Metabolism of sepsis and multiple organ failure

Michie H.R.
North Western Injury Research Center, Manchester University, Bolton Hospitals NHS Trust, Manchester United Kingdom
World Journal of Surgery (USA), 1996, 20/4 (460-464)

'Septic autocannabalism' been coined to describe the metabolic response that follows severe sepsis in humans. The normal protein- and energy- conserving mechanisms evoked during simple starvation are not observed following the onset of sepsis. The metabolic response to sepsis entails rapid breakdown of the body's reserves of protein, carbohydrate, and fat. Hyperglycemia with insulin resistance, profound negative nitrogen balance, and diversion of protein from skeletal muscle to splanchnic tissues are prominent features. These responses are believed to be mediated in large part by inflammatory cytokines such as tumor necrosis factor alpha (TNFalpha), interleukin 1beta (IL-1beta), and IL-6. Secondary induction of catecholamines, cortisol, and glucagon by cytokines is likely to be another important effector mechanism. Infection and inflammation elicit a complex network of interwoven responses, and no single mediator alone accounts for the responses observed. Sepsis also commonly involves alterations in cardiovascular function with altered flow to key metabolic sites, hypoxia, damage to the gut's mucosal barrier, secondary organ failure, and alterations in capillary permeability. These structural and functional alterations also strongly influence the metabolic profile during infection. If these catabolic responses persist for more than a few days, severe malnutrition results and is likely to be an important risk factor for mortality in these patients. The altered metabolic milieu during sepsis prevents effective use of exogeneously delivered glucose and protein; at best, administration of these agents ameliorates but does not prevent the persistence of catabolism. Delivery of agents that antagonize cytokines and other moieties such as glutamine and growth hormone may, in the future, help to restore nitrogen balance during sepsis.

Fibronectin fragment mediated cartilage chondrolysis. II. Reparative effects of anti-oxidants

Homandberg G.A.; Hui F.; Wen C.
Department of Biochemistry, Rush Medical College, Rush-Presbyt.-St Luke Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3864 USA
Biochimica et Biophysica Acta - Molecular Basis of Disease (Netherlands), 1996, 1317/2 (143-148)

In an accompanying manuscript, it was shown that the cartilage chondrolytic activities of fibronectin fragments (Fn-f), which are mediated through catabolic cytokines such as TNF-alpha, IL-1 and IL-6, could be suppressed by anti-oxidants (AOs). The AOs neutralized reactive oxygen species (ROS) which are known to mediate catabolic cytokine action. The objective in this work was to test whether AOs would promote restoration of proteoglycan (PG) in Fn-f treated cartilage, since under normal culturing conditions, PG is, not restored after removal of the Fn-f. Cartilage was first cultured with an amino-terminal 29-kDa Fn-f to cause loss of about half of the total PG and then treated with NAC (1 and 10 mM) or glutathione (10 microM) or DMSO (0.1 or 1%). Treatment with NAC and glutathione maximally caused restoration of PG within 14 days to normal or supernormal levels, while DMSO was less effective. Catalase, but not superoxide dismutase, enhanced PG content to a small but significant extent. The restoration of PG in Fn-f treated cartilage occurred throughout the full depth of the cartilage slices as shown by histochemical analysis. However, removal of the AO allowed a subsequent decrease in PG content suggesting that the AOs had not blocked cytokine expression but had merely suppressed cytokine activities. Addition of NAC to IL-1 treated cartilage promoted a restoration of PG, while addition to chymopapain or trypsin treated cartilage was not very effective, suggesting that the effect of Aos requires a cytokine driven damage system. We conclude that the AOs promote a restoration of PG in the Fn-f treated cartilage by suppressing the effects of catabolic cytokines. The data suggest a potential for AOs in reversing tissue damage caused by cytokines.

Fibronectin fragment mediated cartilage chondrolysis. I. Suppression by anti-oxidants

Homandberg G.A.; Hui F.; Wen C.
Department of Biochemistry, Rush Medical College, Rush-Presbyt.-St Luke Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3864 USA
Biochimica et Biophysica Acta - Molecular Basis of Disease (Netherlands), 1996, 1317/2 (134-142)

Fibronectin fragments damage cartilage in vitro by greatly enhancing metalloproteinases and suppressing proteoglycan (PG) synthesis which results in severe cartilage PG depletion. Since reactive oxygen species (ROS) have been implicated in catabolic cytokine action and preliminary data suggested that catabolic cytokines such as TNF-alpha, IL-1alpha, IL-1beta and IL-6 are responsible for fibronectin fragment mediated damage, selected anti-oxidants (Aos) were tested as inhibitors of cytokine, ROS and fibronectin fragment activity. Damage was measured by depletion of cartilage PG during tissue culture. The AO, N-acetylcysteine (NAC), decreased the extent of cartilage PG depletion caused by TNF-alpha and IL-1alpha and by the ROS, hydrogen peroxide and superoxide anion, confirming that the cytokines operate through ROS and that ROS can initiate cartilage PG depletion. NAC at 0.1 and 1 mM, totally suppressed PG depletion caused by a highly potent amino-terminal 29-kDa fibronectin fragment (Fn-f) for 14 days in culture. NAC at 10 mM totally blocked Fn-f mediated PG depletion for 21 days and increased the cartilage PG content by 30% above normal levels, Glutathione (10 microM) and DMSO (1%) were also totally effective while catalase and superoxide decreased Fn-f mediated damage only during the first week and superoxide dismutase alone caused damage after 1 wk. The AOs caused protection by reducing the major catabolic activities of the Fn-f: enhanced release of stromelysin-1 (MMP-3) and suppression of PG and protein synthesis. NAC also decreased normal rates of PG degradation and increased the half-lives of labeled PG in both control and Fn-f treated cartilage. We conclude that the Fn-f mediates cartilage chondrolysis through ROS, consistent with the involvement of catabolic cytokines in the Fn-f mechanism, and that AOs greatly reduce Fn-fmediated cartilage chondrolysis. In an accompanying manuscript we also report that AOs promote reparative responses in Fn-f and cytokine treated cartilage.

