Brain metabolism during fasting

No effect of hyperketonemia on local cerebral glucose utilization in conscious rats

Local cerebral glucose utilization was measured by the [14C]2-deoxy-D-glucose method in conscious control and hyperketonemic rats. Hyperketonemia was induced by 3 days of starvation or by infusion of 3-hydroxybutyrate in fed rats. These treatments produced combined blood ketone body concentrations (acetoacetate + 3-hydroxybutyrate) of from 1.2 to 2.4 mM. Neither treatment significantly affected glucose utilization in any of the 15 brain regions studied. These observations indicate that hyperketonemia in resting, conscious rats does not interfere with brain uptake and phosphorylation of glucose.

Parenteral nutrition: current status and concepts

Parenteral nutrition is regarded as a form of nutrition in some countries and as an extension of intravenous fluid therapy in others. The optimum clinical application of parenteral nutrition as a form of therapy requires detailed knowledge of the nutrient solutions themselves, including the commonly used solutions such as dextrose, soybean oil emulsion, synthetic crystalline L-amino acid solutions; older solutions such as xylitol, protein hydrolysates; and newer solutions such as glycerides and special purpose amino acid solutions. Additionally, information has accumulated over the past 10 years, leading to the rational use of vitamins and trace elements in parenteral nutrition. Metabolism of the substrates has been correlated with known pathways of intermediary metabolism in normal, starved and stressed subjects. Several new concepts have arisen: a) Infusion of excessive quantities of dextrose results in lipogenesis and increased carbon dioxide production. Hyperalimentation of this type is being replaced by infusion of lesser quantities of dextrose, supplemented by intravenous infusion of lipid as a calorie source. b) Protein hydrolysates and racemic synthetic crystalline amino acid solutions have been replaced by synthetic crystalline L-amino acid solutions. c) A new fat emulsion based on safflower oil is competing successfully with the traditional soybean oil emulsion. d) Newer substrates are being explored. These include branched chain amino acids, keto analogues of amino acids, synthetic glycerides and maltose. e) Deficiencies of essential fatty acids, trace elements and vitamins have been studied in patients on long term parenteral nutrition and their mechanisms elucidated. Official recommendations for intravenous administration of these nutrients have been made. f) Several techniques have been applied in several circumstances, including protein sparing therapy, cyclic nutrition, home therapy, and parenteral nutrition in liver and renal failure. Parenteral nutrition is now used extensively, not only in major hospitals where the resources of a team approach with physician, nurse, pharmacist and dietitian are available, but also in smaller hospitals where all of these facilities may not be at hand. However, whatever the setting, the principles behind the clinical application of parenteral nutrition should be well understood by those involved, including current approaches to safe preparation and infusion of parenteral nutrition solutions.

A controlled, prospective, randomized trial evaluating the metabolic effects of enteral and parenteral nutrition in the cancer patient

In order to evaluate the metabolic effects of enteral versus parenteral nutritional support in the cancer patient, patients with localized, squamous cell carcinoma of the distal esophagus were randomized to one of three nutritional regimens: oral feeding, jejunal feeding, or total parenteral nutrition (TPN). Patients were initially studied in the postabsorptive state and again two weeks after beginning, and while receiving, enteral or parenteral feedings. Radioisotopic tracer methods were utilized to evaluate parameters of glucose and alanine kinetics, and arterial substrate and hormone levels were measured. Arterial plasma glucose and blood lactate levels increased and plasma free fatty acid, serum triglyceride, and serum cholesterol levels decreased to comparable levels in patients receiving jejunal feedings or TPN. Changes in serum insulin, plasma glucagon, serum cortisol, serum growth hormone, and serum thyroxine were similar in patients receiving enteral and parenteral nutrition. Enteral and parenteral nutrition also had comparable effects on both alanine and glucose kinetics. In particular, both jejunal feedings and TPN were equally efficacious in markedly suppressing gluconeogenesis in the cancer patient. Our data would support the conclusion that there are few, if any, differences in the measured metabolic effects of enteral venous parenteral nutritional support in the group of cancer patients studied.

