Urea, glucose and alanine kinetics in man: effects of glucose infusion

Quantitation of monosaccharide isotopic enrichment in physiologic fluids by electron ionization or negative chemical ionization GC/MS using di-O-isopropylidene derivatives

The aldonitrile pentaacetate and other derivatives lack ions in the electron ionization (EI) spectra possessing an intact hexose structure and thus must be analyzed by chemical ionization GC/MS in order to study multiple isotopomers. We report methods for quantitation of hexose di-O-isopropylidene acetate (IPAc) or pentafluorobenzoyl (PFBz) esters. These were prepared in a two-step procedure using inexpensive reagents that do not adversely impact the isotopomer structure of the sugar. The acetate derivative possesses an abundant [M - CH3] ion in the EI spectrum which is suitable for quantitative analysis of isotopomers. The negative chemical ionization (NCI) spectrum of the corresponding pentafluorobenzoyl derivative has a dominant molecular anion. Moreover, the PFBz derivative is about 100-fold more sensitive than the acetate, which offers some advantages for analysis of minor hexoses found in plasma. Isotopic calibration curves of [U-13C]glucose are linear over the 0.1-60% tracer/tracee range tested. The useful range for isotopic tracer studies is 25-2500 pmol for EI analysis of the acetate derivative and 0.1-55 pmol for NCI analysis of PFBz derivative (sample amount injected). For most studies where sample size is not limited, EI-GC/MS analysis of the IPAc derivative is preferred. NCI-GC/MS analysis is reserved when sample size is limiting or when studies involve hexoses other than glucose that are normally present at low concentration.

The effect of preoperative carbohydrate loading on hormonal changes, hepatic glycogen, and glucoregulatory enzymes during abdominal surgery

The effect of preoperative glucose infusion on preoperative alterations in hepatic glycogen content, the activity of key hepatic glucoregulatory enzymes (fructose 1,6-diphosphatase [FDPase]), pyruvate kinase (PK), hormonal developments, and plasma levels of free fatty acids (FFA) were investigated in 16 patients undergoing open cholecystectomy. Patients were randomized to receive (group G) or not receive (group C) overnight glucose infusion (5 mg.kg-1.d-1) preoperatively. Infusion of glucose overnight resulted in preoperative elevations of insulin and c-peptide (P < 0.05) and lower plasma levels of FFA, while the same glucose levels were found in both groups, 4.6 mmol/L. During and after surgery, only minor changes in the plasma levels of insulin, c-peptide, catecholamines, glucagon, cortisol, growth hormone, and FFA were found, with minimal differences between groups. The hepatic glycogen content was 65% higher in group G and a significant reduction was confirmed only in this group of patients during surgery. The higher glycogen content was associated with a higher FDPase activity ratio (P < 0.05), which remained unchanged during surgery. In contrast, a significant (P < 0.05) increase in the activity of this enzyme was found in group C. The PK activity ratio did not differ between groups and remained unchanged during surgery. The finding of enhanced FDPase activity suggests that the indirect route (via gluconeogenesis) represents an important contributor to the increased glycogen formation during glucose infusion. Additionally, surgery in the overnight fasted patient induces enzymatic changes favoring gluconeogenesis. Lastly, preoperative high-dose glucose infusion has only minor effects on the endocrine response, plasma levels of FFA, and glycogen depletion during elective open cholecystectomy.

Physiologic hyperinsulinemia stimulates protein synthesis and enhances transport of selected amino acids in human skeletal muscle

