Acetylcarnitine and free carnitine in body fluids before and after birth

HPLC–(Q)-TOF-MS-Based Study of Plasma Metabolic Profile Differences Associated with Age in Pediatric Population Using an Animal Model

A deep knowledge about the biological development of children is essential for appropriate drug administration and dosage in pediatrics. In this sense, the best approximation to study organ maturation is the analysis of tissue samples, but it requires invasive methods. For this reason, surrogate matrices should be explored. Among them, plasma emerges as a potential alternative since it represents a snapshot of global organ metabolism. In this work, plasma metabolic profiles from piglets of different ages (newborns, infants, and children) obtained by HPLC–(Q)-TOF-MS at positive and negative ionization modes were studied. Improved clustering within groups was achieved using multiblock principal component analysis compared to classical principal component analysis. Furthermore, the separation observed among groups was better resolved by using partial least squares-discriminant analysis, which was validated by bootstrapping and permutation testing. Thanks to univariate analysis, 13 metabolites in positive and 21 in negative ionization modes were found to be significant to discriminate the three groups of piglets. From these features, an acylcarnitine and eight glycerophospholipids were annotated and identified as metabolites of interest. The findings indicate that there is a relevant change with age in lipid metabolism in which lysophosphatidylcholines and lysophoshatidylethanolamines play an important role.

The association between newborn screening analytes as measured on a second screen and childhood autism in a Texas Medicaid population

Autism (or autism spectrum disorder [ASD]) is an often disabling childhood neurologic condition of mostly unknown cause. We previously explored whether there was an association of ASD with any analyte measured in the first newborn screening blood test. Here we explore the second screen. Our matched case-control study examined data on 3-5 year-old patients with any ASD diagnosis in the Texas Medicaid system in 2010-2012. Subjects were linked to their 2007-2009 newborn screening blood test data, which included values for 36 analytes or analyte ratios. Data were available for 3,005 cases and 6,212 controls. The most compelling associations were evident for fatty acid oxidation analytes octanoylcarnitine (C8) and octanoylcarnitine/acetylcarnitine (C8/C2). Their adjusted odds ratios comparing 10th versus first analyte deciles were between 1.42 and 1.54 in total births, term births, and males. C8 was consistent with first screen results. Adipylcarnitine (C6DC), an organic acid analyte, showed opposite results in the two screens. Several other analytes exhibiting significant associations in the first screen did not in the second. Our results provide evidence that abnormal newborn blood levels of some carnitines may be associated with risk of later ASD, possibly related to their involvement with mitochondrial function in the developing brain.

Systematic Evaluation of Key L-Carnitine Homeostasis Mechanisms during Postnatal Development in Rat

Background

The conditionally essential nutrient, L-carnitine, plays a critical role in a number of physiological processes vital to normal neonatal growth and development. We conducted a systematic evaluation of the developmental changes in key L-carnitine homeostasis mechanisms in the postnatal rat to better understand the interrelationship between these pathways and their correlation to ontogenic changes in L-carnitine levels during postnatal development.

Methods

mRNA expression of heart, kidney and intestinal L-carnitine transporters, liver γ-butyrobetaine hydroxylase (Bbh) and trimethyllysine hydroxylase (Tmlh), and heart carnitine palmitoyltransferase (Cpt) were measured using quantitative RT-PCR. L-Carnitine levels were determined by HPLC-UV. Cpt and Bbh activity were measured by a spectrophotometric method and HPLC, respectively.

Results

Serum and heart L-carnitine levels increased with postnatal development. Increases in serum L-carnitine correlated significantly with postnatal increases in renal organic cation/carnitine transporter 2 (Octn2) expression, and was further matched by postnatal increases in intestinal Octn1 expression and hepatic γ-Bbh activity. Postnatal increases in heart L-carnitine levels were significantly correlated to postnatal increases in heart Octn2 expression. Although cardiac high energy phosphate substrate levels remained constant through postnatal development, creatine showed developmental increases with advancing neonatal age. mRNA levels of Cpt1b and Cpt2 significantly increased at postnatal day 20, which was not accompanied by a similar increase in activity.

Conclusions

Several L-carnitine homeostasis pathways underwent significant ontogenesis during postnatal development in the rat. This information will facilitate future studies on factors affecting the developmental maturation of L-carnitine homeostasis mechanisms and how such factors might affect growth and development.

