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: Federal Register Notice April 7,1998 (FR Vol 63, Nbr 66, Pages 1701117012) Docket Nol 98N-0182 Dear Colleague:

m G N m

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

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ATTACHMENT 1

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Comments to Docket No. 98N-O 182 June 10, 1998 Page 2

BULK DRUG SUBSTANCE CHECKLIST
1. 2. 3. Ingredient name: L-Glutamine Chemical name: 2-aminoglutaramic acid; glutamic acid 5-amide. 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. 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

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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 State of solution (Transmittance) More Than 98.0% 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

SPECIFICATION AND PROCEDURE

Specific rotation [a~ +34.2 - +=~ Chloride (Cl) ___ Sutfate (S04) Iron (Fe)
I

Not More Than 0.021 % Not More Than 0.028% Not More Than 10 ppm

Heavy metals (as Pb) Not Mom ThanlOPPm Arsenic (As@3)
1

Not More Than 1 f)prn Not More Than 020% Not More Than 0.10% I Morel-ha nm.s%

LOSS On drying Residue on ignition
purity (dry baaii)

Not More Than 1.0% For~gn ‘im atis I(TLC, 30 pg) Pyrcgen” Free

IDENTIFICATION

(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.

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Gharni e, L- - RTECS - Regis[~ of Toxic Effeds of Chemical Substances

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Glutamine, LRTECS - Registry of Toxic Effects of Chemical Substances
Document Outline

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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
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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
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3. gamrna-GIutarnine 4. Glumin 5. Glutamic acid 5-amide

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6. 7. 8. 9. 10. 11. 12.

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httpYt165.212.125 .WAT/URTRTMA2275 lUH-IT’M

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
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Glufami , L- - RTEC-S - Regisq of Toxic Effects of Chemied Sub~

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7.0 STATUS IN

U.S.A

EPA TSCA Section 8(b) CHEMICAL INVENTORY

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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
t+rlil !iospila\. ~crlh. .4 fGfrotio

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

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)

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

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

GLUTAMINE

Surge~, Royal Perth Hoapl~ Wefthgton ~ Pert& WA -, . Austrak.

Rec+ved for pubtiotfoq May 9, tS97. Amepted for pubticatl~ September 2S, W. Correspond~ -e WCs4dey, PhD, Unherslfy ~ of

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

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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 int@stina.1 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

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

w
Gktaminase

NI&
Glutamate ~ A.tnhIo acid Biosynthesis I TCA cycle PILL PadwaYS Oututxntne&gWtarhWtttlk!~
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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

_ in the jejurt~f

n&”’fhe aninuds tm-ated with~hada_flow

hefghtkzypt depth tiO and ]ess hl-pithdid ~hO @esthartthe ratsdeprlvedoflW ‘lhen+forthegut tohavemdy~ti~k~ q vant to $he optimal formulation of entend and

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GLIJ’r,\hflNE A~l) NUCLEOTII)}; MHTAIKX.ISM lKIVC tile

]laI”CIILCI-dl lluL[-l~Ii&. ~LlwlcnLw]{l[,io1)5sllould
cap~city to provide a source Or NT

to sustiin adequate ~
Glulaminase
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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.

carba:o’’’’’osphare
I

CPS 1 NH3 ~

ST SYNTll ESIS
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-

Glutamate meu.w 11 (CPS Ii).

Pyrimidines

i% 3. Metabolism of gluw-nirw nitmgcn LO pjrimidine nuciewi& h ~. bamoyl ph0Spb02 SWII’IC* [ (CPS t) ad GUil~Oy! @O@lW? Viyzed 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-

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.
firimidines

,R_.< z <.’, ? . . . -.

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-

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NT SYNTIIESIS ALONG TI{E Cl? YPT-trILLtJS *~ls

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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

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-

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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 can generate purirtes by de nooo synthesis has.yet to be .. 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

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

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GLUTAM1~C AND NUCLEOTIDE METAIIOLISKI

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T]{F; RIXATIONSIIIPS BETWEEN GI,UTAMINEAND NT AfETABOLIS\! in this section tve build upon tile biochemical pathways linking GLN amd NT metabolism by presenting evidence

4

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

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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
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-

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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

