Indicators of lean body mass catabolism: emphasis on the creatinine excretion rate

Glycine protects against doxorubicin-induced heart toxicity in mice

Doxorubicin (DOXO) is a well-known cancer chemotherapeutic. However, its toxic effect on the heart limits its clinical application. This study aimed to assess the effectiveness of glycine administration to counteract the DOXO-induction of cardiomyopathy in mice. Fifty male albino mice were divided into five groups (n = 10/group) as follows: control, DOXO, Gp100, Gp150, and Gp200. Histopathological examination of the heart, and biochemical examinations for heart function (creatine phosphokinase (CPK), lactate dehydrogenase (LDH), and aspartate aminotransferase (AST)), inflammation (tumor necrosis factor-alpha (TNF-α) and interleukin 10 (IL-10)), oxidative stress (malondialdehyde (MDA), glutathione (GSH), superoxide dismutase (SOD), catalase, nitric oxide (NO), and uric acid), kidney function (urea and creatinine), and minerals (calcium, phosphorus, sodium, and potassium) were carried out. Cardiomyopathy induced by DOXO treatment (15 mg/kg total dose) was ascertained via pathological alterations seen in heart tissue and verified biochemically via increases (P < 0.001) in CPK, LDH, AST, TNF-α, IL-10, MDA, NO, Na, and K levels along with decreases (P < 0.001) in GSH, SOD, catalase, and uric acid. Glycine co-treatment, using doses of 100, 150, and 200 mg/kg, in a dose-dependent manner, displayed ameliorated heart architecture, significantly (P < 0.001) improved biochemical heart function tests, reduced oxidative stress and inflammation, and controlled mineral levels. The positive actions of glycine in DOXO-induced cardiotoxicity amelioration via modulating oxidative stress, inflammation, and immunity are confirmed. Glycine antioxidative properties may be behind its positive outcomes. Finally, we present glycine as a worthy possible option against DOXO-induced heart damage after more validation.

A comparison of haematological and biochemical blood indices between the Žemaitukai and Arabian horses participating in endurance competitions

The study was conducted on 30 clinically healthy Arabian horses and 28 Žemaitukai horses that competed in endurance race over the same distance (40 km). Blood samples were taken before and immediately after the exercise. The environmental conditions during the competitions varied, with a mean temperature of 22.5 °C and a mean relative humidity of 73.20%. The Žemaitukai horses showed lower haematological values and increased muscle catabolism after exercise. Arabian horses have higher aerobic capacity compared to the Žemaitukai horses which probably contributes to their superior low- to moderate-intensity exercise performance. Serum activity of muscle enzymes suggested that the muscle tissue of the Arabian horses has higher tolerance for exercise-induced muscle catabolism and lower muscle catabolism than that of muscle tissue of the Žemaitukai horses. Further studies need to be carried out to identify the diferences in muscle tissue of both breeds.

CHALLENGES TO ANIMAL WELFARE DURING TRANSPORTATION OF WILD MAMMALS: A REVIEW (1990-2020)

Wild mammal transport is an important component of conservation translocation as well as the economic wildlife trade. This article reviews the physiological responses to transport that have been measured in wild mammalian species, factors associated with these responses, and interventions that have been applied to mitigate these responses. By organizing the literature review along the "five domains model" of animal welfare, namely, the physical-functional domains (nutrition, environment, health, behavior) and the mental domain (mental state), it can be demonstrated that wild mammal transport is associated with challenges to ensuring positive animal welfare in all five domains. Transported wild mammals can experience dehydration, catabolism, fatigue, immunosuppression, behavioral changes, and stress. Factors influencing these physiological responses to transport have only been researched in a few studies encompassing species, journey length, ambient temperature, vehicle motion, stocking density, orientation, habituation, vehicle speed allowance, and road type. The administration of tranquilizers has been shown to mitigate negative physiological responses to transport. There is a need to further investigate species and situation-specific physiological responses to transport and factors associated with these responses in order to identify challenges to ensuring animal welfare and improving translocation success.