"Accelerated starvation" and the skipped breakfast in late normal pregnancy

After dinner at 6 P.M. food was withheld from non-pregnant women and women in the third trimester of pregnancy: there were lean and obese women in each group, and all had normal carbohydrate metabolism. Levels of circulating fuels and glucoregulatory hormones were monitored between 6 A.M. (12 h fast) and noon (18 h fast) the following day. In non-pregnant women plasma levels of glucose, alanine, free fatty acids (FFA) beta-hydroxybutyrate, insulin, and glucagon remained constant between 6 A.M. and noon except for slight fall in plasma alanine in the obese women and slight increases in beta-hydroxybutyrate in the lean. By contrast, in pregnant women the concentrations of all substances measured changed profoundly after extension of the overnight fast. Levels of plasma glucose, which were significantly lower than those in non-pregnant women at 6 A.M., fell further during the subsequent 6 h; plasma alanine levels declined significantly during the same interval, and there were coincident rises in plasma FFA and beta-hydroxybutyrate and reductions in plasma insulin. The changes in lean and obese women were of similar magnitude; habitus did not therefore seem to have effects additional to those of pregnancy on the response to skipping breakfast. In all the pregnant women final levels of FFA and beta-hydroxybutyrate were strongly correlated and inversely related to final levels of plasma glucose. The studies indicate that "accelerated starvation" can be unmasked during pregnancy even with the minor dietary deprivation common in conventional clinical circumstances. Thus, insofar as it may be desirable to avoid ketonaemia during pregnancy, the common practice of skipping breakfast whether by personal preference or for doctor-initiated laboratory testing should be avoided in pregnant women.

Fat-derived fuels during a 24-hour fast in children

We examined the availability of fat-derived fuels in 23 normal children aged 1.9 to 16.7 years who fasted for 24 h. We found a rapid and progressive rise in the blood concentrations of free fatty acids (FFA) and ketones. There was a highly significant negative correlation between the concentrations of beta-hydroxybutyrate (beta OHB) and glucose and also between beta OHB and age. With time, the ratio of beta OHB to acetoacetate (AcAc) progressively increased. We briefly review the vital role of ketones in the adaptation to fasting and point out that qualitative tests of ketones can be misleading. Our results indicate that quantitative determinations are essential in the evaluation of suspected disorders of fuel metabolism and that the results must be interpreted according to the age of the child, the duration of fasting, and the concomitant concentrations of glucose.

Hypoalaninemia and ketotic hypoglycemia: cause or consequence?

A shortage of alanine for gluconeogenesis is believed responsible for various forms of hypoglycemia and in particular ketotic hypoglycemia (KH). We examined the glucose-alanine relationship in two groups of fasting children, 18 with KH and 44 controls. Glucose levels declined in both groups but significantly more in KH; to 1.98 +/- 0.20 versus 3.26 +/-0.13 mM (mean +/- SEM; P less than 0.001). Alanine also fell in both groups, the concentrations correlating significantly with the concomitant glucose levels (KH: r = 0.64, P less than 0.001, and controls: r = 0.50, P less than 0.001). The relationship of alanine to glucose gave virtually identical regression equations, y = 0.054x + 0.063 for KH and y = 0.054x + 0.050 for controls. The differences in alanine levels between the two groups were too small to account for the greater decline in glucose in KH. The results indicate that hypoalaninemia rather than causing hypoglycemia results from it.

Neurotoxicity of industrial chemicals and contaminants: aspects of biochemical mechanisms and effects

Nervous system toxicity by industrial chemicals and contaminants cannot be explained by a single mechanism because of the complex functional capacity of the brain and spinal cord. The nervous system is dependent on the adequate supply of oxygen, and therefore, its lack in the ambient air causes rapid dysfunction. Similar effects to hypoxia are caused by agents which reduce oxygen availability at the cellular level by histotoxic mechanisms, e.g., through the inhibition of mitochondrial respiration. Hypoxic effects are rapidly produced, and in cases where a significant number of cells are fatally damaged permanent disability may remain. Acutely harmful effects are also brought about by organic solvents. The typical mode of exposure is that of vapour inhalation. The lipid-soluble molecules pass the blood-brain barrier rapidly and depress the nerve cell membrane functions. This hinders the formation of action potentials. Neuronal cells acquire tolerance towards the membrane-depressant effects in repeated or prolonged exposure so that similar doses do not produce equivalent effects. The development of the tolerance can be regarded as one of the long-term effects of lipophilic chemicals. They may also produce metabolic adaptation so that their biotransformation is enhanced. This may increase the risk of producing more toxic intermediates. The toxic effects thus created can be cumulative since neurons do not multiply by cell division in the postnatal life. The neurotoxicity of metals is more clearly associated with the accumulation of the dose. Adult brain possesses a blood-brain barrier to many water-soluble compounds such that a threshold concentration must be overcome before appreciable toxic effects are seen. Children are in this respect more vulnerable because of their immature barrier function.

