Document 1067117

I.V. Systems Division
Regulatory Affairs
.
Baxter Healthcare Corporation
Route 120 & Wilson Road
Round Lake, Illinois 60073-0490
847.546.6311
Fax: 847.270.4668
————=
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Haxter
June 10, 1998
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Dockets Management Branch (HFA-305)
Food and Drug Administration
12420 Parklawn Drive, Room 1-23
Rockville, MD 20857
RE:
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Federal Register Notice April 7,1998 (FR Vol 63, Nbr 66, Pages 1701117012)
Docket Nol 98N-0182
Dear Colleague:
Baxter Healthcare Corporation is nominating L-Glutamine as a bulk drug substance for
inclusion on the list of bulk drug substances that may be used in pharmacy compounding that
do not have a USP or NF monograph and are not components of approved drugs.
Attachment 1- Bulk Drug Substance Checklist includes the information requested in the
notice.
We appreciate the opportunity to nominate this bulk drug substance for inclusion on the list
for use in pharmacy compounding. If you have any questions regarding this nomination,
please contact me.
Sincerely,
+-..
Marcia Marconi
Vice President
Regulatory Affairs
(847) 270-4637
(847) 270-4668 (FAX)
Enclosure
NoM8
m
1 0 )1 9 9 8
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ATTACHMENT 1
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.-a.
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Comments to Docket No. 98N-O 182
June 10, 1998
Page 2
BULK DRUG SUBSTANCE CHECKLIST
1.
Ingredient name: L-Glutamine
2.
Chemical name: 2-aminoglutaramic acid; glutamic acid 5-amide.
3.
Common name: Glutamine
4.
Chemical grade or description of the strength, quality, and purity of the
ingredient: See Product Specification Sheets at the Tab entitled PRODUCT SPECS.
5.
Information about how the ingredient is supplied: White crystals or crystalline
powder.
.#’%
6.
Information about recognition of the substance in foreign pharmacopoeias and
the status of its registration in other countries, including whether information has been
submitted to USP for consideration of monograph development: This bulk drug
substance has not been submitted to USP for consideration of monograph development. To
the best of our knowledge, this bulk drug substance is not listed in the BP, EP or JP. This
bulk drug substance is listed in the Food Chemicals Codex, Fourth Edition, effective July 1,
1996, page 174.
7.
A bibliography of available safety and efficacy data, including any relevant peer
reviewed medical literature:
a.
b.
c.
d.
e.
.— .
f.
McCauley R, Kong S, and Hall, J: Glutamine and Nucleotide Metabolism
Within Enterocytes. JPEN 22:105-111, 1998
Fish, J, et al: A Prospective Randomized Study of Glutamine-Enriched
Parenteral Compared with Enteral Feeding in Postoperative Patients. Am J
Clin Nutr 65:977-983.1997
Palmer, T et al: Effect of Parenteral L-Glutamine on Muscle in the Very
Severely Ill. Nutrition 12:316-320, 1996
Lacey, Jet al: The Effects of Glutamine-Supplemented Parenteral
Nutrition in Premature Infants. JPEN 20:74-80, 1996
Homsby-Lewis, Let al: L-Glutamine Supplementation in Home Total
Parenteral Nutrition Patients: Stability, Safety, and Effects on Intestinal
Absorption. JPEN 18:268-273, 1994
Khan, K et al: The Stability of L-Glutamine in Total Parenteral Nutrition
Solutions. Clinical Nutrition 10:193-198, 1991
3
Comments to Docket No. 98N-O 182
June 10, 1998
Page 2
-
Copies of these articles are found after the Tab labeled ARTICLES.
Information about the dosage form into which the drug substance will be
8.
compounded, including formulations: See the Hornsby-Lewis article listed as 7.e above
for information about the dosage forms.
Information about the strength of the compounded product: Diluted in a total
9.
parenteral nutritional (TPN) formula to about 0.2 to 0.3 grams per kilogram of patient weight
and a final concentration of about 1 to 1.5°/0.
Information about the anticipated route of administration of the compounded
product: Parenteral administration mixed in a total parenteral nutrition (TPN) formulation.
10.
Information about the past and proposed use of the compounded product,
11.
including the rationale for its use or why the compounded product, as opposed to a
commercially available product, is necessary: When the GI tract is not fed, as in TPN, the
cells lining the gut begin to die off allowing bacterial translocation and subsequent
septicemia. Glutamine is used to maintain the integrity of the gut barrier properties. No
commercial y available product exists in the US.
Available stability data for the compounded product: Hornsby-Lewis et al
12.
reported 22 days stability at refrigerated temperatures (See article 7.e. above).
Kahn reported 0.6 to 0.9?40 degradation per day at room temperature (See article 7.f. above).
Additional relevant information: The stable form glutamine dipeptide is available
13.
in Europe in commercial pharmaceutical products.
I JUN
10 1998
—.
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.,.
L-GLUTAMINE cASNO._9
MOLECULAR STRUCTURE
AND FORMULA
H2N—f—cH2—cH2-cH-cooH
I
o
NH2
C~H10N203 :146.15
N : 19.17%
DESCRIPTION
White crystals or crystalline z
odorless
Slight taste
SPECIFICATION
AND PROCEDURE
State of solution
(Transmittance)
More Than 98.0%
Specific rotation [a~ +34.2 - +=~
___
Chloride (Cl)
Not More Than 0.021 %
Sutfate (S04)
Not More Than 0.028%
Not More Than 10 ppm
Iron (Fe)
I
Heavy metals (as Pb) Not Mom ThanlOPPm
Not More Than 1 f)prn
Arsenic (As@3)
1
LOSS On drying
Not More Than 020%
Residue on ignition
Not More Than 0.10%
I
purity (dry baaii)
Morel-ha nm.s%
Not More Than 1.0%
For~gn ‘im atis I(TLC, 30 pg)
Pyrcgen”
IDENTIFICATION
.—=
Free
sec.-1
c=1O,2NHCI
Sat.-Z dry
c=2,6NHU
sec.4, 0.5 g
0.30 ml of O.01 N HCI
SSC.-5, 0.6 g
0.35 ml of O.OIN H#04
Sec.ql), 2.0 g Incineration
2.0 ml of Standard solution
,
sec.-7-(l),l.og
1.0 ml of Standard solution
SeC.*(l)-B, 1.0 g
1.0 ml of Standard solution
sec.-9-(1)
105Z,3M
I sec.-lo, 2 g
I Sec.-n-(2), dr’y-O2g + WI
100mf-+TakelOrnl
0.01 NHsS041 ml = 1.4615m9
Gf+dwh
Sec.-l3, Solvent A
Nin k Standard (0.12 fd
sec.-zs 1.0 Q1OO ml
(1) To 5 ml of sample solution (1 4 50) add 5 drops of dilute hydrochloric add and 1 ml
of sodium nitrite eolutii; the oobless gas is evofved.
(2) To5mlof aam@e~*(lelooo)ti lmlof2%ti@ti**dW
for 3 minutes; a purple color is pduoed.
..
‘ Ju~ f () t998
. ...
1
hr@/165.212. 125.mATMRTmTh.0i2275 100.HTI
Gharni e, L- - RTECS - Regis[~ of Toxic Effeds of Chemical Substances
.
4
Glutamine, LRTECS - Registry of Toxic Effects of Chemical Substances
~
Document Outline
10 SUBSTANCE IDENTIFI CATION
2:0 SYNONYM{ S)~RADENAME(S\
!)~ ALTH HAZARD DATA
Q NIOSH DOC UMENTS
O STATUS IN U.S.
O SUBSTANCE IDENTIFICATIONA
I’ECS Number: MA22751OO
.-=
hemicd Name: Glutamine, L-
AS Number: 56-85-9
:ilstein Reference Number:
1. BRN 1723797
2. 4-04-00-03038 (Beilstein Handbook Reference)
[olecular Formula: C5-H1O-N2-O3
[olecular Weight: 146.17
iiswesser Notation: ZV2YZVQ
ubstance Investigated as: Drug, Mutagen, Human Data
ast Revision Date: 1997
.0 SYNONYM(S)/TRADENAME(S)A
1. 2-Arninoglutaramic acid
2. Cebrogen
_+4z
1 of3
3. gamrna-GIutarnine
4. Glumin
5. Glutamic acid 5-amide
b
511i98 1041 AM
-.
Glutami
. . . .- - . . . - . —
I
a— - - -------
httpYt165.212.125 .WAT/URTRTMA2275 lUH-IT’M
L-- RTECS - Regisq of Toxic Effects of Chemical Substances
6.
7.
8.
9.
10.
11.
12.
Glutamic acid amide
Glutamine
L-2-Aminoglutaramidlc acid
L-G1utamine (9CI)
Levoglutamid
Levoghmunide
Stimuhna
,0 HEALTH HAZARD DATAA
CUTE TOXICITY
DLO/TCLO - LOWEST PUBLISHED TOXIC DOSWCONC
Man
TDLo - ROUTE: Oral; DOSE: 27 mg/kg/lW intermittent tJO
TOXIC EFFECTS:
Behavioral - Euphoria
D50/LC50 - LETHAL DOSWCONC 50% KILL
Rat
LD50 - ROUTE: Oral; DOSE: 7500 mglkg w
Mouse
LD50 - ROUTE: W, DOSE: 21700 mglkg -
;ENETIC EFFECTS
ISTER CHROMA’ITD EXCHANGE
Humun
CELL TYPE: lymphocyte; DOSE: 10 mg/L =
~THER MULTIPLE DOSE TOXICITY DATA
Rat
ROUTE: Oral; DOSE: 260 mg/kg/30D intermittent w
TOXIC EFFEC’1’W
Behavioral - Food intake (animal)
Blood - Changes in spleen
Others - Death
.0 NIOSH DOCUMENTSA
National Occupational Exposuxe Survey 1983: Hazard Code X4814 Number of Industries 4;
Total Number of Facilities 841; Number of Occupations 1A Total Number of Employees 8491;
Total Number of Female Employees 5700
I JIJN 1 0
-..
199/
7’
5112981041 AM
r
. . . . . .—— . . ..— -.— ——-————-..—......-”= .- .- ~— ——. .- . . . . . . . . . . . . —~J/ltiQ12.lfi.@AT~T~W~5 100.HTM
Glufami , L- - RTEC-S - Regisq of Toxic Effects of Chemied Sub~
7.0 STATUS IN
U.S.A
EPA TSCA Section 8(b) CHEMICAL INVENTORY
_——_ .
*
rJUN 1011998
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5112f98 10:41 AM
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Review
Glutamine and Nucleotide M e t a b o l i s m Within Enterocytes
Rcmwt: McC.+LW, PII~ SIA(;- EIX KOW B% .WJOII\ I I.u.L FRA(X
From the thiutrsity lleporfmcnf of fjnrgery. h’uy?l
ABSTRACT. Glutamine has an in~porf&t role as a source of
ene~ for enterocy&s. However, it may also have a key role as
a source of nitrogen for the syntksis of nucleotides. The relarive contribution of de norro synthesis and salvage pathways
seen~ to b-e affected by the position of enterocyz.es within the
c~t–lillus axis as well as the dietay intake of nucleic acids
and glutamine. Nucleotides are especially importanl to
emerocytes dwing intestinal developmen~ matution, and repair. Hence an undetstarrding of nucleotide metabolism within
entemcytes has important implications regarding both the composition and route of administration of nutrient solutions. Many
The effects of glutamine (GLN) on the gut certainly
are profound and have led to the suggestion that GLN
may act as a “biological modifier” and a “pharn~aconutlient” However, the mechanisms of action of GLN
are poorly defined It is of interest thaL in the context of
tumor growth, GLN may act via GLNdependent proliferation genes.’ It also shotdd be noted that GLN and epiderrna.1 growth factor have a positive additive effect on
enterocyte proliferation in uitro.z
The role of GLN as an important respiratory fuel for
the rapidly dividing cells of the gut has been well documented, In cent.raq less attention has been directed at
the role of GLN as a source of nitxogen for the ~ths.k
of nucleotides (NT). The catabolism of GLN within
enterocytes yields nitrogen as well as energy, and the
nitrogen derived from GLN can enter various biosynthetic pathways. The term “ghttarnine oxsynthesis” has
been proposed to embtace such duality of action8
In this review we explore one possible explanation for
the trophic effect of GLN on enterocytes It is postulated
that GLN might provide @erocytes with both energy and
nitrogen for the synthe+is of NT. llte initiaI sections de
Mtie~pMc~*ofGMmdMonfie@LMk
foIlowed by a review of the biocherrbl pathways Iesdirtg to the incorporation of nitrogen derived from GLN
into NT We close with a disctdon about the ability of
GIN to promote NT synthesis within enterc@ea
Rec+ved for pubtiotfoq May 9, tS97.
Amepted for pubticatl~ September 2S, W.
Correspond~ -e WCs4dey, PhD, Unherslfy ~ of
Surge~, Royal Perth Hoapl~ Wefthgton ~ Pert& WA -,
.
Austrak.
t+rlil !iospila\. ~crlh. .4 fGfrotio
impofinl questions remain unanswered, in particular: Does
glutarnine stimulate intestinal de nooo pyrimidine synthesis via
the action of carbamoyl phosphate synthetase I? Can de nouo
punne synthesis maintain intestinal purine pcds in the absence
of diemy nucleic acids? And, what are the specMc effecrs of
parentenlly administered nucleotides on the metabolism and
u-ell-beh~g of enterocytes? A greater understanding of these issues will lead [o a more tional approach toward the nutritional
modulation of gut dysfunction. (/onrnal or Parcnhral and Enleral
Nxtritioll 22105-111, 199S)
GLUTAMINE
GLN, a Aarbon amino acid with 2 amino moieties, accounts for 30% to 35% of the amino acid nitrogen that is
transported in the plasma Thii role of GLN as a “nitr~
gen shutde- helps to protect the body against the toxic
effects of high circulating Ievefs of ammorth GLN also
is important as a respiratory fuel. In autoperfused rat
small “intestine 57% of GLN carbon is oxidd to CO? and
3296 of the total CO~ released by the bowel is derived
from GLN.’ Because GIN is degraded extensively in the
gug .tiis means that both GLN carbon and nitrogen are
t-eddy awulable for the synthesis of other amino acick
lactate, and NT. Complex interorgan exchange mechanisms usually result in a constant level of circulating
GLN. However, during periods of catabolic stress the
intracellular concentntion of GLN declines by >50% and
the plasma concentration falls by up to 30%6
GLN is a maor respirat& fuel for enterocytes. In
19S7, Hwarrg et s16 reported that the infusion of GfJ%nriched solutions of parenterd nutrients resulted in an
increase in the mucosa! weight and DNA content of the
stnd boweL Later it was demonstrated that there is a
d~nse ~atio~p between the “~nc~~on
of Mined GLN and the extent of jejunal atrophy; An h
takeofat kst4#k#d of GLNwasre@red toreduce
the gut a&oplw assockM with parent.ersl nutrition in
rodents ‘Ms dosage is approxhately 80% of the total
dsk’ protein requirement of the parentetdly nouxished
rats A Iarge number of laboratory studies have ahown
that there are functional advantages asdated with
GLN-enriched parenteml nufaftion sohttio~ which ittclude optimum ntatumdon of the intestine duting gro~
Sncreased adaptive hyperplasii after inte5timd resection, increased disaccharidase acthri~ within the
unstked mucous layer of tie brush bordeq the healing
of entemcdi~ and maintenance of the barrier function
105
.
___
9
of IhC W.3 These findings IKIVC Icd w the dwcloptncnt
solutions of GLN dipcptid= SUCh as alarIyl-GLN.
Phosphatedependent glutaminasc catdyzcs the ratcIirniting step of GLN degmdation in entcrocyLcs This reaction generates glutamate and ammonia (Fig. 1).
Glutamate then can be converted into energy via the tricarbo@c acid cycle or be diverted into various biosynthetic pathways. The latter include the liberation of alanine (for gluconeogenesis) and the production of omithine,
citrulline, and proline. Ghxarninase is a rnitochondrial enzyme with aK. for GLN of 2.2 rnmoVL and in the mt jejunurn
has a specific activiw of 4.8 Wmol/h/mg protein? These
figures indicate that it is a very active enqmte that works
at a maximal capacity even in the presence of low concent171tiOnS of GLN.
The extent to which supplements of GLN may be beneficial to patients is unchxw. A number of clinical studies have suggested that GLN enhances nutritional status by promoting a positive nitrogen balance and
conserving skeletal muscle-a For example, in patients
undergoing elective cholecystectomy, alanyl-GLN-ennched total parented nutrition maintained the postoperative concentration of both fTee GLN and polyribosomes in skeletal muscle.’” How-ever, there is a lack of
controlled clinicaf trials evaluating the potential benefits
of pro!iding GLN to catabolic patients.” It is of interest
that. in an uncontrolled study, Wihnore’s group]? found
that combined treatment with GLN, growth hormone, and
a fiber-containing diet significantly increased protein
absorption of patients with shott-bowel qv’rtdrome.
We will now consider NT metabolism within
enterocytes. ‘II@ will provide a foundation for the later
discussion that links the ammonia generated by the action of glutarnhse with the synthesis of NT.
of stable
———.-
.:;+_,.&
-=—=
huildmg bI{WL5 f{,r l/ IN.A, \~]l<’r\’:Ls ~’1’ \\”i Lll (ICUXYI-IIIW.I
.WC bulldi]]g I) Iocks for DNA Their Prcscllcc is
cspccial]y i m p o r t a n t cturin: illlcstimd ~lcvcloIJINcm.
maturation, and rcp,mr.
NT promote the grot~lll and rmturalion of the dcvcl.
oping gut. Uauy CL al’3 evaluated tJ~c effect of added NT
(0.S% for 2 weeks) on gut growtil .wld l~laUJmLlon in wcalJgroups
ling rats. These supplements increased mucosal pro[cin
and DNA concentration in the jejunum by at Icast 50%,
and this increase was accompanied by an enhancemcru
of disaccharidase activity. NT ako promote the healing
of darnaged gut in wcanling rats.’~ The gu[ has the biochemical pathways to degrade dietary nucleic acids to
either NS or purine and pyrimidine bases, and most dietary nucleic acids are absorbed as NS.l~ As cow’s milk
is lacking in NT contenL whereas human milk is rich in
cytosine and adeninc derivatives, it has been suggested
that infant fomwlas should be enriched with NT.’s
Dietary deprivation of NT has an adveme effect on the
gut. He et a116 reported that the addition of NT to
ent.erocyte cuftures promoted growth and proliferation.
Furthermore, tats fed a NT-free diet have a reduced fractional rate of protein synthesis and a reduced concent.mtion of DNA in the intestine.” Leleiko et al’s found a
dramatic decrease in srnd [email protected] total RNA after the
removal of dietary purines and pyrimidines or the administration of Gmercaptopurine (a purine antimetabolite). It was suggested that all messenger RNA (mRNA)
species were not equafly affected, and this suggests a
potential mechaniim by which dietary components may
control the synthesis of specific proteins. Leleiko and
Walsh’s have discussed the evidence that the effects of
purines may be mediated through regulatory proteins
that bind to specific promoter regions genes involved in
regulating intestinal growth
NT AND PROTEIN Metabolism
Supplements of NT may help to presetwe the structure
and function of the gut during parenteral nutritiom I.@na
The nomenclature of NT is complex NT consist of a et ala found that mts who received parenteral nutzition
purine or pyrimidine base, a pentose sugar, and one or
more phosphate groups. Nucfeosides (NS) cart be viewed enriched with the NWNT mixture OG-VI (Otsuka Pharmaceutical Factory, Inc, Tokushirw Japan) had inas subsets of NT inasmuch as they consist of a purirte or creased jejrmal weigh~ DNA cortten~ and crypt cell propwimidine base and a pentose sugar. It is impoxtartt to duction rate. Although OG-VI contains p recursom for the
appreciate that NS and NT can contain either ribose or synthesis of both the ptuinea and pyrimidines, adendeoxyribose pentose gt’OUpS. NT with @&? groups ate ine monophosphate was not included because its sdrninMration has been associated with hypotension and
bmdycardkx The OG-Wenriched solution had a trophic
effect on the intestine greater than the effect of 3.1 g
GnMtiGbutWd~ofGWkI=titie
4.0 g GLN/lrg body wtld @ is hIOWn to PrOdUCe Optil’t’d
w
_ in the jejurt~f
Gktaminase
NI&
1-
Glutamate ~ A.tnhIo acid
Biosynthesis
I
TCA cycle
PILL PadwaYS Oututxntne&gWtarhWtttlk!~
Dama@gutrewires fW. Ith=beenrePOIted@4
days of NT/NS-emkhed parented nutrition significantly
SmProved healing of ulcers induced by indomethacln in
rats= Because the NT/NS incmsed aypt lengt& ctyptvDIus tie, and mkotic indq the authors suggested that
theeffectof NT/NSwasrdsted tomin~hti*
Of@ proliftiom= A N’knriched diet tdso plVXtlOt.ed
healing of intestine after ktoae4nduced diadma in
n&”’fhe aninuds tm-ated with~hada_flow
hefghtkzypt depth tiO and ]ess hl-pithdid ~hO
@esthartthe ratsdeprlvedoflW
‘lhen+forthegut tohavemdy~ti~k~
● vant to $he optimal formulation of entend and
.-4?
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~ JUN 1 0 1998
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a.**,..4— . . ~ ..
.-& ,--- ----
----. — . —- . . . ..- .—.
GLIJ’r,\hflNE A~l) NUCLEOTII)}; MHTAIKX.ISM
]laI”CIILCI-dl lluL[-l~Ii&. ~LlwlcnLw]{l[,io1)5sllould
cap~city to provide a source Or NT
107
lKIVC tile
to sustiin adequate
levels of nucleic acid synthesis. In tile next section we
describe how the guc c.m derive NT from either existing
nucleic acids via salvage pathways or by de MIX) synthesis.
~
Glulaminase
carba:o’’’’’osphare
CPS 1
NH3 ~
I
F-
ST SYNTll ESIS
Glutamate
I_lnder nomd circumstances, the gut metabolizes dietary
NT via satvage path~vays. 13 Ho\vever, in times of depri~ation bofl pyrimidine and purines may be synthesized by de
mm pathways. Figure ? provides an overview of the bio-
i% 3. Metabolism of gluw-nirw nitmgcn LO pjrimidine nuciewi& h ~.
bamoyl ph0Spb02 SWII’IC* [ (CPS t) ad GUil~Oy! @O@lW? V-
chemical pathways involved in the synthesis of NT. It is
important to review this information because it provides a
background for discussions about the interrelationships
between the metabolism of NTand GLN.
iyzed by glutaminase, GLN-nitxogen can gut.icipate in both
of the CPS reactions. CPS I is located in the mitochondria
with other enzymes of urea synthesis, whereas CPS H is
located within the eytosol as past of a mukknzyrne conlplex that contains twootherenzymes fromthede now pathway. Tatibana and Shigesada= have suggested that the di.sttibution of CPS I and CPS II within the cell is to separate
the pathways for urea and pyrimidine synthesis.
Anaiyses of the complementary DNA of rat CPS I and
CPS !I suggest that they have arisen from the fusion of
two ancestrai genes a glutarninase subunit and a synthetase subunit-r’ The glutarninase domain is active in
CPS IL enabling the use of GLN as a nitrogen donor. in
contrasL the substitution of a swine residue for a cysteine tildue in the glutaminase domain of CPS I has resuited in a loss of the abiiity to bmd GLN. fnstea~ CPS I
uses ammonia as the nitrogen donor and has acquired
an fi-acetyl-glutamatAinding region in the Gterminal
haif of the synthetase domain
Jones= has suggested that the reaction catalyzed by
CPSIfis theratAimiting stepinthede woo synthesis
of pysimidinea in the intestine. Although the intestine
contains CI%S ~ its level of activity is low.= ‘lTie activity
of CPS II is regulated by the intmee!iuiar concen@ation
of the positive effectms (ATP and 5-phosphonboayl-lpyrophosphate) and the inhibitors (UDP and UTP).n ‘Ihe
fti steps in & now pytisnidine qynthesis cuhr&@e .
the fomation of ~, which is the buiiding block for *?
formation of UDR UTP, and (XP
Some individuals lack the last two enzysnea of & xutm
pyrimidme synthesis and suffer from erotic aeid~
which is associated with retarded growth and SSVere
anemia lkeatrnent with cytidine or uridine rwemea the
anem@ and reduces the excretion of erotic acid.= We
are not swam of any studies that have investigated the
jejUIitUIl Of pStieCttS with 01’OdC aciduria
I?YriRddinSS Can be formwj from dietary nucleic aeMS by salvage pathwaga ‘fhese parhwaya are eompkq
a s i n d i c a t e d b y t h e f a c t t h a t pyrirgidi.ne
phosphoriitxansferase can sahmge both uracif and
tlWmin& The Mestine can also salvage appreciable uridine Ikom blood via uridine phosphorylase and has a 20fold greater activity of uridine phosphorylase than
~SZ=* As a general COmsnen& th~ ~ a ~ of detailed knowledge about the ap@fic role of other advage enzym~
‘he aetivi~ of pyrisnidfne phosphoribmsyltransferase
intheintestine isofgreat intemst~italsocom
verts the anticancer proagm 6’deo~-&41uorouridine
to its active fong S-fiuorwmcil. l’lds -on fa inhib-
firimidines
,R_.<
. . . -. z <.’, ?
