fluid

Rapid, sensitive and accurate stable isotope dilution assays were developed for the measurement of orotic acid and uracil in amniotic fluid. The method utilizes [15N2]orotic acid and [15N2]uracil as internal standards, isolation by liquid partition chromatography and quantitation by chemical ionization selected ion monitoring gas chromatography-mass spectrometry. Orotic acid at a concentration of 0.26 +/- 0.05 mumol/l and uracil at a concentration of 0.55 +/- 0.13 mumol/l were detectable in normal amniotic fluid. As affected fetuses with argininosuccinate synthetase or ornithine carbamoyl transferase deficiency showed no significant elevation of orotic acid and/or uracil in their surrounding amniotic fluids, this method unfortunately seemed not to be useful for prenatal diagnosis of these inherited disorders. Nevertheless, it provides significant advantage over available methods for the quantitation of orotic acid and uracil in which the analysis of these compounds must be very accurate, highly specific and sensitive (e.g. detection of heterozygosity for ornithine carbamoyl transferase deficiency).

Arginine-responsive asymptomatic hyperammonemia in the premature infant

We found that more than 50% of premature infants have elevated plasma ammonium levels during the first 2 months of life. Ammonium levels were twice normal and were unaccompanied by clinical symptoms of vomiting or lethargy. Ten of these infants were given supplements of arginine (1 to 2 mmol/kg/day PO) for 1 to 2 weeks preceded and followed by control periods. In each infant, plasma ammonium levels fell significantly within 2 days of start of arginine supplementation, and increased once arginine was discontinued. We studied 59 additional premature infants, of whom 26 had normal ammonium levels and 33 were hyperammonemic. Plasma arginine and ornithine levels were significantly lower in the hyperammonemic group, but there was no difference in urinary excretion of arginine or ornithine between groups. Half of the hyperammonemic infants received arginine supplementation between 2 and 8 weeks of age. Plasma ammonium levels in the arginine group was 33 + 1 mumol/L., compared to 45 + 2 mumol/L in the untreated group. Follow-up at 18 months of age showed similar IQ scores in all groups, suggesting that significant neurologic deficits do not result from this transient metabolic defect. The mechanism of the hyperammonemia is unclear.

Plasma ammonia concentrations in newborns and children

Many, mostly congenital, hyperammonemic syndromes may occur in the first days of life. For the diagnosis of these disorders plasma ammonia levels physiologically present in neonates and early childhood should be known, preferably by the use of an enzymatic method. Full-term newborns had higher capillary ammonia concentrations on the first day of life (30-144 mumol/l) than on the fifth day (31-104 mumol/l). In the same individuals the arterial (38-89 mumol/l) are lower than the capillary concentrations (69-112 mumol/l). The venous concentrations in school children were not higher than in adults. The scatter of capillary values, however, is great. For diagnostic purposes of disorders of ammonia detoxication sampling of arterial or venous blood is preferable.

Plasma ammonia levels in preterm infants receiving parenteral nutrition with crystalline L-amino acids

In order to investigate the severity and incidence of hyperammonemia in preterm infants receiving total parenteral nutrition (TPN) with crystalline L-amino acids having high arginine content (Travasol), we determined the plasma ammonia (PA) levels in a group of 29 preterm infants on TPN, weekly and 1 wk posttherapy. Their mean gestational age was 29.9 +/- 2.6 wk and mean birth weight 1208 +/- 262 g. Thirty five blood samples obtained from 15 preterm infants not on TPN with mean gestational age 32.2 +/- 1.9 wk and a birth weight of 1495 +/- 161 g served as a control. In the parenteral nutrition group the mean PA level (140 +/- 58 micrograms/100 ml) was significantly higher (p less than 0.001) than that in the same group one week post TPN (97 +/- 34 micrograms/100 ml) and in the control group (86 +/- 35 micrograms/100 ml). The incidence of hyperammonemia (greater than 160 micrograms/100 ml) was 30% in the TPN group versus 3% in the controls (p less than 0.01). Maximal PA level during that treatment was 405 versus 216 micrograms/100 ml 1 wk post-TPN versus 163 micrograms/100 ml in the controls. The data show a significant increase in PA levels in preterm infants receiving TPN with Travasol, possibly because of its high glycine content.

