Blood and urinary amino acids in children receiving total parenteral nutrition

Clmicsl Nutrhm

1 .221-228. 1982

Blood and Urinary Amino Children Receiving Total Parenteral Nutrition

Acids in

P.P. Kamoun, Ph. Parvy, A. Morali, J. F. Duhamel and C. Ricour Laboratoire de Biochimie gbnbtique, Service de Gastroent6rologie pediatrique et de Nutrition, HBpital Necker-Enfants Malades, 149 Rue de SrAvres, 75730 Paris, Cedex 15, France (reprint requests to PPK) ABSTRACT. Plasma

concentrations

patients

receiving

composition amino

of

the

appropriate

and are

in

of

for

valine

the

infusates

ineffective

autputs

for

high

amino

the

maintenance

concentrations

and isoleucine

to

of

hyperalimentstion

infusates

The use

acids.

cysteine

and urinary intravenous

used bring

but not

induces

the

of

were estimated

evaluate

of

normal

branched

for

a very

decreased

acids

to

the blood

chain

high

plasma

urinary

dosaqe

concentrations

levels

and

of

seems

essential

to be

concentration

excretion

cystine

of

amino acids

The high

leucine.

in niheteeen

adequacy

of

back

of

cysteine

and cystine

to normal.

TNTRODUCTI0N. The increasing some of

use

potential

benefits

and metabolic acid

mixtures

of

containing

tissues,

GF.1 for

total

children

of

concentrations

(3,4,5). of

isamsjor

participant

parenteral

The measurements

repeated

acids

are in

to

we have

nutrition were

a variety

the

evaluate

the

urea

cycle

plasma

and improved use

times

of

during

amilro

and cysteine in

and cysteine

is

the

nor)-

capable

consequences

and urinary

the

special

arginlne

GFl and a more conventional

at different

offer

nutrltiunal

predominantly

some metabolic

determined

with

to meet

amino acids:

metabolised

complications

acids

the

suggested

of

amino

on different

;5‘

branched-chain

amino

nutrition,

based

Ghadimi

branched-chain

In order

revealed

and adaptability

Many studies

high

parenteral

has

Solutionsofcrystalline

composition

patient.

described

methionine.

receiving

'Vamin) .

the

nutrition

(1,2‘1.

been

arginine for

acids

consistency

because

substitution

parenteral

amino

of

have

solution>

hepatic

total

of

needs

solutions

:GFl

of

them involving

of

trsing

amino acids amino

course

acid of

In solullon

treatment.

MATERIALS AND METff0DS. Nineteen

children

catheter

(6).

intractable

All

in

Body weights

the varied

+

10.8

with

critically

or extensive

continuous ill small

Intensive

Digestive

from

to

and 29 months

age was 68.2

treated

were

diarrhoea

nutrition

1’2 days

were

2350

(mean ? SD ‘range

with

total a variety

of

bowel

resection,

Care

Unit

7OlOg

(mean 4 SD

: 4.0

+ 6.2

51 to 83).

parenteral

of

nutrition

severe

months’.

gastrointestinal

requiring the

The

total

Necker-Enfants

: 3672 ? 1048’ weight

by central

and their percentage

venous

disorders,

parenteral llalades ages

tiospltnl

were

deficiency

between for

The nineteen children were divided into two groups comparable for age and weight. Nine children were fed intravenously with Vamin for a period of 12 days then with GFl for a period of 12 days.

Ten children were similarly fed first with GFl then with Vamin. The

composition of Vamin (KabiVitrum, Stockholm) and GFl (Egic Montargis, France) is shown in Table I. Table II.

The mean value for the administered quantities of amino acids are recorded in Total infusion of amino nitrogen of Vamin and GFl was 21.3 f 4.8 and 21.0 +

4.9 mmol.kg/day respectively. The caloric supply, carbohydrates only, was 416 kJ.kg/day.

TABLE 1.