Pyrimidines
Llacil, cytosine, and thymine are the pyrirnidine bases
commonly found in nucleic acids. The pyrimidine NS (undine and cytidine) are formed by linkage of the pytintidine bases to a ribose pentose sugar. The pyrimidine
mono-, di- and triphosphates (UMP, UDP, UT~ CMP, CDP,
and CTP) are phosphoric esters of the pyrimidine NS.
Derh’atives of thymine are only found in DNA whereas
derivatives of uracil are found only in RNA
Cfimloy] phmphate is the substrate for tie ~ n~~
synthesis of the pyrimidine NT (Fig 3). It can be derived
from GLN in the reaction catafyzed by carbasnoyl phosphate syntietase II (CPS fI) or from amrnoNz CO= and Mg
adenosine triphosphate (ATP) in the reaction eataiyxxf by
carbamoyl phosphate synthetase I (CPS f). Because ammonia can be generated from GLN in the reaction cata-
*
r
Gh-PRPP-AT
FGAM-S
APRT
HGPRT
De Novo
‘“””’ 1
as]
CPSII
PP
3X
meu.w 11 (CPS Ii).
_—_
..
%.
-. .
~JUN I o 1998
. . - ..—. — ---—— -— . -. —.- —i. .
10S
This obscnation has implications for LIIC
nutrilion support of palicnls WCC!l~illg 3ntic.anccr agents.
The circadian patccrn of d)ymdinc kinasc, an enzyme
t!lynli(iine.~’1:
localized tO intestil)al c~vLs. and O[hcr pUrinC! Salvage
enzymes may explain I he otmmcd circadian variation
in the Ioxicity of anficcxnccr cinlgs ‘“
Pu ri)lcs
. . . .-+ : : ..-. . .
———–=
.
Vol. 22, Alu.” z
h!C(:AUl,l:Y 1:1’ .A1,
itcd Itri[t]ill IIIC illlesllll:!] IUUCOW by IIUCI1. UrldlIIC, WI(]
c
. ., .-—_. ,-- ._-..,- --- _ . - -.
Adenine and gumiw m> the purine bases cxNnmotIly
found in nucleic acids. The pllrirw MS (adtwosim? and guanosine) are formed by linkage of the punrm bases to a
ribose pentose sugar. The pwine mono-, di-, and triphospha[es {AM~ ADR ATP, G\If! GDP, and GTP) arc phosphoric esters of the purine NS. The dwil’atiws of adeninc
anrf guanine are found in both I)NA and RNA
The rafe-limiting step of de now puntw synthesis is
catalyzed by gluts.mine phosihoribosyl pyrophosphate
antidotransfetase (Ghl-PRPP-AT). The activity of thii enzyme is regulated by the intracellular concentration of
5-phosphonbosyl- l-pyrophospl~ate, AMP, and GMP.W A
further nine reactions lead to the synthesis of inosine
monophosphate (IMP), whiJ) cam be convat.ecl to the other
purines (.4hW, XMIl and GMP). ‘I%ere are two imevemible
reactions in the de now synd~esis of purines that involve
GLN as a substrate: the rate-limiting step involving GlnPPRT-AT and the step catalyzed by phosphoribosylfortnylglycinamidine .syrdhetase (FGAM-S).
The capacity of the intestine forde notJo purine synthesis
is equivocal. l%e early work of Savaiano and Clifford= found
that rat intestinal cells did not incorporate [W]glycine into
adenine and guanine and concluded that intesdrtaf cells
lack de now purine synthesis. However, BOZJ et aim =
cently have challenged the idea that the intestine is not
capable of de mwo pttrine synthesis. By using %labeIed
amino acids and gas chromatography-mass spectrometry,
it was found that the intesdne of pregnant mice derived
92% of RNA-bound purines from de now synthesis. Because
there also are con~dictoty reports about intesdnal GlnPRPP-AT and FGAM-S acdvity,ms the extent that the gut
to be
can generate purirtes by de nooo synthesis has.yet
..
resolved.
The main purine salvage enzymes cue hypOxanthinqpnine phosphoriboql transfemse @GPRT) and adetdrte
phosphoribosyl transfexase (APRT). Both of th+%e enzymes are aclive in intesdrtq= but feeding a purirte-free
diet caused a 5-fold reduclion in the expression of HGPRT
and a 10-fold reducdon in the expression of APRT mRNA=
In &XO@ with these result& Walsh et rda found that 8
puximhwe diet_ a 4-fold reduction in the tzanxr@
tion rate of the HGPRT gene and were able to Me-ntifj a
regubtoty ekment within the HGPRTget= IlwY postallated that intake of putitm would stimulate the synthesis
of specMc proteins that would bmd to and promote the
tzarwr@tion of the HCPRTgem
Purine NS phosphorykse ako Ss a purine salvage
enryrrw ft atdyzes the formation of kmsine.artd. ~
nosine tim hypoxanthine and gusrdnq reqwWdY
of interest that purine NS phospho@se k an indicator
of pn?savab‘on hjJW during storage of the donor organ
before atnsU bowel tmtspkrttationu Ruine Ns phOsphO
@ase acdvities in lutnfnal effIuenk co~ with the
dmation ofpresemab“ontirneand predicMmsumivaL
NT SYNTIIESIS ALONG TI{E Cl? YPT-trILLtJS *~ls
Cell position within the cJYPt-~~llus niS affects NT
biosynthesis in cnterocytes. ch~~’~i~~ ~d potten” obsewed that the ability of enterocYtes to incorporate
[’Hl@l~idine via the ~va~e Pa~~\raY decreased = uw
cells moved from the CIYPtS tot~ad Lhe VWIS tips. In a
m o r e d e t a i l e d sIudy, Uddin ct A$’ used [“’l{ )orotic acid
and [:’H]ur~dine to examine the relative race ~d IOQI.
i-zation of de trouo and salvage synthesis of pyrimidines
in the rat duodenum. Figure 4 has been constructed hy us-
ing data presented in that study.Ji It demonswatcs that in
cells mainly incorporated uridine via the
salvage pathway. wherw the villus cells mainly incorpolaced orot ic acid ~la the de JJOJW path\vay. These observathe crypts the
tions were con finmxl by Bissonnet k“
REUTIVE CSAGE W TIIE DE NOVO .4ND SALVAGE
PATHWAYS
The relative contribution of de now synthesis and salvage path ways to intestinal NT pools has significance
with regard to the appropriate composition of nutrition
suppott regimens. We are aware of only one study that
examined the relative contribution of the two pathways
to intestinal pyrimidine pools. Zaharaevitz et al~ found
that de notJo synthesis made a twofold greater contribution to intestinal NT pools than the salvage pathways.
This was in contrast to liver, where salvage pathways
made the greater contribution. The relative tates of de
JWVO Synthes-k and salvage pathways in intestine would
imply that intestine may be able to maintain pyrimidme
pools in the absence of dietary nucleic acids.
Even less is known about the relative rates of de now
and salvage purine synthesii in the intestine. However,
as previously dkcusse& tapidly dividing crypt cells are
dependent on dietary nucleic acids w maintain NT pools.
‘flms, feeding a nucleic-acid free diet may impair the proliferative capacity of the ctypt cells and thereby reduce
villous height and absorptive capacity. This could account in par& for the atxophic changes obsemd in the
gut of animals fed nttc.feic acid-free diets.7
.
EzEl
Fk41tddw~ oi&aaE47mthesis8rutsdvageLntt7wa3’sto
XNApooktn entemgtatn&UacmtpodtiomatongthecaypGdlusd
cmstNddrIuridataprc9tmM bYudcrmetat-
-.
I
/2-
.
.—.—. .— .- --- . -— ------ ..- . . .
.
Jlfl?cll-Ap?i[ lg~s
—.
4
GLUTAM1~C AND NUCLEOTIDE METAIIOLISKI
in this section tve build upon tile biochemical pathways
linking GLN amd NT metabolism by presenting evidence
in support of tile concept that GLN supplements might
stimulate the rate of synthesis of NT within enterocytes.
“Radioisotopes cannot be used to study the fate of nitrogen from GLN because 13N has a half-life of only 10
minutes. In contras~ “C, which has an exceedingly long
half-life has been used extensively to study the role of
not studied.”
WindnmeHe# studied of the flux of metabolizes across
isolated segments of rat intestine and concluded that asp
proximately 80% of the ammonia genemted by glutami-
‘%
109
T]{F; RIXATIONSIIIPS BETWEEN GI,UTAMINEAND NT
AfETABOLIS\!
carbon as a fuel.4G Stable isotopes such as 15N and 13C,
which can be detected by mass spectrometry are an alternative to radioisotopes. For example, lSN-GLN has
been used to trace the fate of entetal GLN in humans.
Altiough tM work showed that 54% of enteml GLN was
sequestered within the splanchnic bed, the amount of
GLN-nitrogen metabolized to NT within enterocytes was
. —.—. -. . . . . ,.
. . ..—. .
nase is released into the portal vein, contributing importantly to the large ammonia flux between intestine and
liver that also includes ammonia generated by tie in@tinal microflora. The remaining ammonia apparently is
converted to carbamoyl phosphate.” This seems to be
appropriate because it has been established that carbarnoyl phosphate is a substrate for the synthesis of the pyrimidines (Fig. 2). The structure of GLN metabolism
withii enteroc@s means that as GLN is oxidized to release energy, there is a coincident release of nitrogen
that can be synthesized into NT. This armngement is an
example of the coupling of a biosynthetic pathway (NT
synthesis) to a catabolic pathway (degradation of GLN),
and it allows for the precise control of the rate of bbsynthesis of important end-products.‘l%e liver is adapted to cope with large amounts of smmonia It has a highest level of CPS I activity of any k
sue and also has a high content of /V-acetylgfutarnate,=
a positive effecter of CPS L~* Thus liver is able to synthesize excess ammonia mpidly into carbamoyl phosphate, which - then be metabolized to urea One consequence of this adaptation is that carbamoyl phosphate
generated by CPS I can contribute to & novo pyrirnidine
Synthesis. This arises because the mitochondrial znembmrte is permeable to carbamoyl phospha@= and airbamoyl phosphak generated in the mitochondria by CPS
I can leak jnto the cytosol and stimulate pyrimidine synthesis (Ag 6). &nce mitochondxial carbamoyl phosphate
a stimulate hepatic pyrimidine synthesis when dwre Ss
excess smrnorda~ or GIN.= ‘Ilte effect of an krease in
Ptidi.ne syn&@s - he@xyksonthemteofhqW
@CWE pro~don h=yet to be defined cIearly.
Theintesdrte tdsohas CPSIactivityand also isexposed to large amounts of arnrnom= but because the
activity of CPSIln Iiverisabout2$ times that of the
intestin~it seems unIikelythat excesaammoniaor GW
would stimulate int&tinal pyzimidine ~thesis. HOWA
ever, iike the Iiveq in&stirte has a M@ content of AL
scetyiglu-n the aksteric mtivator of CPS ~ ana
akhoughC f%Iiskssact ivejnint estinethanlivqthe
intestine hasarelatively Mghcontent of CPSImRNA
lMshigh CPSImRNAcontent might enable”thegutto
I
Crsl
N H ,
— GrbmwYl
W!C
I
Ura
(-cd) I
%.5. Carbansoyl Phosphate gencmt~ in she mitihondria by carbansoyl
@-h* wt- I (C= O mw led~ inlo ~ CWSOI d tinmlm
P*i~~ wthes~. ~ a~~:Y Of cysfok cartmnoyl pkspha~e symthe(ase 11 (CPS II) ssuy nm alw)am be tie rate-limiting step of pysimidusc
Svnthesk.
respond rapidly to any change in concentration of anlrnonias In support of this observation, in mice, a l-hour
infusion of 13NH?CI induced an increase in & now pyrimidine synthesis in the liver (fourfold) and intestine
(twofold).” l%ti~er research is necessary to detem~ine
whether GLN can stimulate pyrimidine synthesis within
enterocytes. A poskive result might help to explain why
GLN can have atrophic effect on the jejunum
There also are unanswered questions about de novo purine synthesis within the intestine. On one hand there are
reports that intestine has very low activity of Gln-PRPP-AT
and RMM-!Y= and is not capable of & novo pwi,ne ~thesL+; on the other hand, thexe are reports that the intestine
has appreciable Gln-PRPP-AF activity and that the& *SOW
pathway makes alargercontribution than thesafvage pathways to the intestinal purine pools.= l%us it has yet to be
demonstrated that de moo synthesis alone cart maintain
purine pools within the intfstine
tidbwefmsecdontiere kan incrwse in nucleic
acid synthesis and cell proliferadon in the remaining small
intestine. ‘he actlvi~ of both glu
“
tammasew
and enzymes
involved in& now and salvage pyrirnidine synthesis are
increased atl,ersmau bowel resectiom= studies evaluating
the effect of GLN on gut, adaptation in experimental snirnals have produced contradictory restdts.a It impossible
that the effect of GLN supplements on gut adaptation may
be dependent on the route of supply. A key area for further
reseamhwill betheeffect ofparenteral andent.etal NT
supplements on gut adaptation after massive small bowel
resectiom
In gcmclusio~ our review has Qreased the Iinlage between GLN and NT metabolism within enterocytes. A
number of questions remain unanswered. Does GLN
stimulate intesdnal & nuw pyrimidine synthesis via the
action of carbatnoyl phosphate aynthetase I? Can &.novo
purine synthesis maintain bmsdnsl purine pools in the
absence of dietary nucleic acids? At@ what are tie ~
CMc effects of parenteraUy admMs@d NT on the
metabolism and well-&@ of enwm? A greater
undemtandirtg of these ISSU& w ]ead to a more ratb
M approach toward the nutritio~ modulation of gut
dY@ttnctiom
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.._. . . . . . . . . . . . —. .. — ’ . ——. .——. -... —. —— —-— —__ .—. ._ . .
A!ardi -A I,ril IWS
.--r..
$
“
CLUTAMINE A~~ NUCLEOTIDE
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..7.-.- . . .. ,> . . . .
,: .
_—-m__
*
–—-7
.
-.
I JUN I o 1998
/5
-.
..
\.
A prospective randomized study of glutamine-enriched
parenteral compared with enteral feeding in postoperative
patients’4
Judith Fish, George Sporay, Karen Beyer, John Jones. Todd Kihara, Alfred Kennedy. Gzroline Apovian.
and Gor&m L Jensen
Plasma amino acids were mc.asurcd in 17 postsubj@s randomly assigned to rcceivc for a 5 d tulx
feeding or Iota! parcntcral nufrifion (TPN) that had idcn(ical enABSTRA~
operative
U.W. ni~ogcn. and glu~inc conlcn~. -W- r=wi~ g=~ w
pancreatic surgery for malignancy and were well-mmchcd for age
4...:?:...<::: -?:,.2.::.. .:
.
and body mass index. Tube feeding or TPN began on possopcmive
day I and advanrxd in &Ily 25% increments to rnccI goals of 105
kJ-kg body wt-’ .,-’, 1.5 g prmein-kg body W-’. d-’. ● nd
0.3 g glutaminc - kg body wt-’ - d-’. Dclivcrcd energy, nitrogen,
arrd glutamine were closdy matciwd on day 4. Nitrogen ldana
and plasma proteins did not differ significantly between feeding
groups. Total indispensable amino acids.bnnchcd-duin amino
acids, and glutarnk dcclirscd 25% on postopcradve day I atmparcd with prcopcratk &y O. Indkpcmable and bmckkbirs
amino acid cxrnomtntions wcsc scstomd with 5 d of cithcz tube
feeding or l?N. Glutamirsc corrcustmtkms dd not differ aigni!icarrr.ly by fcding group, though ● trend suggested that ghrtarrdnc
rccovcrd rnorc slowly in the Usbc-fcd than “m the TPN-fcd subjects. Pkna amino aci& atkwisc rcflcctcd formrda composition
wirh ia(ios of valinc to Ic.ucinc of 1.24 and 3.69 gm&L in subjects
rccciving 5 d of tubs feeding or TPN. rcapccdvely. Tlscsc findings
suggcsr that glutaminc-tnrichcd tube fcdng and 7PN can result
in similar profiles for most plasma amino acids at carefully
matched doses.
Am J CJin Nsur 19975597743.
KEY WORDS
Ghrtsrsnine. tube fcdng. total parentcml
nutritio~ TPN, enteral nutrition, postoperative patients, amino
acids, humans
INTRODUCTION
Glutaminc. is. the most abundant amino acid in plasma ad
skektad musck (1-3) and was seccntly mcogn&d 8S a 6
tionadiy C’sXstial amino Xid. Akhougb glutaminc is usually
adequately synLbcSid its the body, plasma mld alhtlar asttm.tiotts MI rapidly X injttq or surgcty (4). Glutadttc
bas many fisnctiotl% ticis my incrusc tbcdanattdfosghs-
taminc consumption in the atrcssd state and may, shcrcforc.
play ● sole in modulating the protein catabolic rqonsc to
injury (8, 9). Traditional nutrition suppofl dscmpics comain
vCS’y liHIc glut.amine bCCiSUSC of its unrecognized rcquircmcnt
and its poor stability in solution.Glutamirsc can bc successfully
supplernamxl in parent-l solutions (10-12) or lube-feeding
formulas (13). Both modcs of nutrition suppon appear to bc
well toksa:cd, but it is unckar whether cn[cral glutarninc is
metabolimd diffcsendy than pascntcral glubminc. We hypothCS-kCd that there would bc ass appreciable ‘first-pass’” clew
ante, with cntcml glutaminc first m-bolized by the gastrointesdnal trau and Iivcs before reaching UK gcncml circulation
This study was designed to compare plasma amino acid pm
fdcs in poslopmtive patients randomly assigned to tive
parcntcsal or entmal nutrition supplemented with glutamine.
SUB.JEC3S AND ME3’HODS
Subjects
Patients bctweam 18 and 75 y of age schcdulcd for elcctivc
up gastrointestinal surgery wese dlgible for study. Paticnta
wcsc candidates for postopaative nutition au- ● nd were
=* to squire nutrition supposl for z 5 d. Exclusion
aitcsia wcsc as follows insulin+cndcnt diabcle& susal dtia (creatininc cons.sstmtion >221 I.UIWVL or 2.5 mgfdLL
W - (total biliibin Cfnsantntioss >51 #mom w
3 mg/dL), ● u[oimmune di~ cotiltiorss precluding use of
atcnl fccdng (~ bowel obstmcdon or pancreatitia), *IC
stezoid sssq ardii d~ (class ttl or IV. New York State
Heart Association), Glasgow Conta Scale <5 (14), chronic
OMIIJUiW pUlrnOnary d~ @slid *of attron di. cMcinoSn&
oxi&(FCOJ> 375kI%os SOmm Hg]. ~
~ ~.
cami.nc incatabolic staIcs. Itscswsascbc pmfarcdordd8tivc
Subssatc foraslcmqtcs aldmayltave avitalsokisstb
maintcmulocofittks&inaI intcgtityuKl functbn(s.6).lt is8lso
8tsuckotidcpmc wor(7)Mdmay tcgoktcprotcintur ttovcrby
sbuttlingttkogatbct w05nskldstz uackandvis ocmlotgans
(8). Tbcgas&ointcstbal kactlws marbdlyi=ascd gJuArr JC?in Num W9765-S7743.Ri nrcdio US AO1997AmdCaII ~fa~Nrddm
.——:
-. _
977
.-
,
I
This invcstigion was appro\,ed hy the Gcisingcr lns(i[utiomd Research Review Ikrd witi infcmncd consm by sIandard protocol. Twcmy consenting subjccf-s were randomly assigned preopctatively by a compncr-gcncnmd r a n d o m
squencc lo rcccivc glutaminc-nrichcd enteral or parcmcral
feeding pcxxoprmttivcl y.
Nutrition support
Nasocmcric PcrsIpyloric feeding Iubcs (8 Fr Frederick-Millcc Cook Company, Blooming[on, IN) were placed during
!
,
surge~ and p.itioncd in shc jejunum to the figamcrrt of Trcirz
(15). Ccnrral venous aeccss was also Obraincd.
Tube-feeding and total parentcral nurxition (TPN) formulas were closely matched for energy, protein. ni~rogen, and
glutaminc (TabIe 1). The measured ghrtamine comenl was
113 al ~molll- in the TPN fomrula and 109010 prr-tof/l.. in
the [ulx-fczding formula (Trsbk 2). The tube-feeding formula was elemental (Vivonex Plus: Sandoz Nutrition, Minneapolis). The TPN formula was composed of an amino acid
solution formtrlatal by combining a commercially ● vailable
formulation (Rcn Amin; Baxter Hcallh Care Corp. Glendale,
CA) with free L-ghstamine (Ajinomoto USA lnc, Tcaneck,
NJ). The proccdurc for glutamine-enriched TPN formulation
was descnbcd previously (11). TPN solutions were compounded daily as a 3-in- I admixture. Standard elccwolyte,
multivitamin, mineral, and trace element solutions were
used (As- W&boro, MA).
Tube feeding or TPN was initiated at full strength Either
rnodc of nutrition supporl was begun at 1800 on day 1 postsurgcry and advarux.d in identical incrcmcrtts on the basis of
god Cncrgy nqu ircmcntsof 105 kJ. kg body wt-’”d-’ (Table 3). GoaJ nutaition afso prov-idcd 1.5 g protein” kg body
WI-l -d-l -d s).3 g glutarninc. kg body W-l -d-’. Nutrition
suppoI-I was con[inucd for 10 d or until the subjcet was able to
consume an ond diet other than clrar liquids. Tube-fceXng
toluancc was monitored with daily reeorchrg of nausea. distentio~ or disrrhca. Subjects were afso monitored for mmpfications rsssoeiatcd wirfs central venous acccas (csthctcr infection, site inf~io~ and venous occlusion). A minimum fccdng
threshold of 4184 M/d by (he fourth postopcnuive day was
csmbl[skd for find dm rc~’icw so lhm InCIUdCd s[udy SU[)J12 CL.
would have rcceivcd adcqu.3[c cnwral fccdin: for xmlyscs.
Laboratory arsalyscs
VcnouS plasma amino acid conccn[rmions were measured aI
baseline on days O, 1, 5, and 10 (Table 3). Blood ssmplcs ~’crc
collcctcd into hcparin-containing collection tubes from indwelling catie[ers at IWO each sample day. Tube feeding and
TPN were s[oppcd 30 min bdorc sampling. Plasma samples
were slorcd at —70 “C. Rcferencc v31 ucs were dc!crmincd from
analyses of venous plasma samples from four hcaldty fas[in:
adults..
Plasma was dcprotcinixzl by using membrane filuarion
(Ccnrs-ifrcc; Amicon, Bcvcrly, MA) and supplemented with the
internal standard S-2-aminocthyl-L-cyslcinc. The amino acids
were scpammd by ion cxchangc with a three-boffcr lithium
citrate systcm on a Beckman 7300 amino acid analyzer (SomcrscL, NJ). Poslcolumn dcrivatization with ninhydrin wms folIowd by spccwophotomcwic dcm-ction at 440 and 570 nm.
Sys!cms Gold Software was used for @ identification by
retention time and for peak integration (16, 17).
Other starrdard Iabomory procedures inchsdcd the mcasurcmcn( of serum sodium potassium, chloride. bicarbnatc, blood
urea nitrogen, crcatinirrc. and ghrcosc and complcsc bkd
counts on days O, 1.3, 5, 7. and 10. Gnccnuations of mag-
nesium, phosphorus, ionized cafaunL albumin. transfcrrirt. and
prealbunsin wcsc dctcnnincd and Iivcr function tests were
wndtsacd on days 0.5. and 10.
Nitrogcrr balance was ~ OO-&yS 1,4, and 10. Totd
urine utu nitrogen was deticd with a rkogen anafyzcr
(ht~ Houston) (18) from 24-h urine sarnplcs. Nlwogcrr balance was caksslatcd as follows: [tube-feeding pmxein intake
(gY6-W – [ted (UW rtittwcJs (g) + 2], or ss ~N protein
intake (gY6.13] - (total urine urea nitrogen (g) + 2].