Effects of human aging on patterns of local cerebral glucose utilization determined by the [18F]fluorodeoxyglucose method

The [18F]fluorodeoxyglucose (FDG) scan method with positron emission computed tomography was used to determine patterns of local cerebral glucose utilization (LCMRglu) in 40 normal volunteer subjects aged 18 to 78 years. Throughout all the studies, each subject was quiet, without movement, with eyes open and ears unplugged, exposed only to ambient room light and sound. For the entire group, whole brain mean CMRglu was 26.1 +/- 6.1 mumol 100 g-1 min-1 (mean +/- SD, n = 40). At age 78, mean CMRglu was, on the average, 26% less than at age 18, an alteration of the same order as the variance among subjects at any age. The gradual decline of mean CMRglu with advancing age occurred at a faster rate than was reported for mean cerebral oxygen utilization, possibly due to increasingly altered pathways for glucose utilization, or to increasing oxidation of ketone bodies or other alternative substrates. Glucose utilization in the hemispheres was symmetrical and mean CMRglu of overall cortex, caudate, and thalamus was equal in individuals at all ages. The slopes of decline with age were similar when LCMRglu was averaged over zones corresponding to centrum semiovale, caudate, putamen, and frontal, temporal, parietal, occipital, and primary visual cortex. However, the metabolic ratio of superior frontal cortex to superior parietal cortex declined with age, possibly due to selective degeneration of superior frontal cortex or to differences between age groups in the sensory and cognitive response to the study. These results should be useful in distinguishing age from disease effects when the FDG scan method is used.

Diet induced ketosis in epilepsy and anaesthesia. Metabolic changes in three patients on a ketogenic diet

Ketogenic diets have a high fat and low carbohydrate and low protein content to induce ketosis which is monitored by daily urine testing. Lapses in diet are frequently associated with loss of anticonvulsant control. There has, as yet, been no report of children maintained on a ketogenic diet subject to anaesthesia and surgery: this paper records the changes in metabolic variables observed in three patients undergoing simple inhalation anaesthetics for minor surgery.

Energy-metabolizing enzymes in brain regions of adult and aging rats

The regional enzyme activities of glucose metabolism in the rat brain were investigated. Hexokinase (EC 2.7.1.1) and pyruvate dehydrogenase (EC 1.2.4.1), key enzymes for glucose metabolism, showed no changes in activity in all the regions studied of the aging brain as compared with the adult brain. However, the activity of D-3-hydroxybutyrate dehydrogenase (EC 1.1.1.30) is low throughout the adult brain and, in contrast with hexokinase and pyruvate dehydrogenase, its activity decreases significantly during aging. Other enzymes that showed significant decreases during aging are aldolase (EC 4.1.2.13), lactate dehydrogenase (EC 1.1.1.27), citrate synthase (EC 4.1.3.7), and NAD+-linked isocitrate dehydrogenase (EC 1.1.1.41). The catabolic enzyme in cholinergic metabolism, acetylcholinesterase (EC 3.1.1.7), selected as an example of a non-energy-metabolising enzyme, also showed significant decreases in all regions of the brain in aging, although its highest activity remained in the striatum. These results are discussed with respect to the energy metabolism in various brain regions and their status with aging.