We have investigated the mechanisms of the anabolic effect of insulin on muscle protein metabolism in healthy volunteers, using stable isotopic tracers of amino acids. Calculations of muscle protein synthesis, breakdown, and amino acid transport were based on data obtained with the leg arteriovenous catheterization and muscle biopsy. Insulin was infused (0.15 mU/min per 100 ml leg) into the femoral artery to increase femoral venous insulin concentration (from 10 +/- 2 to 77 +/- 9 microU/ml) with minimal systemic perturbations. Tissue concentrations of free essential amino acids decreased (P < 0.05) after insulin. The fractional synthesis rate of muscle protein (precursor-product approach) increased (P < 0.01) after insulin from 0.0401 +/- 0.0072 to 0.0677 +/- 0.0101%/h. Consistent with this observation, rates of utilization for protein synthesis of intracellular phenylalanine and lysine (arteriovenous balance approach) also increased from 40 +/- 8 to 59 +/- 8 (P < 0.05) and from 219 +/- 21 to 298 +/- 37 (P < 0.08) nmol/min per 100 ml leg, respectively. Release from protein breakdown of phenylalanine, leucine, and lysine was not significantly modified by insulin. Local hyperinsulinemia increased (P < 0.05) the rates of inward transport of leucine, lysine, and alanine, from 164 +/- 22 to 200 +/- 25, from 126 +/- 11 to 221 +/- 30, and from 403 +/- 64 to 595 +/- 106 nmol/min per 100 ml leg, respectively. Transport of phenylalanine did not change significantly. We conclude that insulin promoted muscle anabolism, primarily by stimulating protein synthesis independently of any effect on transmembrane transport.

Effects of insulin and glucose on urea synthesis in normal man, independent of pancreatic hormone secretion

We investigated the inhibitory effect of insulin and glucose on hepatic amino- to urea-nitrogen conversion independent of endogenous insulin and glucagon secretion. Alanine-stimulated urea synthesis kinetics, as quantified by functional hepatic nitrogen clearance, i.e. the slope of the linear relation between blood alpha-amino nitrogen concentration and urea synthesis rate, were measured four times in each of six healthy volunteers, namely during spontaneous hormone responses, and during hormonal control by somatostatin and maintenance of basal hormone levels and euglycaemia, hyperinsulinaemia (85 +/- 8 mU/l), or hyperglycaemia (8.4 +/- 0.5 mmol/l). Hormonal control and euglycaemia reduced functional hepatic nitrogen clearance (mean +/- SD) by two-thirds (from 32.9 +/- 5.2 l/h to 12.2 +/- 3.4 l/h, p < 0.01). Hyperinsulinaemia did not change this (13.2 +/- 2.8 l/h), whereas hyperglycaemia further reduced functional hepatic nitrogen clearance by 40% to 7.4 +/- 1.3 l/h (p < 0.01). The reduction by hormonal control and euglycaemia is attributable to the abolition of the glucagon response to alanine infusion, as glucagon is known to up-regulate functional hepatic nitrogen clearance. Insulin did not regulate hepatic amino- to urea-nitrogen conversion, implying that the effect of insulin on urea production is due to its effect on blood amino acid supply to the liver. In contrast, glucose in itself reduced hepatic amino nitrogen conversion, independent of the hormonal responses to glucose. This means that the hepatic component of the amino-N-sparing effect of glucose depends on hyperglycaemia but not on hyperinsulinaemia.

Regulation of urea synthesis by glucose and glucagon in normal man

The separate effects of glucose and glucagon on alanine stimulated hepatic amino-N to urea-N conversion, quantified by the Functional Hepatic Nitrogen Clearance (FHNC) (i.e. the linear slope of the relation between urea synthesis rate and blood alpha-amino-N concentration), were studied in 7 healthy subjects. FHNC was measured four times in each: during constant infusion of alanine alone; alanine superimposed on constant glucose infusion; alanine superimposed on glucose and low stepwise glucagon infusions; and alanine super-imposed on glucose and high constant glucagon infusions. Glucose halved the glucagon response to alanine. This reduction was abolished by the low stepwise glucagon infusion, aimed at re-establishing portal glucagon levels. The high glucagon infusion resulted in 3-fold elevated glucagon levels. During alanine infusion alone FHNC was (mean +/- SEM) 32.5 +/- 1.9 l/h. Glucose reduced FHNC by 43% to 18.4 +/- 0.9 l/h (p < 0.01). The low stepwise glucagon infusion only partially normalized FHNC as reduced by glucose (to 24.6 +/- 1.5 l/h, (p < 0.01 vs alanine alone)). The high glucagon infusion increased FHNC by 35% despite hyperglycaemia (to 44.1 +/- 1.5 l/h, (p < 0.01 vs alanine alone)). The results show that both glucose and glucagon are independent but opposite regulators of hepatic amino-N conversion. The physiological glucose effect is accomplished by a combination of both the effect of glucose itself and the inhibition by glucose of the glucagon response to alanine. Hyperglucagonaemia increases FHNC and overrules the inhibition by glucose. This may explain the defect nitrogen sparing by glucose and to some extent the catabolism in hyperglucagonaemic stress conditions, despite prevailing hyperglycaemia.