Could L-carnitine be an acute energy inducer in catabolic conditions?

Keskin S; Seven A; Mert M; Akalp F; Yurdakul F; Candan G
Pediatrics Department, Cerrahpasa University, Istanbul, Turkey.
Dev Med Child Neurol (England) Mar 1997, 39 (3) p174-7

Serum free carnitine levels in five children (aged between 2.5 months and 4 years) with the findings of septic shock without disseminated intravascular coagulopathy and seven children (aged between 1.5 and 6.5 years) with the first attack of idiopathic status epilepticus were compared with those of eight healthy children (aged between 2.5 months and 5 years). Serum free carnitine levels showed a statistically significant decrease in the sepsis (mean 51.5 +/- 19 mg/L) and status epilepticus groups (mean 4.1 +/- 12.4 mg/L) (P = 0.006 and P = 0.001, respectively) when compared with the controls (mean 90.8 +/- 17.2 mg/L).

Bacterial carnitine metabolism.

Kleber HP
Institut fur Biochemie, Fakultat fur Biowissenschaften, Pharmazie und Psychologie, Universitat Leipzig, Germany
kleber@rz.uni-leipzig.de
FEMS Microbiol Lett (Netherlands) Feb 1 1997, 147 (1) p1-9

L-(-)-Carnitine is a ubiquitously occurring substance, essential for the transport of long-chain fatty acids through the inner mitochondrial membrane. Bacteria are able to metabolize this trimethylammonium compound in three different ways. Some, especially Pseudomonas species, assimilate L-(-)-carnitine as sole source of carbon and nitrogen. The first catabolic step is catalysed by the L-(-)-carnitine dehydrogenase. Others, for instance, Acinetobacter species, degrade only the carbon backbone, with formation of trimethylamine. Finally, various members of the Enterobacteriaceae are able to convert carnitine, via crotonobetaine, to gamma-butyrobetaine in the presence of C and N sources and under anaerobic conditions. This two-step pathway, including a L-(-)-carnitine dehydratase and the crotonobetaine reductase, was demonstrated in Escherichia coli. The DNA sequence encompassing the cai genes of E. coli, which encode the carnitine pathway, has been determined. Some bacteria are also able to metabolize the non-physiological D-(+)-carnitine, which results as a waste product in some chemical procedures for L-(-)-carnitine production based on the resolution of racemic carnitine.

Release of ischemia in paced rat Langendorff hearts by supply of L-carnitine: role of endogenous long-chain acylcarnitine.

Hulsmann WC; Peschechera A; Serafini F; Ferrari LE
Thorax Center, Erasmus University, Rotterdam, The Netherlands.
Mol Cell Biochem (Netherlands) Mar 9 1996, 156 (1) p87-91

Rat Langendorff hearts perfused with media that do not contain erythrocytes or fluorocarbon as oxygen carriers are borderline aerobic during 5 Hz pacing. This follows from the release of catabolic products measured: lactate, urate and Iysophosphatidyl-choline (IysoPC). Addition of L-carnitine to the perfusion medium reduced the level of these compounds, while the release of long-chain acylcarnitine (LCAC) increased. Previously, we found (Biochim Biophys Acta 847:62-66,1985) that micromolar LCAC protects membranes during reperfusion after ischemia. Therefore, the observed inverse relation between LCAC and the other compounds measured suggests that LCAC is the basis of an acute relief of imminent ischemia by carnitine addition. LCAC may be released from various cell types, including vascular endothelium, as demonstrated. The cationic amphiphilic nature of LCAC is responsible for protection of membrane functions in imminent ischemia.

Prevalence of essential fatty acid deficiency in patients with chronic gastrointestinal disorders.