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
ItEIWtENCES

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110
J ~ ! ? ~o TC, Bcauchamp W), T~w-nd CM, etak GIuurrrinc is essential for cpidcrmal growtJ\ fWmr.~InuIaL& @@@nal cell pwicration. Sur. gcry (s1 L41uis) 114,147-53, 1993 3. Hall JC, Heel W. McCadCy R Glumrinc. BrJ Surg S3305-312, 1996 4 Wmdmuel]er HG, Spamh AE; Uptake snd mcmbolism of plxma gluwnine by the smafl inwstine. J LXOI Chcm 16507=79, 1974 5 .%skana?.i J, C%pcntier YA. Mkhckn CB, et al Muscle and plasma amino acids following it@ry. Ann Surg 1927&85, 19S0 6. f{wsng Tf+ ODwycr SZ Smith RI. et ak Presmvation of and bowel mucosa using glutamim+mriched parented nutrition. W Forum 3S:56-5S, J967 7. Piate]t C. Mccauley K Mccullocb Ret ak l%c influemx of parcnuxal gluumine and bnnchcd chain amino acids on total paremcral rrutsition-imduced awophy of the WI- JPEN 1734 S-354, 1993 8. Tao RC, Yoshinuua NN, Chirm IB et af: Det.crmination of ti~wtous non-protein energy and nirxogcn requirements in growing tars. J Nutr 109:904-915, 1979 9. Pinkus LM, Whdmuellcr HG Phosphawdependeru gtutamhasc of small inlcstine: Imcahzation and role in intestinal glutaminc metab Iii. Arch Biihem Biophys IS2:50G-617. 1977 10 Hammarqiiat R Wememran J, von der Decken ~ et d: AlanyIglutamine coumemcts the depletion of fme gl utamincand the frostop esative decline in protein synthesis in skelctat muscle. Am Surg 212:03744, 1990 11. Buchnun AL Ghxamine la it a conditiorafly required nutrient for the human gastroinkadnal s@cm? J Anr Cdl Nutr 1S199-205, 1996 12. Byne Th Pessinger ~ Young LS, et ak A new tseatrnent for patients with shon-bowel syndrome Growh hormon% glutamine, and a modfiti dieL Arm ~ ~243-%5, 1% 13. Uauy R, QIIan R. Gil A Role of nuclcotik in intesdnal development and repair ImpIicatiom for infant nuuitinn. J Nutr 124(SUI>PI}I 430S 1441s. 1994 14. Bueno J, Torrcs M, Abrrendms A, et al: Effect ofdicwy nuclcotides on smal! intestinal mpairafterdiarrhocz Hia@logical and ullnstmcmral changes. Gut 35926%33, IN 15. C.amer JD, Walker WA The mle of ndeotkks in human nufsition J Nutr Biochcns 6:5W2, 1996 16. He Y, Chu SK UhlIres Wk Nocleutide supplements after prolifenLion and differendstion of cuftured hurnatr (-2) and rat(IDX) intestinal epitheliaf cells J Nu& 1231017-1027, 1993 17. L.opes-Navarro AT, Omega m Peragon J, etaL Deprivation of nude otidesdccmaes pmleinsyrrtJwsii intheliver andamaflinteadnein rats Ck3LmeWemfogy 11&176@17@, 1996 18. Leleiko N.S, Martin B& Walsh hf. et aL lkue+ed lC gene expn?s “ don reaufts from a purine- and p@-niik-free diet and 6-nrcrapuridmc phosphorylasc prt*l”~ul~cllL ~~lwm 1’l~llJcOI 34. iO 1-10.>, 19s5 30. Skold (). Enzymes of uracil mcubohsm in @$ucs wItiI diffcrcm growth characteristics. Bmchinl BIOPIIYS AcM 44. !-12, 19G0 31. Au ~ Wienljes MC. Bnrncr Sk Effect of undmc -Lhinistmtjon On 5’-deoxy-5-fluorouridine disposition in raf-$. Cancer ChCnlOLhcr Pharrnacol 225-10, 19ss 3?. WWn@ Mc, Au m Wubinon Of inbsmal l]}TInlidlnC nucleoside frhm phorylzscs Pharmacol Rcs 4:425-42S, 19S7 33 ?Aang R, Lu 2. Uu T, et al Rektionslup between circadmn4qrendcn[ ttxicity of &fluorcdeox_ridinc and cir=dmn rhythm of pyrimidine q= Possible relmance tn ffuoropynmidine Chmnotitcrapy. ~. cer Rcs 5W?31&2S22. 1993 34 Tauda M. Iixunuma K Webcrc: ~t Iiwr glutaninc 5-phosplIoribo@ l+ympho@uLeandouansfcrasc[EC242.141 Purification andpro[} etiss. J Biodrem Sj 1347- 13’A, 1979 35. Sa-o DA. Ctifford .U Adcttinc, the precm=.or of nucleic acids in intestinal celts unable to ~tfi~”zc purincs de now. J Nutr 111: ls161S22! 19s1 36. BozaJJ. Jahoor F, Reeds PJ. Riborwcfcic acid nucfcoddes in matemd usd fetal @sues dcrh? afn~ tmclusivcly from synthesis de novo in pregnant mice. J NuIr 1’26:1749-1753, 1996 37. LdAko NS, Bronstein AD, Fkdiga DS, et af: De now purine nucle. 0dde5 synthesk in lhe ral small and krge intcstirrc Effect Of dje~ pro@in and fmrirres J Pcdiatr tksLmcnlcrol NuK231XJ19, 19S3 3S. Elliott W, Weber JG: Proliferation-linked increase in pl]~hori~lfomlylglydt=!tlitli!!c symheiasc actitity (EC 63.5.3) Cancer Res 4494X)-X34. 19S4 39. Wusurneda Y, Pm.@ X Donohuc JP. 6 al ~Iratic capacities of putine de rmvo and aafwtge Ixttfways for nucicotidc aynthcsk in normal and ncopLxtir IL%sues Camcr Rcs 44.?47$2479, 1984 ~f). Walah W, suKIw.p~.+ bk.iko t4S A rrgulxlory clcmcm Ls cltarxterizcd by purtne-mmfiit ed and crll-typc5fwciftc gcmc ts-wrxrip Lkm. Mol Czll Biot IO::EG4361, MO 41. Mueffcr~Rao PN. S@erJT.etak Hyafuronicaddandtin enucleo aide phosphotyke in wmkr and hii cmwnts Of 5dI bOWCI ~ :W&=We= of ~ don injuty. Thnsplantadon 55: lZ2542 Chw-ahstd S, P@en CS Cell @don depcndesce oftsbcfliig thynridu nudeddes sningthe&novoand sah5gepathways intheW of Use ansdl intestine. Cefi T&me Kinet 19647459$1966 43. Uddin M, Aftmann Gc, LAfond CR Radiiutogmphic -ion of
ditrcrernxs in the patwrn of ~1-utidii and ~~rotk add hxxporatiott into RNA of migrating columnar celk in the rat anti buestkm

