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I.V. Systems Division Baxter Healthcare Corporation 847.546.

6311
Regulatory Affairs Route 120 & Wilson Road Fax: 847.270.4668
Round Lake, Illinois 60073-0490

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Haxter .s=
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June 10, 1998 d
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Dockets Management Branch (HFA-305)
Food and Drug Administration m
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12420 Parklawn Drive, Room 1-23 N
Rockville, MD 20857 m

RE: Federal Register Notice April 7,1998 (FR Vol 63, Nbr 66, Pages 17011-
17012)

Docket Nol 98N-0182

Dear Colleague:

Baxter Healthcare Corporation is nominating L-Glutamine as a bulk drug substance for


inclusion on the list of bulk drug substances that may be used in pharmacy compounding that
do not have a USP or NF monograph and are not components of approved drugs.
Attachment 1- Bulk Drug Substance Checklist includes the information requested in the
notice.

We appreciate the opportunity to nominate this bulk drug substance for inclusion on the list
for use in pharmacy compounding. If you have any questions regarding this nomination,
please contact me.

Sincerely,

Marcia Marconi
Vice President
Regulatory Affairs
(847) 270-4637
(847) 270-4668 (FAX)
+-..

Enclosure
NoM8
m 1 0 )1 9 9 8

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ATTACHMENT 1

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

BULK DRUG SUBSTANCE CHECKLIST

1. Ingredient name: L-Glutamine

2. Chemical name: 2-aminoglutaramic acid; glutamic acid 5-amide.

3. Common name: Glutamine

4. Chemical grade or description of the strength, quality, and purity of the


ingredient: See Product Specification Sheets at the Tab entitled PRODUCT SPECS.

5. Information about how the ingredient is supplied: White crystals or crystalline


powder.

6. Information about recognition of the substance in foreign pharmacopoeias and


.#’%
the status of its registration in other countries, including whether information has been
submitted to USP for consideration of monograph development: This bulk drug
substance has not been submitted to USP for consideration of monograph development. To
the best of our knowledge, this bulk drug substance is not listed in the BP, EP or JP. This
bulk drug substance is listed in the Food Chemicals Codex, Fourth Edition, effective July 1,
1996, page 174.

7. A bibliography of available safety and efficacy data, including any relevant peer
reviewed medical literature:

a. McCauley R, Kong S, and Hall, J: Glutamine and Nucleotide Metabolism


Within Enterocytes. JPEN 22:105-111, 1998
b. 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
c. Palmer, T et al: Effect of Parenteral L-Glutamine on Muscle in the Very
Severely Ill. Nutrition 12:316-320, 1996
d. Lacey, Jet al: The Effects of Glutamine-Supplemented Parenteral
Nutrition in Premature Infants. JPEN 20:74-80, 1996
e. 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
f. Khan, K et al: The Stability of L-Glutamine in Total Parenteral Nutrition
Solutions. Clinical Nutrition 10:193-198, 1991

3
Comments to Docket No. 98N-O 182
June 10, 1998
Page 2
-

Copies of these articles are found after the Tab labeled ARTICLES.

8. Information about the dosage form into which the drug substance will be
compounded, including formulations: See the Hornsby-Lewis article listed as 7.e above
for information about the dosage forms.

9. Information about the strength of the compounded product: Diluted in a total


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.

10. Information about the anticipated route of administration of the compounded


product: Parenteral administration mixed in a total parenteral nutrition (TPN) formulation.

11. Information about the past and proposed use of the compounded product,
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.

12. Available stability data for the compounded product: Hornsby-Lewis et al


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).

13. Additional relevant information: The stable form glutamine dipeptide is available
in Europe in commercial pharmaceutical products.

I JUN 10 1998
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.,.
L-GLUTAMINE cASNO._9
MOLECULAR STRUCTURE
AND FORMULA

H2N—f—cH2—cH2-cH-cooH
I
o NH2
C~H10N203 :146.15
N : 19.17%

DESCRIPTION White crystals or crystalline z


odorless
Slight taste

SPECIFICATION State of solution sec.-1


AND PROCEDURE More Than 98.0% c=1O,2NHCI
(Transmittance)
Sat.-Z dry
Specific rotation [a~ +34.2 - +=~ c=2,6NHU
Not More Than 0.021 % sec.4, 0.5 g
Chloride (Cl) 0.30 ml of O.01 N HCI
SSC.-5, 0.6 g
___ Sutfate (S04) Not More Than 0.028% 0.35 ml of O.OIN H#04
Not More Than 10 ppm Sec.ql), 2.0 g Incineration
Iron (Fe) 2.0 ml of Standard solution
I ,
sec.-7-(l),l.og
Heavy metals (as Pb) Not Mom ThanlOPPm 1.0 ml of Standard solution
SeC.*(l)-B, 1.0 g
Arsenic (As@3) Not More Than 1 f)prn 1.0 ml of Standard solution
1
sec.-9-(1)
LOSS On drying Not More Than 020% 105Z,3M
Residue on ignition Not More Than 0.10% I sec.-lo, 2 g
I I Sec.-n-(2), dr’y-O2g + WI -
100mf-+TakelOrnl
purity (dry baaii) Morel-ha nm.s% 0.01 NHsS041 ml = 1.4615m9
Gf+dwh
Not More Than 1.0% Sec.-l3, Solvent A
For~gn ‘im atis I(TLC, 30 pg) Nin k Standard (0.12 fd
Pyrcgen” Free sec.-zs 1.0 Q1OO ml

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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. ...
1
Gharni e, L- - RTECS - Regis[~ of Toxic Effeds of Chemical Substances hr@/165.212. 125.mATMRTmTh.0i2275 100.HTI

.
4

Glutamine, L-
RTECS - Registry of Toxic Effects of Chemical Substances

Document Outline
~
10 SUBSTANCE IDENTIFI CATION
2:0 SYNONYM{ S)~RADENAME(S\
!)~ ALTH HAZARD DATA
Q NIOSH DOC UMENTS
O STATUS IN U.S.

O SUBSTANCE IDENTIFICATIONA

I’ECS Number: MA22751OO

.-= hemicd Name: Glutamine, L-

AS Number: 56-85-9
:ilstein Reference Number:
1. BRN 1723797
2. 4-04-00-03038 (Beilstein Handbook Reference)

[olecular Formula: C5-H1O-N2-O3

[olecular Weight: 146.17

iiswesser Notation: ZV2YZVQ

ubstance Investigated as: Drug, Mutagen, Human Data

ast Revision Date: 1997

.0 SYNONYM(S)/TRADENAME(S)A

1. 2-Arninoglutaramic acid
2. Cebrogen
3. gamrna-GIutarnine
_+4z
4. Glumin
5. Glutamic acid 5-amide
b
1 of3 511i98 1041 AM
-. I . . . .- - . . . - . — a— - - -------

Glutami L-- RTECS - Regisq of Toxic Effects of Chemical Substances httpYt165.212.125 .WAT/URTRTMA2275 lUH-IT’M

6. Glutamic acid amide


7. Glutamine
8. L-2-Aminoglutaramidlc acid
9. L-G1utamine (9CI)
10. Levoglutamid
11. Levoghmunide
12. Stimuhna

,0 HEALTH HAZARD DATAA

CUTE TOXICITY
DLO/TCLO - LOWEST PUBLISHED TOXIC DOSWCONC

Man
TDLo - ROUTE: Oral; DOSE: 27 mg/kg/lW intermittent tJO
TOXIC EFFECTS:
Behavioral - Euphoria

D50/LC50 - LETHAL DOSWCONC 50% KILL

Rat
LD50 - ROUTE: Oral; DOSE: 7500 mglkg w
Mouse
LD50 - ROUTE: W, DOSE: 21700 mglkg -

;ENETIC EFFECTS
ISTER CHROMA’ITD EXCHANGE

Humun
CELL TYPE: lymphocyte; DOSE: 10 mg/L =

~THER MULTIPLE DOSE TOXICITY DATA


Rat
ROUTE: Oral; DOSE: 260 mg/kg/30D intermittent w
TOXIC EFFEC’1’W
Behavioral - Food intake (animal)
Blood - Changes in spleen
Others - Death

.0 NIOSH DOCUMENTSA
National Occupational Exposuxe Survey 1983: Hazard Code X4814 Number of Industries 4;
Total Number of Facilities 841; Number of Occupations 1A Total Number of Employees 8491;
Total Number of Female Employees 5700
I JIJN 1 0 199/
-..
7’
5112981041 AM
. . . . . .—— . . ..— -.— ——-————-..—......-”= .- .- ~— ——. .- . . . . . . . . . . . . —-

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

7.0 STATUS IN U.S.A


~J/ltiQ12.lfi.@AT~T~W~5 100.HTM

EPA TSCA Section 8(b) CHEMICAL INVENTORY

_——_ .

rJUN 1011998

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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 impofinl questions remain unanswered, in particular: Does
ene~ for enterocy&s. However, it may also have a key role as glutarnine stimulate intestinal de nooo pyrimidine synthesis via
a source of nitrogen for the syntksis of nucleotides. The rela- the action of carbamoyl phosphate synthetase I? Can de nouo
rive contribution of de norro synthesis and salvage pathways punne synthesis maintain intestinal purine pcds in the absence
seen~ to b-e affected by the position of enterocyz.es within the of diemy nucleic acids? And, what are the specMc effecrs of
c~t–lillus axis as well as the dietay intake of nucleic acids parentenlly administered nucleotides on the metabolism and
and glutamine. Nucleotides are especially importanl to u-ell-beh~g of enterocytes? A greater understanding of these is-
emerocytes dwing intestinal developmen~ matution, and re- sues will lead [o a more tional approach toward the nutritional
pair. Hence an undetstarrding of nucleotide metabolism within modulation of gut dysfunction. (/onrnal or Parcnhral and Enleral
entemcytes has important implications regarding both the com- Nxtritioll 22105-111, 199S)
position and route of administration of nutrient solutions. Many

The effects of glutamine (GLN) on the gut certainly GLUTAMINE


are profound and have led to the suggestion that GLN
GLN, a Aarbon amino acid with 2 amino moieties, ac-
may act as a “biological modifier” and a “pharn~a-
conutlient” However, the mechanisms of action of GLN counts for 30% to 35% of the amino acid nitrogen that is
transported in the plasma Thii role of GLN as a “nitr~
are poorly defined It is of interest thaL in the context of gen shutde- helps to protect the body against the toxic
tumor growth, GLN may act via GLNdependent prolif-
eration genes.’ It also shotdd be noted that GLN and epi- effects of high circulating Ievefs of ammorth GLN also
is important as a respiratory fuel. In autoperfused rat
derrna.1 growth factor have a positive additive effect on small “intestine 57% of GLN carbon is oxidd to CO? and
enterocyte proliferation in uitro.z
The role of GLN as an important respiratory fuel for 3296 of the total CO~ released by the bowel is derived
the rapidly dividing cells of the gut has been well docu- from GLN.’ Because GIN is degraded extensively in the
mented, In cent.raq less attention has been directed at gug .tiis means that both GLN carbon and nitrogen are
the role of GLN as a source of nitxogen for the ~ths.k t-eddy awulable for the synthesis of other amino acick
lactate, and NT. Complex interorgan exchange mecha-
of nucleotides (NT). The catabolism of GLN within
enterocytes yields nitrogen as well as energy, and the nisms usually result in a constant level of circulating
nitrogen derived from GLN can enter various biosyn-
GLN. However, during periods of catabolic stress the
intracellular concentntion of GLN declines by >50% and
thetic pathways. The term “ghttarnine oxsynthesis” has
been proposed to embtace such duality of action8 the plasma concentration falls by up to 30%6
GLN is a maor respirat& fuel for enterocytes. In
In this review we explore one possible explanation for
19S7, Hwarrg et s16 reported that the infusion of GfJ%n-
the trophic effect of GLN on enterocytes It is postulated riched solutions of parenterd nutrients resulted in an
that GLN might provide @erocytes with both energy and
increase in the mucosa! weight and DNA content of the
nitrogen for the synthe+is of NT. llte initiaI sections de stnd boweL Later it was demonstrated that there is a
Mtie~pMc~*ofGMmdMonfie@LMk
foIlowed by a review of the biocherrbl pathways Iesd- d~nse ~atio~p between the “~nc~~on
irtg to the incorporation of nitrogen derived from GLN of Mined GLN and the extent of jejunal atrophy; An h
into NT We close with a disctdon about the ability of takeofat kst4#k#d of GLNwasre@red toreduce
the gut a&oplw assockM with parent.ersl nutrition in
GIN to promote NT synthesis within enterc@ea
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 itt-
clude optimum ntatumdon of the intestine duting gro~
Rec+ved for pubtiotfoq May 9, tS97. Sncreased adaptive hyperplasii after inte5timd resec-
Amepted for pubticatl~ September 2S, W. tion, increased disaccharidase acthri~ within the
Correspond~ -e WCs4dey, PhD, Unherslfy ~ of
Surge~, Royal Perth Hoapl~ Wefthgton ~ Pert& WA -, unstked mucous layer of tie brush bordeq the healing
Austrak. . of entemcdi~ and maintenance of the barrier function
105
.

___

9
of IhC W.3 These findings IKIVC Icd w the dwcloptncnt huildmg bI{WL5 f{,r l/ IN.A, \~]l<’r\’:Ls ~’1’ \\”i Lll (ICUXYI-IIIW.I
of stable solutions of GLN dipcptid= SUCh as alarIyl-GLN. groups .WC bulldi]]g I) Iocks for DNA Their Prcscllcc is
———.- Phosphatedependent glutaminasc catdyzcs the ratc- cspccial]y i m p o r t a n t cturin: illlcstimd ~lcvcloIJINcm.
Iirniting step of GLN degmdation in entcrocyLcs This re- maturation, and rcp,mr.
action generates glutamate and ammonia (Fig. 1). NT promote the grot~lll and rmturalion of the dcvcl.
Glutamate then can be converted into energy via the tri- oping gut. Uauy CL al’3 evaluated tJ~c effect of added NT
carbo@c acid cycle or be diverted into various biosyn- (0.S% for 2 weeks) on gut growtil .wld l~laUJmLlon in wcalJ-
thetic pathways. The latter include the liberation of ala- ling rats. These supplements increased mucosal pro[cin
nine (for gluconeogenesis) and the production of omithine, and DNA concentration in the jejunum by at Icast 50%,
and this increase was accompanied by an enhancemcru
citrulline, and proline. Ghxarninase is a rnitochondrial en-
zyme with aK. for GLN of 2.2 rnmoVL and in the mt jejunurnof disaccharidase activity. NT ako promote the healing
has a specific activiw of 4.8 Wmol/h/mg protein? These of darnaged gut in wcanling rats.’~ The gu[ has the bio-
chemical pathways to degrade dietary nucleic acids to
figures indicate that it is a very active enqmte that works
at a maximal capacity even in the presence of low concen- either NS or purine and pyrimidine bases, and most di-
t171tiOnS of GLN. etary nucleic acids are absorbed as NS.l~ As cow’s milk
The extent to which supplements of GLN may be ben- is lacking in NT contenL whereas human milk is rich in
eficial to patients is unchxw. A number of clinical stud- cytosine and adeninc derivatives, it has been suggested
ies have suggested that GLN enhances nutritional sta- that infant fomwlas should be enriched with NT.’s
tus by promoting a positive nitrogen balance and Dietary deprivation of NT has an adveme effect on the
conserving skeletal muscle-a For example, in patients gut. He et a116 reported that the addition of NT to
undergoing elective cholecystectomy, alanyl-GLN-en- ent.erocyte cuftures promoted growth and proliferation.
nched total parented nutrition maintained the postop- Furthermore, tats fed a NT-free diet have a reduced frac-
erative concentration of both fTee GLN and polyribo- tional rate of protein synthesis and a reduced concen-
somes in skeletal muscle.’” How-ever, there is a lack of t.mtion of DNA in the intestine.” Leleiko et al’s found a
dramatic decrease in srnd int@stina.1 total RNA after the
controlled clinicaf trials evaluating the potential benefits
of pro!iding GLN to catabolic patients.” It is of interest removal of dietary purines and pyrimidines or the ad-
that. in an uncontrolled study, Wihnore’s group]? found ministration of Gmercaptopurine (a purine antimetabo-
that combined treatment with GLN, growth hormone, and lite). It was suggested that all messenger RNA (mRNA)
a fiber-containing diet significantly increased protein species were not equafly affected, and this suggests a
absorption of patients with shott-bowel qv’rtdrome. potential mechaniim by which dietary components may
We will now consider NT metabolism within control the synthesis of specific proteins. Leleiko and
enterocytes. ‘II@ will provide a foundation for the later Walsh’s have discussed the evidence that the effects of
.:;+_,.& discussion that links the ammonia generated by the ac- purines may be mediated through regulatory proteins
tion of glutarnhse with the synthesis of NT. 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 Phar-
maceutical Factory, Inc, Tokushirw Japan) had in-
as subsets of NT inasmuch as they consist of a purirte or creased jejrmal weigh~ DNA cortten~ and crypt cell pro-
pwimidine 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, aden-
deoxyribose pentose gt’OUpS. NT with @&? groups ate ine monophosphate was not included because its sdrnin-
Mration has been associated with hypotension and

w
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
_ in the jejurt~f
Gktaminase Dama@gutrewires fW. Ith=beenrePOIted@4
days of NT/NS-emkhed parented nutrition significantly
NI& SmProved healing of ulcers induced by indomethacln in
rats= Because the NT/NS incmsed aypt lengt& ctypt-
vDIus tie, and mkotic indq the authors suggested that
1- theeffectof NT/NSwasrdsted tomin~hti*
Glutamate ~ A.tnhIo acid Of@ proliftiom= A N’knriched diet tdso plVXtlOt.ed
healing of intestine after ktoae4nduced diadma in
Biosynthesis n&”’fhe aninuds tm-ated with~hada_flow
I hefghtkzypt depth tiO and ]ess hl-pithdid ~hO
TCA cycle @esthartthe ratsdeprlvedoflW
‘lhen+forthegut tohavemdy~ti~k~
PILL PadwaYS Oututxntne&gWtarhWtttlk!~ ● vant to $he optimal formulation of entend and

.-4?

..= ~ JUN 1 0 1998

I(9
I
....... . . ...7.. ..4G-.- a.**,..4— . . ~ .. .-& ,--- ---- ----. — . —- . . . ..- .—.

) To rch-April 1 ~:)s GLIJ’r,\hflNE A~l) NUCLEOTII)}; MHTAIKX.ISM 107

]laI”CIILCI-dl lluL[-l~Ii&. ~LlwlcnLw]{l[,io1)5sllould lKIVC tile


cap~city to provide a source Or NT to sustiin adequate
levels of nucleic acid synthesis. In tile next section we
describe how the guc c.m derive NT from either existing
~
Glulaminase
carba:o’’’’’osphare
CPS 1
nucleic acids via salvage pathways or by de MIX) syn- NH3 ~
thesis.
F- I
ST SYNTll ESIS Glutamate Pyrimidines
I_lnder nomd circumstances, the gut metabolizes dietary i% 3. Metabolism of gluw-nirw nitmgcn LO pjrimidine nuciewi& h ~.
NT via satvage path~vays. 13 Ho\vever, in times of depri~a- bamoyl ph0Spb02 SWII’IC* [ (CPS t) ad GUil~Oy! @O@lW? V-
tion bofl pyrimidine and purines may be synthesized by de meu.w 11 (CPS Ii).
mm pathways. Figure ? provides an overview of the bio-
chemical pathways involved in the synthesis of NT. It is iyzed by glutaminase, GLN-nitxogen can gut.icipate in both
important to review this information because it provides a of the CPS reactions. CPS I is located in the mitochondria
background for discussions about the interrelationships with other enzymes of urea synthesis, whereas CPS H is
between the metabolism of NTand GLN. located within the eytosol as past of a mukknzyrne conl-
plex that contains twootherenzymes fromthede now path-
firimidines
way. Tatibana and Shigesada= have suggested that the di.s-
Llacil, cytosine, and thymine are the pyrirnidine bases ttibution of CPS I and CPS II within the cell is to separate
commonly found in nucleic acids. The pyrimidine NS (un- the pathways for urea and pyrimidine synthesis.
dine and cytidine) are formed by linkage of the pytinti- Anaiyses of the complementary DNA of rat CPS I and
dine bases to a ribose pentose sugar. The pyrimidine CPS !I suggest that they have arisen from the fusion of
mono-, di- and triphosphates (UMP, UDP, UT~ CMP, CDP, two ancestrai genes a glutarninase subunit and a syn-
and CTP) are phosphoric esters of the pyrimidine NS. thetase subunit-r’ The glutarninase domain is active in
Derh’atives of thymine are only found in DNA whereas CPS IL enabling the use of GLN as a nitrogen donor. in
derivatives of uracil are found only in RNA contrasL the substitution of a swine residue for a cys-
Cfimloy] phmphate is the substrate for tie ~ n~~ teine tildue in the glutaminase domain of CPS I has re-
synthesis of the pyrimidine NT (Fig 3). It can be derived suited in a loss of the abiiity to bmd GLN. fnstea~ CPS I
from GLN in the reaction catafyzed by carbasnoyl phos- uses ammonia as the nitrogen donor and has acquired
phate syntietase II (CPS fI) or from amrnoNz CO= and Mg an fi-acetyl-glutamatAinding region in the Gterminal
adenosine triphosphate (ATP) in the reaction eataiyxxf by haif of the synthetase domain
,R_.<
. . . -. z <.’, ? carbamoyl phosphate synthetase I (CPS f). Because amm- Jones= has suggested that the reaction catalyzed by
onia can be generated from GLN in the reaction cata- 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
De Novo of the positive effectms (ATP and 5-phosphonboayl-l-

r
Gh-PRPP-AT
‘“””’ 1
as]
pyrophosphate) 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 *?
FGAM-S CPSII 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 ae-
MS by salvage pathwaga ‘fhese parhwaya are eompkq
APRT PP 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
HGPRT 3X phosphoriitxansferase can sahmge both uracif and
tlWmin& The Mestine can also salvage appreciable uri-
dine Ikom blood via uridine phosphorylase and has a 20-
fold greater activity of uridine phosphorylase than
~SZ=* As a general COmsnen& th~ ~ a ~ of de-
tailed knowledge about the ap@fic role of other ad-
vage 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-
_—_