Urea cycle enzymes in human liver: ontogenesis and interaction with the synthesis of pyrimidines and polyamines

All the five enzymes of urea synthesis and the formation of urea in vitro can already be demonstrated in human liver as early as the 9th week of fetal development. At this stage the activity of carbamoyl phosphate synthetase is the highest, whereas that of ornithine carbamoyltransferase is the lowest as compared to those in the adult. The kinetic parameters of the urea cycle enzymes are the same in fetal liver as in adult liver, except that the Km values of ornithine carbamoyltransferase for L-ornithine are 3.5 mM and 0.42 mM in the fetus and in adult liver, respectively. Urea formation in vivo seems to begin in the second half of fetal life, and a gradual increase can be detected in the activity of the enzymes of urea synthesis. The activity of ornithine decarboxylase, the glutamine-dependent carbamoyl phosphate synthetase and aspartate carbamoyltransferase, however, changes in the opposite direction. The concentration of carbamoyl phosphate and aspartate remains constant, but that of ornithine gradually decreases during ontogenesis. The ornithine, carbamoylphosphate and aspartate pools are probably utilized in the polyamine, pyrimidine and urea syntheses at varying rates.

Hyperammonemia during total parenteral nutrition in children

Serial blood ammonia (NH3) determinations in 19 low birth weight (LBW) infants, 14 term neonates and 12 children receiving total parenteral nutrition (TPN) have shown that 73% of patients had one or more elevated NH3 values (greater than 150 micrograms/dl). The mean blood NH3 was 220 +/- 13 micrograms/dl in LBW infants, 180 +/- 9 micrograms/dl in 10 infants, and 140 +/- 7 micrograms/dl in children. All of these values are significantly higher than normal (p less than 0.001). There was no difference in incidence or mean blood ammonia concentration between patients receiving casein hydrolysate and those receiving a crystalline amino acid solution. Only four patients were symptomatic and several infants remained fully alert despite blood NH3 concentration in excess of 400 micrograms/dl. One infant who had sustained hyperammonemia was given another amino acid source (Travasol) containing 1.2 mmol/dl of arginine; blood NH3 promptly fell to the normal range. However, six of seven additional infants had hyperammonemia while receiving Travasol (mean = 184 micrograms/dl). Hyperammonemia is common during TPN in children, often is not recognized clinically, and occurs with equal frequency in infants and older children. The high levels observed in LBW infants may be due to hepatic immaturity. Blood NH3 concentration should be monitored frequently during TPN. Persistent hyperammonemia should be treated by decreasing protein content of the infusate. The role of supplemental arginine is unclear.

Ultrastructure of hepatic mitochondria in a child with hyperornithinemia, hyperammonemia, and homocitrullinuria

Ultrastructural studies of hepatic tissue obtained at biopsy from a nine year old severely retarded boy with hyperornithinemia, hyperammonemia, and homocitrullinuria showed mitochondria of bizarre shapes and unusual internal features. Among the latter were tubules extending throughout the length of the large mitochondria that on cross section had a rosette-like arrangement; the presence of a periodic, approximately 300 A thick, sievelike membrane interposed between the tubules and the inner mitochondrial membrane; and "bulges" of mitochondrial matrix occasionally formed between these two membranes. Since to be metabolized ornithine must enter the mitochondria, the hyperornithinemia is regarded as a reflection of its inability to reach the mitochondrial interior. It is speculated that among other possible causes, the unusual sievelike membrane may be the barrier to ornithine's access to the mitochondrion.