Neonatal blood carnitine concentrations: normative data by electrospray tandem mass spectometry

Despite a number of published reports, there is limited information about carnitine metabolism in the newborn. To establish normative data, we analyzed whole-blood carnitine concentrations in 24,644 newborns at age 1.85 +/- 0.95 d and umbilical cord whole blood and plasma carnitine concentrations in 50 full-term newborns. Total carnitine (TC), free carnitine (FC), and acylcarnitine (AC) were measured by electrospray tandem mass spectrometry. AC/FC ratios were derived from these measurements. The entire cohort was stratified according to TC values into a middle TC group representing 90% of the population and lower and upper TC groups representing 5% of the population, respectively. Normative data were derived from the middle TC group of full-term infants (N = 19,595). TC was 72.42 +/- 20.75 microM, FC was 44.94 +/- 14.99 microM, AC was 27.48 +/- 8.05 microM, and AC/FC ratio was 0.64 +/- 0.19 (+/-SD). These values differed significantly from umbilical cord whole blood TC values of 31.27 +/- 10.54 microM determined in 50 samples. No meaningful correlation was found between TC and gestational age or birth weight in any group. In controlled analyses, prematurity was not associated with TC levels, whereas low birth weight (<2500 g) and male sex were significantly associated with higher TC levels. The association of low birth weight with higher TC values may be related to decreased tissue carnitine uptake. The sex effect may be related to hormonal influences on carnitine metabolism. Our study provides normative data of carnitine values measured by the highly precise method of electrospray tandem mass spectrometry in a large cohort of newborns and provides the basis for future studies of carnitine metabolism in health and disease states during the neonatal period.

Plasma free and total carnitine measured in children by tandem mass spectrometry

Free and total carnitine quantification is important as a complementary test for the diagnosis of unusual metabolic diseases, including fatty acid degradation disorders. The present study reports a new method for the quantification of free and total carnitine in dried plasma specimens by isotope dilution electrospray tandem mass spectrometry with sample derivatization. Carnitine is determined by looking for the precursor of ions of m/z = 103 of N-butylester derivative, and the method is validated by comparison with radioenzymatic assay. We obtained an inter- and intra-day assay coefficient of variation of 4.3 and 2.3, respectively. Free and total carnitine was analyzed in 309 dried plasma spot samples from children ranging in age from newborn to 14 years using the new method, which was found to be suitable for calculating reference age-related values for free and total carnitine (less than one month: 19.3 +/- 2.4 and 23.5 +/- 2.9; one to twelve months: 28.8 +/- 10.2 and 35.9 +/- 11.4; one to seven years: 30.7 +/- 10.3 and 38.1 +/- 11.9; seven to 14 years: 33.7 +/- 11.6, and 43.1 +/- 13.8 micro M, respectively). No difference was found between males and females. A significant difference was observed between neonates and the other age groups. We compare our data with reference values in the literature, most of them obtained by radioenzymatic assay. However, this method is laborious and time consuming. The electrospray tandem mass spectrometry method presented here is a reliable, rapid and automated procedure for carnitine quantitation.

Energy requirements of surgical newborn infants receiving parenteral nutrition

The energy requirement for mature newborn infants receiving total parenteral nutrition is approximately 100 kcal.kg-1.d-1. There is no necessity to increase the caloric intake after an uncomplicated operation. Energy requirements are affected by the maturity of the infant, the degree of operative stress, opioid medication, and the presence or absence of sepsis. In general, glucose intake should not exceed the resting energy expenditure. Glucose administration exceeding 18 g.kg-1.d-1 is associated with lipogenesis and reduced oxygenation of exogenous lipid. Resting energy expenditure varies widely between infants, and energy intake, based on clinical and biochemical monitoring, should be adjusted for individual patients.