..
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~JUN I o 1998
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10S h!C(:AUl,l:Y 1:1’ .A1, Vol. 22, Alu.” z

itcd Itri[t]ill IIIC illlesllll:!] IUUCOW by IIUCI1. UrldlIIC, WI(] NT SYNTIIESIS ALONG TI{E Cl? YPT-trILLtJS *~ls
This obscnation has implications for LIIC
t!lynli(iine.~’1:
nutrilion support of palicnls WCC!l~illg 3ntic.anccr agents. Cell position within the cJYPt-~~llus niS affects NT
The circadian patccrn of d)ymdinc kinasc, an enzyme biosynthesis in cnterocytes. ch~~’~i~~ ~d potten” ob-

c 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 ‘“
sewed 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.
Pu ri)lcs
i-zation of de trouo and salvage synthesis of pyrimidines
Adenine and gumiw m> the purine bases cxNnmotIly in the rat duodenum. Figure 4 has been constructed hy us-
found in nucleic acids. The pllrirw MS (adtwosim? and gua- ing data presented in that study.Ji It demonswatcs that in
nosine) are formed by linkage of the punrm bases to a the crypts thecells mainly incorporated uridine via the
ribose pentose sugar. The pwine mono-, di-, and triphos- salvage pathway. wherw the villus cells mainly incorpo-
pha[es {AM~ ADR ATP, G\If! GDP, and GTP) arc phos- laced orot ic acid ~la the de JJOJW path\vay. These observa-
phoric esters of the purine NS. The dwil’atiws of adeninc tions were con finmxl by Bissonnet k“
anrf guanine are found in both I)NA and RNA
The rafe-limiting step of de now puntw synthesis is REUTIVE CSAGE W TIIE DE NOVO .4ND SALVAGE
catalyzed by gluts.mine phosihoribosyl pyrophosphate PATHWAYS
antidotransfetase (Ghl-PRPP-AT). The activity of thii en- The relative contribution of de now synthesis and sal-
zyme is regulated by the intracellular concentration of vage path ways to intestinal NT pools has significance
5-phosphonbosyl- l-pyrophospl~ate, AMP, and GMP.W A with regard to the appropriate composition of nutrition
further nine reactions lead to the synthesis of inosine
monophosphate (IMP), whiJ) cam be convat.ecl to the other suppott regimens. We are aware of only one study that
purines (.4hW, XMIl and GMP). ‘I%ere are two imevemible examined the relative contribution of the two pathways
reactions in the de now synd~esis of purines that involve to intestinal pyrimidine pools. Zaharaevitz et al~ found
that de notJo synthesis made a twofold greater contrib-
GLN as a substrate: the rate-limiting step involving Gln- ution to intestinal NT pools than the salvage pathways.
PPRT-AT and the step catalyzed by phosphoribosylfortnyl- This was in contrast to liver, where salvage pathways
glycinamidine .syrdhetase (FGAM-S). made the greater contribution. The relative tates of de
The capacity of the intestine forde notJo purine synthesis JWVO Synthes-k and salvage pathways in intestine would
is equivocal. l%e early work of Savaiano and Clifford= found imply that intestine may be able to maintain pyrimidme
that rat intestinal cells did not incorporate [W]glycine into pools in the absence of dietary nucleic acids.
adenine and guanine and concluded that intesdrtaf cells
. . . .-+ : : ..-. . . lack de now purine synthesis. However, BOZJ et aim = Even less is known about the relative rates of de now
———–= and salvage purine synthesii in the intestine. However,
. cently have challenged the idea that the intestine is not
capable of de mwo pttrine synthesis. By using %labeIed as previously dkcusse& tapidly dividing crypt cells are
amino acids and gas chromatography-mass spectrometry, dependent on dietary nucleic acids w maintain NT pools.
it was found that the intesdne of pregnant mice derived ‘flms, feeding a nucleic-acid free diet may impair the pro-
92% of RNA-bound purines from de now synthesis. Because liferative capacity of the ctypt cells and thereby reduce
there also are con~dictoty reports about intesdnal Gln- villous height and absorptive capacity. This could ac-
PRPP-AT and FGAM-S acdvity,ms the extent that the gut count in par& for the atxophic changes obsemd in the
can generate purirtes by de nooo synthesis has.yet to be gut of animals fed nttc.feic acid-free diets.7
..
resolved.
The main purine salvage enzymes cue hypOxanthinqp-
nine phosphoriboql transfemse @GPRT) and adetdrte
phosphoribosyl transfexase (APRT). Both of th+%e en-
zymes 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 postal- EzEl
lated 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 Fk41tddw~ oi&aaE47mthesis8rutsdvageLntt7wa3’sto .
@ase acdvities in lutnfnal effIuenk co~ with the XNApooktn entemgtatn&UacmtpodtiomatongthecaypGdlusd
dmation ofpresemab“ontirneand predicMmsumivaL cmstNddrIuridataprc9tmM bYudcrmetat-

-.
I

/2-
. .—.—. .— .- --- . -— ------ ..- . . . . . ..—. .

Jlfl?cll-Ap?i[ lg~s GLUTAM1~C AND NUCLEOTIDE METAIIOLISKI 109

T]{F; RIXATIONSIIIPS BETWEEN GI,UTAMINEAND NT


AfETABOLIS\!
—.
in this section tve build upon tile biochemical pathways

4
linking GLN amd NT metabolism by presenting evidence
in support of tile concept that GLN supplements might
stimulate the rate of synthesis of NT within enterocytes.
I N H ,
Crsl
— GrbmwYl
W!C
Ura
(-cd) I I
“Radioisotopes cannot be used to study the fate of ni-
trogen 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
carbon as a fuel.4G Stable isotopes such as 15N and 13C, %.5. Carbansoyl Phosphate gencmt~ in she mitihondria by carbansoyl
which can be detected by mass spectrometry are an al- @-h* wt- I (C= O mw led~ inlo ~ CWSOI d tinmlm
ternative to radioisotopes. For example, lSN-GLN has P*i~~ wthes~. ~ a~~:Y Of cysfok cartmnoyl pkspha~e sym-
been used to trace the fate of entetal GLN in humans. the(ase 11 (CPS II) ssuy nm alw)am be tie rate-limiting step of pysimidusc
Svnthesk.
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 respond rapidly to any change in concentration of anl-
not studied.” rnonias In support of this observation, in mice, a l-hour
WindnmeHe# studied of the flux of metabolizes across infusion of 13NH?CI induced an increase in & now pyri-
isolated segments of rat intestine and concluded that asp midine synthesis in the liver (fourfold) and intestine
proximately 80% of the ammonia genemted by glutami- (twofold).” l%ti~er research is necessary to detem~ine
nase is released into the portal vein, contributing impor- whether GLN can stimulate pyrimidine synthesis within
tantly to the large ammonia flux between intestine and enterocytes. A poskive result might help to explain why
liver that also includes ammonia generated by tie in@- GLN can have atrophic effect on the jejunum
tinal microflora. The remaining ammonia apparently is There also are unanswered questions about de novo pu-
converted to carbamoyl phosphate.” This seems to be rine synthesis within the intestine. On one hand there are
appropriate because it has been established that carbarn- reports that intestine has very low activity of Gln-PRPP-AT
oyl phosphate is a substrate for the synthesis of the py- and RMM-!Y= and is not capable of & novo pwi,ne ~the-
rimidines (Fig. 2). The structure of GLN metabolism sL+; on the other hand, thexe are reports that the intestine
withii enteroc@s means that as GLN is oxidized to re- has appreciable Gln-PRPP-AF activity and that the& *SOW
lease energy, there is a coincident release of nitrogen pathway makes alargercontribution than thesafvage path-
. —.—-
. -. . . . . ,. that can be synthesized into NT. This armngement is an
example of the coupling of a biosynthetic pathway (NT
ways to the intestinal purine pools.= l%us it has yet to be
demonstrated that de moo synthesis alone cart maintain
synthesis) to a catabolic pathway (degradation of GLN), purine pools within the intfstine
and it allows for the precise control of the rate of bb- tidbwefmsecdontiere kan incrwse in nucleic
‘% synthesis of important end-products.- acid synthesis and cell proliferadon in the remaining small
‘l%e liver is adapted to cope with large amounts of sm- intestine. ‘he actlvi~ of both glu “
tammasew and enzymes
monia It has a highest level of CPS I activity of any k involved in& now and salvage pyrirnidine synthesis are
sue and also has a high content of /V-acetylgfutarnate,= increased atl,ersmau bowel resectiom= studies evaluating
a positive effecter of CPS L~* Thus liver is able to syn- the effect of GLN on gut, adaptation in experimental sni-
thesize excess ammonia mpidly into carbamoyl phos- rnals have produced contradictory restdts.a It impossible
phate, which - then be metabolized to urea One con- that the effect of GLN supplements on gut adaptation may
sequence of this adaptation is that carbamoyl phosphate be dependent on the route of supply. A key area for further
generated by CPS I can contribute to & novo pyrirnidine reseamhwill betheeffect ofparenteral andent.etal NT
Synthesis. This arises because the mitochondrial znem- supplements on gut adaptation after massive small bowel
bmrte is permeable to carbamoyl phospha@= and air- resectiom
bamoyl phosphak generated in the mitochondria by CPS In gcmclusio~ our review has Qreased the Iinlage be-
I can leak jnto the cytosol and stimulate pyrimidine syn- tween GLN and NT metabolism within enterocytes. A
thesis (Ag 6). &nce mitochondxial carbamoyl phosphate number of questions remain unanswered. Does GLN
a stimulate hepatic pyrimidine synthesis when dwre Ss stimulate intesdnal & nuw pyrimidine synthesis via the
excess smrnorda~ or GIN.= ‘Ilte effect of an krease in action of carbatnoyl phosphate aynthetase I? Can &.novo
Ptidi.ne syn&@s - he@xyksonthemteofhqW purine synthesis maintain bmsdnsl purine pools in the
@CWE pro~don h=yet to be defined cIearly. absence of dietary nucleic acids? At@ what are tie ~
Theintesdrte tdsohas CPSIactivityand also isex- CMc effects of parenteraUy admMs@d NT on the
posed to large amounts of arnrnom= but because the metabolism and well-&@ of enwm? A greater
activity of CPSIln Iiverisabout2$ times that of the undemtandirtg of these ISSU& w ]ead to a more ratb
intestin~it seems unIikelythat excesaammoniaor GW M approach toward the nutritio~ modulation of gut
would stimulate int&tinal pyzimidine ~thesis. HOWA dY@ttnctiom
ever, iike the Iiveq in&stirte has a M@ content of AL
scetyiglu-n the aksteric mtivator of CPS ~ ana ItEIWtENCES
akhoughC f%Iiskssact ivejnint estinethanlivqthe
intestine hasarelatively Mghcontent of CPSImRNA
lMshigh CPSImRNAcontent might enable”thegutto
.-=

-.. - ;JUN I o 1 9 9 8

/3
.4

-- -.. —. —. -.,. _
—__
—— G — -. .-,. . _ - . _ . . _ -—— . . _____ . ._

110

J ? ~o TC, Bcauchamp W), T~w-nd CM, etak GIuurrrinc is essential for uridmc phosphorylasc prt*l”~ul~cllL ~~lwm 1’l~llJcOI 34. iO 1-10.>,
~ cpidcrmal growtJ\ fWmr.~InuIaL& @@@nal cell pwicration. Sur. 19s5
gcry (s1 L41uis) 114,147-53, 1993 30. Skold (). Enzymes of uracil mcubohsm in @$ucs wItiI diffcrcm
! 3. Hall JC, Heel W. McCadCy R Glumrinc. BrJ Surg S3305-312, 1996 growth characteristics. Bmchinl BIOPIIYS AcM 44. !-12, 19G0

4 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
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
amino acids following it@ry. Ann Surg 1927&85, 19S0
6. f{wsng Tf+ ODwycr SZ Smith RI. et ak Presmvation of and bowel phorylzscs Pharmacol Rcs 4:425-42S, 19S7
mucosa using glutamim+mriched parented nutrition. W Forum 33 ?Aang R, Lu 2. Uu T, et al Rektionslup between circadmn4qrendcn[
3S:56-5S, J967 ttxicity of &fluorcdeox_ridinc and cir=dmn rhythm of pyrimidine
7. Piate]t C. Mccauley K Mccullocb Ret ak l%c influemx of parcnuxal q= Possible relmance tn ffuoropynmidine Chmnotitcrapy. ~.
gluumine and bnnchcd chain amino acids on total paremcral rrutsi- cer Rcs 5W?31&2S22. 1993
tion-imduced awophy of the WI- JPEN 1734 S-354, 1993 34 Tauda M. Iixunuma K Webcrc: ~t Iiwr glutaninc 5-phosplIoribo@
8. Tao RC, Yoshinuua NN, Chirm IB et af: Det.crmination of ti~wtous l+ympho@uLeandouansfcrasc[EC242.141 Purification andpro[}
non-protein energy and nirxogcn requirements in growing tars. J Nutr etiss. J Biodrem Sj 1347- 13’A, 1979
109:904-915, 1979 35. Sa-o DA. Ctifford .U Adcttinc, the precm=.or of nucleic acids in
9. Pinkus LM, Whdmuellcr HG Phosphawdependeru gtutamhasc of intestinal celts unable to ~tfi~”zc purincs de now. J Nutr 111: ls16-
small inlcstine: Imcahzation and role in intestinal glutaminc metab 1S22! 19s1
Iii. Arch Biihem Biophys IS2:50G-617. 1977 36. BozaJJ. Jahoor F, Reeds PJ. Riborwcfcic acid nucfcoddes in matemd
10 Hammarqiiat R Wememran J, von der Decken ~ et d: AlanyI- usd fetal @sues dcrh? afn~ tmclusivcly from synthesis de novo in
glutamine coumemcts the depletion of fme gl utamincand the frostop pregnant mice. J NuIr 1’26:1749-1753, 1996
esative decline in protein synthesis in skelctat muscle. Am Surg 37. LdAko NS, Bronstein AD, Fkdiga DS, et af: De now purine nucle.
212:03744, 1990 0dde5 synthesk in lhe ral small and krge intcstirrc Effect Of dje~
11. Buchnun AL Ghxamine la it a conditiorafly required nutrient for the pro@in and fmrirres J Pcdiatr tksLmcnlcrol NuK231XJ19, 19S3
human gastroinkadnal s@cm? J Anr Cdl Nutr 1S199-205, 1996 3S. Elliott W, Weber JG: Proliferation-linked increase in
12. Byne Th Pessinger ~ Young LS, et ak A new tseatrnent for patients pl]~hori~lfomlylglydt=!tlitli!!c symheiasc actitity (EC 63.5.3)
with shon-bowel syndrome Growh hormon% glutamine, and a mod- Cancer Res 4494X)-X34. 19S4
fiti dieL Arm ~ ~243-%5, 1% 39. Wusurneda Y, Pm.@ X Donohuc JP. 6 al ~Iratic capacities of
13. Uauy R, QIIan R. Gil A Role of nuclcotik in intesdnal development putine de rmvo and aafwtge Ixttfways for nucicotidc aynthcsk in nor-
and repair ImpIicatiom for infant nuuitinn. J Nutr 124(SUI>PI}I 430S mal and ncopLxtir IL%sues Camcr Rcs 44.?47$2479, 1984
1441s. 1994 ~f). Walah W, suKIw.p~.+ bk.iko t4S A rrgulxlory clcmcm Ls cltar-
14. Bueno J, Torrcs M, Abrrendms A, et al: Effect ofdicwy nuclcotides on xterizcd by purtne-mmfiit ed and crll-typc5fwciftc gcmc ts-wrxrip
smal! intestinal mpairafterdiarrhocz Hia@logical and ullnstmcmral Lkm. Mol Czll Biot IO::EG4361, MO
changes. Gut 35926%33, IN 41. Mueffcr~Rao PN. S@erJT.etak Hyafuronicaddandtin enucleo
15. C.amer JD, Walker WA The mle of ndeotkks in human nufsition J aide phosphotyke in wmkr and hii cmwnts Of 5dI bOWCI
Nutr Biochcns 6:5W2, 1996 ~ :W&=We= of ~ don injuty. Thnsplantadon 55: lZ25-

_-:.,. . . . 16. He Y, Chu SK UhlIres Wk Nocleutide supplements after prolifenLion


and differendstion of cuftured hurnatr (-2) and rat(IDX) intesti-
nal epitheliaf cells J Nu& 1231017-1027, 1993
17. L.opes-Navarro AT, Omega m Peragon J, etaL Deprivation of nude
42 Chw-ahstd S, P@en CS Cell @don depcndesce oftsbcfliig thynri-
du nudeddes sningthe&novoand sah5gepathways intheW
of Use ansdl intestine. Cefi T&me Kinet 19647459$1966

d 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-nrcrap-
43. Uddin M, Aftmann Gc, LAfond CR Radiiutogmphic -ion of
ditrcrernxs in the patwrn of ~1-utidii and ~~rotk add hxxpo-
ratiott into RNA of migrating columnar celk in the rat anti buestkm
J Cd Bid 9S461%1629. 19S4
bJpurinebtthetalamaoisLtestineandcdonGasLmentcro@yXMol4- 44. B&onneae IL llte de tunuand aaf~me PaLhwaya for t.he~- of
10ZO, 198i p~ feaidueSofR!!_tUte in d~erent kations within
19. Leleiko NS, Wakh MJ: Dxpwiste ndcoddes and the gasuointes the mouse doodend epi[helium Cell Tksrse Res 207:131-137, K@
W tract- Nuoidort 1 M2W30, 1996 45. Zahammz “ DW, &idemon IX, Mafinowald NM, et ak Contsiion of de
20. I@na~Tat@aktzKidoxetal Intnvenottsdmhktmb“on of nucleo. nomandaafvage” ~thesis to the umifnucfeodde pool in mouse
aides andanuc.leotide rnialum~ infcstimd mucced atrophy tiasues andtumcIra bt\%m SurJBkxhem21M9 X?9QlW2
induced by total pasmmaf nutsltim JPEN 1726270, 1993 46. Whlnwefler H& Ghxamine udtkation by the amafl bt- Ada’
21. 0g05his Iwasa~YonezawaT etaLEiTecLofn@ecrtMea ndntsckw - 6W01-23S, Im
sidemMureon mtsgfvcntofaf pamntmlnu@tiionafLec7O%hepa@ 47. Ma@sewaD&MarsnomCampbeO ffiSpLmchticbeddiation
ctorny JPEN ~~ 19s5 ~~~ and @_C acid in humans Am JPhyaio12M EsM-s.$
22 VcaabuguMP,Me@d ~Ct&LUat tiwnotta nudeosidcs and
● nuclecdde promote healing of mall bowd ukem in expdmml ~ Wiiuelfec Hfl N~of~andlurninaf
“ ghmminein
enb?romms Dig Dk M 4L14SH457, 1996 bues5mlnmcosafn\i w. fNGl_hf*fkmk~
23. Txfbana49dgesda lLnvoasbamyl@@late~of ~ ~ D, S= H (*). S@w=-VX S=@ 1S% pp
tnamtdSspedt5csolMlncosrldc4@mkJineandm~
akAdv-Regul 10249-27Llm2 4%. N; E& Qabtree a Ada+ * cad’llnine~-b
24. H~J,SaIoWL+SyCZetatCMnmyi-~ll@ ~~~~
> evolutJmaLy MesmdMEinthe ~~d@@=4— QJRp Phyde47ct47ws9,1!w
dattandarnmonk@entkntaLb=mylphqMeaynd-s=JMd m MorimotoBUBaady JEAtKnaonD12=em f__oma@
Bid 243131-IQ W94 tdne4mula@d dtruOheamtkds ~J=61+~
i 25. Jonea ME PgdmIdk NY bkywksk ioanirnsk cksle+eruysnq M. McGh’anm, Bsdfotd Nw Mendu-M&J:7be re@adiaofar-
andseguwm ofwbiwntkk Anmt Hev Biodtanlwks ml’@#=#@em@=eehak mbdKmd&Biodunr
-

279, 1960 J 16A416=~ 1976


. 26. Jonea WAndemoa D, Andemon GuatCxm@ne~kt sat EL Natale PJ, ~ntblay GC Studies on the availability o:
*
&atlea Afdt Biodwsn BiophW95@%607,1%l ~~f-~~~==mf-
+ 27. &ddZMottiaHEWberQRe@ =rrypmp4esandb du@ourd bxkKMal mactkma Insai GveLArch Biod’=t BioPhYa l=-
.. =d=mof~~~~6#~
it@ htnormaf andpmlifemtingfis5uCJ Bid3kK&srlsnla-m432-w
S& _MZkM=tIXM@obkk
Aheted@ydkOrderof@midinemetab&m =P@=~~

— r.
~
1-i
Am JDia C4dtdllWX+74fJ.1967
29. MoyesJD, Ff~JRBahgeofoWhe hthemou= UTed of

.--~
‘r@ff ? (J 1998

P/
.._. . . . . . . . . . . . —. .. — ’ . ——. .——. -... —. —— —-— —__ .—. ._ . .