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10ZO, 198i 19. Leleiko NS, Wakh MJ: Dxpwiste ndcoddes and the gasuointes W tract- Nuoidort 1 M2W30, 1996 20. I@na~Tat@aktzKidoxetal Intnvenottsdmhktmb“on of nucleo. aides andanuc.leotide rnialum~ infcstimd mucced atrophy

induced by total pasmmaf nutsltim JPEN 1726270, 1993 21. 0g05his Iwasa~YonezawaT etaLEiTecLofn@ecrtMea ndntsckw
sidemMureon mtsgfvcntofaf pamntmlnu@tiionafLec7O%hepa@ ctorny JPEN ~~ 19s5 22 VcaabuguMP,Me@d ~Ct&LUat tiwnotta nudeosidcs and q nuclecdde promote healing of mall bowd ukem in expdmml enb?romms Dig Dk M 4L14SH457, 1996 23. Txfbana49dgesda lLnvoasbamyl@@late~of tnamtdSspedt5csolMlncosrldc4@mkJineandm~ akAdv-Regul 10249-27Llm2 24. H~J,SaIoWL+SyCZetatCMnmyi-~ll@ evolutJmaLy MesmdMEinthe ~~d@@=4—

J Cd Bid 9S461%1629. 19S4 44. B&onneae IL llte de tunuand aaf~me PaLhwaya for t.he~- of p~ feaidueSofR!!_tUte in d~erent kations within the mouse doodend epi[helium Cell Tksrse Res 207:131-137, K@ 45. ZahammzDW, &idemon IX, Mafinowald NM, et ak Contsiion of de “ nomandaafvage” ~thesis to the umifnucfeodde pool in mouse tiasues andtumcIra bt\%m SurJBkxhem21M9 X?9QlW2 46. Whlnwefler H& Ghxamine udtkation by the amafl bt- Ada’ - 6W01-23S, Im 47. Ma@sewaD&MarsnomCampbeO ffiSpLmchticbeddiation ~~~ and @_C acid in humans Am JPhyaio12M EsM-s.$

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QJRp Phyde47ct47ws9,1!w m MorimotoBUBaady JEAtKnaonD12=em f__oma@ tdne4mula@d dtruOheamtkds ~J=61+~ M. McGh’anm, Bsdfotd Nw Mendu-M&J:7be re@adiaofar-

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&atlea Afdt Biodwsn BiophW95@%607,1%l 27. &ddZMottiaHEWberQRe@ =rrypmp4esandb du@ourd =d=mof~~~~6#~ it@ htnormaf andpmlifemtingfis5uCJ Bid3kK&srlsnla-m432-w

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EL Natale PJ, ~ntblay GC Studies on the availability o: ~~f-~~~==mfbxkKMal mactkma Insai GveLArch Biod’=t BioPhYa l=-

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,I:IUC dc It,wu pyriIIIICII,W S-yINJIC+S AICh Lhchcm Biophp 236:1-10, 19s’) 1} CIIIIJLIY GC, Crandafl DE, Kmott CE, CI al Orotic acid biosymhw SIS in rat In!cr Studies on the source of carbamoyl phosphate. ,\rcIl B]ochem BIophys 17S:264 -277, 1977 Ily.nIl J, Nguyen Jl, Brmdayan M, cc al: Expression of nuclear genes cllcodlng the urea cycle enzymes, carbamoM-phosphaLc mUm&sc I and omithmc cartmmoyl iransfcrase in rat liver and intesdrud muCOSJ Eur J 13iochem 152.2S7-292. 19S5 2aharctiIz DIV. Napier EA. Andemon LW et al StAmdadon of umcil nuclcotidc synthesis in mou.sc liver, imcsdnc and 16dney by ~ nium chloride infusion Eur J B!whem 17S192-19S, 198S NimbcrgW, SOutra ~fAv,SalJmmlRJLafi lnmdnal@aminc~

hsm after nussivc small bowel msccdon AM J %ug 159.27-33, 1930 59 N*Y2WUI H, Wacr E ~~idine ti=wfietic e-= ~ ~ in=tirre afwr SIIUJI bo.cl rcsctiom Gasmocntcrolo~ @4S04S7, 1975 60 Miclmil S, hlohmnmdd~w1{, Park JH, ctak Eff@of gh~pl~ mcntcd elcmcnti dIct on mucod adaption following small bowel resection in nas. J Pediatr Gasf-roentcrol Nutr 21:394498, 19% 61 VandcrhoofJL Blacku’oud IX, hfo!wmdpom H, eta Efkcrs of oral supplemen=tion of glwanrine on small intesdnaf mucosal mass fOl. iou@ -Om J Am Cdl NUU 11=27, 1992 62 Tarnada H, Nezu R, h!awuo Y. Afanyl glufamine+nriched total parented nutrition mores imesdmf adaptim after q ither proximaf or disd massive r-on in r=.. JPEN 17236-242, 1993

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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

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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-’. q 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 q 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

taminc consumption in the atrcssd state and may, shcrcforc. play q 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

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-

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- q 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), q 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. oxi&(FCOJ> 375kI%os SOmm Hg]. ~ cMcinoSn& ~ ~.

