EDITORIAL COMMENTS 233

(3) Amount and type of eicosanoids produced and released; REFERENCES

(4) Production of lymphokines necessary for lymphocyte 1. Manner T, Katz DP, Skeie B, Newsholme E, Kirvela 0, Askanazi
proliferation and differentiation; J. Fish oils and the lung. Clin Nutr 1993; 12:131
(5) Inhibition of blood clotting through suppression of 2. Ayala A, Chaudry IH. Dietary n-3 polyunsaturated fatty acid modu-
thromboxane AZ synthesis; lation of immune cell function before or after trauma. Nutrition
(6) Reduction of microvascular permeability; 1995;ll:l
( 7) Anti-inflammatory effect. 3. Kinsella JE, Lokesh B, Broughton S, Whelan J. Dietary polyunsatu-
rated fatty acids and eicosanoids: potential effects on the modula-
Strategy focused on the positive effects of n-3 PUFA on ARDS tion of inflammatory and immune cells: an overview. Nutrition
is promising, but the speed of n-3 PUFA incorporation into plasma 1990;6:24
4. Cooper AL, Gibbons L, Horan MA, Little RA, Rothwell NJ. Effect
phospholipids and various tissues may limit the therapeutic value
of dietary fish oil supplementation on fever and cytokine production
of n-3 PUFA.” Simoens et al.” investigated in dogs the effect of
in human volunteers. Clin Nutr 1993; 12:321
four different lipid emulsions on the fatty acid composition of 5. Gorlin R. The biological actions and potential clinical significance
various tissues. This study shows clearly that intravenously admin- of dietary w-3 fatty acids. Arch Intern Med 1988; 148:2043
istered n-3 PUFA are rapidly incorporated into membrane phos- 6. Sprague RS, Stephenson AH, Dahms TE, Lonigro AJ. Proposed
pholipids, resulting in an increased n-3 PUFA/n-6 PUFA ratio. role for leukotrienes in the pathophysiology of multiple systems
Parenteral administration could speed up the therapeutic effect of organ failure. Crit Care Clin 1989;5:3 15
n-3 PUFA in ARDS treatment, but corroboration still awaits more 7. Lewis RA, Austen KF. The biologically active leukottienes. Bio-
extensive clinical trials. synthesis, metabolism, receptors, functions and pharmacology. J
Clin Invest 1984;73:889
8. Klein J, Zijlstra FJ, Vincent JE, et al. Cellular and eicosanoid
composition of bronchoalveolar lavage fluid in endotoxin protection
against pulmonary oxygen toxicity. Crit Care Med 1989; 17:247
ZDENEK ZADAK, MD, PHD 9. Blank MC, Bilo HJ, Nauta JJ, et al. Dose-response effects of fish-
ZUZANA CERVINKOVA, MD, PHD oil supplementation in healthy volunteers. J Clin Nutr 1990; 52: 120
Metabolic and Gerontological Clinic 10. Simoens CH, Richelle M, Rossle C, Derluyn M, Deckelbaum RJ,
University Hospital Carpentier VA. Manipulation of tissue fatty acid profile by intrave-
nous lipids in dogs. Clin Nutr 1995; 14:177
Hradec Kralove
Czech Renublic PI1 SO899-9007(96)00408-X

Potential of Ketone Body Esters for

Parenteral and Oral Nutrition
The report by Birkhahn et al.’ in this issue of Nutrition exogenous ketone bodies.3 There is evidence that ketone bod-
describes the synthesis and initial biological testing of the ies are good substrates, not only for peripheral tissues but
monoester and triester of glycerol and DL-3-hydroxybutyrate. also for the developing brain’ and the lactating mammary
These compounds, which are nonionized, sodium-free pre- gland.’ For reasons that are not understood, the capacity
cursors of DL-3-hydroxybutyrate, are potential substrates for of peripheral tissues to utilize physiologic ketone bodies is
intravenous nutrition. decreased in diabetes. However, this is probably the only
Because of the life-threatening aspects of diabetic ketoac- real case of intolerance to ketone bodies.
idosis, ketone bodies are most often viewed as harmful com- Although ketone bodies are good fuels for peripheral tis-
pounds: their presence in body fluids is to be minimized. In sues, they are also strong acids that cannot be administered
fact, physiologic ketone bodies, i.e., acetoacetate and D-3- in the free form. Infusing ketone bodies as sodium salts
hydroxybutyrate, are water-soluble forms of fat that are very would result in a dangerous sodium overload. In addition,
well used by peripheral tissues, except in diabetes.’ Also, acetoacetic acid and its salt are unstable, decomposing spon-
nondiabetic animals can be administered a very large fraction taneously to acetone and CO2 .8 This nonenzymatic decompo-
of their caloric requirement as ketone bodies without marked sition is catalyzed by free amino groups in proteins.
accumulation in body fluids and without acidosis.3.4 Even It has been proposed’ that D-3-hydroxybutyric acid be
pigs, which have a congenital defect in HMG-CoA synthase administered as a mixture of basic amino acid salts (with
(a key liver mitochondrial enzyme involved in ketone body arginine and lysine). However, the administration of a large
production5), are able to rapidly metabolize large doses of amount of these salts might interfere with the transport of
234
other amino acids across the blood-brain barrier. In addition,
it is probably not advisable to administer large amounts of
arginine or lysine to patients suffering from hepatic and/or
renal pathologies.