Sodium-dependent carnitine transport in human placental choriocarcinoma cells

The JAR human placental choriocarcinoma cells were found to transport carnitine into the intracellular space by a Na(+)-dependent process. The transport showed no requirement for anions. The Na+-dependent process was saturable and the apparent Michaelis-Menten constant for carnitine was 12.3 +/- 0.5 microM. Na+ activated the transport by increasing the affinity of the transport system for carnitine. The transport system specifically interacted with L-carnitine, D-carnitine, acetyl-DL-carnitine and betaine. 6-N-Trimethyllysine and choline had little or no effect on carnitine transport. Of the total transport measured, transport into the intracellular space represented 90%. Plasma membrane vesicles prepared from JAR cells were found to bind carnitine in a Na(+)-dependent manner. The binding was saturable with an apparent dissociation constant of 0.66 +/- 0.08 microM. The binding process was specific for L-carnitine, D-carnitine, acetyl-DL-carnitine, and betaine. 6-N-Trimethyllysine and choline showed little or no affinity. It is concluded that the JAR cells express a Na(+)-dependent high-affinity system for carnitine transport and that the Na(+)-dependent high-affinity carnitine binding detected in purified JAR cell plasma membrane vesicles is possibly related to the transmembrane transport process.

Sodium-dependent high-affinity binding of carnitine to human placental brush border membranes

The interaction of carnitine with human placental brush-border membrane vesicles was investigated. Carnitine was found to associate with the membrane vesicles in a Na(+)-dependent manner. The time course of this association did not exhibit an overshoot, which is typical of a Na+ gradient-driven transport process. The absolute requirement for Na+ was noticeable whether the association of carnitine with the vesicles was measured with a short time incubation or under equilibrium conditions, indicating Na(+)-dependent binding of carnitine to the human placental brush-border membranes. The binding was saturable and was of a high-affinity type with a dissociation constant of 1.37 +/- 0.03 microM. Anions had little or no influence on the binding process. The binding process was specific for carnitine and its acyl derivatives. Betaine also competed for the binding process, but other structurally related compounds did not. Kinetic analyses revealed that Na+ increased the affinity of the binding process for carnitine and the Na+/carnitine coupling ratio for the binding process was 1. The dissociation constant for the interaction of Na+ with the binding of carnitine was 24 +/- 4 mM. This constitutes the first report on the identification of Na(+)-dependent high-affinity carnitine binding in the plasma membrane of a mammalian cell. Studies with purified rat renal brush-border membrane vesicles demonstrated the presence of Na+ gradient-driven carnitine transport but no Na(+)-dependent carnitine binding in these membrane vesicles. In contrast, purified intestinal brush-border membrane vesicles posses neither Na+ gradient-driven carnitine transport nor Na(+)-dependent carnitine binding.

Renal handling of carnitine in ill preterm and term neonates

OBJECTIVE

To investigate the renal handling of carnitine in preterm and term ill neonates.

METHODS

We studied the fractional tubular reabsorption of carnitine and the proximal renal tubular function of infants in the first week of life who were receiving very little or no carnitine in their diets.

RESULTS

Mean plasma levels were low: total carnitine was 16.4 +/- 7.0 mumol/L, free carnitine was 9.2 +/- 5.0 mumol/L, and acylcarnitine was 7.2 +/- 4.1 mumol/L. The most premature group of neonates (gestation age, 26 to 31 weeks) had a fractional tubular reabsorption rate of free carnitine of 94.3% +/- 3.3%, which was lower than in the other two groups (98.1% +/- 2.4% for gestational age 32 to 36 weeks, p = 0.001; and 99.2% +/- 0.6% for gestational age 37 to 42 weeks, p = 0.002). In all patients the fractional tubular reabsorption of acylcarnitine was lower than that of free carnitine, indicating possible tubular secretion of acylcarnitine. It correlated with the total plasma carnitine levels (r = 0.53; p = 0.002). The fractional tubular reabsorption of free carnitine also correlated with gestational age (r = 0.60; p < 0.001).

CONCLUSIONS

Ill neonates have a fractional tubular reabsorption rate of free carnitine within the normal range. It increases with gestational age, and has the same maturation rate as the other known indexes of proximal tubular function.

