Plasma amino acids and protein levels in chronic renal failure and changes caused by oral supplements of essential amino acids

Protective impacts of Artemisia annua against hepatic toxicity induced by gentamicin

The current study aimed to investigate the ameliorative effects of Artemisia annua (RA) extract on hepatic toxicity induced by gentamicin injection mice. Sixteen mice were divided into four groups; the control group received saline, the second group received 1% A. annua (RA) extract, third group injected 80 mg/kg gentamicin (GEN) intraperitoneally. The protective group treated with a combination of GEN and A. annua. All mice were treated for consecutive 15 days. Results confirmed that hepatic biomarkers (GPT, GCT, GOT, IL-6 and IL-1β), all were altered after gentamycin injection. The histological analysis confirmed that gentamycin injected mice showed portal vein congestion, micro and macro steatosis, and nuclear pyknosis of hepatocytes. The protective group showed intact central vein with less microsteatosis of some hepatocytes. Immunochemistry analysis confirmed that the immunoreactivity of COX-2 gene showed negative impact in examined groups. Unlike, NF-κB gene exhibited diffuse positive expression in the gentamicin group. TGF-β1 immunoreactivity was mild positive in control and highly upregulated in gentamicin treated mice, all were normalized after RA administration. In conclusion, RA showed a beneficial impact against gentamycin induced hepatic toxicity at cellular and biochemical levels by regulating proteins and inflammatory markers associated with liver activity.

Taify Pomegranate Juice (TPJ) Abrogates Acrylamide-Induced Oxidative Stress Through the Regulation of Antioxidant Activity, Inflammation, and Apoptosis-Associated Genes

Acrylamide (ACR) has various effects on biological systems, including oxidative stress and its associated metabolic disorders. Previous research reports that plants growing at high altitude have a different profile of antioxidants. In the current report, the Taify pomegranate juice (TPJ) of the Taify pomegranate growing at the Taif region (high altitude), Saudi Arabia, was investigated for its protective activity from ACR-induced oxidative stress. Rats were treated with ACR, TPJ, or TPJ+ACR, and various assays, including blood chemistry, liver function biomarkers, gene expression of endogenous antioxidant enzymes, oxidative stress regulatory genes, inflammation biomarkers, and apoptosis, were estimated using biochemical, real-time PCR, histopathological, and immunohistochemical analysis. TPJ showed a protective function of ACR-induced alteration of AST, ALT, GGT, urea, total proteins, albumin, MDA, and NO. It also increased the level of the endogenous antioxidative enzymes, including SOD, catalase, and GSH. It showed anti-inflammatory activity by reduction the TNF-α, IL-6 secretion and the enhancing of IL-10 levels. At the gene expression level, TPJ upregulated the expression of endogenous antioxidant genes (SOD and catalase) and of antioxidant-regulating genes Nrf2 and HO-1; downregulated the expression of inflammatory genes TGF-β1, COX2, and the apoptotic gene caspase-3; and upregulated the expression of antiapoptotic gene Bcl2. At the histological level, TPJ showed a protective effect from the ACR-induced hepatic histological damage. Results of this study conclude that TPJ has a protective effect from ACR-induced oxidative stress and its associated metabolic alterations through its antioxidant and anti-inflammatory activities.

Beneficial impact of dietary methyl methionine sulfonium chloride and/or L-carnitine supplementation on growth performance, feed efficiency, and serum biochemical parameters in broiler chicken: role of IGF-1 and MSTN genes

