Enteral feeding a structured lipid emulsion containing fish oil prevents the fatty liver of sepsis

NAFLD Aggravates Septic Shock Due to Inadequate Adrenal Response and 11β-HSDs Dysregulation in Rats

Background: Non-alcoholic fatty liver disease (NAFLD) is linked with metabolic syndrome. Previous studies showed that obesity may disrupt adrenal function and adversely affect its counter-regulations against shock. This study hence evaluated adrenal function abnormalities in NAFLD with shock. Methods: Sprague-Dawley rats were fed with regular chow-diet (control) or high fat diet (HFD, 60% energy derived from fat). Blood tests were performed at the end of the 4th, 6th and 8th week, respectively. Experiments were performed at the end of the 8th week. Results: HFD rats developed NAFLD. HFD rats had 27% and 51% increase in plasma corticosterone at the 6th and 8th week in usual status. However, HFD rats had 5 times more reduction of mean arterial pressure in response to lipopolysaccharide-induced sepsis as compared to control rats. The corticosterone increment ratio was also lower in HFD rats, even after ACTH administration. 11β-HSD system tended to generate more corticosterone in HFD rats under hemodynamic stable status without shock and the trend was lost in HFD rats with septic shock. Conclusion: Rats with NAFLD had profound septic shock due to inadequate corticosterone response. This is, at least partly, due to 11β-HSDs dysregulation in sepsis.

Medium and Long Chain Fatty Acids Differentially Modulate Apoptosis and Release of Inflammatory Cytokines in Human Liver Cells

Medium chain fatty acids (MCFA) can be more easily absorbed and supply energy more rapidly than long chain fatty acids (LCFA). However, little is known about the inflammatory response by the treatment of MCFA in human liver cells. Thus this study used human liver cells (LO2) to evaluate the effects of MCFA on apoptosis and inflammatory response. Tetrazolim-based colorimetric assay and lactate dehydrogenase assay were used to measure the viability of LO2 cells, isolated spleens and liver cells from BALB/C mice. Inverted fluorescence microscopy and flow cytometry were used to assess the cell apoptosis. Activity of superoxide dismutase and malondialdehyde level were measured to determine the oxidative damage. mRNA or protein levels of classical pro-inflammatory cytokines were analyzed by quantitative real-time polymerase chain reaction (qPCR), enzyme-linked immunosorbent assay and western blotting. The results showed that the liver cells treated with the fatty acids at 200 μM for 24 h exhibited good viability. Fatty acids induced inflammatory cytokines at transcriptional and translational levels to a lesser extent than lipopolysaccharide. LCFA (oleic acid) up-regulated tumor necrosis fator-α, monocyte chemoattractant-1 and interleukin-1β while down-regulated IL-6 and IL-8 secretion to a higher extent than MCFA in mRNA and protein levels. These findings suggested that MCFA may induce apoptosis to a less extent and exert more gentle inflammation than LCFA in human liver cells.

Management of sepsis in patients with liver failure

PURPOSE OF REVIEW

Sepsis constitutes the most common cause of death in the ICU. Liver dysfunction is manifested among previously normal subjects with sepsis but even more so in populations with preexisting liver disease. Managing these patients is more challenging. We will review recent literature in sepsis and liver disease, and their bedside application.

RECENT FINDINGS

At the cellular-chemical level, studies showed that platelet aggregation and neutrophil activation occur before and are independent of microcirculatory changes which are apparent in all animal septic models. At the clinical level, early goal-directed therapy, euglycemia, low tidal volume ventilation, and early and appropriately dosed renal replacement therapy among others are all tools to improve sepsis survival. Acknowledgement of liver disease as an immunocompromised host, and identification and treatment of complications can positively change the outcome of sepsis in liver disease.

SUMMARY

Much has been advanced in the field of sepsis management. Understanding the pathophysiology of liver dysfunction and decompensation of a diseased liver incites questions for future research. Early goal-directed therapy, lactate clearance, glycemic control, low volume ventilation strategies, nutrition, adrenal insufficiency, renal dysfunction, hepatorenal syndrome prevention and treatment are some of the issues in the management of sepsis, with or without liver disease, that are relevant in this review.

Dyslipidemia in the Critically Ill

Total and HDL cholesterol levels fall at the onset of acute illness and the cholesterol levels normalize as the patient recovers. Hypocholesterolemia may predispose the critically ill patient to sepsis and adrenal failure. Early enteral nutrition and tight glycemic control accelerate the recovery of the cholesterol levels.