Speed and Blood Parameters Differ between Arabian and Žemaitukai Horses during Endurance Racing

Fédération Equestre Internationale (FEI) has described equine endurance racing as the second largest discipline in the world, above which is only show jumping. The Žemaitukai is an ancient indigenous Lithuanian horse breed known since the 6th or 7th century. The Arabian horse breed is one of the oldest human-developed horse breeds in the world. Compared with other race horse breeds, the muscle tissue of Arabian horses is characterized by significant differences in structure-a predominance of oxidative fiber type I is observed in Arabians, making them the prevailing breed in endurance racing. The Arabian horses are recognized as the leading breed in endurance competitions. Speed, pace, and total time in the race strategy have been extensively studied in human sports, and in contrast, this strategy appears to have been virtually ignored in equestrian sport, despite the potential for contributing to performance optimization. In relation to speed and total time in the race, there are limited data on postrace physical, biochemical, and blood gas parameters of endurance horses. Thus, this study was carried out to investigate the effects of speed on the blood parameters of the Arabian and Žemaitukai horses during an endurance race. Blood samples were taken before and immediately after the exercise. Biochemical and blood gas indicators were analyzed. The study showed significant increases in mean blood gasometrical indicators, such as partial carbon dioxide pressure (8.09-15.18%, p < 0.001); base excess in the extracellular fluid (14.01%, p < 0.001 in the Arabian horses and 172.01% in the Žemaitukai breed, p = 0.006); decreases of the blood electrolyte ionized calcium (4.38-8.72%, p < 0.001) and the hematocrit and hemoglobin values (20.05-20.12%, p < 0.001 in the Arabian horses and 6.22-6.23% in the Žemaitukai breed, p = 0.003-0.004); and decreases in the base excess in the blood values (29.24-39.38%, p < 0.001) and lactate (13.45-31.97%, p < 0.001) in the blood of both breeds in the post-competition horses. Significant increases after competition were determined for the values of creatinine (21.34-30.82%, p = 0.001-0.004), total bilirubin (50.84-56.24%, PH < 0.001), and albumin (2.63-4.48%, p = 0.048-0.001) for both breeds. For the faster Arabian horse breed, recovering after racing took half the time that the local Žemaitukai breed did.

Short-Term Variations in Neutrophil-to-Lymphocyte and Urea-to-Creatinine Ratios Anticipate Intensive Care Unit Admission of COVID-19 Patients in the Emergency Department

Background: Timely assessment of COVID-19 severity is crucial for the rapid provision of appropriate treatments. Definitive criteria for the early identification of severe COVID-19 cases that require intensive care unit admission are lacking.

Methods: This was a single-center, retrospective case-control study of 95 consecutive adults admitted to the intensive care unit (cases) or a medical ward (controls) for laboratory-confirmed COVID-19. Clinical data were collected and changes in laboratory test results were calculated between presentation at the emergency department and admission. Univariate and multivariable logistic regression was performed to calculate odds ratios for intensive care unit admission according to changes in laboratory variables.

Results: Of the 95 adults with COVID-19, 25 were admitted to intensive care and 70 to a medical ward after a median 6 h stay in the emergency department. During this interval, neutrophil counts increased in cases and decreased in controls (median, 934 vs. −295 × 10⁶/L; P = 0.006), while lymphocyte counts decreased in cases and increased in controls (median, −184 vs. 109 × 10⁶/L; P < 0.001). In cases, the neutrophil-to-lymphocyte ratio increased 6-fold and the urea-to-creatinine ratio increased 20-fold during the emergency department stay, but these ratios did not change in controls (P < 0.001 for both comparisons). By multivariable logistic regression, short-term increases in the neutrophil-to-lymphocyte ratio (OR = 1.43; 95% CI, 1.16–1.76) and urea-to-creatinine ratio (OR = 1.72; 95% CI, 1.20–2.66) were independent predictors of intensive care unit admission.

