Clinical Biochemistry:
Implications for Nutritional Support
JOHN M. KINNEY, M.D.
From the Departments of Medicine and
The title &dquo;Clinical Biochemistry&dquo; is sufficiently gen-
eral to allow many interpretations. I have chosen to focus
upon selected aspects of the subject which are either
recent developments or information which modifies some
of the conventional wisdom in the field of nutritional
support. Clinical interest in this general area began with
the biochemical changes associated with starvation and
how these differed from the corresponding changes in
the acutely ill or injured patient. Attention is now being
directed more to the response of the fed state in the
presence of hypermetabolism, insulin resistance, and
increases in proteolysis and lipolysis. The experience of
the 1970s with high-carbohydrate, lipid-free total par-
enteral nutrition (TPN) is now coming into better focus
as we learn more about the multiple roles played by lipids
in the regulation of metabolism. This presentation is
meant as an overview which will include brief mention
of certain subjects to be dealt with in greater detail in
subsequent presentations.
ENERGY METABOLISM
In the 1950s
rapid weight loss in many hospital pa-
tients, particularly those with
acute surgical diagnoses,
was thought to be associated with increases in resting
energy expenditure (REE) of 150% or more. Measure-
ment with techniques of serial indirect calorimetry re-
vealed that actual increases in REE might reach 50-
100% above normal in severe third degree burns, but
that other conditions were usually less than 50% above
normal. Major elective operations were found to result
in increases of less than 10% while multiple injury caused
increases 10-25% and major sepsis caused increases of
20-50% above normal. Serious tissue depletion reduced
the REE by 20% and advanced cachexia might have
reductions of as much as 40%.
Commercial development of portable gas exchange
equipment started in the late 1970s2 and resulted in a
surprising number of commercial devices which began to
be used for bedside measurements in the hospital during
the 1980s. Measurements of REE have been reported in
a wide variety of clinical conditions and the span of
values appears to have contracted from -40% to +100%
in the 1960s to only -20% to +60% in the majority of
patients in current studies. The changes in postoperative
patients are still relatively smalP while the extremes of
Reprint requests: John M. Kinney, MD, 8 Harvard
on-Hudson, NY 10706.
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Surgery, St. Lukes-Roosevelt Hospital Center, New York, New York
hyper- and hypometabolism have each been reduced. The
treatment of major burns has undergone significant
changes, each of which has reduced the stimulus to
hypermetabolism.4.5 Lengthy open treatment with anti-
bacterial ointments on the burn surface in improperly
heated rooms with the prolonged presence of dead or
dying tissue and frequent septic complications all con-
tributed to severe and sustained hypermetabolism. The
current early excision of the burn eschar presumably
removes the stimulus associated with white cell activa-
tion and catabolic hormone secretion, while thermal
balance with the ambient environment could be achieved
much more readily.
The past 20 years have brought increased awareness
of hospital malnutrition and the formation of nutrition
support programs which have greatly reduced the severe
malnutrition and cachexia which was formerly seen in
occasional patients and was associated with extreme
decreases in the REE. 6,7
The observation that the range of REE in clinical
conditions is not as large as previously thought has led
some to question whether the measurement has any
clinical value. The first benefit of actual measurement is
to improve the physicians’ skill in correctly estimating
the probable REE in patients where the measurement is
not made. An important reason for measuring the REE
is that it serves as a &dquo;metabolic marker&dquo; for many bio-
chemical and physiologic changes which are increased
with hypermetabolism and decreased with hypometabo-
lism. The nutritional importance of the REE is seen in
terms of the 24-hr needs for calories and nitrogen. The
same information is an important reference for the pa-
tient requiring intensive care when seen in terms of the
minute to hour requirements for cardiac output and
alveolar ventilation. Thus energy measurements may
become an important link between the short-term phys-
iologic problems and the longer-term metabolic and nu-
tritional problems of the patient.