Familial infantile apnea and immature beta oxidation

Infants with inborn errors of fatty acid metabolism may present with apnea, periodic breathing, and sudden infant death syndrome (SIDS). Recognition of these disorders and initiation of appropriate therapy may prevent SIDS. Metabolic pathways develop during gestation and post-natally. We report three siblings with apnea and periodic breathing, as well as biochemical defects consistent with a non-specific abnormality of beta oxidation. One infant died a witnessed sudden infant death. The two survivors were treated with L-carnitine supplementation resulting in rapid resolution of both respiratory and metabolic abnormalities. Enzyme activity for short, medium, and long chain acyl coenzyme A dehydrogenases was normal in these two infants. Although a unique enzymatic deficiency was not identified, our experience with this family supports the need for routine biochemical evaluation of infants with "near miss" SIDS, also called acute life-threatening events (ALTE), as well as those who have died of SIDS.

Carnitine metabolites in infants with cystic fibrosis: a prospective study

Acylcarnitine is low in cord blood in patients with cystic fibrosis, suggesting that fatty acid metabolism is disturbed in utero. Carnitine metabolites (total, free, short- and long-chain acylcarnitine) were measured prospectively in 23 newly diagnosed infants with cystic fibrosis treated with a carnitine-containing, predigested formula for 6-12 months. Total (p < 0.002), free (p < 0.004), and long-chain (p < 0.001) plasma concentrations of carnitines were significantly less than controls (n = 48) at diagnosis. Total and free concentrations were corrected with nutritional management, whereas short- and long-chain acylcarnitines remained unchanged. By three years of age all plasma concentrations of carnitine metabolites were significantly less than controls despite a carnitine-containing diet. Urinary carnitine metabolites were increased at diagnosis and follow-up. The physiological significance of these observations in cystic fibrosis is unknown, but could be compatible with disturbed regulatory control with resultant increased utilization.

Effect of carnitine supplement to the dam on plasma carnitine concentration in the sucking foal

The changes in carnitine in plasma and milk during the first 3 months of lactation were studied in 14 broodmares and their foals. Six of the mares (Group S) were given a supplement of 10 g carnitine split between the morning and evening feeds, starting 2 weeks before birth. At birth the plasma carnitine concentration in Group S mares was about twice that in Group NS mares (no supplement). In both groups the concentration initially declined in the days after birth. Whilst this trend was reversed in Group S mares, the concentration in Group NS mares remained at a reduced level for the remainder of the study. Milk concentrations declined continuously over the monitoring period in both groups. There was no apparent relationship between milk and plasma concentrations. Despite this the milk concentration tended to be higher in Group S than in Group NS mares although differences were not significant. There was an immediate drop in the plasma concentration in foals after birth which was reversed in foals of Group S mares but not in those of Group NS mares. There were no apparent side effects of carnitine supplementation.

Serum carnitine level in phenylketonuric children under dietary control in Greece

Although total, free and esterified carnitine blood levels were found to be low (p less than 0.001) in phenylketonuric patients under dietary treatment compared to controls, no clinical signs of carnitine deficiency were noticed. Exclusion from the PKU diet of nutrients rich in carnitine has been suggested. Supplementation of the diets with carnitine or preferably enrichment of the PKU formulas with carnitine will rectify the restriction of extrinsic carnitine in PKU dietary treatment.

Acylcarnitine is low in cord blood in cystic fibrosis

Carnitine metabolites (total, free, short and long chain) were analyzed in cord blood of cystic fibrosis (n = 5), non-CF siblings (n = 7), and controls (n = 8). Total acylcarnitine (short and long chain combined) was significantly lower (less than 0.001) in CF compared to both control groups. Total and free carnitine showed no significant differences between the three groups. These findings are compatible with disturbed fatty acid metabolism in utero and may be related to the increased energy expenditure characteristic of CF infants.

Plasma carnitine concentration and lipid metabolism in infants receiving parenteral nutrition

The relationships among plasma total carnitine concentration, postnatal age, and fatty acid metabolism were evaluated in 57 infants receiving parenteral nutrition. Concentrations of plasma carnitine, triglycerides, free fatty acids, acetoacetate, and beta-hydroxybutyrate were determined before and at 2 and 4 hours from the beginning of a standardized 2-hour lipid infusion. Plasma carnitine concentrations declined with increasing postnatal age. There were no significant differences in gestational age or triglyceride concentrations between infants less than or equal to 4 weeks of age and those greater than 4 weeks of age, whereas free fatty acid concentrations were lower and acetoacetate and beta-hydroxybutyrate concentrations were higher in the younger infants. Infants less than or equal to 4 weeks of age were further grouped according to plasma carnitine concentration greater than 13 nmol/ml (group 1) and less than or equal to 13 nmol/ml (group 2) and were then compared with infants greater than 4 weeks of age (group 3). There were no significant differences in triglyceride concentrations among the three groups; free fatty acids, acetoacetate, and beta-hydroxybutyrate concentrations for group 2 patients were similar to those of group 1 patients or fell between values for group 1 and group 3 patients. These results demonstrate decreasing plasma carnitine concentrations and possibly for more than 4 weeks.