The purpose of this study was to examine the effect of dietary supplementation with methyl methionine sulfonium chloride (MMSC), and L-carnitine (L-CAR) alone or in combination on the growth performance of broilers through their impact on the expression of IGF-1 and MSTN genes associated with growth in broilers. One-day-old female Ross 308 broiler chicks were allocated into four groups, each of which received a broiler starter diet and water daily ad libitum. The control group (group 1) was given drinking water without any additives. Group 2 received 0.25 g L-carnitine per liter of drinking water, group 3 received 0.25 g MMSC per liter of drinking water, and group 4 received 0.25 g of both L-carnitine and MMSC per liter of drinking water. Birds were given a starter diet to 21 days after which they received a broiler grower diet to 35 days when the experiment ended. There were five replicate groups of 12 birds per treatment. Body weights and feed intake were recorded weekly. Compared to the control group of birds, supplementation with MMSC either alone or in combination with L-carnitine resulted in an increase in growth rate or feed utilization efficiency; L-carnitine by itself had no effect. MMSC supplementation, again either alone or in combination with L-carnitine, increased jejunal and ileal villi height, increased serum total proteins and globulins, downregulated myostatin (MSTN) mRNA, and upregulated insulin growth factor-1 (IGF-1) mRNA expression. Supplementation with L-carnitine alone showed none of these effects. We conclude that MMSC supplementation improved growth performance through the upregulation of IGF-1 mRNA expression and downregulation of MSTN mRNA expression.

The Protective Impact of Salsola imbricata Leaf Extract From Taif Against Acrylamide-Induced Hepatic Inflammation and Oxidative Damage: The Role of Antioxidants, Cytokines, and Apoptosis-Associated Genes

Salsola imbricata is a herbal plant native to Saudi Arabia, known for its antioxidative and anti-inflammatory properties. This study explored the protective effects of an ethanolic leaf extract of Salsola imbricata against the oxidative stress and hepatic injury caused by acrylamide. Rats received intragastric administrations of 20 mg/kg of body weight of acrylamide to induce hepatic injury, or 300 mg/kg of body weight of Salsola ethanolic extract orally for 7 days before acrylamide administration. The treatments were continued for 3 weeks. Blood and liver samples were collected from all the groups, and the following biochemical parameters were tested: serum ALT (alanine aminotransferase), AST (aspartate aminotransferase), GGT (gamma glutaryl transferase), urea, albumin, total proteins, catalase, SOD (superoxide dismutase), reduced glutathione (GSH), nitric oxide (NO), and MDA (malondialdehyde). Quantitative real-time PCR (qRT-PCR) was used to examine the expression of Nrf2 (Nuclear factor-erythroid factor 2-related factor 2), HO-1 (Hemoxygenase-1), COX-2 (Cyclooxgenase-2), TGF-β1 (transforming growth factor-beta1), Bax, and Bcl2 (B-cell lymphoma 2), which are associated with oxidative stress, fibrosis, apoptosis, and anti-apoptotic effects. The annexin and survivin immunoreactivity were examined at the immunohistochemical level. Pretreatment with the Salsola ethanolic extract reduced the negative impact of acrylamide on ALT, AST, GGT, urea, albumin, and total proteins. The Salsola ethanolic extract reversed acrylamide's effects on serum and tissue antioxidants. Nrf2/HO-1 expression was downregulated, while COX-2 and TGF-β1 were upregulated in the acrylamide-administered group and normalized by the pre-administration of Salsola ethanolic extract to the acrylamide experimental group. The immunoreactivity of annexin and survivin was restored in the experimental group administered Salsola ethanolic extract plus acrylamide. In conclusion, Salsola ethanolic extract inhibits and regulates the side effects induced in the liver by acrylamide. Salsola induced its impacts by regulating inflammation, oxidative stress, and apoptosis-/anti-apoptosis-associated genes at the biochemical, molecular, and cellular levels. Salsola is recommended as oxidative stress relievers against environmental toixicity at high altitude areas.

Protective Impacts of Moringa oleifera Leaf Extract against Methotrexate-Induced Oxidative Stress and Apoptosis on Mouse Spleen

Objective

The current study was aimed to examine the possible ameliorative impacts of MO leaf extract (MOLE) against MTX-induced alterations on oxidative stress of mouse spleen and explore the possible molecular mechanism that controls such impacts.

Methods

Adult male mice were allocated into 4 groups: control, Moringa oleifera leaf extract (MOLE), MTX, and MOLE plus MTX. Mice received MOLE orally for a week before MTX injection and continued for 12 days. Serum and spleen were sampled for biochemical and quantitative gene expressions.