The first acceptable form for administering large amounts of
ketone bodies was presented by Birkhahn et al.,“’ who described
the synthesis of the monoester of glycerol and acetoacetate, re-
ferred to as monoacetoacetin. Esterification of acetoacetic acid
ensures its stability. Monoacetoacetin, which is water soluble,
is hydrolyzed by plasma, tissue, and digestive esterases.” This
hydrolysis yields glycerol, which is used by the liver and kidney
for gluconeogenesis. It also yields acetoacetic acid, which is imme-
diately neutralized to acetoacetate, a physiologic fuel. Monoace-
toacetin can be safely infused in normal and burned rats and exerts
a nitrogen-sparing effect in burned rats.‘2.‘3
To increase the caloric density per osmol of monoacetoacetin,
Birkhahn et al.’ synthesized the triester of glycerol and acetoace-
tate. Since this triester is not very soluble in water, they sought
to increase its solubility and caloric density by reducing it with
hydrogen to the triester of glycerol and DL-3-hydroxybutyrate. The
equivalent monoester was also synthesized. The hydrolysis of
these esters yields glycerol and racemic DL-3-hydroxybutyrate.
The D-moiety (also called R-3-hydroxybutyrate) is the physiologic
ketone body that equilibrates with acetoacetate via mitochondrial
D-3-hydroxybutyrate dehydrogenase. The L-moiety is not a physi-
ologic compound; however as a CoA ester, it is one of the final
intermediates of fatty acid P-oxidation. L-3-hydroxybutyrate (also
called S-3-hydroxybutyrate) is well used by the livert4 and periph-
eral tissues.‘” Although it is “nonphysiologic,” L-3-hy-
droxybutyrate is metabolized to the same intermediates and end-
products as D-3_hydroxybutyrate, i.e., acetyl-CoA, CO,, and lipids.
Metabolism of L-3-hydroxybutyrate starts by mitochondrial activa-
tion to L-3-hydroxybutyryl-CoA (the intermediate of fatty acid /?-
oxidation), which is then converted to acetoacetyl-CoA and then
to acetyl-CoA.‘4
Birkhahn et al.’ infused rats for 7 d with the mono- or triglycer-
ide of m_-3-hydroxybutyrate at one-half of their caloric require-
ment. Control rats were infused with glucose or saline. No obvious
toxicity from the ketone body esters was detected after 7 d. Isoca-
loric amounts of ketone body esters and of glucose had similar
nitrogen-sparing effects compared with saline infusion. Thus,
these esters show good potential for parenteral nutrition.
The preparation of a nonionized, water-soluble form of ketone
bodies has also b&en sought by other groups. Desrochers et alI5
synthesized the mono- and diester of m-3-butanediol and either
acetoacetate or m-3-hydroxybutyrate. These compounds, after
metabolism of the diol moiety in the liver, are converted to a
mixture of D- and L-3-hydroxybutyrate. The 1,3-butanediol-ketone
body esters can be infused to anesthesized, hypoglycemic dogs at
up to 90% of their caloric requirements without marked ketosis.4
They also partially alleviate the symptoms of insulin-induced hy-
poglycemia in conscious dogsI Leverve et al. (personal commu-
nication) synthesized the triester of glycerol and D-3-hydroxybu-
tyrate. To ensure the physiologic stereochemistry of the hydroxy-
butyrate moiety, they developed an elegant but complicated (and
probably costly) synthesis procedure. One has to balance the phys-
iologic character of all hydrolysis products of glycerol-D-3-
hydroxybutyrate with the potentially high cost of its production.
In contrast, the esters that yield racemic DL-3-hydroxybutyrate ‘J’
can be made in large amounts at a relatively low cost.
The above discussion concentrates on esters that could be used
for intravenous feeding. One should also take into account that
some of these esters, including those that are poorly water soluble,
could be used for enteral feeding, either orally or via nasogastric
tube. A combination of intravenous and nasogastric administration
EDITORIAL COMMENTS
of these esters could be useful for the nutrition of trauma and burn
patients. These conditions are associated with very low ketosis,
presumably because of the hypermetabolic status of the liver.
