Whole body protein synthesis in relation to basal energy expenditure in healthy children and in children recovering from burn injury

Lower oxygen consumption and Complex I activity in mitochondria isolated from skeletal muscle of fetal sheep with intrauterine growth restriction

Fetal sheep with placental insufficiency-induced intrauterine growth restriction (IUGR) have lower hindlimb oxygen consumption rates (OCRs), indicating depressed mitochondrial oxidative phosphorylation capacity in their skeletal muscle. We hypothesized that OCRs are lower in skeletal muscle mitochondria from IUGR fetuses, due to reduced electron transport chain (ETC) activity and lower abundances of tricarboxylic acid (TCA) cycle enzymes. IUGR sheep fetuses (n = 12) were created with mid-gestation maternal hyperthermia and compared with control fetuses (n = 12). At 132 ± 1 days of gestation, biceps femoris muscles were collected, and the mitochondria were isolated. Mitochondria from IUGR muscle have 47% lower State 3 (Complex I-dependent) OCRs than controls, whereas State 4 (proton leak) OCRs were not different between groups. Furthermore, Complex I, but not Complex II or IV, enzymatic activity was lower in IUGR fetuses compared with controls. Proteomic analysis (n = 6/group) identified 160 differentially expressed proteins between groups, with 107 upregulated and 53 downregulated mitochondria proteins in IUGR fetuses compared with controls. Although no differences were identified in ETC subunit protein abundances, abundances of key TCA cycle enzymes [isocitrate dehydrogenase (NAD+) 3 noncatalytic subunit β (IDH3B), succinate-CoA ligase ADP-forming subunit-β (SUCLA2), and oxoglutarate dehydrogenase (OGDH)] were lower in IUGR mitochondria. IUGR mitochondria had a greater abundance of a hypoxia-inducible protein, NADH dehydrogenase 1α subcomplex 4-like 2, which is known to incorporate into Complex I and lower Complex I-mediated NADH oxidation. Our findings show that mitochondria from IUGR skeletal muscle adapt to hypoxemia and hypoglycemia by lowering Complex I activity and TCA cycle enzyme concentrations, which together, act to lower OCR and NADH production/oxidation in IUGR skeletal muscle.

Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose 15 N Glycine Stable Isotope Protocol With End-Product Enrichment

BACKGROUND

We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery.

MATERIALS AND METHODS

A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown.

RESULTS

We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance.

CONCLUSION

The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.

New ways of defining protein and energy relationships in inborn errors of metabolism

Dietary restrictions required to manage individuals with inborn errors of metabolism (IEM) are essential for metabolic control, however may result in an increased risk to both short and long-term nutritional status. Dietary factors most likely to influence nutritional status include energy intake, protein quality and quantity, micronutrient intake and the frequency and extent to which the diet must be altered during periods of increased physical or metabolic stress. Patients on the most restrictive diets, including those with intakes consisting of low levels of natural protein or those with recurrent illness or frequent metabolic decompensation carry the most nutritional risk. Due to the difficulties in determining condition specific requirements, dietary intake recommendations and nutritional monitoring tools used in patients with IEM are the same as, or extrapolated from, those used in healthy populations. As a consequence, evidence is lacking for the safest dietary prescriptions required to manage these patients long term, as tolerance to dietary therapy is generally described in terms of metabolic stability rather than long term nutritional and health outcomes. As the most frequent therapeutic dietary manipulation in IEM is alteration in dietary protein, and as protein status is critically dependent on adequate energy provision, the use of a Protein to Energy ratio (P:E ratio) as an additional tool will better define the relationship between these critical components. This could accurately define dietary quality and ensure that not only an adequate, but also a safe and balanced intake is provided.

Malnutrition in critically ill children: from admission to 6 months after discharge

BACKGROUND & AIMS

Little is known about the nutritional status of critically ill children during hospitalisation in and after discharge from an intensive care unit. We set up a prospective, observational study to evaluate the nutritional status of children in an intensive care unit from admission up to 6 months after discharge. A secondary aim was identifying patient characteristics that influence the course of the various anthropometric parameters.

METHODS

The nutritional status of 293 children--104 preterm neonates, 96 term neonates and 93 older children--admitted to our multidisciplinary tertiary pediatric and neonatal intensive care unit was evaluated by anthropometry upon and during admission, at discharge and 6 weeks and 6 months following discharge.