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

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.

squencc lo rcccivc glutaminc-nrichcd enteral or parcmcral feeding pcxxoprmttivcl y.
Nutrition support

Laboratory arsalyscs
VcnouS plasma amino acid conccn[rmions were measured aI

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 q 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

,

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 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

EJ=sYw
EncrgY distrii (% amirIo as5rk) (% fat)

4300

4300 11

18 6

(% carlmbydra@ &zuosc) Nonprouin cncagynkrogcu Toral gt ~ w) Total niaogm f#lJ

76 Ilsl Iw 7.13

6 76 1121
10S3

733

‘vi Flus(saado% MMupdia). mdcmcdforsrndswids . -Ad&aoybcan —d. mdtokm rncdfidcmtmrdb aadmmdad rsudtivirmlis!a and minds. *65% Rsrt Arlirs(Baascr. Gksxw%mk LduhdDcw=llom

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~

Tcarm&tU).20% L3payIlU (AbboU. AbboU~u70%6arboaa . (Abboa), aJtdahndaIdrrsLdMrarrum and-(Asrla.wcadrcmM$).

.-. -

, Jut.1

10

1998

17

~hr”ri;it.\!. l,\ I\l.E 2

co\ll’/\[<l;l) W[”i’1{ l.A]{l~~l[J+,\L G[.urAh$!~[~

979

Plx<ma amino acid conccnmtions on days O. 1. WICI 5’ PkmLl Amino acid (pnolA-) and Iypc Of feeding’ 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)

my o

Day I

DaY 5

Formula
PwL.fL

33s 11” 21 z 10 525=206 5622135 1% z 52 11!33s 195t51 1262S4 79:39 57:m 78 z 33 77:18 5727 55 z 16 387 z l% 413=125 98 z 17 78 = 17 164 z 26 151 z 32 48 z 16 32 z 14 45 z 12 43213 49 = 17 37 z 12 6629
56%10

40=6 %215 389 z 160 474 z )79 17! = 18 I08Z40 212 z 28 3% z 141 84213 73Z25 83Z28 74Z34 53223 32 s 10 61 z 12 53 = 15 24=6 21 = 15

28500 31409
109010

1!3641 144409 43566 47004 61379 51682 345s1 so 939 34822 3642 m 11021 1894 m ND 128S8 49 39293 29221 33 m 29436 40 ND 105 112 m ND 16225 w 501

41 * 17 44z17 11.I.272 6.8 = 3.4 73Z34 58220 180252 204=57 22=1O 23211

69=21 6.723.7
67 z 15
56=10

7+7 =29

3.4 %55 99Z34 93234 141238 155259

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

15=6 13=6 43=9 37*12
54%32

19=7 1729 73=16 63Z24

47?20
170273
1%=~

75=34 ~=~. s
117*M ~=fi ~*~ ~=~~

9W Sl%z a258 29722 10372 25228 10
25716

114Z35 137*43

1242 Si

162$ s~
m*42 134 * sl

339*24 1R*4S
43*9

67*2O

S*33
46*35

la

-

_-——__

..-

I JUN 10

1998

/%

. . --- —. —.. -. —.. . -—. . .._ ___ _- . ..__ -.. _ . .

-. -—-- --.. — ----- _

9s0 TAnLE 2
Cominucd

1’1s11 El Al.

Plasma

iii

Amino

acid (#mol/L) and t% of feeding?

Day O

Day 1 7 5 : 18 64:9
S2 : so 53:28

I-)$+ 5 69 z 17 70 = 16

Fomml a 9 !37
14774

Sc.rinc’ (126 z 14) IT TPN Glu8ammc’ (24 ? 6)
77= TPN

105 z 27 109:36

WO 149 46s z 5s 577 z 200 872 = 126 1043 z 313 1.24:0.32 3.69 z 0.64 0.37:026 0.47:0.33
151:0.43 i .78 = 0.46 0.29 = 0.35 020 = 0.16

XBW’ (413 = 34) lTTPN ZMA’ (776 : 57) 7’3= lYN Valine:lcucincJ (1 .68 = 0.08)
TF TPN

411:134 354 = 107
81 OZ248 774 z 218

309:52 261255

243095 139856 372753 259650 0.32 1.42 ND
ND

.

621:94 567:107
I .68 z 0.20 t.98 20.32 0.21 t 0.07 0.21 z 0.14 1.01 = 0.19 1.0120.13 0332032 0.13 z 0.07

1.48 t 022 1.70 = 0.19 034 z 0.32 0.[8 :0.12
1.03 = 0.33 1.W z 0.32

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

3.57 1s.43
0.033 0.001

0.18 z 0.11
0.1720.13

-* .- . . . , - . . . . , ,. -. v. . s. ,

‘Rcfa-crKc amucdvalucsin~ @z SDJ). ‘ Signmanl fading glwpby-rknc ~ P <0.05 (UANOVA). 4izsEhL ‘ Signifmt diffcmmxs aauss timG P < 0.0S (MANOVA). q SignifW diffcnmccs befumco fding groups. P <0.05 (MANOVA). 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

m. na dckcsable.

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

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

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).

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

ww

/7

—— ———— .. :_,.._ - ___ .__ .-. _

..

EtWEltAl ~~)hlpA~ED WIT1 { l>,\ Rl:NTEl:,ll, GI.[ rr/khfl NE

9s I

__—=

T,illl.l; 3 Expmimcnul dcsi~n’ Swdy day o I 2 3
4
Enrollment

‘4

Proccdums 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

bbmmory amlyscs+ V.mCIus pksnn am,”o acids, pro[cins, clccwolyles 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

5 7 9 10

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 q 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~ q 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

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.

Tsrbc fccdusg (“-5w2~

Im (a- SM5FJ

-- -

., .-..

-.-b-

.

—..

.-—a.

.

.—

_.

.—. ——.

-——

.

.

.

.

.

.

