Increased risk of alteration of nutritional status in hospitalized elderly patients with advanced cancer

Malnutrition is common in patients with advanced cancer and is associated with worse prognosis. The aim of this study was to follow-up the nutritional status of elderly patients with advanced cancer in comparison with that of younger ones, in the course of hospitalization. Eighty-eight (44 males and 44 females) patients with advanced cancer entered the study. Two groups were defined according to age : superior 70 y (n = 45) and < 70 y (n = 43). Nutritional status by means of anthropometric variables and daily intake were assessed on Day 0, Day 30 and Day 60. A blood sample was collected on Day 0 for determination of serum proteins. The two groups of patients did not differ in terms of anthropometry and biological variables on admission to our department ; only bicipital skinfold thickness and energy intake were lower in the elderly patients. After one month hospitalization, tricipital skinfold thickness and fat mass decreased in these patients. After two months, mid-arm circumference also decreased. Unlike the older group, the younger patients increased their daily energy and protein intakes. During hospitalization, older persons with advanced cancer cannot improve their energy intake and therefore, are at particular risk of aggravating their nutritional status.

Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters

BACKGROUND & AIMS

We have estimated the prevalence of severe malnutrition in groups of patients hospitalized for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition.

DESIGN

A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged < or = 74 or the 10th percentile when aged > or = 75 were defined as severely malnourished. Sensitivity of BMI < 20 to detect malnutrition was assessed.

RESULTS

The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P < 10(-4)). In multivariate analysis, low TST was associated with female gender (P < 10(-4)) mild and tense ascites (P = 0.038, P = 0.0004), low MAMC with male gender (P < 10(-4)), low BMI with female gender (P = 0.0082), hip fracture (P = 0.0407) and cancer (P = 0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r = 0.821, P = 0.0066).

CONCLUSION

Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI < 20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients.

Serum leptin levels in alcoholic liver cirrhosis: relationship with gender, nutritional status, liver function and energy metabolism

OBJECTIVE

To determine serum leptin levels in alcoholic liver cirrhosis and the relationship with gender, nutritional status, liver function, energy metabolism, inflammatory state and refeeding.

SUBJECTS

Thirty-seven hospitalized alcoholic cirrhotic patients (M/F: 24/13), 27 hospitalized patients at risk of malnutrition but with normal liver function (M/F: 15/12) as control patients, and 31 healthy control subjects (M/F: 17/14) participated.

DESIGN

Liver function was assessed from Child-Pugh classification; anthropometric parameters and resting energy expenditure (REE) were measured; caloric intake was evaluated over 5 days; and serum leptin and insulin were assayed. The same protocol was performed after 1 month refeeding in 22 patients. Healthy subjects were studied as controls for anthropometric parameters and serum leptin levels.

RESULTS

Serum leptin levels were higher in male cirrhotic patients than in the other two male groups (P=0.0079) and in the same range in the female groups. They were higher in female than in male subjects in the three groups. In female cirrhotic patients, logarithmically transformed serum leptin levels correlated significantly with fat mass (P=0.0043), insulin levels (P=0.0072), REE (P=0.0133), bilirubin levels (P<0.0001), prothrombin time (P=0.0003) and Pugh score (P=0.0266) in simple regression analysis and with insulin levels (P=0.0137), but not with fat mass (P=0.0761), Pugh score (P=0.4472) and REE (P=0.4576) in multiple regression analysis. In the male cirrhotic and control patients, log (leptin) levels correlated with CRP (C reactive protein) (r=0.365, P=0.0223). Log (leptin) levels did not correlate with caloric intake in any of the groups. Leptin levels (P<0.05) and fat mass (P<0.02) increased with refeeding while liver function improved (P<0.01).

CONCLUSION

There is a gender difference in regulation of serum leptin level in alcoholic liver cirrhosis. Insulin level is the best determinant of leptin level in female patients while inflammatory state related to alcoholic hepatitis seems to have a greater influence in male patients. Although leptin levels positively correlated with REE in female patients, there is no evidence that leptin reduces caloric intake and fat stores in these patients.

[Nutritional status assessment in 57 hospitalized aged patients: impact of the causal disease]

PURPOSE

To study the nutritional status in elderly patients hospitalized for rehabilitation and to compare it among patients with hip fracture and those with medical care.

METHODS

Patients were nutritionally assessed upon admission (d0) to our unit by measurement of anthropometric, biological parameters and dietary intake. Thirty-seven patients were operated for hip fracture (group I) and 21 were hospitalised for medical disease (group II). Nutritional status was compared in the two groups on d0 and was evaluated after one month (d30) in the operated group.

RESULTS

No significant difference could be observed for any anthropometric or biologic (albumin, transthyretin and transferrin) in the two groups. Daily food intake related to body weight was much the same in both groups (31 kcal/kg). C-reactive protein and orosomucoid levels were above the reference range in both groups. Hip fracture operated patients had higher orosomucoid than non-operated ones (1.50 +/- 0.4 versus 1.14 +/- 0.4 g/L; P = 0.002). One-month follow-up of nutritional status performed in 31 operated patients showed a significant decrease in TST and MAC (respectively p = 0.02 and p = 0.007) and in orosomucoid (p = 0.003) although daily food intake increased.

CONCLUSION

Twenty-eight percent of patients were undernourished upon admission in the unit. A moderate inflammatory state still remained in all our patients, particularly in those who had undergone surgery. This inflammatory state persisted two months after surgery.

Serum levels of insulin-like growth factor-1 in the three months following surgery for a hip fracture in elderly: relationship with nutritional status and inflammatory reaction

BACKGROUND AND AIMS

Serum IGF-1 level declines with advancing age and is a reliable index of protein-energy undernutrition in elderly patients in a metabolically stable condition. We have examined the value of IGF-1 as an indicator of malnutrition in elderly patients during recovery within 1 month after surgery for a hip fracture and we have studied the relationship between changes in IGF-1 levels, nutritional status and inflammatory reaction during 2 month follow up.

