Trace metal abnormalities in adults during hyperalimentation

Zinc and liver disease

Zinc is an essential trace element required for normal cell growth, development, and differentiation. It is involved in DNA synthesis, RNA transcription, and cell division and activation. It is a critical component in many zinc protein/enzymes, including critical zinc transcription factors. Zinc deficiency/altered metabolism is observed in many types of liver disease, including alcoholic liver disease (ALD) and viral liver disease. Some of the mechanisms for zinc deficiency/altered metabolism include decreased dietary intake, increased urinary excretion, activation of certain zinc transporters, and induction of hepatic metallothionein. Zinc deficiency may manifest itself in many ways in liver disease, including skin lesions, poor wound healing/liver regeneration, altered mental status, or altered immune function. Zinc supplementation has been documented to block/attenuate experimental ALD through multiple processes, including stabilization of gut-barrier function, decreasing endotoxemia, decreasing proinflammatory cytokine production, decreasing oxidative stress, and attenuating apoptotic hepatocyte death. Clinical trials in human liver disease are limited in size and quality, but it is clear that zinc supplementation reverses clinical signs of zinc deficiency in patients with liver disease. Some studies suggest improvement in liver function in both ALD and hepatitis C following zinc supplementation, and 1 study suggested improved fibrosis markers in hepatitis C patients. The dose of zinc used for treatment of liver disease is usually 50 mg of elemental zinc taken with a meal to decrease the potential side effect of nausea.

Continuous venovenous hemodiafiltration trace element clearance in pediatric patients: a case series

Continuous renal replacement therapy (CRRT) is used to treat critically ill children with acute kidney injury. The effect of CRRT on trace element clearance is poorly characterized. The purpose of this study was to quantify the transmembrane clearance of chromium, copper, manganese, selenium and zinc during continuous venovenous hemodiafiltration (CVVHDF). The transmembrane clearance of trace elements was assessed prospectively in five critically ill children receiving CVVHDF at the pediatric intensive care unit of a tertiary care university hospital. Pre-filter blood and effluent samples were measured for trace element concentrations. Transmembrane clearance of trace elements was calculated, and daily loss of each trace element was determined. Daily trace element loss via CVVHDF was compared with daily standard supplementation of trace elements in pediatric parenteral nutrition. Five patients (age range 23 months to 15 years) with a body weight range of 10.5-53 kg completed the study. The median transmembrane clearance of chromium, copper, manganese, selenium and zinc during CVVHDF was calculated as 0 ml, 0.59 ml, 2.48 ml, 1.22 ml, and 1.90 ml, respectively, per 1.73 m(2) body surface area per minute. The calculated CVVHDF losses were substantially smaller than the daily parenteral supplementation for all trace elements.

Technical aspects of trace element supplementation

Routine supplementation of total parenteral nutrition mixtures with the readily available single or combination trace elements products is becoming more widespread. As more is learned about deficiency syndromes and monitoring techniques, so too must we understand more about the physicochemical interactions between individual trace elements and other nutrients, that could ultimately affect bioavailability. Expert pharmaceutical assessment of these complex reactions, that have been demonstrated to occur in solution, becomes increasingly important in order to optimize the efficacy of micronutrient therapy.

The necessity of selenium substitution in total parenteral nutrition and artificial alimentation

For the trace element selenium, in contrast to zinc, iron, copper, chromium, manganese and iodine, there is still no clear official recommendation with regard to routine substitution in artificial nutrition. An overview of the manifestations of selenium deficiency in humans during the period 1979-1995 shows that nutritive deficiencies are exclusively TPN-induced or the result of severe malnutrition. The pathology of TPN-induced selenium deficiency and the analytic assessment of selenium status are described. Patients undergoing long-term parenteral nutrition or suffering from an increased loss of intestinal secretions have to be characterized as being especially at risk for clinical selenium deficiency. The relationship of the serum selenium kinetics in pediatric and adult patients to the depletion of body compartments during the course of short-term and prolonged TPN is discussed. Because of the importance of the selenoproteins, the regularly occurring depletion during selenium-free TPN and the borderline supply of selenium in Germany the routine substitution of selenium in TPN is strongly recommended. The pharmaceutical industry should be encouraged to develop a trace element solution that includes selenium, so that the nutritive requirement of patients on TPN can be satisfied. Adequate intravenous dosage recommendations are based on maintenance of glutathione peroxidase homeostasis. The routine supplementation dosage may not meet the selenium requirements of intensive care patients under conditions of increased metabolic demands on their anti-oxidative system.

