Safety of a new transpulmonary echocontrast agent (Albunex) in repeated echocardiographic studies in patients

BACKGROUND AND HYPOTHESIS

Multiple contrast-enhanced echocardiographic studies are to be expected in patients with cardiac ischemic disease, but the sonication process used to produce the echocontrast agent Albunex may result in new epitopes that could cause an immunogenic response.

METHODS

Repeated exposures to intravenous Albunex over a period of time long enough to allow development of an eventual immune reaction were performed in 12 patients while monitoring for lymphocyte transformation, microsphere specific IgE and IgG antibodies, and systemic, pulmonary artery, capillary wedge, and right atrial pressures, as well as cardiac output, left ventricular fractional shortening, and blood gases.

RESULTS

No significant 3H-thymidine incorporation and thus no specific blastic transformation of the patients' lymphocytes were observed either for high or low Albunex concentrations, corresponding to the expected hepatic and plasma concentrations of microspheres. No formation of microsphere-specific IgE and IgG antibodies was observed after the first or second Albunex exposure. Furthermore, no clinically significant hemodynamic or respiratory adverse reactions were observed in any patient.

CONCLUSION

These results suggest that repeated exposures to intravenous Albunex induce no adverse effect on the cellular and humoral immune systems and on left and right heart hemodynamics in patients.

Enhanced natriuretic response to neutral endopeptidase inhibition in heart-transplant recipients

Heart-transplant recipients (Htx) generally present with body fluid and sodium handling abnormalities and hypertension. To investigate whether neutral endopeptidase inhibition (NEP-I) increases endogenous atrial natriuretic peptide (ANP) and enhances natriuresis and diuresis after heart transplantation, ecadotril was given orally to 8 control subjects and 8 matched Htx, and levels of volume-regulating hormones and renal water, electrolyte, and cyclic guanosine monophosphate (cGMP) excretions were monitored for 210 minutes. Baseline plasma ANP, brain natriuretic peptide (BNP), and cGMP were elevated in Htx, but renin and aldosterone, like urinary parameters, did not differ between groups. NEP-I increased plasma ANP (Htx, 20.6+/-2.3 to 33.2+/-5.9 pmol/L, P<0.01; controls, 7.7+/-1. 2 to 10.6+/-2.6 pmol/L) and cGMP, but not BNP. Renin decreased similarly in both groups, whereas aldosterone decreased significantly only in Htx. Enhanced urinary sodium (1650+/-370% versus 450+/-150%, P=0.01), cGMP, and water excretions were observed in Htx and urinary cGMP positively correlated with natriuresis in 6 of the Htx subjects. Consistent with a normal circadian rhythm of blood pressure, without excluding a possible effect of NEP-I, mean systemic blood pressure increased similarly in both groups at the end of the study (6.9+/-2.0% versus 7.4+/-2.8% in controls and Htx). Thus, systemic hypertension, mild renal impairment, and raised plasma ANP levels are possible contributory factors in the enhanced natriuresis and diuresis with NEP-I in Htx. These results support a physiological role for the cardiac hormone after heart transplantation and suggest that long-term studies may be useful to determine the potential of NEP-I in the treatment of sodium retention and water retention after heart transplantation.

Circulating adrenomedullin is increased after heart transplantation

OBJECTIVE

Adrenomedullin (ADM), secreted by the failing human heart, is a newly discovered potent endogenous vasorelaxing and natriuretic peptide that may play a role in cardiorenal regulation. No data are available on ADM in heart-transplant recipients (Htx) and the aim of this study was to determine the short- and long-term responses of ADM after heart transplantation.

METHODS

Circulating ADM and its relationship with parameters of cardiovascular hemodynamics, humoral factors and renal function were determined in normal subjects and Htx early (1, 2, 4, 8, 15 and 30 days) and late (32 +/- 16 months) after transplantation. Additionally, ADM was obtained in matched hypertensive and renal-transplant patients (n = 9 in each group).

RESULTS

Plasma ADM, elevated in heart failure patients, further increased transiently at day 1 after transplantation (from 37.9 +/- 15.9 to 125.8 +/- 15.3 pmol/l, P < 0.01) and, although decreasing thereafter, remained elevated until the 30th day after transplantation (52.1 +/- 25.2 pmol/l). Late after transplantation. ADM concentrations were still increased compared to normal values (31.3 +/- 5.3 vs. 19.4 +/- 2.7 pmol/l, P < 0.001). ADM positively correlated with endothelin, atrial natriuretic peptide (ANP) and cyclosporine. ADM was also correlated with increased diastolic (r = 0.68, P < 0.04) and systolic (r = 0.66, P < 0.05) blood pressure in late Htx. No relationship was observed between ADM and left ventricular mass index, aldosterone and creatinine. ADM elevation was similar in hypertensive, renal-transplant patients and in Htx.