Whole-body beta-oxidation of 18:2omega6 and 18:3omega3 in the pig varies markedly with weaning strategy and dietary 18:3omega3

Segregated early weaning (SEW) into a cleaner nursery increases food intake and growth in pigs, presumably because of reduced immune stimulation compared with conventionally reared, nonsegregated pigs (NSW). The aim of the present study was to evaluate the oxidation of linoleic acid (18:2omega6) and alpha-linolenic acid (18:3omega3) in SEW and NSW pigs. Pigs consumed a control or high 18:3omega3 diet (omega6 PUFA/omega3 PUFA; 21.3 vs. 2.5, respectively) and were weaned at either 14 days old into a SEW nursery or at 21 days old into a conventional NSW nursery. The major acute-phase protein of pigs but not haptoglobin increased in 35-day-old NSW pigs. NSW pigs had 15-25% lower carcass 18:2omega6 and 20-30% lower carcass 18:3omega3 (% composition) at 49 days old. Between 35- and 49-days-old, NSW pigs had a higher whole-body oxidation of 18:2omega6 (40-120%) and 18:3omega3 (30-80%). The high 18:3omega3 diet decreased the whole-body oxidation of 18:2omega6 by 73% and of 18:3omega3 by 63% in NSW pigs. We conclude that moderately cleaner housing SEW significantly decreases 18:2omega6 and 18:3omega3 oxidation in pigs.

Fatty infiltration of the liver in severely burned pediatric patients: autopsy findings and clinical implications

BACKGROUND

Trauma induces hypermetabolic responses that are characterized by the mobilization of all available substrates. The marked increase of peripheral lipolysis after a burn can lead to the development of fatty liver, which has been associated with immunodepression and increased mortality.

METHODS

All autopsies of pediatric burn patients between January 1988 and January 1998 were reviewed. Patient demographics, hospital course, cause of death, and hepatic and septic macroscopic and microscopic findings were recorded.

RESULTS

Thirty-seven pediatric patients (4 +/- 1 years old) were included in the study. The mean burn size was 69% +/- 5% total body surface area burned. Eighty percent of the patients presented with fatty infiltration of the liver. Liver weight/body weight ratio was 77 +/- 5 gm/kg, representing 2.1 times the liver weight of age- and sex-matched controls (p < 0.001). Patients with severe fatty infiltration of the liver had a higher incidence of sepsis (p < 0.001).

CONCLUSION

Fatty infiltration of the liver is a common condition in fatal burns. Severe fatty infiltration of the liver is associated with an increased incidence of sepsis, although a causative effect could not be found. It is notable that fatty infiltration of the liver occurred in the complete absence of parenteral nutrition.

Effect of medium-chain fatty acid positional distribution in dietary triacylglycerol on lymphatic lipid transport and chylomicron composition in rats

The present study was carried out to examine if the positional distribution of medium-chain fatty acid (MCF) in dietary synthetic fat influences lymphatic transport of dietary fat and the chemical composition of chylomicrons in rats with permanent cannulation of thoracic duct. Four types of synthetic triacylglycerol were prepared: (i) sn-1 (3) MCF-sn 2 linoleic acid, (ii) interesterified sn-1(3) MCF-sn 2 linoleic acid, (iii) sn-2 MCF-sn-1(3) linoleic acid, and (iv) interesterified sn-2 MCF-sn-1(3) linoleic acid. A purified diet composed of equal amounts of the synthetic fat and cocoa butter was given to rats with permanent lymph duct cannulation. The positional distribution of MCF in the dietary fat had no significant effect on the lymph flow, triacylglycerol output, phospholipid output, lipid composition of chylomicrons, or the particle size. The positional distribution of MCF in the synthetic triacylglycerol was maintained in the chylomicron triacylglycerol. These results showed that MCF in the dietary triacylglycerol is transported into lymphatics and the positional distribution is well preserved in chylomicron triacylglycerol.

Metabolic derangements in sepsis and septic shock

This article examines the spectrum of metabolic alterations in sepsis and septic shock. The clinical manifestations, neuroendocrine control, and bioenergetics of the "ebb" and "flow" phases of sepsis are reviewed. Characteristic alterations in carbohydrate, fat, and protein metabolism induced by sepsis are outlined. Finally, the implications of these metabolic alterations for the nutritional support of patients with sepsis are discussed.