In&rccs cdm”rrrctry was paformcd on days 1.5. and 10
posropcratively with the MCUKCOpe mctabofic cart (Qbcrtrrcdi~ LOukvill% Co). Steady sratc mcasurcmcrrts were made
over = 10 miss with ongoing fccdhrg. Mcasares Were “ilot
auemptcd in uncoopwative or mctficafly unsrablc paticnss, nor
in those who rnaintai&d > 60% inspired oxygen or who wcm
using a continuous positive sirway pressure rna-sk
StatisfiaI methods
EJ=sYw
EncrgY distrii
(% amirIo as5rk)
(% fat)
(% carlmbydra@ &zuosc)
Nonprouin cncagynkrogcu
Toral gt ~ w)
Total niaogm f#lJ
4300
4300
18
6
11
6
76
1121
76
Ilsl
Iw
7.13
10S3
733
‘vi Flus(saado% MMupdia). mdcmcdforsrndswids
. rncdfidcmtmrdb aadmmdad
-Ad&aoybcan —d. mdtokm
rsudtivirmlis!a and minds.
*65% Rsrt Arlirs(Baascr. Gksxw%mk LduhdDcw=llom
Tcarm&tU).20% L3payIlU (AbboU. AbboU~u70%6arboaa
. and-(Asrla.wcadrcmM$).
(Abboa), aJtdahndaIdrrsLdMrarrum
.-. -
Continuous data m summariud as rrtcana t SEX TW
sample f teals W= used to compare patients mndomfy assigned
tothc SwOfcding gmup5withrUpCCt so bodymassindcx
(BMI). age at study entry, and nutsicnts rcceiwd on day 4. Tbc
bs!ancaofscxbuweut thctwofcedinggmups wastitih
F-s cxacl ~ A tUUhiVSliStC anafyais o f ~
-OVA) modd was fitted W the dSy~ and dsy-5 data for
aIburnitb palbut& transfcrli4 cirolcstcsOL and Wlm
--Lwlti*-WMfoff$=@ tP#Y”
time intcmetiotu feeding gtoup diff~ at bsaeJirlc+ and
time diff~ within fdng group wete paforrncd.
MANOVAwasafao uscdtocvduatc fcec@Pp, *~
fcedinggtoup+y4me ir3tcracdon clfccBortcxhauof acid conceatIadons masurcd ottdsya QLand5. si.Uwaction effcaswacimpmtsdto tskEpKQxkx=amspom@rnabs c.ffeczsofcidKr dmc4xfccdiog gKKtp. AIf
t%tawac twoaided and8Pvaltu <03 waa~
, Jut.1
10
1998
17
~hr”ri;it.\!.
979
co\ll’/\[<l;l) W[”i’1{ l.A]{l~~l[J+,\L G[.urAh$!~[~
l,\ I\l.E 2
Plx<ma amino acid conccnmtions on days O. 1. WICI 5’
PkmLl
Amino acid (pnolA-) and Iypc Of feeding’
my o
Day I
DaY 5
Formula
PwL.fL
Mc[hioninc’ (34 z 3)
TF
TIW
CWaminc’ (490 : S9)
7-F
7??$
Leucine’ (129 z 12)
TF
TPN
VsdineJ (216 = 14)
T-F
TPN
lsolcucines’ (68 z 9)
TF
TPN
Argininc’ (7S Z 9)
-I-F
TPN
Taurine” (59 : 6)
TF
TPN
TymsincJ (58 2 5)
TF
TPN
Asparaginc’ (62 t 11)
TF
m
ASpaIuIcJ (7.0 z 0.7)
TF
TF’N
%mylalanind (52 t 4)
TF
TPN
Lysinc’ (150 = 16)
IT
TPN
CiWullincs (28 = 1)
TF
TTJN
Onsichiru+ (50 t 9)
-IT
TPN
Qsrinc(54=4)
IT
TPN
Pmlk& (185 2 47)
TF.
m“
Alarsin&C94=55)
lF
IFN
71slwni& (12S = 21)
7F
IFN
Gly&I# (271 = S3)
TF
TFu
Hk64inc(76*8)
TF
33s 11”
21 z 10
40=6
%215
28500
31409
525=206
5622135
387 z l%
413=125
389 z 160
474 z )79
109010
1% z 52
11!33s
98 z 17
78 = 17
17! = 18
I08Z40
144409
43566
195t51
1262S4
164 z 26
151 z 32
212 z 28
3% z 141
47004
61379
79:39
57:m
48 z 16
32 z 14
84213
73Z25
51682
345s1
78 z 33
77:18
45 z 12
43213
83Z28
74Z34
so 939
34822
5727
55 z 16
49 = 17
37 z 12
53223
32 s 10
3642
m
6629
61 z 12
53 = 15
11021
1894
24=6
21 = 15
m
ND
7+7 =29
3.4 %55
128S8
49
99Z34
93234
39293
29221
141238
155259
33 m
29436
56%10
41 * 17
44z17
11.I.272
6.8 = 3.4
69=21
6.723.7
73Z34
58220
56=10
67 z 15
180252
204=57
22=1O
23211
15=6
13=6
19=7
1729
40
ND
43=9
37*12
73=16
63Z24
105
112
54%32
75=34
~=~. s
m
ND
47?20
117*M
~=fi
16225
w 501
~*~
~=~~
9W
Sl%z
1242 Si
162$ s~
a258
29722
m*42
134 * sl
339*24
1R*4S
10372
25228
S*33
43*9
170273
1%=~
114Z35
137*43
67*2O
1!3641
46*35
“
la
10
-
25716
_-——__
..-
I JUN 10
1998
/%
. . --- —. —.. -. —.. . -—. . .._ ___ _- . ..__ -.. _ . .
9s0
-. -—-- --.. — ----- _
1’1s11 El Al.
TAnLE 2
Cominucd
Plasma
iii
Amino
acid (#mol/L) and t% of feeding?
Sc.rinc’ (126 z 14)
IT
TPN
Glu8ammc’ (24 ? 6)
Day O
105 z 27
109:36
77=
TPN
Day 1
I-)$+ 5
Fomml a
7 5 : 18
64:9
69 z 17
70 = 16
14774
9 !37
WO
149
S2 : so
53:28
XBW’ (413 = 34)
lTTPN
ZMA’ (776 : 57)
7’3=
lYN
Valine:lcucincJ (1 .68 = 0.08)
TF
TPN
411:134
354 = 107
309:52
261255
46s z 5s
577 z 200
243095
139856
81 OZ248
774 z 218
621:94
567:107
872 = 126
1043 z 313
372753
259650
1.48 t 022
1.70 = 0.19
I .68 z 0.20
t.98 20.32
1.24:0.32
3.69 z 0.64
0.32
1.42
034 z 0.32
0.[8 :0.12
0.21 t 0.07
0.21 z 0.14
0.37:026
0.47:0.33
ND
1.03 = 0.33
1.W z 0.32
1.01 = 0.19
1.0120.13
151:0.43
i .78 = 0.46
3.57
1s.43
0.18 z 0.11
0332032
0.13 z 0.07
0.29 = 0.35
020 = 0.16
0.033
0.001
.
A5parlaleasp.3ragincs (O. I 2: 0.02)
TF
TPN
Pknylalanincxyrosinc’ (0.90 Z 0.05)
l-l=
TPN
Gluiarnawglutamine (0.05 z 0.02)
-I-F
TPN
-*
.- . . . , - . . . . , ,. -. v.
. s.
,
0.1720.13
ND
m. na dckcsable.
‘Rcfa-crKc amucdvalucsin~ @z SDJ).
‘ Signmanl fading glwpby-rknc ~ P <0.05 (UANOVA).
4izsEhL
‘ Signifmt diffcmmxs aauss timG P < 0.0S (MANOVA).
● SignifW diffcnmccs befumco fding groups. P <0.05 (MANOVA).
significant. SAS software (SAS Institute
Inc. Gry, NC) was
used for the analyses.
RESULTS
TwusSy paticats W- CNO!kd inSO 3bc study three sssbjeus
did not m@ goal feeding by &y 4: one sub- I@ tubcfecding aoxss, one had tube feeding held because of high
nasogasfric drainag~ and one subj- had tube fading SSoppcd
becmsc of diarrhea. Of the swnaining subjt@s for f~ data
sevicw. 7 received tube feeding and 10 mccived TPN. k
were no significant differulCCS bctWUlthctwogfoups foragG
sc.x. and BMI(Table4). Tbctwogmupsbadsimilar@noscs
and surgical procdu.rcs. Both groups ceceivcd energy, nib
geq and mud glutaminc thatdidnc+diffcrai@fkandyonday
4 (Table $. Tc@ orioaty nitsggesL mcamred resting actgy
upcnditln% andnitrogal bdanceooday4wcrc also not
signkmtly diffaalt baweea groupa (I’able 5). An inadequate number of subjects cuntinucd to require nutrition support
atdaylOa@tbacforqa comp@on benvceugroupa was
doncordyat tbccadiertinwpints
Baseline ~ Ofpksnnpsotdnsa ndcbokstd
andtotal l~counts wcmnot@@6cao@diffm
Prcopdvcly bctwceal gronps B+lgm9psbdas@6cant
dropiss plasma pmteins@qe@vdy (TSble 6).
Baseline plasma amino acid profiles did no( diffcz significantly between groups for any mcasumd amino acid. All subje.cls had hypoarninoacidemia on pcstopaativc day 1. Total
indispensable amino acids. bmnclnxkb.0 amino ac~ and
ghMarnine dcchned 25% on postopuafivc &y 1 cumpa.rcd wish
W=@ve d.aY O Ukble 2). BY day 5, plasma COncumiitiOIIS
of most amino aci& apprIMchcd baseline values. ‘mere Wac
significant difhencxs for feeding gmup-by-tirnc intemcdons
for methioninq lcucinq and ~lne and significant diKerenoes
bmwcen feeding groups for isokucine and @urine (Table 2). In
cacis~the plasma arninoacidprofik wasconskent with
she sespeuivc tube-feeding or ~N fcmnula composition
- fiorrr tubfcd and TPN-fed subjects was -y distinguWdonthc basis ofsados Cfvalincto k4scineonday5
Of 124 and 3.69 #DO~ ~Vdy (Tabk 2). ~ *
stWcd Iomaximh thcinbcrult diffcaWsces irlfnsmrdacotnpsitim Plasmrs@tamincdido(x @essi@6cadybemwm
groups. Bcxbgn3ups badadsop inpbglu-P@oP
emth’clyan da* byday5. Tbme wa%bowcves. alrcnd
fNoringarcbJr ntobasdincgluramlnc
. ca2ncentlalions byday5
inadycbc’IPN &bjcct&wbacas mncUmkm inlhctubcfcdsubjcus ondayssandned sigsd!icantiy diffcsuu dmseonday o@gurel). Glltarsu@dlurIki ~~*~tmtkmsdidti~a cigrIW .
=@@ f=fMiPJP.
I
JUN 10
/7
ww
—— ———— .. :_,.._ - ___ .__ .-. _
..
EtWEltAl ~~)hlpA~ED WIT1 { l>,\ Rl:NTEl:,ll, GI.[ rr/khfl NE
__—=
‘4
9s I
T,illl.l; 3
Expmimcnul dcsi~n’
Proccdums
Swdy day
o
I
bbmmory amlyscs+
V.mCIus pksnn am,”o acids, pro[cins, clccwolyles
Enrollment
Ini[iaic TPN or IUtK feeding al 25% of csrimmcd
energy nmds
Increase TPN or K& feding 10 50% of estimlwd
energy reds
Increase TPN or Iubc kcding to 75% of cs[immcd
energy d
lncrcasc l’PN w tube (ding 10 ILK)% of esiinwcd
Cncrgy lrcC&
103% TPN or ruk frzding
1 KS% TPN or tube feding
100% m or tube feeding
Completion
2
3
4
5
7
9
10
Vc”ws plasma zmino acids. indirccr caknimcwy. TUN. elecrrolycs
—
Ekcrro!yws
-ruN
Venous ptasma amino acids. prokins. ckcvoI~. indirceI UIU%KLIY
Ekclmlytcs
—
Venous ptamu amino acids. indirrm Cakx+wtry. prOSeins. eklnlyles. TUN
i TPN. mral paruwral nurriliom TUN. tad u- nitrogen.
~ protein. muwred were abmin. rnnsfcrrin. and rrreabumin: ekwol.yw ~asured WIY ~iom P=$ium *W. ~~c. bl~ u~3
nirro,yn.
craininc. and @Osc.
DISCUSSION
Many researchers have suggested possible benefits of
ci~hcr emcral or parentcral glutaminc supplementation in
swessed subjects. Ttrcsc benefits may differ because the
cn:cral mode of supplcmcotation may be associated with
appreciable first-pass chrancc of glsrtaminc by the intestine
and liver (5, 6.9. 19-21). The objective of tl-is research
design was not to show superiority of entcral or parcntczal
nutition, bu~ rrdscr to idcnti~ diffacsrces in SISC plasma
amino acid profiles thal might result from the two modes of
glutaminc supplementation.
Dcchclottc et al (22) evaluated the absorption ● nd rnelabolic
cffccrs of emua[ly administered glutarninc using stable-iaotopc
methods in hcakhy subjects. Plasrrrs glutarrsinc showed a dosc-
depcndcnt incr~ Byproducts of glufaminc metabolism
(plasma alaninc. glutamate citrullir& aSp5rtS% Snd u=) dSO
increased. On the bask of these rcsuft.ss they concluded that
glutarninc is cffccfivcly absorbed by the jcjunum.
Dominique @ al (23) evaluated glutamine muatmlism in
healthy adult Sncrl Lhrough Usc of stable-isotOpc rncdmds with
isonifrogcnous and isocnag@”c cntaal and paJ’cnk!rrd nrStsitiO1’S. my r’cport~ ● dccrcasc k protein breakdown. with
cntcml nufrilion and a rise in the appcamx mte of glufaminc
in both groups which was signif-t only in the crrtcrally fed
group. [n contsast with the firxhga of Ihc prcscm invcstigatiom
TABLE 4
Pa&m Ctmdddd
Tsrbc fccdusg
(“-5w2~
Im
(a- SM5FJ
-- -
the parcnwal regimen providal no glutarninc whereas cmcral
feeding containd glutaminc in small pcptides.
Pemmcm c! al (24) demibd aucnuation of the fall in albumin in abdominal trauma patients randomly assigned10 cntual
compared with parcn[cral nutrition that dchvercd comparable
amounts of nitrogm and -. It is difficult to relate their
observation to the present ~dy because the cntcral and parented feedings WIXC not mrdchcd for gfutarnk the patient
population was substantially diffcrcr& and the diffucrscc in
afbumin was significant on day 10.
Pcarlstonc u al (2S) mmparcd the eff@s of crrmsl and
parcntx-al fcukrg in rnainourkhd Canca patients. my rcponcd enhanced rc@on of essential and total amino acid
concentrations in those subjects receiving parustcral nutrition
compared with stsosc subjects receiving tube fcediig or an oral
di- Although the crstual and parmtcrad formulas were designed to be matched for ~, they differed in nihmgcrs
content glutamine+ and ohcr amino acids. Because the cntcral
and parmtcral feedings were not matched for these key cusratitourts andwc.rc notadvsmcedat thcsarncm~itwasnof
possible to compare these okrvations wifh those fmm the
Pr==t -Y.
., .-..
-.-b-
.
—..
.-—a.
.
9s2
—
Albumin (pnlol/L)
Day O
DZY 5
Transfcrrin (wwd/L)
Day O
Day 5
Prcdb.min (pmoUL)
Day O
Day 5
Total Iymphcqv smmt ( 10’/L)
my o
Day 5
Omlesrerol (mmOt/L)
Day O
DaY 5
_.
.—. ——.
-——
.
.
.
.
.
.
..
—.-
_
FfSH ET AL
T,\lJLE 6
~twxuq =wwmcntr
d
.—
650
TutK feeding
7TW
521.6 z 435 [7]
391.2 243.5’(7I
463.7 :29.0 [IO]
391.2: 29.0 [10]
29.2 z 3 [6]
18.6 z 2.42[7]
2Z4 z 2.4 [IO]
17.5 t
I
I
E Day 5
tZ Day 1
tK Day O
i
2.tF[lo]
3.9 = 0.6 [6]
1.7 = 0.5’ p]
3.5 = 0.5 [101
Z22 0.5’ {ioj
1.35 z 0.15 [6]
0.897 z 0.23 [6]
13420.23 [9]
1.14 z 0.18 [IO]
3.8 = 0.4 [7]
S3 z 0.8 [IO]
4.0 x o.s~ [10]
3.2 = 0.4 [7]
T
‘ i 2 SEM: n in bracks, TIIcrc were M signifikam dlffa.aces bctwxn
wtmcnt groups.
2 Significantly diffcrem from day-O value within (rcauncnt group. P C
0.05.
Alverdy (26) fcd a glutarnineuuichcd diet to animals and
compared them with animak receiving an identical solution
parcnltially. They reported I= mortality from mcthotrcxate in
the oral diet group than in the intnvenously fed group. There
was also less bacterial translocation to the spleen in the orally
fcd group shan in the intravenously ful group. Although this
study shows an outcome befit to intraluminal feeding, it does
not Scpame the efrccx of glutamisrc hrn those of Oshcr
nutrients.
Char study was designed to carefully matdr aatcaal and parenlcral feeding for energy, nitrog~ and glutaminc. Usual
ptacficc is 10 begin psuwrtmal nusrition at goal sates whereas
cntual feedings are advanced to goal sates over acvcaal &ys.
We chose [o adminisr~ TPN at the same advancement achcdule as that for cntcd feeding so that diff~ in pksma
amino acid profiles would not reflect diffcrcnccs inthc
amounts of adm”nistcrcd nutition. ‘llris design nzsultcd in *
administration of entcral and parcntaal feedings that W- not
significantly diffkmnt in amounts of energy, nitroguL or ghJtaminc Boti groups achieved zero nitrogen balance by day 4.
despite manifesting the expected stscss maponsc postswgay.
T?me was a pos@pca-ative decline in plasma pmtci~ chokstu-ol, asad amino acids but no sign-ttcant diff~ bctwan
groups. l-he limitations of measuring nitsogcn kakncc 8nd
tfacsc labontoty indexes at a single afaost-term fokw+ip in
~stopcrative subjects must be unpbaaii because sdtmgcn
balance andlabolatofy indcxcsmayaIaobc acnsitivctoperturbadon by nonnutitional ftiots Iike fluid x inf~
andinfkmmm “Oa ~h~-~=
ducedglutamirac concentradons bavcbcamdcacrii afisx&jury in critically ill patients (13, 27). W cbangca likely
result from the mobikadon of body amino acids dtat arc
usociated with acute injury qmnw (19. 2S),
Byday50f fecdii(bods cntdand~ M
pksmaaminoa cidswacm stlxcdb baadine Valw.?slho
.
diffcaWxa?s inplasma amino acidcOx@moM bUwccm
PP$on&y5~a===hti=#w~”
mulacornpnsitiomL lbcradO Of_ tikucincdifked
Tube-fed
TPN-fecf
Rgure I. Mean (a SEM) ptasnu glumminc Cmuxnumions al days o.
1. and 5 in Iubc-fcd (n = 7) and TPN (total patrmml nurt+ion)-fcd (n =
IO) aubjcus. Giummine did MI differ aignifiuntly 4xswcuI fding
groups. bul concentrations on day 5 rcnmincd aignifiidy diffcrcn! fmm
day42 values only in rfac tube-fed subjects (@’cd r test. P < 0.05).
greatly in the parented and cntaal formulas; thcrcfow the
plasma mtios of thcac amino acids saved 10 easily distinguish
the formula rwckxl.
The Small intcsfinc is the primary site of glufatninc
uptake
and metabolism in the body (5). In a messed stat% glutaminc
uptake by the
intestine is aaclemcd. Studies in dogs
s h o w n t h a t poatlapsmtomy,
bSVC
glutamirac conmmption by *
intestinal trau is incruscd by 75% (4). Entemcytca obtain
glutam.kc by absorption across the brush border fmm the
lumen and also from amslating glutarnk Enterctcytcs bavc
biglr conccnhations of glutami~ wtdcb catalyzca the byb
Iysis of glutaminc to glutmmte and ammoniz It appears daat
~~ =bolizc gMarnine aimiiarfy r e g a r d l e s s o f
Whcthcrglutaminc cntusfromthc lumcnor==aatbcti
blood (9). l-be d products of ghltamirac mcsabcalisan arc
scleawl into pod circulation and c.x~ctcd or rnctabolii by
she liver befors reading systemic simulation (29).
It acana that catted ghstaminc would pduce a different
circulating amino acid profile than would parented gfutaminc
because of this tirst-pass tnctabolii My the TPN subjects
dbitcd a txcnd favoring restoration of plasma ghstaminc by
day5. wcandothcr invcsqWxsbve*~ Iiak
diange in pksma glutaminc Conanuatiixls with tbc aitcral
psovisha of glutaminc at corstpatable dosing conoxstratkna in
ark normal Voluntsa=a (11) 4x aiticauy ill patients (13).
Zcgk u al (lo) rcporkd aaignificant rise in pksmaghstamitu
. . ~e=d
with pafustd glutamina admmwra
8ndpa-Oducts ofglutaminc metabolism did not diffa aignificantlybyfccding gsoup.mtbepmsestt asudy, d=~ong
WI mquirc * invcsdgatiolL
Our Study suggests shatcamfu!ly uultcbcdp==d astd
cnteral suppl~tion @ rcmlt in compambk pmfika for
most&cukthg W2h0-ThC mnhipleOtk&~of@J
_
taminc mdabolkm (akckml muack kidney, and bt@ mm
daobaveat3 issfluaiam pI=maatnho asWs@O. Tp -
position ofdacf-ulafd appuratobcakey~cd
- -.
J
JUN f
O 1998
21
ENf”ERAL COMI’ARED \VITIJ pARr~ERAL GfJJTAMl~E
.—-—=
k
pl,vsma ajllino :icid concmurations. Furthdr swdics with Ion:.
Icrrn feedings or diffcrcn[ gluraminc doses may give bct[er
insight into shc pmcn[id difknces between parcn[eral arrd
cn[cral supp!emcnlxion. 1[ is possible shal Shc provision of
pwen[er-al glutaminc at 100% of the projccrd requirement
from she firs~ day would have r~uhcd in higher plasma gluciminc concenfra[ions by the fifti day. Although plasma amino
acid concenrrxions are useful in evaluating glutamine rncsabolism, intracellular gkxamine metabolism is also an imporum
aspect of evaluating Ihe response [o glutamine supplemcn[ation. Tissue biopsy, menovcnous differences across ex@-
ties, and turnover studies were beyond flsc scow of the prcscnl
study, brn migh( serve 10 berwx define how ghssarnine supplcmen~tion affecss amino acid metabolism and what dose of
glufaminc is optimal for patienrs in sfrc5sed uatea.
❑
The assistance of Peggy Bomm wirh drc amino acid anafyses awf of
Duane H.yd! widI she statistical analyses is gnrefrrlly acknowledged.
REFERENCES
;+ .:.= y ..?...! . . .
I. bcey JM, Wilmorc DW. k glurarrrinc z corrditionafly esxrrrial amino
=-d? NUU Rcv 199rJ48.297-309.
2. Askaruzi J. Carperxiu YA. Michclscn CB. cl af. Muselc and plasm
amino ads following injury. Arm Surg 199&19Z7845.
3. Bergsrrom J, Furor P. Nor- LO, d d. Issoacdhdar fme amino acid
concentration in human musck tissue. J Appl Pbfiiol 1974*393-7.
4. Swba WV/. WkrorK DW. Possopcmtive akuarion in mcriovemus
exchange of amino xi& _ the gamoinlesdnal - Susgery
1983.%:342-50.
5. Swba WW. Jnksiind glutamine meralulisnr and auoisioss. J Num
Biochem 1993;4:2q.
6. Souba WW. Smkb R?, Whore DW. Glusamine mcsabkm
tryshe
~ inta - JPEN J Pammcr Mea-d NW 19855.3xt3-17.
7. Frisex WTL synlhesii and Cambofissn of 0Udee4irfea. kc FrkefJ wR
d. Human biocfrcrnkuy. New York Murnilian Co. 1982292-304.
8. Rennie N. Hundal HS. Babi P. es al ~
. Ofagfuramine
earricr in skeletal muscle have inrportam eortsequeres for nisrogen
loss in injury. infersion and ehmnii &ease_ hrrax 1986zl~l 1.
9. Windmuelkr HG. Glutanrine utifizasion by she small kmsdne. A&
ErUymol 198253201-37.