CONCLUSIONS

Circulating ADM is increased after heart transplantation, in relation to hypertension, endothelin, cyclosporine and ANP. In view of ADM's biological properties, these results might suggest a compensatory role for ADM against further development of vasoconstriction and fluid retention states after heart transplantation.

Enhanced brain natriuretic peptide response to peak exercise in heart transplant recipients

We investigated the atrial (ANP) and brain natriuretic peptides (BNP), catecholamines, heart rate, and blood pressure responses to graded upright maximal cycling exercise of eight matched healthy subjects and cardiac-denervated heart transplant recipients (HTR). Baseline heart rate and diastolic blood pressure, together with ANP (15.2 +/- 3.7 vs. 4.4 +/- 0.8 pmol/l; P < 0.01) and BNP (14.3 +/- 2. 6 vs. 7.4 +/- 0.6 pmol/l; P < 0.01), were elevated in HTR, but catecholamine levels were similar in both groups. Peak exercise O2 uptake and heart rate were lower in HTR. Exercise-induced maximal ANP increase was similar in both groups (167 +/- 34 vs. 216 +/- 47%). Enhanced BNP increase was significant only in HTR (37 +/- 8 vs. 16 +/- 8%; P < 0.05). Similar norepinephrine but lower peak epinephrine levels were observed in HTR. ANP and heart rate changes from rest to 75% peak exercise were negatively correlated (r = -0.76, P < 0.05), and BNP increase was correlated with left ventricular mass index (r = 0.83, P < 0.01) after heart transplantation. Although ANP increase was not exaggerated, these data support the idea that the chronotropic limitation secondary to sinus node denervation might stimulate ANP release during early exercise in HTR. Furthermore, the BNP response to maximal exercise, which is related to the left ventricular mass index of HTR, is enhanced after heart transplantation.

Normal short-term renal response to acute volume expansion in heart transplant recipients: a role for atrial natriuretic peptide?

BACKGROUND

The breakdown of blood pressure and body fluid homeostasis observed in heart transplant (Htx) recipients may partly be due, as in heart failure, to a blunted renal response to elevated atrial natriuretic peptide (ANP).

METHOD

This possibility was addressed through determination of the relationship between ANP, the urinary cyclic guanosine monophosphate (cGMP), a biologic marker of ANP renal activity, and the early renal responses to 10 mL/kg isotonic saline infusion over 30 minutes in 8 control subjects and 8 matched Htx recipients.

RESULTS

Urine flow, natriuresis, and urinary cGMP excretion increased similarly in both groups, resulting in elimination of, respectively, 1/2 and 2/3 of the sodium and the water load during the experiment that lasted 4 hours and 30 minutes. Plasma renin and aldosterone decreases were similar in both groups. Elevated ANP further increased in Htx after saline infusion (from 19.5 +/- 3.7 to 33.8 +/- 5.6 pmol/L, P < .001). Plasma cGMP paralleled ANP in both groups (r = 0.81; P < .001). Significant correlations were observed between plasma ANP and urinary cGMP excretion (r = 0.48, P < .025 and r = 0.43, P < .05 in Htx recipients and control subjects) and between plasma ANP and urinary sodium excretion (r = 0.64, P < .001 in Htx recipients).

CONCLUSION

In spite of a relative renal hyporesponsiveness to the cardiac hormone, with higher plasma ANP being not associated with increased renal excretions in Htx recipients, ANP is likely to participate in the appropriate short-term renal response to acute volume expansion in Htx recipients.

Erythrocytes participate significantly in blood transport of amino acids during the post absorptive state in normal humans

To investigate the participation of erythrocytes in the blood transport of amino acids during the course of intestinal absorption in humans, erythrocyte and plasma amino-acid concentrations were determined following ingestion of an oral load of amino acids. In addition to baseline plasma and erythrocyte amino acid concentrations in 18 subjects, plasma and erythrocyte amino acids kinetics during the 125 min following an oral amino acid load were further determined in 9 of the 18 subjects. The results showed that human erythrocytes contained most amino acids at similar or higher concentrations than plasma. Furthermore, the correlations observed between plasma and erythrocyte contents clearly indicated that erythrocytes were involved in the transport of amino acids by the blood. For some amino acids erythrocyte transport sometimes exceeded that of plasma. Significant correlation coefficients showed that strong plasma-erythrocyte relationships existed for alanine, valine, methionine, isoleucine, leucine, phenylalanine, and ornithine. In conclusion, our data supported the hypothesis that both blood compartments, plasma and erythrocytes, are involved significantly in the blood transport of amino acids in humans during the postabsorptive state.