Conclusion: Short-time changes in neutrophil-to-lymphocyte ratio and urea-to-creatinine ratio emerged as stand-alone parameters able to identify patients with aggressive disease at an early stage.

Comparison for immunophysiological responses of Jeju and Thoroughbred horses after exercise

OBJECTIVE

The study was conducted to investigate variations in the immunophysiological responses to exercise-induced stress in Jeju and Thoroughbred horses.

METHODS

Blood samples were collected from the jugular veins of adult Jeju (n = 5) and Thoroughbred (n = 5) horses before and after 30 min of exercise. The hematological, biochemical, and immunological profiles of the blood samples were analyzed. Blood smears were stained and observed under a microscope. The concentration of cell-free (cf) DNA in the plasma was determined using real time polymerase chain reaction (PCR). Peripheral blood mononuclear cells (PBMCs) and polymorphonuclear cells were separated using Polymorphprep, and the expression of various stress-related and chemokine receptor genes was measured using reverse transcriptase (RT) and real-time PCR.

RESULTS

After exercise, Jeju and Thoroughbred horses displayed stress responses with significantly increased rectal temperatures, cortisol levels, and muscle catabolism-associated metabolites. Red blood cell indices were significantly higher in Thoroughbred horses than in Jeju horses after exercise. In addition, exercise-induced stress triggered the formation of neutrophil extracellular traps (NETs) and reduced platelet counts in Jeju horses but not in Thoroughbred horses. Heat shock protein 72 and heat shock protein family A (Hsp70) member 6 expression is rapidly modulated in response to exercise-induced stress in the PBMCs of Jeju horses. The expression of CXC chemokine receptor 4 in PBMCs was higher in Thoroughbred horses than in Jeju horses after exercise.

CONCLUSION

In summary, the different immunophysiological responses of Jeju and Thoroughbred horses explain the differences in the physiological and anatomical properties of the two breeds. The physiology of Thoroughbred horses makes them suitable for racing as they are less sensitive to exercise-induced stress compared to that of Jeju horses. This study provides a basis for investigating the link between exercise-induced stresses and the physiological alteration of horses. Hence, our findings show that some of assessed parameters could be used to determine the endurance performance of horses.

Plasma Transthyretin as A Biomarker of Sarcopenia in Elderly Subjects

Skeletal muscle (SM) mass, the chief component of the structural compartment belonging to lean body mass (LBM), undergoes sarcopenia with increasing age. Decreased SM in elderly persons is a naturally occurring process that may be accelerated by acute or chronic nutritional deficiencies and/or inflammatory disorders, declining processes associated with harmful complications. A recently published position paper by European experts has provided an overall survey on the definition and diagnosis of sarcopenia in elderly persons. The present review describes the additional contributory role played by the noninvasive transthyretin (TTR) micromethod. The body mass index (BMI) formula is currently used in clinical studies as a criterion of good health to detect, prevent, and follow up on the downward trend of muscle mass. The recent upsurge of sarcopenic obesity with its multiple subclasses has led to a confused stratification of SM and fat stores, prompting workers to eliminate BMI from screening programs. As a result, investigators are now focusing on indices of protein status that participate in SM growth, maturation, and catabolism that might serve to identify sarcopenia trajectories. Plasma TTR is clearly superior to all other hepatic biomarkers, showing the same evolutionary patterns as those displayed in health and disease by both visceral and structural LBM compartments. As a result, this TTR parameter maintains positive correlations with muscle mass downsizing in elderly persons. The liver synthesis of TTR is downregulated in protein-depleted states and suppressed in cytokine-induced inflammatory disorders. TTR integrates the centrally-mediated regulatory mechanisms governing the balance between protein accretion and protein breakdown, emerging as the ultimate indicator of LBM resources. This review proposes the adoption of a gray zone defined by cut-off values ranging from 200 mg/L to 100 mg/L between which TTR plasma values may fluctuate and predict either the best or the worst outcome. The best outcome occurs when appropriate dietary, medicinal and surgical decisions are undertaken, resuming TTR synthesis which manifests rising trends towards pre-stress levels. The worst occurs when all therapeutic means fail to succeed, leading inevitably to complete exhaustion of LBM and SM metabolic resources with an ensuing fatal outcome. Some patients may remain unresponsive in the middle of the gray area, combining steady clinical states with persistent stagnant TTR values. Using the serial measurement of plasma TTR values, these last patients should be treated with the most aggressive and appropriate therapeutic strategies to ensure the best outcome.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Impact of the structure and dose of protein intake on clinical and metabolic outcomes in critically ill children: A systematic review