There is continued uncertainty regarding the most
appropriate reference for reporting energy expenditure
measurements. Using body weight for the metabolic body
size offers convenience if the patient can readily be
weighed. Tradition has tended to use equations with
height and weight, with or without corrections for sex
and age.’ The popular Harris-Benedict equations have
been reported by Daly and coworkers9 to give values for
REE which are up to 10% higher than measured in
Lane, Hastings- normal subjects. The influence of nutritional intake has
often not been emphasized when reporting the REE of
148S

disease or injury. The energy expenditure values of over
230 severely ill adult patients and 37 normal subjects, all
of whom received only intravenous nutrition, were ana-
lyzed retrospectively by Shaw-Delanty and coworkers.lo
The patients were classified as nutritionally depleted,
postoperative, injured, or septic with depletion. The REE
of the normal subjects on 100 g of dextrose per day was
only 85% of the predicted values when using either the
Harris-Benedict or Aub-DuBois equations. The effect of
the disease state on the REE as measured by either
equation revealed that the depletion of the septic patients
resulted in a lower REE than that found in the injured,
but nondepleted, patients. When the results were ex-
pressed as kilocalories per kilogram, the weight loss of
the depleted patients caused them to appear to have a
higher REE than the normal subjects or the postopera-
tive patients. It is reasonable to use the fat-free mass
when body fat or total body water can be measured, yet
some indicator of the body cell mass such as total body
potassium would theoretically be the best indicator of
the metabolic body size.
The recommendations for caloric intake of acutely ill
patients have gradually decreased over the past 20 years
as the result of several factors. The recognition of rapid
weight loss in the acutely ill patient was initially attrib-
uted to an extremely high energy expenditure, which was
found to be less than expected when actually measured.
The concept of adding a &dquo;stress factor&dquo; to a predicted
normal energy expenditure as a means of estimating the
actual energy expenditure was sometimes applied by
adding the stress factor to the measured energy expend-
iture which already included the hypermetabolic influ-
ence of the stress, thereby arriving at a caloric require-
ment higher than needed for energy equilibrium. How-
ever, some investigators believed that the protein
breakdown of acute illness or injury could only be over-
come by a large positive balance of calories. The use of
a large positive calorie balance during the acutely cata-
bolic phase of injury or sepsis appears to carry the chance
of adding more diet-induced thermogenesis to any stress-
induced thermogenesis. 12 There will also be an increased
ventilatory demand, which is most evident with high
carbohydrate loads, and a greater chance of deposition
of fat in liver cells. The dominant reason for a positive
balance of calories and nitrogen is to build new tissue. It
seems reasonable to provide intakes of calories and ni-
trogen which produce equilibrium or &dquo;maintenance&dquo; dur-
ing the height of catabolic stress and carefully increase
the intake as the stress subsides in order to rebuild
whatever tissue has been lost. Furthermore, the extent
of nitrogen retention with increasing caloric intake is far
greater as the calorie intake approaches equilibrium than
when further calories are given to achieve a positive
calorie balance.
Measurements of gas exchange can only reflect fuel
oxidation under steady-state conditions where body gas
stores are not fluctuating and the patient’s ventilation is
representative of what is normally occurring when the
measurement is not being made.’
The nonprotein respiratory quotient (RQ) has indi-
cated that fat is emphasized as a tissue fuel in the early
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149S
&dquo;ebb&dquo; or shock phase&dquo; and also in the subsequent flow
or catabolic phase after injury. 12 The clinical use of the
RQ for the management of the patient on nutritional
support has sometimes involve certain misconceptions
such as the following:
1. The RQ is only meaningful if corrected for nitrogen
excretion to provide a nonprotein RQ. This correction is
relatively small and is not essential to the general inter-
pretation of the RQ.
2. Carbohydrate is a &dquo;preferred fuel&dquo; because fat cannot
be converted into carbohydrate to provide fuel for the
brain, glycolysis, etc. Fat also plays certain key roles as
fuel for gut mucosa, membrane composition, and spe-
cialized phospholipid roles, functions which carbohy-
drate does not provide. Thus there is no &dquo;preferred fuel&dquo;
for all tissues.
3. A RQ over 1.0 guarantees that all tissues are burning
carbohydrate. This is a whole body measurement in which
lipogenesis may be occurring in some tissues with a RQ
above 1.0 while fat oxidation in other tissues has a RQ
below 1.0.