Siguel EN; Lerman RH
Clinical Nutrition Unit, Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, MA, USA.
Metabolism (United States) Jan 1996, 45 (1) p12-23

Patients with chronic intestinal disorders causing malabsorption, nutritional losses through diarrhea, or catabolic illness would be expected to have essential fatty acid (EFA) deficiency (EFAD), but such deficiency has not been demonstrated in patients treated in accordance with the prevailing standard of care. We studied plasma fatty acid patterns of 56 reference or control subjects and 47 patients with chronic intestinal disorders (mostly Crohn's disease) using high-resolution capillary column gas-liquid chromatography. Patients exhibited a shift in fatty acid metabolism similar to that previously shown to be associated with EFAD. Compared with control subjects, patients had (1) decreased polyunsaturated fatty acid (PUFA) levels (43.7% v 50.4%, P < .0001), (2) increased monounsaturated fatty acid (MUFA) levels (25.8% v 22.0%, P < .0001), (3) higher ratios of mead (20:3 omega 9) to arachidonic (20:4 omega 6) acid (0.020 v 0.013, P < .04), and (4) lower concentrations of total (214 v 284 mg/dL, P < .01), saturated ([SFA] 63 v 75 mg/dL, P < .001), MUFA (56 v 63 mg/dL, P < .001), and PUFA (93 v 143 mg/dL, P < .001). Patients had metabolic shifts toward increased production of MUFA and an increased ratio of derivatives to precursors of omega 6 fatty acids, shifts that occur when cells are EFA-deficient. More than 25% of the patients had biochemical evidence of EFAD according to at least one criterion. Optimal diagnosis requires a concurrent evaluation of concentrations of fatty acids in plasma and in lipoproteins (percent fatty acids). On indices of EFA status that depend on percents, ratios, or concentrations of fatty acids or on the production of abnormal fatty acids, the patients were between patients with severe whole-body EFAD and healthy subjects, a state referred to as absolute EFA insufficiency. Patients with chronic intestinal disease should be evaluated for likely EFA deficiencies and imbalances, and treated with substantial amounts of supplements rich in EFAs, such as oral vegetable and fish oils, or intravenous lipids if necessary.

Induction of muscle glutamine synthetase gene expression during endotoxemia is adrenal gland dependent.

Lukaszewicz GC; Souba WW; Abcouwer SF
Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
Shock (United States) May 1997, 7 (5) p332-8

Skeletal muscle plays a crucial role in maintaining nitrogen homeostasis during health and critical illness by exporting glutamine, the most abundant amino acid in the blood. We hypothesized that induction of glutamine synthetase (GS) expression, the principal enzyme of de novo glutamine biosynthesis, in skeletal muscle after endotoxin administration was adrenal gland dependent. We studied the expression of GS in normal and adrenalectomized rats after intraperitoneal administration of Escherichia coli lipopolysaccharide (LPS). Treatment of normal rats with LPS resulted in a marked increase in GS mRNA that was dose and time dependent, and preceded the increase in GS protein and specific activity. The increase in muscle GS mRNA observed in normal rats in response to LPS was abrogated in adrenalectomized rats at 3 h after high dose LPS treatment and markedly attenuated at 5.5 h after low dose LPS treatment. These and other studies implicate glucocorticoid hormones as a key, but not exclusive, regulator of skeletal muscle GS expression after a catabolic insult.

Gut endotoxin restriction prevents catabolic changes in glutamine metabolism after surgery in the bile duct-ligated rat.

Houdijk AP; Teerlink T; Bloemers FW; Wesdorp RI; van Leeuwen PA
Department of Surgery, Free University Hospital, Amsterdam, The Netherlands.
Ann Surg (United States) Apr 1997, 225 (4) p391-400

OBJECTIVE: The objective of this study was to investigate the role of gut-derived endotoxemia in postoperative glutamine (GLN) metabolism of bile duct-ligated rats.

SUMMARY BACKGROUND DATA: Postoperative complications in patients with obstructive jaundice are associated with gut-derived endotoxemia. In experimental endotoxemia, catabolic changes in GLN metabolism have been reported. Glutamine balance is considered important in preventing postsurgical complications.

METHODS: Male Wistar rats were treated orally with the endotoxin binder cholestyramine (n = 24, 150 mg/day) or saline (n = 24). On day 7, groups received a SHAM operation or a bile duct ligation (BDL). On day 21, all rats were subjected to a laparotomy followed 24 hours later by blood flow measurements and blood sampling. Glutamine organ handling was determined for the gut, liver, and one hindlimb. Intracellular GLN muscle concentrations were determined.

RESULTS: Compared to the SHAM groups, BDL rats showed lower gut uptake of GLN (28%, p < 0.05); a reversal of liver GLN release to an uptake (p < 0.05); higher GLN release from the hindlimb (p < 0.05); and lower intracellular muscle GLN concentration (32%, p < 0.05). Cholestyramine treatment in BDL rats maintained GLN organ handling and muscle GLN concentrations at SHAM levels.

CONCLUSIONS: Disturbances in postoperative GLN metabolism in BDL rats can be prevented by gut endotoxin restriction. Gut-derived endotoxemia after surgery in obstructive jaundice dictates GLN metabolism.

Glucocorticoid-dependent induction of interleukin-6 receptor expression in human hepatocytes facilitates interleukin-6 stimulation of amino acid transport

Fischer C.P.; Bode B.P.; Takahashi K.; Tanabe K.K.; Souba W.W.; Evers B.M.; Beauchamp R.D.; Norton J.A.; Fischer J.E.
Cox Building, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114 USA
Annals of Surgery (USA), 1996, 223/5 (610-619)

OBJECTIVE: The authors studied the effects of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) on glutamine and alanine transport in isolated human hepatocytes. They also evaluated the role of dexamethasone in modulating this response and its effects on the expression of the plasma membrane high-affinity IL-6 receptor.