10. Zicgkx TR Young 3S. BenfeJl ~ U sL Clii.ka3 and oscsatmiii
eflieacy of gluraminc suppkmenfal parmrcnl nuoidoo * a bone
lIM170W U#MCltiOIS. A nndomized doubk+find. eOSSSSOfkd S&dy.
b Jruun Mcd 1~116:821-8.
11. Zicglcr TR. MfcUK. SmkhR,ad.gafayad UMaEoUeclTeasd
+.gI-.nc administration in humans.J= J PamIrer Esstcrd Nsu
199& 14@rrppl)137S45S.
. ..-
9s3
IZ. ~hlwrb pR, A~WC KI TCXJI ~XCMCnl ““ma~~” wuh ghm!mlnc in
bone rnurow Lraqknu[ion ad oh; clinical q@ic3ti0n5 (z random.
id double-blmd srudy). JPEN J I%renrcr Emaal Nuu 1993:17:
407-13.
13. Jenrcn GL. Miller RH. Talabiska DG. Fish J. Gianfenmc L A
double-bIind prospective nndomizcd smdy of gluraminc<tichcd
COMPU~ wi~ ~n~d ~ptidc-~~ f=ding in ~[ically ill Wicnu
Am J Clin MM 199664 :61>21.
14. T-k G. Janrren B. Asscssmem of coma and impairrd consciws.
nsss. A prartical scale. Lance! 1974:2 .81-3
15. lenscn GL. Spray GS. WhiIrnirc S, TuAsr.cwski R. Reed MJ. Inrra.
Opcnsivc placcrncn[ of she nasocmerk fading tube ● @cd altertivc? JPEN J Paremer Grural NUK 1995:19.244-7.
16. Siocrrm RH. Cummings JG. Amino xid arsafysis of physiolog”~I
samples. In: Ho- FA. cd. Tc.chniiuc in dmgnossk human bio.
dkmsical gencdes. New York Wiky-fis% 1991:87-126.
17. Jxz P, SIocum B. Amino ad anafysis of phys”dog”d fluids for
dm-kzal usx. Pal Alto. CA: Beckman Insrrurswnm 1986.
18. JGmsxansinidcs fW, Bochm J(A. RuI time. COSI-effalivc srwhod for
dckrmining total urinary nitrogen. Clin Clwm 1988342518-20.
19. Fclig P. Amino xid sntsabolism in man. Annu Rcv Eiochern
197544333-55.
20. Mzrliss EB. Aoki IT. Potisky T. cr al. Muscle and splanchnic
gl.tamirsc and gluranrxc rnaabdism in poslabsorpivc and srarved
man. J Clin Invest 197150:8147.
21. Mathews Da M-o MA. Campbell RG.Splandusii M ufiltition
Of @UWrlilK ti giUCamiC a c i d i n bUrMltS. Am J pflySiOl
1993264 :E848-54.
22 M-P.Dw.D,Ra~u~u&-~&~k
Cffecss of erxdy adminisrcscd glwalninc irsfs-. AsDJPfsysiol
199 I 260736774
23. Dominique D. JusI B. Messing B. a al. GJuram& maabobm -m
beafrby adult mem~toclsrmlandinsn— fkding. Am I
Clin Nusr W94219:139~
24. Merson VM. Moom~JoncsTN, aaf. TotafasraaJ wuitioaverans
UNaJparenrcral rsusridonaflersnajor torso isljuy aucmsmh Ofhepsic
JrmIcin =Prka-itiradon. surgery 1W104:1992O7.
2S. Parkrossc DB. L.ce J, A3uarsder RH. aaLEfias oferucralansf
parustcd nuoision onanrino acidlmmlsin nnarpadcrsM. JPENJ
Pascnrcr Enrcral Nuw 1995; 19:2044J.
26. Afvesdy JA. Effects of gkrramine-supplanm!ed dti au bnmn&gy
of IJSC sw JPEN J Parust= EmI.aa3 ?krsr 15%M4(~.109S-13S.
27. Jcevarusxkm M. Ywrrg D~ Rarnias ~ ScbiIkr WR Arninedduria
of aevcrc tnunsa Am J Cfin Nurr 1989;49:814-22
28. Harper AEMHksRH,Bf ockKP.Bm rrch4raiaan sinoas Afmemb
liarn Armu Rev Nusr 1984;4-54.
29. Smisb RJ. Gkatarnine maabofb anrJiss physiok@c@mrsanm
~ J Parwircr Emad NUIJ l%Kl14(aqspfY~.
I JUN 1 0 ~ 1998
—.— $ --- --— --— . ..—-— — —. . ——. .
A1)l>LIE1) NU’1’I/1’I’lONAL INVEYI’IGA’I’10N
, .-..., . . - ----- . ..
,7-
.,.
.
K,,!, ,1,<,,, \’<,1 I 2. x’, 5. I y,’,
Effect of Parenteral bGhtamine on Muscle
in the Very Severely 111
1. E. ALLAN PALMER BMEDSC1. BM. BS. FRCANAES.
RICHARD D. GRIFFTTHS, BSC, MD, tiCP, AND’ CHtiSTINA JONES, BSC, BN, MPH
Deparnncw of Medicine, lhi”versi~ of Livetpoof, Live~ool,
and the Intensive Clue Unu, Whiston Hospital, Presco(, UK
From the Intensive Care Research Group,
Dare accepted: 18 July 1995
Aa.n-Facr
Glm.amine (Gtn ) -supplemented pcriopcmstive msal paremcral nusrition (7PN) has (men reponcd 10 seduce she ioss of
intramuscular glufansinc folIowisrg routine surgcsy. This aaudy invcstiga[cs whcshcr glu!ansinc-supplcmen[ed TPN an aker
muscle biochernisuy acute] y in she vw acvcrcty ilt patient. Thirry-cigh[ paticms (age 19-77 yr; swan 5S yr), aiticall y
ilI (APACHE 11 range 8-31; median 17) admia.af to she intensive care unit (ICU) were rccruitcd so receive either
mmvcntiona! TPN (CTPN) or an isonirsogcnous, isouscsgetic fed supplerncmed wish 25 g ayscd]ine L-glusamirse pa 24
h (GTPN) in a prospscdve, double blind. bhxk-random”zcd srudy. In a mprewwive sample of shcsc paticsrss, sclativcs
consented to a paired muscle biopsy taken before fcding (10 GTPN/9 CTPN patkrsts; KU D*Y 2-4) and repeated 5
days tati”( t6 patienrs KU Day 7-9). Muscle biopsies and matcling ptasma samples wem analyzed using a coupled
glutarrrhasc-glu!arnatc dchydrogtxsasc dzymasic assay. A corrcaion was made using sodium to account for the massive
cimngcs in cxrmcdlulsr fluid volume. The average muscle Gln content &fore feeding was vay few. BctwcuI biopsies no
consistent partan of change was aa.n with or withour csogasous Gin. It also pmvcd diftiaslt in these very sick patients
so arrcu ● low plasma Gln with sXH.WTPN during ths initial phase of SIK acvcsc Wsscas TPN supplanmsation with 25
@4 b. L-ghJ_ appWs hdL%Ptc h tk amts @06 SO COumcraa ShC musck d phSDM biodsussical cbarsgca asen
in dscsc patiaxs. R is udmowas wfadsa USy lag= k cxndd alter SMS state. Nutrition 19%$ 12316-320
Key words: Glutamins. musctq parcnscml autririoq critically-iU
LNTRODLICt’10N
L-@@ ItIhIe is Chssifd as a noncssuItid amino acid in
humans bust at tie crlhdar level them is the capacity for
ks synthesis. Dk4ary intake, togcrh= wids cndogmous production is normally adequate to satis& mquhmcnts. It i& tsoweves. a.vay important amino acid bccausc it is &c psimary
nitrogen donor in DNA synthesis aI the ccUular kvel and is
in intuorgao ammonia sranspofl and biasbonatc
gca~tion in the kidney. WbcsI metabolic demand fos glumss@ exceeds available supply,LS is dsought to ocxx in died
W=& ● relative dcficiesbq tesuks lhis may have askssc
also involvd
-1==-’ -Y @ Su-tiom Se@rc glutlmine for
botb-norms! and admu!atcd cell divisf~ e.g., caaqtcs of
k GI tsa@a white l)lood al&J and fibsoblastsL’ Failure of
such odlulau poputsdon& as sn@t oqus during subsaaw ddiacncy, might aesdt in ● breakdown of
impaimd imrnuns msponsiva d 2&%5!5!-&
Tbcscmdld inicdfca nltessemjsldtcmosl aidcally ill
Patkrsswhoam thcsubjcaof (b,iaatudy.
Nmisioo L23t6-3Xl, 1996
Wlscvicl science tsac, 1996
Printed indae USA Ati*suavd.
Muscle wasting in the aitically ill is a severe chnisd problems Gluraminc-enriclsed total paseutcral nutrition (lTN)
Whcm given preemptively has beul Shown to r?sult in an improwncmt in muscle biochcdmy aticJ a snc&un intensity
surgical stress (Opm cholqstcUom y): fasconmthisshor(
report enmincs tbc effcu of L-@taminc-supplancntcd TPN
on muscle and plasma glutamirsc biochemistry in patients alsudyvesy scvcmJy ilLThia aborIpapcrdocs Oot reporton
orlwr Outccrrsss snasuma thatwil lrsquir calargercoborinf
padeats.
h4AlzRlAls AND MEfnoos
GI Utamincscq SJimmcnt siot!lcaitican yiuascootkssowm
AtdEtisoc ofstudy *nocsdlcrwork inlhese vaysui-
ouslyill patiuus had bcenpubIishut Nonsd diuaayisstak
anltaials4-8gof L-giubmiasq avariabk~ofwllich
Snsybcabsort dbydlcgmrointesdsd tmcLMywoskby
Furat and Co!kagucs’suggc stcdd.laf aflerscvaemlarsa ghstamincdanand wasmarkcdfyiswased Uldsuggcaie dtobeiaa
!!!!!!r
EtSEVIER
..
C@9%9007S6tSls.oo
PIl so899-9un(%)OO06U
IJUN 101598
23
.-.. -— ----- , -— . .
l’Al/ENTEl/AL
-.. — . . . —.
.—
. --- _ * , ” , _ . . - . . .
I.. GLIJ”I’AMl Nli AND
MUSCLE IN IHE VERY SIW13tElY
cxccss of 20 g/24 h A wgct dose Of 25 g L-glulamin&24 h
was chosen for [his study on hrgcly empirical grounds as a
comprom!sc tretwccn WIKN nughl be clinically desirable arrd
pllwmaeculically praclical. L-gluramine is ab.scm from commcrciall y available paremeral amino acid sohrlions duc to perceived
manufacturing and slotage difficulties. Following the method of
Hardy. Grimble, and KfcElroy, * two TPN all-in-one admixtures
[glutaminc enriched (GTPN) and conventional (~N)] were
formulated for central venous adminis~tion, resulting in the
administration of 1“5.5 g nitrogen and 2000 nonnitrogcn sxlorics
(1: 1 CHO to fat) per 24-h pmiod. In addition, GTPN rcaukcd
in shc administration of 25 g L-giUtdISdnC, with correspondingly
less nitrogen from other amino acid soumcs (Table I). Eva
in GTPN the quantities of amino acid were adequate to satisfy
rucrmmcndcd daily amounts.
Thk study WSS fommtly SppmVCd by the SL Helena &
Knowsley Research ErAiea ComrnitIcc. AfrJx KU admission
and hemcdynarnic stabilization, ● chnkaf dcckion as to the
nd for TPN supporr was made by rise attersdmg consultants.
Provided exclusion criteria were abscn: (hepatic faiharc, nonrcsccd mafignan[ disease. pregnancy, or age under 16), the
patient-s relativfi were approached for conxnt for study inchrsion in a two-stage proms. Consent was rcqrscstcd fisst for
studying TPN administration and, second. in those patients
witJrou[ major disturbance of coagulation or symptomatic
rhrombocytopcnia. for obiaining paired percutaneous muscle
biopsies of the tibialis amcrior muscle. A two-stage mnscrrt
was necessary to satisfy cshical considerations in this highly
stressful situation.
Patients were prospectively randomised using a double
blind, scaled envelope, block-randornization technique. Block
si= wwc limited to six paticrts so rhat changes in grxseral
ICU the.mpcutic techniques would have cquaf effect on glutamine and control patients. Bascfinc plasma and muscle aampl=
W= taken before TPN adrrdnktrsrtion and sqscated 5 daya
.
later. Muscle biopsy of tibialis anterior was performed using
the conebotome’ technique and the sample imrncdiatefy prcTABLE L
~N~ OF SUP~(OTPN) AND
uNsuPPLEMEmED (cl’PN) RJxixMES
GITN ( d )
CfPN (ml)
~% L-@tdnC SOhdOrl
(Stile supply
ILL
317
served in liquid ni[rogen pending x<s:!Y. The mu. sck sampic
was powder homogenized and an acid cxlrucl made using 2’%
pcrcl)loric acid and assayed for glulmninc and glulamlc acid
using a coupkd ghstaminasc-glutama[c dchydrogcrrase assay.’0
Previous work wi[hin our d-cnl CICMIY showd demxabk
changes in muscle histology and biochcmisq in this patkw
population over rhk shorr :imc pxiod.’”~ A longer in[cwaI
was not scleaxl so as 10 limit the influence of secondary clinical cvenls, not primarily rcJated 10 TTW administration.
In preparation for thiswork the enzymatic gluraminc-ghsramate assay was oprimimd for the expcclcd aubstratc concentrations in human muscle tissue baud on rcwlu in rbc literature
and our own preliminary work. All assays wrc performed in
duplicate, togctk with known standard comxnmations of both
substaneca being assayed. TIKse standards indicated a rncan
sCCOV~ Of L-ghItSMilSC of 82.7: 9.8% (SD) and Of L-ghSIaMiC
● cid of 86.2 t 10.6% (SD). Statistically. the recovery fraedon
shows a norrttaf diswibution for bosh assays and duct noc show
any drift ovw time. Tleac results m in acadancc with odrcm
who have used this assay ~rriquc.w Results prcscntd in this
paper bavc bcus corrcdcd for variability rcvcafcd by standard
assay.
Sodium content of the acid cxtraer was assayed using a
model 5000 Atomic Absorption spcctrophoromctcx with air/
aektylcnc flame (Pcrkin-~mcr. Bcaeonsficld, Bucks, UK) and
used to correct assay results for changes in extmcclhrlar fluid
volume using the mclhod of Jackson. ” Plasma samples were
““snap from” in liquid oitrogcm and dcprotcinizd using pcxchforic acid before cazymatic assay.
Statiaticzd cornpisom were made using t test and MannWhitney U&at as appropriate (ARCUS PRO-STAT V3.0, kin
IZ BuclsatL Univcssity of @wpool ). Serial measurements were
analyxed according to Martbcws.’4 Measurements for each paticat were
d by a descriptive statistic (&g. slope of
mcasurcmcot
versus drtas). summary
values were tkrrOrn-
pamd bdwcco groups using citk pammcmic or
nonpammdxic
infrxcaltial statistics as appropriate. Rcaldts am indicated 8s
mm or median =95% s%ntkkaec intavals.
RESULTS
Thirtyught patkws, age mnge 19-77 yr (mean 55 yr),
fulfilled k Study artty Csitcri% and Conamt Waa Obmirlc!d
Dkgnoacs itseludaf perforated abdominal viacus, acute ~
atim blunt tram burns, @L Although individual diagnoaca
may vary (Tabk U), aU patients exhibited some dcgrcc of the
syatcmicir@rnmatOrymsp onacsyndmmc(sIRs)r$ aDdaocan
be Oonsidmd to Cxbiit Simikritics Wirb regard to their mctabolicremxtaeIUn eaaacvaityaem niingto the APACfiEII
~. ~
Hospital)
15 (Lmpotd
Pharsna&Gxford
Nutritioa UK)
Efoarnin 10 (Leqokt
Pharena&Gxford
NuoidoaI UK)
100D
EJoarnin
Sterik wata
Glucose 50% @XX@
Glueesc 20% (GaIm)
Elolii 20%
--a
Oxfcxd Numkiorr US(I
SOD
mm
300
Sofl
catinga auecedd mkmizadon pm=ss(ovedf tndiao
APACHE II 17, mttgc 8-31). lPN was comtnaed typicaUy
3dayaaffcsIcu admkskm(mcdian3 daY&iubxquartikmw
24daya).1’km waatKrai@icmt diffu==iu~of
pSe-Mm-I~stay * Cootrd and amdy ~
admmmadou d utaminckvclswcmmmkcdly
-
~h~pti(-~%of-)~ muack
(-19% of nosmsln;Tabk ~).GIU_@_ WWCdtamatidy ekvatcd itt @SlltS (335%). Extracdukr fluid voluassc
apmascdaaapsarxatagcby wc@oftbem*biw@~~3M(M=5sa).auggesdn8 a-it==
.
fromnotmal valucaof-_” dutiOfI~~f~X&
Caitical iuDcsa.
Gebx-tsrcgfma comaim3.1 Ldot415SgnirrWr4200iKcd
(l:lcHcMsr).E& etrc4ylaan dtr=zmfnuatsad dadas Kqubad."
aat0mwmiod
oTPNarrdcfPN-Ggt mmmc4f#emcowd
.
Ioal palurtsral rwrxtr@ rcqccddy.
-. -
Noconskad cbrsshthsmsde kvelswcteai!aa
b & imem’al bctwui-biiet (os-&@’aksat 6mcspaa
h plasma giutamk acid
Iiooblopa”kd patklata). AD
incruac
in *
kvckwaaaccsa in both GIFt’laod CIPN@=Q*-tudeofwbkhw aarsotaignificaatb ctwcca~~kfv)
.
.
—— —- . . ..
31s
—”.-.. . . . . . . . —.- -
..- ----
--.-.
.
I}AI<l+TfiltA[. LtiLU’I’Ahll Nl, ,iNl) MIJS~Ll: IN “1”1{1: VEI:Y S1:1”1:1<1:1.}’ JI.I.
TABLE
II
I
DIAGNOSES PRECIPITATING lCU ADSIISSION
a
Gluuminc Patron! DIzgnosIs
APC
13x
Smde Inhdatton. pncumomus
ARDS. pneumoniz
ScPticaemia. ARF
Scpticaemia. MOF
.%ptiC shuck. MOF
Sqximernk hear! failure
Sqsicaemi< pancmuc abscess
Cbolangitis. ARF
Scpticaemi% perforamd colon
Bums 40%
Fall, skull, VdSCbd & rib skscnus.s
RTA. lung conttion
Head injury. lung comusion
Smtus epilepsy. alcohol. pneumonia
Seizure. retained pmducu of czmczption
Pu-ilossitis
Pufm-md colon
Pancseatitis. ARF
I
8
23
23
23
23
23
23
23
24
25
25
3
32
32
37
YC5
Y=
Yes
Yes
Yes
Yes
Yes
“ Ycs
37
53
Yss
Yes
i
R\
Comrol Pa[icm Diagnosis
Yes
2
5
18
23
23
23
23
2s
25
36
37
37
37
37
37
37
Yes
Yes
50
53
53
55
Asfima. COAD
Resp. failure, MOF
Cardiac mmss. MOF
Sepsis. NJSSUCCd bladder
Sep~icacmiS, pyelonephritis
Sepsis. pedonitis, ARF
Peritonitis, pcxfomtd colon
RTA multiple injury
RTL multiple injusy
Ca @agus -on
Pcdnmti GU. MOF
Bowel obssmcdnn. resecsion
Racial pedomtiorL MOF
Pufomted GU
Perfm-atd colon
Bowel dJSbWliOSS. mseuion
Diapluigmatic k-nk. Jwad
injury
Pancrcatitis
Pancreasisis
MU scidoais, pneumonia W
I
APC
Yes
Yes
Yes
Yes
Yes
Yu
ICU = intensive we unit Bx = psticms who consented to have muscle biopsies; AK = Apache II dkgnosdc CO& CGAO . chnssic
obstructive airwsy di~. APJYS = acuts seapisaory &stress ayndrom~ MOF = mukiple nsgan fail- ARF = acwt rmsl failure; RTA =
mad srafslc accident GU = gswic UIGW.
_—_ .
. .>.&
.,—
‘4
but was significantly diffc.rrm to H, indicating a gusualizxd
@rcasc in plssnsa glutamic acid levels regardless of the type
of nutritional aupplemustation.
“ Muscle glutamine levels did not show a conais@st psaan
of dsange with eitk nutitionaf regime, shhough issdividssaf
psticnls did show significant gains and Iosaca (Fig. 1). “Simifarfy, no significant frusds for muscle glutsmic scid or J&
proportion of fhc muscle samples takco up by cxtrsdlsdsr hsid
W- dacctcd OVff She tinscspan utdcr study.
DISCUSS1ON
supply of glutsmine in the diet is sd~ and fbc
demand tic same or in~cd, risen tie tody must look for
ff the
sk.rnstive sources. The swo svsilable options am tithes sn
increase in synfksi.s, or nsobiition of stored amino scid. LGhstarnine is SySStki2cd de 00V0 i.o humans within SkCfUZd
musdq the Iivcr, snd the polmonay tree W lungs m-e sble
so inca-case Synthesis during Cpisock of surgical stress” Sssd
subaequust scfsai.%’s HOWCW. pdsssonasy @nmine flux has
not &r.n evaluated in septic patients where that is cvidusce
of pncumoniA ARDS. a other dyafunaion. Sirnilstiy, whereas
fiv~ gluraminc synthcsii is increased during scidosis,m this
isasamsult of-umcaaed smmonia production snd fomss a
scsvusging pstiwsy, as route to tbe kidney what the srnsnntsia
is cxcaetcd. A conai.mxx finding in all studies of intuorgsn
glutsmine flu is a rs@ced ~ in glusaminc seksc from
TABLE III.
TABLE IV.
PLASMA AND MU.SCUE GLUT- AND GLUTAhfME
EVHS BEK)RE lTN ADMNISTRA170N
WGES IN PIASMA AND MUSCLE GLUTAMINE AND
aAMfCACID ~DURfNGlHEF3RST
S DAYS OF T7+l
Pi&ding Vsluca =~d
(-z 95% a)
Plsanugfumninc
. amsol.Lyt
Plasma glusamase
ssusml . L-t
w)
n
~~*~
S35
+OJ138*W77
41X15.=0.026
Plasma gfusssrdc M _ +0.016 30.012t +0.012= M06t
Muscle @S(SMiSW S+MSF
4-074 *OS52 +o.04d*o.443
Muscle glutmic * dmngc +0017& 02S4 +0.100 a 0.14S
ECFdsassgu
_—-.
u?
CfPN
Plasms@asninsdsangoa
.
0.343 = 0.082
GrPN
-..
~=~
+0.1 * Is
.
—.. --- . - —..— --- . . -. . . . . . -.. _A -_
-_J ___ ._
L.
.-+
.
.
.
,-.
-----
]J,\l<l:Nq’l;l:,\[. ,-.GI/U[-,\\IINl:
.,,
.
,\sl) \l( ~S{”l.l; IN “1”111: VE1{}’ S[:vj:l{];].y IIJ.
.
.
.
j!<]
nous pruducrion plm cxogcrsous admintsmllon ) never cmchcs up
\vidl demand w Ula[ aO unknown control prm-c<~ f~iom J IOUW
plzs.nm glutmni nc Conccnua[ion. MU$CIC glu:ami m ICVCIS shou,
a simiku pa[krn indicating thin. akhough rnzssivc quXltiri6- Of
glu~mirsc as-c rclcascd by skclcd muscle -ch day, body consumption is grcatm by orders of magniruck unlike the nomml
surgical situation in which thcm is a mctabohc rcaponsc to a single
S t r e s s - ’ l h e o~”on” - in tfmc vcsy scvcrcly ill paticms, rhc
ssrcss “‘trigger.’ is ongoing with rqxalcd episodes of syswrnic
inffamrnadors, pain, and tissue oauma N’hole tmdy glurarninc
consumption might incmasc in a supply +wdcm marmcr as
mom ghmmine is made av~ablc so mom is used for sissuc repair
and immune function. This study has sho~m a markd inuca.sc
in ECF volume within the muscle mxiicd and is consisscnl with
previous obscrvadons. No significant changes were observed duri.ngthc prx-iod ofthisstssdy. hbrcccmtly bccsrarguedxstsa
cfaangc.s in cellular hydration ssatc migtn be the mccharrism
1s ,
whereby intracctfufar muscle gkrtamim JCVC15 arc contmksl.
If
possible to charge
muscle inaacdlular glutaminc kvck by MIrnrknd rnartipulasicm
akmc during this SCVM’dy df period.