Under these conditions, the citric acid cycle in the liver can accom-
modate most of the carbon processed through fatty acid P-oxida-
tion, resulting in minimal ketogenesis. In the final analysis, keto-
genesis represents simply a spillover of carbon that cannot be
processed by the liver citric acid cycle. In trauma and bum patients,
whose peripheral tissues are insulin resistant, the ketone body
esters would provide to peripheral tissues a water-soluble form of
energy that does not require insulin for its metabolism.
Another potential use of ketone body esters administered
enterally is the treatment of intractable epilepsy by therapeu-
tic ketosis.‘7,‘8 Many children whose epileptic seizures are
not controlled by a combination of drugs are treated by the
so-called “ketogenic diet,” a high-fat diet. This diet is de-
signed to induce and maintain a constant degree of ketosis,
which, in some cases and for unknown reasons, inhibits sei-
zure activity. Since the presence of carbohydrates in the diet
inhibits ketogenesis from long-chain fatty acids, the keto-
genie diet contains very few, if any, carbohydrates. For this
reason, it is often not well accepted by the patients. We
hypothesize that some of the ketone body esters could be
used in epileptic children together with an almost normal
diet containing carbohydrates. The production of ketone bod-
ies from these esters occurs by either simple hydrolysis or
via liver alcohol dehydrogenase. These processes are not
inhibited by carbohydrates. The inclusion of these ketone
body esters in the children’s diet may facilitate the dietary
management of their epileptic condition.
The mechanisms by which ketone bodies inhibit seizure activ-
ity are not understood. It is not clear whether the active agent is
acetoacetate, D-3-hydroxybutyrate, or acetone (resulting from the
spontaneous decomposition of acetoacetate). It is therefore not
(clear whether the nutritional treatment of epileptic seizures would
be optimized by ketone body esters that yield a mostly reduced
form of ketone bodies (glycerol-tri-m-3-hydroxybutyrate, glyc-
erol-tri-D-3-hydroxybutyrate, or DL-1,3-butanediol-DL-3-hydroxy-
butyrate), a mostly oxidized form of ketone bodies (glycerol
triacetoacetate), or a mixture of reduced and oxidized ketone
bodies (DL-1,3-butanediol diacetoacetate, or a mixture of the
above esters). The availability of the various forms of ketone
body esters should allow this question to be resolved in properly
controlled clinical trials.
HENRI BRUNENGRABER, MD, PHD
Department of Nutrition
Case Western Reserve University
Cleveland, OH 44106
REFERENCES
1. Birkhahn RH, McCombs C, Clemens R, Hubbs J. Potential of
the monoglyceride and triglyceride of m-3-hydroxybutyrate for
parenteral nutrition: synthesis and preliminary biological testing in
the rat. Nutrition 1997;13:213
2. Balasse EO, F&y F. Ketone body production and disposal: effects
of fasting, diabetes, and exercise. Diabetes Metab 1989;Rev. 5:247
3. Desrochers S, Dubreuil P, Brunet J, et al. Metabolism of R,S-
1,3-butanediol acetoacetate esters, potential parenteral and enteral
nutrients in conscious pigs. Am J Physiol 1995;268:E660
4. Ciraolo ST, Previs SF, Agarwal KC, et al. Model of extreme hypo-
glycemia in dogs made ketotic with (R,S ) - 1,3-butanediol acetoace-
tate esters. Am J Physiol 1995;269 (Endocrinol Metab 32):E67
5. DuCe PH, Pegorier JP, Quant PA, Herbin C, Kohl C, Guard J.
Hepatic ketogenesis in newborn pigs is limited by low mitochon-
EDITORIAL COMMENTS
drial 3-hydroxy-3-methylglutaryl-CoA synthase activity. Biochem
J 1994;298:207
Pate1 MS, Owen OE. Development and regulation of lipid synthesis
from ketone bodies in the rat brain. J Neurochem 1977;28: 109
Buckley BM, Williamson DH. Acetoacetyl-CoA synthetase; a lipo-
genie enzyme in rat tissues. FEBS Lett 1975;60:7
Pederson KJ. The ketonic decomposition of beta-carboxylic acids.