STUDY DESIGN

Forty elderly patients (mean age 84.0+/-1.9) were nutritionally assessed upon admission to our rehabilitation unit (D0) then monthly (D30-D60) by measurement of anthropometric and biological parameters. Two groups of patients were defined on the basis of mid-arm circumference (MAC) and tricipital skinfold thickness (TST) measurement at D0: group 1, undernourished (n=13) and group 2, normally nourished (n=27). Changes in anthropometric and biological parameters during the study were compared between these two groups of patients.

RESULTS

IGF-1 level was significantly lower in group 1 (79.5+/-9.1 vs 108+/-8.6 ng/ml, P<0.05) while usual serum protein levels were in the same range in the two groups. Orosomucoid level significantly decreased during 2 month follow-up in group 2 (P<0.01), CRP level decreased but not significantly. TST and MAC decreased in group 2 (respectively P<0.02 and P<0.05) while anthropometric parameters tended to slightly increase in group 1 in relation with an increase in caloric intake (P<0.05). IGF-1 level increased significantly during the study in group 2 (P<0.05) and was significantly lower in patients with complications occurring between D0 and D30 in comparison with patients without complications (respectively P<0.05 at D0, P<0.02 at D30). IGF-1 level correlated with body mass index, MAC, TST, muscle midarm circumference, albumin and transthyretin levels. Changes in IGF-1 levels positively correlated with those in transthyretin levels and negatively with those in orosomucoid levels.

CONCLUSION

IGF-1 level seems a reliable index of protein-energy under-nutrition in elderly patients in the recovery period after surgery for a hip fracture. This marker is influenced by the inflammatory reaction. Decline of inflammatory reaction, rather than change in nutritional status, is responsible for the variation in IGF-1 level during a 2 month follow-up.

Effects of lipopolysaccharide on TNF-alpha production, hepatic NOS2 activity, and hepatic toxicity in rats with cirrhosis

BACKGROUND/AIMS

Septic shock results in high mortality in patients with cirrhosis. Nitric oxide synthase 2 (NOS2) is induced by bacterial lipopolysaccharides (LPS) and plays a major role in the inflammatory response to bacterial infections. Little is known about the regulation of NOS2 in cirrhosis under septic conditions. Thus, the aim of this study was to determine tissue NOS2 activity, serum nitrate and tumor necrosis factor (TNF-alpha) levels and hepatic toxicity in cirrhotic rats after LPS administration.

METHODS

Serum nitrates, TNF-alpha and transaminases were determined after LPS-administration in rats with secondary biliary cirrhosis and in sham-operated rats. Liver, lung, aortic and peritoneal macrophage NOS2 activities were determined by converting L[14C] arginine into L[14C] citrulline in a calcium free medium. Nitrate and TNF-alpha production were determined in a culture medium of peritoneal macrophages after in vivo LPS administration.

RESULTS

LPS (1.5 mg/kg) induced 50% mortality in cirrhotic rats and no mortality in sham-operated rats. After LPS, TNF-alpha, nitrate and transaminase levels were significantly higher in cirrhotic rats compared to sham-operated rats. After LPS administration, there were no differences in NOS2 activity in the aorta, lungs, or peritoneal macrophages of the two groups, whereas NOS2 activity was significantly higher in the cirrhotic liver compared to the normal liver.

CONCLUSIONS

In rats with cirrhosis, LPS administration induces higher mortality, hepatic toxicity, hepatic NOS2 activation and TNF-alpha release than in sham-operated rats. These results confirm the harmful role of septic shock in liver disease.

Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up

A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.

Up-regulation of nitric oxide production by interferon-gamma in cultured peritoneal macrophages from patients with cirrhosis

We previously described a long-lasting overproduction of nitric oxide (NO) in cirrhotic patients with spontaneous bacterial peritonitis. The aim of the present study was to investigate the presence of the inducible NO pathway in peritoneal macrophages. Ascitic fluids were collected from 29 patients with cirrhosis, aged between 35 and 82 years. Peritoneal macrophages were isolated and cultured in the presence or absence of 1 microg/ml lipopolysaccharide and/or 500 units/ml interferon-gamma (IFN-gamma) for 6 days. NO production was measured as nitrate+nitrite (NO(x)), inducible NO synthase (iNOS) protein expression was analysed by immunocytochemistry and Western blot analysis using a specific anti-(human iNOS) antibody, and the catalytic activity of NOS was revealed by cytochemical staining for NADPH-dependent diaphorase. Cultured macrophages spontaneously released small amounts of NO(x) [median (10-90th percentile) of 18 separate experiments: 3.3 (0-8) micromol/l]. Addition of lipopolysaccharide alone or in combination with IFN-gamma to the culture medium did not change the levels of NO(x), while IFN-gamma alone dramatically increased NO production [13.4 (3.5-28.3) micromol/l; P<0.001]. Macrophages were stimulated by IFN-gamma to a greater extent in patients with recent spontaneous bacterial peritonitis (n=13) than in those in a stable clinical condition (n=18) [19.8 (10.5-30.1) and 10.0 (3.2-14.5) micromol/l respectively; P<0.001]. Macrophages freshly isolated or stimulated with IFN-gamma expressed iNOS protein, as shown by Western blot and immunocytochemical analysis, and stained for NADPH diaphorase. Our findings demonstrate the presence of iNOS protein in peritoneal macrophages from cirrhotic patients. The role of IFN-gamma appears to be a determinant for the up-regulation of NO production, particularly under conditions of infection. Therefore peritoneal macrophages producing large amounts of NO at the site of infection may contribute to maintaining splanchnic vasodilation in these patients.