CARBOHYDRATE METABOLISM
The role of glucose as a central controlling factor in
the metabolic state of the critically ill patient may result
in part from the fact that glucose can be more easily
analyzed than other plasma substrates. Glucose intoler-
ance and insulin resistance are well-established features
of acute catabolism. The &dquo;diabetes of stress&dquo; or &dquo;diabetes
of injury&dquo; has been recognized since the 1950s, but such
terms imply a lack of insulin. The term &dquo;insulin resist-
ance&dquo; has evolved as the condition has come to be rec-
ognized as being one of diminished responsiveness.
The term &dquo;insulin resistance&dquo; can be divided into the
insulin regulation of hepatic glucose production as dis-
tinguished from the utilization of glucose by peripheral
tissues. The dominant role of the liver in fuel homeosta-
sis involves unique characteristics. The liver contains all
of the enzymes necessary for the synthesis and degra-
dation of glucose, glycogen, and fat. Furthermore, it can
change the direction of carbon flow over key pathways
of carbohydrate and lipid metabolism in response to
changes in hormonal and nutritional states. During star-
vation the fall in circulating insulin levels causes glucose
and ketone bodies to be released to provide fuel for the
central nervous system, for glycolytic tissues and rapidly
turning-over tissues such as gut mucosa. However, the
metabolic understanding of the events when the starva-
tion is ended has been undergoing revision in the past
few years. It was formerly thought that ingestion of
carbohydrate after a period of starvation caused rapid
increases in circulating glucose and insulin which pro-
moted the efficient uptake of glucose by the liver and its
prompt conversion into storage products such as glyco-
gen and fat.
lVlcGarry and co-workers13 have reviewed findings in
the past few years which have changed this former view.
The ready conversion of glucose to glycogen in L’iuo and
its limited incorporation in L’itro has been termed the
&dquo;glucose paradox.&dquo; It now appears that glucose is a poor
substrate for liver metabolism, regardless of nutritional
150S
state. The capacity of the liver for phosphorylation may
be insufficient to support glycogen synthesis directly
from glucose, as shown in Figure 1. The three carbon
intermediates, rather than glucose itself, serve as the
precursors for fatty acid synthesis and for glycogen for-
mation in the liver following glucose ingestion. Insulin,
although essential for the induction of anabolic processes
in uivo, probably exerts its acute hepatic effects not in
direct fashion (as in muscle or adipose tissue) but indi-
rectly by suppressing the secretion of glucagon and coun-
teracting its catabolic action.&dquo;
A current question remains as to the site of the initial
conversion of glucose into lactate. Although muscle
would seem to be a logical site, it has been reported that
after glucose loading in humans there is little net output
of lactate across forearm muscle. Most of the lactate
appears to be of splanchnic origin. Balance studies have
shown that uptake of glucose across the liver is much
less than the amount of glycogen formation. 13 Hagstrom
and coworkers 15 have used a microdialysis technique in
the adipose tissue of healthy volunteers and compared
the levels of glucose, pyruvate, and lactate in venous
blood with those in the dialyzate following glucose inges-
tion. There was a more marked increase of lactate in the
dialyzate than in venous blood, suggesting that adipose
tissue is a source of lactate production from glucose and
may play a significant role in the whole body glucose
homeostasis of man.
The essentiality of insulin for hepatic glycogen syn-
thesis in vivo stems from three indirect actions of the
hormone, according to McGarry and co-workers.l3 First, tion both by inhibiting the rate of hepatic glucose pro-
insulin suppresses pancreatic glucagon secretion; second, duction and
v v
xnT
FIG. 1. Hepatic glucose metabolism with refeeding. The former
concept of glucose entering the hepatic cell directly to form glycogen is
shown in the upper diagram. The alternate concept, supported by
recent data, indicates that glucose ingestion results in production of
lactate. which then ravels to the liver and is used for glycogen forma-
tion. See McGarry and co-workers’-’ for details.