Transient carnitine-responsive medium-chain dicarboxylic aciduria in an infant with cholestasis, hypoglycemia and cardiac failure

In a cholestatic infant showing hypoglycemia and cardiac failure, non-ketotic medium-chain dicarboxylic aciduria was disclosed by urinary organic acid analysis. As urinary excretion of long-chain fatty acids was also increased, a defect in beta-oxidation of long-chain fatty acids appeared likely. To try to improve this abnormality, carnitine supplements were given, which led to the complete resolution of clinical and laboratory abnormalities. This is the first reported case of a cholestatic infant who responded to carnitine supplementation. Deficiency of carnitine palmitoyl transferase was suspected as the underlying cause.

Renal conservation of carnitine by infants and adults: no evidence of developmental regulation

To determine the efficiency of renal conservation of carnitine in infants, urinary carnitine excretion was measured at intervals in 10 infants while plasma carnitine concentration was manipulated by supplementing carnitine-free formula with 0 microM, 140 microM and 280 microM L-carnitine. As carnitine supplementation increased from 0 microM to 280 microM, fractional excretion of free carnitine increased tenfold from 0.6% to 6.0%; fractional excretion of acylcarnitine esters increased to a lesser degree (10.5-15.6%). At all supplementation levels fractional excretion of acylcarnitine esters was significantly greater than fractional excretion of free carnitine. We conclude that free and esterified carnitine are handled differently in the infant kidney. Results in infants were compared to previously reported data for adults. Mean fractional excretions of total, free and esterified carnitine by infants (7.2%, 5.4% and 12.7%, respectively) were similar to those by adults (6.5%, 5.0% and 15.0%). Thus, renal losses of carnitine apparently do not account for the low plasma carnitine concentrations observed in infants fed carnitine-free formulas.

Carnitine plasma concentrations in 353 metabolically healthy children

Carnitine plasma concentrations were determined by an enzymatic radioisotopic method in 353 metabolically healthy children and in 41 adults. There was a positive correlation between total and free carnitine plasma concentrations and the age of the children. Both free and acylcarnitine concentrations were elevated on the 1st day of life, reflecting an increased rate of fatty acid oxidation. Carnitine plasma concentrations decreased after the 1st day and subsequently increased during the 1st year. From the 2nd year of life until adulthood, no further change was noted. Up to 17 years of age no differences were seen between male and female individuals. However, adult males had higher carnitine concentrations in plasma than adult females. Total carnitine concentrations were higher in 10- to 17-year-old females and lower in 10- to 17-year-old males compared with adults of the same sex, indicating a possible role for sex hormones in the regulation of carnitine plasma concentrations.

A simple fluorometric method for the determination of serum free carnitine

A new fluorometric method for the determination of serum free carnitine is described. The addition of carnitine to a system containing carnitine acetyltransferase (EC 2.3.1.7) and acetyl-CoA gives rise to the formation of CoA. The system is coupled to N-(p-(2-benzimidazolyl)-phenyl)-maleimide (BIPM). A fluorescent agent, CoA-BIPM, is produced proportionally to concentration of carnitine. By measuring the fluorescence intensity of BIPM, the carnitine content of serum can be determined. The coefficients of variation, within-run and between-run, of the method were 5.2 and 2.6%, respectively. Recovery of carnitine added to serum was 98-113%. Comparison with a colorimetric method showed a good correlation (r greater than 0.90). The method has sufficient sensitivity to measure concentrations as low as 10 mumol/l.