Results

As compared with the MTX-injected group, MOLE effectively reduced the changes in total proteins, spleen MDA, SOD and catalase activities, and changes in serum antioxidants levels. Moreover, there is downregulation of antioxidant genes (SOD and catalase) and antiapoptotic genes (XIAP and Bcl-xl) along with upregulation in Bax and caspase-3 mRNA (apoptotic genes) in the MTX-injected group. MTX induced changes in IL-1β, IL-6, TNF-α, and IL-10 expression. MOLE restored and ameliorated the changes induced in biochemical, antioxidants, apoptosis, and apoptosis associated genes that were induced by MTX intoxication.

Conclusion

Current findings indicated that pretreatment with MOLE to MTX-intoxicated mice showed the potential usage of MO for oxidative stress and apoptosis treatment.

Amino acids and the kidney

The kidney has an important role in the metabolism of amino acids and control of plasma concentrations. Reabsorption by the tubules recovers about 70g/day of amino acids, derived from both the diet and metabolism in other tissues. Amino acids regulate haemodynamics and proteolysis and maintain integrity of the kidney. Abnormal plasma and muscle amino acid profiles in chronic renal failure (i.e. low essentials and tyrosine with high nonessentials) first indicated malnutrition, which can be partially corrected by supplementation. The loss of effective kidney tissue and uraemia, in addition to nutrition, have been considered in studies of phenylalanine hydroxylation used to investigate low tyrosine. Investigations in normal kidney have shown that glutamine uptake maintains acid-base homeostasis, glycine and citrulline are removed, and serine and arginine are released into the circulation. These metabolic processes are impaired in chronic renal failure. Uraemia affects most tissues and causes malnutrition, whilst acidosis activates catabolism of amino acids and proteins in muscle. Hyperinsulinaemia probably depresses plasma branchedchain amino acids and particularly valine. These abnormalities are less likely to respond to dietary supplementation.

Effects of single administration of Rokumi-gan (TJ-87) on serum amino acid concentration of 6 healthy Japanese male volunteers

Rokumi-gan (TJ-87) has beneficial effects on renal diseases, including pollakisuria, dysuria and edema. We previously reported that its long-term administration clinically improved serum protein concentration and edema in renal failure. In this study, we focused on amino acid/protein contents in Rokumi-gan as one of its effectors. Commercially prepared Rokumi-gan contained arginine, aspartate and glutamate at the high levels, alanine, phenylalanine and serine at the moderate levels, and glycine, histidine, isoleucine, leucine, lysine and valine at the low levels. To examine effects of Rokumi-gan on serum amino acid concentrations, 6 healthy Japanese volunteers were treated with commercially prepared Rokumi-gan, an amino acid mixture, and lactose. In subjects treated with an amino acid mixture containing similar amounts of amino acids in Rokumi-gan (10 g), or lactose, serum amounts of many amino acids, except for arginine, gradually and significantly decreased until 6 hr after their treatments. In contrast, a single treatment with Rokumi-gan (10 g) increased serum levels of several amino acids, alanine, arginine, glutamate, glycine and serine. Serum concentrations of almost of all tested amino acids showed the peak value 1-2 hr after administration, and they were sustained at the basal level even 6 hr after the treatment. Our present results suggest that Rokumi-gan may be a beneficial amino acid supplier, because it could sustain serum amino acid concentration at the higher level than an amino acid mixture supplement.

Metabolism and clinical interest of serum transthyretin (prealbumin) in dialysis patients

Chronic renal failure is responsible for an increase in serum concentrations of transthyretin. Elevated serum transthyretin during renal insufficiency is secondary to the lack of retinol-binding protein degradation in renal tubules and to the subsequent increase in the fraction of transthyretin bound to retinol-binding protein. In both hemodialysis and peritoneal dialysis patients, serum transthyretin was demonstrated to be a reliable marker of nutritional status, exhibiting significant relationships with energy and protein intakes as well as with fat stores and lean body mass. Serum transthyretin levels less than 300 mg/l were shown to be associated with an increased risk of morbidity and mortality in dialysis patients. The predictive value of transthyretin was shown to be independent of serum albumin. Regular measurements of both serum albumin and transthyretin make it possible to detect patients whose prognosis is compromised by malnutrition and in whom an active nutritional therapy must be undertaken. Simultaneous measurements of inflammatory markers such as serum C-reactive protein are required to evaluate the role of inflammation in serum albumin and transthyretin variations. These low-cost protein parameters should be incorporated in the regular assessment of dialysis patients and measured every 1 to 3 months.

