Urinary Amino Acids

Clinical & Interpretive Guide

This Urinary Amino Acids Clinical & Interpretive Guide is the copyright of Analytical Reference Laboratories Pty Ltd (ACN 099 349 005). Except as permitted under the Copyright Act 1968 (Cth), no part of this publication may in any form or by any means or process (electrical, mechanical, microcopying, photocopying, recording or otherwise) be reproduced, stored in a retrieval system or transmitted without the specific written permission of Analytical Reference Laboratories Pty Ltd.

Urinary Amino Acids Clinical Guide

USES OF URINARY AMINO ACID ANALYSIS

Urinary Amino Acid analysis should be considered whenever a thorough nutritional and metabolic assessment of an individual is required. In addition to family history, a variety of presenting conditions may indicate disordered amino acid metabolism, including chronic fatigue, frequent headaches, chronic digestive dysfunction, intolerances to foods and chemicals, chronic inflammation, depression, learning disabilities, malnutrition, neurological disorders or symptoms of degenerative disease.

Urinary Amino Acid measurement was once limited to the detection of inborn errors of metabolism, such as phenylketonuria (PKU). Many practitioners therefore are not aware of the vast amount of clinical information now available to them through amino acids analysis. With advancements in amino acid measurement, more than 40 analytes can now be assessed, providing information on a wide spectrum of metabolic and nutritional disorders as detailed below. Dietary Protein aDequacy Since the essential amino acids must be derived from the diet, low levels of essential and semi-essential amino acids can indicate dietary inadequacy. Catabolism of body protein may contribute relatively small amounts of essential amino acids to blood & urine. Gastrointestinal Dysfunction Urinary Amino Acids analysis can indicate various aspects of gastrointestinal dysfunction. Measured levels in the urine of the peptides anserine and carnoserine may result from either excess amounts in the diet or deficient peptidase activity in the gut; subnormal levels of nutritionally essential amino acids together with elevated levels of these peptides indicates incomplete digestive breakdown of protein.1 Altered intestinal permeability is commonly seen in such individuals. Amino Acid Metabolism

Disorders Associated with Amino Acid Imbalances

Alcoholism Ammonia toxicity Ataxia Behavioural disorders Cardiovascular disease Chemical intolerances Depression Dermatitis Detoxification impairments Excessive inflammation Hyperlipidaemias Hypertension Hypotonia Inflammatory disorders Insomnia Mental retardation Myopathies Neural tube defects Neurological dysfunction Ocular disorders Oxidative stress Vitamin and mineral deficiencies