..

—.-

_

9s2 T,\lJLE 6 ~twxuq =wwmcntr

FfSH ET AL 650 TutK feeding 7TW 463.7 :29.0 [IO] 391.2: 29.0 [10]
2Z4 z 2.4 [IO] 17.5 t

d

T

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

I

I

E Day 5 tZ Day 1 tK Day O

i

521.6 z 435 [7] 391.2 243.5’(7I 29.2 z 3 [6] 18.6 z 2.42[7]
3.9 = 0.6 [6] 1.7 = 0.5’ p]

2.tF[lo]

3.5 = 0.5 [101 Z22 0.5’ {ioj 13420.23 [9] 1.14 z 0.18 [IO]

1.35 z 0.15 [6] 0.897 z 0.23 [6] 3.8 = 0.4 [7]
3.2 = 0.4 [7]

S3 z 0.8 [IO] 4.0 x o.s~ [10]

‘ 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.

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
uptake and metabolism in the body (5). In a messed stat% glutaminc uptake by the

the formula rwckxl. The Small intcsfinc is the primary site of glufatninc

intestine is aaclemcd. Studies in dogs

bSVC

s h o w n t h a t poatlapsmtomy,

glutamirac conmmption by *

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

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 -

PP$on&y5~a===hti=#w~” mulacornpnsitiomL lbcradO Of_ tikucincdifked

position ofdacf-ulafd appuratobcakey~cd

- -.
J

JUN f

O 1998

21

ENf”ERAL COMI’ARED \VITIJ pARr~ERAL GfJJTAMl~E 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@-

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.

k

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. u
The assistance of Peggy Bomm wirh drc amino acid anafyses awf of Duane H.yd! widI she statistical analyses is gnrefrrlly acknowledged.

REFERENCES
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.

;+ .:.= y ..?...! . . .

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 q @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

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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
From the Intensive Care Research Group,

Deparnncw of Medicine, lhi”versi~ of Livetpoof, Live~ool, and the Intensive Clue Unu, Whiston Hospital, Presco(, UK 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 q 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=& q relative dcficiesbq tesuks lhis may have askssc

also involvd

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

-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 q breakdown of
impaimd imrnuns msponsiva d 2&%5!5!-& Tbcscmdld inicdfca nltessemjsldtcmosl aidcally ill Patkrsswhoam thcsubjcaof (b,iaatudy.

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

Nmisioo L23t6-3Xl, 1996
Wlscvicl science tsac, 1996 Printed indae USA Ati*suavd.

!!!!!!r
EtSEVIER

C@9%9007S6tSls.oo PIl so899-9un(%)OO06U

..

IJUN 101598

23

.-.. -— ----- , -— . .

-.. — . . . .—. . --- _ * , ” , _ . . - . . . —
MUSCLE IN IHE VERY SIW13tElY

l’Al/ENTEl/AL

I.. GLIJ”I’AMl Nli AND

ILL

317

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, q 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

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 q 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 tkrrOrnpamd bdwcco groups using citk pammcmic or

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

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

GITN ( d )
~% L-@tdnC SOhdOrl (Stile supply ~. ~

CfPN (ml)

Hospital) 15 (Lmpotd Pharsna&Gxford Nutritioa UK) Efoarnin 10 (Leqokt Pharena&Gxford NuoidoaI UK)
EJoarnin

100D 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

-

Sterik wata Glucose 50% @XX@ Glueesc 20% (GaIm) Elolii 20% --a Oxfcxd Numkiorr US(I

~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." oTPNarrdcfPN-Ggt mmmc4f#emcowd aat0mwmiod . Ioal palurtsral rwrxtr@ rcqccddy.

Noconskad cbrsshthsmsde kvelswcteai!aa b & imem’al bctwui-biiet (os-&@’aksat 6mcspaa h plasma giutamk acid Iiooblopa”kd patklata). AD

kvckwaaaccsa in both GIFt’laod CIPN@=Q*-tudeofwbkhw aarsotaignificaatb ctwcca~~kfv)

incruac

in *

.

-. -

.

—— —- . . ..
31s

—”.-.. . . . . . . . —.- -

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.

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 i
R\ APC 2 5 18 23 23 23 23 2s 25 36 37 37 37 37 37 37 50 53 53 55 Comrol Pa[icm Diagnosis
Asfima. COAD

a

DIAGNOSES PRECIPITATING lCU ADSIISSION Gluuminc Patron! DIzgnosIs 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 13x APC I 8 23 23 23 23 23 23 23 24 25 25 3 32 32 37 37 53

I

YC5 Y= Yes

Yes Yes Yes Yes “ Ycs Yss Yes

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

Yes Yes Yes

Yes Yes Yu Yes

Yes Yes

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&

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

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

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. PLASMA AND MU.SCUE GLUT- AND GLUTAhfME EVHS BEK)RE lTN ADMNISTRA170N

TABLE IV.
WGES IN PIASMA AND MUSCLE GLUTAMINE AND aAMfCACID ~DURfNGlHEF3RST S DAYS OF T7+l GrPN CfPN

Pi&ding Vsluca =~d
(-z 95% a) Plsanugfumninc . amsol.Lyt Plasma glusamase ssusml . L-t . 0.343 = 0.082 ~~*~ n S35 w)

+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

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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
whereby intracctfufar muscle gkrtamim JCVC15 arc contmksl.
this wczc the casG dscn it might nos psovc If

GITNO

C3TN1

CITNO

43TN1

FIG. 1. M.sck gluramine before. after, and five days toral parrmual nutrition (TPN) q 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,
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 -

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$, aod ia psrdcadar tlsc immune system, tie 6s musadoskcksa.i aystcut sakes oothcrole ofastoragccagan mnsumcd intimcsoftsccd Ymw&y’-XL!$%%ti2Tz:%%?