Effect of experimental renal failure on the pharmacokinetics of losartan in rats

The purpose of this investigation was to determine whether the pharmacokinetics of the angiotensin II receptor antagonist losartan is altered in renal failure. Male Wistar rats were pretreated with uranyl nitrate or subjected to bilateral ureteral ligation to produce acute renal failure (ARF). Saline-injected and sham-operated rats, respectively, served as controls. Uranyl nitrate-treated rats showed significantly higher serum concentrations of losartan after oral administration and the area under the serum concentration-time curve (AUC(0-24)) of losartan increased about 3-fold compared to control rats. The systemic clearance of losartan significantly decreased from 410 +/- 254ml/h/kg in control to 177 +/- 112ml/h/kg in uranyl nitrate-treated rats. In order to investigate the mechanisms of reduced clearance of losartan associated with ARF, a hepatic microsome fraction was prepared from normal and ARF rats. No significant difference was found in the metabolism of losartan by hepatic microsomes prepared from ARF and control rats. In addition, the metabolic activity of microsomes was examined in the presence of uremic rat serum. The unbound clearance of losartan and the unbound clearance associated with the formation of EXP3174 in the presence of uremic serum were significantly lower than those in the presence of control serum. Furthermore, the metabolism of losartan was inhibited by indoxyl sulfate, a uremic toxin, in an uncompetitive manner. These results suggest that ARF is associated with reduced clearance of losartan due to the inhibition of hepatic metabolism by accumulated uremic toxin(s).

Patterns of fasting plasma amino acid levels in chronic renal insufficiency: results from the feasibility phase of the Modification of Diet in Renal Disease Study

Fasting plasma amino acid levels were measured in 78 patients with chronic renal insufficiency (glomerular filtration rate [GFR], 8.0 to 56.0 mL/min), who had been enrolled in phase II of the Modification of Diet in Renal Disease study, prior to their beginning the experimental portion of the protocol. Alterations in many plasma amino acid levels were observed in the patients with the mildest degrees of renal insufficiency, and the number and severity of abnormalities tended to be greater in the patients with more severe renal failure. In patients with GFRs greater than 24.5 mL/min, 15 to 24.5 mL/min, and less than 15 mL/min, statistically significant abnormalities were observed in the concentrations or ratios of 9, 14, and 18 amino acids, respectively. The following correlations of amino acid levels or ratios with GFR were observed (all P < 0.001): citrulline, r = -0.41; citrulline to arginine ratio, r = -0.42; glycine to serine ratio, r = -0.37; N-tau methylhistidine, r = -0.65; and cystine, r = -0.37. Other weaker correlations observed were valine, r = 0.26 (P < 0.025); valine to glycine ratio, r = 0.32 (P = 0.004); and sum of isoleucine, leucine, and valine, r = 0.21 (P = 0.061). N-tau methylhistidine and the essential to nonessential amino acid ratio became altered with declining GFR in a nonlinear fashion. Thus, many of the characteristic alterations in the plasma amino acid profile that are observed in chronic end-stage renal disease are already present in mild renal insufficiency. Progressive loss of renal function generally results in increasing abnormalities; these changes in plasma amino acid concentrations with reduction in GFR were usually linear.

Changes in plasma and urinary amino acid levels during diabetic ketoacidosis in children

Plasma and urinary concentrations of different amino acids were investigated during diabetic ketoacidosis (DKA) and 12, 24, 72 hours after initiation of therapy. In DKA, plasma concentration of glutamic acid, aspartic acid, valine, leucine and isoleucine significantly increased while that of asparagine and glutamine decreased compared to levels in well-controlled diabetic patients. The urinary excretion of branched-chain amino acids, histidine, serine and threonine was elevated while those of glutamic acid, glutamine, glycine and taurine were reduced. Among the different amino acids, histidine excretion had the highest variability. A strong correlation was found between the urinary excretion of several amino acids and that of the beta-2-microglobulin characterizing tubular dysfunction. Changes in the excretion of different amino acids reflect the altered metabolic state and renal function due to DKA.