Amniotic fluid propionylcarnitine in methylmalonic aciduria

Amniotic fluid samples from pregnancies complicated by foetal methylmalonic aciduria and from metabolically normal pregnancies were obtained at 16-18 weeks of gestation and analysed for total, free and acylcarnitine and individual carnitine esters. The amniotic fluid concentrations of total acylcarnitine and propionylcarnitine were higher in pregnancies with higher in pregnancies with methylmalonic aciduria than in normal pregnancies. The predominant carnitine ester was propionylcarnitine in the methylmalonic aciduria group and acetylcarnitine in the normal group. These findings suggest that in methylmalonic aciduria, abnormalities of carnitine metabolism already occur early in gestation. The amount of propionylcarnitine in amniotic fluid may be useful as an additional indicator of foetal methylmalonic aciduria.

Carnitine: an overview of its role in preventive medicine

Carnitine (beta-hydroxy-gamma-N-trimethylaminobutyric acid) is required for transport of long-chain fatty acids into the inner mitochondrial compartment for beta-oxidation. Widely distributed in foods from animal, but not plant, sources, carnitine is also synthesized endogenously from two essential amino acids, lysine and methionine. Human skeletal and cardiac muscles contain relatively high carnitine concentrations which they receive from the plasma, since they are incapable of carnitine biosynthesis themselves. Since the discovery of a primary genetic carnitine deficiency syndrome in 1973, carnitine has become the subject of extensive research. It is now recognized that carnitine deficiency may also occur secondary to genetic disorders of intermediary metabolism as well as to a variety of clinical disorders, including renal disease treated by hemodialysis, the renal Fanconi syndrome, cirrhosis, untreated diabetes mellitus, malnutrition, Reye's syndrome, and certain disorders of the endocrine, neuromuscular, and reproductive systems. Administration of the anticonvulsant valproic acid and total parenteral nutrition may also induce hypocarnitinemia. In many instances, the physiological implications of secondary carnitine deficiency have not been resolved. However, evidence for a specific carnitine requirement for the newborn, especially if preterm, is accumulating. Moreover, carnitine administration may have a favorable effect on some forms of hyperlipoproteinemia. Carnitine, now recognized as a conditionally essential nutrient, is a significant factor in preventive medicine.

The metabolic effects of oral L-carnitine administration in infants receiving total parenteral nutrition with fat

beta-Oxidation, an important pathway in the metabolism of free fatty acids, occurs within the mitochondria in mammals. L-Carnitine is an essential cofactor in the transfer of long-chain fatty acids across the inner mitochondrial membrane. Maintenance of normal carnitine concentrations in whole blood and tissues, either through diet or biosynthesis, would appear necessary for adequate utilization of fat as an energy source. Infants, especially premature ones, without an exogenous dietary source of carnitine, have decreased plasma carnitine levels compared with infants receiving carnitine-supplemented feedings. To determine the importance of carnitine supplementation in a total parenteral nutrition program in infants in which a fat emulsion serves as a major calorie source, the following study was undertaken. Twelve infants receiving total parenteral nutrition (TPN) with fat for seven days were divided into two treatment groups. Group 1 was orally supplemented for seven days with carnitine (70 mumol/l/kg/24 h in 24 mL of 5% dextrose), while the second group received seven days of placebo supplementation (dextrose 5%, 24 cc/24 h). Plasma carnitine levels in the carnitine-supplemented group were significantly higher (29 +/- 8 nmol/mL) than in the control group (12.4 +/- 3.5 nmol/mL) after seven days of treatment. However, clearance of serum triglycerides and free fatty acids was not significantly different between the two groups. Baseline triglyceride levels in the carnitine-supplemented group were 96 +/- 42 mg/dL, increased to 242 +/- 101 mg/dL after the lipid challenge and decreased to 121 +/- 47 mg/dL two hours after the lipid infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Carnitine deficiency

Carnitine is an essential cofactor in the transfer of long-chain fatty acids across the inner mitochondrial membrane. Carnitine is metabolized from lysine, trimethyllysine and butyrobetaine. Butyrobetaine undergoes hydroxylation in the liver, brain and kidney to form carnitine which in turn is transported via the plasma to the heart and skeletal muscle where it is important for allowing beta oxidation of fatty acids. Three clinical forms of carnitine deficiency have been described: myopathic, systemic and mixed forms. Carnitine deficiency results in accumulation of neutral lipid within skeletal muscle, myocardium and liver. Ultrastructurally, myofibrils are disrupted and there is an accumulation of large aggregates of mitochondria and lipid deposits within the skeletal muscle and myocardium. Carnitine therapy has been effective in the treatment of the myopathic and some cases of systemic and mixed forms. Several syndromes of secondary carnitine deficiency have been described; these may be secondary to genetic defects of intermediary metabolism and to other conditions, particularly following hemodialysis.