beta-Hydroxybutyrate as a precursor to the acetyl moiety of acetylcholine

Rat brain cortex slices were incubated with 10 mM-glucose and trace amounts of [6-3H]glucose and [3-14C]beta-hydroxybutyrate. The effects of (-)-hydroxycitrate, an inhibitor of ATP-citrate lyase; methylmalonate, an inhibitor of beta-hydroxybutyrate dehydrogenase; and increasing concentrations of unlabeled acetoacetate were examined. The incorporation of label into lactate, citrate, malate, and acetylcholine (ACh) was measured and 3H:14C ratios calculated. Incorporation of [14C]beta-hydroxybutyrate into lactate was limited because of the low activity of gluconeogenic enzymes in brain, whereas incorporation of 14C label into Krebs cycle intermediates and ACh was higher than in previous experiments with [3H-,14C]-glucose. (-)-Hydroxycitrate (5.0 mM) reduced incorporation of [3H]glucose and [14C]beta-hydroxybutyrate into ACh. In contrast, slices incubated with methylmalonate (1 mM) showed a decrease in 14C incorporation without appreciably affecting glucose metabolism. The effects of high concentrations of methylmalonate were nonselective and yielded a generalized decrease in metabolism. Acetoacetate (1 mM) also produced a decreased 14C incorporation into ACh and its precursors. At 10 mM, acetoacetate reduced 3H and 14C incorporation into ACh without substantially affecting total ACh content. From the results, it is suggested that in adult rats beta-hydroxybutyrate can contribute to the acetyl moiety of ACh, possibly via the citrate cleavage pathway, though it is quantitatively less important than glucose and pyruvate. This contribution of ketone bodies could become significant should their concentration become abnormally high or glucose metabolism be reduced.

Metabolic responses to bicycle exercise after several days of physical work and energy deficiency

The responses of plasma free fatty acids (FFA), free glycerol, beta-hydroxybutyrate (BUT) and glucose to bicycle exercise (corresponding to 50% of the maximal VO2) were investigated in 11 cadets of the Norwegian Military Academy, before a combat course (control experiment) and on the third and fifth day of such a course which involved nearly continuous intense military activities and pronounced energy deficiency. Pre-exercise levels of FFA, glycerol and BUT were greatly elevated on days 3 and 5 as compared with pre-exercise levels before the course. The increases in plasma FFA, glucose and BUT in response to bicycle exercise were much more pronounced on days 3 and 5 than before the course. The increases observed during (and before) the course were approximately in mmol/l: FFA 1.0 (0.3), glycerol 0.3 (0.08), BUT 0.6 (0.0). The day 5 responses were lower than those on day 3. The plasma glucose concentration appeared to decrease slightly after exercise on days 3 and 5. The results demonstrate that several days of strenuous work and pronounced energy deficiency do appreciably increase acute metabolic responses to exercise, and indicate that there is a very high FFA-utilization under such conditions.

Effects of liver damage on ketone-body production and nitrogen balance in starved rats

The metabolic effects of intraperitoneal administration of carbon tetrachloride (1ml/kg) were studied in starved rats. The most notable change in circulating substrates was an 80% fall in ketone-body concentrations, which was associated with the doubling of urinary nitrogen losses. The results demonstrate the importance of starvation ketosis in permitting fat mobilization to decrease effectively protein losses during starvation.

Energy metabolism in rat brain: inhibition of pyruvate decarboxylation by 3-hydroxybutyrate in neonatal mitochondria

The effect of 3-hydroxybutyrate on pyruvate decarboxylation by neonatal rat brain mitochondria and synaptosomes was investigated. The rate of [1-14C]pyruvate decarboxylation (1 mM final concentration) by brain synaptosomes derived from 8-day-old rats was inhibited by 10% in the presence of 2 mM-D,L-3-hydroxybutyrate and by more than 20% in the presence of 20 mM D,L-3-hydroxybutyrate. The presence of 2 mM-D,L-3-hydroxybutyrate did not affect the rate of [1-14C]pyruvate decarboxylation (1 mM final concentration) by brain mitochondria; however, at a concentration of 20 mM-D,L-3-hydroxybutyrate, a marked inhibition was seen in preparations from both 8-hydroxybutyrate, a marked inhibition was seen in preparations from both 8-day-old (35% inhibition) and 21-day-old (24% inhibition) but not in those from adult rats. Although the presence of 100 mM-K+ in the incubation medium stimulated the rate of pyruvate decarboxylation by approximately 50% compared with the rate in presence of 1 mM-K+, the presence of 20 mM-D,L-3-hydroxybutyrate still caused a marked inhibition in both media (1 and 100 mM-K+). The presence of 20 mM-D,L-3-hydroxybutyrate during the incubation caused an approximately 20% decrease in the level of the active form of the pyruvate dehydrogenase complex in brain mitochondria from 8-day-old rats. The concentrations of ATP, ADP, NAD+, NADH, acetyl CoA, and CoA were measured in brain mitochondria from 8-day-old rats incubated in the presence of 1 mM-pyruvate alone or 1 mM-pyruvate plus 20 mM-D,L-3-hydroxybutyrate. Neither the APT/ADP nor the NADH/NAD+ ratio showed significant changes. The acetyl CoA/CoA ratio was significantly increased by more than twofold in the presence of 3-hydroxybutyrate. The possible mechanisms and physiological significance of 3-hydroxybutyrate inhibition of pyruvate decarboxylation in neonatal rat brain rat mitochondria are discussed.