Role of the plasma and erythrocytes in veno-arterial portal changes during post prandial state in the rat

The determination of plasma and whole blood free amino acid concentrations in arterial and portal venous blood during post prandial state in the rat was used to estimate the role of the erythrocytes in amino acid exchanges. The erythrocyte contents were calculated from plasma, whole blood concentrations and the hematocrit. The veno-arterial concentration differences in plasma were significant for all amino acids except a-aminobutyrate and ornithine whereas in the erythrocytes only 8 amino acids exhibit significant differences (ASP, ALA, VAL, MET, ILE, LEU, TYR, PHE). For 6 amino acids, a significant correlation between the plasma and the erythrocyte concentration has been found (VAL, ILE, LEU, TYR, PHE, HIS). These data suggest that in vivo during the time of contact between blood and organ tissues, some amino acids but not all are significantly taken up by the erythrocytes. Thus, it may be concluded that erythrocyte amino acid blood transport in arterio-venous portal exchanges, concerns particularly tyrosine and essential amino acids. The erythrocyte amino acid transport represents quantitatively about 20 per cent of the total blood transport.

Endothelin participates in increased circulating atrial natriuretic peptide early after human heart transplantation

BACKGROUND

Hemodynamic improvement after heart transplantation is expected to normalize the neuroendocrine balance, but circulating atrial natriuretic peptide (ANP) remains elevated. Endothelin stimulates ANP secretion and its concentration increases after heart transplantation, suggesting a role for this peptide in the cardiovascular adaptative response to heart transplantation.

METHODS

To investigate whether endothelin may induce ANP increase in heart transplant recipients, we monitored daily ANP, endothelin, and related hormonal, biologic, and hemodynamic parameters before and during the first week after either heart transplantation (n = 15) or coronary artery bypass grafting (n = 10).

RESULTS

Surgery induced a transient secretory peak of arginine vasopressin and endothelin in both groups at day 1. Bypass grafting did not modify normal ANP (11.8 +/- 2.1 pmol/L), endothelin (2.4 +/- 0.3 pmol/L), renin activity (0.11 +/- 0.04 pmol/L/sec), or aldosterone (492 +/- 122 pmol/L) values. Heart transplantation normalized the renin-aldosterone axis, but the early decrease observed for ANP (from 27.2 +/- 4.8 to 21.14 +/- 1.4 pmol/L) was only partial and transient. Endothelin further increased (from 4.4 +/- 0.8 to 9.14 +/- 1.8 pmol/L; p < 0.01) after transplantation. Positive correlations were observed between endothelin, isoproterenol dose, creatinine, right atrial pressure, and ANP, but multiple correlation analysis showed the important role of endothelin (r = 0.69, p < 0.001). Cyclic guanosine monophosphate correlated with ANP (r = 0.65, p < 0.001).

CONCLUSIONS

Elevated endothelin, suggesting vascular dysfunction, likely contributes to the ANP increase observed early after heart transplantation. Furthermore, ANP, through a cardiac endothelium feedback, may act in the maintenance of circulatory homeostasis in heart transplant recipients.

Contrast echocardiography in coronary artery diseased patients: effect of systemic and pulmonary artery pressures on left heart opacification after intravenous injection of Albunex

BACKGROUND

Contrast echocardiography is a useful tool for assessing repeatedly patients with coronary artery disease. Nevertheless, elevated pulmonary artery and systemic blood pressures likely to be associated with cardiac ischemia may limit the left ventricular opacification (LVO) because of the microspheres' sensitivity to pressure.

OBJECTIVE

To determine the effects of systemic and pulmonary artery blood pressures on LVO.

METHODS

We performed 55 intravenous injections (0.08 and 0.22 ml/kg) of a new transpulmonary contrast agent (Albunex), during two separated exposures, into 20 cardiac ischemic patients while monitoring invasively their cardiac indexes, and intracardiac, systemic, and pulmonary artery blood pressures. LVO was graded qualitatively from faint to full.

RESULTS

A logistic model with the grade of LVO as the dependent variable and a selection from among the dose, exposure, right and left atrial blood pressures, systolic systemic and pulmonary artery blood pressures (ranges 94-208 and 14-45 mmHg, respectively), cardiac index, stroke index, and pulmonary and systemic vascular resistances as the explanatory variables demonstrated that increasing the dose gives an increasing probability of LVO (P = 0.02) and that increasing the pulmonary artery pressure reduces that probability (P = 0.006). A decreased cardiac index tended also to be associated with decreased LVO. The systemic blood pressure and the pulmonary and systemic vascular resistances had no statistically significant effect on the grade of LVO.

CONCLUSIONS

LVO after intravenous administration of Albunex is dose-dependent and limited by an elevated pulmonary artery pressure. These data suggest that one should use higher doses for cardiac ischemic patients with elevated pulmonary artery pressures and that use of Albunex has the potential to detect pulmonary hypertension in patients.