A!ardi -A I,ril IWS CLUTAMINE A~~ NUCLEOTIDE METABOLISM 111

,I:IUC dc It,wu pyriIIIICII,W S-yINJIC+S AICh Lhchcm Biophp 236:1-10, hsm after nussivc small bowel msccdon AM J %ug 159.27-33, 1930
19s’) 59 N*Y2WUI H, Wacr E ~~idine ti=wfietic e-= ~ ~ in=-
.--r..
1} CIIIIJLIY GC, Crandafl DE, Kmott CE, CI al Orotic acid biosymhw tirre afwr SIIUJI bo.cl rcsctiom Gasmocntcrolo~ @4S04S7, 1975
SIS in rat In!cr Studies on the source of carbamoyl phosphate. 60 Miclmil S, hlohmnmdd~w1{, Park JH, ctak Eff@of gh~pl~
,\rcIl B]ochem BIophys 17S:264 -277, 1977 mcntcd elcmcnti dIct on mucod adaption following small bowel
$

Ily.nIl J, Nguyen Jl, Brmdayan M, cc al: Expression of nuclear genes resection in nas. J Pediatr Gasf-roentcrol Nutr 21:394498, 19%
cllcodlng the urea cycle enzymes, carbamoM-phosphaLc mUm&sc I 61 VandcrhoofJL Blacku’oud IX, hfo!wmdpom H, eta Efkcrs of oral
and omithmc cartmmoyl iransfcrase in rat liver and intesdrud mu- supplemen=tion of glwanrine on small intesdnaf mucosal mass fOl.
COSJ Eur J 13iochem 152.2S7-292. 19S5 iou@ -Om J Am Cdl NUU 11=27, 1992
2aharctiIz DIV. Napier EA. Andemon LW et al StAmdadon of umcil 62 Tarnada H, Nezu R, h!awuo Y. Afanyl glufamine+nriched total
nuclcotidc synthesis in mou.sc liver, imcsdnc and 16dney by ~ parented nutrition mores imesdmf adaptim after ● ither proxi-
nium chloride infusion Eur J B!whem 17S192-19S, 198S maf or disd massive r-on in r=.. JPEN 17236-242, 1993
NimbcrgW, SOutra ~fAv,SalJmmlRJLafi lnmdnal@aminc~

..7.-.- . . .. ,> . . . .
,: .

_—-m__

–—-7

-.
I JUN I o 1998

/5
-. ..

\.

A prospective randomized study of glutamine-enriched


parenteral compared with enteral feeding in postoperative
patients’4
Judith Fish, George Sporay, Karen Beyer, John Jones. Todd Kihara, Alfred Kennedy. Gzroline Apovian.
and Gor&m L Jensen

ABSTRA~ Plasma amino acids were mc.asurcd in 17 post- taminc consumption in the atrcssd state and may, shcrcforc.
operativesubj@s randomly assigned to rcceivc for a 5 d tulx play ● sole in modulating the protein catabolic rqonsc to
feeding or Iota! parcntcral nufrifion (TPN) that had idcn(ical en- injury (8, 9). Traditional nutrition suppofl dscmpics comain
U.W. ni~ogcn. and glu~inc conlcn~. -W- r=wi~ g=~ w vCS’y liHIc glut.amine bCCiSUSC of its unrecognized rcquircmcnt
pancreatic surgery for malignancy and were well-mmchcd for age and its poor stability in solution.Glutamirsc can bc successfully
and body mass index. Tube feeding or TPN began on possopcmive supplernamxl in parent-l solutions (10-12) or lube-feeding
day I and advanrxd in &Ily 25% increments to rnccI goals of 105 formulas (13). Both modcs of nutrition suppon appear to bc
kJ-kg body wt-’ .,-’, 1.5 g prmein-kg body W-’. d-’. ● nd well toksa:cd, but it is unckar whether cn[cral glutarninc is
0.3 g glutaminc - kg body wt-’ - d-’. Dclivcrcd energy, nitrogen, metabolimd diffcsendy than pascntcral glubminc. We hypoth-
arrd glutamine were closdy matciwd on day 4. Nitrogen ldana CS-kCd that there would bc ass appreciable ‘first-pass’” clew
and plasma proteins did not differ significantly between feeding ante, with cntcml glutaminc first m-bolized by the gastroin-
groups. Total indispensable amino acids.bnnchcd-duin amino tesdnal trau and Iivcs before reaching UK gcncml circulation
acids, and glutarnk dcclirscd 25% on postopcradve day I atm- This study was designed to compare plasma amino acid pm
parcd with prcopcratk &y O. Indkpcmable and bmckkbirs fdcs in poslopmtive patients randomly assigned to tive
amino acid cxrnomtntions wcsc scstomd with 5 d of cithcz tube parcntcsal or entmal nutrition supplemented with glutamine.
4...:?:...<::: -?:,.2.::.. .: feeding or l?N. Glutamirsc corrcustmtkms dd not differ aigni!i-
carrr.ly by fcding group, though ● trend suggested that ghrtarrdnc
rccovcrd rnorc slowly in the Usbc-fcd than “m the TPN-fcd sub- SUB.JEC3S AND ME3’HODS
jects. Pkna amino aci& atkwisc rcflcctcd formrda composition Subjects
. 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 Patients bctweam 18 and 75 y of age schcdulcd for elcctivc
suggcsr that glutaminc-tnrichcd tube fcdng and 7PN can result up gastrointestinal surgery wese dlgible for study. Paticnta
in similar profiles for most plasma amino acids at carefully wcsc candidates for postopaative nutition au- ● nd were
matched doses. Am J CJin Nsur 19975597743. =* to squire nutrition supposl for z 5 d. Exclusion
aitcsia wcsc as follows insulin+cndcnt diabcle& susal dti-
KEY WORDS Ghrtsrsnine. tube fcdng. total parentcml a (creatininc cons.sstmtion >221 I.UIWVL or 2.5 mgfdLL
nutritio~ TPN, enteral nutrition, postoperative patients, amino W - (total biliibin Cfnsantntioss >51 #mom w
acids, humans 3 mg/dL), ● u[oimmune di~ cotiltiorss precluding use of
atcnl fccdng (~ bowel obstmcdon or pancreatitia), *IC
stezoid sssq ardii d~ (class ttl or IV. New York State
Heart Association), Glasgow Conta Scale <5 (14), chronic
INTRODUCTION
OMIIJUiW pUlrnOnary d~ @slid *of attron di-
Glutaminc. is. the most abundant amino acid in plasma ad oxi&(FCOJ> 375kI%os SOmm Hg]. ~. cMcinoSn&
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-
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 gJu-

Arr JC?in Num W9765-S7743.Ri nrcdio US AO1997AmdCaII ~fa~Nrddm 977

.——:

-. _
.-

This invcstigion was appro\,ed hy the Gcisingcr lns(i[u- csmbl[skd for find dm rc~’icw so lhm InCIUdCd s[udy SU[)J12 CL.
tiomd Research Review Ikrd witi infcmncd consm by sIan- would have rcceivcd adcqu.3[c cnwral fccdin: for xmlyscs.
, dard protocol. Twcmy consenting subjccf-s were randomly as-
I signed preopctatively by a compncr-gcncnmd r a n d o m Laboratory arsalyscs
squencc lo rcccivc glutaminc-nrichcd enteral or parcmcral
VcnouS plasma amino acid conccn[rmions were measured aI
feeding pcxxoprmttivcl y.
baseline on days O, 1, 5, and 10 (Table 3). Blood ssmplcs ~’crc
collcctcd into hcparin-containing collection tubes from in-
Nutrition support dwelling catie[ers at IWO each sample day. Tube feeding and
Nasocmcric PcrsIpyloric feeding Iubcs (8 Fr Frederick-Mill- TPN were s[oppcd 30 min bdorc sampling. Plasma samples
cc Cook Company, Blooming[on, IN) were placed during were slorcd at —70 “C. Rcferencc v31 ucs were dc!crmincd from
surge~ and p.itioncd in shc jejunum to the figamcrrt of Trcirz analyses of venous plasma samples from four hcaldty fas[in:
(15). Ccnrral venous aeccss was also Obraincd. adults..
! Tube-feeding and total parentcral nurxition (TPN) formu- Plasma was dcprotcinixzl by using membrane filuarion
las were closely matched for energy, protein. ni~rogen, and (Ccnrs-ifrcc; Amicon, Bcvcrly, MA) and supplemented with the
glutaminc (TabIe 1). The measured ghrtamine comenl was internal standard S-2-aminocthyl-L-cyslcinc. The amino acids
113 al ~molll- in the TPN fomrula and 109010 prr-tof/l.. in were scpammd by ion cxchangc with a three-boffcr lithium
, the [ulx-fczding formula (Trsbk 2). The tube-feeding for- citrate systcm on a Beckman 7300 amino acid analyzer (Som-
mula was elemental (Vivonex Plus: Sandoz Nutrition, Min- crscL, NJ). Poslcolumn dcrivatization with ninhydrin wms fol-
neapolis). The TPN formula was composed of an amino acid Iowd by spccwophotomcwic dcm-ction at 440 and 570 nm.
solution formtrlatal by combining a commercially ● vailable Sys!cms Gold Software was used for @ identification by
formulation (Rcn Amin; Baxter Hcallh Care Corp. Glendale, retention time and for peak integration (16, 17).
CA) with free L-ghstamine (Ajinomoto USA lnc, Tcaneck, Other starrdard Iabomory procedures inchsdcd the mcasurc-
NJ). The proccdurc for glutamine-enriched TPN formulation mcn( of serum sodium potassium, chloride. bicarbnatc, blood
was descnbcd previously (11). TPN solutions were com- urea nitrogen, crcatinirrc. and ghrcosc and complcsc bkd
pounded daily as a 3-in- I admixture. Standard elccwolyte, counts on days O, 1.3, 5, 7. and 10. Gnccnuations of mag-
multivitamin, mineral, and trace element solutions were nesium, phosphorus, ionized cafaunL albumin. transfcrrirt. and
used (As- W&boro, MA). prealbunsin wcsc dctcnnincd and Iivcr function tests were
Tube feeding or TPN was initiated at full strength Either wndtsacd on days 0.5. and 10.
rnodc of nutrition supporl was begun at 1800 on day 1 post- Nitrogcrr balance was ~ OO-&yS 1,4, and 10. Totd
surgcry and advarux.d in identical incrcmcrtts on the basis of urine utu nitrogen was deticd with a rkogen anafyzcr
god Cncrgy nqu ircmcntsof 105 kJ. kg body wt-’”d-’ (Ta- (ht~ Houston) (18) from 24-h urine sarnplcs. Nlwogcrr bal-
ble 3). GoaJ nutaition afso prov-idcd 1.5 g protein” kg body ance was caksslatcd as follows: [tube-feeding pmxein intake
WI-l -d-l -d s).3 g glutarninc. kg body W-l -d-’. Nutrition (gY6-W – [ted (UW rtittwcJs (g) + 2], or ss ~N protein
suppoI-I was con[inucd for 10 d or until the subjcet was able to intake (gY6.13] - (total urine urea nitrogen (g) + 2].
consume an ond diet other than clrar liquids. Tube-fceXng In&rccs cdm”rrrctry was paformcd on days 1.5. and 10
toluancc was monitored with daily reeorchrg of nausea. dis- posropcratively with the MCUKCOpe mctabofic cart (Qbcr-
tentio~ or disrrhca. Subjects were afso monitored for mmpfi- trrcdi~ LOukvill% Co). Steady sratc mcasurcmcrrts were made
cations rsssoeiatcd wirfs central venous acccas (csthctcr infec- over = 10 miss with ongoing fccdhrg. Mcasares Were “ilot
tion, site inf~io~ and venous occlusion). A minimum fccdng auemptcd in uncoopwative or mctficafly unsrablc paticnss, nor
threshold of 4184 M/d by (he fourth postopcnuive day was 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
EJ=sYw 4300 4300 bs!ancaofscxbuweut thctwofcedinggmups wastitih
EncrgY distrii F-s cxacl ~ A tUUhiVSliStC anafyais o f ~
(% amirIo as5rk) 18 11
(% fat) 6 6 -OVA) modd was fitted W the dSy~ and dsy-5 data for
aIburnitb palbut& transfcrli4 cirolcstcsOL and Wlm
(% carlmbydra@ &zuosc) 76 76
Nonprouin cncagynkrogcu Ilsl 1121 --Lwlti*-WMfoff$=@ tP#Y”
Toral gt ~ w) Iw 10S3 time intcmetiotu feeding gtoup diff~ at bsaeJirlc+ and
Total niaogm f#lJ 7.13 733 time diff~ within fdng group wete paforrncd.
‘vi Flus(saado% MMupdia). mdcmcdforsrndswids
MANOVAwasafao uscdtocvduatc fcec@Pp, *~
-Ad&aoybcan —d. mdtokm . rncdfidcmtmrdb aadmmdad fcedinggtoup+y4me ir3tcracdon clfccBortcxhauof -
rsudtivirmlis!a and minds. acid conceatIadons masurcd ottdsya QLand5. si-
.Uwaction effcaswacimpmtsdto tskEpKQxkx=-
*65% Rsrt Arlirs(Baascr. Gksxw%mk LduhdDcw=llom
Tcarm&tU).20% L3payIlU (AbboU. AbboU~u70%6arboaa amspom@rnabs c.ffeczsofcidKr dmc4xfccdiog gKKtp. AIf
. and-(Asrla.wcadrcmM$).
(Abboa), aJtdahndaIdrrsLdMrarrum t%tawac twoaided and8Pvaltu <03 waa~

.-. - , Jut.1 10 1998


17
~hr”ri;it.\!. co\ll’/\[<l;l) W[”i’1{ l.A]{l~~l[J+,\L G[.urAh$!~[~ 979
l,\ I\l.E 2
Plx<ma amino acid conccnmtions on days O. 1. WICI 5’

PkmLl
Amino acid (pnolA-) and Iypc Of feeding’ my o Day I DaY 5 Formula
PwL.fL
Mc[hioninc’ (34 z 3)
TF 33s 11” 40=6 28500
TIW 21 z 10 %215 31409
CWaminc’ (490 : S9)
7-F 525=206 387 z l% 389 z 160 109010
7??$ 5622135 413=125 474 z )79 1!3641
Leucine’ (129 z 12)
TF 1% z 52 98 z 17 17! = 18 144409
TPN 11!33s 78 = 17 I08Z40 43566
VsdineJ (216 = 14)
T-F 195t51 164 z 26 212 z 28 47004
TPN 1262S4 151 z 32 3% z 141 61379
lsolcucines’ (68 z 9)
TF 79:39 48 z 16 84213 51682
TPN 57:m 32 z 14 73Z25 345s1
Argininc’ (7S Z 9)
-I-F 78 z 33 45 z 12 83Z28 so 939
TPN 77:18 43213 74Z34 34822
Taurine” (59 : 6)
TF 5727 49 = 17 53223 3642
TPN 55 z 16 37 z 12 32 s 10 m
TymsincJ (58 2 5)
TF 6629 61 z 12 11021
TPN 56%10 53 = 15 1894
Asparaginc’ (62 t 11)
TF 41 * 17 24=6 m
m 44z17 21 = 15 ND
ASpaIuIcJ (7.0 z 0.7)
TF 11.I.272 69=21 7+7 =29 128S8
TF’N 6.8 = 3.4 6.723.7 3.4 %55 49
%mylalanind (52 t 4)
TF 73Z34 67 z 15 99Z34 39293
TPN 58220 56=10 93234 29221
Lysinc’ (150 = 16)
IT 180252 141238 33 m
TPN 204=57 155259 29436
CiWullincs (28 = 1)
TF 22=1O 15=6 19=7 40
TTJN 23211 13=6 1729 ND
Onsichiru+ (50 t 9)
-IT 43=9 73=16 105
TPN 37*12 63Z24 112
Qsrinc(54=4)
IT 54%32 75=34 m
TPN 47?20 ~=~. s ND
Pmlk& (185 2 47)
TF. 170273 117*M 16225
m“ 1%=~ ~=fi w 501
Alarsin&C94=55)
lF ~*~ 9W
IFN ~=~~ Sl%z
71slwni& (12S = 21)
7F 114Z35 1242 Si a258 “
IFN 137*43 162$ s~ 29722
Gly&I# (271 = S3)
TF m*42 339*24 10372
TFu 134 * sl 1R*4S 25228
Hk64inc(76*8) -
TF 67*2O S*33 43*9 10 la
46*35 25716

_-——__

..-
I JUN 10 1998

/%
. . --- —. —.. -. —.. . -—. . .._ ___ _- . ..__ -.. _ . .
-. -—-- --.. — ----- _

9s0 1’1s11 El Al.


TAnLE 2
Cominucd

Plasma

iii Amino acid (#mol/L) and t% of feeding? Day O Day 1 I-)$+ 5 Fomml a
Sc.rinc’ (126 z 14)
IT 105 z 27 7 5 : 18 69 z 17 9 !37
TPN 109:36 64:9 70 = 16 14774
Glu8ammc’ (24 ? 6)
77= S2 : so WO
TPN 53:28 149
XBW’ (413 = 34)
lT- 411:134 309:52 46s z 5s 243095
TPN 354 = 107 261255 577 z 200 139856 .
ZMA’ (776 : 57)
7’3= 81 OZ248 621:94 872 = 126 372753
lYN 774 z 218 567:107 1043 z 313 259650
Valine:lcucincJ (1 .68 = 0.08)
TF 1.48 t 022 I .68 z 0.20 1.24:0.32 0.32
TPN 1.70 = 0.19 t.98 20.32 3.69 z 0.64 1.42
A5parlaleasp.3ragincs (O. I 2: 0.02)
TF 034 z 0.32 0.21 t 0.07 0.37:026 ND
TPN 0.[8 :0.12 0.21 z 0.14 0.47:0.33 ND
Pknylalanincxyrosinc’ (0.90 Z 0.05)
l-l= 1.03 = 0.33 1.01 = 0.19 151:0.43 3.57
TPN 1.W z 0.32 1.0120.13 i .78 = 0.46 1s.43
Gluiarnawglutamine (0.05 z 0.02)
-I-F 0.18 z 0.11 0332032 0.29 = 0.35 0.033
TPN 0.1720.13 0.13 z 0.07 020 = 0.16 0.001

-* m. na dckcsable.
‘Rcfa-crKc amucdvalucsin~ @z SDJ).
‘ Signmanl fading glwpby-rknc ~ P <0.05 (UANOVA).
.- . . . , - . . . . , ,. -. v. 4izsEhL
‘ Signifmt diffcmmxs aauss timG P < 0.0S (MANOVA).
. s. , ● SignifW diffcnmccs befumco fding groups. P <0.05 (MANOVA).

significant. SAS software (SAS Institute Inc. Gry, NC) was Baseline plasma amino acid profiles did no( diffcz signifi-
used for the analyses. cantly between groups for any mcasumd amino acid. All sub-
je.cls had hypoarninoacidemia on pcstopaativc day 1. Total
indispensable amino acids. bmnclnxkb.0 amino ac~ and
RESULTS ghMarnine dcchned 25% on postopuafivc &y 1 cumpa.rcd wish
TwusSy paticats W- CNO!kd inSO 3bc study three sssbjeus W=@ve d.aY O Ukble 2). BY day 5, plasma COncumiitiOIIS
did not m@ goal feeding by &y 4: one sub- I@ tubc- of most amino aci& apprIMchcd baseline values. ‘mere Wac
fecding aoxss, one had tube feeding held because of high significant difhencxs for feeding gmup-by-tirnc intemcdons
nasogasfric drainag~ and one subj- had tube fading SSoppcd for methioninq lcucinq and ~lne and significant diKerenoes
becmsc of diarrhea. Of the swnaining subjt@s for f~ data bmwcen feeding groups for isokucine and @urine (Table 2). In
sevicw. 7 received tube feeding and 10 mccived TPN. k cacis~the plasma arninoacidprofik wasconskent with
were no significant differulCCS bctWUlthctwogfoups foragG she sespeuivc tube-feeding or ~N fcmnula composition
sc.x. and BMI(Table4). Tbctwogmupsbadsimilar@noscs - fiorrr tubfcd and TPN-fed subjects was -y dis-
and surgical procdu.rcs. Both groups ceceivcd energy, nib tinguWdonthc basis ofsados Cfvalincto k4scineonday5
geq and mud glutaminc thatdidnc+diffcrai@fkandyonday Of 124 and 3.69 #DO~ ~Vdy (Tabk 2). ~ *
4 (Table $. Tc@ orioaty nitsggesL mcamred resting actgy stWcd Iomaximh thcinbcrult diffcaWsces irlfnsmrdacotn-
upcnditln% andnitrogal bdanceooday4wcrc also not psitim Plasmrs@tamincdido(x @essi@6cadybemwm
signkmtly diffaalt baweea groupa (I’able 5). An inade- groups. Bcxbgn3ups badadsop inpbglu-P@oP
quate number of subjects cuntinucd to require nutrition support emth’clyan da* byday5. Tbme wa%bowcves. alrcnd
atdaylOa@tbacforqa comp@on benvceugroupa was fNoringarcbJr ntobasdincgluramlnc
. ca2ncentlalions byday5
doncordyat tbccadiertinwpints inadycbc’IPN &bjcct&wbacas mncUmkm inlhctubc-
Baseline ~ Ofpksnnpsotdnsa ndcbokstd fcdsubjcus ondayssandned sigsd!icantiy diffcsuu -
andtotal l~counts wcmnot@@6cao@diffm dmseonday o@gurel). Glltarsu@dlurIki -
Prcopdvcly bctwceal gronps B+lgm9psbdas@6cant ~~*~tmtkmsdidti~a cigrIW .
dropiss plasma pmteins@qe@vdy (TSble 6). =@@ 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’

‘4 Swdy day
o Enrollment
Proccdums bbmmory amlyscs+
V.mCIus pksnn am,”o acids, pro[cins, clccwolyles
I Ini[iaic TPN or IUtK feeding al 25% of csrimmcd
energy nmds Vc”ws plasma zmino acids. indirccr caknimcwy. TUN. elecrrolycs
2 Increase TPN or K& feding 10 50% of estimlwd
energy reds —
3 Increase TPN or Iubc kcding to 75% of cs[immcd
energy d Ekcrro!yws
4 lncrcasc l’PN w tube (ding 10 ILK)% of esiinwcd
Cncrgy lrcC& -ruN
5 103% TPN or ruk frzding Venous ptasma amino acids. prokins. ckcvoI~. indirceI UIU%KLIY
7 1 KS% TPN or tube feding Ekclmlytcs
9 100% m or tube feeding —
10 Completion Venous ptamu amino acids. indirrm Cakx+wtry. prOSeins. eklnlyles. TUN
i TPN. mral paruwral nurriliom TUN. tad u- nitrogen.
~ protein. muwred were abmin. rnnsfcrrin. and rrreabumin: ekwol.yw ~asured WIY ~iom P=$ium *W. ~~c. bl~ u~3
nirro,yn. craininc. and @Osc.