Intestinal permeability in liver cirrhosis: relationship with severe septic complications

OBJECTIVES

Patients with liver cirrhosis are at high risk of severe septic complications such as spontaneous bacterial peritonitis (SBP) and bacteraemia. The aims of this study were to assess intestinal permeability in patients with liver cirrhosis and to search for a relationship between an impaired intestinal permeability and the occurrence of severe septic complications.

METHODS

Intestinal permeability was assessed in a group of 80 cirrhotic patients (Child A, n = 13; Child B, n = 26; Child C, n = 41) and 28 healthy control subjects. A severe septic complication (bacteraemia and/or SBP) occurred in 16 patients, within 10 days before (n = 8 cases) or after (n = 8 cases) the test was performed. Lactulose (LAC) 10 g was given orally together with mannitol (MAN) 5 g, and urinary excretion rates were determined.

RESULTS

Urinary mannitol excretion (MAN%) was lower while the LAC/MAN ratio was higher in patients than in control subjects (P < 0.001); these abnormalities were more marked in Child C patients (Child C patients vs control subjects: MAN%, 8.20 +/- 0.79 vs 14.59 +/- 0.58, P < 0.001; LAC/MAN, 0.066 +/- 0.026 vs 0.017 +/- 0.001, P < 0.02). When compared with non-infected patients, septic patients had a lower MAN% and an increased LAC/ MAN ratio (5.45 +/- 1.12 vs 9.83 +/- 0.87, P < 0.02; 0.130 +/- 0.063 vs 0.029 +/- 0.005, P < 0.02).

CONCLUSION

Although the main mechanism involved in the decrease in MAN% is likely a reduction in area of the intestinal absorptive surface, these results argue in favour of an increased intestinal permeability in liver cirrhosis, especially in patients with severe infectious complications. The impairment of intestinal function barrier may contribute to severe septic complications in these patients.

Vascular nitric oxide production during the development of two experimental models of portal hypertension

BACKGROUND/AIMS

The aim of this study was to determine the relative roles of constitutive NOS (NOS3) and inducible NOS (NOS2) isoforms during the development of two models of portal hypertension in rats.

METHODS

Vascular reactivity of aortic rings for norepinephrine was performed in control, sham-operated, portal-vein-stenosed and secondary biliary cirrhotic rats 1, 4, 7, 14 and 28 days after surgery. NOS activity and nitrate plasma levels were also measured.

RESULTS

An impaired response to norepinephrine observed in sham-operated, portal-vein-stenosed and cirrhotic rats at days 1 and 4 compared with controls was reversed after L-NNA and aminoguanidine. Portal hypertensive rats remained hyporeactive at days 7, 14 and 28 compared with sham-operated rats. At days 7 and 14 in portal-vein-stenosed rats, vascular hyporeactivity was reversed by L-NNA and W7. At days 14 and 28 in cirrhotic rats, vascular hyporeactivity was reversed by L-NNA and W7. Nitrate levels increased at day 1 in the 3 groups, and increased at days 14 and 28 in portal hypertensive rats. Total NOS-activity increased in cirrhotic rats at day 28, in portal-vein-stenosed rats at day 14, and in sham-operated rats at day 1 compared to controls. NOS2 activity increased only in sham-operated rats at day 1.

CONCLUSIONS

This study shows that for two models of portal hypertension, increased NO production in the first days is related to NOS2 induction secondary to surgery. On the other hand, when portal hypertension has fully developed, the NOS3 isoform appears to play the major role.

Analysis of nitrite and nitrate in biological fluids by capillary electrophoresis

OBJECTIVES

We report a method for determining nitrite and nitrate in biological fluids by capillary electrophoresis.

METHODS

A Waters capillary electrophoresis system was used with a filter for detection at 214 nm. After dilution with distilled water, the sample was loaded hydrostatically onto a 60 cm x 100 microm capillary and electrophoresed at 15 kV in 15 mmol/L sulfate buffer, pH 8.0, containing 2.5% electroosmotic flow modifier.

RESULTS

The retention times for nitrite and nitrate were 3.9 +/- 0.8 and 4.0 +/- 0.8 min, respectively. The detection limit was 10 micromol/L for serum nitrate. The recovery was 93-115% for nitrite and 92-106% for nitrate. The within-day and between-day coefficients of variation were lower than 3.3% and 5.0%, respectively, for two pools with normal (28 micromol/L) and high (87 micromol/L) nitrate concentration. A comparison with the nitrate reductase method gave a correlation coefficient of 0.982.

CONCLUSION

Capillary electrophoresis provides many advantages, namely low cost, small sample and buffer requirements, rapidity, which makes its use particularly suitable for clinical laboratories.

Lack of a nitric-oxide response during the course of Leishmania infantum infection in the golden hamster (Mesocricetus auratus), with or without treatment with liposomal amphotericin B

Liver and spleen volumes and serum concentrations of nitrate (the end-product of NO in vivo), albumin, gamma-globulin, protein, creatine and urea were measured during the course of progressive infections with Leishmania infantum MON-1 (MHOM/PR/93/CRE29) in 10 Syrian golden hamsters. Each hamster was infected by intraperitoneal injection with 4 x 10(7) promastigotes. Five of the infected animals were treated, with 6 mg liposomal amphotericin B (L-AmB)/kg given by intracardiac injection, on day 107 post-infection (p.i.). Compared with those in the uninfected hamsters used as controls, the liver volumes in the infected animals became significantly enlarged by day 40 p.i. (38% larger than the controls; P < 0.001) whereas significant enlargement of the spleen was first detected on day 72. Each infected animal had detectable serum levels of antileishmanial antibodies on day 72. There were significant elevations in gamma-globulin concentration as early as day 40 (P < 0.05) but significant falls in albumin concentrations were only detected from day 107 (P < 0.001). Nitrate, creatinine and urea concentrations remained unchanged during the course of infection, even after L-AmB treatment. Serum nitrate levels were not enhanced by L. infantum infection nor by the L-AmB treatment which induced a 98.2% decrease in parasite burden. The lack of NO production in visceral leishmaniasis, with or without L-AmB treatment, points to the unresponsiveness of inducible nitric oxide synthase in this rodent model.