Effect of short-term endurance training on exercise capacity, haemodynamics and atrial natriuretic peptide secretion in heart transplant recipients

Exercise tolerance of heart transplant patients is often limited. Central and peripheral factors have been proposed to explain such exercise limitation but, to date, the leading factors remain to be determined. We examined how a short-term endurance exercise training programme may improve exercise capacity after heart transplantation, and whether atrial natriuretic peptide (ANP) release may contribute to the beneficial effects of exercise training by minimizing ischaemia and/or cardiac and circulatory congestion through its vasodilatation and haemoconcentration properties. Seven heart transplant recipients performed a square-wave endurance exercise test before and after 6 weeks of supervised training, while monitoring haemodynamic parameters, ANP and catecholamine concentrations. After training, the maximal tolerated power and the total mechanical work load increased from 130.4 (SEM 6.5) to 150.0 (SEM 6.0) W (P < 0.05) and from 2.05 (SEM 0.1) to 3.58 (SEM 0.14) kJ.kg-1 (P < 0.001). Resting heart rate decreased from 100.0 (SEM 3.4) to 92.4 (SEM 3.5) beats.min-1 (P < 0.05) but resting and exercise induced increases in cardiac output, stroke volume, right atrial, pulmonary capillary wedge, systemic and pulmonary artery pressures were not significantly changed by training. Exercise-induced decrease of systemic vascular resistance was similar before and after training. After training arterio-venous differences in oxygen content were similar but maximal lactate concentrations decreased from 6.20 (SEM 0.55) to 4.88 (SEM 0.6) mmol.l-1 (P < 0.05) during exercise. Similarly, maximal exercise noradrenaline concentration tended to decrease from 2060 (SEM 327) to 1168 (SEM 227) pg.ml-1. A significant correlation was observed between lactate and catecholamines concentrations. The ANP concentration at rest and the exercise-induced ANP concentration did not change throughout the experiment [104.8 (SEM 13.1) pg.ml-1 vs 116.0 (SEM 13.5) pg.ml-1 and 200.0 (SEM 23.0) pg.ml-1 vs 206.5 (SEM 25.9) pg.ml-1, respectively]. The results of this study suggested that the significant improvement in exercise capacity observed after this short-term endurance training period may have arisen mainly through peripheral mechanisms, associated with the possible decrease in plasma catecholamine concentrations and reversal of muscle deconditioning and/or prednisone-induced myopathy.

Persistent exercise intolerance following cardiac transplantation despite normal oxygen transport

To define the respective roles of the periphery and central oxygen transport in the exercise limitation of heart transplanted patients (HTR), we compared 11 HTR (15.1 +/- 10.8 months after transplantation) to six age and weight matched normal controls (C), during an incremental exercise test (30 W/3 min steps; supine position), up to peak exercise level. The C stopped between 120 and 240 W (mean = 180 +/- 39 W), whereas the HTR all reached 90 W, with a significantly lower oxygen uptake (VO2), cardiac index (CI) and arterio-venous oxygen difference (AVO2D) values (respectively VO2: 16.6 +/- 2.6 vs 30.0 +/- 9.3 ml.min-1.kig-1 STPD; CI: 6.84 +/- 1.10 vs 10.55 +/- 2.86l.min-1.m-2; AVO2D: 94 +/- 13 vs 109 +/- 9 ml.l-1; all p < 0.05) but with similar lactate (LA) values (respectively 7.25 +/- 1.98 vs 7.71 +/- 1.55 mmol.l-1; p = NS). At the 90 W step which corresponds to the peak level that all the HTR reached, the C were close to their anaerobic threshold and showed similar parameters of oxygen transport (VO2: 17.4 +/- 2.0; CI: 7.50 +/- 0.41; AVO2D:90 +/- 10) but a lower lactate level (LA: 2.93 +/- 4.76; p < 0.002). At the same intermediate exercise levels VO2, CI and AVO2D were similar in both groups, while the closely matched LA and ventilation increased faster in HTR, reaching significantly higher levels as soon at the 30 W step. This evidence for an increased anaerobic exercise energy generation in HTR suggests that the periphery participates significantly in their exercise limitation, a phenomenon that might be improvable by retraining.

VALUES

means+/-standard deviation.

Atrial natriuretic factor secretion: a role for atrial systolic ejection force?

