Nutrition and protein turnover: a review

Hepatic encephalopathy: a critical current review

Hepatic encephalopathy (HE) is a serious neuropsychiatric complication of cirrhosis and/or porto-systemic shunting. The clinical symptoms are widely variable, extending from subtle impairment in mental state to coma. The utility of categorizing the severity of HE accurately and efficiently serves not only to provide practical functional information about the current clinical status of the patient but also gives valuable prognostic information. In the past 20–30 years, there has been rapid progress in understanding the pathophysiological basis of HE; however, the lack of direct correlation between pathogenic factors and the severity of HE make it difficult to select appropriate therapy for HE patients. In this review, we will discuss the classification system and its limitations, the neuropsychometric assessments and their challenges, as well as the present knowledge on the pathophysiological mechanisms. Despite the many prevalent hypotheses around the pathogenesis of the disease, most treatments focus on targeting and lowering the accumulation of ammonia as well as inflammation. However, treatment of minimal HE remains a huge unmet need and a big concerted effort is needed to better define this condition to allow the development of new therapies. We review the currently available therapies and future approaches to treat HE as well as the scientific and clinical data that support their effectiveness.

Changes in Plasma Somatomedin-C in Response to Ingestion of Diets with Variable Protein and Energy Content

We have attempted to determine the relative importance of dietary intake of protein and energy in restoring plasma immunoreactive somatomedin-C (Sm-C) concentrations after fasting. Ten healthy human volunteers were fasted for 5 days, then divided into two refeeding groups. One group (variable energy) was refed 1.0 g protein/kg ideal body weight, and in 9-day sequences, 11, 18 and 25 kcal of energy/kg. The other group (variable protein) was given 35 kcal energy/kg, and in 9-day sequences, 0.2, 0.4, and 1.0 g protein/kg. When subjects were refed the variable energy diets there was no significant increase in Sm-C at 11 kcal/kg (0.47 +/- 0.13 to 0.45 +/- 0.12 U/ml), suggesting that there is a threshold energy requirement below which optimal protein intake is not sufficient to raise the Sm-C. When subjects were refed 18 and 25 kcal/kg, it became apparent that the more energy added to the diet, the greater the absolute concentration of Sm-C attained (0.66 U/ml on 18 kcal/kg and 0.97 U/ml on 25 kcal/kg). Sm-C correlated with nitrogen balance (r = 0.58) during refeeding with the variable energy diets and was a good indicator of acute directional change in nitrogen balance. However, Sm-C was not a reliable indicator of nitrogen repletion, since it rose almost to control levels on the 25 kcal/kg diet while nitrogen balance remained slightly negative.(ABSTRACT TRUNCATED AT 250 WORDS)

Restricting sulfur amino acid intake in growing pigs challenged with lipopolysaccharides decreases plasma protein and albumin synthesis

Litvak, N., Htoo, J. K. and de Lange, C. F. M. 2013. Restricting sulfur amino acid intake in growing pigs challenged with lipopolysaccharides decreases plasma protein and albumin synthesis. Can. J. Anim. Sci. 93: 505–515. Chronic subclinical levels of disease occur frequently in swine production and compromise nutrient utilization efficiency. Methionine and cysteine (M+C) are involved in the pig's response to immune system stimulation (ISS), acting as substrates for the synthesis of compounds involved in the immune response, such as acute phase proteins (APP). This study was conducted to determine the impact of ISS with lipopolysaccharide (LPS) and M+C intake (high vs. low; 4.0 vs. 2.2 g d−1) on the fractional synthesis rate (FSR) of plasma albumin and fibrinogen, as well as protein in plasma and various tissues of starter pigs. Fifteen pigs (9.8±1.4 kg body weight) were allotted to one of three treatments: (1) Control (LPS− and high M+C), (2) LPS+ and high M+C, or (3) LPS+ and low M+C. Pigs were given intramuscular injections of increasing doses of LPS 1 and 3 d before determining FSR using an intravenous infusion of a flooding dose of L-[ring−1H5]-phenylalanine. Plasma levels of APP were not affected by the LPS challenge (P>0.10); only plasma albumin levels decreased with reduced M+C intake (P=0.02). Total plasma protein FSR was increased during the LPS challenge (50.3 vs. 56.9% d−1, SEM = 1.6; P=0.01). Albumin FSR was not affected by an LPS challenge (P>0.10), but decreased with reduced M+C intake during the LPS challenge (49.5 vs. 41.9% d−1, SEM = 1.6; P=0.005). Spleen protein FSR tended to increase during the LPS challenge (P=0.08). There were no treatment effects on protein FSR in liver, small intestine, loin or plasma fibrinogen (P>0.10). Restricting M+C intake during a LPS challenge decreases albumin synthesis and tends to reduce plasma protein synthesis, implicating M+C as important nutrients involved in the immune response.