Serum and tissue nitrate levels in murine visceral leishmaniasis correlate with parasite load but not with host protection

Nitrate levels were measured in serum and in organs from Lshs BALB/c and Lshr C3H/HeN mice during the acute phase (30 d) of infection by Leishmania donovani strain LV9. Serum nitrate levels increased rapidly in BALB/c mice from a baseline level (17 +/- 4 mumol/L) to a plateau (504 +/- 129 mumol/L) at 24 d and correlated with parasite loads in the liver (r = 0.817, P < 0.01) and in the spleen (r = 0.854, P < 0.001). Liver and spleen nitrate contents were enhanced 2.7-fold and 22.8-fold, respectively, with respect to uninfected controls (2692 +/- 249 vs. 992 +/- 231 nmol, P < 0.02 and 20 +/- 1 vs. 456 +/- 43 nmol, P < 0.02). In contrast, serum nitrate increased to a lesser extent in C3H/HeN mice, from 31 +/- 5 mumol/L to 86 +/- 5 mumol/L at 20 d. Liver nitrate content did not differ significantly between infected and control mice (1093 +/- 83 vs. 867 +/- 104 nmol), whereas the former had a higher spleen nitrate content (145 +/- 22 vs. 40 +/- 2 nmol, P < 0.02). Our findings indicate that production of NO by the susceptible BALB/c strain exceeded that of the resistant C3H/HeN strain during the acute stage of infection by L. donovani. Tissue NO overproduction in organs infected by L. donovani was related to the progression of parasitic disease and contributed to high nitrate serum levels. It would be very interesting to extend this investigation to human disease with the aim of evaluating serum nitrate as a marker of parasite load in the follow-up of patients suffering from visceral leishmaniasis.

Influence of liver failure, ascites, and energy expenditure on the response to oral nutrition in alcoholic liver cirrhosis

The influence of liver failure, ascites, and energy expenditure on the response to oral nutrition was assessed in a group of 55 alcoholic cirrhotic patients. Caloric intake, nutritional status, resting energy expenditure (REE), and Child-Pugh score were evaluated before and after 1 mo of oral nutrition. Patients were severely malnourished, 73% had muscular midarm circumference (MMAC) below the 5th percentile of a reference population, 51% had triceps skinfold thickness below the 25th percentile. Eleven patients were in class A of Child, 19 in class B, and 25 in class C. Twenty-six patients were nonascitic, whereas ascites was resolved in 10 ascitic patients by the end of the study and 19 patients had refractory ascites. Liver damage was more pronounced and did not improve during the study in patients with refractory ascites. Caloric intake was approximately 40 kcal/kg of body weight and was in the same range in the three groups according to Child classification. Fat mass (FM) increased, respectively, from 17.4% +/- 1.7% to 19.5% +/- 1.4%, P < 0.01, in Child A patients; from 17.1% +/- 1.4% to 19.3% +/- 1.4%, P < 0.001, in Child B patients; and from 17.6% +/- 1.5% to 18.8% +/- 1.5%, P < 0.05, in Child C patients. The increase in FM was comparable in the three groups, whereas MMAC and the creatinine/height ratio did not change significantly. FM was lower and did not increase in patients with refractory ascites. Child C patients were characterized by an increase in the rate of glucose oxidation (P < 0.02) and a decrease in the rate of lipid oxidation (P < 0.05). High-density lipoprotein cholesterol and apolipoprotein (Apo) A1 were reliable indices of improvement of liver function in patients with severe liver failure, ApoA1 was also a marker of improvement of metabolic impairment. With respect to the measured REE/predicted REE ratio calculated according to Harris-Benedict equation (r), 19 patients were considered hypermetabolic (r < 1.1), 30 normometabolic (0.9 < r < 1.1), and 6 hypometabolic (r < 0.9). An increase in FM correlated with r (P < 0.01) and was more marked in hypermetabolic patients. In contrast to the other two groups, Child-Pugh score and nutritional status remained unchanged in the hypometabolic patients. These results show that severe liver failure did not preclude improvement of nutritional status provided caloric intake was high. In Child C patients, improvement of nutritional status paralleled improvement of liver function and normalization of oxidative metabolism. Refractory ascites had negative effects on changes in nutritional status and liver function. Despite adequate caloric intake to energy requirements, hypometabolism has a poor prognosis regarding both nutritional status and liver function.

Long-lasting NO overproduction in cirrhotic patients with spontaneous bacterial peritonitis

Nitric oxide production was studied in cirrhotic patients with spontaneous bacterial peritonitis (SBP) or with other infections. We followed up on the time course of serum nitrate levels in 51 hospitalized patients aged between 34 and 81 years. Four groups were defined: patients with SBP (group 1, n = 14), patients with bacteremia (group 2, n = 11), patients with urinary tract infection (group 3, n = 11) and patients in a stable clinical condition (group 4, n = 20). The four groups did not differ in terms of Pugh score (11 +/- 1, 10 +/- 1, 11 +/- 1, and 10 +/- 1, respectively). Serum nitrate levels averaged 31 +/- 2 micromol/L in group 4 (84 samples). On the day results of cytobacteriological examination were positive, mean serum nitrate levels were 75 +/- 17, 63 +/- 9, and 36 +/- 9 micromol/L, respectively, in groups 1 (17 cases), 2 (11 cases), and 3 (11 cases) (P < .001). The maximum nitrate values recorded during follow-up were higher in groups 1 (149 +/- 15 micromol/L) and 2 (112 +/- 11 micromol/L) than in group 3 (66 +/- 7 micromol/L; P < .001 and < .01, respectively). These maximum values were recorded in all groups approximately 2 weeks after the infection was diagnosed. The mean duration of NO overproduction, as defined by nitrate level (3)90 micromol/L, was 15 +/- 3 days in group 1 and 5 +/- 1 day in group 2. When the nitrate concentration was studied in serum and ascitic fluid sampled on the same day, it was found to be higher in ascitic fluid than in serum in eight cases of SBP in the period preceding the peak serum nitrate concentration (100 +/- 17 vs. 63 +/- 14 micromol/L; P < .001). Our data indicate that SBP in cirrhotic patients led to a long-lasting increased local production of NO. This overproduction may contribute to maintaining splanchnic vasodilation and thus worsen the hyperkinetic state in these patients.