DISCUSSION the parcnwal regimen providal no glutarninc whereas cmcral


feeding containd glutaminc in small pcptides.
Many researchers have suggested possible benefits of Pemmcm c! al (24) demibd aucnuation of the fall in albu-
ci~hcr emcral or parentcral glutaminc supplementation in min in abdominal trauma patients randomly assigned10 cntual
swessed subjects. Ttrcsc benefits may differ because the compared with parcn[cral nutrition that dchvercd comparable
cn:cral mode of supplcmcotation may be associated with amounts of nitrogm and -. It is difficult to relate their
appreciable first-pass chrancc of glsrtaminc by the intestine observation to the present ~dy because the cntcral and par-
and liver (5, 6.9. 19-21). The objective of tl-is research ented feedings WIXC not mrdchcd for gfutarnk the patient
design was not to show superiority of entcral or parcntczal population was substantially diffcrcr& and the diffucrscc in
nutition, bu~ rrdscr to idcnti~ diffacsrces in SISC plasma afbumin was significant on day 10.
amino acid profiles thal might result from the two modes of Pcarlstonc u al (2S) mmparcd the eff@s of crrmsl and
glutaminc supplementation. parcntx-al fcukrg in rnainourkhd Canca patients. my rc-
Dcchclottc et al (22) evaluated the absorption ● nd rnelabolic poncd enhanced rc@on of essential and total amino acid
cffccrs of emua[ly administered glutarninc using stable-iaotopc concentrations in those subjects receiving parustcral nutrition
methods in hcakhy subjects. Plasrrrs glutarrsinc showed a dosc- compared with stsosc subjects receiving tube fcediig or an oral
depcndcnt incr~ Byproducts of glufaminc metabolism di- Although the crstual and parmtcrad formulas were de-
(plasma alaninc. glutamate citrullir& aSp5rtS% Snd u=) dSO signed to be matched for ~, they differed in nihmgcrs
increased. On the bask of these rcsuft.ss they concluded that content glutamine+ and ohcr amino acids. Because the cntcral
glutarninc is cffccfivcly absorbed by the jcjunum. and parmtcral feedings were not matched for these key cusr-
Dominique @ al (23) evaluated glutamine muatmlism in atitourts andwc.rc notadvsmcedat thcsarncm~itwasnof
healthy adult Sncrl Lhrough Usc of stable-isotOpc rncdmds with possible to compare these okrvations wifh those fmm the
isonifrogcnous and isocnag@”c cntaal and paJ’cnk!rrd nrStsi- Pr==t -Y.
tiO1’S. my r’cport~ ● dccrcasc k protein breakdown. with
cntcml nufrilion and a rise in the appcamx mte of glufaminc
in both groups which was signif-t only in the crrtcrally fed
group. [n contsast with the firxhga of Ihc prcscm invcstigatiom

TABLE 4
Pa&m Ctmdddd

Tsrbc fccdusg Im
(“-5w2~ (a- SM5FJ

-- -
., .-.. -.-b- . —.. .-—a.
. — .— _.
.—. ——.
-—— . . . . . . .. —.- _

9s2 FfSH ET AL

T,\lJLE 6 650
~twxuq =wwmcntr
E Day 5

d Albumin (pnlol/L)
TutK feeding 7TW T
I I
tZ Day 1
tK Day O i
Day O 521.6 z 435 [7] 463.7 :29.0 [IO]
DZY 5 391.2 243.5’(7I 391.2: 29.0 [10]
Transfcrrin (wwd/L)
Day O 29.2 z 3 [6] 2Z4 z 2.4 [IO]
Day 5 18.6 z 2.42[7] 17.5 t 2.tF[lo]
Prcdb.min (pmoUL)
Day O 3.9 = 0.6 [6] 3.5 = 0.5 [101
Day 5 1.7 = 0.5’ p] Z22 0.5’ {ioj
Total Iymphcqv smmt ( 10’/L)
my o 1.35 z 0.15 [6] 13420.23 [9]
Day 5 0.897 z 0.23 [6] 1.14 z 0.18 [IO]
Omlesrerol (mmOt/L)
Day O 3.8 = 0.4 [7] S3 z 0.8 [IO]
DaY 5 3.2 = 0.4 [7] 4.0 x o.s~ [10]
Tube-fed TPN-fecf
‘ i 2 SEM: n in bracks, TIIcrc were M signifikam dlffa.aces bctwxn
wtmcnt groups. Rgure I. Mean (a SEM) ptasnu glumminc Cmuxnumions al days o.
2 Significantly diffcrem from day-O value within (rcauncnt group. P C 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
0.05.
groups. bul concentrations on day 5 rcnmincd aignifiidy diffcrcn! fmm
day42 values only in rfac tube-fed subjects (@’cd r test. P < 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 greatly in the parented and cntaal formulas; thcrcfow the
the oral diet group than in the intnvenously fed group. There plasma mtios of thcac amino acids saved 10 easily distinguish
was also less bacterial translocation to the spleen in the orally the formula rwckxl.
fcd group shan in the intravenously ful group. Although this The Small intcsfinc is the primary site of glufatninc
uptake
study shows an outcome befit to intraluminal feeding, it does and metabolism in the body (5). In a messed stat% glutaminc
not Scpame the efrccx of glutamisrc hrn those of Oshcr uptake by the intestine is aaclemcd. Studies in dogs bSVC
nutrients. s h o w n t h a t poatlapsmtomy, glutamirac conmmption by *
Char study was designed to carefully matdr aatcaal and par- intestinal trau is incruscd by 75% (4). Entemcytca obtain
enlcral feeding for energy, nitrog~ and glutaminc. Usual glutam.kc by absorption across the brush border fmm the
ptacficc is 10 begin psuwrtmal nusrition at goal sates whereas lumen and also from amslating glutarnk Enterctcytcs bavc
cntual feedings are advanced to goal sates over acvcaal &ys. biglr conccnhations of glutami~ wtdcb catalyzca the byb
We chose [o adminisr~ TPN at the same advancement achcd- Iysis of glutaminc to glutmmte and ammoniz It appears daat
ule as that for cntcd feeding so that diff~ in pksma ~~ =bolizc gMarnine aimiiarfy r e g a r d l e s s o f
amino acid profiles would not reflect diffcrcnccs inthc Whcthcrglutaminc cntusfromthc lumcnor==aatbcti
amounts of adm”nistcrcd nutition. ‘llris design nzsultcd in * blood (9). l-be d products of ghltamirac mcsabcalisan arc
administration of entcral and parcntaal feedings that W- not scleawl into pod circulation and c.x~ctcd or rnctabolii by
significantly diffkmnt in amounts of energy, nitroguL or ghJ- she liver befors reading systemic simulation (29).
taminc Boti groups achieved zero nitrogen balance by day 4. It acana that catted ghstaminc would pduce a different
despite manifesting the expected stscss maponsc postswgay. circulating amino acid profile than would parented gfutaminc
T?me was a pos@pca-ative decline in plasma pmtci~ choks- because of this tirst-pass tnctabolii My the TPN subjects
tu-ol, asad amino acids but no sign-ttcant diff~ bctwan dbitcd a txcnd favoring restoration of plasma ghstaminc by
groups. l-he limitations of measuring nitsogcn kakncc 8nd day5. wcandothcr invcsqWxsbve*~ Iiak
tfacsc labontoty indexes at a single afaost-term fokw+ip in diange in pksma glutaminc Conanuatiixls with tbc aitcral
~stopcrative subjects must be unpbaaii because sdtmgcn psovisha of glutaminc at corstpatable dosing conoxstratkna in
balance andlabolatofy indcxcsmayaIaobc acnsitivctoper- ark normal Voluntsa=a (11) 4x aiticauy ill patients (13).
turbadon by nonnutitional ftiots Iike fluid x inf~ Zcgk u al (lo) rcporkd aaignificant rise in pksmaghstamitu
. . ~e=d
andinfkmmm “Oa ~h~-~= with pafustd glutamina admmwra
ducedglutamirac concentradons bavcbcamdcacrii afisx&- 8ndpa-Oducts ofglutaminc metabolism did not diffa aignifi-
jury in critically ill patients (13, 27). W cbangca likely cantlybyfccding gsoup.mtbepmsestt asudy, d=~ong
result from the mobikadon of body amino acids dtat arc WI mquirc * invcsdgatiolL
usociated with acute injury qmnw (19. 2S), Our Study suggests shatcamfu!ly uultcbcdp==d astd
Byday50f fecdii(bods cntdand~ M cnteral suppl~tion @ rcmlt in compambk pmfika for
pksmaaminoa cidswacm stlxcdb baadine Valw.?slho most&cukthg W2h0-ThC mnhipleOtk&~of@J _
.
diffcaWxa?s inplasma amino acidcOx@moM bUwccm taminc mdabolkm (akckml muack kidney, and bt@ mm
PP$on&y5~a===hti=#w~” daobaveat3 issfluaiam pI=maatnho asWs@O. Tp -
mulacornpnsitiomL lbcradO Of_ tikucincdifked position ofdacf-ulafd appuratobcakey~cd

- -.
J JUN f O 1998

21
ENf”ERAL COMI’ARED \VITIJ pARr~ERAL GfJJTAMl~E 9s3

pl,vsma ajllino :icid concmurations. Furthdr swdics with Ion:. IZ. ~hlwrb pR, A~WC KI TCXJI ~XCMCnl ““ma~~” wuh ghm!mlnc in
Icrrn feedings or diffcrcn[ gluraminc doses may give bct[er bone rnurow Lraqknu[ion ad oh; clinical q@ic3ti0n5 (z random.
.—-—= insight into shc pmcn[id difknces between parcn[eral arrd id double-blmd srudy). JPEN J I%renrcr Emaal Nuu 1993:17:
cn[cral supp!emcnlxion. 1[ is possible shal Shc provision of 407-13.
pwen[er-al glutaminc at 100% of the projccrd requirement 13. Jenrcn GL. Miller RH. Talabiska DG. Fish J. Gianfenmc L A
k from she firs~ day would have r~uhcd in higher plasma glu- double-bIind prospective nndomizcd smdy of gluraminc<tichcd
ciminc concenfra[ions by the fifti day. Although plasma amino COMPU~ wi~ ~n~d ~ptidc-~~ f=ding in ~[ically ill Wicnu
acid concenrrxions are useful in evaluating glutamine rncsab- Am J Clin MM 199664 :61>21.
14. T-k G. Janrren B. Asscssmem of coma and impairrd consciws.
olism, intracellular gkxamine metabolism is also an imporum nsss. A prartical scale. Lance! 1974:2 .81-3
aspect of evaluating Ihe response [o glutamine supplemcn[a- 15. lenscn GL. Spray GS. WhiIrnirc S, TuAsr.cwski R. Reed MJ. Inrra.
tion. Tissue biopsy, menovcnous differences across ex@- Opcnsivc placcrncn[ of she nasocmerk fading tube ● @cd alter-
ties, and turnover studies were beyond flsc scow of the prcscnl tivc? JPEN J Paremer Grural NUK 1995:19.244-7.
study, brn migh( serve 10 berwx define how ghssarnine supplc- 16. Siocrrm RH. Cummings JG. Amino xid arsafysis of physiolog”~I
men~tion affecss amino acid metabolism and what dose of samples. In: Ho- FA. cd. Tc.chniiuc in dmgnossk human bio.
glufaminc is optimal for patienrs in sfrc5sed uatea. ❑ dkmsical gencdes. New York Wiky-fis% 1991:87-126.
17. Jxz P, SIocum B. Amino ad anafysis of phys”dog”d fluids for
The assistance of Peggy Bomm wirh drc amino acid anafyses awf of
dm-kzal usx. Pal Alto. CA: Beckman Insrrurswnm 1986.
Duane H.yd! widI she statistical analyses is gnrefrrlly acknowledged.
18. JGmsxansinidcs fW, Bochm J(A. RuI time. COSI-effalivc srwhod for
dckrmining total urinary nitrogen. Clin Clwm 1988342518-20.
REFERENCES 19. Fclig P. Amino xid sntsabolism in man. Annu Rcv Eiochern
197544333-55.
I. bcey JM, Wilmorc DW. k glurarrrinc z corrditionafly esxrrrial amino 20. Mzrliss EB. Aoki IT. Potisky T. cr al. Muscle and splanchnic
=-d? NUU Rcv 199rJ48.297-309. gl.tamirsc and gluranrxc rnaabdism in poslabsorpivc and srarved
2. Askaruzi J. Carperxiu YA. Michclscn CB. cl af. Muselc and plasm man. J Clin Invest 197150:8147.
amino ads following injury. Arm Surg 199&19Z7845. 21. Mathews Da M-o MA. Campbell RG.Splandusii M ufiltition
3. Bergsrrom J, Furor P. Nor- LO, d d. Issoacdhdar fme amino acid Of @UWrlilK ti giUCamiC a c i d i n bUrMltS. Am J pflySiOl
concentration in human musck tissue. J Appl Pbfiiol 1974*393-7. 1993264 :E848-54.
4. Swba WV/. WkrorK DW. Possopcmtive akuarion in mcriovemus 22 M-P.Dw.D,Ra~u~u&-~&~k
exchange of amino xi& _ the gamoinlesdnal - Susgery
Cffecss of erxdy adminisrcscd glwalninc irsfs-. AsDJPfsysiol
1983.%:342-50.
199 I 260736774
5. Swba WW. Jnksiind glutamine meralulisnr and auoisioss. J Num
23. Dominique D. JusI B. Messing B. a al. GJuram& maabobm -m
Biochem 1993;4:2q.
- beafrby adult mem~toclsrmlandinsn— fkding. Am I
6. Souba WW. Smkb R?, Whore DW. Glusamine mcsabkm tryshe
Clin Nusr W94219:139~
;+ .:.= y ..?...! . . . ~ inta - JPEN J Pammcr Mea-d NW 19855.3xt3-17.
7. Frisex WTL synlhesii and Cambofissn of 0Udee4irfea. kc FrkefJ wR 24. Merson VM. Moom~JoncsTN, aaf. TotafasraaJ wuitioaverans
d. Human biocfrcrnkuy. New York Murnilian Co. 1982292-304.
UNaJparenrcral rsusridonaflersnajor torso isljuy aucmsmh Ofhepsic
8. Rennie N. Hundal HS. Babi P. es al ~ -
. Ofagfuramine JrmIcin =Prka-itiradon. surgery 1W104:1992O7.
earricr in skeletal muscle have inrportam eortsequeres for nisrogen 2S. Parkrossc DB. L.ce J, A3uarsder RH. aaLEfias oferucralansf
loss in injury. infersion and ehmnii &ease_ hrrax 1986zl~l 1. parustcd nuoision onanrino acidlmmlsin nnarpadcrsM. JPENJ
9. Windmuelkr HG. Glutanrine utifizasion by she small kmsdne. A& Pascnrcr Enrcral Nuw 1995; 19:2044J.
ErUymol 198253201-37. 26. Afvesdy JA. Effects of gkrramine-supplanm!ed dti au bnmn&gy
10. Zicgkx TR Young 3S. BenfeJl ~ U sL Clii.ka3 and oscsatmiii of IJSC sw JPEN J Parust= EmI.aa3 ?krsr 15%M4(~.109S-13S.
eflieacy of gluraminc suppkmenfal parmrcnl nuoidoo * a bone 27. Jcevarusxkm M. Ywrrg D~ Rarnias ~ ScbiIkr WR Arninedduria
lIM170W U#MCltiOIS. A nndomized doubk+find. eOSSSSOfkd S&dy. of aevcrc tnunsa Am J Cfin Nurr 1989;49:814-22
b Jruun Mcd 1~116:821-8. 28. Harper AEMHksRH,Bf ockKP.Bm rrch4raiaan sinoas Afmemb
11. Zicglcr TR. MfcUK. SmkhR,ad.gafayad UMaEoUeclTeasd liarn Armu Rev Nusr 1984;4-54.
+.gI-.nc administration in humans.J= J PamIrer Esstcrd Nsu 29. Smisb RJ. Gkatarnine maabofb anrJiss physiok@c@mrsanm
199& 14@rrppl)137S45S. ~ J Parwircr Emad NUIJ l%Kl14(aqspfY~.

. ..-
I JUN 1 0 ~ 1998
—.— $ --- --— --— . ..—-— — —. . ——. . , .-..., . . - ----- . .. ,7- .,. .

A1)l>LIE1) NU’1’I/1’I’lONAL INVEYI’IGA’I’10N K,,!, ,1,<,,, \’<,1 I 2. x’, 5. I y,’,

Effect of Parenteral bGhtamine on Muscle


in the Very Severely 111

1. E. ALLAN PALMER BMEDSC1. BM. BS. FRCANAES.


RICHARD D. GRIFFTTHS, BSC, MD, tiCP, AND’ CHtiSTINA JONES, BSC, BN, MPH

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 ● 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 Muscle wasting in the aitically ill is a severe chnisd prob-


L-@@ ItIhIe is Chssifd as a noncssuItid amino acid in lems Gluraminc-enriclsed total paseutcral nutrition (lTN)
humans bust at tie crlhdar level them is the capacity for Whcm given preemptively has beul Shown to r?sult in an im-
ks synthesis. Dk4ary intake, togcrh= wids cndogmous produc- prowncmt in muscle biochcdmy aticJ a snc&un intensity
tion is normally adequate to satis& mquhmcnts. It i& tsow- surgical stress (Opm cholqstcUom y): fasconmthisshor(
eves. a.vay important amino acid bccausc it is &c psimary report enmincs tbc effcu of L-@taminc-supplancntcd TPN
nitrogen donor in DNA synthesis aI the ccUular kvel and is on muscle and plasma glutamirsc biochemistry in patients al-
also involvdin intuorgao ammonia sranspofl and biasbonatc sudyvesy scvcmJy ilLThia aborIpapcrdocs Oot reporton
gca~tion in the kidney. WbcsI metabolic demand fos glum- orlwr Outccrrsss snasuma thatwil lrsquir calargercoborinf
ss@ exceeds available supply,LS is dsought to ocxx in died padeats.
W=& ● relative dcficiesbq tesuks lhis may have askssc
h4AlzRlAls AND MEfnoos
-1==-’ -Y @ Su-tiom Se@rc glutlmine for
botb-norms! and admu!atcd cell divisf~ e.g., caaqtcs of GI Utamincscq SJimmcnt siot!lcaitican yiuascootkssowm
k GI tsa@a white l)lood al&J and fibsoblastsL’ Failure of AtdEtisoc ofstudy *nocsdlcrwork inlhese vaysui-
such odlulau poputsdon& as sn@t oqus during subsaaw ddi- ouslyill patiuus had bcenpubIishut Nonsd diuaayisstak
acncy, might aesdt in ● breakdown of anltaials4-8gof L-giubmiasq avariabk~ofwllich
impaimd imrnuns msponsiva d 2&%5!5!-& Snsybcabsort dbydlcgmrointesdsd tmcLMywoskby
Tbcscmdld inicdfca nltessemjsldtcmosl aidcally ill Furat and Co!kagucs’suggc stcdd.laf aflerscvaemlarsa ghsta-
Patkrsswhoam thcsubjcaof (b,iaatudy. mincdanand 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
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l’Al/ENTEl/AL I.. GLIJ”I’AMl Nli AND MUSCLE IN IHE VERY SIW13tElY ILL
317