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

Plasma ghrtamkc levels, aftbottgh Oot a rdkcdon of body storc& do givt SOMC ‘mdicadoo of the atme Of whok bOdy srscSabofic 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-

inthcvay scvuely illtocotdirm apositiwcffEuyand ioffuf=0S Onoutcmme A=O~ ‘I%e Sir Juka l%ora Chsu+abk Ttu% Oxford NuOitiOa. ~

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 Turstaa diptOid fibmblasts iss media of 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 *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
Clcaive Coun-=d y~- P= @@* ~ ma@G-

8. Hardy G, W- D. McElroy B, 7%ompsotr GR. Formtdadon
of q 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

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E(f,.cL\

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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

Of acwc

nKLd)OllC

acidosis

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: q 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

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The Effects of Glutamine-Supplemented Parenteral Nutrition in

u! 111 11 .18

Premature Infants
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

P 1

{
1 1

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.

Background: GMarnine (GIN) is the primary fuel for rapidly dividing cells, yet it is not a constituent of parenteral

ii&2F-~’ :
r

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*

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
ReCAvedferpubDcartcq Marc41t?9,19P6. ~~~ ComW&wrandrqr$-%%%%sswWitmat%MLW4Yma andw’anen\Hq@ 7sF’1an&a Bostab MA&?ll&

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

74
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I JUN 1 0, 1998

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GLliT.+MINE-SUPPLE\l ENTED lNFAN”fX
TABLE 1

-75

4

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.

timoasilion of sofutions Studs sc.luLion (Ami.osyn Standard solution pF + glutammc; 7% (Aminosyn PP. 7% solution)
(m,g1100

mL)

solution) (mg~IOO ml.)

Lysine Leucine Phenylalanine Valine Isoleucine Methicmine Threonine

475 631 300 452 634 125

3s0 665 240 262 427 z

Study Design
The major aims of this study were (1) to teat whether GfX was weft tolemtcd in this population of premature infants and to invesrigsle (2) 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 q 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).

Tryptiphan Alanine A@rrine Glycine Histidine
Proline

125 490 361 270 220
570 576 347 370 z o

100 a92 669 216 176
4s6 4s1 278 396
as

Glutamate Serine &partate
‘l@sine

Taurine Ghrtsmine q 20% glutamine solution.

34 1400”

_— *

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4

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 q vafuate bactererrrta infants were weighed daUy on q 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

+’ >.+: .,. ,:.:.

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 q 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 (>

q

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

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

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the rc.sulw were
group” had
higher

4

500 400 300

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-

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-

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.-= *

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

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 q 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.

100

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

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

,.

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>

females). ‘lkem were no baseline differencesbetmenthe

ma &?q”Cbho?t fntheZSOOgCOho* th-WeRnO____ cant differem= inplamaGLN, glutmate+ or BUN ~le fV). During TPN (but not for MM BWH), the GLN-

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

suPPlem=@WWMmon infants wMh@&bld

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. . . . . .

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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

]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

third week of TPN, the GLN-supplemented group had a

not reach stat-&ical significance.
OISCUSS1ON

Cestational age (weeka) Apgar score (5-IniIIUt.d Sex (M/F) Entry age (days) fvH {+1-)

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.
26=1 6S z 1.5 7/15 4.1 z 09 3/19 1.2 ? 0.4 15L22 5!22 0122
9113

Bir& nunk # single bkths
#twins # triplets Delivem IV to C)
Plaama ghtamine

2622 6.4 z 2.0 12/10 3.7 ? 0.8 1/21 1.4 ? 0.7 16/22 4122 2122
5/17

Baaetin-e

(p.mol/L) Plasma glutamate (prnol/L) Plasma ammonia (prnoI/L) BUN (mmol/LJ *No differences between groups.

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

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L4CEY ET AL

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.

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7s

Vo[. 20,

No.

I

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in hcafthy adulfsm where increasing loads of GLN did not
resiuft in clinical toxicity or abnomd glutamate levels, buL there was a nonsignificant increase in glutamate in pro-

50
GLN

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

0

J -

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

..
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

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)

K NS
NS

NS

917 Y 134 26.6 x 21 6.6 z L6 4f7 3.720.7
0/11 L3 =“0-5 6/11 Wll 0/11 S/8

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

N: NS
NS
Ns NS Ns Ns Ns Ns

NS NS NS

z
Ns NB Ns NB X8 m NB Ns NB

47== go=~l
lo4*16 21*11 929 1429 225262 142*48

R

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

E E

I JUN 10 1998

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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

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

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 int@.inaf 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 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.
REFERENCES
infanL NCP 8226232, 1993 Z Bergstm5m J, Fiirst P, Noree W, et ak Irrtmcelkdar free amino acid concenrnti?n in human muscle tissue J Mpl Physiol 36593-697, 1974 3. i&leK_~@Metti~Sroti~Of~Mm cetts in t&sue txtture to Lgtu(arnine and b@xntc add J Biil Chem 21S607+516 19Y3 4. Ehrem G, Hsck&%eMJu4M IL Protein melabokm ort& sue cells in sifru. 7. l%e chemical nature of some obtigat.e factors of tissue cdl nmition Acts Fhyskd Sand 1S21S-230, 1949 5. kiati MSM Newshofme12A GlutamLne~k~ Of the rat- W&em J 212S35-SC4 19S3 6. Newshotme E& Newahobne P, M z et ak A role for muscle in the irnrmmesy aternan dirsirngmrtancein qe m’, ~s@.$~ burns Nutrition 4261-263, 19SS 7. Newsholme P, Newsholme W Rstes of utiliion of giq gfumrnineand Okbtd fOMUtJOn Ofend-produckb’ mouseperb “ ned macroPha&s in culture ~ J 261 fZll+l& 1~

1. R= J, Gibhm K~SE@d:Nutimt Adti~

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.