Markers of oxidative stress in fit, health-conscious elderly people living in the Paris area. The Research Group on Ageing (GERBAP)

Lipid peroxidation index and antioxidant indicators were assessed by biochemical means in 193 healthy elderly volunteers (103 men and 90 women), ages 70-89 y and living freely in the Paris area. Lipid peroxidation index was in the same range as in young adults. Zinc, copper, and selenium levels were satisfactory and similar to those in young adults, though the range of copper values tended to be higher. Copper and selenium levels were higher in elderly women than in men. However, for selenium values this sex-related difference disappeared in elderly volunteers > 75 y. Copper-zinc-superoxide dismutase and glutathione peroxidase activities were similar to those in young adults, with no influence of sex or age. Vitamin E and total carotene, closely related to cholesterol levels, were satisfactory. Our findings show that markers of oxidative stress are not influenced by old age when good health and nutritional status are preserved, as in this selected population.

Serum and urinary nitrate levels in liver cirrhosis: endotoxemia, renal function and hyperdynamic circulation

BACKGROUND/AIMS

The relationship between nitric oxide production, endotoxemia, renal function and hyperdynamic circulatory syndrome has not been yet investigated in patients with cirrhosis.

METHODS

Serum and urine nitrate, endotoxemia and cardiac index were measured in 59 patients with cirrhosis.

RESULTS

Patients with a tense ascites had higher serum nitrate levels than healthy control subjects (39 +/- 7 vs 19 +/- 4 mumol/l, p < 0.01). Patients with mild ascites and without ascites had normal values of nitrate levels. In the group of patients not treated with diuretics (n = 38), creatinine and nitrate clearances were lower in ascitic patients than in nonascitic patients (respectively 0.82 +/- 0.12 vs 1.48 +/- 0.32 ml/s, p < 0.02 and 0.30 +/- 0.07 vs 2.89 +/- 2.04 ml/s, p < 0.05). Endotoxin levels were higher in patients with cirrhosis than in control subjects and paralleled the severity of liver failure (Child A/B/C vs control subjects: 0.056 +/- 0.014/0.064 +/- 0.005/ 0.090 +/- 0.008 vs 0.027 +/- 0.005 Endotoxin Units/ml, p < 0.001). Serum nitrate levels did not correlate with endotoxemia (r = -0.110). On the other hand, levels of orosomucoid, a protein synthesized by the liver in response to a stimulation by cytokines correlated with those of nitrate (respectively r = 0.343, p < 0.01). Hemoglobin levels were negatively correlated with serum nitrate levels (r = -0.328 p < 0.02). Cardiac index was higher in patients than in control subjects and paralleled the degree of liver failure (Child A/B/C vs control subjects: 3.60 +/- 0.25/ 4.10 +/- 0.19/4.47 +/- 0.25 vs 3.15 +/- 0.12 l.min.m2, p < 0.001). Cardiac index did not correlate with serum nitrate levels, urine nitrate excretion and endotoxemia.

CONCLUSIONS

Renal impairment accounts for the increased levels of serum nitrate in ascitic patients. A stimulation of nitric oxide production by cytokines may occur but endotoxemia is not involved in such a mechanism. Anemia has a role in nitric oxide activity. Nitric oxide generation assessed by nitrate in serum and urine does not seem to participate in the hyperdynamic circulatory syndrome in patients with cirrhosis.

Enzyme electrophoresis combined with serogrouping for improved differentiation of Clostridium difficile strains

We used enzyme electrophoresis to study a set of epidemiologically related and unrelated isolates of Clostridium difficile. The 53 strains belonged to the most frequent serogroups (A1, C, G, H and K). Nine electrophoretic profiles were defined on the basis of five enzymes, and two were characteristic of a single strain. Each serogroup was resolved into two or three different enzyme patterns. By combining the two methods we were able to resolve the strains into 12 types. There was an excellent correlation between enzyme electrophoresis and serogrouping data. This method may be of use in investigating nosocomial transmission.

Increased serum nitrate concentration in cardiac transplant patients. A marker for acute allograft cellular rejection

The purpose of the present study was to investigate whether nitrate serum level, reflecting total body production of nitric oxide in vivo, could serve as a noninvasive marker for acute human cardiac rejection. Serum nitrate concentration was determined by an enzymatic method. During routine right ventricular endomyocardial biopsies in 59 recipients, 145 tissue samples were obtained. Two groups of biopsy specimen were considered on the basis of posttransplant delay: group 1, < or = 90 days (n=47; 12-90 days); and group 2, >90 days (n=98; 3-81 months). All patients had normal ventricular systolic function on the day of biopsy and none had evidence of infection. Rejection grade correlated closely with serum nitrate concentration (P<0.001). In both groups, nitrate serum concentrations differed significantly (P<0.001) among cases without rejection, those with mild ongoing rejection (grade 1A/1B), and those with focal or diffuse aggressive infiltrates (grade 2 or higher). A cutoff value of 20 micromol/L, was determined that was positively predictive for grade 2 or higher rejection in 62% cases of early episodes of rejection and in 68% cases of late rejection. Conversely, a serum nitrate level below 20 micromol/L was negatively predictive in 97% and 94% of early and late cases, respectively. We conclude that the acute rejection process of the human transplanted heart is accompanied by a significant increase in serum nitrate level, reflecting increased nitric oxide production during the immune response. Because of its high negative predictive value, irrespective of the posttransplantation delay, nitrate serum determination may have clinical utility in the noninvasive monitoring of the cardiac transplant patient and could also add important information to endomyocardial biopsy analysis for treatment decision making.