RESULTS

Upon admission, 24% of all children appeared to be undernourished. Preterm and term neonates, but not older children, showed a decline in nutritional status during admission. At 6 months after discharge almost all children showed complete recovery of nutritional status. Length of stay and history of disease were the parameters that most adversely affected the nutritional status of preterm and term neonates at discharge and during follow-up.

CONCLUSION

While malnutrition is a major problem in pediatric intensive care units, most children have good long-term outcome in terms of nutritional status after discharge.

Assessment of whole body protein metabolism in critically ill children: can we use the [15N]glycine single oral dose method?

BACKGROUND & AIMS

Most stable-isotope methods to evaluate whole body protein metabolism in patients are invasive and difficult to use in children. In this study protein metabolism was evaluated with the non-invasive [15N]glycine single oral dose method in critically ill children and the value of the method is discussed.

METHODS

[15N]glycine (100mg) was given orally to children (mean age 5.5 years; range 0.6-15.5 years) with meningococcal septic shock (MSS, n = 8), pneumonia (n = 5), and to healthy, fed and post-absorptive children (n = 10). Urine was collected during 9h, total amount of NH(3), labelled NH(3) and nitrogen were measured, and protein turnover, synthesis and breakdown were calculated using urinary NH(3) as end-product.

RESULTS

Mean protein turnover in children with MSS, pneumonia and fed and post-absorptive healthy children was 0.63+/-0.13, 0.38+/-0.10, 0.28+/-0.03 and 0.28+/-0.02g N/kg/9h, respectively. Mean protein synthesis was 0.55+/-0.12, 0.29+/-0.09, 0.18+/-0.02, 0.20+/-0.02g N/kg/9h, respectively. Mean protein breakdown was 0.56+/-0.14, 0.28+/-0.12, 0.08+/-0.03, 0.28+/-0.02g N/kg/9h, respectively. Protein turnover, synthesis and breakdown were significantly increased in MSS patients compared to fed healthy children (P <0.01) and post-absorptive children (P <0.05). Protein turnover, protein synthesis, protein breakdown were significantly correlated with disease severity and body temperature (P <0.05).

CONCLUSION

Results of whole body protein metabolism measured with the [15N]glycine single oral dose method in children with MSS and in healthy children were in line with expectations based on results obtained in earlier reports and with different methods.

Uptake of alpha-aminoisobutyric acid and cycloleucine on skeletal muscles in burned rats

The uptake of alpha-aminoisobutyric acid (AIB) and aminocyclopentane-carboxylic acid (cycloleucine) was studied in soleus muscles isolated from small rats (body weight 50-60 g) during the first 6 h after a major thermal injury, the so-called 'ebb phase' or 'hypometabolic phase'. Soleus muscles were dissected intact from rats at 0.5, 1, 3 and 6 h after extensive deep burn injury (30 per cent TBSA) and then incubated for 2 h in Krebs-Henseleit bicarbonate buffer (pH 7.4), 5.5 mM glucose, bovine serum albumin and radiolabelled AIB or cycloleucine. The results were expressed as the distribution ratio of AIB or cycloleucine between intracellular and extracellular fluid. The AIB uptake in vitro was found to be significantly increased (30 per cent) in the initial half hour postburn only, and then slowly reduced during the subsequent hours to near the value found in non-burn animals. Muscle cycloleucine uptake in vitro showed no significant change in these studies. In our second study, extensor digitorum longus leg muscle were incubated in Krebs-Henseleit bicarbonate buffer with different pH values (7.2-7.5). No significant difference was found in muscle AIB uptake. In summary, since muscle amino acid uptake remained relatively stable during this period, it is suggested that the alteration of amino acid transport across muscle cells may not be a contributing factor to the alteration of amino acid flux during the early phase of stress.

Control of protein synthesis and its relationship to the bioenergetics of growth

A key goal of nutritional therapies designed to prevent or treat protein energy malnutrition (PEM) is achievement of adequate growth rates and thus positive balances of protein and energy. Positive protein balance is the net result of protein turnover, i.e., of recycling protein through energy-requiring anabolic and catabolic pathways. Thus, protein turnover is inexorably linked to energy metabolism and to energy balance. A long-standing hypothesis is that new tissue synthesis is predominantly a postprandial event. Thus, postprandial rates of protein turnover may regulate the bioenergetics of growth. Traditional methods to evaluate nutritional therapies for diarrhea and PEM, i.e., metabolic balance, 15N-labeled amino acids, fecal output, illness duration, or change in body weight, are not specific to studies of the regulation of acute protein turnover and growth by nutritional intervention. Newer techniques based on 13C-labeled amino acids should be applied to evaluate nutritional interventions such as dietary substrate ratios, protein quality, feeding frequencies, or ratios of dietary protein to energy in terms of their abilities to optimize postprandial protein turnover and thus nutritional management of diarrhea or PEM.