COMPOS7TION OF L-AMINO ACID SOLUT70NS. !mma~.L! Ratio Vamin GFl Vamin/GFl Alanine

34.7

45.0

0.77

Arginine

18.9

57.5

0.33

Aspartic Acid

30.4

3.8

8.00

Cysteine

11.6

28.1

0.41

Glutamic Acid

61.2

3.4

18.00

Glycine

28.0

53.4

0.52

Histidine

15.5

13.0

1.19

Isoleucine

29.0

61.1

0.49

Leucine

40.1

122.1

0.33

Lysine

26.3

32.8

0.80

Methionine

12.7

4.0

3.20

Phenylalanine

33.0

24.3

1.36

Proline

70.4

17.5

4.02

Serine

71.4

38.2

1.87

Threonine

25.2

20.1

1.25

5.9

0.03

Tryptophan

4.9

Tyrosine

2.8

2.8

1.00

36.4

63.0

0.58

Valine

Venous blood samples were drawn into a heparinised syringe at 7 a.m. during total parenteral nutrition and the sample was immediately centrifuged to avoid losses of cystine. A portion of plasma was immediately deproteinised with crystalline sulphosalicylicacid (50 mg/ml). The deproteinised samples were stored in -7O'C until analysis. Urine was collected under thymol during the 24 days and was kept in the frozen state until the analysis of amino acids which was performed after deproteinisationwith sulphosalicylic acid. Deproteinised samples were passed through a 0.63 x 35 cm column (C-3 Chromo-beads Technicon) and elution was performed at 57.5'C with a flow-rate of 0.55 ml/min. Three citric acid-sodium citrate buffers (0.1 mol/l) were used: a) Buffer pH 3.25; 2.2’-thiodiethanol; made with

39/l

b) or Brig

Buffer 35

pH 4.25;

and respectively

c)

6X (v/v)methylcellosolve;

0.5%

(v/v!

Buffer 6.00; 0.55 mol/l NaCl.All buffers were

used during 70, 40 and 110 minutes. The column

was regenerated for the next cycle with 4.4 ml of 0.4 mol/l NaOH then with 12.1 ml of pH

222

ESSENTTAL AND SEMI ESSENTIAL AMINO ACTD SUPPLY.

FABLE II.

(mmo1.kg/day;meun + SDI

Vamin

12th Day GFl Vamin

6th Day GFl

Arginine

0.73 f 0.16

2.03 f 0.48

0.79 ?:0.09

2.31 c 0.28

Cysteine

0.45 -t0.10

0.99 f 0.23

0.48 f 0.05

1.13 f 0.14

Isoleucine

1.14 f 0.26

2.16 + 0.50

1.24 + 0.14

2.46 + 0.30

Leucine

1.54 + 0.35 4.31 f 1.01

1.67 f 0.18

4.91 + 0.60

Lysine

1.01 it0.23

1.16 ?:0.27

1.10 t 0.12

1.32 + 0.16

Methionine

0.49 + 0.11

0.14 i 0.03

0.53 + 0.06 0.16 + 0.02

Phenylalanine

1.27 ?r0.29

0.86 i 0.20

1.38 ? 0.15

0.98 ?:0.12

Threonine

0.97 c 0.22

0.71 f 0.17

1.05 f 0.12

0.81 f 0.10

Valine

1.40 f 0.32

2.22 ? 0.52

1.52 + 0.17

2.53 5 0.31

3.25 buffer. All other conditions were those indicated by Technicon (Technicon TSMl Amino Acid Analyser). Tryptophan could not be determined by this method and histidine and ornithine were not separated. Urinary creatinine was determined according to Jaffe's method. Statistical evaluations were performed with the Student's t-test or with the non-parametric test of Mann and Whitney.