USES OF URINARY AMINO ACID ANALYSIS CONtINUED inflammation Three amino acids are critical to antioxidant, anti-inflammatory functions: cysteine, glutathione and taurine. Cysteine is considered to be a rate-limiting factor in the synthesis of the tripeptide, glutathione (GSH). Functioning as a reducing agent to maintain other molecules in the reduced form, GSH is thought to be important during the inflammatory response, influencing the production of phagocytes. Taurine acts as a specific scavenger; when it is low the inflammatory response is enhanced and aldehydes may form, commonly resulting in aldehyde sensitivities and oxidative stress reactions. Detoxification imPairment Many amino acids are involved in the bodys detoxification of endogenous and exogenous compounds. Included in this group are methionine, cysteine, glutathione, glutamine, glycine, alanine, aspartic acid and taurine. Deficiencies in any of these may result in impaired Phase II conjugation reactions, an accumulation of potentially toxic intermediates and subsequent tissue damage. Subnormal urine levels of these amino acids can imply impaired detoxification functions which can provoke neurological diseases, chemical intolerances and chronic fatigue.2 carDiovascular Disease Impaired methionine metabolism, particularly the condition known as homocystinuria, has been associated with cardiovascular disease3 and stroke4. Homocysteine is an intermediate in the catabolism of methionine and can be either remethylated into methionine or broken down to cysteine. The accumulation of homocysteine may contribute to oxidative damage of LDL cholesterol and the vascular endothelium. Vitamins B6, B12, folic acid and betaine and serine, are all essential to methionine catabolism. Therefore, deficiencies of any of these nutrients may aggravate the condition. neuroloGical Dysfunction Amino acids such as tryptophan, phenylalanine and methionine may influence pain threshold, mood and sleep patterns. Tryptophan is the precursor of serotonin, which influences sleep patterns and mood. Phenylalanine converts to the neurotransmitter tyrosine and to the adrenal catecholamine, noradrenalin, both of which influence mood and behaviour. Consequences of Amino Acid Imbalances Low tyrosine/phenylalanine abnormal levels of mood regulating dopamine & catecholamines urine versus Plasma The body fluids that are most commonly assessed for amino acid content are urine from a first morning void and plasma following an overnight fast. There are several advantages of urine versus plasma analysis. Urine analysis reveals more distinctive patterns related to problems in enzymatic activity, nutrient cofactor adequacy and transport. Urine is also not subject to the circadian rhythm variation in amino acids that is present in blood, which means that excesses or deficiencies over a period of time can be more easily assessed. Many conditions of amino acid wasting, such as cystinuria, are therefore identifiable in urine samples. Due to renal conversion of amino acids, urine levels typically drop before plasma levels. For these reasons, urine is more likely to reveal marginal deficiencies. Only severe deficiencies will result in low values on both tests. Possible reasons for selecting plasma amino acid analysis over urine amino acid analysis include severe malnutrition, anorexia, hematuria conditions (including menstruation) and rheumatoid arthritis, where the common pattern of low histidine only shows in a plasma sample. Blood plasma analysis is also recommended if poor renal clearance or renal failure is known beforehand. In addition, in urinary wasting conditions or in nephrotic syndromes, the plasma levels are indicative of status while the urine levels serve to confirm the diagnosis. A comprehensive assessment of the overall metabolic state would include both urine and plasma analysis, measured in the same time period, particularly for patients with degenerative disease or with severe intolerances to foods or environmental substances. Urine Amino Acid analysis is the preferred option if a choice has to be made. conclusion Amino acids form the basic constituents of every living cell and participate in numerous biochemical reactions in the body. Significant progress in Amino Acid research provides practitioners with a wealth of information on amino acid imbalances and related symptomatology. Results can be utilised in the design of specific replacement therapy, aimed at restoring balance where it is needed. Urinary Amino Acids analysis should always be considered whenever a thorough nutritional assessment is required. references
1. Scriver CR, Gibson K. Disorders of Beta and Gamma Amino Acids in Free and Peptide-linked forms. In: Scriver C, Beaudet A, Sly W, Valle E. editors. The metabolic and molecular bases of inherited disease. Vol 1. 7th Ed. New York: McGraw-Hill Book Company, 1995:1349-1370 2. Timbrell JA. Toxic responses to foreign compounds. In: Principals of biochemical toxiology, 2nd ed. London and Bristol, PA: Taylor & Francis Inc, 1994:221-232 3. Boushey C, Beresford S, Omnen G, Motulsky A. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease. Possible benefits of increasing folic acid intakes. JAMA 1995; 274(13); 1049-1057 4. Brattstrom L, Lindgren A, Israelsson B, Malinow MR, Norrving B, Upson B, et al. Hyperhomocysteinaemia in stroke: prevalence, cause and relationships to type of stroke and stroke risk factors. European Journal of Clinical Investigation 1992: 22(3):214-221

Low taurine & high homocysteine

cardiovascular problems

Low methionine, glycine & glutathione

poor detoxification

5. Kinscherf R, Fischbach T, Mihm S, Roth S, Hohenhaus-Sievert E, Weiss C, Edler L, Brtsch P, Drge W. Effect of glutathione depletion and oral N-acetyl-cysteine treatment on CD4+ and CD8+ cells. FASEB J 1994;8(6): 448-451