Protein and energy interactions throughout life. Metabolic basis and nutritional implications

We review selected aspects of the interactions between protein and energy in human metabolism and nutrition. Following a short account of the underlying metabolic basis for the effects of energy on protein metabolism, the contribution made by whole body protein turnover to the metabolic rate is discussed, including the relationship between protein turnover and energy metabolism at different phases of life. The effects of changes in energy metabolism and intake on the nitrogen economy of the host are also reviewed briefly and we explore the relationship between amino acid oxidation and requirements for indispensable amino acids. Interactions between energy and protein metabolism need to be investigated in greater detail and also they must be considered in relation to further attempts to establish more precisely energy and amino acid requirements of people under various circumstances.

Advances in hospital nutrition

The General Clinical Research Center facilities have been largely responsible for expansion of knowledge in the field of hospital nutrition. Expansion of this knowledge base has led to major medical advances in this century. Without the meticulous attention necessary for metabolic balance studies many if not most of these advances would have been seriously delayed. The role that General Clinical Research Centers have played and will continue to play cannot be overestimated.

Determinants of urinary nitrogen excretion in burned patients

A retrospective study of urinary urea excretion has been performed in 91 burned patients. Maximum mean excretion occurred between days 5 and 8 after injury. The rate of excretion during this peak period correlated significantly with the sex and age of the patient as well as the burn size. It is suggested that peak nitrogen excretion may be more accurately predicted if all three variables are considered. However, the wide variation seen in patient response and differences in clinical management mean that regular measurement of urinary urea excretion still provides the most reliable guide to dietary protein requirements after a burn.

Contribution of whole-body protein synthesis to basal metabolism in layer and broiler chickens

The effect of starvation on whole-body protein synthesis and on the contribution of protein synthesis to basal metabolic rate was investigated in young chickens (Expt 1). Strain differences between layer and broiler chickens in whole-body protein synthesis and degradation rates were examined when the birds were starved (Expt 2). In Expt 1, 15-d-old White Leghorn male chickens were used, while in Expt 2 Hubbard (broiler) and White Leghorn (layer) male chickens at 14 d of age were used. They were starved for 4 d, and heat production was determined by carcass analysis after 2 and 4 d of starvation. Whole-body protein synthesis rates were measured on 0, 2 and 4 d of starvation (Expt 1), and on 0 and 4 d of starvation (Expt 2). The results showed that starving reduced whole-body protein synthesis in terms of fractional synthesis rate and the amount synthesized. Whole-body protein degradation was increased by starvation both in terms of fractional synthesis rate and the amount degraded on a per kg body-weight basis. Reduced fractional synthesis rate of protein in the whole body was accounted for by reductions in both protein synthesis per unit RNA and RNA:protein ratio. In the fed state, whole-body protein synthesis and degradation rates, whether expressed as fractional rates or amounts per unit body-weight, tended to be higher in layer than in broiler chickens. In the starved state, the difference in the rate of protein synthesis between the two strains virtually disappeared, while the degradation rates were higher in layer than in broiler birds.(ABSTRACT TRUNCATED AT 250 WORDS)

Close association of accelerated rates of whole body protein turnover (synthesis and breakdown) and energy expenditure in children with newly diagnosed acute lymphocytic leukemia

Using a single-dose [15N]glycine turnover technique, we studied protein metabolism in 15 children with newly diagnosed acute lymphocytic leukemia (ALL). As in our previous study, we observed increased rates of whole body protein synthesis (S) and breakdown (B) in comparison to healthy controls. In eight patients, we assessed basal metabolic rate (BMR). There was a significant linear regression between BMR (kcal/d) (Y) and S (g protein/d) (X): y = 3.7 X + 850 (R = 0.925, p less than 0.001). There was also a significant linear correlation between BMR, expressed as a percentage of the normal value, and S expressed as a percentage of the mean value in the healthy children (r = 0.79, p less than 0.05). There were also significant positive correlations between BMR and body weight (r = 0.75, p less than 0.05) or age (r = 0.83, p less than 0.05) and between S and weight or age (both, r = 0.86, p less than 0.01). BMR (kcal/d) also correlated with B (g protein/d) (r = 0.91, p less than 0.01). Multiple regression analysis revealed that BMR was much more highly related to S than to weight. These data suggest that increased rates of S are closely related to increased energy requirements in patients with ALL. Furthermore, these data provide evidence for the biological relevance of whole body protein kinetics.