Whole body protein turnover in children with human immunodeficiency virus (HIV) infection

The purpose of this study was to determine the rate of whole body protein turnover (WBPT) in human immunodeficiency virus (HIV)-infected children, and to determine the relationship between WBPT and growth. The rate of WBPT was calculated from the cumulative excretion of labeled urinary ammonia after a single intravenous dose of 15N-glycine in three groups of children: 1) HIV+ with growth retardation (HIV+ Gr); 2) HIV+ with normal growth (HIV+); and 3) HIV-uninfected with normal growth (HIV-). Twenty-six children between 2 and 11 y of age were studied (10 HIV+ Gr, 12 HIV+, 4 HIV-). All children were afebrile and free of acute infection during the study. Rates of WBPT (mean +/- SD) for the study groups were: HIV+ Gr, 12.2 +/- 4.8; HIV+, 10.7 +/- 5.1; and HIV-, 8.6 +/- 2.1 g.protein.kg-1.d-1 (NS, P > 0.05). Although not statistically significant, mean WBPT was 42% greater in HIV+ Gr, and 24% greater in HIV+ compared to HIV-. Statistically significant correlations were found between WBPT and Z scores for height (r = -0.39, P = 0.05) and weight-for-age (r = -0.51, P = 0.01) and dietary intake of protein (r = 0.39, P = 0.05), and between protein balance (synthesis-catabolism) and intakes of energy (r = 0.47, P = 0.02) and protein (r = 0.40, P = 0.04). There was no statistically significant correlation between WBPT and resting energy expenditure (r = 0.27, P = 0.19), or CD4 cell number (r = 0.05, P = 0.82). These data suggest an association between increased rates of protein turnover and low weight and height-for-age Z scores, and that it may be possible to achieve positive protein balance given an adequate intake of nutrients.

Protein synthesis in the heart in vivo, its measurement and patho-physiological alterations

Changes in cardiac protein composition occur in a variety of patho-physiological situations and are usually accompanied by modifications in protein synthesis. Although adjustments in protein synthesis during starvation may be adaptive, the alterations in protein synthesis seen in response to ethanol ingestion may be pathological and an important step in the genesis of alcoholic heart muscle disease. The alterations in heart muscle in hypertension are initially adaptive but in the long term they are deleterious, and involve both transcription and translation. While adequate methods exist for quantifying the amount of mRNA for contractile and non-contractile proteins, such studies of gene-expression provide no dynamic information on the rate at which tissue proteins are lost or accrued. This can only be determined by measuring the rate of protein turnover, i.e. either protein synthesis or protein breakdown. Techniques for directly determining the rates of protein breakdown are limited or involve surgical procedures. Methods for measuring the rate of protein synthesis are described, and are illustrated by their application to the investigation of starvation and ethanol toxicity. In particular, attention is focused on the fact that reliable rates of protein synthesis are obtained only if the specific radioactivity of the precursor at the site of protein synthesis (aminoacyl-tRNA) is assessed.