Early alterations of plasma free amino acids in chronic renal failure

In order to assess the influence of renal failure and nutritional status on the fasting concentrations of free plasma amino acids, we studied 81 ambulatory adult patients with varying degrees of chronic renal failure. Each of the patients was in good general and nutritional condition. Compared to 33 healthy controls, patients with mild renal failure (Ccr greater than 25 ml/mn) exhibited significantly (p less than 0.01, Student's t test) raised concentrations of cystine, citrulline, ornithine, taurine and 3-methyl-histidine and low level of serine. Concentrations of cystine, citrulline, and 3-methyl-histidine in plasma but not of taurine or ornithine rose in parallel with the progression of renal failure. A significant, but moderate decrease in valine, leucine and isoleucine concentrations was observed in patients with the most marked degree of renal failure (Ccr less than 10 ml/mn). We conclude that changes in the plasma concentration of several non essential amino acids are already present in the early stage of renal failure in patients with no sign of protein malnutrition: these may result from altered metabolic pathways of amino acids related to uremia and/or nephron loss per se whereas the moderate decrease in branched-chain amino acids that is observed only in the advanced stage of renal failure may be, at least in part, nutritional in origin.

Amino acid metabolism in uremia

The uremic syndrome is multifactorial, and affects most tissues and organs. Disturbances in protein and amino acid metabolism may play important roles, especially in chronic uremia, either directly or by production of toxic metabolites, with resultant negative nitrogen (N) balance, muscle wasting, reduced protein synthesis, and characteristically abnormal intracellular free amino acid concentrations. There are also grossly abnormal amino acid levels in the plasma of uremic patients, e.g., increases in conjugated amino acids, high levels of several nonessential and low levels of essential amino acids. The ratios of tyrosine/phenylalanine and of valine/glycine are decreased. The low tryptophan levels may contribute to encephalopathy as a result of an imbalance in neurotransmitter synthesis. Citrulline is found in excess; the explanation is unresolved. There are elevated concentrations of the sulfur-containing amino acids: cystine, taurine, cystathionine, and homocysteine. Excess of the latter is implicated in the atherogenesis of renal failure. Disturbed metabolism and interorgan exchange of amino acids in the uremic state explains some of the abnormalities in tissue and plasma concentrations of individual amino acids. Enzymatic defects are involved in the disturbed metabolism of branched chain amino acids (BCAA), with possible antagonism among them, which impairs growth and amino acid utilization. Carbohydrate intolerance, associated with insensitivity of peripheral tissues to insulin and hyperinsulinemia, elicits decreased plasma BCAA. Protein synthesis rates in normal and pathological conditions are more closely related to the intracellular amino acid pool than to plasma amino acid levels. Concentrations of individual amino acids in the plasma pool are poor indicators of their intracellular concentrations. Muscle contains the largest pool of protein and free amino acids in the body. In chronic renal failure patients, the intracellular concentrations of valine, threonine, lysine, and carnosine are low. With low protein diets and in hemodialysis, serine, tyrosine, and taurine often are also low. The low taurine may be related to fatigue and to uremic cardiomyopathies. The commonly used amino acid supplements generally fail to correct the intracellular amino acid deficits. A "New Formula" has been developed to correct these intracellular amino acid abnormalities, and to supplement a low protein diet. It provides more valine than leucine, increased tyrosine and threonine, and less histidine, leucine, isoleucine, lysine, methionine, and phenylalanine than in formulas customarily used for patients with chronic renal failure. It is uncertain whether other ap