Energy metabolism in healthy black Kenyan children

1. Twenty-four healthy black Kenyan children, mean age 29 (SD 19) months, were studied over a 24 h period. Energy expenditure (EE) was determined using a ventilated-hood indirect calorimeter; measuring oxygen consumption and carbon dioxide production. Metabolizable energy intake was measured in twenty children. Anthropometric measurements were used to estimate surface area and lean body-weight. 2. The mean daily intake of metabolizable energy was 338.4 (SE 28.4) kJ/kg; 70% of gross dietary energy being provided by carbohydrate. The level of postprandial EE was significantly (P less than 0.05) higher than the resting level (12.6 (SE 0.47) and 11.38 (SE 0.37) kJ/kg per h respectively) while the level of the postprandial respiratory quotient (RQ) was similar to the resting level (0.94 (SE 0.02) and 0.98 (SE 0.03 respectively). In 33% of total observations of the resting RQ the value was more than 1.0. These findings suggest that short-term fat storage may be a normal feature of metabolism in children, and also that the energy cost of (postprandial) fat synthesis is increased by a high-carbohydrate diet. 3. Values for the resting metabolic rate and various estimators of body size were compared using regression analysis. It was evident that, in these young children with considerable variation in body composition, body-weight remained a satisfactory metabolic-size estimator.

Principles of burn dressings

Throughout history burn wounds have been treated by covering with dressings of many different materials. The successful application of a burn dressing remains an objective for biomaterial development. This paper examines how the burn wound differs from other skin injuries, the requirements of the ideal burn wound dressing, and reviews the type of dressings available. The dressings in common use in the treatment of burns are compared with the 'ideal' dressing, in so far as it can be defined.

Altered protein kinetics in vivo after single-limb burn injury

Recovery from burn injury is associated with stimulated whole-body protein turnover. Since skeletal muscle and liver are the tissues most likely to influence whole-body measurements, we studied protein kinetics in soleus and plantaris muscles as well as liver 3 days after a 3 s burn on one hindlimb of the rat. Muscles from both the burned and unburned limbs of burned rats were compared with those of uninjured controls to distinguish between local and systemic factors involved. The following measurements were performed: (1) fractional growth rate of the tissue protein pool, determined from tissue protein content on days 2, 3 and 4; (2) fractional protein-synthetic rate, measured by [14C]tyrosine constant infusion on day 3; (3) fractional protein-degradation rate, calculated from the difference between the rates of protein synthesis and growth. Protein growth by soleus and plantaris muscles of control rats and unburned limb of burned rats was not paralleled by those in the burned limb, which showed progressive atrophy between 2 and 4 days post-burn (P less than 0.005). Protein synthesis by soleus but not plantaris muscle in the unburned limb of burned rats was enhanced by 62% (P less than 0.04) above control. Protein synthesis by burned-limb soleus and plantaris muscles was elevated by 114% (P less than 0.001) and 67% (P less than 0.02) respectively above control. Protein degradation by both soleus and plantaris muscles in the unburned limb of burned rats did not differ from control. In contrast, that of soleus and plantaris muscles in the burned limb was stimulated by 230% (P less than 0.001) and 164% (P less than 0.001) respectively compared with controls. Protein turnover of soleus muscles in both control and burned rats was more rapid than in corresponding plantaris muscles. Liver protein mass exhibited steady growth in control rats, but remained unchanged in burned animals between 2 and 4 days post-burn. Liver protein synthesis in burned rats was elevated by 56% (P less than 0.01) and protein breakdown was stimulated by 61% (P less than 0.002) above those of controls. The data indicate that both local and systemic factors influence tissue protein turnover in animals recovering from a single-hindlimb scald.

Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding

This study was performed to investigate the mechanism whereby immediate enteral feeding after burn injury reduces postburn hypermetabolism and hypercatabolism. Fifty-seven burned guinea pigs (30% TBSA) were divided into three groups: A (N = 19), given 175 kcal/kg/day beginning 2 hours after burn; B (N = 20), given 175 kcal/kg/day with an initial 72-hour adaptation period; and C (N = 18), given 200 kcal/kg/day with the same adaptation period as B. Resting metabolic expenditure (RME) on PBD 13 was lowest in group A (109% of preburn level), compared with group B (144%, p less than 0.001) and group C (137%, p less than 0.01). On PBD 1, group A had the greatest jejunal mucosal weight and thickness (p less than 0.001), and mucosal weight had negative correlations with plasma cortisol (r = 0.829, p less than 0.001) and glucagon (r = 0.888, p less than 0.001). Two weeks after burn, urinary vanillyl mandelic acid (VMA) excretion, plasma cortisol, and glucagon were lowest in group A (p less than 0.05 to p less than 0.01). These hormones also significantly correlated with RME (p less than 0.01 to p less than 0.001). These findings suggest that immediate postburn enteral feeding can prevent hypermetabolism via preservation of gut mucosal integrity and prevention of excessive secretion of catabolic hormones.

Energy and nitrogen balances in 24 severely burned patients receiving 4 isocaloric diets of about 10 MJ/m2/day (2392 Kcalories/m2/day)

Twenty-four subjects with burns ranging from 25-70 per cent received for 12 days exclusively per os a series of 4 isocaloric diets of about 4000 Kcal--'normal', or hyperproteic, or hyperlipidic, or hyperglucidic according to a randomized schedule. Oxygen consumptions were measured at the end of each diet and nitrogen balance was determined every day. Though patients were not massively overfed there remained a positive energy gap. The nitrogen balance was found to be equilibrated on the whole but clearly positive with the hyperproteic diet and clearly negative with the hyperlipidic-normoproteic diet. Thus there is no rationale for the huge energy overfeeding classically used.

Whole-body leucine and lysine metabolism: response to dietary protein intake in young men

Whole-body leucine and lysine metabolism was explored in young adult men by a primed constant intravenous infusion of a mixture of L-[1-13C]leucine and L-[alpha-15N]lysine over a 4-h period. Subjects were studied after an overnight fast (postabsorptive state) or while consuming hourly meals (fed state) after adaptation to diets providing either a surfeit level of protein (1.5 g.kg body-1.day-1), a level approximating maintenance requirements (marginal intake) (0.6 g.kg body wt-1.day-1), or a grossly inadequate level (0.1 g.kg-1.day-1). The change in protein intake from a marginal to a surfeit level was associated with an increased leucine flux and incorporation of leucine into body protein. In the fed state, oxidation of leucine increased sharply and release of leucine from tissue protein diminished. When dietary protein intake was reduced from the requirement to inadequate level, leucine flux and body protein synthesis and protein breakdown were reduced, together with a smaller reduction in leucine oxidation. The response of the metabolism of [15N]lysine was responsible for maintenance of leucine and other essential amino acid economy, and they appear to be related to the nitrogen and amino acid requirements of the subject. These findings also demonstrate an effect of meals, modulated by their protein content, on the dynamics of whole-body amino acid metabolism.

Effects of dietary intake and hemodialysis on protein turnover in uremic children

The dynamic aspects of protein metabolism in uremic children were studied by using newly developed gas chromatography and mass spectrometry micromethods for determining nitrogen-15 enrichment in plasma lysine during a continuous i.v. infusion of 15N-lysine. Protein flux in uremic children was low and varied directly with protein and energy intake, which themselves were closely related in the diets consumed by the study subjects. Hemodialysis did not alter acutely protein flux. Protein flux in children undergoing chronic hemodialysis was still reduced below normal but was higher than that in nondialyzed uremic children at each level of protein-energy intake. The ratio of protein flux to protein intake was 0.05 +/- 0.003 g of protein x kg-1 x day-1 x kcal ingested in the nondialyzed uremic children, but it increased to a normal vaue of 0.11 +/- 0.03 g x kg-1 x day-1 x kcal in those on longterm hemodialysis. We conclude that the low protein turnover rates in our uremic population reflect the decreased protein-energy intake commonly found in such patients and that reduction of azotemia by chronic hemodialysis may improve whole body transport at a given energy intake.