Enhancement of the anabolic effects of growth hormone and insulin-like growth factor I by use of both agents simultaneously

The use of growth hormone (GH) as an anabolic agent is limited by its tendency to cause hyperglycemia and by its inability to reverse nitrogen wasting in some catabolic conditions. In a previous study comparing the anabolic actions of GH and IGF-I (insulin-like growth factor I), we observed that intravenous infusions of IGF-I (12 micrograms/kg ideal body wt [IBW]/h) attenuated nitrogen wasting to a degree comparable to GH given subcutaneously at a standard dose of 0.05 mg/kg IBW per d. IGF-I, however, had a tendency to cause hypoglycemia. In the present study, we treated seven calorically restricted (20 kcal/kg IBW per d) normal volunteers with a combination of GH and IGF-I (using the same doses as in the previous study) and compared its effects on anabolism and carbohydrate metabolism to treatment with IGF-I alone. The GH/IGF-I combination caused significantly greater nitrogen retention (262 +/- 43 mmol/d, mean +/- SD) compared to IGF-I alone (108 +/- 29 mmol/d; P < 0.001). GH/IGF-I treatment resulted in substantial urinary potassium conservation (34 +/- 3 mmol/d, mean +/- SE; P < 0.001), suggesting that most protein accretion occurred in muscle and connective tissue. GH attenuated the hypoglycemia induced by IGF-I as indicated by fewer hypoglycemic episodes and higher capillary blood glucose concentrations on GH/IGF-I (4.3 +/- 1.0 mmol/liter, mean +/- SD) compared to IGF-I alone (3.8 +/- 0.8 mmol/liter; P < 0.001). IGF-I caused a marked decline in C-peptide (1,165 +/- 341 pmol/liter; mean +/- SD) compared to the GH/IGF-I combination (2,280 +/- 612 pmol/liter; P < 0.001), suggesting maintenance of normal carbohydrate metabolism with the latter regimen. GH/IGF-I produced higher serum IGF-I concentrations (1,854 +/- 708 micrograms/liter; mean +/- SD) compared to IGF-I only treatment (1,092 +/- 503 micrograms/liter; P < 0.001). This observation was associated with increased concentrations of IGF binding protein 3 and acid-labile subunit on GH/IGF-I treatment and decreased concentrations on IGF-I alone. These results suggest that the combination of GH and IGF-I treatment is substantially more anabolic than either IGF-I or GH alone. GH/IGF-I treatment also attenuates the hypoglycemia caused by IGF-I alone. GH/IGF-I treatment could have important applications in diseases associated with catabolism.

Substrate efficacy in early nutrition support of critically ill multiple trauma victims

The metabolic consequences of excessive nutrition support in patients have been increasingly recognized in recent years. Time-dependent optimal nutrition support is desired for an early and uncomplicated recovery after severe injury or illness. Metabolic effects of adding balanced amino acids to glucose infusion during total parenteral nutrition were investigated in 18 patients after major trauma (injury severity score 32 +/- 2). Two studies were conducted on each subject, one in the early "flow" phase of injury (40-60 hours postinjury) in the basal state without any dietary intake and then after 4 to 6 days of intravenous nutrition provided solely as glucose (24 +/- 2 kcal/kg per day, 80% resting energy expenditure, n = 8) or isocaloric glucose (28 +/- 3 kcal/kg per day) with amino acids (275 +/- 28 mg of nitrogen per kilogram per day, n = 10). Whole-body fuel substrate kinetics were studied for energy metabolism (indirect calorimetry), protein kinetics (primed-constant infusion of 15N glycine), and lipid mobilization (two-stage infusion of 10% glycerol). Injury-induced hypoaminoacidemia was equally modulated whether the glucose-based nutrition had amino acids or not. The negative nitrogen balance is reduced similarly in both groups. Protein breakdown rate is significantly (p = .025) decreased in both groups and it is more so (30% vs 18%) in patients receiving total parenteral nutrition. Intravenous nutrition could not stimulate protein synthesis. Whole-body lipolysis rate as well as net fat oxidation rate are suppressed more when glucose alone is given, and this also results in less reesterification. Provision of intravenous glucose alone, not to exceed the resting energy expenditure, seems to be superior to isocaloric glucose with amino acids during this early catabolic flow phase of injury because the injured body could not assimilate this exogenous amino acid.