cxccss of 20 g/24 h A wgct dose Of 25 g L-glulamin&24 h served in liquid ni[rogen pending x<s:!Y. The mu. sck sampic
was chosen for [his study on hrgcly empirical grounds as a was powder homogenized and an acid cxlrucl made using 2’%
comprom!sc tretwccn WIKN nughl be clinically desirable arrd pcrcl)loric acid and assayed for glulmninc and glulamlc acid
pllwmaeculically praclical. L-gluramine is ab.scm from commcr- using a coupkd ghstaminasc-glutama[c dchydrogcrrase assay.’0
ciall y available paremeral amino acid sohrlions duc to perceived Previous work wi[hin our d-cnl CICMIY showd demxabk
manufacturing and slotage difficulties. Following the method of changes in muscle histology and biochcmisq in this patkw
Hardy. Grimble, and KfcElroy, * two TPN all-in-one admixtures population over rhk shorr :imc pxiod.’”~ A longer in[cwaI
[glutaminc enriched (GTPN) and conventional (~N)] were was not scleaxl so as 10 limit the influence of secondary clini-
formulated for central venous adminis~tion, resulting in the cal cvenls, not primarily rcJated 10 TTW administration.
administration of 1“5.5 g nitrogen and 2000 nonnitrogcn sxlorics In preparation for thiswork the enzymatic gluraminc-ghsra-
(1: 1 CHO to fat) per 24-h pmiod. In addition, GTPN rcaukcd mate assay was oprimimd for the expcclcd aubstratc concentra-
in shc administration of 25 g L-giUtdISdnC, with correspondingly tions in human muscle tissue baud on rcwlu in rbc literature
less nitrogen from other amino acid soumcs (Table I). Eva and our own preliminary work. All assays wrc performed in
in GTPN the quantities of amino acid were adequate to satisfy duplicate, togctk with known standard comxnmations of both
rucrmmcndcd daily amounts. substaneca being assayed. TIKse standards indicated a rncan
Thk study WSS fommtly SppmVCd by the SL Helena & sCCOV~ Of L-ghItSMilSC of 82.7: 9.8% (SD) and Of L-ghSIaMiC
Knowsley Research ErAiea ComrnitIcc. AfrJx KU admission ● cid of 86.2 t 10.6% (SD). Statistically. the recovery fraedon
and hemcdynarnic stabilization, ● chnkaf dcckion as to the shows a norrttaf diswibution for bosh assays and duct noc show
nd for TPN supporr was made by rise attersdmg consultants. any drift ovw time. Tleac results m in acadancc with odrcm
Provided exclusion criteria were abscn: (hepatic faiharc, nonrc- who have used this assay ~rriquc.w Results prcscntd in this
sccd mafignan[ disease. pregnancy, or age under 16), the paper bavc bcus corrcdcd for variability rcvcafcd by standard
patient-s relativfi were approached for conxnt for study inchr- assay.
sion in a two-stage proms. Consent was rcqrscstcd fisst for Sodium content of the acid cxtraer was assayed using a
studying TPN administration and, second. in those patients model 5000 Atomic Absorption spcctrophoromctcx with air/
witJrou[ major disturbance of coagulation or symptomatic aektylcnc flame (Pcrkin-~mcr. Bcaeonsficld, Bucks, UK) and
rhrombocytopcnia. for obiaining paired percutaneous muscle used to correct assay results for changes in extmcclhrlar fluid
biopsies of the tibialis amcrior muscle. A two-stage mnscrrt volume using the mclhod of Jackson. ” Plasma samples were
was necessary to satisfy cshical considerations in this highly ““snap from” in liquid oitrogcm and dcprotcinizd using pcx-
stressful situation. chforic acid before cazymatic assay.
Patients were prospectively randomised using a double Statiaticzd cornpisom were made using t test and Mann-
blind, scaled envelope, block-randornization technique. Block Whitney U&at as appropriate (ARCUS PRO-STAT V3.0, kin
si= wwc limited to six paticrts so rhat changes in grxseral IZ BuclsatL Univcssity of @wpool ). Serial measurements were
ICU the.mpcutic techniques would have cquaf effect on gluta- analyxed according to Martbcws.’4 Measurements for each pa-
mine and control patients. Bascfinc plasma and muscle aampl= ticat were d by a descriptive statistic (&g. slope of
W= taken before TPN adrrdnktrsrtion and sqscated 5 daya mcasurcmcot versus drtas). summary values were tkrrOrn-
later. Muscle biopsy of tibialis anterior was performed using pamd bdwcco groups using citk pammcmic or nonpammdxic
. the conebotome’ technique and the sample imrncdiatefy prc- infrxcaltial statistics as appropriate. Rcaldts am indicated 8s
mm or median =95% s%ntkkaec intavals.
TABLE L RESULTS
Thirtyught patkws, age mnge 19-77 yr (mean 55 yr),
~N~ OF SUP~(OTPN) AND fulfilled k Study artty Csitcri% and Conamt Waa Obmirlc!d
uNsuPPLEMEmED (cl’PN) RJxixMES
Dkgnoacs itseludaf perforated abdominal viacus, acute ~
atim blunt tram burns, @L Although individual diagnoaca
GITN ( d ) CfPN (ml) may vary (Tabk U), aU patients exhibited some dcgrcc of the
syatcmicir@rnmatOrymsp onacsyndmmc(sIRs)r$ aDdaocan
~% L-@tdnC SOhdOrl be Oonsidmd to Cxbiit Simikritics Wirb regard to their mcta-
(Stile supply bolicremxtaeIUn eaaacvaityaem niingto the APACfiEII
~. ~
Hospital) 100D catinga auecedd mkmizadon pm=ss(ovedf tndiao
EJoarnin 15 (Lmpotd APACHE II 17, mttgc 8-31). lPN was comtnaed typicaUy
Pharsna&Gxford 3dayaaffcsIcu admkskm(mcdian3 daY&iubxquartikmw
Nutritioa UK) SOD 24daya).1’km waatKrai@icmt diffu==iu~of
Efoarnin 10 (Leqokt pSe-Mm-I~stay * Cootrd and amdy ~ -
Pharena&Gxford admmmadou d utaminckvclswcmmmkcdly
NuoidoaI UK) mm ~h~pti(-~%of-)~ muack
Sterik wata 300 (-19% of nosmsln;Tabk ~).GIU_@_ WWCdtamati-
Glucose 50% @XX@ Sofl dy ekvatcd itt @SlltS (335%). Extracdukr fluid voluassc
Glueesc 20% (GaIm) apmascdaaapsarxatagcby wc@oftbem*biw@- .
Elolii 20% ~~3M(M=5sa).auggesdn8 a-it==
--a fromnotmal valucaof-_” dutiOfI~~f~X&
Oxfcxd Numkiorr US(I Caitical iuDcsa.
Noconskad cbrsshthsmsde kvelswcteai!aa
Gebx-tsrcgfma comaim3.1 Ldot415SgnirrWr4200iKcd b & imem’al bctwui-biiet (os-&@’aksat 6mcspaa in *
(l:lcHcMsr).E& etrc4ylaan dtr=zmfnuatsad dadas Kqubad." Iiooblopa”kd patklata). AD incruac
h plasma giutamk acid
oTPNarrdcfPN-Ggt mmmc4f#emcowd
. aat0mwmiod kvckwaaaccsa in both GIFt’laod CIPN@=Q*--
Ioal palurtsral rwrxtr@ rcqccddy. tudeofwbkhw aarsotaignificaatb ctwcca~~kfv) .

-. -
. —— —- . . .. —”.-.. . . . . . . . —.- - ..- ---- --.-. .

31s I}AI<l+TfiltA[. LtiLU’I’Ahll Nl, ,iNl) MIJS~Ll: IN “1”1{1: VEI:Y S1:1”1:1<1:1.}’ JI.I.

TABLE II
I
DIAGNOSES PRECIPITATING lCU ADSIISSION

a
i
Gluuminc Patron! DIzgnosIs 13x APC Comrol Pa[icm Diagnosis R\ APC
I
Smde Inhdatton. pncumomus I Asfima. COAD 2
ARDS. pneumoniz YC5 8 Resp. failure, MOF 5
ScPticaemia. ARF Y= 23 Cardiac mmss. MOF 18
Scpticaemia. MOF Yes 23 Sepsis. NJSSUCCd bladder 23
.%ptiC shuck. MOF 23 Sep~icacmiS, pyelonephritis Yes 23
Sqximernk hear! failure 23 Sepsis. pedonitis, ARF Yes 23
Sqsicaemi< pancmuc abscess 23 Peritonitis, pcxfomtd colon 23
Cbolangitis. ARF 23 RTA multiple injury Yes 2s
Scpticaemi% perforamd colon Yes 23 RTL multiple injusy 25
Bums 40% 24 Ca @agus -on 36
Fall, skull, VdSCbd & rib skscnus.s 25 Pcdnmti GU. MOF 37
RTA. lung conttion Yes 25 Bowel obssmcdnn. resecsion Yes 37
Head injury. lung comusion Yes 3 Racial pedomtiorL MOF Yes 37
Smtus epilepsy. alcohol. pneumonia Yes 32 Pufomted GU Yu 37
Seizure. retained pmducu of czmczption “ Ycs 32 Perfm-atd colon 37
Pu-ilossitis 37 Bowel dJSbWliOSS. mseuion Yes 37
Diapluigmatic k-nk. Jwad
Pufm-md colon Yss 37 injury 50
Pancseatitis. ARF Yes 53 Pancrcatitis 53
Pancreasisis Yes 53
MU scidoais, pneumonia W Yes 55

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.

.,—
_—_ . . .>.&
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
sk.rnstive sources. The swo svsilable options am tithes sn
increase in synfksi.s, or nsobiition of stored amino scid. L-
Ghstarnine is SySStki2cd de 00V0 i.o humans within SkCfUZd
musdq the Iivcr, snd the polmonay tree W lungs m-e sble
of dsange with eitk nutitionaf regime, shhough issdividssaf so inca-case Synthesis during Cpisock of surgical stress” Sssd
‘4 psticnls did show significant gains and Iosaca (Fig. 1). “Simi-
farfy, no significant frusds for muscle glutsmic scid or J&
proportion of fhc muscle samples takco up by cxtrsdlsdsr hsid
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
W- dacctcd OVff She tinscspan utdcr study. fiv~ gluraminc synthcsii is increased during scidosis,m this
isasamsult of-umcaaed smmonia production snd fomss a
DISCUSS1ON scsvusging pstiwsy, as route to tbe kidney what the srnsnntsia
supply of glutsmine in the diet is sd~ and fbc
ff the is cxcaetcd. A conai.mxx finding in all studies of intuorgsn
demand tic same or in~cd, risen tie tody must look for glutsmine flu is a rs@ced ~ in glusaminc seksc from

TABLE III. TABLE IV.

PLASMA AND MU.SCUE GLUT- AND GLUTAhfME WGES IN PIASMA AND MUSCLE GLUTAMINE AND
EVHS BEK)RE lTN ADMNISTRA170N aAMfCACID ~DURfNGlHEF3RST
S DAYS OF T7+l

Pi&ding Vsluca =~d GrPN CfPN


(-z 95% a) w)
Plasms@asninsdsangoa +OJ138*W77 41X15.=0.026
Plsanugfumninc . Plasma gfusssrdc M _ +0.016 30.012t +0.012= M06t
. amsol.Lyt 0.343 = 0.082 n Muscle @S(SMiSW S+MSF 4-074 *OS52 +o.04d*o.443
Plasma glusamase Muscle glutmic * dmngc +0017& 02S4 +0.100 a 0.14S
ssusml . L-t ~~*~ S35 ECFdsassgu ~=~ +0.1 * Is
.

_—-.
u? -..
—.. --- . - —..— --- . . -. . -
. . . . -.. _A -_ -_J ___ ._
L. .-+ . . . ,-.
----- .,, . . . . . . .

]J,\l<l:Nq’l;l:,\[. ,-.GI/U[-,\\IINl: ,\sl) \l( ~S{”l.l; IN “1”111: VE1{}’ S[:vj:l{];].y IIJ. j!<]

1s , 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 con-
sumption 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 dur-
i.ngthc prx-iod ofthisstssdy. hbrcccmtly bccsrarguedxstsa
cfaangc.s in cellular hydration ssatc migtn be the mccharrism
whereby intracctfufar muscle gkrtamim JCVC15 arc contmksl. If
this wczc the casG dscn it might nos psovc possible to charge
GITNO C3TN1 CITNO 43TN1 muscle inaacdlular glutaminc kvck by MIrnrknd rnartipulasicm
akmc during this SCVM’dy df period.
FIG. 1. M.sck gluramine before. after, and five days toral parrmual The finding of an CIcVatiors in plasma glucsnrac has bcul trotcd
nutrition (TPN) ● dministration 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 dam-
tie skeletal muscle where it is she mos[ abundant free amino age, during eariy atagcs of systtmic sepsis. T?rcy also found a
acid. Muscle intracellular ghttaminc levels arc known to fall smaU, statisdcalfy nonsignificant ‘h—ease in kvsls in paticnrs with
during surgical stress, and this may have a direct infhsencc on unsmmplicatcd .surgicaf .sn-css. Pksma glutama[e kvefs mi-@t bc
muscle protein synthesis.” ass itsd@ct refkdon of flux through the ghstamioc-glutamic acid
Plasma and tmrsck ghmamirse levels were wry low before the maabcsfic pathway, a high kvc.1 indidng high kvcfs of glurmtinc
instigation of l’PN on Day 3 of she psticnrs’ ilbicss. n-is suggests utilization. Sucis a hypthcaii would bc consistent with the fitsding
that the balanti of g@rtsinc supply arrd demand at shis @tt has of incma.sin g levels pxtmrgcq, sqxia and in the critically iIl with
alrrady bccncxceedcd andsbcmsximal mtcoffsroductionor -c i+~aW SUFUXOC ayndmmc. Ilk MSY bc fdcwt
mlcasc of Rlusck glutamim Wiu almdy bc taking pram fn totheadmmamo.Onofgfutsmdc acid, wi’lidsfosmspsm Ofthc
healthy volurstcus infusion of the stress horrnoncs adrwafinc, amino acid IssknIminmccu mmmcsciafly available fmmuladoas.
glucagon, and COs-dsol hcmascs lirnbamino acideffluxandrc- f3aogca insstmck mayrsot bcfhcsmstirnp=ns cfktof
ducq markcss Of PrOtdn symthcsia.= ~ primary trigger for thk . gluaminc Suppkrnmta!ioa ExogcOouS glutaminc Xk&mtmdoo
rcsponacmaybcatt incmasc in CirQrladng glucoccsm‘coid kvcls, mayhavc aaignificaat impaclin dsoscsissucs wbcrcit isan
which catI prducc a similar el%ct-= Exogaous adrninisnation ~dalsxs_ =&she GItracs aadlivcr, 6broblasI$, aod ia
Of ~ ~&y Of L-@uWtdlSS in this situation appears so bc unable psrdcadar tlsc immune system, tie 6s musadoskcksa.i aystcut
. tosumarcsuod shcchaogcsthathavc $bdyt&CISp*kiS sakes oothcrole ofastoragccagan mnsumcd intimcsoftsccd
Uokrsown Wtlcshm mUsmcts&g mcamlml[ carrier or giving larger
doscawould altcrrhis - Ymw&y’-XL!$%%ti2Tz:%%?
Plasma ghrtamkc levels, aftbottgh Oot a rdkcdon of body inthcvay scvuely illtocotdirm apositiwcffEuyand ioffuf=0S
storc& do givt SOMC ‘mdicadoo of the atme Of whok bOdy srscSa- Onoutcmme
bofic flux. Plasma kvcla, low u d-se Start of mraidonaf aup#aoa-
tatioq swaitslowo dcspitcalasgc popottionofafl amitsoacids A=O~
being Suppficd as gltstamiR This mggcsu Citkr Supply (codOgc- ‘I%e Sir Juka l%ora Chsu+abk Ttu% Oxford NuOitiOa. ~

L Mobarban S. Ghtarnk a COdkiOMliy SSSSSISid OStttb( w 8. Hardy G, W- D. McElroy B, 7%ompsotr GR. Formtdadon
anodscr nutritional pusr.le. Nutr Rev 199Z5&331 of ● glutaraioc—ooo taioing Sc4al parcatual nutrition adxmfs for
2 Souba WW, Smith RJ, WIktrorc DW. GkstasairK snctabofii by clitic-d USC. Proc Nutr Soc 199251 :136A
Use iotcstioaf WacL JPEN 19S3;9:608 9. Cd&y L Smitfs m Dicoichson P. HcUiWCU TR Edwards
3. Newsbolme E& Newsbolmc P, Cud R C%alloncr m fiwi RHT. Pacutaacoua rmmckbiopsy wisbdse coachaofac. Clia
MSH. Artsk forsorsscle iatbeimsauoc$yststtr and its @ormnca Sci 19S7;71(S):1523A
in Slugu’y, Sraunlq is and bums. Nuuition 19S&4:261 10. bssd P. ffilutarrdac and L-glatarrme Uv-mcdsod Widt @tarlli-
4. Iitwim J. tiwtb T of urstaa diptOid fibmblasts iss media - aascaadglatamate dcbydtwmae k Bqmeyw w, GsaasI
diffcrcot arsdoo acid composidoa. J CeU Sci 1974; 14.* I
s. Ruloie MJ. Leasl Sissus Wasdag kt cdsicauy iu patkara-ia & ymdaxwda qfl%zymltic Amzfysis. Vtzkg Qttmk Bcdilu
prcvcatable Br J Ins Care 199%3:139 .
11. Hclli;wcll ~ Coakky ~ Wqpmmk$m NM. ~~~ m
6. Hammqv@. F, Wcmmrraa J. M R vondcr-Dsckaa & vii
aam E Additioo of @dW b M@ PSS@wal tnsUiti9a ahcr ~~,fk=Cf.M~P,B*M N=rmix.@
Clcaive Sayopatby in Uiticalfy.ifl patksl& J Pathology 1991; 1*W
Coun-=d y~- P= @@* ~ ma@G- 12 Gsiffiths RD. *w HdUti T. MXkOOSOP. ~b
*itrogco bakace. - Surg lcd:4Y” RR. EffcUofpaasive aO@cWagott dtc*ofm4rn&
7. I%rUP. Bagsssom J,13ao LasaLkdhlsoa Ofaadoauid aitica!fy411 Nutrisioo 1995: 11:42S
SUPPIY On aitmgrn sod amho acid mstabdiira in aevata tfaama. 13. &kaosl MJ.JOOCS D& Edwards RNT. M~ of~ciam
Aaa Cl& Sand 19%494:136 ats60tk cktncwxitIab sdkbkpsYssosPks ofm+fi

-. _
..-. — ,.’- . . . . . . . ..— -.—= ,,. - .= .--. —.- ---- — -- . ..- —--— — — -.

.\20 I’AI:I:N”I”EKAI. I.-G1.IJ”I’AN1IXI: AN1) MIJSC1.1: IN l’1~1: v~~~ sEvlXEL}’ 1[.[

I,:ICIC,Z)[. wittl ncurooluscular dd.sordcr> Clan Cltinl ACM 2(I F,,x A E(f,.cL\ Of acwc nKLd)OllC acidosis on renal. gwl, hwr, and
19s5.147:21s nwdc nkdmlism m UK b= Kjdntq Inl
of &M1inc d a11flm11i2
14 hl~[tllct$s JNS, Almian DG, Campfxll kfJ, R+swm P. Analysis of 19s2. ?1.439
_—_ .SCri:!l mmwrcnwm in mcd!c.al mwarch Ilr t.kxf J 1990.3(M 230 2 I \~mn~ E. H.unmarqvist l:. von-d=-fkkn A. N’cnscrman J Kolc
15 Bone RC. a al. Arncrian CcdJcgc of Clew PIiyswans/Socmy of O r gluwninc and iLs analogs m Jxm70amatic mUKiC pKW,n &
Cni)al Cm Mcdicmc Comcnsus confcm~. Dcfimuons of .sepis awIo aod nw~bolism JPEN 1$%3. 14 (SUPPI):125S

4 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[.
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. m-
a .scvcrily of disease clss.sification Git Cam hid I9S5.I3:818 fltiung changes in ~wcin symti,s. CIm Sci 1989.77.611
23. Muhlbachu F. Kapadia CR Colpoys MF, Sm”dI W. Wilmorc DW.
17. Wcmcnnan J, HamrnaqvisI F. AJi hm Virmam E GIuurninc d Erfcru of gl uaankoids on gluwminc mcdmlism in skkd musdc
omithinc-a-kaoglutarm M nu &mchcd*n amino acids twhc.c #um J phytird 1984:247(1 PI I):E75
IJX lOSS of muscle glttw-inc afur surgical OaUITU. Muabdism 24. Waussingm D, RodI E Lang F. Gcmk W. The aJJufar hydmtim suit:
1989. 3E(Suppl I ):63 ● majockmmiwu for @n u@x&sn in hufth and d!sac
la. [{mko.,itz K. PlumfeY DA MAn TD. HaUUMW RD.ti~d EM Lanccl 1993:341:1330
3d, Soda WW. bn~ glutamine Jiux folknvi.ng cpm h- surguy. J 2s. ZJcgla m Yslsmg M. BcmkJJ Kad. ainiar d nEElbOric CJficacy
Surg R= 1991:51:82 of gluwninc-supplcnlwcd paluumr mmiliols afuf bolw marrow
19. Plurofey D& Souba WW, Hautamaki RD. h4ardn T13. Fiyrm X. Snn5plmmtion. hm Inkm Mcd 1992:116:821
Rout WR.GpclamiEU .AcceJemdhmg amino timkasein 26. Van & HuM RRWJ. Van Ike! BK. VaI Meycn.fddI ~ a al
hypcrdymamic sqic surgicaf patkrns. Arch Surg IM, 12S57 Gluuaminc 8nd dsc ~XiOOOfgU! intcJ@Y. bnca 1993341:1363

..
.

.- I JUN ? O 1996

27
—.. ., ——,—. —. —-------- .— .— —.—.——— —.—------- . . . . . . -.. .

l’!!! :11. N’, I j,:


ih.t<i in [t S,4

f:i!
.—.= t>! !
<,

4
pl
{) r

The Effects of Glutamine-Supplemented Parenteral Nutrition in u!


111
Premature Infants 11
.18
P
JANm M. L\c~Y, DRPH, RD*; JW B. CROUCH , MPH, RDt5; hmnzm BENEZW RPH2 STEVEN A RINGE% W pNDt; 1
C. KRISrANN WILMORE, RD*; D ONNAMARIE MAGtJRL RIW; AND D OUGLAS w. WIIJIORE. MD*$ .
From the “hzboratoryfor SuW”col Mefabolion and Ndn”tba. iN~m&l In fmsiat Cwe Unit, tRescorrh F%armaq and Whttn”fio. Suppvrt service,
Bighorn and Wanwa k Hospital, B@oII {
1
1
ABSTRACT. Background: GMarnine (GIN) is the primary fuel to be tdgher in the GIN groups but the levels were well within
normal limits. In the 400-g cohort (n = 24), glutarnin=upple-
for rapidly dividing cells, yet it is not a constituent of parenteral
nutritional 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 =
and (2) to examine the effects of glutamine-supplemented .04). l%ere w= a tendency toward a shomx Iengtlr of stay in the
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 observa-
group 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)

The premature infant is extremely vulnerable to insufR- relative instability in schtion. However, after usual guid-

. . . . ..
ii&2F-~’ :
r
aent 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
lines for preparation of IVnutrient solutions, GLNhas been
shown to be stable,’=uand a variety of humart’=and ani-
maf studiesw’e have demonstrated an improved out-
more hostile ex utem surroundings where the food supply come when GLN was added to parenteral nutrition
* may be intermittent inadequate, or imperfect. Unlike the GLN supplementation maybe of particular benefit to
adtd~ the premature infant has limited nutrient stores to pretenn infants receiving IV feedings. ~ infants are
meet metabolic requirements during shofi4enn fasts.’ gIWW@3 ~d GLN is one of the primatynutrients thatpm
Even when nutients are provided enterally or intrave- vides purine and pyridme precurso IS for cell replication-
nously, the immature intestinal ttact and liver may not al- Secm@ GLN isneded for maturadon of the irttesdnal tract
ways optimize absorption and metabolism of such and tnayaid in prevention of enterocolitis.~~ L@ly, GLN
fwdings. Unfortunately, other priorities of medical care enhances grow@ dweloprnent and function of the immun-
often prechtde optimal nutrient delivq, contributing to ologic system’ and thIM should be of benefit to the pre
additional nutritional risk mature infant who k vulnerable to infections This study
The amfno acid glutamirte (GLN) k the most abundant reports our prelimii safety and efHcacy findinga of ~
amino add in muscle and plasma of adu!t humsn# it is .GLJQ+upplemented parenteral nutient solutions used in
important for cell growth and synthesis and is an essen- a neonatal intensive care unit Q4KT.JJ
tial 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 MraceJlu-
lar 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&

74

.—— ‘w&
.