SUMMARY BACKGROUND DATA: Animal studies indicate that cytokines are important mediators of the increased hepatic amino acid uptake that occurs during cancer and sepsis, but studies in human tissues are lacking. The control of transport by cytokines and cytokine receptor expression in the liver may provide a mechanism by which hepatocytes can modulate amino acid availability during catabolic disease states.

METHODS: Human hepatocytes were isolated from wedge biopsy specimens and plated in 24-well trays. Interleukin-6 and TNF-alpha, in combination with the synthetic glucocorticoid dexamethasone, were added to hepatocytes in culture, and the transport of radiolabeled glutamine and alanine was measured. Fluorescent-activated cell sorter (FACS) analysis was used to study the effects of dexamethasone on IL-6 receptor number in the well-differentiated human hepatoma HepG2.

RESULTS: Both IL-6 and TNF-alpha exerted a small stimulatory effect on alanine and glutamine transport. Dexamethasone alone did not alter transport rates, but pretreatment of cells augmented the effects of both cytokines on carrier-mediated amino acid uptake. Dexamethasone pretreatment and a combination of IL-6 and TNF-alpha resulted in a greater than twofold increase in transport activity. Fluorescent-activated cell sorter analysis demonstrated that dexamethasone induced a threefold increase in the expression of high-affinity IL-6 receptors.

CONCLUSIONS: Interleukin-6 and TNF-alpha work coordinately with glucocorticoids to stimulate amino acid uptake in human hepatocytes. Dexamethasone exerts a permissive effect on cytokine-mediated increases in transport by increasing IL-6 receptor expression on the cell surface. It is likely that this upregulation of IL-6 receptors "primes" human liver cells for subsequent stimulation by cytokines. The resulting increase in hepatic amino acid transport provides the liver with substrate to support key metabolic pathways during catabolic states.

Feeding conjugated linoleic acid to animals partially overcomes catabolic responses due to endotoxin injection.

Miller CC, Park Y, Pariza MW, Cook ME
Poultry Science Dept., U.W. Madison 53706.
Biochem Biophys Res Commun 1994 Feb 15;198(3):1107-12

The ability of conjugated linoleic acid to prevent endotoxin-induced growth suppression was examined. Mice fed a basal diet or diet with 0.5% fish oil lost twice as much body weight after endotoxin injection than mice fed conjugated linoleic acid. By 72 hours post injection, mice fed conjugated linoleic acid had body weights similar to vehicle injected controls; however, body weights of basal and fish oil fed mice injected with endotoxin were reduced. Conjugated linoleic acid prevented anorexia from endotoxin injection. Splenocyte blastogenesis was increased by conjugated linoleic acid.

The effect of polyunsaturated fatty acids on the progress of cachexia in patients with pancreatic cancer

Wigmore SJ, Ross JA, Falconer JS, Plester CE, Tisdale MJ, Carter DC, Fearon KC
University Department of Surgery, Royal Infirmary of Edinburgh, UK.
Nutrition 1996 Jan;12(1 Suppl):S27-30

Cachexia is common in patients with pancreatic cancer and has been associated with persistent activation of the hepatic acute phase response and increased energy expenditure. Fatty acids have been shown to have anticachectic effects in animal models and to reduce inflammatory mediators in healthy subjects and patients with chronic inflammatory disease. Eighteen patients with unresectable pancreatic cancer received dietary supplementation orally with fish oil capsules (1 g each) containing eicosapentaenoic acid 18% and docosahexaenoic acid 12%. Anthropometric measurement, body composition analysis, and measurement of resting energy expenditure and serum C-reactive protein were performed before and after supplementation with a median of 12 g/day of fish oil. Patients had a median weight loss of 2.9 kg/month (IQR 2- 4.6) prior to supplementation. At a median of 3 months after commencement of fish oil supplementation, patients had a median weight gain of 0.3 kg/month (IQR 0.-0.5) (p < 0.002). Changes in weight were accompanied by a temporary but significant reduction in acute phase protein production (p < 0.002) and by stabilisation of resting energy expenditure. This study suggests a component fish oil, perhaps EPA, merits further investigation in the treatment of cancer cachexia.

Comparison of the effectiveness of eicosapentaenoic acid administered as either the free acid or ethyl ester as an anticachectic and antitumour agent

Hudson EA, Tisdale MJ
CRC Nutritional Biochemistry Research Group, Aston University, Birmingham, UK.
Prostaglandins Leukot Essent Fatty Acids 1994 Aug;51(2):141-5

A comparison has been made of the effectiveness of eicosapentaenoic (EPA) acid administered as either the free acid or the ethyl ester as an anticachectic and antitumour agent in mice bearing an experimental cachexia-inducing tumour (MAC16 colon adenocarcinoma). While the free acid of EPA was effective in reversing host body weight loss and inhibiting tumour growth the ethyl ester was ineffective in either respect at the same dose level, even when administered with a high fat diet. The lack of effectiveness of the ethyl ester correlated with the inability to reach effective plasma and tumour concentrations of EPA over the initial time period. Whereas effective plasma concentrations of EPA were achieved within 24 h after administration of the free acid, a time lapse of 96 h was required with the ethyl ester, even when combined with a high fat diet. Due to the acuteness of the MAC16 model this time is too long for a therapeutic benefit to be realized.