The finding of an CIcVatiors in plasma glucsnrac has bcul trotcd
in septic surgical patients, afdrough rsot comrncnhxl on as a specific
finding. P1umky a al. (Tabk II)” rtoccd a 174% irxxac in
maid glutamate levels in padcnts without underlying lung damage, during eariy atagcs of systtmic sepsis. T?rcy also found a
smaU, statisdcalfy nonsignificant ‘h—ease in kvsls in paticnrs with
unsmmplicatcd .surgicaf .sn-css. Pksma glutama[e kvefs mi-@t bc
ass itsd@ct refkdon of flux through the ghstamioc-glutamic acid
maabcsfic pathway, a high kvc.1 indidng high kvcfs of glurmtinc
utilization. Sucis a hypthcaii would bc consistent with the fitsding
of incma.sin g levels pxtmrgcq, sqxia and in the critically iIl with
-c i+~aW SUFUXOC ayndmmc. Ilk MSY bc fdcwt
this wczc the casG dscn it might nos psovc
GITNO
C3TN1
CITNO
43TN1
FIG. 1. M.sck gluramine before. after, and five days toral parrmual
nutrition (TPN) ● dministration
tie skeletal muscle where it is she mos[ abundant free amino
acid. Muscle intracellular ghttaminc levels arc known to fall
during surgical stress, and this may have a direct infhsencc on
muscle protein synthesis.”
Plasma and tmrsck ghmamirse levels were wry low before the
instigation of l’PN on Day 3 of she psticnrs’ ilbicss. n-is suggests
that the balanti of g@rtsinc supply arrd demand at shis @tt has
alrrady bccncxceedcd andsbcmsximal mtcoffsroductionor
mlcasc of Rlusck glutamim Wiu almdy bc taking pram fn
healthy volurstcus infusion of the stress horrnoncs adrwafinc,
.
.
totheadmmamo.Onofgfutsmdc
acid, wi’lidsfosmspsm Ofthc
amino acid IssknIminmccu mmmcsciafly available fmmuladoas.
f3aogca insstmck mayrsot bcfhcsmstirnp=ns cfktof
gluaminc Suppkrnmta!ioa ExogcOouS glutaminc Xk&mtmdoo
mayhavc aaignificaat impaclin dsoscsissucs wbcrcit isan
~dalsxs_ =&she GItracs aadlivcr, 6broblasI$, aod ia
psrdcadar tlsc immune system, tie 6s musadoskcksa.i aystcut
sakes oothcrole ofastoragccagan mnsumcd intimcsoftsccd
glucagon, and COs-dsol hcmascs lirnbamino acideffluxandrcducq markcss Of PrOtdn symthcsia.= ~ primary trigger for thk .
rcsponacmaybcatt incmasc in CirQrladng glucoccsm‘coid kvcls,
which catI prducc a similar el%ct-= Exogaous adrninisnation
Of ~ ~&y Of L-@uWtdlSS in this situation appears so bc unable
tosumarcsuod shcchaogcsthathavc $bdyt&CISp*kiS
Uokrsown Wtlcshm mUsmcts&g mcamlml[ carrier or giving larger
doscawould altcrrhis
-
Ymw&y’-XL!$%%ti2Tz:%%?
Plasma ghrtamkc levels, aftbottgh Oot a rdkcdon of body
storc& do givt SOMC ‘mdicadoo of the atme Of whok bOdy srscSa-
inthcvay scvuely illtocotdirm apositiwcffEuyand ioffuf=0S
Onoutcmme
bofic flux. Plasma kvcla, low u d-se Start of mraidonaf aup#aoatatioq swaitslowo dcspitcalasgc popottionofafl amitsoacids
being Suppficd as gltstamiR This mggcsu Citkr Supply (codOgc-
L Mobarban S. Ghtarnk a COdkiOMliy SSSSSISid OStttb( w
anodscr nutritional pusr.le. Nutr Rev 199Z5&331
2 Souba WW, Smith RJ, WIktrorc DW. GkstasairK snctabofii by
Use iotcstioaf WacL JPEN 19S3;9:608
3. Newsbolme E& Newsbolmc P, Cud R C%alloncr m fiwi
MSH. Artsk forsorsscle iatbeimsauoc$yststtr and its @ormnca
is and bums. Nuuition 19S&4:261
in Slugu’y, Sraunlq
4. Iitwim J. tiwtb T
of urstaa diptOid fibmblasts iss media diffcrcot arsdoo acid composidoa. J CeU Sci 1974; 14.* I
s. Ruloie MJ. Leasl Sissus Wasdag kt cdsicauy iu patkara-ia &
prcvcatable Br J Ins Care 199%3:139 .
6. Hammqv@. F, Wcmmrraa J. M R vondcr-Dsckaa & vii
aam E Additioo of @dW b M@ PSS@wal tnsUiti9a ahcr
Clcaive
Coun-=d y~- P= @@* ~ ma@G-
*itrogco bakace. - Surg lcd:4Y”
7. I%rUP. Bagsssom J,13ao LasaLkdhlsoa Ofaadoauid
SUPPIY On aitmgrn sod amho acid mstabdiira in aevata tfaama.
Aaa Cl& Sand 19%494:136
-. _
A=O~
‘I%e Sir Juka l%ora Chsu+abk Ttu% Oxford NuOitiOa. ~
8. Hardy G, W- D. McElroy B, 7%ompsotr GR. Formtdadon
of ● glutaraioc—ooo taioing Sc4al parcatual nutrition adxmfs for
clitic-d USC. Proc Nutr Soc 199251 :136A
9. Cd&y L Smitfs m Dicoichson P. HcUiWCU TR Edwards
RHT. Pacutaacoua rmmckbiopsy wisbdse coachaofac. Clia
Sci 19S7;71(S):1523A
10. bssd P. ffilutarrdac and L-glatarrme Uv-mcdsod Widt @tarlliaascaadglatamate dcbydtwmae k Bqmeyw w, GsaasI
ymdaxwda qfl%zymltic Amzfysis. Vtzkg Qttmk Bcdilu
11. Hclli;wcll ~ Coakky ~ Wqpmmk$m NM. ~~~ m
~~,fk=Cf.M~P,B*M N=rmix.@
Sayopatby in Uiticalfy.ifl patksl& J Pathology 1991; 1*W
12 Gsiffiths RD. *w HdUti T. MXkOOSOP. ~b
RR. EffcUofpaasive aO@cWagott dtc*ofm4rn&
aitica!fy411 Nutrisioo 1995: 11:42S
13. &kaosl MJ.JOOCS D& Edwards RNT. M~ of~ciam
ats60tk cktncwxitIab sdkbkpsYssosPks ofm+fi
.
.
..-. —
.\20
_—_
4
,.’-
. . . . . . . ..— -.—=
,,. - .=
.--.
—.-
—
----
--
.
..-
—--—
—
I’AI:I:N”I”EKAI. I.-G1.IJ”I’AN1IXI: AN1) MIJSC1.1: IN l’1~1: v~~~ sEvlXEL}’
I,:ICIC,Z)[. wittl ncurooluscular dd.sordcr> Clan Cltinl ACM
19s5.147:21s
14 hl~[tllct$s JNS, Almian DG, Campfxll kfJ, R+swm P. Analysis of
.SCri:!l mmwrcnwm in mcd!c.al mwarch Ilr t.kxf J 1990.3(M 230
15 Bone RC. a al. Arncrian CcdJcgc of Clew PIiyswans/Socmy of
Cni)al Cm Mcdicmc Comcnsus confcm~. Dcfimuons of .sepis
and organ ftilurc and guidchms for (he UW of ionovauvc thcmpms
in .scpsis Ct+ Cam t.%d 1992.20,%4
16 Knaus WA, Dmpcr E%, \\’ag!scr DP. ?.unmcnmn JE APACHE 1[.
a .scvcrily of disease clss.sification Git Cam hid I9S5.I3:818
17. Wcmcnnan J, HamrnaqvisI F. AJi hm Virmam E GIuurninc d
omithinc-a-kaoglutarm M nu &mchcd*n amino acids twhc.c
IJX lOSS of muscle glttw-inc afur surgical OaUITU. Muabdism
1989. 3E(Suppl I ):63
la. [{mko.,itz K. PlumfeY DA MAn TD. HaUUMW RD.ti~d EM
3d, Soda WW. bn~ glutamine Jiux folknvi.ng cpm h- surguy. J
Surg R= 1991:51:82
19. Plurofey D& Souba WW, Hautamaki RD. h4ardn T13. Fiyrm X.
Rout WR.GpclamiEU .AcceJemdhmg amino timkasein
hypcrdymamic sqic surgicaf patkrns. Arch Surg IM, 12S57
.
2(I F,,x A
E(f,.cL\
Of acwc
nKLd)OllC
acidosis
—
-.
1[.[
on renal. gwl, hwr, and
m UK b= Kjdntq Inl
19s2. ?1.439
2 I \~mn~ E. H.unmarqvist l:. von-d=-fkkn A. N’cnscrman J Kolc
O r gluwninc and iLs analogs m Jxm70amatic mUKiC pKW,n &
awIo aod nw~bolism JPEN 1$%3. 14 (SUPPI):125S
22 \{ ’cmum.3n J, BOM D. Hwnmarqvig F. llumdl S, wm+.~~m,
A. \~mnam E !jtress honnonc— T glvcn 10 ksrdly Vol””,- ~j,cr ~
omccnwauon and con figwmrion of rihomcs in slzlcsal musck. mfltiung changes in ~wcin symti,s. CIm Sci 1989.77.611
23. Muhlbachu F. Kapadia CR Colpoys MF, Sm”dI W. Wilmorc DW.
Erfcru of gl uaankoids on gluwminc mcdmlism in skkd musdc
#um J phytird 1984:247(1 PI I):E75
24. Waussingm D, RodI E Lang F. Gcmk W. The aJJufar hydmtim suit:
● majockmmiwu for @n u@x&sn in hufth and d!sac
Lanccl 1993:341:1330
2s. ZJcgla m Yslsmg M. BcmkJJ Kad. ainiar d nEElbOric CJficacy
of gluwninc-supplcnlwcd paluumr mmiliols afuf bolw marrow
Snn5plmmtion. hm Inkm Mcd 1992:116:821
26. Van & HuM RRWJ. Van Ike! BK. VaI Meycn.fddI ~ a al
Gluuaminc 8nd dsc ~XiOOOfgU! intcJ@Y. bnca 1993341:1363
nwdc nkdmlism
of &M1inc d a11flm11i2
..
.-
I JUN ? O 1996
27
—.. ., ——,—. —. —-------- .—
.— —.—.——— —.—------- . . . . . .
-.. .
j,:
l’!!! :11. N’, I
S,4
ih.t<i in [t
f:i!
.—.=
t>! !
<,
4
pl
{) r
The Effects of Glutamine-Supplemented Parenteral Nutrition in
u!
111
Premature Infants
11
.18
P
1
JANm M. L\c~Y, DRPH, RD*; JW B. CROUCH , MPH, RDt5; hmnzm BENEZW RPH2 STEVEN A RINGE% W pNDt;
C. KRISrANN WILMORE, RD*; D ONNAMARIE MAGtJRL RIW; AND D OUGLAS w. WIIJIORE. MD*$ .
From the “hzboratoryfor SuW”col Mefabolion and Ndn”tba. iN~m&l In fmsiat Cwe Unit, tRescorrh F%armaq and Whttn”fio. Suppvrt service,
Bighorn and Wanwa k Hospital, B@oII
{
1
1
Background: GMarnine (GIN) is the primary fuel
for rapidly dividing cells, yet it is not a constituent of parenteral
to be tdgher in the GIN groups but the levels were well within
normal limits. In the 400-g cohort (n = 24), glutarnin=upplenutritional formulas administered to newborns ‘llre aims of this mented infants required fewer days on TPN (13 m 21 days, # =
prospective, mndomizecL double-blind trial were (1) to confirm .02), had a shorter length of time to full feeds (8 as 14 day% p =
the safety of glutamine supplementation for premature infants .03), and needed less time on the ventilator (38 us 47 dam p =
.04). l%ere w= a tendency toward a shomx Iengtlr of stay in the
and (2) to examine the effects of glutamine-supplemented
parenteml nutrition on length of stay, days on total parented NICU (73 w 90 days, NS). These findings were not obsemed in
nutrition (TP~, days on the ventilator, and other clinical out- the infants z800 g (n = 20). COnCZUSZ-OUS: Glutamine SPpem tm be
comes. Mefho&: Premature infants received either Sandard or safe for use in premature infants and seems to be conditionally
glutaminesupplemented TPN and were monitored throughout essential in premature infants with extremely low bti weights.
length of stay for various health and biochemical indices. The Larger multicenter trials are needed to confirm these observagroup was examined as a whole (n= 44; bfi weight range 530 tions and further evaluate the efikacy of GLN in these high-risk
to 1250 g) and ‘br two weight subgroups, <800 and =800 g Re- premature infants (/oxmaf 0/ Parenteral and IMeral l$ktrition
suk Serum ammoN~ blood urea nitrogen, and glutamate tended 20:74-80, 1990)
ABSTRACT.
. . . . ..
ii&2F-~’ :
r
*
The premature infant is extremely vulnerable to insufRaent nutrient intake and apeMc nutrient deficienaes. Jfi
utero, tinder optial conditions, its nutrient supply is ideal
and constant After delivery, the infant is faced with the
more hostile ex utem surroundings where the food supply
may be intermittent inadequate, or imperfect. Unlike the
adtd~ the premature infant has limited nutrient stores to
meet metabolic requirements during shofi4enn fasts.’
Even when nutients are provided enterally or intravenously, the immature intestinal ttact and liver may not always optimize absorption and metabolism of such
fwdings. Unfortunately, other priorities of medical care
often prechtde optimal nutrient delivq, contributing to
additional nutritional risk
The amfno acid glutamirte (GLN) k the most abundant
amino add in muscle and plasma of adu!t humsn# it is
important for cell growth and synthesis and is an essential nutrient for the replication of cells in tk=mte CUkUreLw
In additiow GLN is an important fuel source for l,yrqsb
cyteq”macro@sg~T and en@ocyte& this *O acid
also plays a key role in acid-base homeoataskm: and
semesasan
recumor for the @or MraceJlular antiotitie-pmd=
=Ot@Y, GLNwxthoughttibe “nottessen~ti
was not included in IV amino acid RWalreabecauseofsts
relative instability in schtion. However, after usual guidlines for preparation of IVnutrient solutions, GLNhas been
shown to be stable,’=uand a variety of humart’=and animaf studiesw’e have demonstrated an improved outcome when GLN was added to parenteral nutrition
GLN supplementation maybe of particular benefit to
pretenn infants receiving IV feedings. ~ infants are
gIWW@3 ~d GLN is one of the primatynutrients thatpm
vides purine and pyridme precurso IS for cell replicationSecm@ GLN isneded for maturadon of the irttesdnal tract
and tnayaid in prevention of enterocolitis.~~ L@ly, GLN
enhances grow@ dweloprnent and function of the immunologic system’ and thIM should be of benefit to the pre
mature infant who k vulnerable to infections This study
reports our prelimii safety and efHcacy findinga of ~
.GLJQ+upplemented parenteral nutient solutions used in
a neonatal intensive care unit Q4KT.JJ
ReCAvedferpubDcartcq
Marc41t?9,19P6.
~~~
ComW&wrandrqr$-%%%%sswWitmat%MLW4Yma
andw’anen\Hq@ 7sF’1an&a Bostab MA&?ll&
74
.——
‘w&
.
-- -
I JUN 1 0, 1998
Czf
..
---- --. ., —.. . .
]0 ,lltOr>L~CbrldUl~ 1996
—
4
& , . ...--
*J. . -A= ----.-_. -.
fants w?rc included if LhCy mcLat least six of the followirrgcriteriz
Irln.hwei:lltc 1500g, ~csL1Lion31 a:c<3?\vcck; 5-nlinule.*gwxOre
< 6, need for >?l%oxygcn; need for\tcntilatoW =si~ce; low blood
pressure for a:c, suspccled intravcnuiculu hcmomhage, the presence
ofsmzures, Lhc prcsencc ofpatcnt ductusmeriosus,the presence of
umbihcaf, arterial and venous cathem~ snd birth weight .1000 g (giving special consideration to the extremely -lo~v-bifi.weight infan~).
lnfan:s were excluded from the study for severe centrsl nervous sys[em damage incompatible WM a prolonged life, renal failure timiting
pro[ein intake, and inborn errors of metabolism or tiver disease preventing the delivery of appropriate nutrient requirements.
The major aims of this study were (1) to teat whether GfX was weft
tolemtcd in this population of premature infants and(2) to invesrigsle
the potentiaf benefits of GLN-supplemented TPN for thest brfants uaLng a variety of clinical indicato~ bscfudhg length of stay @S), days
on TPN, ventilator use, and incidence of infecdous episodes
Because of safety concern, this study was initiated as an open4abel u-id. After the initial four patients received gluuuriine, infants were
then randomized by balancedassignment into control and txeabrrent
groups, and the study was btiided so that none of the invesdgato~
nursing staff, or dietitians knew. whkh solution the infsnts were receiving. The onfy pemon aware of the assignments was the research
pharrrracis~ who kept the code seafed until the time of dats analysis.
Infanrs who met the entry criteria were randomized by geststional ages
(. or a 32 weeks), high-risk NEC scor% and multiple b- (in the
event of twins, sibtings were assigned to opposite groups). The treatment com.isted of addition of GLN to the TPN solution. GLN was initially added at 15% weight per volume ofUre andno ● cid mix (n = 4),
increased to 20% (n . 15) and later increased to 2S% (n = 3). Both the
control and GLN diets were isocsfonc and iaordtrogenous (Table I).
+’ >.+: .,. ,:.:.
_—
*
4
a
,.-
,L2SWJI
*.-
,.
.,-,
,.-+=
.-
ah. .
-75
GLliT.+MINE-SUPPLE\l ENTED lNFAN”fX
Study Design
,. ;. .: . .
S_; .
General Procedures
l%e ctinical care, including nutrition suppo~ of *e brfsrrts was
managed by the staff of the NNX, which fottowed genemtty acceptd
pmtocots M-w initial blood cuftures, aU of the infanfs received ant.iiiic thempy for at least the fust 3 days of life Fotlow-up btood cuttures
were obtained when ctinicafly indicated to ● vafuate bactererrrta infants were weighed daUy on ● standard infant gmm scafe urtks pre
eluded by the patient’s condition (e& K the infant were on a high-4kequency ventilator). Routine blood was drown daily during the btitiaf
course and subsequently twice a week or more often If medicalty brdicared to monitor
lectrolytes, biood gases, complete blood count and
●
bsdices of renal function. For the present study, 1 mL of blood was
dtzwrr before tie hdtiation of the study brfusfon and once a week thafter to monitor amino acid and ammonia concentntiorq this wxs
conditional on the other reqdrementa for obfabdng blood samples
Ilerefore, not atl infants were meamred for all varhblea. fn the rnajorivofNmSbl@fwti_GN~m*mti*d
of the first week of lT’N (apprordrnately day ~
Ptasma levels Of fJhl@llble and @Jt9MStC w=e ~tied ~ a.
p-ilr-fi titfrate by an ~ $pectmthm mmetric merhorLPlasma arnmontswas measmedbyan enzyndcmetAod @grna Kk
170-B, St Ixx@ MO).= S@ndard cfirdal Womtory methods were used
for the assessment of kmatocdg brood urea tdmogen (BUN), Wlrlte
blood cd count (WC), and bbbonate (dedved fsusn bkmd CO
measurement)? wsWolde weR em@oyed
to detemdne presence
TABLE 1
timoasilion of sofutions
Studs sc.luLion (Ami.osyn
Standard solution
pF + glutammc; 7%
(Aminosyn PP. 7% solution)
(m,g1100
Lysine
Leucine
Phenylalanine
Valine
Isoleucine
Methicmine
Threonine
475
631
300
452
634
125
Tryptiphan
Alanine
A@rrine
Glycine
Histidine
125
490
361
270
220
Proline
Glutamate
Serine
&partate
solution) (mg~IOO ml.)
3s0
665
240
262
427
z
570
576
347
370
100
a92
669
216
176
4s6
4s1
278
396
as
‘l@sine
Taurine
Ghrtsmine
● 20% glutamine solution.
mL)
z
o
34
1400”
or metilic decompensation. Advancement to fuU entenl nutrition
generally required 7 to 14 dsya. - milk or infant formulas (icluding Similac Special Care [Ross Labontories, Columbus, OH] and
Enfamil Premature Formula. [Mead JohruoN EvamswWq tNl) were used.
Parentersl nutition was disconti-med wisen fluid needs were met by
the entenl route or when parented fluids t-an befow 1A rrrLA
This therapy was continued on theLAa of the CW status of the
infant or the presence of positive blood cutturea. fstfants were dis
charged from the NICU when they were approximately 25 week
gestational age, had ● chieved cardiovascular stability and
thermoregrd@ow wzre able to take aU focal orafly, and had consistent
weight gain. Warts were either transferred home or to level I or U
nurseries before d-e and were foUowed to *e there
Endpoints
Primary endpoints irscfurted time to full entenf feed% days on~,
ventilator days Uuoughout BWi length of stay @SJ and weight @m
per day (averaged across c@. at BWH). Secondary endpobsts brctuded
PIasma GIJ4 tevels (@O~), BUN and incidence Of ele+afed BUN (>
a9mom[>x@&]), &~dalwm(4x Wcefld
L) thlW@OUt ~ at B~ freqmrq of Postthe blood crdtures, ~
tiBW(_aL@~h*MWUB~,~tim(*
Mudd~*BWpl-&n&4K~KW]ti&Ma
hospiti).
Standard Them@
Blood banstbdons wae &neraUy dmMstedtomabttafa beaz@
ocrit>oxl@o%) vOhmle%md>a 40@oqlfMLntk eureiFdmdm3wm-a~ ~elu&ttfOetlm$ dwnced Overato
4dayaastofembA Rotebrandt4Mswere ~bYo.6to10ultg
~-,~~=~~~eb~~
usts’Igwtolo%dextlWeti~ ~m~ktroseso!utkm wbtfuaedby acentmlcdbe@r. N=og=trkfeadln@
Wea-elrdttated ecepatknrsa obngerreqoked Umblllcal**
c?==ldde==wed~~,d~W.
J%%
of -C resIdos&
-W*(=
~ stoo&=d~r=P~
. = -
I JUN 1 0 1998
27
---
------.
76
..—
*p= 0.03
4
the rc.sulw were
pooIcd. AS shown in ~ahlc 1[1, t.hc GLh’
mean plasma GI.N ICVCIS (439 us 295
pmoVL, p = .04 ~normal range 0[ plasma GLN in l-nlonth-
group” had
f
500
higher
okl breast-fed neonates: 142 to S50 pnlo~’i 1). in add i Lion,
plasma glutamate Ievcls tended to be higher in the GLNsupplemented group (1SS us 152 ~mo~, # = .07 [normal
plasma levels of glutamate in l-month~ld breast-fed neo-
400
nates: 24 to 243 +mol/L’’]), but there were no significant
differences between serum bicarbonate or glutamate-glutamine ratios. There was a trend toward higher plasma
ammonia levels in the GLN group, but this difference was
200
not statistically significant (5 us 4 wmo~ {0.9 us 0.7 @
mL] p. .15 the normal range of ammotia in 0- to 2-weekold infants is 5.6 to 9.2 p,moVL [0.96 to 1-57 p.#mL]~.
The GLN-supplemented group had a higher proportion
of infants with at least one case of high BUN (12/17 us W
n
17, # = .04) during tie study when compared with conw
trols. Mean BUN during TPN (avetaged over days of TPN)
o
15
20
25
also tended to be higher in the GLN group (7.8 [range: 2.9
GLN Dose
to 11.4 mmoVL] us 6.4 mmoVL (range: 1.4 to 18.6 mmoVL],
M), though the means of both groups were within the
(% of Amino Ac/ds)
normal ty’tge, which for premature infants is 1.1 to 8.9
.
PIG. 1. Plaama GLN concentitim generally increased x the percentage mnloVL (3 to 25 mg/dL)a. Total calorie and protein intakes
of ammo acids given as glumm-me increased. ‘flw 2(% dose ia aignifi- were significantly higher only for week 1 in the control
cantiy dflerenl from tie O dose, by ~OVA CD). ~ - qu~@
group (323 us 294 IWkg per daY [77 us 70 kcalfkg per day],
of glmrrrine administered to each infant depended on infusion rate of
I = .O& 2.1 us 1.9 g proteirdkg per day, 9 = -03). Low white
the nutrient solution and the indtidual body weight of the infantceu countis were seen III fewer Man= who r=eived GLNsupplemented TPN compared with controls (2%?2 us 7/22,
weight subgroups (c SW and z S00 g) were ● xamined withii each # = .13) (Table UX) (mean values GLN us controk 20.1 m
group. Anaty+5 of covariance was employed to contd for bti we”@L
21.7 X K? cell.dI+ NS). ‘Ihe number of red blood cell tmnsclass. F%her’s exact teat was used to test betweenuuup ditTerencea
fusions and average lymphocyte counts did not differ bein frequenaea of abnormal latm*rY vatueS Potsntiat oothera in Uw
data set were ~hed by analyzing residuats (difS~ between lm-een groups. Them were no Other statisddy significant
observed and predicted values of dependent variable} Qu.k’s diktanc% differences between the groups.