-- -
I JUN 1 0, 1998

Czf
.. ---- --. ., —.. . . & , . ...-- *J. . -A= ----.-_. -. S_; . a ,.- ,L2SWJI *.- ,. .,-, ,.-+=
.- ah. .

]0 ,lltOr>L~CbrldUl~ 1996 GLliT.+MINE-SUPPLE\l ENTED lNFAN”fX -75

fants w?rc included if LhCy mcLat least six of the followirrgcriteriz TABLE 1
— Irln.hwei:lltc 1500g, ~csL1Lion31 a:c<3?\vcck; 5-nlinule.*gwxOre timoasilion of sofutions
< 6, need for >?l%oxygcn; need for\tcntilatoW =si~ce; low blood Standard solution Studs sc.luLion (Ami.osyn

4 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 (giv-
ing special consideration to the extremely -lo~v-bifi.weight infan~).
Lysine
Leucine
(Aminosyn PP. 7% solution)
(m,g1100

475
631
mL)
pF + glutammc; 7%
solution) (mg~IOO ml.)
3s0
665
lnfan:s were excluded from the study for severe centrsl nervous sys- Phenylalanine 300 240
[em damage incompatible WM a prolonged life, renal failure timiting Valine 452 262
pro[ein intake, and inborn errors of metabolism or tiver disease pre- Isoleucine 634 427
venting the delivery of appropriate nutrient requirements. Methicmine 125
Threonine z
Study Design Tryptiphan 125 100
Alanine 490 a92
The major aims of this study were (1) to teat whether GfX was weft A@rrine 361 669
tolemtcd in this population of premature infants and(2) to invesrigsle Glycine 270 216
the potentiaf benefits of GLN-supplemented TPN for thest brfants ua- Histidine 220 176
Lng a variety of clinical indicato~ bscfudhg length of stay @S), days Proline 570 4s6
on TPN, ventilator use, and incidence of infecdous episodes Glutamate 576 4s1
Because of safety concern, this study was initiated as an open4a- Serine 347 278
bel u-id. After the initial four patients received gluuuriine, infants were &partate 370 396
then randomized by balancedassignment into control and txeabrrent ‘l@sine as
groups, and the study was btiided so that none of the invesdgato~ Taurine z 34
nursing staff, or dietitians knew. whkh solution the infsnts were re- Ghrtsmine o 1400”
ceiving. The onfy pemon aware of the assignments was the research
pharrrracis~ who kept the code seafed until the time of dats analysis. ● 20% glutamine solution.
Infanrs who met the entry criteria were randomized by geststional ages
(. or a 32 weeks), high-risk NEC scor% and multiple b- (in the or metilic decompensation. Advancement to fuU entenl nutrition
event of twins, sibtings were assigned to opposite groups). The treat- generally required 7 to 14 dsya. - milk or infant formulas (iclud-
ment com.isted of addition of GLN to the TPN solution. GLN was ini- ing Similac Special Care [Ross Labontories, Columbus, OH] and
tially added at 15% weight per volume ofUre andno ● cid mix (n = 4), Enfamil Premature Formula. [Mead JohruoN EvamswWq tNl) were used.
increased to 20% (n . 15) and later increased to 2S% (n = 3). Both the Parentersl nutition was disconti-med wisen fluid needs were met by
control and GLN diets were isocsfonc and iaordtrogenous (Table I). the entenl route or when parented fluids t-an befow 1A rrrLA
This therapy was continued on theLAa of the CW status of the
General Procedures infant or the presence of positive blood cutturea. fstfants were dis
charged from the NICU when they were approximately 25 week
l%e ctinical care, including nutrition suppo~ of *e brfsrrts was gestational age, had ● chieved cardiovascular stability and

,. ;. .: . .
_—
*
+’ >.+: .,. ,:.:.
managed by the staff of the NNX, which fottowed genemtty acceptd
pmtocots M-w initial blood cuftures, aU of the infanfs received ant.iii-
ic thempy for at least the fust 3 days of life Fotlow-up btood cuttures
were obtained when ctinicafly indicated to ● vafuate bactererrrta in-
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

fants were weighed daUy on ● standard infant gmm scafe urtks pre Endpoints
4 eluded by the patient’s condition (e& K the infant were on a high-4ke-
quency ventilator). Routine blood was drown daily during the btitiaf Primary endpoints irscfurted time to full entenf feed% days on~,
course and subsequently twice a week or more often If medicalty brdi- ventilator days Uuoughout BWi length of stay @SJ and weight @m
cared to monitor● lectrolytes, biood gases, complete blood count and per day (averaged across c@. at BWH). Secondary endpobsts brctuded
bsdices of renal function. For the present study, 1 mL of blood was PIasma GIJ4 tevels (@O~), BUN and incidence Of ele+afed BUN (>
dtzwrr before tie hdtiation of the study brfusfon and once a week th- a9mom[>x@&]), &~dalwm(4x Wcefld
after to monitor amino acid and ammonia concentntiorq this wxs L) thlW@OUt ~ at B~ freqmrq of Postthe blood crdtures, ~
conditional on the other reqdrementa for obfabdng blood samples tiBW(_aL@~h*MWUB~,~tim(*
Ilerefore, not atl infants were meamred for all varhblea. fn the rnajor- Mudd~*BWpl-&n&4K~KW]ti&Ma
ivofNmSbl@fwti_GN~m*mti*d hospiti).
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 merhorL-
Plasma 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

Standard Them@
Blood banstbdons wae &neraUy dmMstedtomabttafa beaz@
ocrit>oxl@o%) vOhmle%md>a 40@oqlfMLntk eureiFdmdm3-
wm-a~ ~elu&ttfOetlm$ dwnced Overato
4dayaastofembA Rotebrandt4Mswere ~bYo.6to10ultg
~-,~~=~~~eb~~
usts’Igwtolo%dextlWeti~ ~m~k-
troseso!utkm wbtfuaedby acentmlcdbe@r. N=og=trkfeadln@
Wea-elrdttated ecepatknrsa obngerreqoked Umblllcal**
c?==ldde==wed~~,d~-
W.

J%% -W*(=
of -C resIdos& ~ stoo&=d~r=P~

. = -

I JUN 1 0 1998

27
--- -------
.

76

..— the rc.sulw were pooIcd. AS shown in ~ahlc 1[1, t.hc GLh’
*p= 0.03 f group” had highermean plasma GI.N ICVCIS (439 us 295
pmoVL, p = .04 ~normal range 0[ plasma GLN in l-nlonth-
4 500 okl breast-fed neonates: 142 to S50 pnlo~’i 1). in add i Lion,
plasma glutamate Ievcls tended to be higher in the GLN-
400 supplemented group (1SS us 152 ~mo~, # = .07 [normal
plasma levels of glutamate in l-month~ld breast-fed neo-
nates: 24 to 243 +mol/L’’]), but there were no significant
300 differences between serum bicarbonate or glutamate-glu-
tamine 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-week-
100 old 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
w 17, # = .04) during tie study when compared with con-
o 15 20 25 trols. Mean BUN during TPN (avetaged over days of TPN)
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],
(% of Amino Ac/ds) M), though the means of both groups were within the
. 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
the nutrient solution and the indtidual body weight of the infant- I = .O& 2.1 us 1.9 g proteirdkg per day, 9 = -03). Low white
ceu countis were seen III fewer Man= who r=eived GLN-
supplemented TPN compared with controls (2%?2 us 7/22,
weight subgroups (c SW and z S00 g) were ● xamined withii each # = .13) (Table UX) (mean values GLN us controk 20.1 m
group. Anaty+5 of covariance was employed to contd for bti we”@L
class. F%her’s exact teat was used to test betweenuuup ditTerencea
21.7 X K? cell.dI+ NS). ‘Ihe number of red blood cell tmns-
,-. . .!. .---,.:..
...... in frequenaea of abnormal latm*rY vatueS Potsntiat oothera in Uw fusions and average lymphocyte counts did not differ be-
.-= 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.
*
s measure of the degree to wtdch the dmated coetlkient would
change if uu aarnple were dela was emptoyed to detect anY obser-
vations with an unwnmlly targe mexure of influence LeWage w= Tivo Wtight Classes
atso used to examine the “extremene” of ot6erVaU0rW.a Data w LiWable arta3ysis (Kaplan-Meier) revah?d that at varY-
reported as means z SD.
ins le* of *Y (SW, the fxea@nertt had varying ef-
fects (Fig. 2). Cox regression demonstrated a significant
RESUL3S
interaction between birth weight and treatment in deter-
Group as a Whole mining U3S. Because of * we examined the effect of
Between May 1990 and August 1= ~ infants W-
GLN, controlling for bti weight groups, z 800 and z 800
enrolld 33 of these were subsequently excluded for the & = this was the general midpoint of the group (lWe
following reasons 16(8 controls and 8 tr@rnent group) fv-
The four weight subgroups were similar at baseline,
,. had insuffiaent time on TPN, 4 (3 controls and 1 trea&
except that in the Z SOO-g treatment group the I@ority of
rnent group) developed serious conditions that prevented
study participation because of surgery or Qansfw 4 (2 tij*hW@&Ae ~m2#=.W), Woof*om
wemt2-iplets Eachoftheother* s@iWJFMn@
controls and 2 treatment group) developed NBC, which
precluded enteml feedings 9 (4 controls and S tmtanent twice as many famles as males How@er, there were no
outime differences between sexes in the group as a
81’ouP) ~edffom cornplidons relathgtotheundeMW wholq except for a bend toward grea@ w~t @n per
condition On% a statkticsd outlier (for two dependent
variables ~ stBWHandTPN d@,W=eXdU=~ *inxnales(K4 mM9@%*=.w>
inf&nthadabirth wei@of1470&~&4-d ll& ma &?q”Cbho?t
daylengthof stay. (Tests weredone-.-tititiw
individual and exclusion of this obsemtkmhad no effect fntheZSOOgCOho* th-WeRnO____
on tie significance of the dab or conclusions) - final cant differem= inplamaGLN, glutmate+ or BUN ~le
santp!eslze of the study popuMon-44 (M males 26 fV). During TPN (but not for MM BWH), the GLN-
females). ‘lkem were no baseline differencesbetmenthe suPPlem=@WWMmon infants wMh@&bld
contsd and treatm=t @OI@S ~le ~ IKW *- * adtums(5=qp=.W~a-PXe~X
males andthefernde%mbtie n-dmti tive~_w4@W@tin_d4_
central w PerSphml Knee (data not shown). takenW=O,#=.@Hwe=dti~M~de
Since no differences Snmeanplasmagl~~ mdnedfor M3S*Bm&differen- w=mkW
txation were seen among the tiuee GIN * _ 1), mitisii=ny e-t ~le W. -_*~ = m g

---
--——— .—. - -——.— —.— ‘
—-. — .--— —-- . . . . . . . . ..s. . . . . . .,- -
. . . . . .

with positive cuhrcs, there was no difference in the num- third week of TPN, the GLN-supplemented group had a
ber with central m peripheral lines. Finally, males in this signific~,t]y Iligher ]yMplIOcyte count tJs con[rols (~5.9 ~S
cohort had a significantly greater average weight gain than 15.8, p = .04). Length of stay was ~so slloficr Jn ~~e supple-
females (17.3 m 12.3 #d, # = .05). They also tended ta gain mented group (73 m 90 days), although tJUS difference did
more weight than males in the < 800-g group (17.3 m 15.2 not reach stat-&ical significance.
gfd> NS).
OISCUSS1ON
77ze c 800g Cohort In ufero, the fetus derives a large amount of GLN from
Serum GLN was higher in the GLN-supplen~ented group the placenta and from amniotic fluid, the latter of which is
(400 m 225 kmolfL,2 = .05), but there were no differences thought to contribute up to one fifth of4he total protein
between the treatment and control groups in serum load. After birth, the amino acids in greatest concentra-
glutamate or ammonia (Table IV). The frequency of el- tions in mother’s milk are glutamine, glutamate, and tau-
evated 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 in-
fant 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
Conb-ol GLN’ toxicity we increased the dose to 20% A small number of
22 22 infants were studied at the 25% leve~ but no clear advan-
~ifi weight (g) 6002165 8112175 tages were observed.
Cestational age (weeka) 26=1 2622
Apgar score (5-IniIIUt.d 6S z 1.5 6.4 z 2.0
Sex (M/F) 7/15 12/10 S@kty of CIJVAdministration
Entry age (days) 4.1 z 09 3.7 ? 0.8
fvH {+1-) 3/19 1/21 GLN appeared to be well tolerated in this study popula-
Bir& nunk 1.2 ? 0.4 1.4 ? 0.7 tions, as indicated by the within-normal levels of plasma
# single bkths 15L22 16/22 ammonia and glutamate and improved GLN levels in both
#twins 5!22 4122 weight classes. h’tong infants = 800 g, the plasma
# triplets 0122 2122 glutamate levels were higher in the GLN group, but these
Delivem IV to C) 9113 5/17
Baaetin-e differences were also seen in this group at baseline (’lhble
Plaama ghtamine (p.mol/L) 363*139 X42169 W). In the< 800-g group, plasma glutamate was slightly
Plasma glutamate (prnol/L) 159 t 132 187 = 110 higher (177vs 142 psnol/1+ NS), but not significantly. Mo-
Plasma ammonia (prnoI/L) 7=5 6=2
over, the infsn~ showed no developmental disorders to
BUN (mmol/LJ 6.7 ? 22 7.0 ? 24
indicate any neurotmdc e.fkts of GLN orglutsm@e. These
*No differences between groups. findings are s“darto those of aGLN dose-response study

-. -
;JUN I o 1998

3/
.._ __ .—..—. —. -“ - - .-. ,. —..
=-- —=-= .— —.. &-. _. -.. . . , .- . . ..— ----- . . . . —.. .,. . . .
—..

7s L4CEY ET AL Vo[. 20, No. I

1oo- 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-
portion to the GLN dose.
There was, however, a greater number of GLN-supple-
mented infants with at least one episode of high (s &9
50 mmol/L) BUN during TPN in both weight classes (Table
W), altiough this difference was not significant Because
GLN
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 appropri-
J - ate. We further analyzed the total nitrogen intake and
0 N-kilodorie ratios of the two groups in each weight
30 60 90 120
class. There were no significant differences in these
Length of Stay (Days) indices either by week (week 1 through 4 of TPN) or
averaged over the days of TPN (data not shown). In the
Fk. 2 The percentage of infants hospitalized over rime for infants in the Z&JO-g infants, the only differences seen were in week
control (n = 22) us GLN-tJ4 (n =22) groups. At etier weeks of tros 1 for total nitrogen (conwols 0.372 #kg per day m GLN-
pital stay, the perccnrdge of infants in rhe NICU wa5 approxhrmtely the supplemented 0.804 @g per day, 4< .02), artd this re-
same for bdr groups. However, at tater weeks, more contxol infants flected a higher overall intake of total prote-in for week 1.
remsined in the NICU; at 80 daYs, eg, < 25% of the infaru in the GLN- There were no significant dtiferences in N-kcaf ratios in
supplemented group remained hospitalized, compared with >4096 of rhe
control infants. Cm promotional harard regres-s”mn revested that length either weight class.
of sray was determined by a signKicanr”mtemction between bti weight
and the treawnent received (J < .03). Therefore, subgroups of two bfi ~fica~ of CLNAdministratwn
weight cohorts (c 8!M and z S&l g) were crealed to control for the ef-
fec!s of birih weight on thii response. Among subjects 2800 g, a greater number of GLN-

TALUS IV
Trm wright ctassrs

n
..
Birth weight (g) 664:s2 NS 917 Y 134 Wt5:lls) NS
Geatitional age (weeks)
Apgar amre (~minute)
25.1 * 1s
S.8 z L4 K
NS
26.6 x 21
6.6 z L6
27.0 z LO
7.3*L2
NS
NS
Ses (WI?)
Entry age (days)
NH (+/-)
W8
42x 42
318 NS
4f7
3.720.7
0/11
712
4.02 LO
0/10
N:
NS
L3 =“0-5 L6 = of) NS
Birth number
# siogle &As
#twins
12% 0.4
9/11
2/11
R
NS
6/11
Wll
6!9
1/10
Ns
NS
# triplets 0/11 Ns 0/11 2/10 Ns
Delivery mode (vaginal or c-section) 6/5 S/8 lJ8 Ns
Baseline
plasma glutamine (p.mol/L) 3252143 288 * 112 Ns
PlaSma gtutamate QUnolfL) 2Y2.* 123 168 a 116 Ns
Plasma Smrooois (ploolm
BUN (mmol/L)
Outcome”
826
7.6 = L4
6*1
6.4 =21 z
47==
Vsodfator days (total)
~ Of ~y, BWH (days)
Length of S@, total (dsys)
go=~l
lo4*16
R
Ns
TPN days 21*11 NB
Day of fimt eoteml feeds 929 Ns
TimetofuUfee& 1429 NB
Plssma $Utamfne flurrolm 225262 X8
E =b&r’W’K&y 142*48 m
NB
BUN 6nrool/L) (d- IPN) Ns
FrequeacY Ofhisir BUN b Ofpatientq Tw) NB
Frequeocyofpc8itive adb(no. 6fPs~TPN)
=~@Aw&- b dwh% m E
E

I JUN 10 1998

.32-
—. ..-— ---- ,..__--. -. .x----- -. —-— . . , _
. . . . . . . . .
E—

sIIl)plmne IIfcd II Ifa JI1.S had posiLivc Mood cultures durin: Concl:tsio?u
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=. GLN supplementation may reduce the length of stay in
the hospitaf and promote enterd nutritiOn in these neo-
IIis finding is inconsistent with other studies of GLN nates. This prelimiruuy study should serve= the basis for
supplementation in hum<ws. 21~ This difference may have
a larger multi-institutional, randomized, prospective, clini-
been a artifac~ of tile small sample size; it underscores cal trial of GLN supplementation to facilitate appropriate
the need for larger clinical triafs in this area evaluation of GLN in neonates as well as of tie multiple
In the ve~-low-birth-weight (c 600 g) cohort, GLN-
variables present in this patient population.
supplernented TPN was associated with shorter time to
full feeds, fetrcr days on TPN, reduced LOS in the neona- ACKNOWLEDGMENTS
tal intensive care unit, fewer infants with episodes of low
WEC, earlier initiation of enteral feeding, and fewer days The authors thank Elizabeth Chambers, MS, Lourdes
on the ventilator. Reduced length of stay with GLN supple- Holejko, BS, Ramona Faris, MS, and Elaine Brom MS,
mentation has been reported in two other recent clinical for their technical laboratory expettisq Danny O. Jacobs,
trials?)m and may have been attributable to improved nutri- MD, for his generous medicaf and statistical advic% and
tional status,?’ enhanced bowel mucosal development= the staff of the Neonatal Intensive Care Unit for their ex-
and nommhzation of body Waterz’=a’fhe decrease in days cellent care and professional assistance throughout this
on TPN along with earlier enteral feeding may have con- study. We also thank Ester Awnehwm4 Ma RD, and N~cy
tributed to improved int@.inaf cell maturation and nutri- R Ehrlich for their helpful comments and suggestions for
ent absorption in the treated infants. This might have led the manuscript ‘IT& work was supported in part by a grant
to the observed earlier discharge from the NICU. Berseth from KabiWrurn, !%.ockholm, Sweden.
and Nordyke’; reported that in tlds Klgh-risk population,
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nificanL The size of these infants also made it difficult to
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rather than on the basis of definitive criti Other po$+
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their stay in the NICIJ. Nevertheless% the full impact of a
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longer period of time has* i% untfl the children
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anen@ etc). llwre.fore, a larger study withlor@errn fol-
10WUp would be reqlimd to un&@VOCd&d~ti
safety of this tr4mtent.
.

--- ‘ JUN f O 1998

33
—— .= —.. .=-.. -.— —-.. . -_ *,. ,= ..--AS-.

.- __”.
—-—-— —-— .- _.-<
—-—— ______ . .

so J.ACEY ET AL ~70/. 20, Are. I

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. .