J Am Chem Sot 1929;51:2098
Beylot M, Chassard D, Chambrier C, et al. Metabolic effects of
D-P-hydroxybutyrate infusion in septic patients: inhibition of lipol-
ysis and glucose production, but not of leucine oxidation. Crit Care
Med 1994;22:1091
10. Birkhahn RH, Border JR. Intravenous feeding of the rat with short-
chain fatty acid esters. II. Monoacetoacetin. Am J Clin Nutr
1978;31:436
11. Sun Q. Birkhan R. Monoacetoacetin hydrolysis in the rat (abstract).
FASEB J 1993;7:A413
12. Birkhahn RH, McMenamy RH, Border JR. Monoglyceryl acetoace-
Inherent Plant Toxins
Inherent plant toxins are naturaUy occurring compounds associ-
ated with adverse health effects in laboratory animals, livestock,
or man. Some of these compounds in food plants also show
protective health effects in mammals. A well-known example of
this is the group of glucosinolates found in Brussicaceue, such as
cabbage, Brussels sprout, and rapeseed. Glucosinolates can be
hydrolized to vinyloxazolidones, thio-, and isothiocyanates, which
cause toxic effects in mammals (hepatoxicity, thyrotoxicity, and
mutagenicity). On the other hand, protection against genotoxic
and carcinogenic effects of other compounds were found to be
associated with certain (indole) glucosinolates.
The function of inherent plant toxins has been the subject
of much speculation. One of the functions ascribed to them is
acting as a defense mechanism against attack by herbivores
(e.g., insects) and pathogens. There is an extensive literature
demonstrating the deterrent and/or toxic nature of these com-
pounds for such organisms (phytoalexins). Some specific ex-
amples suggest that a protective role against insects could be
their primary function, but in most cases one can only speculate
on which of the many possible evolutionary pressures have
played a major role in selecting for high levels of biologically
active compounds. For flavonoids and glucosinolates, physio-
logic roles in plants have been established, e.g., color and hor-
monal regulation. In the scientific field of plant-breeding tech-
nology, much is still unknown about the function of plant tox-
ins. Because of the speculation, some experts in plant breeding
and selection refer to these compounds as secondary plant me-
tabolites. It is important to realize that changes in levels of plant
toxins may have potential consequences for other properties of
the plant product. Likewise, modification of plant properties
may lead to toxicologic implications. Since they are biologi-
235
tate: a ketone body-carbohydrate substrate for parenteral feeding
of the rat. J Nutr 1979; 109: 1168
13. Maiz A, Moldawer LL, Bistrian BR, Birkhahn RH, Long CL,
Blackbum GL. Monoacetoacetin and protein metabolism during
parenteral nutrition in burned rats. Biochem J 1985;226:43
14. Lincoln BC, Des Rosiers C, Brunengraber H. Metabolism of (S)-
3-hydroxybutyrate in the perfused rat liver. Arch Biochem Biophys
1987;259:149
15. Desrochers S, Quinze K, Dugas K, et al. (R,S)-1,3-butanediol
acetoacetate esters, potential alternates to lipid emulsions for total
parenteral nutrition. J Nutr Biochem 1995;6:111
16. Singh JV, Hazey JW, Chandar G, Bomont C, David F, Brunen-
graber H. Model of ketotic hypoglycemia and hypolactatemia in
conscious dogs (abstract 1358). FASEB J 1996; lO:A236
17. Kinsman SL, Freeman JM. Efficacy of the ketogenic diet for intrac-
table seizure disorders: 58 cases. Epilepsy 1992; 33: 1132
18. Rothner AD. The management of intractable epilepsy in children.
Int Pediatr 199 1;6:261
PI1 SO899-9007(96)00409- 1
tally active compounds, we need to know which plant toxins
occur in plant genera, species, strains, or varieties and what
their toxic effects are for mammals including humans.
For many years, plant toxins remained a somewhat neglected
area in scientific circles. In the last decade, a turn in scientific
attitude has become perceptible. Internationally, the concern
about the possible risk of inherent plant toxins interfering with
human health is increasing. This is reflected by actions taken
by international bodies such as the European Union, World
Health Organization, Food and Agricultural Organization, In-
ternational Union of Pure and Applied Chemistry, the Interna-
tional Life Sciences Institute, and the Nordic Working Group
on Food Toxicology of the Nordic Council of Ministers. These
actions include exploration of data needed for risk assessment,
stimulation of research to provide these data, and research dedi-
cated to the question of what type of regulation is necessary
and how to deal with the safety evaluation of inherent plant
toxins. In general, data on toxicologic properties and the occur-
rence of inherent plant toxins, essential for safety assessment,
are limited. Nevertheless, some data are currently available for
certain groups of plant components, e.g., glycoalkaloids and
furocoumarins. For these toxins, the actual intake levels are
very close to the adverse-effect levels for humans. Conse-
quently, there is a very small margin of safety. Comparing
inherent plant toxins with other categories of compounds such
as food additives, pesticides, and even environmental contami-
nants makes it obvious that essential gaps in our knowledge
exist when assessing the safety of plant toxins.
The application of new food technology, new breeding and
selection methods, and modem molecular genetic techniques
reinforces our need for toxicologic knowledge of inherent plant