Metabolic alterations in a noncachectic animal tumor system

The increased energy expended by the host to synthesize substrate, which is utilized by the tumor, is a potential cause of cancer cachexia. In vivo glucose and alanine kinetics were examined by tracer methodology in a sarcoma-bearing rat model. The effects of 3-mercaptopicolinic acid, a potent inhibitor of gluconeogenesis, was also examined on this model. Both tumor-bearing (TB) and nontumor bearing (NTB) animals were gaining weight prior to study and the tumors were relatively small. The TB animals had significantly lower plasma glucose and higher blood lactic acid levels compared with NTB animals. After inhibition of gluconeogenesis, the plasma glucose decreased and the blood lactate increased significantly more in TB than NTB animals. The glucose turnover rate was significantly greater in TB compared with NTB animals, as was the rate of glucose recycling and the rate of gluconeogenesis (alanine leads to glucose), both energy demanding processes. These results suggest that the tumor-bearing animal, even prior to significant cachexia, has an excess demand for energy, the provision of which may be a significant factor in malignant cachexia.

Nutritional support in long term intensive care with special reference to ventilator patients: a review

Patients requiring long term intensive care and/or prolonged ventilatory support, are frequently undergoing progressive malnutrition, occasionally complicated by a hypercatabolic state. Sepsis, fever and the requirements for postoperative healing will add further nutritional demands on such patients. In contrast to starvation, critically ill patients maintained on protein-free energy-deficient diet do not adapt to utilization of their lipid to provide energy needs. Mobilization of endogenous fat stores is reduced, and this reduction leads to increased gluconeogenesis from amino acids derived from muscle protein to meet the increased energy needs. Low serum albumin, possible low surfactant production, devitalization of the alveolo-capillary membrane and impaired immunocompetence could contribute to the development of pulmonary transudation, alveolar collapse, low compliance and pulmonary infection. Such sequelae of a protein-free energy-deficient diet would delay weaning patients off prolonged mechanical ventilation. Nutritional assessment, which may be determined serially, and means of nutritional support are outlined.

Glycogen metabolism in the developing accessory lobes of Lachi in the nerve cord of the chick: metabolic correlations with the avian glycogen body

Glycogen synthase, glycogen phosphorylase, glucose-6-phosphate dehydrogenase, 6-phosphogluconate dehydrogenase, and glucose-6-phosphatase were determined for the first time in the necessary lobes of Lachi from late embryonic chicks. The activities of these enzymes were compared with those found in other glycogen-metabolizing tissues, specifically the glycogen body, liver, and skeletal muscle, obtained from the same embryos. The data show that, as in the glycogen body, the accessory lobes of Lachi lack glucose-6-phosphatase, but contain relatively high activity levels of glycogen synthase I, total and active glycogen phosphorylase, and the dehydrogenases of glucose-6-phosphate and 6-phosphogluconate. The percent of glycogen synthase I activity in the Lachi lobes is from two- to 20-fold greater than observed in the glycogen body, liver, or muscle, whereas the percent of glycogen phosphorylase a activity is comparable to that of the liver, but greater than that in the glycogen body or muscle. The activity of each dehydrogenase of the pentose phosphate cycle in the Lachi lobes is similar to that noted in the glycogen body, but is over two- or fivefold greater than that activity found in muscle or liver. Our data, together with other recent evidence, suggest that the role of glycogen in these functionally enigmatic tissues may be to support the precocious process of myelin synthesis in the developing bird, as well as possibly to provide alternate sources of energy for the avian central nervous system.