Overt hepatic encephalopathy precipitated by zinc deficiency

Encephalopathy in liver disease may be unresponsive to protein restriction, lactulose, and neomycin. Zinc supplements have been reported to improve psychometric performance in liver cirrhosis, but the importance of zinc deficiency in overt hepatic encephalopathy has not yet been clearly established. A patient with severe recurrent hepatic encephalopathy was studied to determine the relation between her signs of encephalopathy and zinc deficiency. The study included a period in which zinc deficiency was artificially induced by oral histidine. An episode of overt encephalopathy occurred that was identical to earlier episodes and responded to oral zinc. The study showed an association between encephalopathy and zinc deficiency by successive zinc depletion and supplementation regimens. Long-term zinc supplementation improved severe recurrent hepatic encephalopathy and therefore the quality of life.

Nutritional support in the critical care setting (Part 1)

Over the past two decades nutritional support has rapidly become an integral part of the medical care of critically ill patients. As scientific evidence accumulates supporting the important role of underlying nutritional status in determining the eventual outcome of many illnesses, aggressive nutritional intervention has become commonplace in our medical and surgical ICUs. However, nutritional support, particularly parenteral alimentation, is expensive and associated with important morbidity and even mortality. Furthermore, definite evidence of its clinical efficacy under certain specific conditions is often lacking and in need of properly done prospective studies. This review summarizes the basic principles of nutrition as applied to the critically ill patient in the clinical setting. Special emphasis is on practical considerations regarding cost, efficacy (or lack thereof), and potential advantages, disadvantages, and risk of complications of each proposed approach.

[Trace elements in artificial nutrition. Art and practice]

The trace elements known to be necessary for man are iron, zinc, copper, selenium, chromium, manganese, molybdenum, cobalt and iodine. This review article, which excludes iron, deals with the need for supplemental trace elements during artificial feeding, and the way they should be administered. The biological importance of these trace elements is argued on the basis of their biochemical involvement and the clinical pictures seen in accidental or experimental deficiency states. Assessing a patient's trace element status is rather difficult. The relative merits of different laboratory investigations is discussed: plasma, erythrocyte, capillary and urinary levels, specific enzyme activities, loading tests. The different situations when trace elements are required, assessing the amount needed and the possible toxic risks, are presented from a literature survey.

Zinc metabolism in alcoholic liver disease

Alterations in zinc metabolism or zinc deficiency frequently occur in patients with alcoholic liver disease. Potential manifestations of zinc deficiency include skin lesions, hypogonadism, impaired night vision, impaired immune function, anorexia, altered protein metabolism, diarrhea, and depressed mental function. Because of the variety of ways in which zinc deficiency may present in alcoholic liver disease, clinicians must maintain a high index of suspicion for this nutrient deficiency when caring for these patients. Not only may zinc deficiency occur with alcoholic liver disease, but there also may be altered zinc metabolism. Recent data from alcoholic hepatitis patients demonstrate increased serum levels of the monokine interleukin 1, which is known to cause hypozincemia and an internal redistribution of zinc. This monokine has a host of metabolic functions other than its effect on mineral metabolism that have relevance for alcoholic liver disease such as fever production, neutrophilia, and muscle catabolism. We suggest that the patient with alcoholic liver disease frequently has problems with either zinc deficiency or altered zinc metabolism and the potential implications of this are discussed.

Ocular histopathology of acrodermatitis enteropathica

Acrodermatitis enteropathica is the clinical expression of congenital zinc deficiency and is now treated with supplemental zinc. This report details the ocular histopathology of a child who died before efficacious treatment was available. The findings include corneal epithelial thinning and loss of polarity, anterior corneal scarring and loss of Bowman's membrane, cataract formation, ciliary body atrophy, retinal degeneration, RPE depigmentation, and optic atrophy.

Serum and urine zinc response in head-injured patients

A prospective longitudinal evaluation of serum zinc concentrations was performed in 26 head-trauma patients, and 24-hour urine zinc excretion was determined in 15 of these subjects. Patients had markedly depressed admission serum zinc concentrations (mean +/- standard error of the mean: 40.2 +/- 3.2 micrograms/dl; normal values: 70 to 120 micrograms/dl), which gradually increased during the 16-day study period. All subjects demonstrated increased urinary zinc losses throughout the study period. Urinary zinc excretion was greater in patients with more severe head injuries. Indeed, patients with more severe head trauma had mean peak urinary zinc losses of greater than 7000 micrograms/day (normal less than 500 (micrograms/day). The implications of this altered zinc metabolism for protein metabolism, wound healing, and immune function, and the specific role of zinc in brain function and recovery from injury are discussed.