300
100
......
,-. . .!. .---,.:..
.-=
*
s measure of the degree to wtdch the dmated coetlkient would
change if uu aarnple were dela was emptoyed to detect anY observations with an unwnmlly targe mexure of influence LeWage w=
atso used to examine the “extremene” of ot6erVaU0rW.a Data w
reported as means z SD.
RESUL3S
Group as a Whole
,.
Between May 1990 and August 1= ~ infants Wenrolld 33 of these were subsequently excluded for the
following reasons 16(8 controls and 8 tr@rnent group)
had insuffiaent time on TPN, 4 (3 controls and 1 trea&
rnent group) developed serious conditions that prevented
study participation because of surgery or Qansfw 4 (2
controls and 2 treatment group) developed NBC, which
precluded enteml feedings 9 (4 controls and S tmtanent
81’ouP) ~edffom cornplidons relathgtotheundeMW
condition On% a statkticsd outlier (for two dependent
variables ~ stBWHandTPN d@,W=eXdU=~
inf&nthadabirth wei@of1470&~&4-d ll&
daylengthof stay. (Tests weredone-.-tititiw
individual and exclusion of this obsemtkmhad no effect
on tie significance of the dab or conclusions) - final
santp!eslze of the study popuMon-44 (M males 26
females). ‘lkem were no baseline differencesbetmenthe
Tivo Wtight Classes
LiWable arta3ysis (Kaplan-Meier) revah?d that at varYins le* of *Y (SW, the fxea@nertt had varying effects (Fig. 2). Cox regression demonstrated a significant
interaction between birth weight and treatment in determining U3S. Because of * we examined the effect of
GLN, controlling for bti weight groups, z 800 and z 800
& = this was the general midpoint of the group (lWe
fvThe four weight subgroups were similar at baseline,
except that in the Z SOO-g treatment group the I@ority of
tij*hW@&Ae ~m2#=.W), Woof*om
wemt2-iplets Eachoftheother* s@iWJFMn@
twice as many famles as males How@er, there were no
outime differences between sexes in the group as a
wholq except for a bend toward grea@ w~t @n per
*inxnales(K4
mM9@%*=.w>
ma &?q”Cbho?t
fntheZSOOgCOho* th-WeRnO____
cant differem= inplamaGLN, glutmate+ or BUN ~le
fV). During TPN (but not for MM BWH), the GLN-
suPPlem=@WWMmon infants wMh@&bld
contsd and treatm=t @OI@S ~le ~ IKW *- * adtums(5=qp=.W~a-PXe~X
males andthefernde%mbtie n-dmti tive~_w4@W@tin_d4_
central w PerSphml Knee (data not shown).
takenW=O,#=.@Hwe=dti~M~de
Since no differences Snmeanplasmagl~~ mdnedfor M3S*Bm&differen- w=mkW
txation were seen among the tiuee GIN * _ 1), mitisii=ny e-t ~le W. -_*~ = m g
---
--——— .—. - -——.— —.—
‘
—-.
— .--— —-- . . . . . . . .
.
.
.
.
in the number with central m peripheral lines. Finally, males in this
cohort had a significantly greater average weight gain than
females (17.3 m 12.3 #d, # = .05). They also tended ta gain
more weight than males in the < 800-g group (17.3 m 15.2
gfd> NS).
with positive cuhrcs, there was no difference
.
..s.
.
.
.
.
.
.,- -
.
third week of TPN, the GLN-supplemented group had a
]yMplIOcyte count tJs con[rols (~5.9 ~S
15.8, p = .04). Length of stay was ~so slloficr Jn ~~e supplemented group (73 m 90 days), although tJUS difference did
signific~,t]y Iligher
not reach stat-&ical significance.
OISCUSS1ON
77ze c 800g Cohort
In ufero, the fetus derives a large amount of GLN from
Serum GLN was higher in the GLN-supplen~ented group the placenta and from amniotic fluid, the latter of which is
(400 m 225 kmolfL,2 = .05), but there were no differences thought to contribute up to one fifth of4he total protein
between the treatment and control groups in serum load. After birth, the amino acids in greatest concentraglutamate or ammonia (Table IV). The frequency of el- tions in mother’s milk are glutamine, glutamate, and tauevated BUN levels was higher during TPN, but the differ- rine.a Studies in fetal sheep have revealed that glutamine
ence was not statistically significant The GLN-supple- is ‘quantitatively the major transported gluconeogenic
mented group had fewer days on TPN (13 us 21 days, P = amino acid-u and our rates of delivery are below the rates
.02) and correspondingly shorter time to full feeds from of transfer measured in these studies. Therefore, it is only
the start of enteral feeding (8 us 14 days,$ = .03), and spent in the ti~cial setting of a hospital when the baby takes
less time on ventilator (38 us 47 days, p = .04). During the nothing by mouth that GLN is witidrawn from the infant
because it is not provided in standard TPN or in usual infant formulas. We therefore started our dose-response
TAW.S n
study providing a solution that contained M% of amino
Ckomcierisiia tistudywjn
acids as glutamine, and with no evidence of short-term
GLN’
Conb-ol
toxicity we increased the dose to 20% A small number of
22
22
infants were studied at the 25% leve~ but no clear advan8112175
6002165
~ifi weight (g)
tages were observed.
Cestational age (weeka)
Apgar score (5-IniIIUt.d
Sex (M/F)
Entry age (days)
fvH {+1-)
Bir& nunk
# single bkths
#twins
# triplets
Delivem IV to C)
Baaetin-e
(p.mol/L)
Plasma glutamate (prnol/L)
Plasma ammonia (prnoI/L)
BUN (mmol/LJ
*No differences between groups.
Plaama ghtamine
26=1
6S z 1.5
7/15
4.1 z 09
3/19
1.2 ? 0.4
15L22
5!22
0122
2622
6.4 z 2.0
12/10
3.7 ? 0.8
1/21
1.4 ? 0.7
16/22
4122
2122
9113
5/17
363*139
159 t 132
7=5
6.7 ? 22
X42169
187 = 110
6=2
7.0 ? 24
S@kty of CIJVAdministration
GLN appeared to be well tolerated in this study populations, as indicated by the within-normal levels of plasma
ammonia and glutamate and improved GLN levels in both
weight classes. h’tong infants = 800 g, the plasma
glutamate levels were higher in the GLN group, but these
differences were also seen in this group at baseline (’lhble
W). In the< 800-g group, plasma glutamate was slightly
higher (177vs 142 psnol/1+ NS), but not significantly. Moover, the infsn~ showed no developmental disorders to
indicate any neurotmdc e.fkts of GLN orglutsm@e. These
findings are s“darto those of aGLN dose-response study
-. -
;JUN I o 1998
3/
.._ __ .—..—. —.
-“
,. —..
- - .-.
=-- —=-= .— —.. &-. _.
—..
-.. . . , .- . . ..— -----
.
L4CEY ET AL
7s
.
.
. —.. .,. . . .
Vo[. 20,
No.
I
in hcafthy adulfsm where increasing loads of GLN did not
1oo-
resiuft in clinical toxicity or abnomd glutamate levels, buL
there was a nonsignificant increase in glutamate in pro-
portion to the GLN dose.
There was, however, a greater number of GLN-supplemented infants with at least one episode of high (s &9
mmol/L) BUN during TPN in both weight classes (Table
50
GLN
J -
0
30
60
90
120
Length of Stay (Days)
Fk. 2 The percentage of infants hospitalized over rime for infants in the
control (n = 22) us GLN-tJ4 (n =22) groups. At etier weeks of tros
pital stay, the perccnrdge of infants in rhe NICU wa5 approxhrmtely the
same for bdr groups. However, at tater weeks, more contxol infants
remsined in the NICU; at 80 daYs, eg, < 25% of the infaru in the GLNsupplemented group remained hospitalized, compared with >4096 of rhe
control infants. Cm promotional harard regres-s”mn revested that length
of sray was determined by a signKicanr”mtemction between bti weight
and the treawnent received (J < .03). Therefore, subgroups of two bfi
weight cohorts (c 8!M and z S&l g) were crealed to control for the effec!s of birih weight on thii response.
W), altiough this difference was not significant Because
of the stight elevation in BUN of the GLN-supplemerrted
group that was observed as the GLN dose was increased,
the 20% GLN supplementation appears to be appropriate. We further analyzed the total nitrogen intake and
N-kilodorie ratios of the two groups in each weight
class. There were no significant differences in these
indices either by week (week 1 through 4 of TPN) or
averaged over the days of TPN (data not shown). In the
Z&JO-g infants, the only differences seen were in week
1 for total nitrogen (conwols 0.372 #kg per day m GLNsupplemented 0.804 @g per day, 4< .02), artd this reflected a higher overall intake of total prote-in for week 1.
There were no significant dtiferences in N-kcaf ratios in
either weight class.
~fica~ of CLNAdministratwn
Among subjects 2800 g, a greater number of GLN-
TALUS IV
Trm wright ctassrs
..
n
Birth weight (g)
Geatitional age (weeks)
Apgar amre (~minute)
Ses (WI?)
Entry age (days)
NH (+/-)
Birth number
# siogle &As
#twins
# triplets
Delivery mode (vaginal or c-section)
Baseline
plasma glutamine (p.mol/L)
PlaSma gtutamate QUnolfL)
Plasma Smrooois (ploolm
BUN (mmol/L)
Outcome”
Vsodfator days (total)
~ Of ~y, BWH (days)
Length of S@, total (dsys)
TPN days
Day of fimt eoteml feeds
TimetofuUfee&
Plssma $Utamfne flurrolm
E =b&r’W’K&y
BUN 6nrool/L) (d- IPN)
FrequeacY Ofhisir BUN b Ofpatientq Tw)
Frequeocyofpc8itive adb(no. 6fPs~TPN)
=~@Aw&- b dwh% m
664:s2
25.1 * 1s
S.8 z L4
W8
42x 42
318
12% 0.4
9/11
2/11
0/11
6/5
3252143
2Y2.* 123
826
7.6 = L4
47==
go=~l
lo4*16
21*11
929
1429
225262
142*48
NS
917 Y 134
26.6 x 21
6.6 z L6
4f7
3.720.7
NS
0/11
L3 =“0-5
6/11
Wll
0/11
S/8
K
NS
R
NS
Ns
Wt5:lls)
27.0 z LO
7.3*L2
712
4.02 LO
0/10
L6 = of)
6!9
1/10
2/10
lJ8
288 * 112
168 a 116
6*1
6.4 =21
NS
NS
NS
N:
NS
NS
Ns
NS
Ns
Ns
Ns
Ns
z
R
Ns
NB
Ns
NB
X8
m
NB
Ns
NB
E
E
I JUN 10 1998
.32-
—. ..-— ---- ,..__--.
-.
.x-----
-.
—-—
.
.
,
_
. . . . . . . . .
E—
sIIl)plmne IIfcd II Ifa JI1.S had posiLivc Mood cultures durin:
TI’X (5 M 0, f) = .01), bill not for [)\\’Ii lcngtlI of slay (5VS 3,
NS); lhis \fas lh(, otl]y difference of note in ttlCSC tifan=.
IIis finding is inconsistent with other studies of GLN
supplementation in hum<ws. 21~ This difference may have
been a artifac~ of tile small sample size; it underscores
the need for larger clinical triafs in this area
In the ve~-low-birth-weight (c 600 g) cohort, GLNsupplernented TPN was associated with shorter time to
full feeds, fetrcr days on TPN, reduced LOS in the neona-
tal intensive care unit, fewer infants with episodes of low
WEC, earlier initiation of enteral feeding, and fewer days
on the ventilator. Reduced length of stay with GLN supplementation has been reported in two other recent clinical
trials?)m and may have been attributable to improved nutritional status,?’ enhanced bowel mucosal development=
and nommhzation of body Waterz’=a’fhe decrease in days
on TPN along with earlier enteral feeding may have contributed to improved [email protected] cell maturation and nutrient absorption in the treated infants. This might have led
to the observed earlier discharge from the NICU. Berseth
and Nordyke’; reported that in tlds Klgh-risk population,
early provision of enteral ntrtrients.was associated with
earlier maturation of intestinal motor activity. In addition,
higher lymphocyte counts were noted dfig week 3 in
the GLN-supplemented, < 800-g infants. This is consistent
with the recent repott of Ziegler et al~ who found a sigtitcant increase in lymphocytes in recovered bone marrow transplant patients who received GLN.
(2mfitionrzl Essentiality of CLN
It is not clear whether the 2 800-g group may have had
a larger treatment effect if the gender distribution of infants had been more simila. The fact that the c 800-g
infants showed a discernible treatment effect may be
an illustration of the “conditional essentiality” of GLN,”
whereby the physiologic stressors on the extremely40wbirth-weight infants may have generated an even greah?r
need for exogenous GLN.
Stdy Umitafimrs
Because of the relatively smalf sample size of this pilot
study, differences may have been undetectable statisdcally,
although some of these differences maybe CJiItically *nificanL The size of these infants also made it difficult to
obtain blood samples in suffkient quantities for a more
detailed metabolism study. In additiom thedecisionto Mtiate enteral feedings is made subjectively by the d
rather than on the basis of definitive criti Other po$+
sible confounding wwiables include varying tie*
tetis for transfer hospitals and multiple unknown mattw
nal risk factors. Despite these limitation% this sW*
provid= evidence that GIN supplementation ap~ @
be safe in this population of prematum lnfantsthroughout
their stay in the NICIJ. Nevertheless% the full impact of a
neomtal intention cannot be ful!yassumed until a much
longer period of time has* i% untfl the children
have reached school age (as in studies of 3ron deficienq
anen@ etc). llwre.fore, a larger study withlor@errn fol10WUp would be reqlimd to un&@VOCd&d~ti
safety of this tr4mtent.
---
Concl:tsio?u
GLN supplementation may reduce the length of stay in
the hospitaf and promote enterd nutritiOn in these neonates. This prelimiruuy study should serve= the basis for
a larger multi-institutional, randomized, prospective, clinical trial of GLN supplementation to facilitate appropriate
evaluation of GLN in neonates as well as of tie multiple
variables present in this patient population.
ACKNOWLEDGMENTS
The authors thank Elizabeth Chambers, MS, Lourdes
Holejko, BS, Ramona Faris, MS, and Elaine Brom MS,
for their technical laboratory expettisq Danny O. Jacobs,
MD, for his generous medicaf and statistical advic% and
the staff of the Neonatal Intensive Care Unit for their excellent care and professional assistance throughout this
study. We also thank Ester Awnehwm4 Ma RD, and N~cy
R Ehrlich for their helpful comments and suggestions for
the manuscript ‘IT& work was supported in part by a grant
from KabiWrurn, !%.ockholm, Sweden.
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4. Ehrem G, Hsck&%eMJu4M IL Protein melabokm ort&
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‘ JUN f O 1998
33
—— .= —.. .=-.. -.—
.-
so
—-.. . -_ *,. ,=
19
I iammmpw.~ F, \vemcnrr.wl J. Ali R, ct al Addition of glutaminc to
total pawnleral nutition .af{er elecuvc abdominal surgery spzms
free gluramine in mu.sclc, counteract the fall in muscle protein [email protected], and impro= nitrogen bakmce. Am Surg 2m4W-IGl, 1989
20 Z@er TR, BcnfeU K, SmiLh R-l, et al. %fery and metabcdic effects of
Lgluramine =abmnisuation in humm. JPEN 14:13= 146S, 1930
21. Ziegler TR, Young IS, Benfell K, et d Ciinicd and mctabrrlic efficacy of gluramiw-supplememcd parenteral nutrition followhg bone
marrow oansplamation: A double+ lind, randomised, controlled trial.
Arm Jrrtem Ned 11G621=, 1992
22. Steldc P, Mertes h’, Puchstcin CH, etal: Effeaofparenteral ghrtarnine
peptide supplements on muscle glutanrine k and nitrogen bJamx
afrer major surgety. Ianccl 1231-233, 19S9
23. ScJdoerb Pi?, ~ M: Total parenteml nutrition @Jr glutamioe irr
bone marrow Smnsplantion and other clirkd applications (A randomized, doubleMind study). JPEN 17:407A13, 1993
24. O’Dwyer H, Scott T, Smith Rf, et ak M%orouracr“1 mciciry on arnafl
intesdnal mucosa but not whhe blood cells k &creasdby@ramine
[Abstr]. Ciin Res 35369A, 19S7
25. OTMyer ST, Michie HR. Ziegler ~ et aL A single dose ofendotoxirr
increases intestinal permeability in hdthy humans. tich Surg
123:145$1464, 1938
26. Fox AD, Mipke 5A DePatda .f, et at Effect of a giutanrim?mpple
mented enterd diet on metAowexate-induced errterocofitis. JPEN
12325-331, 1988
27. Souba WIV, XJimberg VS. Hautarnaki ~, et al Oraf gluram-me *
duces bacteriaf UarMcetion following abdominal ra&atiom J S@
Res 431-5, 1990
2s. WanZ X-D, Jacobs DO, O“Dwyer ~, et al Ghrtamine+nriched
Par&deral nutrition prevents mucosal atrophy following massive
bowel ressdion Susg Forum 3944-46, 198S
29. Jacobs DO, fhrrs DA Mealy IL et sf: Combmed etlecta of glutamdrte
rat Jnteaf.ine. Surgery
1968
30. Heltorr WS, Smith RJ, Rounds J, et d Glutandne preveota pancreatic atrophy and fatty iiver dui.ng elemental feeding. J S@ Res
48297-203, 1990
31. Helton WS Jacobs DO, Bormer-Weir S, et XL Effeds of glrsfamfn~
enriched parenteral nutrition on the exocrine pancreas. JPEN
14~ 1990
32 Hong RtY Rounds JD, Hekon WS, er XL Glufarrrbw preserwa JJver
glutarldone after lethal hepatic injury. AnnSurg 215114-119,1992
33. Robkon MK Rodrick MI+ Jacobs DO, et at Glutafhione depletion
br rata impairs T@ snd microphage hrrnrune frmctJon Ardr Surg
1043%364,
—-—
.- _.-<
~70/. 20,
J.ACEY ET AL
and epidermal growth factor on the
..--AS-.
—-—-—
__”.
—-——
______
Are. I
12S29-35, 1993
34. Romtiau JL A re,ic~ of she effects of W~~inc~nnCtled diets on
experimentally induced cnwrocohtis Jf’CN l$l~~loss, 1990
35. Ostertag SC, bGsmma EF, Reism cU et ~. tih Cnlcral feeding
does nor affect the incidence of n~rxns enIer~Olit~ pediatrics
~:27&2S0, 19S6
36 Modiiwation of BemL Erich, and lkr~~cyer. IN Methods of Enzyrnadc hsfysis, 2nd cd, Bergmeyer HU (cd) ~’erk+g Chemi Weinheim
Academic Pr-, lnc, New York, 1974, pp 1704-1702
37. HP: t.-Gluwrdne demrmination M’ith glutis md gtutanrate
dehydrogenase. IN Methods of Enzymatic Analysis, 2nd ed,
Bergrneyer HfJ (cd). Verbg Chcmi Weinfreirh Academic Press, fnc,
New York, 1974, pp 17 J9-1722
38. Mondrac A Ehrbch GE, Seegmiller JE An cwm~~ ~-tion
of ammonia in biological fluids. J bb Clin AJml 66:526-531, 1965
39. BeAn@on ~(ed) $hr@efi D@hmary and tiCyC]O@i Of h
.-ry Medicine and Technology. N% Saundets Co, Philadelphia,
1ss4, p 192
40. Kleinbaurn DG, Kupper U Mufler K12 Applied Regression hafyais
and Other Muftivariable Methods. PW$Kent Pubting co, Boston.
198s
41. Wu PM(, Edwards N, Srom MC: Piasrna amino acidpattem innerrod term breast-fed infants. J Pediarx 109347449, J9S6
42 TJerz NW (cd): Ciinicd Guide to Labomtory Tes@ 2nd ed. WE
Saunders, Philsdelpl@ 1990, p 4S
43. TIets NW (cd) Clinicai Guide to LabomtoV Tests, 2nd ML WB
Saunders, Philadelphia, 1990, p 566
44. Clark RM, Ross%. HiJJ DW, et af. Withindsy lariation of taurine
and other rdtrogen substanms in human miik. J Dairy Sci 70:776-7S0,
19S7
4S. f..evitsky LJ+ Stones@et RS, hfmk L et aL Glutarnine carbon disposal and net gluramine uprake in fetuses of fed and M ewe%
An J phySiOl 1993;265:E722-727
46. &+&ings M Young f+ BenfeJl K @ *. Gl~ Ched inrnve
now feeding attenuates fluid expansion foUowing a standard stress.
Arur ~ 214~, 1991
47. Berseth m Nordyke (1 EnteraJ nutrients promote posmatd rnaturaticmoffnteadnd motor scdvJtybrpmte.mr tnt%rts Arn JPhysiol
26&Glo461051, 1 9 9 3
48. ZJegler TR, Bye ~ Perainger Rf+ et aL Glutamirre-enrJched
par-entenf ntition hueases cimdating lymphocytes sfser bone
marrow Uar#sntation JFEN 18 (%ppl) l= 1994
49. keyx Wire DW. b @tamhle s CWfitiOIdy ~tid %ndnO
add? Nuw Rev 48Zr7-309, 1990
.
.
-..
I JM 1 0 1998
.
.
3 EI-K)IIW
—.,.. -. .. . ..— —— ..l. —-., ——-——
-—-— . . . . . .- ..— .— ___ . - ..-
a
L-Glutamine Supplementation in Home Total Parenteral Nutrition
Patients: Stability, Safety, and Effects on Intestinal Absorption
LYN HoruwsY-Lmmj MD, MOSIIE Srmz, MD; PATRICIA BROWN, RN; M.ARK KMNG, RF%, MS; DAWD Pwusrom, MD;
AND MURRAY F. BSENNAN, MD
From the Gufroenkrolog ond Nut&ion Seraicc, flu Depadment of Media-at, the Department of
Memoriol Sban-KefteAg Grnrzr btcr. New Yod
study was conducted to determine safety and
of bgfutamine when added to total parenterid nutrition
(TP~ solutions of p~ents receiving TPN in the home. Stability
studie5 were fii performed on various concentrations of
@rtamirre in TPN solutions mbced by the Pharrnix metho~
llmse showed that glutamine was stable in home TPN solutions
for ai ix 22 days. The daily home TPN solutions of seven
ABSTRACT. A
efficacy
.5@1e patients were then supplemented with glufarrdne at a
d o s e o f 0 . 2 8 5 #kg of body weight for 4 week. llte
glutamin+TPN solutions were prepared weeldy. Five patients
received
. . the full 4 weeks of glutarnine-TPN. In NO patients,
a&mmstmD‘on of glutarnin&TPNrmxtwes
“
wasstopped at the
end of week 2 and week 3 because of elevations in liver
enzymes A third patient’s liver enryrnes rass at the end o f
SwgeW ad the
Drpart.e.t
of fiannaq,
of the glutamine-TPN solution. Plasma levels of glutarnine
increased during the fmt 3 weeks of supplemenralion but
these increases were not statistically aignbkan~ DXylose
absorption studies performed before and after the admiition of gluramine-TPN did not reveal any improvement in
smaU-boWel absorptive qmcity. In conclusion, stable glutamine-TPN solutions for use by home TPN patierts can be
formulated. However, supplementation of home TPN solutions
at this dose was Mated with apparent hepatic toxicity
and did not demonstrate a beneficial effect on intestinal
absorptive capacity as measured by r+sylose absorption
Therefore on the basis of this study, routine supplementation
of home TPA’ solution with glutamine mot be recommended
@wnal of Parenteral and Enteral Ntiritwn 18268-273, 1994)
week 4. These abnormalities subQded after discontinuation
Patients with various forms of 12MToin~ failure of adenosine tIiDhOSDhate, Durines, and Dwirnidines.2
require long+rm home parenk nutrition (lv~ the There is a positive c&relati;n betieen t& concenbapast 3 decades, extensive research resulted in a tion of glutamine and the ra~ of m u s c l e p r o t e i n
nutritionally and metabolically adequate total parenteral mthesis. Glume is a @or fuel source for rapidly
nutxition (lTN) formula that includes glucose, lipkis, dividing cells such as enterocytes, fibrobkts, colonoSlliItO acids, rnirwds, vitamins, and trace elements.