Urinary Amino Acids Interpretive Guide

NUtRItIONALLY ESSENtIAL AND SEMI-ESSENtIAL AMINO ACIDS

EssEntial amino acid aRgininE Used in the synthesis of GABA and creatine, and can increase the secretion of insulin and growth hormone. Arginine is also a precursor in the synthesis of spermine and spermidine, and has been used to treat oligospermia. HistidinE Precursor to histamine; stimulates gastric acid and required for haemoglobin production. isolEucinE Metabolised to succinyl-CoA. Isoleucine is important in energy production. lEucinE In its metabolised form this substance can be used in the synthesis of mevalonic acid, which in turn, is a precursor to cholesterol, steroid hormones and bile acids. lysinE Involved in elastin cross-linking and the synthesis of carnitine which aids fat utilisation by muscles; also glucogenic. Used in the treatment of herpes simplex. mEtHioninE The synthesis of all proteins in humans begins with methionine. It is a precursor to cysteine and creatine. Creatine phosphate is an important energy source for muscles. Methionine is lipotropic and has an inotropic effect on heart muscle. Methionine will suppress free radical activity and can chelate toxic metals. Precursor to glutathione. PHEnylalaninE Precursor to tyrosine, which in turn is the precursor to adrenalin and noradrenalin. Phenylalanine stimulates the secretion of gastrin, which improves stomach motility and digestion.

low REsult Can reflect a low protein diet. Arginine is also poorly absorbed. Arginine is required for nitric oxide production therefore deficiencies may have substantial effects on cardiovascular and other body systems. Possibly low protein diet, or malabsorption if other AAs are low. May be associated with rheumatoid arthritis. Note: salicylates and steroids lower plasma histidine. A deficiency can cause hypoglycaemia, loss of muscle mass or inability to build muscle. If other BCAAs are low, supplement with niacin. Possible breakdown of skeletal muscle. Confirm with 3-methylhistidine. Low levels can occur with exercise, stress, starvation, burns, surgery, critical illness. Supplement with all BCAAs. Poor dietary intake or high intake of arginine. Low lysine can inhibit transanimation of AAs, collagen synthesis. If concurrent weakness or high triglycerides, supplement with lysine and carnitine.

HigH REsult Can point to a functional block in the urea cycle. Supplement with manganese to activate the enzyme arginase.

High protein intake. If 3-methyl-histidine is high, muscle protein breakdown is indicated. High Intake or incomplete metabolism. If other BCAAs are high, supplement with pyridoxal5-phosphate to improve metabolism. High intake or improper utilisation. Fasting can raise BCAA levels. High leucine can inhibit ureagenesis and stimulate insulin secretion. Check intake and supplement with pyridoxal-5phosphate to improve metabolism. Impaired metabolism of lysine. Supplement with Vitamin C, niacin, B5, B6 and Fe to improve utilisation of lysine.

Poor quality protein diet. Adverse effects on sulphur metabolism. Improve dietary methionine intake or supplement.

High dietary intake of methionine-rich protein or poor metabolism. If other sulphur-containing AAs are low, improve methionine utilisation by supplementing with cofactors Mg and B6.

Low levels can result in altered thyroid function and catecholamine deficits including symptoms of depression, cognitive disorders, memory loss, fatigue and autonomic dysfunction. Reduce trigger factors and supplement with phenylalanine. May increase risk of oxidative stress, fat maldigestion, high cholesterol, atherosclerosis, angina, arrhythmia and seizure disorders. Taurine is an important membrane stabiliser. As an essential component of bile, taurine aids in the digestion of fat-soluble vitamins. Supplement with taurine, cysteine and B6, even if dietary protein adequate. Note: females do not synthesise taurine as easily as males. May cause hypoglycaemic symptoms, particularly if glycine or serine is also low. Supplement with threonine and BCAAs. Correlated with depression, insomnia and schizophrenia. Supplement with 5-HTP which is one enzymatic step away from serotonin. Deficiency of valine or other BCAAs indicates potential muscle loss. If other essential AAs low, possibly low HCl. Supplement with BCAAs. Note: glutamine can be produced from the metabolism of valine. Possibly due to low arginine. As a source of regulatory polyamines, low levels can affect cellular metabolism.