Total parenteral nutrition in children

This article first focuses on the indications for total parenteral nutrition and the effect of its use on the outcome of various nutrient-depleting diseases in infants and children. This is followed by a discussion of some of the newer nutrient additions to total parenteral nutrition regimens, such as biotin, carnitine, zinc, copper, iron, and others.

Effect of carnitine on lipid metabolism in the neonate. II. Carnitine addition to lipid infusion during prolonged total parenteral nutrition

The effect of carnitine administration on lipid metabolism and carnitine and acylcarnitine plasma values of newborn infants, given total parenteral nutrition for the first 7 days of life, was studied during a 4-hour infusion of Intralipid. An increase in plasma concentrations of total carnitine, free carnitine, and short-chain and long-chain acylcarnitine was found, but no significant change in triglycerides, free fatty acids, glycerol, or beta-hydroxybutyrate plasma values was noted, as compared with values obtained without carnitine administration. Moreover, the low free carnitine and short-chain and long-chain acylcarnitine plasma levels found in newborn infants after 7 days of total parenteral nutrition did not seem to impair the utilization of infused lipids. The results support the concept that the relation between the carnitine pool and lipid metabolism can be influenced by intravenous glucose infusion. Low carnitine plasma concentrations do not necessarily signify a depletion of body carnitine, and sufficient tissue carnitine concentrations can probably maintain good lipid utilization for an extended period.

Tissue carnitine concentrations after total parenteral nutrition with and without L-carnitine supplementation

The concentrations (mumoles/g dry weight) of total carnitine (TC), free carnitine (FC) and acylcarnitine (AC) were determined in skeletal muscle, heart, liver, kidney and brain cortex of male mini pigs (4000-5000 g) after seven days of total parenteral nutrition (TPN) with amino acids 5% (3.0g/kg/d), glucose (25g/kg/d) and lipids 20% (4g/kg/d). This regime was administered with L-carnitine supplementation (1.5 mg/kg/d; n = 7) (group 1) and without it (n = 5) (group 2). Orally alimented animals (n = 5) served as controls (group 3). (Average carnitine intake: 3 mg/d) Carnitine free TPN affected only the concentrations in muscle. TC was markedly reduced (3.6 +/- 0.8) when compared with oral controls (5.8 +/- 0.7) (p<0.01). This decrease was exclusively due to AC, whereas FC concentrations remained almost unchanged. In group 1 the concentrations of TC in skeletal muscle, heart and brain cortex were higher than in both the other groups. The increase was mainly due to AC and FC remained unchanged in heart and brain. The concentrations in liver and kidney were not affected by either carnitine free or carnitine supplemented TPN. AC, determined as described, consists almost entirely of acid soluble acetyl-carnitine, the major product of fatty acid oxidation. Since the AC concentrations were almost exclusively altered by the two TPN-regimes we conclude that the observed changes reflect regulatory changes of fatty acid oxidation. Thus the decrease of muscle TC in group 2 is considered a consequence of an insulin induced down regulation (plasma insulin: mean 20 muU/ml; maximum: 60 muU/ml) of fatty acid oxidation in consequence of high glucose intake (25 g/kg/d). The increased TC concentrations after carnitine supplemented TPN are discussed to reflect an enhancement of oxidative degradation of fatty acids as a pharmacological effect of L-carnitine.