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i nsulin serves to offset the potent glycogenolytic effect
< )f glucagon (and probably catecholamines) on the liver;
¡ md third, insulin stimulates glucose uptake in peripheral
tissues. Insulin might be expected to facilitate the pro-
< ruction of lactate and thus
provide a major substrate for
.iver glycogen and fat synthesis.
&dquo;Net&dquo; glucose formation does not increase via the Cori
,
cycle and thus such a cycle may be considered as a waste
~f the energy required to resynthesize glucose from lac-
tate. However, Wolfe14 has noted that the energy to
resynthesize the glucose comes from fat oxidation in the
liver, so the Cori cycle results in a transfer of energy
from adipose tissue to muscle with glucose and lactate
serving as &dquo;currency&dquo; in situations in which the muscle
is unable to fully rely on fat oxidation. Glycerol contrib-
utes only about 3% of the total glucose production during
a short fast, but when there is a stimulus for mobilization
of fat the contribution of glycerol can increase up to
20%.
The concentration of glucose in the blood is normally
regulated within narrow limits while the rate of glucose
uptake and oxidation can vary widely. Brain and red
blood cells may account for more than 50% of glucose
uptake in fasting, yet these tissues probably do not play
a role in the fluctuations seen in the rate of oxidation.
The liver can play a role in the disposition of a glucose
load, but since most of this glucose is not oxidized, the
liver is not a site which influences the rate of whole body
glucose oxidation.
Insulin exerts its control on plasma glucose concentra-
by stimulating glucose uptake in certain
peripheral tissues. The threshold for the action of insulin
on peripheral glucose uptake is higher than the threshold
for the effect of insulin on hepatic glucose production.&dquo;
Thus of the many actions of insulin, its effect on uptake
by peripheral tissues is the least sensitive.
The muscle mass exerts a major influence on the
overall rate of glucose utilization. In the postabsorptive
person at rest, there may be no muscle glucose uptake at
all; yet this can be stimulated by exercise while uptake
is decreased by bed rest. Glucose is rapidly phospho-
rylated once inside the cell and it is possible that insulin
regulates muscle utilization by controlling the rate of
entry into the muscle cell. The alternative role of the
&dquo;glucose-fatty acid cycle&dquo; in regulating glucose uptake
remains controversial. While details of the interrelation-
ships between glucose and fatty acid metabolism have
not been resolved, it is clear that their respective oxida-
tion rates are inversely related.
The primary control of the plasma glucose concentra-
tion under most circumstances is exerted through
changes in the rate of glucose production, and only at
higher rates of glucose intake do changes in insulin-
mediated clearance become important. The brain and
red blood cells are obligatory glucose users and are in-
dependent of insulin action. Other tissues, such as skin,
lung, and wound tissue are also &dquo;insulin independent.&dquo;
Muscle and fat are the two major tissues in which insulin
acts to stimulate glucose uptake. However, the blood
glucose level must rise significantly before these tissues

begin to take up glucose.16 Once the plasma glucose level
is high enough so that glucose uptake in all the insulin-
independent tissues is maximized, muscle and fat begin
to become important in clearing the glucose. Because of
the large mass of both muscle and fat, once these tissues
become involved in the glucose clearance the disposal of
glucose into these tissues increases rapidly with small
increases in either glucose or insulin levels. However, in
the basal state, neither muscle nor fat is significantly
involved in glucose clearance and this explains the ab-
sence of an important peripheral effect of insulin at low
rates of glucose uptake. There is no evidence that insulin
exerts a direct effect on glucose oxidation.
The basal rate of glucose production is elevated in
critically ill patients despite a normal or elevated insulin
level, indicating hepatic insulin resistance. At all rates
of glucose infusion the residual endogenous glucose pro-
duction is higher than would be expected in normal
volunteers. It is likely that the traditional glucoregula-
tory hormones can explain most of the stimulation of
glucose production. 17 Studies with somatostatin suggest
that glucagon, perhaps enhanced by cortisol, is of pri-
mary importance.&dquo; In both sepsis and burn injury, glu-
cagon stimulates glucose production. In sepsis, if the
glucagon is normalized, the catecholamines become im-
portant stimulators. In sepsis there appears to be a factor
inhibiting glucose production that is not present in burn
injury. Endotoxin or cytokines are obvious candidates
for such a factor. In both septic and burn patients the
basal glucose production may be elevated while the glu-
cose concentration is not markedly elevated because of
rapid clearance of the glucose by insulin-independent
tissues. The action of insulin on muscle and adipose
tissue of such patients is greatly blunted.16 Thus there is
both hepatic and peripheral insulin resistance.