RISULTS. Plasma amino acid concentrations in children treated with Vamin and GFl are shown in Table III together with normal plasma amino acid levels for 44 age-matched infants. No differences were found for the same infusate between plasma samples obtained on the 6th or the 12th day of-treatment. Individual plasma amino acid concentrations in these patients were, however, different when compared to controls for statistical evaluation (Table III).in that there were increases in proline and methionine in patients treated with Vamin, + ornithine

and

increases alanine

The

in and

leucine

with

aspartic serine

acid, with

decreases glutamic

decreases

in

methionine

acid in

and

+ glutamine,

cystine

in

tyrosinein

glycine,

both

groups

increases

patients isoleucine,

of

in

histldine

treated lysine?

with

GFl,

phenyl-

patients.

concentrations of the non-essential amino acids with exception of proline and arqinine

were unmodified when in

differences the

essential

was

not

the

amino

the

case

for

of’ plasma

concentrations

solutions

contain

Vamin

and

GFl

treated

patients

were

compared

concentrations in the two solutions. acids

jncreased

valine

cysteine

and

were but

when

their

isoleucine.

directly not

related

cystine.

intake Except to

was for

the

The

despite

plasma

amino

latter acid

striking

concentrations

significantly

these

the

increased amino

Intake

acids

iFiq.1).

of but the

that increase

Both

The cystine concentrations in plasma were

urlrelatedto the intake of cysteine but were related to that of methionine iFig.1'. lyrosine crncentration was similarly related to the supply

223

of

the

sum of

phenylalanine

and

tyrosine.

Fig.1. Lineah

hegheAAion dOh AOt?N? QAAentitiae amino acids between fhe hUtiOA 06 -thtih concen&ationA in amino acid Aoktion (Vumin/GFI 1 and Rhe hUti0 06 .th& concen.ttationA in pb_Ama ( Vant&lGF I ) . The t%eah AtOpt tush cakuLaa2d

by

cumu-Eatinp

htAu.!%

obtined ax &the 6x31 and 12Rh day 06 -tuaXmiment y = (0.59 2 0.10) x + (0.70 * 0.17).

Leu

/

The urinary

excretion

cystine,

isoleucine,

observed

between

in arginine,

is

shown in Table

phenylalanine,

Vamin and GFl were related

leucine

concentrations excretion

of amino acids lysine,

for of which

but cystine

was very

high

(Fig.2)

of the

and in the

when compared

with

FLg.2. kXah hegheAAiOn doh edAt?fItid and Aemi eAAen.tiae am&o acidA be&.wn amino acidernie ILog amino acidemia umoL.1 x 10 -1) and amino acidwtia [Log amino acidwra umo1.kg/day x IO). The tineah Ak?Ope WUA ca.tcu.ta&d by cumuLaZ&g heAu&tA obtained at Rhe 6th and

Rhe

12Rh day 06 Irhea-tvmd. ,joh GFl akzaX%tnen2 ahe in -the The ~~eau&tA 6Oh CyAfitiizt A~UWLeb.

Re.~utti

wehe excLuded 06 .tke tineat

y

q

(0.90

do& tithe de-tehminatiorz ACope

+ 0.26)

x + (0.5ti

IV.

f 0.27).

224

No difference

and valine.

to differences

Excretion

and methionine. all

threonine

in the amino acids

normal

control

range values

was observed

The significant composition

of the

was related except obtained

for

differences solutions

to their

for

cystine

plasma the

in 35 age-matched

+

Threonine

Valine

a :

7

8

3

f

pco.05;

+ 31

* 13

9

8

+ 36

+ 37

f 25

+ 46

? 59

+ 12

b

are

241

:

44

'bl

'd)

ce)

!a'

'a!

:cj

(b)

~~0.01;

from

+ 20

76 ? 13

254

332

420

163

36 ?; 4

195

125+

80+

247

405

480

(a!

6th

+ 25

c

2 10

f 22

3ie

f 12

p
NS

CO.02

co.01

NS

RY

258

d

:

74

269

320

438

160

41

181

126

85

200

373

510

p
f 23

i 10

+ 25

_+ 29

f 44

+ 18

It 3

+ 13

+ 11

9

? 15

f 29

f

!bl

e

:

5

p<0.00001

:

f 13

+

+ 17

+ 28

'b)

'b'

7 'e) + 10

*

values

249

47

191

272

151

107

(c'

/cl

fe!

l(e)

+ 11 152

207

6 + 12

+

+ 25

+ 35

'c!