High protein intake or block in the conversion of phenylalanine to tyrosine. Supplement with Fe and tyrosine (if low). Vitamin C and niacin are also required for conversion.

tauRinE An anti-oxidant which is synthesised in the liver from cysteine. Used in the production of bile and the emulsification and absorption of fats.

May be due to excessive inflammation or supplementation with other AAs.

tHREoninE Can be metabolised to pyruvic acid and used as an energy source. A component of all connective tissue proteins. tRyPtoPHan Precursor of serotonin, melatonin and niacin, and has been used in the treatment of depression and sleep disorders. ValinE Actively taken up into muscle tissue, transported to the liver and metabolised to produce succinylCoA, which is used in the Krebs cycle. oRnitHinE Synthesised from glutamic acid and is a precursor to arginine.

High dietary intake or insufficient metabolism of threonine. Supplement with Zn and B6.

Inadequate metabolism of tryptophan. Supplement with niacin and B6.

High dietary intake or B6 functional deficit. Supplement with B6 if other BCAAs high.

Possible metabolic block in urea cycle, causing excess ammonia burden. Confirm by checking for high glutamine, low glutamic acid.

DIEtARY PEPtIDE RELAtED MARkERS

maRkER ansERinE A dipeptide which functions as an antioxidant. caRnosinE A dipeptide composed of one molecule each of histidine and alanine.

HigH REsult High intake of poultry can contribute to elevated anserine. Zinc is required for the normal conversion to B-alanine and 1-Methylhistidine. Deficiency of the enzyme carnosinase or its cofactor, zinc. Carnosinase enzyme deficits result in neurological development problems and polyneuropathy. Elevated levels may indicate dietary overload of anserine-source foods, increased gut permeability & decreased activity of digestive enzymes in the small intestine. May or may not be symptomatology. May also indicate impaired methionine metabolism. Supplement B12, folate or DMG. May also inhibit carnosinase; supplement zinc. Potential bowel toxicity due to B-alanine production by intestinal bacteria and/or Candida albicans. Potential cause of food sensitivity reactions when combined with low taurine and high 3-Methylhistidine, carnosine and/or anserine, due to impaired renal tubular resorption. Supplement B6 to facilitate amine group transfer. Bowel detox, prebiotics and probiotics to address gut dysbiosis.

1-mEtHylHistidinE A component of anserine.

B-alaninE The rate-limiting precursor of carnosine; carnosine levels are limited by the amount of available beta-alanine. Supplementation with beta-alanine has been shown to increase the concentration of carnosine in muscles, decrease fatigue in athletes and increase total muscular work done.

NON-ESSENtIAL AMINO ACIDS

amino acid alaninE Important in the alanine-glucose cycle which facilitates muscle to derive energy from amino acids. asPaRaginE Increases utilisation of free fatty acid in muscles. asPaRtic acid Inhibits ammonia detoxification in the urea cycle. Can be converted to oxaloacetate using B6 and a-ketoglutaric acid (AKG) and thus enter the krebs cycle. cystEinE A sulphur-containing Amino Acid synthesised in the liver. Cysteine and cystine readily convert to one another and have almost identical functions within the body. Cysteine is an important component of the tripeptide glutathione and also Glucose Tolerance Factor (GTF). cystinE The oxidised form of cysteine. Cysteine and cystine readily convert to one another and have almost identical functions within the body. glutamic acid Precursor to glutamine, proline, ornithine and arginine, as well as glutathione and GABA. Glutamic acid is an excitatory neurotransmitter and can be neurotoxic, especially if B6 status is low. glutaminE Important energy source for the gastrointestinal tract and may stimulate growth hormone. glycinE Important in liver detoxification as part of the tripeptide glutathione. PRolinE Synthesised from glutamic acid. Important component of collagen. sERinE An intermediate in the biosynthesis of glycine. tyRosinE Synthesised from phenylalanine. Tyrosine is the precursor for adrenalin, noradrenalin, dopamine, thyroxine and melanin.