PROTEIN METABOLISM
The observations of Cuthbertson on the increased
excretion of nitrogen after injury were followed by rec-
ognition that increasing the nitrogen intake during the
catabolic phase after injury could lessen the degree of
negative nitrogen balance but would not abolish the
increase in nitrogen loss due to the injury. The extent of
the nitrogen loss has often been related to the type and
severity of the injury, but such comparisons have tended
to be obscured by variations in nitrogen intake. Figure 2
shows a comparison of nitrogen excretion in various
conditions compiled by Goldstein and Elwyn.19,22 These
patients were receiving only 100 g of dextrose per day;
thus with no nitrogen intake, the nitrogen excretion
represents the negative nitrogen balance per day. It is
seen that the malnourished patients excreted twice as
much nitrogen as the normal subjects, suggesting some
degree of underlying disease or stress because uncompli-
cated undernutrition is known to reduce nitrogen excre-
tion. There is evidence that parenteral feeding for the
first 3-4 days after operation&dquo; provides somewhat better
nitrogen balance than parenteral feeding, but thereafter
there seems to be little difference. 21
Whole body protein turnover rates reflect the severity
of the catabolic condition. Elective operation is associ-
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151S
FIG. 2. Nitrogen excretion is shown for various clinical conditions,
while receiving only 100 g of glucose per day. See Elwyn19 for details.
ated with a decrease or no change in protein degradation
coupled with a reduction in synthesis.&dquo; Part of this effect
may be due to an accompanying hypocaloric intake.
Under such conditions there would be no increase in
energy expenditure from protein turnover. This is in
contrast to major injury, sepsis, or extensive burns where
whole body protein turnover studies show a marked
increase in protein degradation, while synthesis rates
may be increased to a lesser degree. Increases in both
synthesis and degradation rates will increase energy ex-
penditure. A minimum of four high-energy phosphate
bonds are required for incorporation of a single amino
acid into protein; thus the minimal cost of synthesis of
100 g of protein would be 70 kcal. Normal protein turn-
over in the adult is approximately 300 g/day. If this were
doubled with injury it would increase the energy expend-
iture by approximately 200 kcal, which would be included
in the energy cost associated with increases in metabolic
cycles (&dquo;futile cycles&dquo;) of carbohydrate and lipid metab-
olism.
Increased excretion of 3-methylhistidine, derived from
the breakdown of actin and myosin, is seen at times
when there are large increases in whole body protein
degradation. This is consistent with the negative nitro-
gen balance being the result of losses in muscle protein
as indicated by 3-methylhistidine output from the leg. 13
It was formerly thought that critical organs such as the
heart and diaphragm were privileged sites which were
spared the protein loss of malnutrition. Autopsies of
malnourished patients have shown that all organs con-
tribute to the protein loss except the brain and nervous
tissue. 21
It has often been stated that albumin is a poor indi-
cator of nutritional status because of its relatively long
half-life and that nutritional status should be monitored
by the measurement of proteins with much shorter half-
lives such as transferrin. It is interesting that despite
this belief, many retrospective evaluations of nutritional
measurements and their prognostic value have nearly
alwavs included the level of serum albumin as one of the
most important variables. Starker and co-workers’~5 con-
ducted a study on a group of depleted surgical patients
who received TPN after having sustained an average of
16% loss of body weight. Two types of response were
found during the first 10 days of nutritional support. The
152S

first response was a weight loss associated with a diuresis amount of nitrogen involved in the muscle efflux of
of water and sodium coupled with a prompt rise in serum glutamine and alanine is much greater than the corre-
albumin. One may speculate that this represented a sponding amounts of these amino acids in muscle pro-
contraction of an expanded extracellular fluid volume at tein. Therefore, it is generally believed that the
a time when nitrogen balance was beginning to improve. branched-chain amino acids are important contributors
The second response shown by other patients in the to the synthesis of glutamine and alanine in muscle.