The increase in plasma concentration of atrial natriuretic factor in heart transplant patients has not been fully elucidated. Besides an eventual pressure or volume overload leading to passive atrial distension, the atrial tension developed during atrial systole, or atrial ejection force, which may be increased by the transplantation procedure, is an important determinant of atrial natriuretic factor release. We therefore determined the plasma concentration of atrial natriuretic factor and the maximal atrial ejection force in 15 heart transplant patients and 8 controls, matched for age and body mass. Atrial ejection force, as defined as the force exerted by the left atrium to accelerate blood into the left ventricle during atrial systole, was obtained using combined two-dimensional imaging and doppler echocardiography. Serum creatinin concentrations, heart rate [91.9 (SD 13.2) vs 71.8 (SD 10.9) beats.min-1], mean arterial blood pressure [103.9 (SD 9.8) vs 87.4 (SD 5.8) mmHg, 13.85 (SD 1.31) vs 11.65 (SD 0.77) kPa], left ventricular posterior wall thickness and interventricular septum thickness were higher in heart transplant patients compared to controls. Plasma concentration of atrial natriuretic factor was also elevated in heart transplant patients [63.9 (SD 18.1) vs 34.0 (SD 3.2) pg.ml-1; P < 0.001]. In contrast, although the left atrial area was greater in heart transplant patients [28.2 (SD 4.8) vs 15.8 (SD 2.5) cm2; P < 0.001], mitral area, transmitral Doppler A-wave maximal velocity and atrial ejection force were similar in transplant and in control patients [7.7 (SD 3.5) vs 8.9 (SD 2.8) kdyn, 77 (SD 35) vs 89 (SD 28)mN]. No significant correlation was observed between concentration of atrial natriuretic factor and atrial ejection force, either in heart transplant patients or in controls. Thus, the elevated plasma concentration of atrial natriuretic factor observed in these heart transplant patients was multifactorial in origin, and was considered to depend upon an hypersecretion rather than upon a decreased clearance rate. Moreover, it is suggested that the atrial ejection force was unlikely to have participated in this enhanced release of atrial natriuretic factor.

Safety and efficacy of a new transpulmonary echo contrast agent in echocardiographic studies in patients

OBJECTIVES

This study was designed to investigate in patients the effect of a new transpulmonary echo contrast agent, made from 5% human serum albumin (Albunex), on systemic and pulmonary hemodynamics and the influence of the contrast doses on left ventricular opacification.

BACKGROUND

New intravenous transpulmonary echo contrast agents are promising, allowing contrast stress echocardiography and myocardial contrast echocardiography. Nevertheless, some shortcomings still remain. Thus, the pulmonary hypertension observed in pigs after Albunex injection should be investigated in humans, and the optimal dose of contrast agent remains to be determined because previous experiments indicated that the left ventricular opacification and attenuation are dose dependent.

METHODS

Albunex in doses of 0.08 and 0.22 ml/kg was successively injected intravenously in 20 catheterized patients; in 11 of them, anti-inflammatory drugs were withdrawn to avoid the blocking of an eventual thromboxane-mediated pulmonary artery hypertension. Systemic blood pressure and pulmonary artery, capillary wedge and right atrial pressures were continuously monitored. Cardiac output, left ventricular fractional shortening and blood gases were determined 5 min before and 5 and 10 min after each injection. The left ventricular opacification was qualitatively assessed by three independent observers using a grading scale from 0 to 3, with 0 indicating an absence of contrast effect and 3 indicating full opacification.

RESULTS

No clinical, hemodynamic or respiratory adverse reactions were observed in any patient. Irrespective of doses, a left ventricular opacification grade > or = 2 was observed in 74% of the 35 injections that could be evaluated. This percentage increased to 94% when the higher dose group was considered alone.

CONCLUSIONS

This first report of the effect of Albunex injected intravenously on pulmonary artery pressures in humans demonstrates that this contrast agent appears to be safe. The significant left ventricular opacification obtained in a majority of patients without an important increase in attenuation supports the use of the higher dose of the contrast agent.

Role of cardiac innervation in atrial natriuretic peptide secretion in transplanted heart recipients

To investigate whether cardiac innervation modulates atrial natriuretic peptide (ANP) secretion, we performed acute volume expansion on eight normal and eight matched (age, weight, and total blood volume) transplanted denervated heart patients (Htx), while monitoring fluid-regulating hormone, systemic blood pressure, and echocardiographic atrial area changes. At rest, plasma ANP and guanosine 3',5'-cyclic monophosphate (cGMP) were lower in control subjects than in Htx (45 +/- 16 vs. 103 +/- 35 pg/l and 0.9 +/- 0.3 vs. 3.5 +/- 1.4 pM, respectively; P < 0.001). Plasma active renin, aldosterone, and catecholamines did not differ significantly in the two populations, whereas arginine vasopressin and cortisol were higher in controls (P < 0.01 and P < 0.005). Although volume expansion (+15%) and atrial stretch were similar in the two groups, plasma ANP and cGMP increased significantly only in the Htx group (103 +/- 35 to 189 +/- 69 pg/l and 3.5 +/- 1.4 to 5.8 +/- 1.4 pM, respectively; P < 0.001). The decrease observed for the other hormones was not significant except for arginine vasopressin and cortisol (P < 0.05 and P < 0.001) in the control group. These results support the hypothesis of an inhibitory role of cardiac innervation in biologically active ANP secretion in humans, at rest and after acute volume expansion.