OBJECTIVE

The aim of this study was to describe the effects of structure/type and total amount of protein intake on protein balance and clinical outcomes in critically ill children.

METHODS

We conducted a systematic review of relevant literature on Embase, PubMed/Medline, Web of Science, Scopus, and Latin American and Caribbean Health Sciences. A partial gray literature search was undertaken and the reference lists of the selected articles were searched manually. Observational and clinical trials that evaluated the total protein intake, structure of the protein source, or both, in critically ill children were included. Nitrogen balance and clinical outcomes (mortality, length of stay, and duration of mechanical ventilation) were the main outcomes of interest.

RESULTS

We found 18 eligible studies, of which 17 assessed the quantity and one described protein structure in relation to the outcomes. In all, 2118 pediatric critically ill patients <18 y of age were included. The total daily protein intake ranged from 0.67 to 4.7 g/kg. Average daily total protein intake >1.1 g/kg, especially >1.5 g/kg, was associated with positive protein balance and lower mortality.

CONCLUSION

In critically ill children, total daily protein intake >1.1 g/kg was associated with positive effects on clinical outcomes and protein balance. The existing data are not sufficient for determining the optimal structure of protein delivered by enteral route in critically ill children.

Protein Requirements of the Critically Ill Pediatric Patient

This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.

Influence of aging on nitrogen accretion during critical illness

BACKGROUND

Aging adversely affects nitrogen accretion during health, but its effect during critical illness is unknown. Nitrogen balance (NB) response to varying protein intakes was compared between critically ill, older and younger patients.

METHODS

Adult patients admitted to the trauma intensive care unit, given enteral or parenteral nutrition, and who had a NB determination within 5-14 days after injury were evaluated. Patients with renal or hepatic disease were excluded. Patients were categorized as older (≥60 years) or younger (18-59 years of age). Data are given as mean ± SD or median [interquartile range].

RESULTS

Fifty-four older (69 [65, 77] years) and 195 younger (35 [27, 47] years) patients were evaluated. NB was blunted for the older patients with an observed trending improvement in NB from -13.5 ± 5.5 to -5.6 ± 8.8 g/d (P = NS) noted at 1.5-1.99 g/kg/d. NB improved from -22.2 ± 8.2 to -11.8 ± 9.9 g/d (P = .05) at 1-1.49 g/kg/d and modestly thereafter for each 0.5-g/kg/d increase in protein intake for the younger patients. Serum urea nitrogen concentration during the NB was highly variable but overall greater for the older patients (20 [14, 33] vs 15 [10, 20] mg/dL, P = .001).

CONCLUSIONS

Improvement in nitrogen accretion was blunted at lower protein intakes in critically ill, older patients compared with younger patients. Individualization of protein intake is warranted.

Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial

BACKGROUND

Traumatic brain injury (TBI) results in a hypermetabolic and hypercatabolic status in which adequate nutrition support is essential to improve clinical outcome. The endocrine system of a patient with TBI is also affected and may play a critical role in either the metabolic or the immunologic response to the trauma. In the present study, the effect of standard, delayed enteral feeding (DEF), compared with early (within 24-48 hours) enteral feeding (EEF), on the endocrine function of patients with TBI was investigated.