Nitrate determination in biological fluids by an enzymatic one-step assay with nitrate reductase

We report a simple, enzymatic, end point method for determining nitrate in serum and urine with use of nitrate reductase from Aspergillus sp. (EC 1.6.6.2). The decrease in absorbance at 340 nm as a result of the oxidation of beta-NADPH is measured. We used FAD as a supplementary electron carrier and added an internal standard to avoid interference from possible inhibitors of the enzymatic reaction. The method was linear from 5 to 200 mumol/L nitrate in serum. Within-run (n = 12) and total (n = 14 days) imprecisions (CV) were 5.1-7.7% and 6.2-9.8%, respectively, at 20-90 mumol/L nitrate in serum. Recoveries of added nitrate were 80-106%. The median (range) concentration in serum of 20 healthy subjects was 16 (0-42) mumol/L.

Short-term changes in energy metabolism after 1 month of a regular oral diet in severely malnourished cirrhotic patients

Malnutrition in patients with liver cirrhosis is currently associated with abnormal fuel metabolism. The aim of this study was to evaluate changes in energy production and substrate oxidation rates in a group of 26 nonanorectic severely malnourished cirrhotic patients in stable clinical condition after 1 month of an oral diet. Child-Pugh score, nutritional status, energy expenditure, rates of nutrient oxidation, and plasma levels of intermediary metabolites in the postabsorptive phase were assessed before and after 1 month of oral nutrition. Upon entry onto the study, caloric and protein intakes were 40.1 +/- 2.0 kcal/kg and 1.44 +/- 0.8 g/kg, respectively. The Child-Pugh score did not change during the study, whereas nutritional status improved as shown by increased muscular midarm circumference, ([MMAC] P < .02), height-creatinine index (P < .05), triceps skinfold thickness ([TST] P < .01), and fat mass (P < .001). Inflammatory state improved during the study, as shown by the decrease of C-reactive protein ([CRP] P < .01) and orosomucoid (P < .001). The ratio of caloric intake to resting energy expenditure (REE) increased (1.53 +/- 0.06 v 1.66 +/- 0.07, P < .05), as well as the rate of glucose oxidation ([Gox] 73.6 +/- 9.9 v 128.1 +/- 10.3 mg/min, P < .001) and urine nitrogen excretion (6.69 +/- 0.47 v 7.96 +/- 0.48 g/d, P < .02). On the other hand, the rate of lipid oxidation (Lox) decreased (67.3 +/- 3.9 v 47.3 +/- 4.9 mg/min, P < .001) and was correlated with the decrease of free fatty acid (FFA) levels (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrate determination in biological fluids by an enzymatic one-step assay with nitrate reductase

We report a simple, enzymatic, end point method for determining nitrate in serum and urine with use of nitrate reductase from Aspergillus sp. (EC 1.6.6.2). The decrease in absorbance at 340 nm as a result of the oxidation of beta-NADPH is measured. We used FAD as a supplementary electron carrier and added an internal standard to avoid interference from possible inhibitors of the enzymatic reaction. The method was linear from 5 to 200 mumol/L nitrate in serum. Within-run (n = 12) and total (n = 14 days) imprecisions (CV) were 5.1-7.7% and 6.2-9.8%, respectively, at 20-90 mumol/L nitrate in serum. Recoveries of added nitrate were 80-106%. The median (range) concentration in serum of 20 healthy subjects was 16 (0-42) mumol/L.

Extensive laboratory assessment of nutritional status in fit, health-conscious, elderly people living in the Paris area. Research Group on Aging

OBJECTIVE

Nutritional status-related biological indexes were measured in fit, health-conscious elderly subjects in order to establish reference values for people over 70 years.

SUBJECTS

103 men and 90 women aged 70-89 years living freely in the Paris area volunteered to participate.

METHODS

Nutritional status was assessed by anthropometric and biochemical methods.

RESULTS

Serum protein and amino acid status was similar to that of young adults, with only 5.2% of the elderly subjects showing transthyretin concentrations < 0.20 g/L, as well as decreased essential amino acid levels. Iron status, assessed in terms of serum and erythrocyte ferritin levels, total iron binding capacity and erythrocyte protoporphyrin tended to be satisfactory, but iron depletion was detected in 8.8% of the subjects. Serum ferritin levels were elevated in 19.7% of the subjects. Folate and vitamin B12 status was satisfactory, while hypovitaminosis D was observed in 48.2% of cases.

CONCLUSION

Our findings suggest that, in aging uncomplicated by disease, nutritional status is similar to that in younger adults, although the range of values tended to be wider, with a higher risk of certain nutrient deficiencies.

One-month regular oral nutrition in alcoholic cirrhotic patients. Changes of nutritional status, hepatic function and serum lipid pattern

