ProteinCatabolism
FoilowingStroke
Ihe Editor -Increased nitrogen
I?'? following surgery, trauma, or rep-
'I8 18JIenerally considered a s an impor-
tant c"~onent of the metabolic re-
'Pon8e to injury. Nitrogen loss is
as the loss of nitrogen or
'Ve"rea in the urine, and the ratio of
n'trogen to creatinine in untimed sam-
P!es Of urine has been used to correct
'ltrogen excretion for body size.'
Patie"t3 and ~ e t h o d s , - ~ attempted
e to
the effect of stroke on protein
tmetabolismby calculating the ratio of urea
a 'leatinine in unlimed rnidmorning urine
BPmplpsfrom 29 patients with moderately
Cerebrovascu~ar accident. There
were l6 men and 13 women, aged 43 to 85
All had normal renal function, as
::;aaed by serum creatinine levels, and
In good nutritional state before
"lake. Patients received infusions of
:pay of 5% dextrose for three days after
attack. The C O U ~ Swas
~ generally
Uncomplicated,except in three patients
had mild urinary tract infection about
Oniweekafter admission,
h eterminations were made on the first 48
stroke and every three to
be therafter, for a total duration of
'IX l8 days. The results were compared
those obtained from a group of 18
Surgical Patients
I Before After
kne
Ch
8Urgery or
Urea-creatnne ratio in untmed urine s a r n p e f O O W n ~arctire
Closed
limits
"liPer of normal values,
indicate men; open circles, women. Dotted line represents
Downloaded From: https://jamanetwork.com/ by a University of Toronto Libraries User on 12/26/2020
surgical patients, nine men and nine
women, aged 40 to 74 years, who were
examined before and four to six days after
elective abdominal surgery (cholecystec-
tomy or vagotomy). All had an uncompli-
cated postoperative course.
Results.-The mean ( ? SEM) urea
to creatinine ratio in the urine of pa-
tients with stroke increased from an
initial value of 12.2-i 0.39 to a peak of
24.5 ? 1.09 between the fourth and
tenth days after the attack (P<.001).
In most cases, this ratio returned to
levels not significantly different from
the corresponding initial values within
three to ten days (12.9k1.1).
In the surgical patients, mean urea
to creatinine ratio (11.12 0.54) in-
creased significantly (P<.01) after op-
eration (14.8 20.61). However, in most
cases, postoperative values did not ex-
ceed the upper limits of normal values
(obtained from a group of 39 healthy
subjects, 19 men and 20 women, aged
40 to 85 years). Moreover, mean post-
operative value was significantly
(P<.01) lower than mean value on days
four through ten in the patients with
stroke (Figure).
Comment. -These findings suggest
that cerebrovascular accidents should
be included in the conditions associ-
Patients With Stroke
Initial Peak Recovery
I [HCO,],, cannot be measured. The pK',
ated with increased protcain cirtiibo-
lism. Since the loss of nitrogen t h ~ i t
occurs after surgery iind triiumii in
thought to bc sufficiently severe to
impair wound healing and rcsistiincc
to infection, mcasures attempting to
preserve protein have bccn proposcd
in surgical patients.'," I t sccms that
efficient protein sparing is iilso of criti-
cal importance in the mnnngcmerlt of
patients with stroke.
T H E O I I OMI ~ I J N ' I ' O K A I , AMI)
KIS,
CHI~ISTO DEI,I,OS,
S MD
Athens, Greece
1. Swaminuthan K, Bradley JA, Hill G H , et id:
The nitrogen to creat~ninercrtio in untirnetl sum-
pies of urine us an index of protein catuboli~rn
after surgery. Po'otltgrad Mcd J 1979;66:868-861.
2. Blnckburn GI,, Flatt JP, Clowe~G H A , et (11:
Protein-sparing therapy during period^ of tittlr-
vntion with ~ e p s i or
s trauma. Ailll Sicrg 1973;177:
688-593.
3. Craig HI', Davidson HA, Tweedle I), et al:
Intravenous glucose, aminor~cidsand fat in the
postoperutive period: A controlled evaluation of
each substrate. Lailcel 1977;2:8-11.
Bicarbonate or CO,?
To the Editor.-In their editorial in
the November 1983 ARCHIVES, Gar-
finkel and Gelfmanl stated that there is
"widespread" uncertainty about what
total CO, content actually is" and that
"CO, (from total CO, content) . . . is
often confused in the clinician's mind
with Pco,." They submit that using the
terms bicarbonate concentration or bi-
carbonate instead would avoid this
confusion and simplify understanding
of acid base metabolism. We disagree.
We believe that to do so would only
further obscure the confusion already
inherent in current clinical bio-
chemical practices.
I t is current teaching that change in
pH results from alteration of the ratio,
in circulating plasma, between concen-
trations of bicarbonate ions ([Hco,~,,)
and of dissolved CO, molecules plus
carbonic acid.' This interrelationship
is presented in the Henderson-Hassel-
balch equation,
pH = pK', + log ([Hco,],,/sPco,) (1)
Where Pco, is the partial pressure of
CO, with which plasma is in equilib-
rium, s is the solubility factor for
plasma and
sPco, = [H,CO, + dissolved CO,],, (2)
pH, Pco, and the solubility factors can
all be measured. A t the present time,
I is the practical coefficient that relates
the variables.' I t is not a true ther-
modynamic constant.' The value for
pK', is determined from measure-
ments of pH, Pco,, and Tco,.' Mea-
Editor's Correspondence 2285
Downloaded From: https://jamanetwork.com/ by a University of Toronto Libraries User on 12/26/2020
Downloaded From: https://jamanetwork.com/ by a University of Toronto Libraries User on 12/26/2020