Brain lactic acidosis and ischemic cell damage: 1. Biochemistry and neurophysiology

This study explores the influence of severe lactic acidosis in the ischemic rat brain on postischemic recovery of the tissue energy state and neurophysiological parameters. Severe incomplete brain ischemia (cerebral blood flow below 5% of normal) was induced by bilateral carotid artery clamping combined with hypovolemic hypotension. We varied the production of lactate in the tissue by manipulating the blood glucose concentrations. A 30-min period of incomplete ischemia induced in food-deprived animals caused lactate to accumulate to 15-16 mumol g-1 in cortical tissue. Upon recirculation these animals showed: (1) a considerable recovery of the cortical energy state as evaluated from the tissue concentrations of phosphocreatine, ATP, ADP, and AMP; and (2) return of spontaneous electrocortical activity as well as of somatosensory evoked response (SER). In contrast, administration of glucose to food-deprived animals prior to ischemia caused an increase in tissue lactate concentration to about 35 mumol g-1. These animals did not recover energy balance in the tissue and neurophysiological functions did not return. In other experiments the production of lactate during 30 min of complete compression ischemia was increased from about 12 mumol g-1 (normoglycemic animals) to 20-30 mumol g-1 by preischemic hyperglycemia and, in separate animals, combined hypercapnia. The recovery of the cortical energy state upon recirculation was significantly poorer in hyperglycemic animals. It is concluded that a high degree of tissue lactic acidosis during brain ischemia impairs postischemic recovery and that different degrees of tissue lactic acidosis may explain why severe incomplete ischemia, in certain experimental models, is more deleterious than complete brain ischemia.

Factors affecting the supply of glucose to the heart of the rat, in vivo

1. The influx of glucose into the heart of intact, living, anaesthetized rats was measured when the levels of insulin the blood were (a) low (as a result of fasting), (b) normal, and (c) high (as a result of injecting insulin). The findings showed that the transport of glucose into cardiac cells is carrier-mediated and is strongly insulin-independent. 2. The major barrier to the supply glucose to the heart from the circulating blood is at the surface membrane of the cardiac cells, rather than at the endothelium of the cardiac capillaries. 3. The extracellular space of the heart was measured and was found to be approximately 25% of the cardiac tissue. 4. During life, glucose, as well as its analogue, 3-O-methylglucose passes across the membranes of the cells of the heart by means of a transport system which is strongly dependent upon insulin and appears to be carried-mediated. A likely explanation for the effect of insulin is that it increases considerably the affinity of the transport carrier for glucose. Saturation of the carrier takes place when the levels of insulin and of glucose in the blood are high. However, when the concentration of insulin is low, e.g. during a fast, the affinity of the carrier for glucose is reduced so that saturation cannot be demonstrated. 5. It is suggested that the low level of insulin that is found in the blood in the early morning, which is due to the night fast, may lead to the cardiac dysfunction which often develops at that time.

Cerebral blood flow and metabolic rate of oxygen, glucose, lactate, pyruvate, ketone bodies and amino acids

The cerebral blood flow (CBF) and cerebral metabolic rate (CMR) of oxygen, glucose, lactate, pyruvate, ketone bodies, and 24 amino acids were examined in 10 healthy subjects, five 21-24 and five 55-65 years old. The subjects were free from drugs. The results of psychometric and neurological examinations were negative. CBF was determined with the nitrous oxide method on the subjects who were awake and normocapnic and had fasted overnight. No differences were found between the young and the old groups except in arterial levels of four amino acids, viz. aspartic acid, methionine, lysine, and tryptophan. In the whole group of 10 subjects, a significant cerebral net uptake (expressed as median values in mumol X kg-1 X min-1) was found not only for oxygen (1719) and glucose (248), but also for acetoacetate (4.3), D-beta-hydroxybutyrate (6.2), arginine (2.0), leucine (5.2), and isoleucine (1.2). There was a significant net release of lactate (-28). CBF was positively correlated to the CMR of oxygen and D-beta-hydroxybutyrate. Arterial concentrations and CMR were positively correlated for ketone bodies, glutamic acid, proline and taurine. It is of particular interest that the whole group of healthy subjects showed a significant cerebral uptake of branched-chain and dibasic amino acids.