Viscosity of water in hibernating and nonhibernating mammals estimated by proton NMR relaxation times

Longitudinal (T1) and transverse (T2) nuclear magnetic resonance relaxation times were measured in vitro at 37, 30, 25, 15, and 5 degrees C on serum, brain, liver, kidney, and heart samples from a hibernator, the European hamster, active in summer (SA), active in winter, or in the hibernating state in winter; from a less efficient hibernator, the golden hamster; and from a homeotherm, the rat. T1 and T2 relaxation times varied between species and in the European hamster between the active and hibernating subjects. Despite the major relaxation time differences between the organs, NMR relaxation time measurements showed a general trend to an increase in the viscosity of water for the European hamster in the active state. Although these modifications were not directly related to the process of hibernation itself, the relaxation times observed in the hibernating animals were closer to those seen in the rat. This evidenced that changes of physical properties of water reflect a better adaptation to low temperatures of the hamster, as compared to the nonhibernator, given that the low water viscosity of SA hamster allows the decrease of the viscosity with temperature during the hibernating state. These in vitro studies permit the study the viscosity which is an important physicochemical parameter involved in NMR longitudinal relaxation time of water proton. More detailed studies of other physiological parameters must be undertaken by further in vivo measurements.

Is fetal acidosis in the human fetus maternogenic during labor? A reanalysis

The purpose of this study was to investigate whether maternogenic fetal acidosis can occur at the time of labor and delivery and to evaluate the extent of the possible maternal contribution to fetal acidosis. We have therefore determined fetal and maternal lactate concentrations and acid-base status under various conditions in 589 women at the end of gestation and during labor. The results show that metabolic acidosis develops in all fetuses because of increased production of lactic acidosis is primarily of fetal origin: 1) the umbilical arteriovenous lactate differences were positive and large in steady-state conditions as well as in depressed newborns; 2) the conditions that could produce a net transfer of lactate from the mother to the fetus, namely a positive maternofetal gradient of lactate and proton, were rarely observed; and 3) the correlation between fetal and maternal lactate levels was very weak, with regression coefficients decreasing from near steady-state conditions to acute stress conditions, indicating that the increase in lactate in the fetus and mother occurs independently. This correlation indicates also that increased maternal lactate production under conditions of labor and delivery can make a contribution by affecting the rate of net transfer from fetus to mother. This is possible in approximately 6% of the fetuses.

The effects of changes in plasma amino acid concentrations on erythrocyte amino acid content

In order to determine the effects of large variations in plasma amino acid concentrations upon human erythrocyte amino acid content, the plasma concentration of blood samples was enhanced (x 3.8) by adding amino acids or decreased (x 0.49) by plasma dilution. Before and after incubation (30 s at 37 degrees C), the erythrocyte contents were calculated from whole blood and plasma amino acid concentrations. Large and rapid plasma concentration variations led to significant erythrocyte changes in 11 amino acids. THR, CIT, alpha AB, VAL, MET, ILE, LEU, TYR, PHE, TRP, and ARG. Relationships between erythrocyte and plasma concentrations were determined for these amino acids. These observations were examined in the light of the role played by erythrocytes in blood amino acid transport.

Lactate movements in the term human placenta in situ

Movements of lactate through the human placenta in situ were derived from maternal and fetal blood sampling performed under conditions that approximate as closely as possible the normal fetal metabolic state. It is reported that, at the end of pregnancy, the human fetus produces lactate which is transferred to the placenta. The actuality of this lactate transfer coupled with proton transfer is discussed taking into account the results of multiple linear regression analysis determined between the umbilical arterio-venous lactate differences and fetal and maternal lactate and proton concentrations. It is finally assumed that this lactate is partly metabolized in the placenta, the remaining part being transferred from the placenta to the mother.

Does fetal acidosis develop with maternal glucose infusion during normal labor?