~ and reticulocytes. It is therefore the preferred
Cartrrtercial amino acid solutions for use in TPN fuel for the srnalf-bowel mucosa.
include the essential amino acids tryptop@ leucine,
It has been suggested tha4 under stress, ghrtamine
isoleucirte, threordrte, histidirte, lysine, valirte, methion- may act more as .an essential amino acid. Studies
ine, and phenylalsnine and the nonessential amino have documented decrease in glutamine pools during
acids serine, alaninq tyrosine, argirdne, glycinq and catabolic iIlness or stress? Patients receiving glutamhte
prolim Ghrtamdne is a nonessential amino acid that after an operation have beerr shown to have a
has not been a component of TPN amino acid scktiorts, decreased catabolic effeCL4 Those patients had impmainly bmuse of problems arising ffctm the difficulty roved nitrogen balanc% muscle protein synthesis,
of getting glutarnine into sohrtio~ its lack of stability and irttracelluliM muscle gluuirnine levels compared
in TPN solutions, and the fact that it is nonessential with a group receiving TPN without glutarnine
Glutamine is, however, the most abundant amino acid
~erehas beeninterest inaddirtg glutamineto TPN
in the body. It makes up approximatdy 60% of tie
because it may be conditionally essential duxing
free artdno adds found intracdhdariy in skeletal
musckl It has several important ftmctionst It carries periods of stress. To dam reported studies in humans
amino nitrogen from peripheral tissues to the splsnch- have described mbdng gMarnine-TPN ~~=m~=a
nicarqit iaartql orfactor inrenal a c i d - b a s e fiquent basis to keep the ntWxes
regdafiow and it donates nitrogen for the formation studies in humans were performed on hospitalized
patlenk. We have urtdataken a study to determine
whether glutamine can remain stable in a TPN solution
for prolonged periods to allow at-home use by patients
Readve4fapobBcdoqJuly~ - ~
~fmtiw~~~
receiving TPN. We aIso avaluated the clinical safety
&mspmbxaadrqriotmques& M9dkGMD, MemoW810sd@ of these SOhltiOCtS and the$r potential effects OfI
teringCaacuCenta, U75YorirAvcnuq NcwYodGNY10@L
irttestinsl absorption.
2a
-. . .
35
..
-.
.-. -.— —+ ., .--— --- —.— . . . . . . .. —.... . . . . . . . . .
M,7J-JI,,:C
hlATEl:l.41S ,\ND MLTIIOIX
.—–-.=
i
ammoni:i, glul:unic acid, Pli, amiilo acids, Nerilily,
p:uticul:im Inattcr, clccLrol@ col~cel~tr~tiolls, c o l o r ,
d e x t r o s e c o n c e n t r a t i o n , viso.~ aPPcm.~~cc, and bag
A n I n v e s t i g a t i o n a l N e w Drug apphcatioIl W:LS fdcd
witli tlw Food and Drug Administration for LIIC usc of
glutine in TPN solutions. The study protoco] was
a p p r o v e d b y the I n v e s t i g a t i o n a l Revic~v B o a r d a t
Memorial Sloan-Kettering Cancer Center. Patients were
weight were quanfiitatcd in tripli@c for cacl~ fommla
on days O, 8, 15, and 22.
recruited from our home TPN population. All patients
gave informed consent before joining the study.
c o m p o u n d i n g p r o c e s s w a s u s e d becau5e it a l l o w s
The solubil.i~ of glutarninc in solute-laden
been problematic in the Past- The
has
Patients were eligible if they received TPN in the
home for at least 5 nights a week and fulfilled the
folfowing criterix age >18 years, no requirements for
insulin, serum bilirubin level <1.5 mg/~ s e r u m
cretinine level <1.8 mgl~ and no chemothempy or
xadiation therapy in the preceding 6 months. Seven
home TPN patients (thee womem four men) were
studied. Their ages ranged from 3S to 81 yeas, and
their weights ranged from 45 to 76 kg (Table l). AU
patients had been receiving home TPN for at least 1
year (average 8.4 years), and all were clinically stable.
Patients were removed from the study if they had an
elevation in LIT results of 2 times the baseline; an
elevzition in amrnoni~ blood urea nitroge~ creadnine,
or glucose of 1.5 times the baselinq or any new physical
or mental status change.
.Glutamine-TPN Mkture
--”+
*
solutions
PnarrrdxA
complete solubilizadon and solute Urdformim in the
preparation of the enriched pmenteral, sOhJtiOns. This
c o m p o u n d i n g process allows the glutamine to be
solubilized firs4 before it is combined with any other
components. In this method, the sterile water for
iqjection is added to a stainless steel mixing tank in
sufficient quantity to ftdfill the total prescription volume.
The ghmmine is aolubilized in the sterile water for
iqjection before adding any additional nutrient compo
nents. Once the glutarnine is in solution, all other
components are added in a sywemadc way m insure
complete dissolution. ‘i%e pH of the compounded
solution is adjusted with either glacial acetic acid or
phosphoric acid in quantities suftlcient to maintain a
pH range between 5 and 7. The refmctive index of the
compounded solution is also tested to ensure complete
solubilization
This process also involves a cold sterilization technique
of two membrane filters. This ensures that the ghhrrdne
is not exposed to a heat.kd process 11-mt can catalyze
product degradation and promote the generation of
potential toxic by-products.
Paiicnts
... . . . . . . . . . ,. .::.
26:1
l..(ll.lTfX\l!>~lI Sl\l’I’l.lChl l\-l’?iI’loN
1991
StaMliW studies of ghrtarnin&TPN solutions were
performed before the solutions were administered to
patients. Glutamine was ndxed in TPN solutions in
concentrations of 1 and 1.5% wtko~ and solutions were
kept at 4*C for 22 days ~able B). ‘fhe composition
of tAe mhrtures was calculated b give a wide range of
concentrations of amino acids, gluco~ electrol~ and
trace elements in an effort to duplicate the various
formulas prescribed to home TPN patients. Glutamine,
Ghdamine-?PN Administratwn
Glutarnine was added to TPN solutions at a dose of
0.285 @g of body weigit Thereforq a typical 70-kg
Pent ~tivti 20 g Of glutarni.ne per day over a lo-hour
to 12-hour infusion (Table Ill). Oux regular home TPN
fotmuda typically includes amino acids in the amount
T-1
Palti &mct@tk
Faoalt.
aa
1
M
2
M
M
s
4
F
6
F
6
M
7
F
TPN, toralpr@entd nutritiqs/p,
g
81
45
64
71
81
42
23
-pOsL
Wdght
(W
64
7a
76
49
62
n
46
nmton
TPN ~)
6.
:
;
16
6
~
~v @=mR@w
T&kular CanCequ’pan@bOIVelresedOnarrdmdbtiOn
Intesdruf ~
Colatr anCer* Snrall-bowd and Iightdarl K$ClinO
Uterine eaner$@srnalttiwd ruedknsndndiatim
&Ohn’sdkU$e& srrdtb+ mecfbn
Maba6rm*ar@-bmd~
——-*
.
,
. ..-. -~ -. —.-=..=..— ..-..—. ..—— — -— -— . — .—— _ _—. ._ —_.._. .-
:~yo
O( ~ :g/k:
IIol:wliy
{Jf botl~ ly{!iglll ‘i’tt~:
1)311 of IIIC to@” .mnillo
g](II:IIIIIIIC’
tf’; LS {’~lil.Sl(l
L’I-ed
acifl (I05c. TIw rcinaindw O f tile
glumminc-TPh’ solulion W.ZS Ixzwt
fomlula of each indi@ual p3ticnL
OIi I.lte
rcgulm TPA]
These
formulas
contin amino acids, dextrose, electrolytes, trace clcmcn~, and waler. Wtarnins am added on a daily basis,
and the lipid is given separately. Xo three-in-cmc solutions
/
i
,.[),)/
I!qy,tj ,.:,’ *,,
,8,
/LJo,
>3
plasma ~nin~
acids were Pcrfomlcd as
collected in lubes con~n.
ing ISYC etllylenediantinelelr-aacctatc ~d kept on i c e .
Piasma was separated by centrifugation and stored at
– 70°C. Amino acids were separated as follows 400 ~L
of plasma was mixed with 400 AL of Semprep (Pickering
AIInlpCS of
follo\vs: Blood
samples
were
Iaboratm-ies, Mountain View, CA) containing 250 pmol
were used. These formulas had been used for at least of L-norleucine (Si~ St- his, MO) per liter as m
6 months before the study. On the first day of the internal standard The resulting deproteinized plasma
study, the glutamine-TPN formula was adm-tistered in was then centrifuged, and the supematant amino acids
the Day Hospital to each patiem so that unexpected were separated by high-perfom,ce liquid chromatogclinical responses could be monitored. Subsequently, raphy (Perkin Elmer, Pltileld, NJ) with a lithium w-on
patients used self-administered @.arnine-TPN solutions exchange column. Individual amino acids were identified
at home for the duration of the study.
and quantiied by postcolumn derivitization with ninhydnn (Pickering Laboratories). The response factor for
~Xylose Absorption Test
calculation of glutamine concentration was determined
A Dxylose absorption teat was performed at baseline
and at the end of the study. Patients were given 25 g
from an external glutamine standard formulated from a
1:1 mixture of ~ WO1 of pure Ct’ystahe L-ghkUtIhe
of o-xylose orally. They had serum mx~lose levels
determined at O, 1, 2, 3, and 5 hours ailer drinking the
D-xylose solution. They also were asked to empty their
bladders at baseline, and a Shour urine collection for
measurement of mxylose was obtained.
from commercially available amino aad standard solution (&-nirto Acid Calibration Standard Pickering Lab
Moniton”ng
B1ood tests including complete cell counL venous
ammonia concentration, serum glutamic oxaloacetic
trmsaminase concentration% serum glutic pyl’uvate
concentration, alkaline phoaphatase concentration, lactic acid dehydrogenase concenuation,
bilirubin level, blood urea nitrogen leve~ creatinine level,
and glucose level were performed. Plasma amino acid
profiles were also obtained.
(Gibco, Grand Island, NY) per liter in water and Semprep.
Response factors for other amino acids were determined
ratories).
The blood tests, including amino acid profiles, were
done at baseline and at weekly intervals for the 4 weeks
of administration of glutamine-TPN and for 2 weeks
thereafter, when patients were receiving their regular
TPN wi~out glutamine. Patients were called eveg other
day and were asked about any new physical or mental
.Symptorns.
S@tlLm
Stability of Glutamine7PN Sohdions
The stability studies on the four glutarnine-TPN
formulas indicated that the glutamine concenb-ation
T,uu III
GMam”ne, anu”no acid, and ubrim in indiuiduat &i/y 17Wwfuh”oas
Patieru
1
2
3
4
5
6
7
TPN, U pammeml nubition.
Gluaninc
(2)
1s3
2 0
2tA
14.4
14.0
2L4
12.o
TOtJ.1 doliu
-%~~lnm
mhtian)
2340
a
2674
ZMl
1779
. 2314
w
AmirlOdds(g)
excluding $utamtne
.
323
513
64-0
26.1
66.6
M-o
=0
6
Dayo
-u
D8yls
PH
Dactmse (%)
6m
loaoo
6al
m
color (xlutuntk)
P=tkuMematter
Anunordunl (Jlpm)
Glutwnic M
Me(%to$$)
Ml
<M
w
Fs
<16
M
H%
PA22
Dqa
6.s
9271
Pm
24.6
Pm
<t6
w
PaIxncnctu# &
as,
-729
-2S1
Pm
w
+.09
-
-
“PZ3.
—
---
37
“
—...—. —..
. ..——.— . . . . -— ..- -.. — ________ .
r e m a i n e d Irilhin Ultilwi SHIM Plmnwcopcia guiriclincs
w,hen so]utiolrs \vc!re kcl)L aL 4°C for up Lo ~~ d:iys (Tab]e.S
IV and V) De\lrose aml CICCWOIXC lCVCIS remained within
United SUlcs I’iwmacopeia limiLs No significant increase-s
fi guWtiC acid or ammonia conccntmtion were detected.
The other amino acick in the SOhtion also remained stable.
Sterility and pyrogcn assays were negative for all samples
Color, PI+, visual appeamnce, and bag weight all remained
within acceptable limk
Or glulalijnc SIIl)l)!CI)ICI)
bc:wl.
l:ILI{)ll, IJIIL dlell a gr~du~ dcclilw
AfLcr 4 weeks of glt]tmninc suppkmenmtion, the
mc.an ph.sma gluiaminc Icwi d e c l i n e d L O ~W presupplenumation level. Two weeks after discontinuation of
glurarnine, the level had decreased
L O 453
~ 82 p-rnoVL.
A WiJcoxon matched pairs cesl was performed, compar-
ing each mean plasma gIuiaminc level obtained with
the levels for every week (eg, baseline compared with
values at week I, week 2, week 3, week 4, and
posttreatrnent weeks 1 and 2). There was no statistically
sigtilcant change noted despite the trend toward an
Oaitpatieni Outcome With Glutanzine-TPN
early increase followed by a subsequent decrease in
Pive patients received glutarnine-TPN for the entire plasma levels. Mean plasma levels of taurine, Lyrosine,
4-week study. in the two other patients, glutamine-TPN m e t h i o n i n e , asparagine, aspartate, histidine, alanine,
administration was discontinued because of elevation glycine, glutamate, and serine did not change signifkantly
of liver function test (LIT) results at the end of weeks compared with baseline values. The mean plasma levels
2 and 3. One of the five patients who completed the of tryptophan and phenylalanine increaed signifkantly
4 weeks of supplementation was noted to have elevated from baseline to w~k 1. Valine and isoleucine levels
LIT results at the end of week 4. AU patients in the increased significantly from week 2 to week 3 and from
study had stable LFI’ restdk for the year before the baseline to week 1 postsupplementation, respectively.
study. The specific changes in liver enzymes in the Lysirre and leucine values decreased sigtilcantly from
three patients are listed in Table VI. Patients who baseline to week 3 and from week 1 to week 2
developed an incrme in LFT results of 2 times baseline postsupplementation, respectively.
were removed from the study. Ammonia levels did not
increase significantly in any patients. The liver enzyme ~Xylose Absorptwn Tests
abnormalities had returned to baseline by 2 weeks after
DXylose absorption tests were performed in six of the
discontinuation of the glutarnine-TPN formula None of seven patients. Patient 3, with pseudo-obstruction did not
the patients who developed increased LFT results had undergo this test because he could not tolerate drinking
any complaints referable to the liver. Because all values the solution He was also the patient who received only
returned to baseline rapidly, no ultrasound, computed 3 weeks of glutarnine. All patients began with markedly
tomogmphy ~ or liver biopsy was performed. Patients abnormal Bxylose absorption ‘here was no evidence of
developed no physical or mental status complaints. Of any significant improvement in in@stbwl absorption of
note, snecdotally, three palients described a sense of wryiose after 4 weeks of glutamin.sTPN in @e patients
irtcreased well-beiig while receiving the glutarninesup or after 2 weeks of glutandne in one padent (EQ 2).
plemented TPN solution
Blood Ieveki of mylose at hours 1 snti 5 did not increase
after glutamirte supplementatior4 nor was there any inmease
Plasma Amino Aa”d Levels
in $hou utinsuy ewxetion of r@OseThe plasma glutamine levels before glutamine suppleDISCUMON
mentation and at weekly intervals after beghing
supplementation are presenk-d in F@re L At baseline,
‘lMs study demomtmtes the f-btity of admhMH@
themean level was560*60p,moVL ‘I%is was a TPN solution containing glutamine to home TPN
st.aMically similar tolevelsof 634= 31prnol& and patients The Pharmix method was used to mix the TPN
627 a 28 p.rnoVL reported previously irt healthy controls’ solutions.’ When TPN solutions were supplemented with
Them- level roseto655*46pmoVL after lweek gltts.min~ they remained stable in solution for at least
TAsuV
AW&ddddi&dU&hhdODat daY 0.8.15. aadZ?
Antno * (%)
D8yo
ma
Dqts
D8yZt
-We
Glutardne(=l.11%)
lm.oo
lm.oo
10MO
10M3
10&64
1-
10L14
S3.02 (NS’)
XW3m
9Z69(NS)
96s3
Glycine
lW.W
100.OD
1106s
9319
9s69
9249 @S)
ml
lW
im66
lmoo
104-M
RM6
W.91 @s)
lsoleudne
lW.00
SLm
lM.12
ml
U&16(NS)
%.11 (?S)
90s7(N5)
9414 (M)
9267(NS)
00.8t
95.2$(M)
0266(NS)
%.61
Vdilw
96s4(?4s)
10WO
l12M
.
Nanotdgnubnt 11-ierewssno s@stka@sknttbtkre$se
in=Wti Ad~ Cnuthtrstperiell
lmoo
100.00
100.00
100.00
lo7m
104.61
10M1
lm13
-- -.
9171
z
9L76
m7a
elm
ma
‘
JON ? 0
199g
..-. —— - — . . . -. —.. =- —. —.-— . . -. —:—”.
272
liOIWSIW.lJ; WS 1:1’ Al.
22 (I;iys Brx:luse of t h i s Stability, lJIC ~ags conla.inin:
I)Ic’ @uLlminc-’H’N so]utions c o u l d IX rjc]ivcrcd to th?
paLicnLs’
homes on a weekly b<ask, ~d dtily comporrnding of Lhe s o l u t i o n s W.W unnccessar-y.
I.‘1
. .
Animzds receiving lon@crm TPN may develop intcstins.i mucosal atxophy, pardcuhrly if they have no oral
intake. h has been posh-dated that this atrophy is caused
or worsened by the lack of glutamine? Grant and SnydeP
found that rats given @arnine-TPN would maintain
mucosal weight in the stomach and colon but not tie
n
small bowel. ODwyer et a.i reported that rats receiving
glwmine had increased intestinal weight DNA conten~
and intestinal villous heigh~
W
1,s, AI()
i n t e s t i n a l vjllrrus hcigl)t V&s noL nlwlsu]-c(l ill
.Y
our
sLudy. Iiowcvcrt the wxylose absorption slu(iics in our
patients did not jn(licatx any improvement in snk-dl-intcstinal absorption after 4 weeks of glutm}inc supplemcntaLion. The o-xy]osc absorption test is the standard
clinical test for cval uating the absorptive capacity of
the small-bowel mucosa. However, it has some limitations. k measures xylose absorption spec-fkally and
does not measure other types of nutrient absorption. It
is also not sensitive enough to pick up subtle changes
in absorptive capacity.
A possible explanation for lack of improvement in
absorption is that our patients may have already achieved
TMU VI
$ecirlc !iueruqme changes in thrm$mtienfs
Highest
Bawline
value
Bihrubin NL = 0.6-1.2
AMdine phosphalase NL = 3&126
WNL=WO
LOH NL = 313-618
.%mrnonia NL = W64
.
.(LT NL = 5-40
0.7
175
3a
520
44
16
126
946
52
41
Patient 6
Bilimbin NL = 0.gL2
M!diie phosph= NL = 3&lLM
AS7NL=540
LDH NL = .3$180
~onia NL = 18+4
ALTNL=5-10
0.3
151
4a
lm
63
68
2?6
m
191
41
%
Pa!ient 3
BihnMn NL - &LO
Alkaline Phospha- NL = 304
m
0.5
03
152
22
126
202
33
MY
272
24
20
ALTNL=$37
LDH NL = 60-200
AnullOnia NL -13-64
02
m
36
276
Nor done
24
0.7
206
O.a
MTNL= 1C47
2 week
dur mdv
0.7
131
21
37
la
32
142
171
90
-.
m
57
NI+ Nomd labmatory valuq AS, serum gluwnic oxahmtic tmnsanu “Iwqmtilacdc acid ~ ALT, serum
600
gtutarnic pyrma.te
LAWA QLUWNE LEVEU hl~bf)
1
I
..-. .— .* 1. . - —--!
I
600
400
200
o’ *
-. _
8
4
6
0
7
I JUN 10 ~ 1998
39
---
J t(?y---n
71
(’
I 994
.—
—e—.
;--w,., . .. . . . .
-Y
.
.
.
.
-.—
—
-..
—_______
_
___
__
adap~tion, in.asmucll as t h e y h a d
it~testinal failure and had been receiving TPN and ord
feedings for long pcnocis. lt is also conceivable that it
GIIK?S a longer period of administration of glutamine to
improve smafl-bowel function. Whether glutarnine given
during d]e early stag= after resection of
\vould resuft in an accelerated raw of
the small bowel
improvement in
absorption cannot be determined from this study.
Although our patients had been receiving home TPN
for an avenge of 8 years, their plasma glutamine levels
were comparable to those of normal healthy people.
Glutarnine supplementation did not result in a n y
sustained increase in serum glutamine levels.
It has been suggested that glutamine supplementation
can prevent bacterial tmnslocation from the intestinal
tnct and thus reduce the rate of sepsis. Alverdy’O found
that chemotherapy-treated rats given TPN without
glutamine had a 100% mortzdity rate and upon necropsy
had higher percentages of positive cultures from
mesenteric lymph nodes, liver, spl~ and blood. Burke
et al’ t found a stadstically significant difference in the
rate of bacterial translocadon in both enterally fed and
glutamine-TPN-fed mts compared with xats fed TPN
alone. These studies suggested that parenteral glutamine
supplementation in animals might help protect them
from bacterial fmanslocation Our study did not evaluate
rates of infections because it was performed in a stable,
small population for a relatively shott pdod.
Recently, Ziegler et afc reported a reduction in the
infection mte in bone manow tmtsplant patients whose
TPN was supplemented with glutarrtine at 0.57 @g of
body weight. They also noted an improvement in nitrogen
balance and a decrease in the length of hospital stay.
These patients were acutely ill after radiatiou chem~
thetapy, and bone mamow taartsplantatiom
Our patients received onfy half the above dose hey
received 0.285 g of glutamine per ldlogfam of body
weight in their TPN. They received this lower dose
because their TPN infusion lasted only 10 to 12 houm
instead of the 24-hour period used in inpatient studies.
Because gfutamin&TPN had not been previously given
inanoutpatient setting, we chose tousea rate that
had previously been ahown to be safe me question
arises whether the results would have been different if
alarger dose had been useti
The only apparent aide effect from glutarnine supplementation was an increase in liver eruym~ which
resolved upon cessation of the glutamine attpplern~
tion in affected patients It is of concern that tluw of
our paiXmta developkd thfs elevation in liver enzymes
-
.,
_
273
l/Gl.UrAMINI; SUPPLEMENTATION
mxxinm] small -bo\vcl
c
.
A p r e v i o u s s t u d y r e p o r t e d a sliglll rkc in tikafinc
phosphatzsc
a n d bilirubin Icvcls during tJw I-month
..
admmstmtioli
of glufamin&TPN to bone marro~~ tmnsplant
not mentioned in that
report. TransaM inase level increases were the most
impressive Iaborat.my value change in our population.
summary, this study showed that a stable
gh!!-&TPN solution can be made for the h o m e
setting. However, it does not give evidence that glutarnine
supplementation causes improvement in small-bowel
paderits6 ~ levels were
absorption in stable home TPN patients who are taking
Evaluation of other potential benefits in
this patient popu!adon such as a de~e in sepsis rate
requires a larger number of patients and a much longer
food orally.
s t u d y . we potentiaf fiver. t o x i c i t y t%om glutamine
supplementation has to be kept in mind if such studies
are u n d e r t a k e
ACKNOWLEDGMENTS
‘Ilds study was patially funded by a grant from
Caremark International Incorporated. The authors gratefully aclmowledge Mr Enc Kastango, RP~ from Caremark
for his assistance in performing glutamine stability
studies.
references
L Buius N, &SOSiiO
E, @ti5tan
F, d d t%@O!O@C
impixtance
Of
@ar&. Metabolism 3S (SuPP~l-6, 19W
2 Iiaussin&!e.r D Glutamine metabolism in the tiva mew snd current concepts. MetsbotisM 3S (SuppI>14-17, 19S9
~ I@adis R Cmtpoyo M ~isngz et ak Maintenance of skeletal muscle
intmeUar@tamtnedtu ingsbndatdsur aicsltn-JPEN*
6s9, 1965
. F, Wemermsn J, Ruston ~ et at Addition of glutsmtne
4—~
tOtat Parentmafnutridon afteretecdveab&mlnal r6urgeryaPamafme
gtutamine and muscle protdn aynthesia and inqmves nirrogen bstsnce. h SurK 205!4S346J 1989
S. %%gter T, Benfetl x Sndth Rj et sk Ssfety and meLdmlic effects of
L.-gfutslnine addnhab.on fn humans JPEN 14 (suppl)137-146! 1990
& ZkgterT’RYo ungLS,BenfeU Ketst C4iniatsndmetabotic s5~
of gluti ~lemented parentsnl nutiition after bone rnsrmw
tm@arMiom Ann Intern Med 11&S214!2& lf19Z
7. Cuemsrk w- Mar@ carehwk In-o@ Totowq NJ,
fLO’Owyer SSmtth RHswYT, et* Msi.ntsnsnce Ofsrnsut.owd
~ with glutsmhean.* psrentaal nutzitiom JPEN 13S78m Im
a GnntJF, BlWderP*6.GluuuntnelnTPN.slugaes44m64t.?4lWs
la AJvdy&Ea’ded nutrkionresuhsl nbcteridtrsnsloationti
thegUtand&thf0Uowtngchern0themPY(Ab@Asc07AthlL %%%:-=% ~ et at BuPPtemu’Ud @ b
n@rlttOn imprWes@kmIume ftmC&UAIdlsurg lz&ls6-x
lwu
—
I
.