group was a body weight which remained the same or Jahoor and co-workers16 studied the responsiveness of
rose slightly, while there was a positive sodium balance the protein kinetics in sepsis and burns to insulin and
and no improvement in the low serum albumin. The rates of glucose oxidation. These studies used isotopic
patients with the second response were considered to leucine and urea together with a hyperinsulinemic, eu-
have some underlying catabolic stimulus which was as- glycemic clamp and a drug which increases glucose oxi-
sociated with a sustained extracellular volume expansion. dation. The results indicate that the maximal effective-
Starker and co-workers2s subsequently studied eight ness of insulin to suppress protein breakdown is not
other patients with an average weight loss of approxi- impaired in such states and that a deficit in glucose
mately 40% but with no signs of underlying catabolic oxidation cannot explain the high rates of proteolysis
stimulus. With such severe malnutrition, there was a and nitrogen excretion.
delay in diuresis and the associated rise in serum albumin Rennie and co-workers31 studied amino acid transport
after starting nutritional support, yet those who even- in a rat limb preparation combining perfusion and iso-
tually showed these changes had an improved outcome. topic tracers. These workers proposed that the removal
Similar findings have been reported by Sitges-Serra and of glutamine by muscle was associated with a transport
associates.2’ system which they designated as system Nffi, a term
The loss of body protein is from intracellular stores, unrelated to the transport systems previously identified
and skeletal muscle represents at least half of the body in muscle. Rennie et al, in collaboration with Jepson et
cell mass, which is consistent with a high proportion of al, 32 proposed a hypothesis building on the properties
proteolysis after injury occurring in muscle. This central which would be necessary for such a glutamine transport
role of muscle in proteolysis is supported by studies of system.33 They defined the behavior of glutamine and
interorgan flow of amino acids. Lund et aF8 measured glutamate in relation to the kinetics and ion dependence
arterial-hepatic venous concentration differences and he- of such transport as well as the effects of branched-chain
patic blood flow to calculate the splanchnic uptake of amino acids, endotoxin, and infections. The authors
amino acids in anesthetized preoperative and postoper- pointed to a link between the size of the glutamine pool
ative patients undergoing cholecystectomy. The values in muscle and the rate of protein synthesis by muscle
for the preoperative splanchnic uptake were similar to which might have extensive implications for the balance
that for peripheral output of normal subjects, namely 7- of anabolism and catabolism of amino acids in the entire
8 g of nitrogen per day. This similarity between total body.
peripheral output and splanchnic uptake is evident for Specialized roles of selected amino acids within certain
most of the individual amino acids as well. The increased types of cells are gradually becoming evident, with exten-
flow of amino acids from muscle to viscera in injury is sive implications for future nutritional support. Gluta-
accompanied by a decreased rather than an increased mine has long been recognized as important for the
plasma amino acid concentration, with the exception of transport of nitrogen to the kidney for ammonia forma-
phenylalanine whose concentration usually rises. This tion. Studies in the acidotic rat have shown that the
suggests a simultaneous increase in splanchnic clearance. increased glutamine requirements of the kidney for am-
Pearl et aF9 reported that the peripheral output and monia formation are matched by increased glutamine
splanchnic clearance of amino acids were greatly reduced output by muscle.