S. WMmuetter HG, Spaeth Ml Uptake and metabokm of plasma gtutarnime by the arnatl intesdm J Bid h 249..7IMO79, 1974 9. Whuetter HG: CMandne utUiratfon by the small in- Adv Enzyrnol 63201-237, law

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J.ACEY ET AL

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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 synti@.s, 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 “1 24. O’Dwyer H, Scott T, Smith Rf, et ak M%orouracr 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

experimentally induced cnwrocohtis Jf’CN l$l~~loss, 1990 35. Ostertag SC, bGsmma EF, Reism cU et ~. tih Cnlcral feeding

12S29-35, 1993 34. Romtiau JL A re,ic~ of she effects of W~~inc~nnCtled diets on

and epidermal growth factor on the
1043%364,

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

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

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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

SwgeW ad the

Drpart.e.t

of fiannaq,

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

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

.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

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)

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

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
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

for prolonged periods to allow at-home use by patients

..

-. . .

35

-.

.-. -.— —+ ., .--— --- —.— . . . . . . .. —.... . . . . . . . . .

M,7J-JI,,:C

1991 hlATEl:l.41S ,\ND MLTIIOIX

l..(ll.lTfX\l!>~lI Sl\l’I’l.lChl l\-l’?iI’loN

26:1

–-.= .— i

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

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

weight were quanfiitatcd in tripli@c for cacl~ fommla on days O, 8, 15, and 22.
has

recruited from our home TPN population. All patients gave informed consent before joining the study.
Paiicnts 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

The solubil.i~ of glutarninc in solute-laden been problematic in the Past- The

solutions PnarrrdxA

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

... . . . . . . . . . ,. .:: .

--”+ *

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,

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.
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 g

1 M 2 M M s 4 F 6 F 6 M 7 F TPN, toralpr@entd nutritiqs/p,

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

IIol:wliy

I!qy,tj ,.:,’ *,,

,.[),)/

,8,

/LJo,

>3

O( ~ :g/k:

{Jf botl~ ly{!iglll ‘i’tt~:

g](II:IIIIIIIC’

tf’; LS {’~lil.Sl(l

L’I-ed

1)311 of IIIC to@” .mnillo

acifl (I05c. TIw rcinaindw O f tile
OIi I.lte

glumminc-TPh’ solulion W.ZS Ixzwt
fomlula of each indi@ual p3ticnL

rcgulm TPA]
formulas

These

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

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

plasma ~nin~
were

/
i

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.
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
from commercially available amino aad standard solution (&-nirto Acid Calibration Standard Pickering Lab

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 . 6

AmirlOdds(g) excluding $utamtne 323 513 64-0 26.1 66.6 M-o =0

TOtJ.1 doliu -%~~lnm mhtian) 2340 a 2674 ZMl 1779 . 2314 w

Dayo

-u

D8yls
m

Dqa

PaIxncnctu# &
as,

PH Dactmse (%)
color (xlutuntk) P=tkuMematter Anunordunl (Jlpm) Glutwnic M Me(%to$$) H%

6m loaoo Ml <M w Pm

6al
Fs <16 M

6.s
9271 Pm w

24.6 Pm <t6 w

-729 -2S1

+.09

PA22

-

-

“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

Or glulalijnc SIIl)l)!CI)ICI)

l:ILI{)ll, IJIIL dlell a gr~du~ dcclilw

bc:wl.

AfLcr 4 weeks of glt]tmninc suppkmenmtion, the
L O 453

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 * (%)

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

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

~ 82 p-rnoVL.

A WiJcoxon matched pairs cesl was performed, compar-

D8yo
lm.oo lm.oo 10MO
lW.W 100.OD lmoo

ma
10M3 10&64 11106s

Dqts
10L14 SLm
9319 9s69 RM6 ml

D8yZt
S3.02 (NS’) XW3m 9Z69(NS)
9249 @S)

-We
96s3 9171
ml z 9L76 m7a elm ma

Glutardne(=l.11%) Glycine

lsoleudne

lW

im66
104-M

U&16(NS) %.11 (?S)
W.91 @s)

lW.00

lM.12
lo7m 104.61 10M1 lm13

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

-- -.

JON ? 0

199g

..-. —— - — . . . -. —.. =- —. —.-— . . -. —:—”.

. .

272

liOIWSIW.lJ; WS 1:1’ Al.

W

1,s, AI()

.Y

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?

i n t e s t i n a l vjllrrus hcigl)t V&s noL nlwlsu]-c(l ill

our

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~

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 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 Pa!ient 3 BihnMn NL - &LO Alkaline Phospha- NL = 304
0.7 175 3a 520 44 16
0.7

2 week dur mdv
02 m 36 276 Nor done 24

206
126 946 52 41
0.5

0.3 151 4a lm 63 68

2?6 m 191 41 %

03 152 22 126 202 33

O.a

m
24 20
171 90 -.