low REsult May indicate hypoglycaemic conditions due to use in gluconeogenesis. Supplement with alanine and BCAAs. Can reflect functional need for Mg in the conversion from aspartic acid. Supplement with Mg. Inhibits ammonia detoxification in the urea cycle. Can be converted to oxaloacetate using B6 and AKG and subsequently enter the krebs cycle. Low levels can reflect decreased cellular energy.

HigH REsult Possible inadequate cellular energy substrates. Check for hypoglycaemia or for exercise prior to urine collection. Chronic use of alanine for energy can result in muscle wasting. Supplement with BCAAs. Can indicate problems with purine and therefore protein synthesis. Seen in epilepsy and stroke. Mg and Zn may counteract high aspartic acid levels.

Possible dietary deficiency of methionine and/or cysteine.

Excessive dietary intake or impaired cysteine metabolism. Cysteine is a major component of tissue antioxidant mechanisms.

Possible dietary deficiency of methionine and/ or cystine. Low cystine can in turn impair taurine synthesis. Can suggest mild hyperammonemia, especially if high glutamine. Use low protein, high complex carbohydrate, B6, AKG and BCAAs to correct ammonia toxicity. Deficient intake or absorption of essential Amino acids. Check overall amino acid level of diet.

Excessive dietary intake or impaired cystine metabolism. Converted to cysteine in presence of B2 & Cu. Cystine is a major component of tissue antioxidant mechanisms. Possible under-conversion to AKG in liver for use in krebs cycle. Supplement with niacin and B6 for improved metabolism. Ammonia accumulation suspected, if low or low normal glutamic acid. Extra AKG is required to combine with ammonia & compensate for energy deficit caused by overutilisation of AKG to deal with toxic ammonia levels. (Use glutamine precursor of AKG). Supplement with Mn, folic acid, B6 and B2 for efficient glycine metabolism to pyruvic acid for oxidation and for glutathione synthesis or gluconeogenisis. Possibly poor utilisation. Supplement with Vitamin C to aid collagen synthesis. Niacin helps oxidise proline to glutamate. With low threonine indicates glucogenic compensation and catabolism. Supplement with threonine and BCAAs. Inadequate utilisation of tyrosine. Supplement with Fe, Cu, Vitamin C and B6.

Possible generalised tissue loss. Glycine is part of the nitrogen pool and important in gluconeogenesis. Supplement with threonine and serine (glycine precursors). Low tissue levels. Proline is a major component of collagen. Low plasma level can mean defective connective tissue synthesis. Proline metabolised to AKG. Check intake of high quality protein. Can lead to disorder of methionine metabolism and deficits in acetylcholine synthesis Supplement with B6, Mn and Mg to improve metabolism. Implicated in depression, hypothyroidism and blood pressure disorders. If phenylalanine is normal or high (barring PKU), Fe supplementation will improve conversion of phenylalanine to tyrosine.