in injury or sepsis for the patients who later died when Newsholme and co-workers34-3s have stressed the im-
compared with those who survived. portance of glutamine as an essential nutrient for rapidly
The largest proportion of amino acids which are trans- dividing cells or cells where there may be sudden large
located from muscle to viscera are in the form of two demands for energy-requiring functions such as phago-
amino acids: alanine and glutamine. The role of gluta- cytosis or secretion (Fig 3). Glutamine provides a major
mine was initially overlooked because of technical diffi- part of the energy requirements of lymphocytes and
culties in measurement. Therefore, the early attention macrophages, but more importantly it serves as a basic
was largely devoted to the &dquo;alanine-glucose cycle.&dquo; Dur- building block for synthesis of nucleic acids and other
ing the 1970s, various reports established that glutamine constituents required for cell division. The glutamine
was decreased in muscle following injury and that the requirements of lymphocytes, macrophages, and the en-
decrease could be as high as ~0~ depending upon the tire immune and hemopoietic system greatly increase
severity of the injury.3° Inasmuch as the concentration with injury or sepsis as cells proliferate. In addition, the
of glutamine is the largest of the free amino acids in healing could be expected to add to the requirements for
muscle and muscle represents a large proportion of the glutamine. Presumably the increased glutamine require-
lean tissue in the body, it is probable that a change in ments of host defense and wound healing would be met
muscle glutamine after injury could provide as much as by an increased output of glutamine from muscle.
10 g or more of glutamine nitrogen during the first 48 hr Another amino acid with unusual properties in regard
before the peak rate of muscle proteolysis occurs. The to host defense is arginine. Barbel3’ has reviewed the

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FIG. 3. Relationship between glutamine production in muscle and
glutamine utilization in various other tissues, shown in diagrammatic
form. BCAA, branched-chain amino acids. For details, see Newsholme
et al. 36
multiple biologic properties of this amino acid and noted
that other urea cycle-related amino acids such as orni-
thine and citrulline share some but not all of the same
properties. Arginine is a potent secretagogue stimulating
the output of growth hormone and prolactin as well as
insulin and to some degree the output of glucagon, so-
matostatin, pancreatic polypeptide, and adrenal catcho-
lamines. The most striking effect of arginine appears to
be as a moduator of T-cell-mediated immunity which has
been demonstrated in both animals and man. It appears
to function as a semiessential amino acid where arginine
supplementation may have particular benefit in a variety
of stress states as well as nutritional depletion.
There has been increasing attention to the integrity of
the gut mucosa in recent years.38 Intestinal adaptation
usually occurs rapidly after small-bowel resection, al-
though it is dependent upon the provision of enteral
nutrients, particularly glutamine. In the dog, glutamine
uptake provides a major portion of energy requirements
of the intestine39 and uptake is doubled by laparot-
omy.39,40 The translocation of endotoxin or bacteria
across an ischemic or malnourished intestinal mucosa
has been reported to be a possible pathway for macro-
phage activation in the portal lymph nodes or in the
liver.41 Fong et al42 studied the effect of TPN-induced
bowel atrophy on the response to lipopolysaccharide in
healthy volunteers who had received enteral or paren-
teral nutrition for 7 days. Counterregulatory hormones
and splanchnic cytokine responses were enhanced after
TPN and bowel rest. This was associated with a magni-
fied acute phase response, peripheral amino acid mobi-
lization, and lactate production.
FAT METABOLISM
The entire adipose tissue in an average adult may be
considered as an organ containing about 30 billion adi-
pocytes, each of which has a single droplet of triglyceride,
roughly 0.5 ug in weight. Given that 30 x 109 x 0.5 g
15 kg of fat, it can be seen that the major energy storage
is held in adipose tissue. Theoretically, this depot can
provide energy sufficient to maintain life for approxi-
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153S
mately 50 days during a total fast.43 It is of interest that
the 10 Irish hunger strikers lived for an average of 62
days of total fasting, with terminal brain failure as re-
flected by coma during the final 48 hr.
The breakdown of triglyceride in adipose tissue yields
glycerol and free fatty acids (FFA). The glycerol cannot
be reutilized before it is released into the bloodstream
and serves as a marker for the rate of triglyceride break-
down. The FFA which result from the triglyceride break-
down may be reesterified into new triglycerides in the
adipocyte or released into the blood and made available
for oxidative fuel in other tissues. There is growing
evidence that the pericellular blood flow in adipose tissue
can serve as another factor in regulating fat balance in
the cell. Hormones which influence intracellular metab-
olism in the adipocyte include those with vasoactive
properties.