The actual effects of glucose infusion on fetal acid-base status were studied during 125 normal deliveries in which plasma glucose and acid-base parameters were determined after maternal infusion of either 10% glucose or Ringer's solution. After 80 minutes, mean (+/- SD) plasma glucose levels were significantly higher in the glucose group (N = 59) than in the Ringer's group (N = 66), both for the mother (183.6 +/- 46.8 versus 95.3 +/- 18.0 mg/dL) and the fetus (108.4 +/- 41.4 versus 64.8 +/- 16.2 mg/dL). Fetal plasma lactate concentrations did not differ between the glucose and the Ringer's groups, but were significantly lower in the fetuses delivered by elective cesarean section in both groups. With glucose administration, fetal pCO2 was higher and pH values were lower than in the Ringer's group. However, the magnitude of acid-base status changes, indicated by both pH and pCO2 shifts (ie, the difference between umbilical artery and scalp values), failed to differ between the two groups. In fetuses with progressing hypoxia, no differences in any of the acid-base parameters were observed between glucose and Ringer's administration. These data indicate that at a glucose infusion rate of 30 g/hour, fetal acidosis, when it occurs, results from hypoxia rather than from maternal glucose administration.

Are there two biological parts in the second stage of labor?

In 228 patients, fetal blood pH, pCO2 and lactic acid were measured in two distinguishable parts of the second stage of labor. The 'first' part begins at full cervical dilatation and ends when the mother starts her first voluntary bearing down efforts. In our study, the fetal acid-base status did not change in this part, regardless of a late developing hypoxia. In contrast, higher levels of lactic acid and pCO2 and lower pH values were observed in the 'final' part of the second stage, indicating increasing acidosis. In this 'final' part, the fetuses with clinical signs of distress, as defined by an ominous Apgar score at birth, showed quicker and larger acid-base shifts than did the normal fetuses. Thus the two parts of the second stage of labor actually differ in their potential to stimulate fetal acidosis. Since such fetal acidosis may develop especially during the 'final' part of labor, we have concluded that special particular attention should be devoted to this part.

The validity of fetal heart rate monitoring during the second stage of labor

Fetal blood pH, pCO2, and lactic acid were measured before and after the final period of the second stage of labor in an attempt to better understand th validity fetal heart rate (FHR) monitoring at this time. Following a classification derived from Melchior, six FHR patterns were recognized: 0, 1, 2a, 2b, 3, and 4. In the second stage of labor, until bearing-down efforts began, the fetal acid-base status did not change regardless of the type of tracing. At the time of delivery, as compared with values measured before the beginning of the final stage, the highest shift of lactic acid, coupled with the lowest pH shift, was associated with the type 3 pattern. The most rapid increases of lactic acid and pCO2 and decreases in pH were associated with type 2b patterns. Both type 3 and 2b patterns were ominous, but low Apgar scores were more frequent in type 3 because the duration of the final stage of labor was longer. Working from the mean slopes of the shifts of biologic parameters as a function of time, theoretical limits were derived and discussed for safe duration of the final stage of labor.

Plasma amino-acids analysis: effects of delayed samples preparation and of storage

This paper describes changes occurring in plasma amino-acid concentrations of: samples which are not prepared for analysis immediately after blood collection and samples stored for 5 to 6 months in the form of either plasma, or of deproteinized plasma, or of deproteinized and at pH 2.2 buffered plasma. Results showed that in order to avoid these changes, plasma should be deproteinized and buffered as soon as possible after blood collection. When analysis could not be performed immediately, storage of samples in a freezer at -18 degrees C in the form of deproteinized and at pH 2.2 buffered plasma showed after 5 to 6 months the best recovery of the initial concentrations, but did not exclude all changes.

Acute versus chronic conditions for studies of fetal nutrient requirements: applicability to the human

In order to validate results obtained in 'acute' versus 'chronic' experimental conditions, two fetal sheep nutrients, lactate and glucose, have been determined in 'acute' conditions and compared with the 'chronic' data in the literature. Maternal and fetal blood glucose in 'acute' conditions was in the range of published 'chronic' data. Fetal blood lactate was similar in 'acute' and during 'chronic' conditions. Maternal and fetal veno-arterial (VA) differences were in the same direction in 'acute' and in 'chronic' conditions for both lactate and glucose and of the same magnitude for lactate. For glucose, a good relationship was observed between umbilical VA differences and maternal arterial concentrations for all 'acute' and 'chronic' values. Thus no fundamental differences appear in the results obtained in 'acute' or during 'chronic' conditions. The applicability of such animal results to the human and the use of acute conditions to study fetal nutrition in the human are discussed.

Rapid bedside estimation of plasma and whole blood lactic acid

A rapid method for the bedside measurement of plasma, intracellular and whole blood lactates is described. The paper described a new method of measuring the L-lactate content of blood using an apparatus ("Lactate Analyzer 640", manufactured by Roche Bio-electronics, Basel) previously designed for this purpose but using aqueous solutions. A novel feature of this new method is the facility to use small blood samples (100-150 mul). We therefore believe that it will become an invaluable tool in obstetrics and neonatology.