Structured triacylglycerol containing medium-chain fatty acids in sn-1(3) facilitates the absorption of dietary long-chain fatty acids in rats

A study was carried out to examine if the positional distribution of medium chain fatty acids (MCF) in triacylglycerol influences dietary fat absorption in rats. Two types of structure-specific fats, one predominantly composed of MCF in sn-1(3) and iinoleic acid in sn-2 [sn1(3)MCF-structured] and the others of MCF in sn-2 and linoleic acid in sn-1(3) [sn-2MCF-structured], were initially prepared, and the two structure-specific fats were interesterified and designated as sn-1(3)MCF-interesterified and sn-2MCF-interesterified. Synthetic fat was mixed with an equal amount of cocoa butter (103 g/kg of diet) and was supplemented to the AIN93G-based diet. Rats were fed on the diets for 4 wk. Long-chain saturated fatty acids were the predominant fatty acids excreted into the feces, and the positional distribution of MCF resulted in an altered fat absorption rate (%) of 81.8, 82.5, 84.2 and 86.3 for the rats fed on the diets containing sn-2MCF-structured, sn-1(3)MCF-interesterified, sn-2MCF-interesterified and sn-1(3)MCF-structured fats, respectively. The proportion of MCF in the serum, liver and adipose tissue triacylglycerols was not affected by the MCF distribution of the dietary fats. These results indicate that the distribution of MCF in dietary triacylglycerol is a determinant of intestinal fat absorption.

Effects of parenteral infusion with fish-oil or safflower-oil emulsion on hepatic lipids, plasma amino acids, and inflammatory mediators in septic rats

This study was designed to investigate the effects of preinfusion with total parenteral nutrition (TPN) using fish-oil (FO) versus safflower-oil (SO) emulsion as fat sources on hepatic lipids, plasma amino-acid profiles, and inflammatory-related mediators in septic rats. Normal rats, with internal jugular catheters, were assigned to two different groups and received TPN. TPN provided 300 kcal. kg(-1). d(-1), with 40% of the non-protein energy as fat. All TPN solutions were isonitrogenous and identical in nutrient composition except for the fat emulsion, which was made of SO or FO. After receiving TPN for 6 d, each group of rats was further divided into control and sepsis subgroups. Sepsis was induced by cecal ligation and puncture; control rats received sham operation. All rats were classified into four groups as follows: FO control group (FOC; n = 7), FO sepsis group (FOS; n = 8), SO control group (SOC; n = 8), and SO sepsis group (SOS; n = 9). The results of the study demonstrated that plasma concentrations of triacylglycerol and non-esterified fatty acids did not differ between the FO and SO groups, regardless of whether the animals were septic. SOS had significantly higher total lipids and cholesterol content in the liver than did the SOC group. The FOS group, however, showed no difference from the FOC group. Plasma leucine and isoleucine levels were significantly lower in the SOS group than in the SOC group, whereas no difference in these two amino acids was observed between the FOC and FOS groups. Plasma arginine levels were significantly lower in both septic groups than in the groups without sepsis when either FO or SO was infused. Plasma glutamine levels, however, did not differ across groups. No differences in interleukin-1beta, interleukin-6, tumor necrosis factor-alpha, or leukotriene B(4) concentrations in peritoneal lavage fluid were observed between the two septic groups. These results suggest that catabolic reaction in septic rats preinfused with FO is not as obvious as those preinfused with SO. Compared with SO emulsion, TPN with FO emulsion prevents liver fat accumulation associated with sepsis. However, parenterally administered FO had no beneficial effect in lowering cytokines and LTB(4) levels in peritoneal lavage fluid in septic rats induced by cecal ligation and puncture.

Lymphatic absorption of structured triglycerides vs. physical mix in a rat model of fat malabsorption

Comparison was made between the intestinal absorption and lymphatic transport of a randomly interesterified fish oil and medium-chain triglyceride (MCT) structured triglycerides (STG) vs. the physical mix in rat small intestine following ischemia and reperfusion (I/R) injury. Under halothane anesthesia, the superior mesenteric artery (SMA) was occluded for 20 min and then reperfused in I/R rats. The SMA was isolated but not occluded in control rats. In both treatment groups, the mesenteric lymph duct was cannulated and a gastric tube was inserted. Each treatment group received 1 ml of the fish oil-MCT STG or physical mix (7 rats/group) through the gastric tube followed by an infusion of PBS at 3 ml/h for 8 h. Lymph was collected hourly for 8 h. Lymph triglyceride, cholesterol, and decanoic and eicosapentaenoic acids increased rapidly and maintained a significantly higher output (P < 0.01) with STG compared with physical mix in control rats over 8 h. After I/R, lymphatic triglyceride output decreased 50% compared with control. Gastric infusion of STG significantly improved lipid transport by having a twofold higher triglyceride, cholesterol, and decanoic and eicosapentaenoic acids output to lymph compared with its physical mix (P < 0.01). We conclude that STG is absorbed into lymph significantly better than physical mix by both the normal intestine and the intestine injured by I/R.