2 (e)

6

* 35

t

193

85

327

415

440

13

45t

5

+ 25

GFI

95*

359

’

Dav

normal

!e:

ce

!e!

(d'

'a:

(b'

!c!

2/e!

6

+ 36

*

with

25k

53

8

k 41

12th

CR GFJ.

57+

430

VAMZN

comparisons



~0.00001

NS


NS

NS

NS

NS


NS

co.01

NS

P

TREATED

controls;

,a

6ca

C 43

:

'a

l(e

i 11

f 15

age-matched

251

40+

166

290

153

E9f

13+

174

191

!c

7cb

f 27

cc

ia

l(e

6!a

8

+ 38

84i:

302

426

453

13+

49+

PATIENTS

+ 25

GFl

0F

85k

353

Day

IN PLASMA

2 (e'l

f 10

4

+ 92

20 +

57

58f

Vamin

ACIDS

402

AMINO

values

9

2

f 12

vormal

210

64+

226

Tyrosine

178k 179k

Proline

Serine

72i

Phenylalanine

1

5

i

163 28*

4

2

f 21

1265

Methionine

Lysine

leucine

642

174

Histidine Ornithine

Isoleucine

k 11

275 +

_+ 20

372

Glycine

acid

2 3

Glutamic Glutamine

84+

35+

Cystine

3

_+ 18

Aspartic

352

Normal Values

f32? acid

JJJ.

Arginine

Alanine

TABLE

NS

NS

co.02


NS


co.01

~0.00001

NS


NS

co. 001

NS

NS

<0.00001

NS

co.00001

infants 1 to 6 months old, 33 infants aged 6 to 12 months old and 45 infants aged 1 to 2 years old. Cystinuria expressed as urno1.g creatinine was respectively : 341 +_13 (range 106 - 750) in controls, 2,708 ?:337 (range 250 - 6,330) in Vamin treated patients and 2,945 2 388 (range '250- 7,650) in GFl treated patients.

TABLE IV

AMlN6JAClDURlA (umol.kg/day;mean + SEM) 6th Day Vamin

Arginine Cystine

12th Day GFl

P

1.30 + 0.17

3.40 & 0.42


Vamin 1.00 + 0.16

GFl 3.81 f 0.51

P to.001 NS

18.73 + 2.00

23.72 + 4.11

NS

Isoleucine

1.06 2 0.13

0.89 * 0.10

NS

Leucine

1.62 + 0.19

3.14 f 0.35


11.81 + 1.57

16.60 f 2.68

NS

2.15 + 0.62

0.74 t 0.14


1.98 2 0.33

0.62 ? 0.13


Lysine Methionine Phenylalanine Threonine Valine

19.35 + 3.67 30.80 ?r5.84 1.00 + 0.13

1.05 + 0.15

NS

2.00 ?r0.32

4.21 ?r0.62

co.01

11.48 + 1.81

20.70 + 3.32

co.05

4.94 + 0.81

4.09 ? 0.52

NS

4.82 i 0.52

NS

14.44 ? 2.42

11.52 f 1.87

NS

22.46 f 4.19

12.91 ? 2.25

NS

2.10 + 0.28

2.33 ? 0.31

NS

2.98 f 0.53

2.56 t 0.39

NS

5.30 ?