Mathematical model to analyse urea synthesis following alanine infusion in control subjects and in patients with liver cirrhosis

A three-compartment model was used to analyse the urea response to an alanine infusion in control subjects and patients with liver cirrhosis. Discriminant analysis showed a good separation between model coefficients of the two groups. A single parameter was derived, able to quantify the liver functional capacity. The method provides a useful diagnostic tool in patients with liver disease.

Does hyperketonemia affect protein or glucose kinetics in postabsorptive or traumatized man?

Leucine and glucose turnover were measured using simultaneous infusions of [13C]leucine and [2H]glucose before and during an infusion of Na DL-hydroxybutyrate (Na DL-HB) in overnight-fasted patients the day before and 3 days after total hip replacement. The ketone body infusion before surgery resulted in a significant increase in plasma leucine concentration and leucine turnover, while glucose concentration and turnover decreased. Surgery increased leucine turnover. Ketone body infusion after surgery caused a further increased leucine turnover while turnover fell as before surgery. We suggest that exogenous ketone bodies decrease hepatic glucose production and probably stimulate a rise in protein synthesis above breakdown leading to a decreased nitrogen excretion as observed by other investigators. Despite the metabolic adaptation to trauma, this response was not affected by surgery.

Tracer priming in human protein turnover studies with [15N]glycine

Sixty-three studies in healthy normal volunteers (n = 29), malnourished cancer (n = 8) or non-cancer patients (n = 9), and postoperative radical cystectomy patients (n = 17) were conducted to evaluate the primed constant infusion labeling technique for the estimation of whole-body protein turnover under a variety of dietary conditions. [15N]Glycine was used as the tracer with a prime to infusion ratio of 1300 to 3300 min and a continuous-infusion rate of 0.11 to 0.33 micrograms 15N . kg-1 . min-1 for 24 to 36 hr. The isotopic steady-state enrichment was reached in all subjects both in urinary urea and ammonia between 10 and 26 hr (mean 18 +/- 2). During protein calorie fasting the attainment of isotopic steady state is much quicker (10 to 18 hr) with a primed constant infusion than with a constant infusion alone (approximately 38 hr). A P/I ratio greater or less than 1800 (min) usually resulted in a delay of plateau attainment without affecting the protein turnover values. Reliable estimates of protein kinetics in humans can be made in clinical conditions with a 26-hr infusion of glycine at the rate of 0.28 microgram 15N . kg-1 . min-1 with a P/I ratio of 1800 min, collecting six urine samples every 2 hr from 16 hr and analyzing for both urinary urea and ammonia enrichments.

The effect of pre-operative glucose loading on postoperative nitrogen metabolism

The nitrogen sparing effect of glucose loading at either 1 mg kg-1 min-1 or 5 mg kg-1 min-1 from the evening before surgery was compared with similar glucose infusions commenced after elective surgery. Thirty-two patients undergoing abdominal surgery of moderate severity were studied. Glucose at 5 mg kg-1 min-1 reduced urea excretion compared with glucose at 1 mg kg-1 min-1. The timing of the carbohydrate infusion was not critical in altering the overall extent of the protein sparing at either rate. High dose glucose infusions markedly reduced overall urea and 3-methylhistidine excretion. This implies a reduction in protein breakdown. A pre-operative high dose infusion of glucose may in particular improve protein synthesis for the first 24 h after surgery.