----- . . .
I JUN I o 199
,.--— —
7
-.
.—.. . — . . —- . ___
——...—- ..: .- . . . . ..> .
The stability of L-glutamine in total parenteral
nutrition solutions
K. KHAN*, G. HARDYt, B. McELROY$ and M. ELIA*
‘Dunn Nutrition Unit, 100 Tennis Court Road, Cambridge CB4 lXJ, UK. tO~ford Alu!rit;on Sysrerns, p O
Box 3 lE, Oxford OX43UH. UK. $Pharmacy Depr. Royal Shrewsbury Hospital. Shrewsbury Hospital,
Shrewsbury. UK [Reprinf requests to ME.)
Af3STRACT-An assessment was made over a period of 14 days of the rate of glutamine
degradation in different intravenous solution: kept at 22-24”C, 4°C, -20°C and –80”C. At room
temperature (22–24”C) degradation rates in mixed parenteral nutrition solutions and aminoacid/dextrose solutions ranged from 0.74L9°A/day, in Perifusin 0.6 Y0/day, and in dextrose alone
as low as 0.15“Alday. At 4“C, glutamine degradation was <0.1 -0.20A/day in all solutions
examined, at -20°C it was minimal (cO.04Y0/day) and at -80°C, it was undetectable.
Glutamine degradation was found to be associated with the formation of equimolar quantities
of ammonia. No glutamate formation was detected.
It is concluded that it is possible to store glutamine in parenteral nutrition solutions kept at 4°C,
with about 20A loss oyer a period of 14 days. The degradation is sufficiently slow to consider the
use of intravenous glutamine in nutritional therapy.
In
production
storage. In previous
AII the currently available commercial amino-aad
solutions that are used in total parenteral nutrition
(TPN) lack free glutamine. ?his is largely because
of fea_s about the instability of glutamine and
possible toxicity of some of its degradation products (pyroglutamic a a d a n d a m m o n i a ) .
However, there is surprisingly little information
about the stabdity of glutarnine, and some of the
work with parenteral nutrition solutions is confusing. For example, in one preliminary report it was
suggested that the rate of degradation of glutarnine
in the presence of other nutricats is as low as
O. I%/day at room temperature (l). In another
preliminary ~mmunication the mte of glutamine
degradation in a parentcrd nutrition solution was
repoficd to be higher, but less than S%/day (2).
However, other workers have reported the rate of
glutamine degradation in buffers, kept at room
tempcmture and a pH sknilar to that of parentcml
nutrition solutions, is even higher at about 1020%lday (3,4, S).
If free gIuta,rnine is to be indudad in patwttcral
nutrition solutions as an alternative to the use of
glutamine containing dipeptidcs (6), it is aasmtiaI
to have infocrnation about its stability arid the type
of degradation products that are formed during
studies we have found that the
stabifity of glu(amine in solution depends not onfy
on tempcratur~ and pH, but also on the composition and mol ity of other constituents in the
solutions (7, 8, [t became obvious that there was a
risk in attempting to predict the rate of degradation of glutaminc in one solution as a muh of
obscmations made on another solution. It also
became clear that the stability and products of
glutarnine degradation should be assessed in a
variety of parented nutrition solutions. This
study aimed to obain such information at various
tempcmturcs, including those that arc likely to
exist during storage or administration of the
intravenous solutions.
Methods
Lghttarnine (Degussa, Frankfutt, Germany) was
added to the solutions to form a final conccnqation
of about 1% (w/v) (70mmol/1). The composition of
the various intravenous solutions is indicatad in
Table 1.
An mixtures were prepared in standard sized
total smmnteral nutrition f’IPN) bags under strict
aseptic
wnditiotts. lle a’lutiotts c&taincd ele
tro[ytes (except vatnin/dextrose) and micrcmu-
-- 193
..-
I JUN
I o 1998
I
,/
f
I
I
i
Tebh t DetGfM tmnfrosftlon of eaeh type Of Solsstlotimlxtssre used to assess the stsbilit y of glu!amine
Codtums18
:tuu#mtl)(mnsolO)
Na (mmoVl)
Nitrogen (g/l)
GbOydrete (kaUf)
SynthamirJ
Aml~~A)t/ AmlnoglccjB)t/ Eloemln (A)tt/ Eloamin (&t)t tl
dex!rose
dextrose
74
46.6
66
43,2
74
46.2
49.1
7.11
577.2
45,3
49.2
42S
4s.3
53:’5
55!:!
52!: ;
1;.0
17.2
1s.9
Synthaminttt/
dextrose
68
74
Pbospfsete (mmolrl)
ii.3
MS (mmoVl)
/
;
a (mmol/f)
Ce
(mmoVl)
Aoetate (mmon
Trece elementt”’e
Vftemhss””””
6;;
2.9
6;:;
2.7
Elotrece B
Elotmx B
1.0
1.3
tt fAOPOld Phmns, OrGZ, AsntrlaK3xford
6%
2.9
6;:~
2.6
Elot%e B
Mvc9+3
Elotrnce B
10.3
MVC9 + 3
MVC9+3
t @fMlkh Sorsl Ltd, Cheater, UK
68
32.5
3s
6.4
563
-
Fet (k@
26
28
5,12
450,4
400
15.0
12
2.5
35
2:
6;.5
Additrace
Multibionta
MVC9+3
dcx!rosc/
lipid
VOmin”/
dextrose Pcrilu\in””
74
-9
460
30
40
54
-
-
5
9
5;
Addilrace
Multibionta
74
-
10
i’,
Nutrition. Oxford, UK
,1
W Baxter, Eghem, Sumey, UK
● Kebl vtsnnn Ltd. Uxbrldee. Mlddieaex. UK
6* ~~- Ltd., Al~on, Hunis; UK
●
●
“” 1 assspoukof tmceelemenu, present k -2.5 LSOIUI1OSN (Elowece B, Uopold Pherma, Oraz, AustridOxford NWidon, Oxford, UK: Addifracc, Kabi, UK)
“”* 1 msrpmsfe of mssltfvemlrss present In 2.5L aolutlons (MW Lyphomed, Chicago, USA/Oxford Nutrition Lid UK; Muhibionta, Merck, UK)
-., ..-. ..--, -- -- .-, ---
,—”
—
-
-
-
-
—
-
-
.
. .. —.. — —-. . ,— --— -
4
0
..-
.-
. .
.-. ..— —. —~ .—-—---- ---- -- - — .—______ _
..
—_
,
I
<
I
I
CLINICAL NUIRtTION t95
[ricn~s ( T a b l e 1 ) . T h e L-glulaminc w a s first
dissolved in stcriic doubly distilled water for
irrjeetion B.P. (z.s~. wh or 173mmot/1), paSSed
2) was measured at room [cmperaturc before,
during and at the end of the ICSI period.
G1utamine (9), glutamate (IO), and ammonia
(Rochc, urea UV method, Kit No:0711144) were
measured in duplicate using standard enzymatic
ieehniques adapted for use on the ~bas Fara
(Roehe) centrifugal autoanalyser. The ‘all in one’
mixfure which included the lipid emulsion (stored
only at 22-24°C and 4“C) was filtered through a
O-2pm filter prior to analysis in order to remove
the lipid.
through a 0.2 ~m filter 10 remove particulate
matter, and then added to the above inmavenous
Solutiondmixtures (Table 1), and dextrose solutions alone to achieve a final dextrose concentration of >25~0 wk. As a eontro] t h e s a m e
intravenous solu[ionsfmixlures were prepared
I
I
I
I
I
without the addition of glutamine. As fufiher
controls, ammonia (as ammonium chloride, Ana-
Iar, British Drug House, Poole, Dorset, UK),
L-glutamate and L-pyroglutamate (Sigma, Dorset, UK) were added separately 10 the same
solutions (without glutamine) IO obtain final concentrations of 10, 10 and 40mmoVl respectively.
G7feufations
Degradation rates (see Table 2) were derived from
(a) the sequential dezline in ghrtamine concentrations, and (b) a combination of initial glutamine
concentration and appearance of ammonia (the
degradation of glutamine was found (O be assoaated with the formation of equimolar quantities
of ammonia; see(7) and resrrltsof this paper). The
second method was used partly because no dilutions were neeessary prior to analysis, and partly
because it is able to detect small changes in
concentrations more accurately than the fust
method (the initial ammonia concentration was
close to zero -cf. glutamine cone.entration). Both
methods of calculation took into consideration the
initial concentrations of ammonia and glutamate,
and the amounts formed over the test period in
control solutions that did not have additions of
Lgluwmsate or ammonia.
The degradation rate K (%/day) was derived by
plotting the log of glutamine eoncenttation (as ‘A
of original) against time (days). K is the antilog of
the gradient thus formed.
Portions of these solutions were sampled at the
same intervals (see below) as the above solutions
and analysed to assess the reeove~ and possible
interconversion of ghrtarnale, glutamine, pyroglui
!
++>.
.. .:.. s% . .. . . . ....—_
.*.
i
I
I
I
.
I
I
I
I
!
i
I1
I
tamate and ammonia. .
Aliquots (20ml) of each solutions were removed
from the TPN bags and kept in sterile glass vials at
room temperature (22-24”C), 4“C, and -WC (all
exeept mixed bag containing lipid). Tbe
‘ “ Synthamin containing solutions were also stored at
–20”C. The TPN bags (Ultrastab, Oxford Nutrition, Oxford), which are impermeable to gases
such as oxygen were also kept at room
temperature, and the contents sampled at intervals. Duplicate samples from all the solutions were
taken at day O (shortly after addition of ghttamine), day 7 and day 14. In some ease-s (dext=
only solutions and all Synthamin containing solutions), additional measurements were made on
days 3 and 30. The pH of each solution (see Table
Tabk 2 Degradation rates (%klay) of fq@naminc in various $oIuriondmixsurcs
Iempcramrcs using she gfuramhe roctbod
ar diffcrem
(A) sod the aorrnafi mefbod (B)t
Tcurpenture
Saludoo tt
Syndummwrw
..
syo~ d
-1= ~
Arniooples BKkrmse
ElOUOiu~
EJoaminmlkU’0=
~ts%
Z-2X
pki
A
. 5.8 am
54
O.n
x
s.s
Z
0.90
A
c
0.10
-w
BAB
0.10
m m
020
S.s
m ::
Q74
42
0.17
%6
6.7
B
0.65
m
ok
o.n
.
&
0.14
tSurarfarddkofroetbod Aaod B
ttFordetaifaf0xnpdk08a2bt4cl
1#1 = oodelcu8bte
.-
_-
---
H
0.25
020
0.18
alo
0.10
0:0
0.10
:
0.10
M m
0.14
%
0.09
:
m m
m
w
m w
m
w
u m
. —.— . . . . ..-. — —, —-. . . . . . ,$--- .
..4 ..—.
-
,
_
_
_
_
_
_
_
_
_
—
.
196 STAf31L1TV OF L-GLUTAMIPW IN TJ’N SOLUTIONS
Pyroglutamate was added (14day period at room
M N OAYS
Frg. 1. the dczradation of L-slutami~ (GW ● 22-2~ in a
dex:rusc solution 15% w/v (*) and in a Synthaminldextrose
mixture (*). see Table 1 [or detailed composition. Rcsulrs ● e
plo[wd on a scmilogari[hmic safe (y axis only).
temperature). [n the umtrol experiments in which
ammonia and glutamate were added to the various
solulions, both metabolizes were completely
recovered at the end of the study. Furthermore, in
the control experiment in which pyroglulamic acid
was added to the intravenous solutions, no
ammonia, glutamate or glutarnine appeared.
The pH of any solution did not change by more
than 0.2pH units during the study period. Initial
ammonia values were close to mmo in the aminoacid containing solutionhnixture (<0.25 mmol/1
and did not rise above 0.5mmoM in any of the
control samples). Glutamine degradation rates in
samples stored in gas impermeable bags, were
virtually identicxd to those stored in glass vials
(room temperature).
Discussion
.
Results
The irstrabatch coefficient of variation for the
measurement of glutamine, glutamate and
ammonia w e r e l.lYO, 0 . 6 % a n d o.s~o,
respectively. ‘Ihe corresponding values for ittterbatch variation were L7~0, 0.8% and 0.7%.
Measurement of these mctabolites in duplicate
samples gave virtually identical results, and therefore, only the mean rmtlts are given below.
Rates of glutamine degradation calculated by
the two methods agreed closely with each other
cable 2) because, as expected (7), ammonia
appeared in the solution at an approximately
equimolar rate as the 10ss of glutaminc @lg. 2).
The degradation rate of glutamirte was highest
at 22-24 “C (0.6-O.9%/&y), five-fold lower at 4°C
(0.1+.2%/day) and undetectable at -WC. In the
TPN samples stored at -WC (Synthamin/
dextrose), degradation was rrtittiil (<0.04%/
day) over a period of 14 days (results not shown in
Table 2). In dextrose solution ($25% WIV 188938kcal/1) at ~-24eC the degradation rate ranged
from 0.10-O.20%/day, the lowcat degradation rate
corresponding to the highest dextrose conecntmtion. In dextrose 15% w/v (563keaM) the rate of
degradation W& -0.15%/day (F’ii. 1). Tbcrdorc,
the presence of additional cottsdtuents in ‘IPN
solutions (Table 1) rxtbancxa gfutamfne degradation (Table 2). The ir.rW concentrations of ammonia in tbe
amino-add containing solutions were less than
0.25mmoltl and reutaincddosc tothisvaltteintbc
oontrd samples or those to which gMamate or.
Ii
i
I
I
I
I
The recognition of the potential imporfarree of
glutamine in the metabolism of various cells and
tissues (2, 11-16), has led to attempts to administer
it as a component of parenteral nutrition solutions.
lle use of soluble and stable glutamine containing
dipeptides, which are readdy hydrolyses within
I
!
I
I
I
I
I
I
t
!
I
I
TMENMY8
.
0.
I
-.
1
1.
r-
.
.
CLINICAL NUtR~ON 197
—_
the body to yield free amino-acids, provides one
\vaY Of achieving this aim (6). Another, more
economic oplion, is (o administer free glutamine,
but (his option depends on the stabili[y and
possible toxicity of ghs:amine and its degradation
products.
Since heating for even short periods of time may
cause substantial degradation of glulaminc (3, 8),
heat s~crilisation was avoided in this study. Instead
(he glutamine solution was aseptidly prepared
and filtered through a 0.2@ filter prior to mixing
it with the other nutrients.
In this study there was close agreement between
the rate of loss of ghrtamine and the rate of
appearanw of ammonia, which increases ~nfidence in the results. The formation of ammonia
occurs irrespective of whether ghrtamine degrades
to glutamate or pyroglutamate. Since no glutamate was formed i( is presumed that glutamine
degrades quantitatively to pyroglutamate.
The rate of glutamine degradation in typical
parenteral nutrition solutions (0.8%/day at room
temperature, or 0,1-0. 15%lday at 4“C) was found
to be slower than that reported in several other
solutions (3, 4, 5) e.g. in buffers maintained at
similar pH and temperature as the parenteral
solutions. The rate of glutamine degradation in the
commonly used intravenous solutions is sufficiently slow to consider the possible efinkal use of
such solutions as a Viabie option (akhough the
degradation of g!utamine in atypical TPN solutions incfuding those with unusual mineral eoneustrations requires investigation).
There are at least four ways in which W:s option
may be achieved. One is to prepare a fresh
glutamine solution and mix it with other nutrients
on the day of administration. This reduces to a
minimum the time over which glutamine can
degrade. Serxmd, since the degradation of glutamine at 4°C is several-fold less than at room
temperature, storage of such solutions at 4*C is
demonstrably associated with the 10SS of only
about 2°A gh.rtamine over a petiod of 14 days.
l%ird, it may be possible to prepare, store rtnrYor
administer glutarrtitre solutions containing
dextrose alone, which S1OWS glutatnirte degradation even further (Eg. 1, Table 1). Fourth, it
may be possible to freeze a solution of gltttatttine in
water, dextrose, or TPN solution (e.g. -2fPC -WC) and thaw it for in!kion or for mixing with
other nutrien& on the day of requirement. Tlte
evidence suggests that over a period of at kast 2-4
weeks there is minimal or undeteuable degradation of glutantine in intravenous solutions storqd
(this work and (7,8) ).
In addition glutaminc dots not appear to affect the
between –2&’C and -80”IC
stability or size of the lipid par-ticks in ‘all in one
mixlure’ (8).
It should be emphasised that the use of gluta-
mine in TPN solutions in clinical practi~ shouId
take into account not only the stabibty of glutamine (and formation of degradation products) but
also the possible toxiaty effeus of such infusions,
which might vary in different circurrtstancts. In
one recent study in which glutamine ~ntaining
solutions were administered in healthy subjects
(17), no toxicity effects were identified and no
significant measurements in ammonia eOneerrtrations were noted.
The inaase in ammonia concentration in TPN
solutions kept at room temperature (0.5 mmol/fJ
day in solutions containing about 70mmol glutamine/L) is small and not likely to be an impottant
clinical problem: The body handles up to about 1
mole of ammonia per day (14gN), which is used to
form urea. Furthermore, administration of an oral
bolus dose of about 7g (-131 mmol) ammonium
chloride (i.e. O.l~g in a 70kg man), which is used
clinically as a diagnostic test for renal tubular
acidosis, provides 20-30-fold more ammonia than
a TPN solution containing a total of as muclr as
5mmol ammonia. Although the latter delivers
ammonia dkectly into the systemic areulation, it is
administered very slowly (frequently over 24 h cf. bolus dose of ammonium chloride).
Alleged toxiaty of pyroglutarnic aad (also
known as S+xoproline, 2-pyrroIidone-5ux-boxylic sad) requires further investigation, but it is
unlikely to cause symptoms if given in small
amounts. Tltis is pattfy because tissues are
noimally exposed to small concentrations of pyroglutamic aad (18), (it is also a nonmal constituent
of mammalian proteit@olypeptides, and an intermediate in the gamma-glutarnyl cycle (19,20), and
partly because of reamt studies in normal subjeus
involving administration of ‘IPN solutions containing ghttarnirre have not been associated with
detectable toxic effects (17). Furthermore protein
hydrolysatcs sueb as ‘Arninosol’ (a tztsein hydroly-
sate), which was at one time used routinely in
‘lTN, mntained substantial amounts of pyroglutantic aad (4% of total N, eorrcsporrdmg to 34mntoI
pyro$utamic acid per 12g N21]). @in, toxiaty
effects due to pyroglutantic acidlor ammonia west
apprcntly not idend.lied.
In sumtmuy this study suggests that it should be
possible to prepare, store and administer glutatnitte in parentera! nutrition solutions, with little
I JUN
10 19%9
y5
.
.
.
..—
._
.._
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I
19S STABILITY OF L-GLUTAMIh’E IN TPN SOLUTIONS
—
but administration of such solutions in clinical practice requires further evaluation of [heir benefits and possible toxicity.
dcgradative loss,
II
12
Referent=
1. Wilmore D W 1990 The safety and efticacy of glulaminc
in humans. (Proceedings of the second international
workshop cm glutaminc metabolism, Stockholm,
Scpwmbcr 1989) CfinicA Nutrition 9: 3S
2. Souba W W, Smith R J, Wilmorc D W 1985. Review:
Glummine metabolism by Ibc inms[inal traa. Journal of
Parenmral and EmtemI Nutrition 9(5): 608417
3. Shih F F 198S Analysis of glu[amine. ghamic mid ● nd
pyro8t”lamic acid in proIcin hydrol~t~ by f%h-.
performance liquid chromatography. Journal of “.
Clu-oma[ography 322 24S-256
4. Twardzik D R, Peterkofsky A 1972. Glutamic ● cid as a
prccurwr to N-terminal pyroghnamic acid in cnmssc
plasma~oma protein. Proceedings of the National
A~dcmy of sciences of the USA 69(l): 274-277
5. Dickinson J C. R=nblum H, Hamilton P B 196.5. Ion
exchange chromatography of the free amino aads in the
plaama of the newborn infant. Pcdiatrks 36(1): 2-13
Atbcrs
S, Werncmxan J. S1ehk Pet ● l 1989. Availability
6.
of amino acids suppfkd by cons!am intravenous infusion
of synthetic dipcp!idcs in healthy man. Clinical Science
76643-648
7. Khan K. Efia M 1991. Faaors ● ffcaing tkxc stabitity of
L-dutamine in solution. Submitted
8. M~Ekoy B. Hardy G ● nd Wtgginx D 1991. Tlxe atabdity
of L~lutamine in A1l-in-Ooe TPN mixwrcs. Submitted
9. Lund P 1974. L-Glumntitse: dewsninariott with
glutaminasc and gluramate dchydrog~. Im
Bergmeycr HU (Ed). Medvxfs of hzymatic Analysis;
New York, London. Academic Press (4): 17)%1722
10. Berm E, Bcrguncyer H U 1974. L-lusamate, UV assay
with glutamate dchydrogenaac and NAD. XIX Bcrgmcycr
*J$.. . . . . ,.:-. , .:. .:.::,:
L.
13
14.
J5.
16.
17.
18.
19.
20.
21.
liU (Ed). ifcthods of enzymatic anakysk Nc~ York.
Imndon. Academic Press (4): 1704-17f)S
Klimbcrg V S, Sa[loum R Me fbspx MCI al 1~. Oral
glulaminc accelcraws healing of the small inlcs!ine and
improves ouwomc after whole abdominal radiation.
Archives of Surgery 12S: 104&1045
RcIuer L J. Wicc B M, Kcnnell D 1979. Evidcncc that
glut amine. not sugar, is the major energy sour= for
cultured Hela AIS. Journal of Biofogiol ascmistry – –.
2.54(8): 2669-2676
Newsholme E A. Newsholme P, Gxri R 1988. The role ‘_
of [he awic ● cid cycfe in CCJIS of the immune WSICM ad. g
iu importance in acpsis trauma snd bucws. Biological ‘
SocicIy Symposia S4: 14>161
<
First P, A!bcrs S, Stehle P 1989. Evidcncc for a
nutritional need for glu:amine in catabolic pat”~ncs. = Kidney Imernationat 36(27): 5287-S292
Gxosimo E, Williams P E. Radoscvidr P M et af 1986.
Role of glu[aminc in ● dapwiona in nitrogcm metablixm
during fassing. Asrwican Journal of Pbysiofogy 2S0:
E622-E62a
Kovaccvic Z, McGivan 1 D 1983. Pbyaiologii rcvi.aw
Mitochondial metabolism of gfutamine and glutamate
and irs physiological aigrsificati”63 )2): S47~S -—
Lo*e D K, Benfetl K, Smith R J, Jacobs DO. Murawski
B. Ziegler T R, Wilmore D W 1990. S&ty of glu{amineenriched paremeral nutrient xhtiorss in humans.
American Journal of CXnicat Nutrition S2 1101-1 J06
Abraham G N, Podell D N 1981. Pyroglutamic atid:
eon-metabolic formation. function in Pmwint and
pcptidca, and characteristics of the .xszynscx affecting iss
removaf. Molecular aad Cd Biochcmkw M 181-190
Mcis[er A. Atsdccxon M E 1983. Glutarhione.
Biochemistry 52711-776
Mcister A 1985. Metabolism and functions of
ghnathione. [IX Oacha R S, Hanxsn R W, Hatt J (cd)
Mctabofic rcgufasions. Amstcrdans: Efacvier S&na
Publisher: 161-170
Aq\ti S, Wredind A 19S7. Pyrrofi&ne artxo+u ● cid
in enzymatic asein bydrofysatca. Acts Pbyaiologica
Scandinavia 39: 147-15/
E
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Submission &te: 4 Aprit 1991; Actzpted: 5 May 1991
1
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