Kinetics of the inhibition of tumour growth in mice by eicosapentaenoic acid-reversal by linoleic acid

Hudson EA, Beck SA, Tisdale MJ
Pharmaceutical Sciences Institute, Aston University, Birmingham, U.K.
Biochem Pharmacol 1993 Jun 9;45(11):2189-94

Oral administration of eicosapentaenoic acid (EPA) (2.0 g/kg) by gavage to female NMRI mice bearing the MAC16 colon adenocarcinoma and with weight loss, prevented further loss in body weight and produced a delay in the growth of the tumour. Cell production and loss were determined by the (125I)5-iodo-2'-deoxyuridine method during the stationary and growth phase of the tumour in animals treated with EPA. Tumour stasis appeared to arise from an increase in the rate of cell loss from 38 to 71% without a significant change in the potential doubling time. During the subsequent growth phase the cell loss factor was reduced to 52% and this was combined with a reduced potential doubling time from 32 to 26 hr. The antiproliferative, but not the anticachectic effect of EPA could be reversed by oral administration of pure linoleic acid (LA), (1.9 g/kg) which acted to increase tumour growth by reducing the cell loss factor to 45%. Despite this reversal, incorporation of EpA into tumour cell lipids was not significantly different in animals administered with either EpA alone or combined with LA. This suggests that the antiproliferative effect of EPA in this system may arise from an indirect effect through the blocking of the catabolic effect of the tumour on host adipose tissue, which normally supplies fatty acids essential for tumour growth. This suggests that LA may be required by some tumours to prevent cell loss and that the catabolism of adipose tissue, which accompanies cancer cachexia effectively supplies this fatty acid to the tumour.

Anticachectic and antitumor effect of eicosapentaenoic acid and its effect on protein turnover

Beck SA, Smith KL, Tisdale MJ
Cancer Research Campaign Experimental Chemotherapy Group, Aston University, Birmingham, United Kingdom.
Cancer Res 1991 Nov 15;51(22):6089-93

The effect of the polyunsaturated fatty acids eicosapentaenoic acid (EPA) and gamma-linolenic acid (GLA) on host body weight loss and tumor growth has been investigated in mice bearing a cachexia-inducing colon adenocarcinoma, the MAC16. EPA effectively inhibited both host weight loss and tumor growth rate in a dose-related manner with optimal effects being observed at a dose level of 1.25 to 2.5 g/kg. At these concentrations host body weight was effectively maintained, and there was a delay in the progression of growth of the tumor, such that overall survival was approximately doubled in EPA- treated animals, using the criteria dictated by the United Kingdom Coordinating Committee for the welfare of animals with neoplasms. Even when tumor growth resumed, weight loss did not occur. Animals bearing the MAC16 tumor showed a decreased protein synthesis and an increased degradation in skeletal muscle. Treatment with EPA significantly reduced protein degradation without an effect on protein synthesis. The effect of GLA on both host body weight loss and tumor growth was much less pronounced than that of EPA, with an effect only being seen at a dose of 5 g/kg, at which some toxicity was observed. In vitro studies showed that while EPA was effective in inhibiting tumor-induced lipolysis, GLA was ineffective in this respect. However, prostaglandin E1, which is formed from GLA in vivo, showed partial reversal of tumor-induced lipolysis and probably accounted for the anticachectic effect of GLA. These results suggest that EPA as the pure fatty acid should be considered for clinical investigation as both an anticachectic and antitumor agent, since prior work has shown that the other major component of fish oil docosahexaenoic acid is without pharmacological activity in this system.

Muscle wasting and dedifferentiation induced by oxidative stress in a murine model of cachexia is prevented by inhibitors of nitric oxide synthesis and antioxidants

Buck M, Chojkier M
Department of Medicine, Veterans Affairs Medical Center, San Diego, CA, USA.
EMBO J 1996 Apr 15;15(8):1753-65

Muscle wasting is a critical feature of patients afflicted by AIDS or cancer. In a murine model of muscle wasting, tumor necrosis factor alpha (TNFalpha) induces oxidative stress and nitric oxide synthase (NOS) in skeletal muscle, leading to decreased myosin creatinine phosphokinase (MCK) expression and binding activities. The impaired MCK-E box binding activities resulted from abnormal myogenin-Jun-D complexes, and were normalized by the addition of Jun-D, dithiothreitol or Ref-1, a nuclear redox protein. Treatment of skeletal muscle cells with a phorbol ester, a superoxide-generating system, an NO donor or a Jun-D antisense oligonucleotide decreased Jun-D activity and transcription from the MCK-E box, which were prevented by antioxidants, a scavenger of reducing equivalents, a NOS inhibitor and/or overexpression of Jun-D. The decreased body weight, muscle wasting and skeletal muscle molecular abnormalities of cachexia were prevented by treatment of TNFalpha mice with the antioxidants D-alpha-tocopherol or BW755c, or the NOS inhibitor nitro-L-arginine.