The effect of a regular oral diet supplying 167 kJ/kg per d (40 kcal/kg per d) on nutritional state, liver function and serum lipid profile was assessed in thirty severely malnourished alcoholic cirrhotic inpatients. Their diet was monitored by a trained dietitian and they were vigorously encouraged to eat all meals served. One month after their entry into the study, protein and energy intakes were significantly higher (P < 0.001) in keeping with an improvement of their nutritional status as evaluated by means of height-creatinine index, muscular mid-arm circumference, tricipital skinfold thickness (P < 0.01 for all) and fat mass (P < 0.001). Assessment of liver function tests showed that levels of aspartate aminotransferase (EC 2.6.1.1), gamma-glutamyl transferase (EC 2.3.2.2) and bilirubin decreased (P < 0.05, P < 0.02 and P < 0.05 respectively) while prothrombin time values increased (P < 0.05). Similarly, serum albumin increased modestly while transthyretin did not change. Orosomucoid and C-reactive protein decreased (P < 0.001 and P < 0.01 respectively), indicating an improvement of the inflammatory state. Apolipoprotein A1 and high-density-lipoprotein (HDL)-cholesterol correlated with several tests of liver function and improved significantly during the study period (P < 0.001 and P < 0.02 respectively). Moreover, changes in cholesterol and HDL-cholesterol correlated with those in transthyretin (P < 0.02 and P < 0.05 respectively). The changes in ApoA1 and HDL-cholesterol were greater in patients whose fat mass increased significantly. Our findings show that adequate oral nutrition resulted in a better nutritional status in cirrhotics after 1 month of hospitalization. The serum lipid variables appeared to be more useful indicators of functional liver improvement than the classic liver function tests which rather indicate liver damage.

Nutritional and metabolic consequences of basal hyperinsulinemia in alcoholic liver cirrhosis: relationship with postprandial changes in erythrocyte insulin-receptor affinity

The nutritional and metabolic consequences of basal hyperinsulinemia were investigated in a group of 13 alcoholic cirrhotic patients; 7 healthy subjects were studied as a control group. Two groups of patients were defined on the basis of fasting insulin level: group 1 (n = 7) displayed acute hyperinsulinemia (> mean of control group + 2SD), and group 2 (n = 6) had lower insulin levels. Nutrition status was assessed by means of anthropometric parameters; the rates of nutrient oxidation were measured after an overnight fast and 2 h after a standard meal intake. Group 1 had better nutrition status in terms of fat mass than group 2 (p < 0.05). Although the basal rates of nutrient oxidation were in the same range in the three groups, postprandially, the rate of lipid oxidation was significantly different (p < 0.01). Moreover, group 1 showed greater inhibition of postprandial lipid oxidation than the control group (p < 0.05), whereas there was no difference between group 2 and the control group. In the postprandial phase, erythrocyte insulin-receptor binding and affinity increased paradoxically in group 1, whereas they decreased in group 2 and healthy subjects (changes in binding, p < 0.025; changes in affinity, p < 0.01). In conclusion, basal hyperinsulinemia in alcoholic liver cirrhosis is related to more marked inhibition of postprandial lipid oxidation and better-preserved nutrition status and may lead to a paradoxical postprandial increase in insulin-receptor affinity.

Postprandial de novo lipogenesis in alcoholic liver cirrhosis: relationship with fuel homeostasis and nutritional status

The prevalence and nutritional consequences of postprandial de novo lipogenesis were evaluated in 24 stable alcoholic cirrhotic patients. Energy expenditure and the rates of nutrient oxidation were assessed by indirect calorimetry after an overnight fast and 2 h after a standard meal supplying 15 kcal/kg (63 kJ/kg) of body weight. Postprandially, net lipogenesis occurred in 16 patients (group L+) as shown by a respiratory quotient clearly above 1.00 (P < 0.01). The rate of lipid oxidation remained positive in 8 patients (group L-). The main mechanism involved in this metabolic pathway appeared to be a sharp postprandial hyperinsulinaemia. When compared to group L+, patient group L- showed an impaired thermic effect of food (P < 0.05), a lower rate of glucose oxidation (P < 0.05) and a mild hyperketonaemia (P < 0.05) at fasting levels. Muscular and fat masses were lower (respectively P < 0.05 and P = 0.05) and the severity of the disease as assessed by the Child-Pugh classification was more pronounced in this group (P < 0.02). The occurrence of postprandial lipogenesis in stable cirrhotic patients is related to better nutritional status. Such a metabolic pathway may explain the nutritional heterogeneity of cirrhotics and is likely to have an effect on the benefits of refeeding.

Use of electrophoretic polymorphisms of esterases for differentiation of Clostridium argentinense strains

Esterase electrophoresis was used to study 10 strains of Clostridium argentinense, including 7 toxigenic and 3 nontoxigenic strains. On the basis of the electrophoretic mobilities and hydrolytic specificities toward five synthetic substrates, different esterase profiles could be defined for almost all strains, revealing the heterogeneity of bacterial clones. Therefore, electrophoretic polymorphism of esterases can be used for differentiation of C. argentinense in population genetic or epidemiological studies.

Alpha 1-acid glycoprotein potentiates lipopolysaccharide-induced secretion of interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha by human monocytes and alveolar and peritoneal macrophages

Although the physiological role of alpha 1-acid glycoprotein (AGP), an acute-phase protein, is poorly understood, several lines of evidence support a modulatory action on the immune response. In this study, we investigated the effect of AGP on the production of interleukin (IL)-1 beta, IL-6 and tumor necrosis factor (TNF)-alpha by human monocytes, macrophages and the monocytic THP-1 cell line. AGP significantly enhanced (2- to 7-fold) the production of these cytokines in monocytes induced by suboptimal concentrations of lipopolysaccharide [E. coli lipopolysaccharide (LPS): 100 ng/ml] in serum-free conditions, whereas it had little or no effect in the absence of LPS. The potentiating effect of AGP was inhibited by specific antibodies. It was concentration dependent and the greatest enhancement was observed with 250-500 micrograms/ml. Moreover, AGP only potentiated the effect of suboptimal concentrations of LPS. AGP did not alter the time course of LPS-induced IL-1 beta, IL-6 or TNF-alpha secretion. AGP acts as a co-inducer and could also potentiate cytokine secretion triggered by Neisseria meningitidis LPS and muramyl dipeptide. The glycan moiety of AGP did not seem to be involved in its potentiating effect, since both its major glycoforms and asialo-AGP potentiated the effect of LPS to the same extent as native AGP. Possible differences in the effect of AGP according to cell maturation were investigated using isolated human macrophages: AGP potentiated LPS-induced cytokine production by both peritoneal and alveolar macrophages. These data suggest that AGP can modulate monocyte/macrophage functions, thereby contributing to the amplification and regulation of immune and inflammatory responses.