Carnitine in human nutrition

The oxidation of long-chain fatty acids is carnitine-dependent. Indeed, only when they are bound to carnitine, in the form of acyl-carnitines, do fatty acids penetrate into the mitochondria to be oxidized. To meet the need for carnitine, animals depend on both endogenous synthesis and an exogenous supply. A diet rich in meat supplies a lot of carnitine, while vegetables, fruits, and grains furnish relatively little. Although it has a low molecular weight and acts at low doses in a vital metabolic pathway, carnitine should not be considered a vitamin, but rather a nutritive substance. Indeed, it seems that the diet of the adult human need not necessarily furnish carnitine: the healthy organism, given a balanced nutrition (sufficiently rich in lysine and methionine), may well be able to meet all its needs. Furthermore, it seems that a reduction of the exogenous supply of carnitine results in a lowering of its elimination in the urine. However, dietary carnitine is more important during the neonatal period. The transition from fetal to extrauterine life is accompanied by an increased role of lipids in meeting energy needs. This change is accompanied by a rise in the body of the levels of carnitine, which is mainly supplied in the maternal milk. Finally, this review briefly surveys the illnesses in which a dietary carnitine supplement proves useful.

Dietary-dependent carnitine deficiency as a cause of nonketotic hypoglycemia in an infant

Recurrent episodes of hypoglycemia, prostration, vomiting, and hepatomegaly were observed in an infant fed a carnitine-free soy formula. The extremely low plasma and urinary carnitine concentrations, elevated plasma free fatty acids, disproportionately low plasma beta hydroxybutyrate, and elevated urinary dicarboxylic acids, in the presence of a fatty liver, suggested that carnitine deficiency was the basis for this child's metabolic disturbance. When the infant was fed an enriched carnitine diet, remarkable clinical, biochemical, and histologic improvement was observed. The possibility that carnitine may be an essential nutrient for some infants is raised by the findings in this patient.

The influence of maternal fat metabolism on fetal carnitine levels

Carnitine facilitates fatty acid transport across mitochondrial membranes, playing a key role in fatty acid oxidation and ketogenesis. To investigate the mechanism by which carnitine and its esters are supplied to the fetus, we measured free carnitine (FC) and acyl carnitine (AC) in amniotic fluid during late pregnancy, and FC, AC and beta-hydroxybutyrate (beta-OHB) in maternal and fetal plasma at vaginal term delivery. Amniotic fluid AC levels were elevated in pregnancies complicated by toxemia and diabetes mellitus, possibly reflecting placental transfer during abnormal fat catabolism. Maternal plasma levels of beta-OHB and AC were elevated and positively correlated at vaginal delivery, indicating enhanced fatty acid utilization. The positive correlation between maternal and fetal FC, AC and beta-OHB plasma levels suggests placental transfer. The maternal-fetal concentration gradient was descending for beta-OHB and AC and ascending for FC. No umbilical venous-arterial gradient for AF and beta-OHB was found, suggesting that the fetus does not utilize substantial amounts of either substance. The results demonstrate that fetal FC and AC levels are influenced by changes in maternal fat metabolism.

Carnitine deficiency in premature infants receiving total parenteral nutrition

Carnitine plays a significant role in fatty acid utilization and ketone body production. Its availability is especially important during the immediate postnatal period. To determine whether low birth weight infants who cannot be orally fed are at risk of developing carnitine deficiency, we compared the carnitine blood levels and urinary excretion of 12 premature infants (Group A) receiving total parenteral nutrition (TPN) with those of 8 infants of similar gestational age and birth weight (Group B) who received carnitine-containing milk formulas. In Group A, serum levels of total and free carnitine fell after 5 days of carnitine-deficient parenteral nutrition, and urinary excretion was significantly reduced. Serum levels and urinary excretion increased after the onset of oral feedings. The control Group B exhibited no significant changes in carnitine blood levels between the first and fifth days of life, but did show a later increase. Children in Group A had lower carnitine blood levels compared to those in Group B on the fifth day of life. These findings suggest that premature infants are not able to synthesize enough carnitine to maintain blood levels, and that carnitine deficiency can occur following TPN. Further investigation of metabolic consequences secondary to deficient carnitine intake in premature infants is necessary before carnitine supplementation should be considered.

Plasma carnitine levels during intravenous feeding of the neonate

The premature infant has a limited capacity for fatty acid oxidation. This study shows that solutions commonly used for intravenous feedings in the newborn infant contain no carnitine. Infants maintained on this solution have significantly lower total, free, and acylcarnitine levels as compared to when they are fed orally with expressed human milk or a proprietary formula, which is known to contain carnitine. The exogenous supply of carnitine to the premature infant may have a significant influence on the ability to stimulate optimal fatty acid oxidation.