INtERMEDIARY MEtAbOLItES AND DIAgNOStIC MARkERS

maRkER

REsult

ExPlanation May be impaired inhibition of lysine metabolism and lowered amine group transfer in the tissues. Supplement B6 and glutamine to facilitate transamination conversion of a-aminoadipic acid to a-ketoadipic acid. May be increased requirement for cofactor. Nutrients for threonine metabolism from which this AA is derived. These include glutamine & B6. Inadequate utilisation of this AA for cellular energy. Alpha-ABA is converted to succinyl Co-A for use in the citric acid cycle via mechanisms requiring B12 and biotin. Indicates lack of a transaminase enzyme. Required to metabolise this AA in the presence of AKG; an apparently benign incidence, seen in kwashiorkor (chronic protein deficiency). May indicate a functional enzyme block in the urea cycle, resulting in ammonia buildup. Supplement with Mg. Lower protein intake is recommended with ammonia build up. May be deficiency of B6 or P-5-P which are required to convert cystathione to cysteine. Low cysteine may therefore be the result. Poor conversion of this serine derivative to phosphoethanolamine, potentially reducing acetylcholine synthesis. Mg is a major cofactor for this conversion. May be due to low arginine from which it is synthesised. A low result may affect cellular metabolism as ornithine is a source of regulatory polyamines (essential for the regeneration of damaged axons in neurons). Potential block in the urea cycle, resulting in excess ammonia. Confirm by checking for high glutamine & low glutamic acid. Inhibition of choline & acetylcholine synthesis due to impaired methionine metabolism involving methylation by SAMe. Supplement B12, folate & betaine HCl or SAMe. Functional Mg deficiency causing incomplete conversion to serine. Indicates active catabolism of muscle protein which may be due to poor antioxidant status. AKG may help to remove ammonia (use glutamine as a precursor). Elevated urea levels may be an indication of kidney disease. Supplement B6. May indicate functional B2 & folate deficiency as metabolism requires the presence of both nutrients.

a-aminoadipic acid

High

Low a-amino-n-butyric acid (alpha-aBa) High

a-aminoisobutyric acid

High

citrulline

High

cystathione

High

Ethanolamine

High

Low ornithine High

Phosphoethanolamine

High

Phosphoserine

High

3-methylhistidine

High

ammonia urea y-aminobutyric acid sarcosine

High High High High

REPRESENtAtIvENESS INDEX Urine amino acid levels are usually representative of blood levels and reflect dietary intake and metabolism as well as excretion. However, abnormal renal clearance, loss of urine during the collection period, decay or spoilage, and presence of blood in the urine could cause the urine specimen to be unrepresentative. The potential of such problems can be assessed from analytical measurements provided on the report as: Markers for Urine Representativeness. The computer scores the four Markers for Representativeness and computes a Representative Index. An index of 10 means all markers are within expected limits. An index below 5 suggests a repeat Urinary Amino Acid analysis with a new urine specimen. MARkERS FOR URINE REPRESENtAtIvENESS Creatinine is a nitrogen-containing waste product formed within the body from creatine when muscles are used in physical activity. Elevated levels of creatinine may be an early sign of certain kidney ailments. High levels may indicate kidney malfunction. The glutamine/glutamate ratio can indicate specimen decay. When aged or poorly preserved, urine glutamine decays to glutamic acid and ammonia. However, in metabolic acidosis some glutamine is transformed into glutamic acid and ammonium ion as a pH-balancing mechanism. High glutamic acid also occurs in gout. Therefore, a low glutamine/glutamic acid ratio may reflect decay or it may be of metabolic origin. A high glutamine/ glutamate ratio is metabolic and does not reflect on specimen representativeness. The ammonia concentration, if elevated, usually indicates overall decay of amino acids. An exception would be elevated ammonia concentration with hyperammonia of metabolic or bacterial origin. Very low ammonia concentration suggests low urine nitrogen levels and may occur in protein-deficient diets. Blood Amino Acid levels may then be normal or low-normal. The arginine/ornithine ratio generally reflects whether the sample is purely urine or whether haematuria is present. A low ratio is consistent with blood in the urine. Urine should not be collected by women during menses. Blood in urine can notably distort results.

kEY

symBol AAs BCAAs 5HTP AKG P-5-P

mEaning Amino Acids Branched Chain Amino Acids E5-Hydroxytryptophan A-ketoglutaric acid Pyridoxal-5-phosphate

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