METHODS

This comparative, prospective, open-labeled, randomized study included TBI patients admitted to the intensive care unit (ICU). Injury severity was assessed by the Glasgow Coma Scale and predicted mortality by the Acute Physiology and Chronic Health Evaluation II. Twenty-five patients received DEF and 34 patients received EEF. The effect of the onset of nutrition on pituitary, thyroidal, gonadal, and adrenal function was investigated on days 6 and 12 after admission to the hospital.

RESULTS

Levels of thyroid-stimulating hormone, free triiodothyronine, free thyroxine, and testosterone (in males) of DEF patients declined in comparison to levels of the day of admission to the ICU. The decrease of hormonal values was less pronounced in the EEF group. Cortisol concentrations rose in the DEF group; a lesser hormonal change was found in the EEF group. Deaths during the study for the DEF group and EEF group were 2 and 3, respectively.

CONCLUSIONS

EEF may exert beneficial effects on the hormonal profile of TBI patients, possibly contributing to a better clinical outcome in this patient group.

Monitoring of protein catabolism in neonates and young infants post-cardiac surgery

AIMS

To evaluate cell catabolism by balance of nitrogen and phosphate, and creatinine excretion in children post-cardiac surgery; to establish protein and energy requirements to minimize catabolism; and to assess nutritional therapy by following these parameters and serial anthropometric measurements.

METHODS

A prospective observational study of children with congenital heart disease undergoing cardiac surgery. Blood samples and 24-h urine collections were obtained postoperatively for creatinine measurement and nitrogen and phosphate balance. Anthropometric measurements (weight, mid-arm muscle circumference and triceps skinfold thickness) were obtained preoperatively and at paediatric intensive care unit and hospital discharge.

RESULTS

Eleven children were studied for 3-10 postoperative days. Anabolism was associated with higher protein and energy intakes compared to catabolism (1.1 vs. 0.1 g/kg/day and 54 vs. 17 kcal/kg/day, respectively). On days with anabolism, phosphate balance was greater compared with that on days with catabolism. Daily creatinine excretion did not correlate with protein balance. Anthropometric measurements did not change significantly over time.

CONCLUSIONS

Children with congenital heart disease undergoing cardiac surgery achieved anabolism with >55 kcal/kg/day and >1 g/kg/day of protein. Balance of phosphate was useful to monitor cell breakdown. Anthropometric measurements were not valuable to evaluate nutritional therapy in this population.

The Sweet Pee model for Sglt2 mutation

Inhibiting renal glucose transport is a potential pharmacologic approach to treat diabetes. The renal tubular sodium-glucose transporter 2 (SGLT2) reabsorbs approximately 90% of the filtered glucose load. An animal model with sglt2 dysfunction could provide information regarding the potential long-term safety and efficacy of SGLT2 inhibitors, which are currently under clinical investigation. Here, we describe Sweet Pee, a mouse model that carries a nonsense mutation in the Slc5a2 gene, which results in the loss of sglt2 protein function. The phenotype of Sweet Pee mutants was remarkably similar to patients with mutations in the Scl5a2 gene. The Sweet Pee mutants had improved glucose tolerance, higher urinary excretion of calcium and magnesium, and growth retardation. Renal physiologic studies demonstrated a prominent distal osmotic diuresis without enhanced natriuresis. Sweet Pee mutants did not exhibit increased KIM-1 or NGAL, markers of acute tubular injury. After induction of diabetes, Sweet Pee mice had better overall glycemic control than wild-type control mice, but had a higher risk for infection and an increased mortality rate (70% in homozygous mutants versus 10% in controls at 20 weeks). In summary, the Sweet Pee model allows study of the long-term benefits and risks associated with inhibition of SGLT2 for the management of diabetes. Our model suggests that inhibiting SGLT2 may improve glucose control but may confer increased risks for infection, malnutrition, volume contraction, and mortality.