Modulation of immune function and weight loss by L-arginine in obstructive jaundice in the rat

Kennedy JA, Kirk SJ, McCrory DC, Halliday MI, Barclay GR, Rowlands BJ
Department of Surgery, Queen's University of Belfast, UK.
Br J Surg 1994 Aug;81(8):1199-201

Jaundiced surgical patients have a high incidence of postoperative complications. Many causative factors have been identified including cachexia and immune suppression. The amino acid L-arginine has anabolic and immunostimulatory properties. It was hypothesized that dietary supplementation with L-arginine would diminish the weight loss and immune suppression of obstructive jaundice. Sixteen male Wistar rats rendered jaundiced by bile duct ligation were allocated to two groups. The test group (n = 8) received drinking water supplemented with 1.8 per cent L-arginine ad libitum and the control group (n = 8) received a solution of isonitrogenous glycine. Both groups had free access to standard chow. Body-weight, and fluid and food intake were recorded. After 21 days, delayed-type hypersensitivity to 2,4-dinitrofluorobenzene was assessed. Animals receiving L-arginine consumed more food than controls (mean(s.e.m.) 414(16) versus 360(13) g, P < 0.05) and lost less weight (mean(s.e.m.) proportion of initial body-weight lost 7.8(1.2) versus 14.8(1.4) per cent, P < 0.05). The delayed-type hypersensitivity response was significantly greater in rats receiving L-arginine (mean(s.e.m.) increase in ear thickness 23.9(2.7) versus 9.4(2.1) per cent, P < 0.05). In this animal model of obstructive jaundice dietary supplementation with L-arginine diminished both weight loss and immune suppression.

Effects of L-carnitine on serum triglyceride and cytokine levels in rat models of cachexia and septic shock

Winter BK, Fiskum G, Gallo LL
Department of Biochemistry and Molecular Biology, George Washington University Medical Center, Washington, DC 20037, USA.
Br J Cancer 1995 Nov;72(5):1173-9

Inappropriate hepatic lipogenesis, hypertriglyceridaemia, decreased fatty acid oxidation and muscle protein wasting are common in patients with sepsis, cancer or AIDS. Given carnitine's role in the oxidation of fatty acids (FAs), we anticipated that carnitine might promote FA oxidation, thus ameliorating metabolic disturbances in lipopolysaccharide (LPS)- and methylcholanthrene-induced sarcoma models of wasting in rats. In the LPS model, rats were injected with LPS (24 mg kg-1 i.p.), and treated with carnitine (100 mg kg-1 i.p.) at- 16, - 8, 0 and 8 h post LPS. Rat health was observed, and plasma inflammatory cytokines and triglycerides (TG) were measured before and 3 h post LPS. In the sarcoma model, rats were implanted subcutaneously with tumour, and treated continuously with carnitine (200 mg kg-1 day-1 i.p.) via implanted osmotic pumps. Tumour burden, TG and cytokines were measured weekly for 4 weeks. Carnitine treatment significantly lowered the tumour-induced rise in TG (% rise) in the sarcoma model (700 plus or minus 204 vs 251 plus or minus 51, P<0.03) in control and carnitine groups respectively. Levels of interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and tumour necrosis factor-cc (TNF-alpha) (pg ml-1) were also lowered by carnitine in both LPS (IL-1beta: 536 plus or minus 65 vs 378 plus or minus 44: IL-6: 271 plus or minus 29 vs 222 plus or minus 32; TNF-alpha: 618 plus or minus 86 vs 367 plus or minus 54, P less than or equal to 0.02) and sarcoma models (IL-1beta: 423 plus or minus 33 vs 221 plus or minus 60; IL-6: 222 plus or minus 18 vs 139 plus or minus 38; TNF-alpha: 617 plus or minus 69 vs 280 plus or minus 77, P less than or equal to 0.05) for control and carnitine groups respectively. We conclude that carnitine has a therapeutic effect on morbidity and lipid metabolism in these disease models, and that these effects could be the result of down-regulation of cytokine production and/or increased clearance of cytokines.

L-carnitine deficiency in AIDS patients

De Simone C, Tzantzoglou S, Jirillo E, Marzo A, Vullo V, Martelli EA
Dipartimento di Medicina Sperimentale, Universita dell' Aquila, Italy.
AIDS 1992 Feb;6(2):203-5

Objective: To evaluate carnitine (3-hydroxy-4-N-trimethyl-ammoniobutanoat e) deficiency in AIDS patients by measuring serum total, free and short-chain carnitine concentrations.

Design: We conducted an open study.

Setting: All patients were seen at the Infectious Diseases Clinic, Universita 'La Sapienza', Rome, Italy.

Patients, participants: Twenty-nine AIDS patients, aged 27-41 years, with a previous history of drug use; and 14 healthy age- and sex-matched controls were studied.

Interventions: Study subjects were administered 500-800 mg zidovudine daily for 2 to 28 months (8 plus or minus 6 months). Main outcome measures: Carnitine deficiency was suspected in study participants prior to data collection because of previously reported cardiac symptoms, muscle weakness, hypometabolism and/or cachexia.

Results: A marked decrease in total and free carnitine was observed in 21 (72%) subjects Nine of these patients also had low levels of short-chain carnitine.

Conclusions: AIDS patients may become carnitine-depleted and therefore at risk for alterations in fatty-acid oxidation and energy supply.