CAPD with an amino acid dialysis solution: a long-term, cross-over study

This prospective cross-over study was undertaken to evaluate the safety and efficacy of a 1% amino acid dialysis solution on the nutritional and metabolic changes, plasma amino acid profiles and peritoneal membrane function of patients on CAPD. Six CAPD patients had one exchange a day with two liters of this solution over a six month period. Every month there was a medical examination, anthropometric measurements and dietary inquiry were made, blood biochemistry tests were done. Every three months renal function, peritoneal function, aminograms of plasma and dialysate and nitrogen balance were determined. Data were compared with those obtained one month prior to and three months after withdrawal of amino acid administration. Nitrogen balance, which was negative (-1.3 g/day) became positive (+3.1 g/day). Patients who were already overweight increased in weight, both in fat and lean mass. Plasma cholesterol and triglycerides significantly decreased and the amino acid profile moved towards normal; plasma urea levels increased and pH and bicarbonate decreased slightly but significantly (P less than 0.05). Plasma protein concentrations did not change. All the above parameters turned towards basal values when amino acids were discontinued. We conclude that amino acids can be used as osmotic agents for CAPD since they do not cause toxic effects or impair peritoneal membrane function. Moreover, they can help the nutritional status, provided that an increase in weight is prevented and the slight worsening of systemic acidosis is corrected.

Zinc balance in combined zinc deficiency and uremia

In order to evaluate whether the hypozincemia associated with chronic renal failure represents true negative zinc balance, male Lewis rats were randomized and pair-fed zinc replete (+Zn) or deplete (-Zn) diets. Subsequently, each animal underwent one- and two-thirds nephrectomy, or a sham operation. Complete balances for zinc, calcium, and magnesium were determined weekly before and after nephrectomy. At sacrifice, -Zn animals had significantly lower (P less than 0.005) plasma zinc levels compared to controls. Nephrectomized (N) animals had significantly elevated plasma creatinine (P less than 0.005), diminished creatinine clearances (P less than 0.005), and increased urinary flows (P less than 0.005) and protein excretion (P less than 0.01) compared to sham-operated (S) controls. Zinc nutritional status had no effect on these parameters in animals with comparable renal function. -Zn/N animals had consistently significantly elevated (P less than 0.005) urinary zinc excretion compared with -Zn/S with similar plasma zinc concentrations. Urinary zinc excretion correlated with urinary flow (r = 0.739, P less than 0.005), urinary protein (r = 0.635, P less than 0.01) and urinary calcium excretion (r = 0.855, P less than 0.005) in -Zn groups. -Zn/N rats had a significantly larger fecal zinc excretion for the first week post-nephrectomy, compared to -Zn/N controls (P less than 0.005). This resulted in negative zinc balance in -Zn/N animals, compared to their pre-nephrectomy balance (P less than 0.05) or to -Zn/S controls for the first (P less than 0.005) and second (P less than 0.05) weeks. -Zn/N rats had lower (P less than 0.02) hepatic zinc concentrations compared to the -Zn/S group.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships between serum total iron-binding capacity and transferrin

The relationship between serum transferrin ( TFN ) and serum total iron-binding capacity (TIBC) in a clinical setting was evaluated in two related studies. The initial study evaluated 101 blood samples representing a cross-section of hospitalized adults. The samples were double assayed for TIBC using clinical and research methodologies. TFN was assayed by a commercial radial immunodiffusion method. Clinical laboratory TIBC correlated well with research laboratory TIBC (r = 0.87, slope = 0.97, p less than 0.001, n = 50) and the relationship of TIBC to TFN yielded the following equation: TFN = 0.83 TIBC -5.6 (r = 0.82, p less than 0.001, n = 101) where TFN = mg/100 ml and TIBC = micrograms/100 ml. The second study evaluated a new TIBC assay and its effect on the TIBC/ TFN relationship. Additionally, the TFN -TIBC relationship was evaluated at low normal and abnormal TIBC levels. In this second study, TFN = 1.0 TIBC -18.8 (r = 0.88, p less than 0.01, n = 126). Subsample analysis for specimens with TIBC between 105 and 160 showed a TIBC- TFN regression line that was not significantly different than the entire sample. Inclusion of ancillary patient data such as hemoglobin and hematocrit did not improve the relationship between TFN and TIBC in either study. The relationship was unaffected by age, sex, race, disease, treatment, fever, surgery, degree of nutritional support, blood transfusion, or blood chemistry parameters in either study. Laboratories deriving TFN from measured TIBC as a nutritional status indicator must determine the relationship for the specific procedures being used in their laboratories.