-..
I JM 1 0 1998
3 EI-K)IIW
—.,.. -. .. . ..— —— ..l. —-., ——-—— -—-— . . . . . .- ..— .— ___ . - ..-

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 SwgeW ad the Drpart.e.t of fiannaq,
Memoriol Sban-KefteAg Grnrzr btcr. New Yod

ABSTRACT. A study was conducted to determine safety and of the glutamine-TPN solution. Plasma levels of glutarnine
efficacyof bgfutamine when added to total parenterid nutrition increased during the fmt 3 weeks of supplemenralion but
(TP~ solutions of p~ents receiving TPN in the home. Stability these increases were not statistically aignbkan~ DXylose
studie5 were fii performed on various concentrations of absorption studies performed before and after the admii-
@rtamirre in TPN solutions mbced by the Pharrnix metho~ tion of gluramine-TPN did not reveal any improvement in
llmse showed that glutamine was stable in home TPN solutions smaU-boWel absorptive qmcity. In conclusion, stable glu-
for ai ix 22 days. The daily home TPN solutions of seven tamine-TPN solutions for use by home TPN patierts can be
.5@1e patients were then supplemented with glufarrdne at a formulated. However, supplementation of home TPN solutions
d o s e o f 0 . 2 8 5 #kg of body weight for 4 week. llte at this dose was Mated with apparent hepatic toxicity
glutamin+TPN solutions were prepared weeldy. Five patients and did not demonstrate a beneficial effect on intestinal
received
. . the full 4 weeks of glutarnine-TPN. In NO patients, absorptive capacity as measured by r+sylose absorption
a&mmstmD‘on of glutarnin&TPNrmxtwes
“ wasstopped at the Therefore on the basis of this study, routine supplementation
end of week 2 and week 3 because of elevations in liver of home TPA’ solution with glutamine mot be recommended
enzymes A third patient’s liver enryrnes rass at the end o f @wnal of Parenteral and Enteral Ntiritwn 18268-273, 1994)
week 4. These abnormalities subQded after discontinuation

Patients with various forms of 12MToin~ failure of adenosine tIiDhOSDhate, Durines, and Dwirnidines.2
require long+rm home parenk nutrition (lv~ the There is a positive c&relati;n betieen t& concenba-
past 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, colono-
SlliItO 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 imp-
mainly bmuse of problems arising ffctm the difficulty roved nitrogen balanc% muscle protein synthesis,
of getting glutarnine into sohrtio~ its lack of stability and irttracelluliM muscle gluuirnine levels compared
in TPN solutions, and the fact that it is nonessential with a group receiving TPN without glutarnine
Glutamine is, however, the most abundant amino acid ~erehas beeninterest inaddirtg glutamineto TPN
in the body. It makes up approximatdy 60% of tie
because it may be conditionally essential duxing
free artdno adds found intracdhdariy in skeletal
musckl It has several important ftmctionst It carries periods of stress. To dam reported studies in humans
amino nitrogen from peripheral tissues to the splsnch- have described mbdng gMarnine-TPN ~~=m~=a
nicarqit iaartql orfactor inrenal a c i d - b a s e fiquent basis to keep the ntWxes
regdafiow and it donates nitrogen for the formation studies in humans were performed on hospitalized
patlenk. We have urtdataken a study to determine
whether glutamine can remain stable in a TPN solution
for prolonged periods to allow at-home use by patients
Readve4fapobBcdoqJuly~ - ~
~fmtiw~~~
receiving TPN. We aIso avaluated the clinical safety
&mspmbxaadrqriotmques& M9dkGMD, MemoW810sd@ of these SOhltiOCtS and the$r potential effects OfI
teringCaacuCenta, U75YorirAvcnuq NcwYodGNY10@L irttestinsl absorption. ..
2a

-. . .

35
-. .-. -.— —+ ., .--— --- —.— . . . . . . .. —.... . . . . . . . . .

M,7J-JI,,:C 1991 l..(ll.lTfX\l!>~lI Sl\l’I’l.lChl l\-l’?iI’loN 26:1

hlATEl:l.41S ,\ND MLTIIOIX ammoni:i, glul:unic acid, Pli, amiilo acids, Nerilily,
.—–-.= 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 p:uticul:im Inattcr, clccLrol@ col~cel~tr~tiolls, c o l o r ,
witli tlw Food and Drug Administration for LIIC usc of 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
glutine in TPN solutions. The study protoco] was weight were quanfiitatcd in tripli@c for cacl~ fommla
i on days O, 8, 15, and 22.
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 The solubil.i~ of glutarninc in solute-laden solutions
recruited from our home TPN population. All patients has been problematic in the Past- The PnarrrdxA
gave informed consent before joining the study. c o m p o u n d i n g p r o c e s s w a s u s e d becau5e it a l l o w s
complete solubilizadon and solute Urdformim in the
Paiicnts preparation of the enriched pmenteral, sOhJtiOns. This
c o m p o u n d i n g process allows the glutamine to be
Patients were eligible if they received TPN in the solubilized firs4 before it is combined with any other
home for at least 5 nights a week and fulfilled the components. In this method, the sterile water for
folfowing criterix age >18 years, no requirements for iqjection is added to a stainless steel mixing tank in
insulin, serum bilirubin level <1.5 mg/~ s e r u m sufficient quantity to ftdfill the total prescription volume.
cretinine level <1.8 mgl~ and no chemothempy or The ghmmine is aolubilized in the sterile water for
xadiation therapy in the preceding 6 months. Seven iqjection before adding any additional nutrient compo
home TPN patients (thee womem four men) were nents. Once the glutarnine is in solution, all other
studied. Their ages ranged from 3S to 81 yeas, and components are added in a sywemadc way m insure
their weights ranged from 45 to 76 kg (Table l). AU complete dissolution. ‘i%e pH of the compounded
patients had been receiving home TPN for at least 1 solution is adjusted with either glacial acetic acid or
year (average 8.4 years), and all were clinically stable. phosphoric acid in quantities suftlcient to maintain a
Patients were removed from the study if they had an pH range between 5 and 7. The refmctive index of the
elevation in LIT results of 2 times the baseline; an compounded solution is also tested to ensure complete
elevzition in amrnoni~ blood urea nitroge~ creadnine, solubilization
or glucose of 1.5 times the baselinq or any new physical This process also involves a cold sterilization technique
or mental status change. of two membrane filters. This ensures that the ghhrrdne
.- is not exposed to a heat.kd process 11-mt can catalyze
Glutamine-TPN Mkture product degradation and promote the generation of
StaMliW studies of ghrtarnin&TPN solutions were potential toxic by-products.
performed before the solutions were administered to
... . . . . . . . . . ,. .::. patients. Glutamine was ndxed in TPN solutions in Ghdamine-?PN Administratwn
--”+ concentrations of 1 and 1.5% wtko~ and solutions were
kept at 4*C for 22 days ~able B). ‘fhe composition
Glutarnine was added to TPN solutions at a dose of
0.285 @g of body weigit Thereforq a typical 70-kg
* of tAe mhrtures was calculated b give a wide range of Pent ~tivti 20 g Of glutarni.ne per day over a lo-hour
concentrations of amino acids, gluco~ electrol~ and to 12-hour infusion (Table Ill). Oux regular home TPN
trace elements in an effort to duplicate the various fotmuda typically includes amino acids in the amount
formulas prescribed to home TPN patients. Glutamine,

T-1
Palti &mct@tk
g Wdght nmton
Faoalt. aa TPN ~) ~
(W
1 M 81 64 6. ~v @=mR@w
2 M 45 7a T&kular CanCequ’pan@bOIVelresedOnarrdmdbtiOn
s M 64 76 : Intesdruf ~
4 F 71 49 Colatr anCer* Snrall-bowd and Iightdarl K$ClinO
6 F 81 62 ; Uterine eaner$@srnalttiwd ruedknsndndiatim
6 M 42 n 16 &Ohn’sdkU$e& srrdtb+ mecfbn
7 F 23 46 6 Maba6rm*ar@-bmd~
TPN, toralpr@entd nutritiqs/p, -pOsL

——-*
.

,
. ..-. -~ -. —.-=..=..— ..-..—. ..—— — -— -— . — .—— _ _—. ._ —_.._. .-

:~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 AIInlpCS of plasma ~nin~acids were Pcrfomlcd as
1)311 of IIIC to@” .mnillo acifl (I05c. TIw rcinaindw O f tile follo\vs: Blood samples collected in lubes con~n.
were
glumminc-TPh’ solulion W.ZS Ixzwt OIi I.lte rcgulm TPA] ing ISYC etllylenediantinelelr-aacctatc ~d kept on i c e .
fomlula of each indi@ual p3ticnL These formulas Piasma was separated by centrifugation and stored at
contin amino acids, dextrose, electrolytes, trace clc- – 70°C. Amino acids were separated as follows 400 ~L
mcn~, and waler. Wtarnins am added on a daily basis, of plasma was mixed with 400 AL of Semprep (Pickering
and the lipid is given separately. Xo three-in-cmc solutions
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
i
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 chromatog-
clinical 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 ninhy-
dnn (Pickering Laboratories). The response factor for
~Xylose Absorption Test calculation of glutamine concentration was determined
A Dxylose absorption teat was performed at baseline from an external glutamine standard formulated from a
and at the end of the study. Patients were given 25 g 1:1 mixture of ~ WO1 of pure Ct’ystahe L-ghkUtIhe
of o-xylose orally. They had serum mx~lose levels (Gibco, Grand Island, NY) per liter in water and Semprep.
determined at O, 1, 2, 3, and 5 hours ailer drinking the Response factors for other amino acids were determined
D-xylose solution. They also were asked to empty their from commercially available amino aad standard solu-
bladders at baseline, and a Shour urine collection for tion (&-nirto Acid Calibration Standard Pickering Lab
measurement of mxylose was obtained. ratories).
The blood tests, including amino acid profiles, were
Moniton”ng done at baseline and at weekly intervals for the 4 weeks
of administration of glutamine-TPN and for 2 weeks
B1ood tests including complete cell counL venous thereafter, when patients were receiving their regular
ammonia concentration, serum glutamic oxaloacetic TPN wi~out glutamine. Patients were called eveg other
trmsaminase concentration% serum glutic pyl’uvate day and were asked about any new physical or mental
concentration, alkaline phoaphatase con- .Symptorns.
centration, lactic acid dehydrogenase concenuation,
bilirubin level, blood urea nitrogen leve~ creatinine level, S@tlLm
and glucose level were performed. Plasma amino acid
profiles were also obtained. 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

Gluaninc AmirlOdds(g) TOtJ.1 doliu


Patieru -%~~lnm
(2) excluding $utamtne mhtian)
1 1s3 323 2340
2 2 0 . 6 513 a
3 2tA 64-0 2674
4 14.4 26.1 ZMl
5 14.0 66.6 1779
6 2L4 M-o . 2314
7 12.o =0 w
TPN, U pammeml nubition.

Dayo -u D8yls Dqa PaIxncnctu# & “


PH 6m 6al m 6.s as,
Dactmse (%) loaoo 9271 -729
color (xlutuntk) 24.6 -2S1
P=tkuMematter Ml Fs Pm Pm
Anunordunl (Jlpm) <M <16 <t6
Glutwnic M w M w w
Me(%to$$) +.09
Pm
H% PA22 - - “PZ3. —

---

37
—...—. —.. . ..——.— . . . . -— ..- -.. — ________ .

r e m a i n e d Irilhin Ultilwi SHIM Plmnwcopcia guiriclincs Or glulalijnc SIIl)l)!CI)ICI) l:ILI{)ll, IJIIL dlell a gr~du~ dcclilw

w,hen so]utiolrs \vc!re kcl)L aL 4°C for up Lo ~~ d:iys (Tab]e.S bc:wl. AfLcr 4 weeks of glt]tmninc suppkmenmtion, the
IV and V) De\lrose aml CICCWOIXC lCVCIS remained within mc.an ph.sma gluiaminc Icwi d e c l i n e d L O ~W presupple-
United SUlcs I’iwmacopeia limiLs No significant increase-s numation level. Two weeks after discontinuation of
fi guWtiC acid or ammonia conccntmtion were detected. glurarnine, the level had decreased L O 453 ~ 82 p-rnoVL.
The other amino acick in the SOhtion also remained stable. A WiJcoxon matched pairs cesl was performed, compar-
Sterility and pyrogcn assays were negative for all samples ing each mean plasma gIuiaminc level obtained with
Color, PI+, visual appeamnce, and bag weight all remained the levels for every week (eg, baseline compared with
within acceptable limk values at week I, week 2, week 3, week 4, and
posttreatrnent weeks 1 and 2). There was no statistically
Oaitpatieni Outcome With Glutanzine-TPN sigtilcant change noted despite the trend toward an
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@Ose-
The plasma glutamine levels before glutamine supple- DISCUMON
mentation and at weekly intervals after beghing
supplementation are presenk-d in F@re L At baseline, ‘lMs study demomtmtes the f-btity of admhMH@
themean level was560*60p,moVL ‘I%is was a TPN solution containing glutamine to home TPN
st.aMically similar tolevelsof 634= 31prnol& and patients The Pharmix method was used to mix the TPN
627 a 28 p.rnoVL reported previously irt healthy controls’ solutions.’ When TPN solutions were supplemented with
Them- level roseto655*46pmoVL after lweek gltts.min~ they remained stable in solution for at least

TAsuV
AW&ddddi&dU&hhdODat daY 0.8.15. aadZ?

Antno * (%) D8yo ma Dqts D8yZt -We


Glutardne(=l.11%) lm.oo 10M3 10L14 S3.02 (NS’) 96s3
lm.oo 10&64 XW3m
10MO 1- SLm 9Z69(NS) 9171
Glycine lW.W 1- 9319 9249 @S) ml
100.OD 106s 9s69 U&16(NS)
lsoleudne lW im66 %.11 (?S)
lmoo 104-M RM6 W.91 @s) z
lW.00 lM.12 90s7(N5) 9L76
lmoo lo7m 9414 (M) ml m7a
100.00 104.61 9267(NS) elm
100.00 10M100.8t 95.2$(M)
100.00 lm13 0266(NS) ma
Vdilw 10WO l12M %.61 96s4(?4s)
Nanotdgnubnt 11-ierewssno s@stka@sknttbtkre$se
. in=Wti Ad~ Cnuthtrstperiell

-- -.
‘ 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 n t e s t i n a l vjllrrus hcigl)t V&s noL nlwlsu]-c(l ill our
I)Ic’ @uLlminc-’H’N so]utions c o u l d IX rjc]ivcrcd to th? sLudy. Iiowcvcrt the wxylose absorption slu(iics in our
paLicnLs’ homes on a weekly b<ask, ~d dtily comporrnd- patients did not jn(licatx any improvement in snk-dl-in-
ing of Lhe s o l u t i o n s W.W unnccessar-y. tcstinal absorption after 4 weeks of glutm}inc supple-
Animzds receiving lon@crm TPN may develop intcs- mcntaLion. The o-xy]osc absorption test is the standard
tins.i mucosal atxophy, pardcuhrly if they have no oral clinical test for cval uating the absorptive capacity of
intake. h has been posh-dated that this atrophy is caused the small-bowel mucosa. However, it has some limitat-
I.‘1 or worsened by the lack of glutamine? Grant and SnydeP ions. k measures xylose absorption spec-fkally and
found that rats given @arnine-TPN would maintain does not measure other types of nutrient absorption. It
mucosal weight in the stomach and colon but not tie is also not sensitive enough to pick up subtle changes
n
small bowel. ODwyer et a.i reported that rats receiving in absorptive capacity.
glwmine had increased intestinal weight DNA conten~ A possible explanation for lack of improvement in
and intestinal villous heigh~ absorption is that our patients may have already achieved

TMU VI
$ecirlc !iueruqme changes in thrm$mtienfs
Bawline
Highest 2 week
value dur mdv

Bihrubin NL = 0.6-1.2 0.7 0.7 02


AMdine phosphalase NL = 3&126 175 206 m
WNL=WO 3a 126 36
LOH NL = 313-618 520 946 276
.%mrnonia NL = W64 . 44 52 Nor done
.(LT NL = 5-40 16 41 24

Patient 6
Bilimbin NL = 0.gL2 0.3 0.5 03
M!diie phosph= NL = 3&lLM 151 2?6 152
AS7NL=540 4a m 22
LDH NL = .3$180 lm 191 126
~onia NL = 18+4 63 41 202
ALTNL=5-10 68 % 33

Pa!ient 3
BihnMn NL - &LO
Alkaline Phospha- NL = 304
MTNL= 1C47
m
O.a

24
MY
272
0.7
131
21
ALTNL=$37 20 142 37
LDH NL = 60-200 171 m la
AnullOnia NL -13-64 90
-. 57 32
NI+ Nomd labmatory valuq AS, serum gluwnic oxahmtic tmnsanu “Iwqmtilacdc acid ~ ALT, serum gtutarnic pyrma.te

LAWA QLUWNE LEVEU hl~bf)


600 1

I I

600 ..-. .— .* 1. . - —--!


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

mxxinm] small -bo\vcl adap~tion, in.asmucll as t h e y h a d 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


it~testinal failure and had been receiving TPN and ord phosphatzsc
.. a n d bilirubin Icvcls during tJw I-month
feedings for long pcnocis. lt is also conceivable that it admmstmtioli of glufamin&TPN to bone marro~~ tmnsplant

c GIIK?S a longer period of administration of glutamine to


improve smafl-bowel function. Whether glutarnine given
during d]e early stag= after resection of
the small bowel
paderits6 ~ levels were not mentioned in that
report. TransaM inase level increases were the most
impressive Iaborat.my value change in our population.
\vould resuft in an accelerated raw of improvement in summary, this study showed that a stable
absorption cannot be determined from this study. gh!!-&TPN solution can be made for the h o m e
Although our patients had been receiving home TPN setting. However, it does not give evidence that glutarnine
for an avenge of 8 years, their plasma glutamine levels supplementation causes improvement in small-bowel
were comparable to those of normal healthy people. absorption in stable home TPN patients who are taking
Glutarnine supplementation did not result in a n y food orally. Evaluation of other potential benefits in
sustained increase in serum glutamine levels. this patient popu!adon such as a de~e in sepsis rate
It has been suggested that glutamine supplementation requires a larger number of patients and a much longer
can prevent bacterial tmnslocation from the intestinal s t u d y . we potentiaf fiver. t o x i c i t y t%om glutamine
tnct and thus reduce the rate of sepsis. Alverdy’O found supplementation has to be kept in mind if such studies
that chemotherapy-treated rats given TPN without are u n d e r t a k e
glutamine had a 100% mortzdity rate and upon necropsy
had higher percentages of positive cultures from ACKNOWLEDGMENTS
mesenteric lymph nodes, liver, spl~ and blood. Burke ‘Ilds study was patially funded by a grant from
et al’ t found a stadstically significant difference in the Caremark International Incorporated. The authors grate-
rate of bacterial translocadon in both enterally fed and fully aclmowledge Mr Enc Kastango, RP~ from Caremark
glutamine-TPN-fed mts compared with xats fed TPN for his assistance in performing glutamine stability
alone. These studies suggested that parenteral glutamine studies.
supplementation in animals might help protect them
from bacterial fmanslocation Our study did not evaluate references
rates of infections because it was performed in a stable,
small population for a relatively shott pdod. L Buius N, &SOSiiO E, @ti5tan F, d d t%@O!O@C impixtance Of
@ar&. Metabolism 3S (SuPP~l-6, 19W
Recently, Ziegler et afc reported a reduction in the 2 Iiaussin&!e.r D Glutamine metabolism in the tiva mew snd cur-
infection mte in bone manow tmtsplant patients whose rent concepts. MetsbotisM 3S (SuppI>14-17, 19S9
TPN was supplemented with glutarrtine at 0.57 @g of ~ I@adis R Cmtpoyo M ~isngz et ak Maintenance of skeletal muscle
body weight. They also noted an improvement in nitrogen intmeUar@tamtnedtu ingsbndatdsur aicsltn-JPEN*
6s9, 1965
;--w,., . .. . . . . balance and a decrease in the length of hospital stay. 4—~ . F, Wemermsn J, Ruston ~ et at Addition of glutsmtne
These patients were acutely ill after radiatiou chem~ tOtat Parentmafnutridon afteretecdveab&mlnal r6urgeryaPamafme
thetapy, and bone mamow taartsplantatiom gtutamine and muscle protdn aynthesia and inqmves nirrogen bst-
-Y Our patients received onfy half the above dose hey snce. h SurK 205!4S346J 1989
received 0.285 g of glutamine per ldlogfam of body 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
weight in their TPN. They received this lower dose & ZkgterT’RYo ungLS,BenfeU Ketst C4iniatsndmetabotic s5~
because their TPN infusion lasted only 10 to 12 houm of gluti ~lemented parentsnl nutiition after bone rnsrmw
instead of the 24-hour period used in inpatient studies. tm@arMiom Ann Intern Med 11&S214!2& lf19Z
Because gfutamin&TPN had not been previously given 7. Cuemsrk w- Mar@ carehwk In-o@ Totowq NJ,
inanoutpatient setting, we chose tousea rate that fLO’Owyer SSmtth RHswYT, et* Msi.ntsnsnce Ofsrnsut.owd
had previously been ahown to be safe me question ~ with glutsmhean.* psrentaal nutzitiom JPEN 13S78-
arises whether the results would have been different if m Im
alarger dose had been useti a GnntJF, BlWderP*6.GluuuntnelnTPN.slugaes44m64t.?4lWs
The only apparent aide effect from glutarnine supple- la AJvdy&Ea’ded nutrkionresuhsl nbcteridtrsnsloationti
thegUtand&thf0Uowtngchern0themPY(Ab@Asc07Ath-
mentation was an increase in liver eruym~ which
. resolved upon cessation of the glutamine attpplern~ lL %%%:-=% ~ et at BuPPtemu’Ud @ b
tion in affected patients It is of concern that tluw of n@rlttOn imprWes@kmIume ftmC&UAIdlsurg lz&ls6-x
our paiXmta developkd thfs elevation in liver enzymes 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 amino-
acid/dextrose solutions ranged from 0.74L9°A/day, in Perifusin 0.6 Y0/day, and in dextrose alone
as low as 0.15“Alday. At 4“C, glutamine degradation was <0.1 -0.20A/day in all solutions
examined, at -20°C it was minimal (cO.04Y0/day) and at -80°C, it was undetectable.
Glutamine degradation was found to be associated with the formation of equimolar quantities
of ammonia. No glutamate formation was detected.
It is concluded that it is possible to store glutamine in parenteral nutrition solutions kept at 4°C,
with about 20A loss oyer a period of 14 days. The degradation is sufficiently slow to consider the
use of intravenous glutamine in nutritional therapy.