Spontaneous activity and food requirements for maintenance and for growth in the genetically obese Zucker rat

This study was undertaken in order to elucidate whether, as compared with those of their lean controls, the low maintenance requirements of genetically obese Zucker rats may be explained by a lower spontaneous activity. In 6 obese and 6 lean rats, daily body weight, food intake and spontaneous activity were recorded during 6 weeks, using a seismographic recorder. The obese rats weighed more (average + 46%) and ate more (average + 42%) than the lean rats, while there was no difference between their daily activity levels. The relationship between food intake (FI) and weight gain (delta W), both expressed per 100 g body weight, was: FI (kcal/day) = 3.3 delta W (g/day) + 20.4 for lean rats and 4.9 delta W (g/day) + 17.4 for obese rats. Thus, the food requirements for maintenance obtained for delta W = O was less than for obese than for lean rats, while for a given gain in body weight, it was higher for obese rats. This did not seem to be because of a lower daily activity level in the obese than in the lean rats.

The effects of dietary self-selection upon the overshoot phenomenon in starved-refed rats

The food intake, liver composition and hepatic activity of pyruvate kinase (PK), glucose-6-phosphate dehydrogenase (G6P-DH), malic enzyme (ME) and acetyl CoA carboxylase (AcCoA Cx) were studied in starved-refed rats. When rats were refed a mixed diet for 3 days, food intake significantly increased (by 33%) from day 1 to 3 and the glycogen accumulation was maximal after 24 hours, but decreased significantly by day 3 (by 34%). In contrast, liver triglycerides sharply increased (10-fold) from day 1 to 3. Furthermore, during refeeding a large increase of G6P-DH, ME and AcCoA Cx was reached on day 3 when the average activity was 5.5- to 6.5-fold higher than before fasting. When rats were refed under conditions of self-selection (carbohydrates, lipids and proteins) total food intake was the same each day, but lipid and carbohydrate intakes varied reciprocally: lipid intake decreased whereas carbohydrate consumption increased during the 3 day refeeding period. Liver glycogen level was unchanged and both the triglyceride accumulation and the overshoot of lipogenic enzymes were highly attenuated: on day 3, they reached 50% of values observed in mixed diet refed rats. Administration of 8-azaguanine during refeeding under self-selecting conditions lowered food intake but had no effect on the pattern of food intake on the first day. In the following days, lipid intake fell dramatically. Azaguanine does not alter liver glycogenesis, but prevents both liver triglyceride accumulation and the overshoot of lipogenic enzymes.

Relationships between spontaneous food intake and metabolic activities in the dormouse (Glis glis L.)

1. The relationships between food intake self-selection and liver substrates (glycogen, fat) or activities of pyruvate kinase, glucose-6-phosphate dehydrogenase, malic enzyme, acetyl CoA carboxylase, glucose-6-phosphatase and phosphoenolpyruvate carboxykinase were determined during the spontaneous variations of body weight in the dormouse. 2. The results show that during the phase of increasing body weight, carbohydrate intake and enzyme activities involved in lipogenesis are on a high level. 3. On the last part of the body weight increasing phase, when lipid intake occurs, lipogenesis is depressed and a gluconeogenetic activity is set on, while total caloric intake is important and body weight is still increasing. 4. These metabolic changes are interpreted as a preparation to hibernating conditions in the dormouse.

[Seasonal fluctuations of food intake and bodyweight in the dormouse Glis glis (author's transl)]

Cycles of body weight lasting a few weeks occurred in dormice fed ad libitum, throughout the year with the same food. The pattern of the fluctuations suggests an oscillation between an upper and a lower limit. When the lower limit is reached, compensatory mechanisms acting on the food intake are induced which cause an increase in body weight to the upper one; when this upper limit is reached, other mechanisms cause the body weight to decrease to the lower one. Thus, body weight and variations in food intake may well be controlled by the difference between the body weight and the limit it will reach. In a warm environment (23-25 degrees C) these fluctuations are smaller than in the cold (5-6 degrees C). They are also smaller during summer than during winter in animals placed in natural climatic conditions. In summer, the body weight stays near the upper limit; in this season, as in the warm environment, the lower limit approaches the upper one. Thus, the main circannual variation of body weight regulation in dormice may be the elevation during summer of the lower body weight limit.

[Effects of glucose, aminoacid or lipid infusion on dietary self-selection in the rat]

Rats with an intracardiac chronic catheter were offered dietary self-selection between glucids, proteins and lipids intakes. They are infused continuously with 0.9% NaCl except on the test day with glucose, amino acids or lipids. Parenteral load is about 25% of the daily total food intake. With glucose infusion a selective decrease in glucids intake is observed of about 80% of the caloric glucose load. Aminoacidemic and lipidic infusions lead not only to decrease respectively in proteins and lipids intakes, but also in glucids intakes. So, in this case, total caloric intake decreased more than caloric load. Results are discussed in the hypothesis of existence of a hepatic chemosensibility.