U.86

DZSCUSSION. The most interesting results obtained in the present study concern the branched chain amino acids and cystine metabolism. The use of the high concentrations of branched chain amino acids has been recommended by some authors (5,7j because of the high tolerance to these amino acids which are metabolised predominantly in non hepatic tissues especially in the muscle which is 45 per cent of the body weight and 60 per cent of the total bcdy protein. Their use 1s also supported by the fact that there is substantial evidence that branched chain amino acids have anabolic effects on muscle protein. Recent studies have suggested other important roles for branched chain amino acids in metabolic regulation. These include protein degradation in the skeletal muscle, nlanine and glutamine release by the muscle, gluconeogenesis,lipid synthesis in peripheral tissues, fuel metabolism in skeletal muscle, insulin secretion, neurotransmitter synthesis in the brain and glyclne metabolism (8,9j. In our study the plasma concentration of isoleucine and valine was unmodified when the uptakes were increased from 1.19 to 2.31 mmol.kg/day for iscleucine and from 1.46 to 2.38 mmol.kg/day for valine, the requirements for infants of isoleucine and valine being respectively 0.85 and 0.81 mmol.kg/day (10). The plasma concentrations were only about 130 and 119 per cent ot the controls repectively for isoleucine and valine and it seems that the tolerance for these amino acids 1s as good as has been described by Ghadimi (5). On the pther hand an intake

of

4.61 mmol.kg/day of leucine (GFl) indtlcc,d an increase of

plasma concentration to 152 per cent of normal while with an intake uf 1.60 mmol.kg/day (Vamin) the leucine concentration in plasma was unmodified when compared with controls, the infant requirement for leucinebeingl.17 mmol.kg/day (10). It is noteworthy that

226

in

patients

with

isoleucine

and

maple

valine

syrup and

Administration

acids.

such

and

immunocompetence

impaired

as

to be avoided

fined, to isoleucine Previous

studies

alimentation solutions the that

(10).

the

and

one

decreased

method

supply study

did

of 0.03

in rat

kidney

acid

any

appear 11.6

additional to normal

GFl

which

cortex

slices

provide

changes,

oxygen

lack

employs

in that

study

(cysteine

28.1 less

of cystine

sodium

based

than

on

the

deprivation,

and

to

ability

into

Kim

(101

0.46

(17).

a cysteine of our

Kinetic

to alteration cystine

and

the

flndlngs

used

supplies

patients

mmol/l

to restore In fact

similar has

the cysteine

the

for likely

cystlne

is at about

we observed

that

parenteral

it seems

solutions.

response

con-

the methionine

cysteine

in their

of leucine acids

during

methionine

pmol/l).

:12'

of cystine-containing

of cystine

and

amino

a limited

related

soluble

in undesirable

mmol.kg/dav

infants

infused

tharl amino

imbalance

decreased

suggested

was

chain

result

infusion

nourished

leucine

acid

chain

of cysteine-enriched

evidence,

and

have

well

is much

excretion

levels

solubility

cystine

may amino

of 4.6U

term

to convert

by use

and

urinary

infant

The

to be changed

pmoljl)

cystine

concentration

solutions.

(ll),

for

branched

ot branched

a short

and

ability

cystine

mmol.kg/day,

a normal

the sick

a limited

levels

f 0.003

found

temperature

amino

not

in

plasma

higher

intravenously

administration

after

debilitated

the plasma

of adding

(cysteine

and

has

the

that

are

the other

deficiency

concentrations

changed

studies in both

infant

Thus

shown

little

than

of leucine

of high

have

were

study

plasma

levels

Vamin

and

in the

the

plasma

valine.

Moreover

In our

concentration

with

and

of cystine

healthy

(15,16).

the use

toxic

of niacin

(13).

and

concentrations

more

amounts

development

in adults

(14)

synthesis

the

plasma

seems

of excess

consequences

needs

disease

leucine

studies

ot pH,

cysteine

transport systems of the kidney are different (18) and distinct separation of the cystlne and

cysteine

mucosa

with

but

a normal

ability

cysteine

due

observed

to inhibition.

of values

cysteine plasma

in our

in intravenous cystine

levels

also

to take

patients

may

urinary

solutions

there

It

proximal

therefore

has tubule

be related of the

in homozygotes

perhaps

be

of human

sum

also

been

because

shown

The

to cysteine of cysteine

intestinai

inability

(20).

for cystinuria.

to be avoided

may

in studies

is an inherited

(19).

in rat

excretion

has and

observed

up cysteine

for cystine

to normal

been

in which

reabsorption

The

observed

has

cystinuria

L cystine

inhibits

excretion

range

mechanism

patients

cystine

part

transport

from

that

excretion and

not

L

increased

restore

cystine

and

cystine

Therefore

it does

to accumulate

is

the

in In the

use

ot

decreased

dangerous.