Treatment effects of parenteral vitamins in total parenteral nutrition patients

To determine the prevalence of abnormal vitamin levels in an adult hospitalized population requiring total parenteral nutrition (TPN) and to assess the effect of routine parenteral vitamin therapy on vitamin levels, we studied 35 general surgical patients. Assays for 12 vitamins were performed both before and after a standard 10-day course of TPN. Patients were given nothing by mouth. The first 25 patients received a daily parenteral vitamin mixture tailored to the recommendations of the Nutrition Advisory Group of The American Medical Association (maintenance dose). The final 10 patients were given a parenteral multivitamin dose providing substantially greater amounts of most vitamins (repletion dose). Only 58% (190/324) of pre-TPN vitamin levels were normal, 25% were low, and 17% were high. No patient had fewer than two abnormal baseline levels. Vitamin levels did not correlate with serum albumin, body weight, or nitrogen balance. After 10 days of treatment, only 39% of low pre-TPN vitamin levels improved; most (45/62) of the low posttreatment levels were low at baseline. The higher repletion dose resulted in a significantly (p less than 0.01) greater percent increase in vitamin A, C, and pyridoxine levels. The prevalence of abnormal vitamin levels in this population is high (42%). Standard parenteral vitamin therapy leads to marginal improvement in abnormally low pre-TPN vitamin levels.

Intravenous branched chain amino acid trial in marrow transplant recipients

Branched chain amino acids (BCAA) improve nitrogen balance and end-organ function in surgical patients, but are untested in marrow transplant recipients. We compared nitrogen balance, urinary 3-methylhistidine-to-creatinine ratio, upper arm anthropometry, serum prealbumin, and day to peripheral engraftment in a randomized, double-blinded trial between 45% (high-leucine) and 23% BCAA intravenous solutions in 40 adult leukemia patients for 1 month following allogeneic marrow transplantation. Nutritional support, provided at approximately 30 nonprotein calories/kg and 0.21 g nitrogen/kg ideal weight, did not differ between groups. Despite greater nitrogen loss and muscle breakdown evidenced by increased 3-methylhistidine-to-creatinine ratio and loss of arm muscle area by study end in the 45% BCAA, no statistical differences were observed when nitrogen balance was compared by week and within stress level as defined by organ and infectious complications. It is likely the patients in the 45% BCAA experienced greater metabolic stress by study end. Serum prealbumin and day posttransplant to peripheral engraftment also did not differ between groups. The chances (power) of this study exceeded 85% in detecting a difference in nitrogen balance of 2.5 g during study week 1 and 4.0 g during week 2. The power during week 3 was 77% for detecting a difference of 4.0 g, and it is unlikely that the true difference exceeds this magnitude. Thus, we did not find any evidence that intravenous BCAA-enriched solutions improved nitrogen balance during the first month after marrow transplantation.

The effects of rate and route of nutrient intake on protein metabolism

Isotopic measurements of protein kinetics are useful for the investigation of metabolic protein disorders during surgical illness. The effects of rate and route (oral vs parenteral) of nutritional substrate intake have not been well defined. Fischer 344 rats were infused with a total parenteral nutrition (TPN) solution at either 25, 100, or 175% of their normal substrate intake or were fed an oral diet ad libitum. After 4 days, [15N]glycine was infused at 0.138 mg 15N/hr for 24 hr. Whole-body protein turnover (WPT), synthesis, and catabolism were determined by 15N urea enrichment. Fractional synthesis rates (FSR) of liver and muscle protein were calculated by analyzing 15N tissue enrichment. WPT (r = 0.93, P less than 0.001) and liver FSR (r = 0.57, P less than 0.01) increased linearly with TPN infusion rates. All rats had protein synthesis rates greater than catabolism rates except for the rats infused with 25% TPN. Although caloric intake was the same in rats fed orally and those infused with 100% TPN, the orally fed rats had faster WPT (P less than 0.001), synthesis (P less than 0.05), catabolism (P less than 0.001), and liver FSR (P less than 0.05) than the TPN rats. Muscle FSR was not significantly affected by either the route of feeding or the TPN infusion rate. In this study, rate and route of substrate intake affected protein kinetics in the whole animal and liver, but not in muscle. Rate and route of nutrient intake need to be carefully specified and controlled during isotopic studies of protein kinetics.