Cerebral blood flow and metabolism during hypoglycemia in newborn dogs

Cerebral blood flow (CBF) and cerebral metabolic rates (CMR) were studied in newborn dogs during insulin-induced hypoglycemia. Pups were anesthetized, paralyzed, and artificially ventilated with a mixture of 70% nitrous oxide and 30% oxygen to maintain normoxia and normocarbia. Experimental animals were given regular insulin (0.3 units/gm IV); controls received normal saline. CBF was determined using a modification of the Kety-Schmidt technical employing 133Xe as indicator. Arteriovenous differences for oxygen, glucose, lactate, and beta-hydroxybutyrate (beta-OHB) were also measured, and CMRO2 and CMRsubstrates calculated. Two groups of hypoglycemic dogs were identified; those in which blood glucose levels were greater than 0.5 mM (group 1), and those in which they were less than 0.5 mM (group 2). CBF did not change significantly from control values of 23 +/- 10 ml/min/100 g (mean +/- S.D.) at both levels of hypoglycemia. Similarly, hypoglycemia did not alter CMRO2 significantly from its initial level of 1.05 +/- 0.37 ml O2/min/100 g. Glucose consumption in brain during normoglycemia accounted for 95% of cerebral energy supply with minimal contributions from lactate (4%) and beta-OHB (0.5%). During hypoglycemia, CMRglucose declined by 29 and 52% in groups 1 and 2, respectively, while CMRlactate increased to the extent that this metabolite became the dominant fuel for oxidative metabolism in brain. The cerebral utilization of beta-OHB was unaltered by hypoglycemia. The findings indicate that insulin-induced hypoglycemia in the newborn dog is associated with an increase in cerebral lactate utilization, supplementing glucose as the primary energy fuel and thereby preserving a normal CMRO2. These metabolic responses may contribute to the tolerance of the immature nervous system to the known deleterious effects of hypoglycemia.

Ketone body transport in renal brush border membrane vesicles

Ketone body uptake by renal brush border vesicles has been investigated. Ketone bodies enter into the brush border vesicles by a carrier-mediated process. The uptake is dependent on an Na+ gradient ([Na+]outside>[Na+]inside) and is electroneutral. The uptake is transport into an osmotically active space and not a binding artifact as indicated by the effect of increasing the medium osmolarity. A pH gradient (alkaline inside) also stimulates the ketone body uptake. Acetoacetate and 3-hydroxybutyrate share the same carrier as demonstrated by the accelerated exchange diffusion and mutual inhibitory effects.

Differential effects of sodium acetoacetate and acetoacetic acid infusions on alanine and glutamine metabolism in man

It has been suggested that ketone bodies might participate in the nitrogen-sparing process occurring during prolonged starvation by inhibiting the muscular production of alanine and glutamine, which are the main gluconeogenic amino acids. The results of the ketone infusion studies on which this theory is based have been reevaluated in this study by following the plasma levels of ketone bodies, alanine, glutamine, and other substrates during 11.5 h in five groups of normal overnight-fasted subjects. Subjects of groups I, II, and III were infused for 3 h, respectively, with Na acetoacetate, Na bicarbonate, or free acetoacetic acid administered in comparable amounts (about 20 mumol/kg per min), whereas group IV was infused with hydrochloric acid (7.0 mumol/kg per min). A control group (V) received no infusion. Na acetoacetate induced a rise in blood pH (+0.1+/-0.003) and a fall in the plasma levels of alanine (-41.8+/-4.6%) and glutamine (-10.6+/-1.4%), whereas free acetoacetic acid had a barely detectable lowering effect on blood pH and induced a rise in alanine (+22.5+/-8.0%) and glutamine (+14.6+/-3.2%) levels. Both infusions were associated with a lowering of plasma glucose, which therefore seems independent of the changes in alanine and glutamine concentrations. Sodium bicarbonate reproduced the alkalinizing effect and the hypoalaninemic action of Na acetoacetate, which seems thus unrelated to hyperketonemia. On the other hand, acidification of blood with hydrochloric acid did not mimic the effects of acetoacetic acid. If the hyperalaninemic and hyperglutaminemic effects of ketone bodies infused in their physiological form (free acids) reflect a stimulation of the muscular output of these amino acids, the participation of ketone bodies in the nitrogen-sparing process of prolonged fasting seems very unlikely. On the other hand, during brief starvation, when both ketogenesis and gluconeogenesis are markedly stimulated, ketone bodies might indirectly contribute in supplying the liver and the kidney with gluconeogenic substrates.