Dietary selenium intake in Belgium for different population groups at risk for deficiency

An estimation of the dietary selenium intake in different population groups in Belgium has been carried out. 24 h duplicate meals and food consumption statistics combined with concentration levels in different foods, as determined by hydride generation atomic absorption spectrometry, are used. Dietary intake of selenium is low to very low, especially for vegetarians (12.7 +/- 9.1 micrograms) and patients on long-term total parenteral nutrition (1.2 +/- 0.8 microgram). The different intakes are discussed and compared with intakes published for other countries, while the importance of bioavailability of the selenium in food in the risk of deficiency is stressed.

Zinc deficiency in surgical patients: a clinical study

Four stressed surgical patients who had different diseases are presented. They had dermatitis associated with low serum zinc levels but were not on total parenteral nutrition. The range of serum zinc varied between 25 and 56 mu/dl when first seen. All but one had hypoalbuminemia and anemia; one patient had diarrhea. When measured, other microelements were normal. These patients were thought to have zinc deficiency and all their symptoms responded favorably to oral zinc and nutritional support. A highlight of previous reported cases of zinc deficiency is presented along with a brief review of the subject. Acute stress including major operations will decrease the serum zinc level temporarily. Zinc deficiency may be the result of chronic zinc depletion caused by other conditions. Chronic leg ulcers are associated with low serum zinc levels and might precipitate zinc selectively. A zinc supplement will help in the healing of these ulcers and wounds in general. The possibility of an interrelationship of zinc and other microelements is raised but is not clear.

Urinary excretion and blood concentrations of trace elements and electrolytes during total parenteral nutrition in Crohn's disease

Urinary excretion of trace elements (Cr, Co, Cu, Fe, Mn, Se, Zn, Sb, Cs, Rb), electrolytes (Na, K, Ca, Mg, phosphate), and nitrogen were determined during days 1-5 and 54-79 of total parenteral nutrition (TPN, nil per os) given to six patients with Crohn's disease. Whole-blood concentrations of Cr, Fe, Zn, Cs, and Rb and serum concentrations of electrolytes were determined before the TPN and on days 54-79 of TPN. The 24-hr urinary excretion of zinc was lower on days 54-79 than on days 1-5, but the rates of excretion of the other essential trace elements during TPN displayed no significant change. The urinary excretion of Cu, Fe, and Mn was numerically lower than the intravenous administration of these elements during days 1-5 and 54-79 of TPN, whereas the urinary excretion of zinc was lower than the supply only during days 54-79. The whole-blood concentration of zinc was low but constant during TPN, whereas the initially low levels of Cr and Fe were normalized on days 54-79. The results suggest that the supply of the essential trace elements Cr, Co, Cu, Fe, Mn, and Zn was largely adequate during two to three months of TPN and that the human body may adapt to a somewhat low supply of zinc, 20-30 mumol/24 hr.

Trace metal requirements in total parenteral nutrition (TPN). 5. Formation constants for the copper(II)--histidine ternary complexes with threonine, lysine, glycine, phenylalanine, valine, and cystine, and discussion of their implications regarding the copper distribution in blood plasma during TPN and the evaluation of the daily dose of copper

Specific metal deficiencies have been reported to affect patients receiving total parenteral nutrition (TPN). Our previous studies on the topic were devoted to the computer-based interpretation of the extra urinary excretion of zinc; a theoretical approach was also proposed, with a view to compensating for the extra losses of this metal. Similarly, the present work deals with the problem of TPN-induced copper deficiency and its remedy. As is the case for zinc, the TPN-induced excretion of copper clearly stems from the relative mobilization of the plasma protein-bound pool of this metal into its diffusable low-molecular-weight fraction; this phenomenon being due to the competitive complexation of copper by the amino acids of the nutritive solution. The computer simulation of this effect thus required that first the equilibrium constants be experimentally determined for the main complexes of copper that might form in the solution as well as in plasma during the infusion. Accordingly, complex formation in the copper-histidine ternary systems with threonine, lysine, glycine, phenylalanine, valine, and cystine was investigated by potentiometry at 37 degrees C in NaCIO4 0.15 mol X dm-3. The implications of the results obtained are discussed with regard to the interpretation of the copper excretion and the estimation of the desirable daily dose of this metal for the TPN mixture under consideration.