The effect of aspirin on protein breakdown in septic man

In pathological states associated with hypermetabolism, such as acute sepsis, there is marked negative N balance. It has been suggested that the pathway for this response is via leukocyte pyrogen (interleukin I) acting on cyclooxygenase to stimulate prostaglandin release, which then stimulates proteolysis via the lysosomal pathway. In vitro, cyclooxygenase inhibitors decrease proteolysis in muscle tissue from septic rats. We tested this hypothesis in vivo in severely septic patients by using aspirin as the test cyclooxygenase inhibitor. Septic patients (n = 4) were given a primed, constant infusion (183 mg prime, then 37 mg/hr) of 15N-labeled urea for 6 hr to obtain a blood [15N]urea plateau. Blood samples were taken every 30 min. At 180 min 1500 mg of aspirin was given po. If aspirin inhibited protein breakdown, the plateau level should rise, since less cold urea derived from protein breakdown will enter the urea pool. Aspirin did not cause any change in either the BUN concentration, its 15N enrichment, or any of the plasma amino acids. In conclusion, cyclooxygenase inhibition by aspirin in vivo does not decrease protein breakdown in hypercatabolic septic patients.

Supplemental essential amino acids augment the somatomedin-C/insulin-like growth factor I response to refeeding after fasting

Plasma somatomedin-C (Sm-C)/insulin-like growth factor I (IGF-I) concentrations have been shown to reflect changes in nitrogen balance induced by manipulation of nutrient intake. To assess the Sm-C/IGF-I response to refeeding a protein restricted diet in which the nitrogen source was supplemented with essential amino acids, six normal adults were fasted for five days, then refed for nine days diets consisting of 35 kcals/kg and 0.48 g protein/kg body weight. In one diet, 80% of the nitrogen was supplied as essential amino acids, and in the other, 80% was supplied as nonessential amino acids. Following the first fast/refeed cycle, a control diet was eaten for two weeks before the fast was repeated and the other test diet was ingested. The refeeding diets were given a random order. Plasma Sm-C/IGF-I fell from a pre-fast mean of 1.64 +/- 0.24 U/mL (mean +/- 1 SEM) to 0.67 +/- 0.18 (P less than 0.001) following fasting, and rose to 1.41 +/- 0.19 U/mL (P less than 0.001) following ingestion of the diet with supplemental essential amino acids. In contrast, when the same subjects were refed a diet in which 80% of the nitrogen was in the form of nonessential amino acids, the plasma Sm-C/IGF-I concentrations rose from 0.74 +/- 0.17 to 1.15 +/- 0.15 U/mL (P less than 0.01). This increase was significantly less than that observed after ingestion of the essential amino acid supplemented diet (0.74 +/- 0.10 U/mL v 0.40 +/- 0.11 U/mL; P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of increasing total parenteral nutrition on protein metabolism

We asked the question, if the amount of nutrients given parenterally is progressively increased, does the rate of whole body protein synthesis rate increase correspondingly and how does the protein breakdown rate change? Eight malnourished patients requiring total parenteral nutrition (TPN) were studied. We measured their whole body protein synthesis and breakdown rate four times at intervals of 3 days using 15N glycine as the tracer. The first study was done pre-TPN. The 2nd, 3rd, and 4th studies were done at increasing TPN rates. The rates were TPN 1, 1440 kcal/day and 7.9 g/N/day; TPN 2, 2160 kcal/day and 11.9 g/N/day; TPN 3, 2880 kcal/day and 15.8 g/N/day. The protein synthesis rate initially increased as the amount of TPN was increased, but increasing the rate from TPN-2 to TPN-3 did not result in further increase. Increasing the rate of TPN above a certain level does not lead to a concomitant increase in the protein synthesis rate.