Apoptotic death of pancreatic cancer cells induced by polyunsaturated fatty acids varies with double bond number and involves an oxidative mechanism

Polyunsaturated fatty acids (PUFAs), reported to be cytotoxic at micromolar concentrations for cancer cells in vitro and in vivo, are currently being tested in clinical trials as anti-cancer agents. This study has shown that seven PUFAs all inhibited the growth in vitro of three pancreatic cancer cell lines and the HL-60 leukaemic cell line. Five PUFAs induced cell death within 20-30 h, but two less potent PUFAs induced death between 50 and 75 h. Apoptosis was demonstrated to be the mode of cell death by light, UV fluorescence, and electron microscopy, together with studies of DNA fragmentation. In a time-course study of PUFA-treated Mia-Pa-Ca-2 cells, apoptosis accounted for an average of 80 per cent of the loss of viability, with 'secondary necrosis', a feature of late apoptosis, apparently accounting for the remainder. Correlations were found between the number of fatty acid double bonds and the proportion of cells undergoing apoptosis induced in both Mia-Pa-Ca-2 cells (R = 0.88, P = 0.0001) and HL-60 cells (R = 0.85, P = 0.0001) and inversely with the micromolar concentrations of PUFAs required for 50 per cent inhibition of growth (IC50) of Mia-Pa-Ca-2 cells (R = -0.73, P = 0.05). Cell death was preceded by progressively increasing lipid peroxidation. The extent of PUFA-induced lipid peroxidation, measured as malondialdehyde (MDA), also correlated with the proportion of apoptosis induced in Mia-Pa-Ca-2 cells (R = 0.69, P = 0.025) or HL-60 cells (R = 0.64, P = 0.043), as well as with the number of fatty acid double bonds (R = 0.82, P = 0.0015). PUFA-induced apoptosis was oxidative, being blocked by both vitamin E acetate and sodium selenite, the latter in a critically time-dependent manner. The cytotoxic effects of exposure to a PUFA and to gamma-irradiation simultaneously with, or prior to, the addition of PUFA.

Substrate utilization/insulin resistance in sepsis/trauma

Endogenous substrate metabolism is markedly altered in critically ill patients. Glucose production is elevated not only in the post-absorptive state, but the normal suppressive effect of exogenous glucose and glucose production is greatly diminished. In the post-absorptive state, glucose clearance is generally elevated, potentially causing hypoglycaemia in extreme cases. Somewhat paradoxically, the ability of insulin to stimulate glucose uptake is diminished, so that hyperglycaemia is often evident during nutritional intake. Lipolysis, the breakdown of peripheral fat, is accelerated, meaning that free fatty acids are released into plasma at a rate far exceeding their oxidation. Some of the excess fatty acids are re-esterified in the liver, leading to accelerated hepatic triglyceride formation. A large increase in hepatic triglyceride stores can ensue if the rate of excretion of triglycerides in very low density lipoproteins is not accelerated commensurately with the increased triglyceride production. Indirect calorimetry measurements support the notion that the large increase in availability of fatty acids may lead to a greater reliance on fatty acids as energy substrates. Nonetheless, carbohydrates should be the predominant source of non-protein calories, because the accompanying insulin response effectively enhances protein synthesis. There is already ample fat available via endogenous lipolysis, and more fat given exogenously provides little further benefit.

Insulin stimulates lipoprotein lipase activity and synthesis in adipocytes from septic rats

Gram-negative sepsis suppresses lipoprotein lipase (LPL) activity in adipose tissue which contributes, in part, to the altered clearance of triglycerides. The suppression in LPL activity occurs when plasma insulin concentrations are elevated and insulin-stimulated glucose utilization is impaired. This study was planned to evaluate whether the presence of insulin resistance was responsible for the decrease in adipose LPL activity. Adipocytes were isolated from epididymal fat pads 24 h after inducing sepsis in male Lewis rats by intravenous injection of 4 x 10(8) colonies of live Escherichia coli/100 g body wt. The decrease in heparin-releasable (HR) LPL activity in adipocytes from the septic rats was evident at the time of isolation and maintained in a 20-h culture. After overnight incubation with insulin (10(-8) M), HR LPL activity was stimulated to a greater extent in adipocytes from septic rats (298%) than in adipocytes from control rats (88%). The insulin stimulation of LPL activity during sepsis could not be attributed to insulin-like growth factor-I (IGF-I) as adipocytes from septic rats appeared to be IGF-I resistant. Insulin-treatment (10(-8) M) increased LPL synthesis 99% in adipocytes from control rats and 136% in adipocytes from septic rats. Insulin treatment also led to a 65 and 62% increase in LPL mass in adipocytes from control and septic rats, respectively. These findings indicate that the sepsis-induced decrease in adipose LPL is not due to insulin resistance with respect to LPL. The insulin stimulation of LPL activity in adipocytes from septic rats appears to be mediated by an increase in LPL synthesis.