Tyrosine supplementation in chronic experimental uremia

The occurrence of low tyrosine tissue levels in uremic subjects, possibly due to impaired phenylalanine hydroxylation, suggests that tyrosine may be an essential amino acid in uremia. Additional dietary tyrosine may thus re-dress the deficiency. This study examined growth and tyrosine/phenylalanine metabolism in uremic rats during tyrosine supplementation. Rats made uremic (U) by 7/8 nephrectomy were compared to pair-fed (CP) and ad libitum-fed (CA), sham-operated controls. Two sets of each group of rats were studied after 21 days on the respective diets: I = Purina Lab Chow; II = same + 3.5% tyrosine. Plasma tyrosine was below normal in U and CP-fed diet I. With diet II, the tyrosine:phenylalanine ratio in U was lower than both CA and CP. In rats fed diet II, the tyrosine:phenylalanine ratio became indistinguishable among the three groups. Growth parameters in U and CP were similar, regardless of the diet. Body weight gain, tibial length, muscle mass, and tissue protein did not improve in uremic animals supplemented with tyrosine. The specific activity of liver phenylalanine hydroxylase in U was not different from CA or CP. However, loss of cortical renal mass appeared to be the major determinant of decreased kidney phenylalanine hydroxylation in experimental uremia. This alteration is likely to be the greatest contributory factor to the alteration of plasma levels of tyrosine and phenylalanine. The data presented do not support a proposed essentiality of tyrosine in uremia.

Enzymatic and pharmacokinetic studies on the metabolism of branched chain alpha-keto acids in the rat

Michaelis-constants and enzyme activities for dehydrogenation and transamination of the three branched chain alpha-keto acids in liver, kidney, skeletal muscle, and brain of rats are reported. After oral load only 11-22% of the keto acids pass the liver unchanged. Blood levels in pharmacokinetic and absorption studies are related to the Michaelis-constants. At the low keto-acid concentrations after oral application, dehydrogenation in the non-hepatic tissues is supposed to prevail over transamination. Data on feed efficiency of branched chain alpha-keto acids reported in the literature support this view. The chance for transamination is better after intravenous administration. The transferability of our data to humans, and various factors influencing the efficiency of branched chain alpha-keto acids are discussed in connection with data reported in the literature.

A controlled study of supplementation with essential amino acids and alpha-keto acids in the conservative management of patients with chronic renal failure

Oral therapy with essential amino acids (EAA) or alpha-keto acids (alpha-KA) has been recommended in patients with renal failure, but quality and quantity of optimal protein intake are still controversial. This study compares sequentially the effect of supplementation with EAA, and with alpha-KA versus placebo in 15 ambulatory patients with chronic renal failure (average creatinine clearance 10.8 ml/min), maintained on a protein diet of 0.57 g/kg body weight (40 g for a 70-kg patient). The actual dietary intake averaged 0.55 g protein/kg and 27 kcal/kg according to repeated 7-day dietary recordings. After a 6-week baseline period on this diet, all patients received additionally 0.112 g EAA/kg for 6 weeks followed by a double-blind crossover study of 0.105 g alpha-KA/kg versus placebo supplementation for 6 weeks each. Fasting blood samples for multiple parameters, including 15 indicators for protein deficiency, as well as anthropometric and clinical data were evaluated every 3 weeks. Laboratory data revealed no indications of protein deficiency. Therapy with alpha-KA diminished serum phosphate concentration (p less than 0.05), however no other significant beneficial effects could be demonstrated during supplementation with either EAA or alpha-KA. Therefore, such supplementation to a 0.55-g/kg-protein diet appears superfluous in stable ambulatory patients with renal insufficiency.