MTNL= 1C47

57 NI+ Nomd labmatory valuq AS, serum gluwnic oxahmtic tmnsanu “Iwqmtilacdc acid ~ ALT, serum

ALTNL=$37 LDH NL = 60-200 AnullOnia NL -13-64

MY 272
142
m

0.7 131 21 37 la 32
gtutarnic pyrma.te

600

LAWA QLUWNE LEVEU hl~bf) 1

600

I ! ..-. .— .* 1. . - —-I

400

200 o’ *

8

4

6

0

7

-. _

I JUN 10 ~ 1998

39

---

.—

—e—.

.

.

.

.

-.—

-..

—_______

_

___

__

-

.,

_

J t(?y---n

71

(’

I 994

l/Gl.UrAMINI; SUPPLEMENTATION

273

c

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
mxxinm] small -bo\vcl

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

improve smafl-bowel function. Whether glutarnine given
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
during d]e early stag= after resection of \vould resuft in an accelerated raw of

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

;--w,., . .. . . . .

-Y

.

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

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, 4—~ Wemermsn J, Ruston ~ et at Addition of glutsmtne 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

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 -- 193

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

storage. In previous

aseptic

wnditiotts. lle a’lutiotts c&taincd ele tro[ytes (except vatnin/dextrose) and micrcmu-

..-

I JUN

I o 1998

f

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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)

I i
SynthamirJ

Aml~~A)t/ AmlnoglccjB)t/ Eloemln (A)tt/ Eloamin (&t)t tl dex!rose dextrose
74 46.6
49.1 7.11 577.2

Synthaminttt/ dextrose
74
32.5 3s 6.4 563 -

dcx!rosc/ lipid
68
26 28 5,12 450,4 400

VOmin”/

dextrose Pcrilu\in””
74
-9 460

66 43,2
45,3 53:’5 1;.0 6;:; 2.7

74 46.2
49.2 55!:! 17.2 6% 2.9

68
42S 4s.3 52!: ; 1s.9 6;:~ 2.6

74
30 40 54 -

Fet (k@
Pbospfsete (mmolrl)

ii.3
6;; 2.9

15.0
2.5 35

12
2: 5 9

/
; Ce

a (mmol/f)

MS (mmoVl)

(mmoVl) Aoetate (mmon

Trece elementt”’e Vftemhss””””

Elotrece B

1.0

MVC9+3

MVC9 + 3

Elotmx B

1.3

Elot%e B Mvc9+3

MVC9+3

Elotrnce B

10.3

Additrace Multibionta

6;.5

5;

Addilrace Multibionta

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10

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tt fAOPOld Phmns, OrGZ, AsntrlaK3xford

W Baxter, Eghem, Sumey, UK q Kebl vtsnnn Ltd. Uxbrldee. Mlddieaex. UK 6* ~~- Ltd., Al~on, Hunis; UK
q q

Nutrition. Oxford, UK

i’,

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“” 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)

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[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

CLINICAL NUIRtTION t95 2) was measured at room [cmperaturc before, during and at the end of the ICSI period.

I
I I

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
without the addition of glutamine. As fufiher controls, ammonia (as ammonium chloride, Ana-

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.
G7feufations

I I I I

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.
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 !

tamate and ammonia. . Aliquots (20ml) of each solutions were removed

++>... .:.. s% . .. . . . ....—_
.

i I I I I I

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

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.
ar diffcrem

Tabk 2 Degradation rates (%klay) of fq@naminc in various $oIuriondmixsurcs Iempcramrcs using she gfuramhe roctbod

(A) sod the aorrnafi mefbod (B)t
Tcurpenture

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pki
54 x s.s

Z-2X
A O.n

B

A
0.10
020 H

c
0.10 0:0 0.10 0.14

-w
BAB m m : : m m

Syndummwrw

. 5.8 am

0.90
ok o.n

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42

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m :: Q74
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& 0.14

0.25 020

0.10
m 0.09

M m

0.18

0.17

alo

0.10

%

w

m w m u m

w

tSurarfarddkofroetbod Aaod B ttFordetaifaf0xnpdk08a2bt4cl 1#1 = oodelcu8bte .-

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_

_

_

_

_

_

.

196 STAf31L1TV OF L-GLUTAMIPW IN TJ’N SOLUTIONS

M N OAYS

Frg. 1. the dczradation of L-slutami~ (GW q 22-2~ in a dex:rusc solution 15% w/v (*) and in a Synthaminldextrose mixture (*). see Table 1 [or detailed composition. Rcsulrs q 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

Pyroglutamate was added (14day period at room

Ii i
I

I
I

I

. 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.
-.

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.

I
!

lle use of soluble and stable glutamine containing dipeptides, which are readdy hydrolyses within

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.

between –2&’C and -80”IC

(this work and (7,8) ). In addition glutaminc dots not appear to affect the

stability or size of the lipid par-ticks in ‘all in one mixlure’ (8). It should be emphasised that the use of gluta-

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).

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

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

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

.

.

.

..—

._

.._

-.. ——
I

19S STABILITY OF L-GLUTAMIh’E IN TPN SOLUTIONS

dcgradative loss,

but administration of such solutions in clinical practice requires further evaluation of [heir benefits and possible toxicity.

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 q 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 q 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 q 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 q ffcaing tkxc stabitity of L-dutamine in solution. Submitted 8. M~Ekoy B. Hardy G q 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 .
Submission &te: 4 Aprit 1991; Actzpted: 5 May 1991 13

14.

J5.

16. 17.

18.

19. 20.

*J$.. . . . . ,.:-. , .:. .:.::,:

L.

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 q 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 q 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 q cid in enzymatic asein bydrofysatca. Acts Pbyaiologica Scandinavia 39: 147-15/

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