Hypoketosis as a cause of symptoms in childhood hypoglycemia

Children with symptomatic hypoglycemia and asymptomatic hypoglycemia-prone children were shown to differ in the degree of ketosis after a 20 h fast. In the latter children the close negative correlation between ketone body levels and glucose levels yielded a regression line against which the former children's data could be compared. Half of the patients were found to be hypoketotic during hypoglycemia. The significance of this hypoketosis in the symptomatology is discussed. The finding of other abnormal responses to fasting, particularly in the patients' nitrogen metabolism, suggests that all these aberrations have a common cause which may be of hepatic origin.

Starvation-induced changes in transport of ketone bodies across the blood-brain barrier

The permeability of the blood brain barrier (BBB) to beta-hydroxybutyrate (beta-HB) was computed in fed and starved (five days) rats by the simultaneous measurement of cerebral blood flow (diffusible indicator method-123I-iodoantipyrine) and brain uptake of 14C-beta-HB (relative to a 3H2O reference). The results from the present study demonstrate that the movement of beta-HB across the BBB in rat is by a carrier-mediated process. During starvation, total movement (carrier-mediated and diffusionary) of this ketone body into brain was observed to be enhanced because of an increase in the diffusionary loss across the cerebral capillary. The calculated transport kinetics also suggest that the beta-HB molecule has a greater affinity for the transport (mediator) protein during starvation, although the maximal rate of uptake by brain due to a carrier processes mediated Vmax is decreased either because there is a smaller quantity of the mediating molecule or because there is trans inhibition by a high cellular concentration of beta-HB or some analog.

New synthetic substrates for parenteral feeding

The glycerol esters of short and medium chain fatty acids are predicted to become important in future nutritional therapy. These compounds provide a mixture of carbohydrate and "carnitine-independent" fat which, together, can serve more tissues than either substrate alone. Medium chain triglycerides are available for enteral feeding, and water-soluble monoglycerides are suggested for parenteral feeding. Two monoglycerides have been tested by continuous infusion into the rat and dog. Experimental evidence indicates rapid ester hydrolysis by endogenous mechanisms which release the basic components of the glycerides. Nutritional tests with these glycerides have produced results at least comparable to glucose as an energy source, and no toxicity has yet been noted. The data suggest that further investigations should be conducted on the benefits of these compounds.

Ketosis and nitrogen excretion in undernourished surgical patients

Hormonal and substrate profiles and urinary nitrogen and urea excretion were measured in 78 underweight patients admitted for surgical investigation, who were placed into either a normo- or a hyperketonemic group, depending upon their levels of acetoacetate and beta-hydroxybutyrate. The two groups were otherwise similar in terms of weight loss, arm muscle circumference, triceps skinfold thickness, and serum protein levels. Before surgery only one-quarter of them were hyperketonemic displaying mean glucose, insulin, and glucagon levels characteristic of starvation-adaption, and excreted significantly less urinary nitrogen than in normoketonemic group. Those patients who underwent surgery tended to retain their presurgery hormonal and substrate profile. The normoketonemic group excreted significantly greater amounts of urinary nitrogen, depleted body protein to a greater extent as evidenced by larger changes in arm muscle circumference and serum protein levels, and mortality was greater. Interference with insulin-glucagon balance by sepsis and disease is suggested as a possible explanation for the failure of three-quarters of the patients to become starvation-adapted. The implications of this finding on the parenteral feeding of undernourished patients are discussed.

Ketone bodies are selectively used by individual brain regions

Close study of 3-hydroxybutyrate uptake by brain suggests that its metabolism is limited by permeability. Furthermore, the permeability characteristics vary from region to region; areas known to have no blood-brain barrier show the highest rate of utilization. The results imply that rather than substitute fuels, ketone bodies should be considered supplements which partially supply specific areas but are incapable of supporting the entire energy requirement of all brain regions.

Metabolic response to surgery in the cancer patient: consequences of aggressive multimodality therapy

The metabolic response to uncomplicated surgery in the patient undergoing primary therapy for malignancy is no different than the response to surgery of similar magnitude for benign disease. Hemodynamic, nutritional-endocrine, and convalescent changes are similar. However, with current aggressive approaches to the management of cancer, the patient often comes to surgery with evidence of major debilitating side effects from his progressive malignancy or from aggressive multimodality therapy. The surgeon must be aware of the consequences of the use of combination therapies on the expected metabolic response to surgery. Awareness of such problems such as the nutritional deficit will allow preventive methods to supercede metabolic salvage procedures.