Long-term effects of a new ketoacid-amino acid supplement in patients with chronic renal failure

Nine patients with severe chronic renal failure (mean glomerular filtration rate 4.8 ml/min; mean serum creatinine 11.3 mg/dl) who were previously on a protein-restricted diet were treated with a diet containing an average of 33 kcal/kg and 22.5 g/day of mixed quality protein, supplemented by a combination of amino acids and mixed salts formed between basic amino acids and keto-analogues of essential amino acids. The supplement was designed to minimize or reverse the amino acid abnormalities of chronic renal failure rather than to meet the normal requirements for the essential amino acids; it contained tyrosine, ornithine, and a high proportion of branched-chain ketoacids, but no phenylalanine or tryptophan and very little methionine. Within one month, serum urea nitrogen fell and serum albumin and transferrin rose significantly; serum creatinine fell slightly. Hyperphosphatemia (present in three patients) was corrected. Nitrogen balance, measured in seven of the nine patients, on the average was neutral, as it was in a preceding control period on a 40 to 50 g/day protein diet. Plasma tyrosine and threonine, which were subnormal before therapy, rose to normal or high normal levels. Branched-chain amino acids did not change. During a total of 63 patient-months of therapy, no side effects or toxicity were observed, and serum albumin and transferrin did not change further. It is concluded that this specially designed supplement added to a 20 to 25 g/d protein diet is an acceptable regimen which can improve or maintain protein nutrition in patients with severe chronic renal failure who would otherwise require dialysis.

Anthropometry and plasma valine, amino acids, and proteins in the nutritional assessment of hemodialysis patients

Non-fasting plasma amino acids, proteins, anthropometric measurements, urea, and creatinine for 17 hemodialysis patients were compared with values in normal patients of similar age and sex. Values were characteristic for renal failure but with similarities to protein-energy malnutrition. Partial correlation coefficients, correcting for age and height, identified nutritional and non-nutritional factors. Plasma valine was the most correlated variable and was used to rank and group the patients. The group with valine less than 150 micrometers/liter had low values for 17 variables. Valine, isoleucine, leucine, threonine, asparagine, weight, and arm muscle circumference were interrelated and reflected malnutrition whereas fat correlated with calorie intake, and histidine and serine with protein intake. Taurine, aspartic acid, cystine, citrulline, urea, creatinine, prealbumin and retinol-binding protein were decreased in malnutrition but were higher than normal due to a loss of renal function. Fourteen variables, less affected by malnutrition, were changed by specific non-nutritional factors. Hemodialysis patients of long standing (1 to 11 years) apart from two patients with recurrent sepsis, were adequately nourished, but those on hemodialysis for less than 15 months, most of whom had previously received peritoneal dialysis, were malnourished. Malnutrition in dialysis patients was due to protein and energy deficiency enhanced by metabolic abnormalities of amino acids. Our study shows that plasma valine is interrelated with other nutritional variables and may be used to assess protein-energy malnutrition.

Metabolic and nutritional factors in children with renal insufficiency

Uremia is associated with a decrease in muscle and adipose tissue mass and a low weight-for-height ratio. These findings are related to dietary deficiencies in uremia--particularly energy deficiency and to metabolic disorders characteristic of uremia. These latter have features of an exaggerated catabolic state which may be modified by other stresses, e.g. short starvation or high-protein diets. Recommendations for diet therapy for children with uremia are of limited value because of the lack of definitive studies. At present, diet should be adequate in energy to improve nitrogen balance and weight gain commensurate with age. There may be advantages to using a protein:energy ratio in the diet that is lower than the ratio used in conventional diets.

Abnormal amino acid and protein metabolism in uremia

The many alterations in amino acid and protein metabolism in renal failure are often poorly defined, and the available data concerning them are usually descriptive. Nonetheless, certain factors play an important role in the altered amino acid and protein metabolism of uremia. These include malnutrition caused by poor nutrient intake, loss of nutrients during dialysis, and abnormal metabolism of nutrients. Other factors include uremic toxins, superimposed catabolic illnesses, endocrine disorders, and the reduced capacity of the failing kidney to synthesize or degrade certain hormones, amino acids, peptides, and small proteins. These aberrations have complex interrelationships which sometimes potentiate each other. It is possible that the administration of sufficient quantities of energy, vitamins, and minerals, as well as the dietary manipulation of protein, amino acid and ketoacid intake may improve the metabolism of amino acids and proteins. Vitamin B6 and zinc have special requirements that may affect protein or amino acid metabolism.