The enzymatic activities of branched-chain amino acid catabolism in tumour-bearing rats

Argiles JM, Lopez-Soriano FJ
Departament de Bioquimica i Fisiologia, Facultat de Biologia, Universitat de Barcelona, Spain.
Cancer Lett 1992 Jan 31;61(3):239-42

Rats bearing the Walker-256 carcinosarcoma showed significant changes in branched-chain amino acid metabolism as compared with their non-tumour-bearing controls. In vitro measurement of branched-chain amino acid transaminase and branched-chain 2-oxo acid dehydrogenase showed significant increases in the skeletal muscle of tumour-bearing animals. In addition, the circulating concentration of leucine was increased in the tumour-bearing group. It can be concluded that the metabolism of branched-chain amino acids in the host is profoundly altered by the presence of a tumour and this may well be one of the main factors contributing to the so-called cancer cachexia.

Branched chain amino acids as the protein component of parenteral nutrition in cancer cachexia

Hunter DC, Weintraub M, Blackburn GL, Bistrian BR
Laboratory of Nutrition and Infection, New England Deaconess Hospital, Harvard Medical School, Boston, Massachusetts 02215.
Br J Surg 1989 Feb;76(2):149-53

A prospective randomized trial was conducted to determine the effects of branched chain amino acids (BCAA) as the protein component of total parenteral nutrition (TPN) on protein kinetics in patients with intraabdominal adenocarcinoma. Nine malnourished patients were given both conventional TPN containing 19 per cent BCAA (AA) and isocaloric, isonitrogenous TPN containing 50 per cent BCAA (BCAA-TPN), in random order. Both (13C)leucine and (14C)tyrosine were employed as tracers to avoid the potential bias due to the different amino acid composition of the two TPN solutions. With BCAA-TPN, leucine and tyrosine flux increased significantly from (meanplus or minuss.d.) 158.0plus or minus37.2 to 243.5plus or minus75.8 micromol kg-1h-1 (P<0.025) and from 35.0plus or minus8.4 to 42.6plus or minus11.0 micromol kg-1h-1 (P<0.05) respectively. Leucine oxidation was significantly higher on BCAA-TPN (24.1plus or minus6.3 on AA versus 68.3plus or minus37.1 micromol kg-1h-1, P<0.025) while tyrosine oxidation was significantly lower (3.7plus or minus1.8 micromol kg-1h-1 on AA versus 2.5plus or minus2.0 micromol kg-1h-1 on BCAA-TPN, P<0.05). Whole body protein synthesis and breakdown was significantly higher on BCAA-TPN by the tyrosine (31.3plus or minus7.3 on AA versus 40.1plus or minus9.3 micromol kg-1h-1, P<0.025 and 33.0plus or minus8.4 on AA versus 41.3plus or minus11.1 micromol kg-1h-1, P<0.05) respectively. Using the leucine tracers both synthesis and breakdown were increased, but not significantly, from 133.8plus or minus40.0 to 175.3plus or minus65.1 micromol kg-1h-1 and from 127.9plus or minus33.6 to 167.7plus or minus71.2 micromol kg-1h-1 respectively. The fractional albumin synthetic rate increased significantly on BCAA-TPN from 4.3plus or minus2.9 on AA to 8.0plus or minus5.1 per cent per day (P<0.05). The reduction in tyrosine oxidation, suggesting improved protein utilization, coupled with an increase in protein and albumin synthesis, strongly support a positive benefit from BCAA-TPN in cancer cachexia.

Zinc in different tissues: Relation to age and local concentrations in cachexia, liver cirrhosis and long-term intensive care

Brandt G, Schenck J
Infusionsther Klin Ernahr 1979 Aug;6(4):225-9

Zinc concentrations in autopsy material of human heart muscle, skeletal muscle, iliac crest, pancreas and liver were analyzed by atomic absorption spectrophotometry. Age dependent differences of zinc concentrations are seen in the liver. High values show liver of premature infants, a minimum is measured in childhood which is followed by an increase in adult and old patients. The other organs show no significant changes. Different diseases like diabetes or liver cirrhosis do not influence the zinc concentration in skeletal muscle and iliac crest. Long-term intensive care patients show a marked decrease in zinc concentration of the heart muscle. In the cirrhotic liver the zinc pool is depleted. In diabetes mellitus zinc concentration of the whole pancreas is normal, in cachexia it is critically decreased.

The role of serum protein in congestive heart failure

Nambu S.; Masuda I.; Waki M.; Kasamatsu K.; Kurata M.; Koh H.; Itoh A.; Hiramori K.
Clinical Research Institute, Cardiovascular Center, National Zentsuji Hospital, Kagawa Japan
Nutritional support in organ failure: proceedings of the International Symposium. ICS836 1990, (45-52)

We searched to elucidate the influence of hypoalbuminemia upon congestive heart failure (CHF) by experimental aortic regurgitation (AR) in dogs and by a follow-up study of patients with CHF (NYHA classes III, IV). We found that (1) In the dog with AR the incorporation of 14C-labeled glycine into myocardial actomyosin was decreased in the condition of hypoproteinemia produced by the combination of plasmapheresis with a low protein diet. But this phenomenon was improved by daily injection of vitamin B12 for 10 days. (2) In the study on protein metabolism using 15N-labeled glycine in humans, over 70 g day of protein intake (28% of total calorie intake) was necessary to prevent a decrease in the active protein pool produced by low calorie intake. (3) In the follow-up study on patients with CHF, we found that the mortality rate from CHF was worse in the patients with both low body mass index and hypoalbuminemia. In conclusion, maintaining both serum albumin and body weight on normal levels may be an important factor in the management of CHF and the prevention of cachexia.