ACKNOWLEDGEMENT. This

work

was

supported

in part

by a research

grant

from

INSERM.

REFERENCES. 1.

Dudrick S J Macfadyen B V Van Buren C T et a.1 1972 metabolic problems and solutions. Annals of Surgery 176

2.

Heird 86

:

W C 2-16

Winters

R W

1975

Total

parenteral

227

nutrition.

Parenteral : 259-264 Journal

hyperalimentation of Pediatrics

:

3.

Anderson G H Bryan H Jeejeeboy K N Corey P 1977 Dose-response relationship between aminoacid intake and blood levels in newborn infants. American Journal of Clinical Nutrition 30 : 1110-1121

4.

Lindblad B S Settergren G Feychting H Persson B 1977 Total parenteral nutrition in infants. Acta Peadiatrica Scandinavica 66 : 409-419

5.

Ghadimi H 1975 Newly devised aminoacid solutions for intravenous administration in total parenteral nutrition : premises and promises.In;Ghadami H led) John Wiley, New York p.393-441

6.

Ricour C Nihoul-Fekete C Nutrition parenterale prolongee chez l'enfant. lY73 Archives francaises de pediatrie 30 : 469-490

7.

Blackburn G L Moldawer L L et.al Usui S 1979 Branched chain aminoacid administration and metabolism during starvation, injury and infection. Surgery 86 : 307-313

a.

Adibi 5 A 1980 Roles of branched-chain aminoacidsinmetabolic regulation. Journal of Laboratory and Clinical Medicine 95 : 475-484

9.

Snell K 1979 Alanine as a gluconeogenlc carrier. Trends in Biochemical Science 4 : 124-128

Considerations in the definition of aminoacld requirements of full 1975 10. Munro H N term and premature infants. In: WintersRW, Hasselmeyer E I; (ed) Intravenous nutrition in the high risk infants. John Wiley, New York ~~407-420 Effect of leucine on enzymes of the 1973 11. tihafoorunissa, Narasinga B S tryptophan-niacinmetabolic pathway in rat liver and kidney. Biochemical Journal 134 : 425-428 Effects on ingestion of Benevenza N J Wohlhueter R M 1970 12. Harper A E disproportionate amounts of aminoacids. Physiological Review 50 : 428-558 Hematological and immunological effects of Aschkenasy A 1977 13. Chevalier P H excess dietary leucine in young rats. American Journal of Clinical Nutrition 3U : 1645-1651 14.

Effect of parenteral alimentation mixtures 1972 Den Bestern L Stegink L D on plasma amlnoacid levels in adult subjects : comparison of the route of administration. Federation Proceedings 31 : 732 abst.

Infusion of protein hydrolysates in the newborn 1971 Baker G L 15. Stegink L D infant : plasma aminoacid concentrations. Journal of Pediatrics 78 : 595-602 Cystine : a semi essential aminoacid in the newborn infant. lY74 16. Pohlandt F Acta paediatrica Scandinawica 63 : 801-804 Urinary excretion of aminoacids Nakajima T 1978 Okada A Konishi H 17. Kim C W in patients receiving intravenous hyperalimentation. Clinica chimica acta 83 : 151-15Y 18.

Characteristics of cystine and cysteine transport Crawhall J C 1968 Segal S in rat kidney cortex slices. Proceedings of the National Academy of Sciences of the United States of America 59 : 231-237

Intestinal transport of cystine and 1967 Segal S Crawhall J C 19. Rosenburg L E tvidence for separate mechanisms. Journal of Clinical cysteine in man. Investigation 46 : 30-34 20.

The tubular 1972 Deetjeir P Silbernagl 5 t'flugers Archives 337 : 277-294

228

reabsorption

of L cystlne and L cystelne