In production storage. In previous studies we have found that the


AII the currently available commercial amino-aad stabifity of glu(amine in solution depends not onfy
solutions that are used in total parenteral nutrition on tempcratur~ and pH, but also on the composi-
(TPN) lack free glutamine. ?his is largely because tion and mol ity of other constituents in the
of fea_s about the instability of glutamine and solutions (7, 8, [t became obvious that there was a
possible toxicity of some of its degradation pro- risk in attempting to predict the rate of degra-
ducts (pyroglutamic a a d a n d a m m o n i a ) . dation of glutaminc in one solution as a muh of
However, there is surprisingly little information obscmations made on another solution. It also
about the stabdity of glutarnine, and some of the became clear that the stability and products of
work with parenteral nutrition solutions is confus- glutarnine degradation should be assessed in a
variety of parented nutrition solutions. This
ing. For example, in one preliminary report it was
suggested that the rate of degradation of glutarnine study aimed to obain such information at various
in the presence of other nutricats is as low as tempcmturcs, including those that arc likely to
O. I%/day at room temperature (l). In another exist during storage or administration of the
preliminary ~mmunication the mte of glutamine intravenous solutions.
degradation in a parentcrd nutrition solution was
repoficd to be higher, but less than S%/day (2). Methods
However, other workers have reported the rate of
glutamine degradation in buffers, kept at room Lghttarnine (Degussa, Frankfutt, Germany) was
tempcmture and a pH sknilar to that of parentcml added to the solutions to form a final conccnqation
nutrition solutions, is even higher at about 10- of about 1% (w/v) (70mmol/1). The composition of
20%lday (3,4, S). the various intravenous solutions is indicatad in
If free gIuta,rnine is to be indudad in patwttcral Table 1.
nutrition solutions as an alternative to the use of An mixtures were prepared in standard sized
glutamine containing dipeptidcs (6), it is aasmtiaI total smmnteral nutrition f’IPN) bags under strict
to have infocrnation about its stability arid the type aseptic wnditiotts. lle a’lutiotts c&taincd ele
of degradation products that are formed during tro[ytes (except vatnin/dextrose) and micrcmu-

-- 193

..- I JUN I o 1998


I
,/
f

I
I
i
Tebh t DetGfM tmnfrosftlon of eaeh type Of Solsstlotimlxtssre used to assess the stsbilit y of glu!amine
SynthamirJ
Aml~~A)t/ AmlnoglccjB)t/ Eloemln (A)tt/ Eloamin (&t)t tl Synthaminttt/ dcx!rosc/ VOmin”/
Codtums18 dex!rose dextrose dextrose lipid dextrose Pcrilu\in””
:tuu#mtl)(mnsolO) 74 66 74 68 74 68 74 74
46.6 43,2 46.2 42S 32.5 26 30
Na (mmoVl) 49.1 45,3 49.2 4s.3 3s 28 40
Nitrogen (g/l) 7.11 6.4 5,12 -9 54
GbOydrete (kaUf) 577.2 53:’5 55!:! 52!: ; 563 450,4 460 -
Fet (k@ - 400
Pbospfsete (mmolrl) ii.3 1;.0 17.2 1s.9 15.0 12
/ MS (mmoVl) 2.5 5
a (mmol/f) 6;; 6;:; 6% 6;:~ 35 2: - 9
; Ce (mmoVl) 2.9 2.7 2.9 2.6
Aoetate (mmon 1.0 1.3 10.3 6;.5 5; 10
Trece elementt”’e Elotrece B Elotmx B Elot%e B Elotrnce B Additrace Addilrace -
Vftemhss”””” MVC9+3 MVC9 + 3 Mvc9+3 MVC9+3 Multibionta Multibionta -
t @fMlkh Sorsl Ltd, Cheater, UK i’,
tt fAOPOld Phmns, OrGZ, AsntrlaK3xford Nutrition. Oxford, UK ,1
W Baxter, Eghem, Sumey, UK
● Kebl vtsnnn Ltd. Uxbrldee. Mlddieaex. UK
6* ~~- Ltd., Al~on, Hunis; UK
● “” 1 assspoukof tmceelemenu, present k -2.5 LSOIUI1OSN (Elowece B, Uopold Pherma, Oraz, AustridOxford NWidon, Oxford, UK: Addifracc, Kabi, UK)
● “”* 1 msrpmsfe of mssltfvemlrss present In 2.5L aolutlons (MW Lyphomed, Chicago, USA/Oxford Nutrition Lid UK; Muhibionta, Merck, UK)

-., ..-. ..--, -- -- .-, --- ,—” — - - - - — - - . . .. —.. — —-. . ,— --— -

4
0 ..-
.-. ..— —. —~ .—-—---- ---- -- - — .—______ _
.- . .
..
.*.

—_ , CLINICAL NUIRtTION t95

I [ricn~s ( T a b l e 1 ) . T h e L-glulaminc w a s first 2) was measured at room [cmperaturc before,


< dissolved in stcriic doubly distilled water for during and at the end of the ICSI period.
irrjeetion B.P. (z.s~. wh or 173mmot/1), paSSed G1utamine (9), glutamate (IO), and ammonia
through a 0.2 ~m filter 10 remove particulate (Rochc, urea UV method, Kit No:0711144) were
matter, and then added to the above inmavenous measured in duplicate using standard enzymatic
I Solutiondmixtures (Table 1), and dextrose solu- ieehniques adapted for use on the ~bas Fara
tions alone to achieve a final dextrose concentra- (Roehe) centrifugal autoanalyser. The ‘all in one’
I tion of >25~0 wk. As a eontro] t h e s a m e mixfure which included the lipid emulsion (stored
intravenous solu[ionsfmixlures were prepared only at 22-24°C and 4“C) was filtered through a
I without the addition of glutamine. As fufiher O-2pm filter prior to analysis in order to remove
controls, ammonia (as ammonium chloride, Ana- the lipid.
Iar, British Drug House, Poole, Dorset, UK),
I L-glutamate and L-pyroglutamate (Sigma, Dor-
set, UK) were added separately 10 the same G7feufations
I
I solutions (without glutamine) IO obtain final con- Degradation rates (see Table 2) were derived from
centrations of 10, 10 and 40mmoVl respectively. (a) the sequential dezline in ghrtamine concentra-
I
Portions of these solutions were sampled at the tions, and (b) a combination of initial glutamine
same intervals (see below) as the above solutions concentration and appearance of ammonia (the
and analysed to assess the reeove~ and possible degradation of glutamine was found (O be asso-
interconversion of ghrtarnale, glutamine, pyroglu- aated with the formation of equimolar quantities
i tamate and ammonia. . of ammonia; see(7) and resrrltsof this paper). The
Aliquots (20ml) of each solutions were removed second method was used partly because no dil-
! from the TPN bags and kept in sterile glass vials at utions were neeessary prior to analysis, and partly
room temperature (22-24”C), 4“C, and -WC (all because it is able to detect small changes in
i exeept mixed bag containing lipid). Tbe
‘ “ Synthamin containing solutions were also stored at
concentrations more accurately than the fust
method (the initial ammonia concentration was

I –20”C. The TPN bags (Ultrastab, Oxford Nutri-


tion, Oxford), which are impermeable to gases
close to zero -cf. glutamine cone.entration). Both
methods of calculation took into consideration the

++>... .:.. s% . .. . . . ...- I such as oxygen were also kept at room


temperature, and the contents sampled at inter-
initial concentrations of ammonia and glutamate,
and the amounts formed over the test period in
.—_
I vals. Duplicate samples from all the solutions were
taken at day O (shortly after addition of ghtta-
control solutions that did not have additions of
Lgluwmsate or ammonia.
. mine), day 7 and day 14. In some ease-s (dext= The degradation rate K (%/day) was derived by
only solutions and all Synthamin containing solu- plotting the log of glutamine eoncenttation (as ‘A
tions), additional measurements were made on of original) against time (days). K is the antilog of
days 3 and 30. The pH of each solution (see Table the gradient thus formed.
I
Tabk 2 Degradation rates (%klay) of fq@naminc in various $oIuriondmixsurcs ar diffcrem
(A) sod the aorrnafi mefbod (B)t
I Iempcramrcs using she gfuramhe roctbod

Tcurpenture

I Saludoo tt
Syndummwrw
syo~ d
..
pki
. 5.8 am
54
A
Z-2X

O.n
B
0.90
A
0.10
020
c
BAB
0.10
-w

m m

-1= ~ ok 0:0 : :
I Arniooples BKkrmse x Z o.n H 0.10 m m

i
ElOUOiu~ s.s m :: 0.25 0.10 M m
! EJoaminmlkU’0= S.s Q74 . 020 0.14 m w
%6 0.65 0.18 m m
6.7 m & alo % w w
~ts% 42 0.17 0.14 0.10 0.09 u m

I1 tSurarfarddkofroetbod Aaod B
ttFordetaifaf0xnpdk08a2bt4cl
1#1 = oodelcu8bte
.-

I
_-

---
. —.— . . . . ..-. — —, —-. . . . . . ,$--- . ..4 ..—. - , _ _ _ _ _ _ _ _ _ — .

196 STAf31L1TV OF L-GLUTAMIPW IN TJ’N SOLUTIONS

Pyroglutamate was added (14day period at room


temperature). [n the umtrol experiments in which
ammonia and glutamate were added to the various
solulions, both metabolizes were completely
Ii
recovered at the end of the study. Furthermore, in
the control experiment in which pyroglulamic acid
was added to the intravenous solutions, no
i
ammonia, glutamate or glutarnine appeared.
The pH of any solution did not change by more
than 0.2pH units during the study period. Initial I
ammonia values were close to mmo in the amino-
acid containing solutionhnixture (<0.25 mmol/1 I
and did not rise above 0.5mmoM in any of the
M N OAYS control samples). Glutamine degradation rates in
Frg. 1. the dczradation of L-slutami~ (GW ● 22-2~ in a
samples stored in gas impermeable bags, were I

dex:rusc solution 15% w/v (*) and in a Synthaminldextrose virtually identicxd to those stored in glass vials
mixture (*). see Table 1 [or detailed composition. Rcsulrs ● e (room temperature).
plo[wd on a scmilogari[hmic safe (y axis only).
Discussion I

Results . The recognition of the potential imporfarree of


glutamine in the metabolism of various cells and
I
The irstrabatch coefficient of variation for the tissues (2, 11-16), has led to attempts to administer
measurement of glutamine, glutamate and it as a component of parenteral nutrition solutions. !
ammonia w e r e l.lYO, 0 . 6 % a n d o.s~o, lle use of soluble and stable glutamine containing
respectively. ‘Ihe corresponding values for ittter- dipeptides, which are readdy hydrolyses within I
batch variation were L7~0, 0.8% and 0.7%.
I
Measurement of these mctabolites in duplicate
samples gave virtually identical results, and there-
I
fore, only the mean rmtlts are given below.
Rates of glutamine degradation calculated by
the two methods agreed closely with each other I
cable 2) because, as expected (7), ammonia
appeared in the solution at an approximately I
equimolar rate as the 10ss of glutaminc @lg. 2).
The degradation rate of glutamirte was highest I
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 t
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 188- I
938kcal/1) at ~-24eC the degradation rate ranged
from 0.10-O.20%/day, the lowcat degradation rate I
corresponding to the highest dextrose conecntm-
tion. In dextrose 15% w/v (563keaM) the rate of
degradation W& -0.15%/day (F’ii. 1). Tbcrdorc, TMENMY8
the presence of additional cottsdtuents in ‘IPN
solutions (Table 1) rxtbancxa gfutamfne degra-
dation (Table 2). - .
The ir.rW concentrations of ammonia in tbe
amino-add containing solutions were less than 0.
0.25mmoltl and reutaincddosc tothisvaltteintbc
oontrd samples or those to which gMamate or. I
-.
1

1.
r- .
.

CLINICAL NUtR~ON 197


—_
the body to yield free amino-acids, provides one between –2&’C and -80”IC (this work and (7,8) ).
\vaY Of achieving this aim (6). Another, more In addition glutaminc dots not appear to affect the
economic oplion, is (o administer free glutamine, stability or size of the lipid par-ticks in ‘all in one
but (his option depends on the stabili[y and mixlure’ (8).
possible toxicity of ghs:amine and its degradation It should be emphasised that the use of gluta-
products. mine in TPN solutions in clinical practi~ shouId
Since heating for even short periods of time may take into account not only the stabibty of gluta-
cause substantial degradation of glulaminc (3, 8), mine (and formation of degradation products) but
heat s~crilisation was avoided in this study. Instead also the possible toxiaty effeus of such infusions,
(he glutamine solution was aseptidly prepared which might vary in different circurrtstancts. In
and filtered through a 0.2@ filter prior to mixing one recent study in which glutamine ~ntaining
it with the other nutrients. solutions were administered in healthy subjects
In this study there was close agreement between (17), no toxicity effects were identified and no
the rate of loss of ghrtamine and the rate of significant measurements in ammonia eOneerrtra-
appearanw of ammonia, which increases ~nfi- tions were noted.
dence in the results. The formation of ammonia The inaase in ammonia concentration in TPN
occurs irrespective of whether ghrtamine degrades solutions kept at room temperature (0.5 mmol/fJ
to glutamate or pyroglutamate. Since no gluta- day in solutions containing about 70mmol gluta-
mate was formed i( is presumed that glutamine mine/L) is small and not likely to be an impottant
degrades quantitatively to pyroglutamate. clinical problem: The body handles up to about 1
The rate of glutamine degradation in typical mole of ammonia per day (14gN), which is used to
parenteral nutrition solutions (0.8%/day at room form urea. Furthermore, administration of an oral
temperature, or 0,1-0. 15%lday at 4“C) was found bolus dose of about 7g (-131 mmol) ammonium
to be slower than that reported in several other chloride (i.e. O.l~g in a 70kg man), which is used
solutions (3, 4, 5) e.g. in buffers maintained at clinically as a diagnostic test for renal tubular
similar pH and temperature as the parenteral acidosis, provides 20-30-fold more ammonia than
solutions. The rate of glutamine degradation in the a TPN solution containing a total of as muclr as
commonly used intravenous solutions is suffi- 5mmol ammonia. Although the latter delivers
ciently slow to consider the possible efinkal use of ammonia dkectly into the systemic areulation, it is
such solutions as a Viabie option (akhough the administered very slowly (frequently over 24 h -
degradation of g!utamine in atypical TPN solu- cf. bolus dose of ammonium chloride).
tions incfuding those with unusual mineral eoneus- Alleged toxiaty of pyroglutarnic aad (also
trations requires investigation). known as S+xoproline, 2-pyrroIidone-5ux-box-
There are at least four ways in which W:s option ylic sad) requires further investigation, but it is
may be achieved. One is to prepare a fresh unlikely to cause symptoms if given in small
glutamine solution and mix it with other nutrients amounts. Tltis is pattfy because tissues are
on the day of administration. This reduces to a noimally exposed to small concentrations of pyro-
minimum the time over which glutamine can glutamic aad (18), (it is also a nonmal constituent
degrade. Serxmd, since the degradation of gluta- of mammalian proteit@olypeptides, and an inter-
mine at 4°C is several-fold less than at room mediate in the gamma-glutarnyl cycle (19,20), and
temperature, storage of such solutions at 4*C is partly because of reamt studies in normal subjeus
demonstrably associated with the 10SS of only involving administration of ‘IPN solutions contain-
about 2°A gh.rtamine over a petiod of 14 days. ing ghttarnirre have not been associated with
l%ird, it may be possible to prepare, store rtnrYor detectable toxic effects (17). Furthermore protein
administer glutarrtitre solutions containing hydrolysatcs sueb as ‘Arninosol’ (a tztsein hydroly-
dextrose alone, which S1OWS glutatnirte degra- sate), which was at one time used routinely in
dation even further (Eg. 1, Table 1). Fourth, it ‘lTN, mntained substantial amounts of pyrogluta-
may be possible to freeze a solution of gltttatttine in ntic aad (4% of total N, eorrcsporrdmg to 34mntoI
water, dextrose, or TPN solution (e.g. -2fPC - pyro$utamic acid per 12g N21]). @in, toxiaty
-WC) and thaw it for in!kion or for mixing with effects due to pyroglutantic acidlor ammonia west
other nutrien& on the day of requirement. Tlte apprcntly not idend.lied.
evidence suggests that over a period of at kast 2-4 In sumtmuy this study suggests that it should be
weeks there is minimal or undeteuable degra- possible to prepare, store and administer gluta-
dation of glutantine in intravenous solutions storqd tnitte in parentera! nutrition solutions, with little

I JUN 10 19%9

y5
. . . ..— ._ .._ -.. —-

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


— dcgradative loss, but administration of such solu- liU (Ed). ifcthods of enzymatic anakysk Nc~ York.
tions in clinical practice requires further evalu- Imndon. Academic Press (4): 1704-17f)S
ation of [heir benefits and possible toxicity.
II Klimbcrg V S, Sa[loum R Me fbspx MCI al 1~. Oral
glulaminc accelcraws healing of the small inlcs!ine and
E
improves ouwomc after whole abdominal radiation.
Archives of Surgery 12S: 104&1045
E
Referent=
12 RcIuer L J. Wicc B M, Kcnnell D 1979. Evidcncc that
glut amine. not sugar, is the major energy sour= for
r
cultured Hela AIS. Journal of Biofogiol ascmistry – –.
1. Wilmore D W 1990 The safety and efticacy of glulaminc 2.54(8): 2669-2676
in humans. (Proceedings of the second international 13 Newsholme E A. Newsholme P, Gxri R 1988. The role ‘_ T
workshop cm glutaminc metabolism, Stockholm, of [he awic ● cid cycfe in CCJIS of the immune WSICM ad. g s
Scpwmbcr 1989) CfinicA Nutrition 9: 3S iu importance in acpsis trauma snd bucws. Biological ‘
2. Souba W W, Smith R J, Wilmorc D W 1985. Review: SocicIy Symposia S4: 14>161 <
c
Glummine metabolism by Ibc inms[inal traa. Journal of 14. First P, A!bcrs S, Stehle P 1989. Evidcncc for a F
Parenmral and EmtemI Nutrition 9(5): 608417 nutritional need for glu:amine in catabolic pat”~ncs. = -
3. Shih F F 198S Analysis of glu[amine. ghamic mid ● nd Kidney Imernationat 36(27): 5287-S292
pyro8t”lamic acid in proIcin hydrol~t~ by f%h-. J5. Gxosimo E, Williams P E. Radoscvidr P M et af 1986.
performance liquid chromatography. Journal of “. Role of glu[aminc in ● dapwiona in nitrogcm metablixm I
Clu-oma[ography 322 24S-256 during fassing. Asrwican Journal of Pbysiofogy 2S0:
4. Twardzik D R, Peterkofsky A 1972. Glutamic ● cid as a E622-E62a
prccurwr to N-terminal pyroghnamic acid in cnmssc 16. Kovaccvic Z, McGivan 1 D 1983. Pbyaiologii rcvi.aw
plasma~oma protein. Proceedings of the National Mitochondial metabolism of gfutamine and glutamate
A~dcmy of sciences of the USA 69(l): 274-277 and irs physiological aigrsificati”63 )2): S47~S -—
5. Dickinson J C. R=nblum H, Hamilton P B 196.5. Ion 17. Lo*e D K, Benfetl K, Smith R J, Jacobs DO. Murawski
exchange chromatography of the free amino aads in the B. Ziegler T R, Wilmore D W 1990. S&ty of glu{amine-
plaama of the newborn infant. Pcdiatrks 36(1): 2-13 enriched paremeral nutrient xhtiorss in humans.
6. Atbcrs S, Werncmxan J. S1ehk Pet ● l 1989. Availability American Journal of CXnicat Nutrition S2 1101-1 J06
of amino acids suppfkd by cons!am intravenous infusion 18. Abraham G N, Podell D N 1981. Pyroglutamic atid:
of synthetic dipcp!idcs in healthy man. Clinical Science eon-metabolic formation. function in Pmwint and
76643-648 pcptidca, and characteristics of the .xszynscx affecting iss
7. Khan K. Efia M 1991. Faaors ● ffcaing tkxc stabitity of removaf. Molecular aad Cd Biochcmkw M 181-190
L-dutamine in solution. Submitted 19. Mcis[er A. Atsdccxon M E 1983. Glutarhione.
8. M~Ekoy B. Hardy G ● nd Wtgginx D 1991. Tlxe atabdity Biochemistry 52711-776
of L~lutamine in A1l-in-Ooe TPN mixwrcs. Submitted 20. Mcister A 1985. Metabolism and functions of
9. Lund P 1974. L-Glumntitse: dewsninariott with ghnathione. [IX Oacha R S, Hanxsn R W, Hatt J (cd)
*J$.. . . . . ,.:-. , .:. .:.::,: glutaminasc and gluramate dchydrog~. Im Mctabofic rcgufasions. Amstcrdans: Efacvier S&na
Bergmeycr HU (Ed). Medvxfs of hzymatic Analysis; Publisher: 161-170
L. New York, London. Academic Press (4): 17)%1722 21. Aq\ti S, Wredind A 19S7. Pyrrofi&ne artxo+u ● cid
10. Berm E, Bcrguncyer H U 1974. L-lusamate, UV assay in enzymatic asein bydrofysatca. Acts Pbyaiologica
with glutamate dchydrogenaac and NAD. XIX Bcrgmcycr Scandinavia 39: 147-15/
.
Submission &te: 4 Aprit 1991; Actzpted: 5 May 1991
1

.- —.. .._

,.
,
.
.


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