Clinical rise of a combination containing phosphocreatinine as adjuvant to physiokinesiotherapy

Riabilitazione (Italy), 1976, 9/2 (51-62)

The authors make a clinical contribution to the therapeutic use of phosphocreatinine, both alone and in combination with vitamin B12, folic acid, vitamin B6 and fructose 1-6 diphosphate. The study was carried out on 24 adult patients of both sexes, suffering from neuromyolesions (paraplegia, hemiparesis, tetraparesis, neuraxitis, myopathy, radiculoneuritis) and presenting, as therapeutic indications, conditions of organic wasting, marked asthenia, cachexia, or the requirement of physical performance and intense muscular effort in connection with the use of kinesitherapy techniques. An analysis of the collected data showed that both phosphocreatinine preparations (the simple form and combined with vitaminic coenzymes) induced significant improvements in the initial symptomatology; no statistically significant difference was observed between the 2 treatments. Particular interest is placed on the finding with regard to the effect on motor re education; in fact, the 2 preparations considered phosphocreatinine influenced this parameter favourably in over half the cases investigated. The drug was excellently tolerated in all the cases studied, from both the clinical point of view and the blood chemistry standpoint. In conclusion, the results obtained make the therapeutic use of phosphocreatinine undoubtedly useful as a valid factor in association with physiokinesitherapy.

Myopathy and HIV infection

Chariot P, Gherardi R
Groupe de Recherche en Pathologie Neuromusculaire, Hopital Henri Mondor, Creteil, France.
Curr Opin Rheumatol 1995 Nov;7(6):497-502

Skeletal muscle involvement may occur at all stages of HIV infection. The most simple classification of muscular disorders in HIV-infected patients is

1) HIV-associated myopathies,
2) zidovudine myopathy,
3) HIV wasting syndrome, and
4) opportunistic infections and tumoral infiltrations of muscle.

Immunohistology for major histocompatibility complex class 1 antigen and histochemical reaction for cytochrome c oxidase are helpful in correctly classifying a myopathy as HIV polymyositis or zidovudine myopathy. Studies of cytokine expression in HIV-infected patients and of supplementation with compounds such as carnitine or micronutrients such as selenium might yield new insights into the pathogenesis and treatment of the various AIDS- associated muscular disorders.

Effects of L-carnitine on serum triglyceride and cytokine levels in rat models of cachexia and septic shock

Winter BK, Fiskum G, Gallo LL
Department of Biochemistry and Molecular Biology, George Washington University Medical Center, Washington, DC 20037, USA.
Br J Cancer 1995 Nov;72(5):1173-9

Inappropriate hepatic lipogenesis, hypertriglyceridaemia, decreased fatty acid oxidation and muscle protein wasting are common in patients with sepsis, cancer or AIDS. Given carnitine's role in the oxidation of fatty acids (FAs), we anticipated that carnitine might promote FA oxidation, thus ameliorating metabolic disturbances in lipopolysaccharide (LPS)- and methylcholanthrene-induced sarcoma models of wasting in rats. In the LPS model, rats were injected with LPS (24 mg kg-1 i.p.), and treated with carnitine (100 mg kg-1 i.p.) at- 16, - 8, 0 and 8 h post LPS. Rat health was observed, and plasma inflammatory cytokines and triglycerides (TG) were measured before and 3 h post LPS. In the sarcoma model, rats were implanted subcutaneously with tumour, and treated continuously with carnitine (200 mg kg-1 day-1 i.p.) via implanted osmotic pumps. Tumour burden, TG and cytokines were measured weekly for 4 weeks. Carnitine treatment significantly lowered the tumour-induced rise in TG (% rise) in the sarcoma model (700 plus or minus 204 vs 251 plus or minus 51, P<0.03) in control and carnitine groups respectively. Levels of interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and tumour necrosis factor-cc (TNF-alpha) (pg ml-1) were also lowered by carnitine in both LPS (IL-1beta: 536 plus or minus 65 vs 378 plus or minus 44: IL-6: 271 plus or minus 29 vs 222 plus or minus 32; TNF-alpha: 618 plus or minus 86 vs 367 plus or minus 54, P less than or equal to 0.02) and sarcoma models (IL-1beta: 423 plus or minus 33 vs 221 plus or minus 60; IL-6: 222 plus or minus 18 vs 139 plus or minus 38; TNF-alpha: 617 plus or minus 69 vs 280 plus or minus 77, P less than or equal to 0.05) for control and carnitine groups respectively. We conclude that carnitine has a therapeutic effect on morbidity and lipid metabolism in these disease models, and that these effects could be the result of down-regulation of cytokine production and/or increased clearance of cytokines.