Plasma ammonia levels in newborn infants admitted to an intensive care baby unit

A fatal case associated with severe hyperammonaemia is described in which no urea cycle enzyme deficiency could be found. This prompted further investigation of blood ammonia levels in neonates admitted to the premature baby unit at Hammersmith Hospital. 102 specimens were taken from 42 babies within the first 3 weeks of life; the babies had a variety of clinical conditions. The mean ammonia level was 94.5 mumol/l (132.3 micrograms/100 ml) (range 32-255 mumol/l) (44.8-357 micrograms/ml), SD +/- 41.0). These results, although higher than the range for older babies in hospital, were not as high as in the baby with severe hyperammonaemia. Serial levels in 10 babies suggested that the range of blood ammonia levels was greatest in the first 2 weeks of life and narrowed considerably after this period. Great care is needed in collecting blood samples and measuring them if accuate results are to be obtained.

Enzyme pathology of the liver in patients with and without nonhepatic cancer

Preliminary studies of 13 enzymes subserving various metabolic pathways were undertaken in tumor-free liver biopsy samples from cancer patients and control subjects. The observations indicate that as a result of nonhepatic neoplasms, with (7 cases) or without (6 cases) hepatic involvement, the biochemical composition of the liver becomes partially undifferentiated. Quantification of appropriate enzymes in histologically normal liver samples could thus distinguish clearly between cancer hosts and controls. The best discriminators include two hepatic enzymes whose concentrations were decreased to less than 30% of normal (soluble glutamate dehydrogenase and the cold stable pyrroline-5-carboxylate reductase) and three for which it was elevated two to four-fold (hexokinase, peptidyl proline hydroxylase and thymidine kinase) in response to distant neoplasms. The same alterations in hepatic enzyme pattern were not seen in any cancer-free patients with or without morphologic liver damage.

Fetal tissue amino acid concentrations in argininosuccinic aciduria and in "maternal homocystinuria"

Free amino acid concentrations have been measured in the tissues of a fetus at risk for argininosuccinic aciduria and of an obligate heterozygous fetus in a mother homozygous for homocystinuria. Argininosuccinic acid was detected in all tissues studied of the homozygous affected fetus from the heterozygous mother. Abnormal concentrations of methionine and cystathionine were observed in the tissues of the fetus who was an obligate heterozygote for homocystinuria. These abnormal free amino acid concentrations occur early in fetal development and may be related to later brain dysfunction.

Urea-cycle enzyme deficiencies and an increased nitrogen load producing hyperammonemia in Reye's syndrome

Assay of urea-cycle enzymes in liver tissue showed ornithine transcarbamylase activities of 18 to 72 per cent of the normal mean in eight patients with Reye's syndrome, below the range of normal in seven of eight, and, in six cases, as low as those in females with X-linked deficiency of this enzyme. Carbamyl phosphate synthetase activities were less than 32 per cent of controls in two patients. Argininosuccinate synthetase and lyase activities were normal in seven patients. Arginase was normal in two biopsy specimens, but below normal in four of five autopsy specimens. The Km's for ornithine and carbamyl phosphate, pH optimum, and heat lability of ornithine transcarbamylase were normal. Two patients excreted 0.64 and 0.58 g per kilogram per day of urinary nitrogen at the peak of hyperammonemia, in spite of peritoneal dialysis. The hyperammonemia of Reye's syndrome apparently results from excess waste nitrogen that overwhelms the ability of reduced ornithine transcarbamylase (and occasionally carbamyl phosphate synthetase) to detoxify the ammonia load.

Citrullinaemia with rapidly fatal neonatal course

An infant with a deficiency of argininosuccinate synthetase in liver and brain developed rapidly increasing apathy, respiratory insufficiency, and convulsions from the fourth day of life, and died on the seventh day. There was a profound derangement of amino acid concentrations in blood, CSF, and urine, with very high citrulline levels. This patient differs from other cases reported previously, both in her fulminant and fatal course in the neonatal period and in the greater biochemical disturbance.