The thermogenic and metabolic effects of food in liver cirrhosis: consequences on the storage of nutrients and the hormonal counterregulatory response

The thermogenic effect of food and the rates of oxidation and storage of nutrients were evaluated by indirect calorimetry in 10 cirrhotic patients and seven normal controls for a 6-hour period, after they had consumed a standard meal supplying 15 kcal/kg body weight with 15%, 30%, and 55% protein, fat, and carbohydrate calories, respectively. Although the thermogenic response to food was not significantly lower in patients than in controls (51.6 +/- 13.5 v 72.2 +/- 8.8 kcal/6 h), patients exhibited a delayed and blunted increment of energy expenditure after the meal intake (P less than .025). The greater part of the glucose load was oxidized in patients (70.2 +/- 3.9% v 50.4 +/- 3.9% in controls; P less than .01), suggesting a defective glucose storage as glycogen. This result could be related to insulin resistance, which was evidenced by a large increase in glucose and insulin levels after the meal intake in patients (P +/- .001). Conversely, lipid oxidation was sharply reduced and de novo lipogenesis occurred in patients, so that the rate of lipid storage was increased. The profiles of circulating levels of catecholamines, thyroid hormones (free thyroxine [FT4] and triiodothyronine [T3]), and glucagon were assayed during the test. Norepinephrine and glucagon levels remained higher in patients throughout the test (P less than .001), whereas thyroid hormones stayed in the same range in the two groups. After an initial increase, glucose levels decreased sharply, inducing an activation of counterregulatory hormones, glucagon, and notably, epinephrine, for which the increment was correlated with the decrease of glucose (r = -.917; P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aging, energy expenditure and nutritional status: evidence for denutrition-related hypermetabolism

Resting energy expenditure (REE) and nutritional status have been evaluated in 39 elderly inpatients (mean age 84.0 +/- 6.9 years). The nutritional status declined with aging as shown by significant negative correlations between age and, respectively, weight (p < 0.001), fat free mass (FFM) (p < 0.01) and body mass index (BMI) (p < 0.01). The best prediction for REE when considering the whole population was given by FFM (p < 0.001). Increased REE was observed in patients after recent surgery, related to an inflammatory state, as shown by increased plasma levels of C-reactive protein and orosomucoid. Irrespectively of the inflammatory state, REE was also found to be related to the nutritional status: patients who showed a BMI < 20 had higher REE than patients with a BMI > 20 (28.4 +/- 1.3 vs. 22.1 +/- 0.7 kcal/kg of body weight; p < 0.001; 35.7 +/- 1.6 vs. 30.9 +/- 1.0 kcal/kg of FFM; p < 0.02). These results increasingly suggest that elderly patients may suffer from denutrition relevant to hypermetabolism.

A macrophage-derived factor induced by alpha 1-acid glycoprotein that inhibits IL-1 comitogenic activity

After exposure to a concanavalin A (Con A)-unreactive variant of alpha 1-acid glycoprotein (AGP), macrophages released an inhibitor of interleukin-1 (IL-1) proliferative activity in the thymocyte comitogenic assay. This effect was observed with AGP concentrations above 100 micrograms/ml in the macrophage supernatant and would appear to be mediated by the macrophages, since native AGP had no activity on thymocyte proliferation. Preliminary physicochemical characterization showed that the factor was partially resistant to heating, undialyzable, and eluted with an apparent molecular mass of 50-100 kDa when subjected to Sephacryl S-200 chromatography. Murine IL-1 and human (h) recombinant (r) IL-1 were affected by this factor to the same extent. IL-1 and IL-2 co-induced thymocyte proliferation, which is mitogen-independent, was also inhibited, whereas hrIL-2 activity was not suppressed when assayed in thymocytes with PHA at a submitogenic concentration or in CTLL cells. The factor did not interfere with TNF alpha or hrIL-6 activity when tested against their specific cell line. These data indicate that the inhibitor may act specifically against IL-1 activity and further elucidate the possible role of AGP in the modulation of IL-1 activity via the secretion of an inhibitor.

Prevalence of tri- and tetraantennary glycans of human alpha 1-acid glycoprotein in release of macrophage inhibitor of interleukin-1 activity

Based on the affinity for concanavalin A (Con A), human alpha 1-acid glycoprotein (AGP) can be separated by chromatography on Con A-Sepharose gel into three variants: Con A unreactive AGP, Con A weakly reactive AGP, and Con A strongly reactive AGP. When exposed to native AGP or to its glycan variants, murine peritoneal macrophages released a factor that inhibited the interleukin-1 (IL-1) proliferative activity as measured in terms of the thymocyte comitogenic assay. Con A unreactive AGP, which contains tri- and tetraantennary glycans and no biantennae, proved to be more effective than Con A weakly and Con A strongly reactive variants, which contain one and two diantennary glycans, respectively. The inhibitory effect was not a function of the negative charge related to the sialyl residues and was not mediated by the mannosyl-fucosyl receptor.

Human alpha 1-acid glycoprotein-exposed macrophages release interleukin 1 inhibitory activity

The concanavalin A-unreactive variants of alpha 1-acid glycoprotein introduced in culture medium of monocytes/macrophages induces the inhibition of thymocyte proliferative activity of interleukin 1. LPS or LPS receptors were not involved in the activity of alpha 1-acid glycoprotein on macrophages. alpha 1-acid glycoprotein did not show any direct effect on thymocytes whereas the monocyte/macrophage-supernatant inhibited the interleukin 1 proliferative effect. The activity of tumor necrosis factor and interleukin 2 was not altered by the alpha 1-acid glycoprotein-macrophage supernatant.