An elaborate apparatus controls the rate of lipolysis
within the adipocyte.43 Adrenergic receptors, insulin, and
other peptide hormone receptors, as well as adenosine
receptors, all on the membrane of the adipocyte, are
major players in the control of lipolysis. The membrane
signals are, in some instances, greatly amplified by the
G proteins which bind guanosine triphosphate under the
influence of membrane receptor events and then act on
adenylate cyclase. Activation of the cyclase generates
cyclic AMP which inaugurates a cascade of protein phos-
phorylation terminating in the phosphorylation and ac-
tivation of a hormone-sensitive lipase, the final step in
the enzymatic breakdown of stored triglyceride.
The controls of the synthetic steps that reesterify fatty
acid to form triglyceride are understood less well. Fatty
acids for triglyceride synthesis are mostly derived from
hydrolysis of circulating lipoproteins by a critically im-
portant enzyme, lipoprotein lipase (LPL). LPL is syn-
thesized and secreted by adipocytes onto the capillary
surface, where it hydrolyzes chylomicrons and very-low-
density lipoprotein triglycerides to yield FFA, which then
can be taken up and esterified by adipocytes. Because
the capacity of human adipose tissue for fatty acid syn-
thesis is minimal, this is the major source of fatty acids
for triglyceride synthesis and storage. LPL activity in
adipose tissue undergoes changes in response to altera-
tions in nutritional and hormonal status. It is decreased
during fasting or diabetes when fat storage is minimal
and rises in the fed state, facilitating uptake of substrate
into the adipocyte. The rate of synthesis of triglyceride
within the adipocyte could potentially be controlled by
the availability of FFA or the glycolytic availability of a-
glycerophosphate. LPL is also present on the capillary
endothelium of muscle and the responsiveness of LPL in
adipose tissue and muscle appears to be regulated so that
their activity is stimulated and inhibited in a compen-
satory fashion. Circumstances which favor muscle up-
take of FFA tend to reduce LPL activity in adipose tissue
and the opposite behavior occurs with high intake and
storage of energy in adipose tissue.
= One of the most potent effects of insulin on adipose
tissue is its ability to inhibit FFA efflux. By this action,
insulin modulates the concentration of circulating fatty
acids and influences the supply of lipid fuels available
154S
for oxidation or hepatic reesterification. Insulin exerts
this action by two mechanisms: (1) inhibition of the
hormone-sensitive lipase, the enzyme that regulates the
hydrolysis of fatty acids from triglycerides stored in
adipose tissue, and (2) promotion of the reesterification
of newly hydrolyzed fatty acids.
Fasting is accompanied by increased entry of both
glycerol and fatty acids into the circulation as the rate
of hydrolysis of adipose tissue triglyceride rises. Because
the decrease in plasma insulin that accompanies fasting
is one of the major causes of this increased rate of
triglyceride hydrolysis, it might be expected that termi-
nation of the fasting state by infusion of glucose and
insulin would inhibit lipolysis in vivo. Recent studies
suggest that glucose infusion into fasting obese subjects
increases fatty acid reesterification more quickly than it
inhibits lipolysis.44 Simultaneous studies of adipose tis-
sue in vitro indicate that the rapid reesterification cannot
be accounted for by changes in adipocyte metabolism.
There is increasing evidence that the local blood flow
around the adipocyte is very labile and perhaps respon-
sive to the same hormonal influences which regulate the
intracellular processes of lipolysis and lipogenesis.45 The
difference in in vivo and in vitro studies of the fasting
obese patients given glucose and insulin might be ex-
plained by a reduction in adipocyte blood flow, limiting
the entry of fatty acid into the circulation and promoting
their reentry into the cell for reesterification.
Plasma FFA concentrations are often in the normal
range with injury, sepsis, or burns, either when fasting
or with hypocaloric dextrose intake, but there is wide
variability. The decrease in plasma FFA levels with
increasing carbohydrate intake appears to be attenuated
in injured or septic patients.46 Plasma glycerol concen-
trations may be increased up to 3-fold with injury, sepsis,
or burns and seem to be correlated with the severity of
the condition. These catabolic states suppress the ketone
body formation which normally occurs in the fasting
state. Glycerol turnover in plasma is increased as much
as 5-fold, while FFA turnover is increased to a lesser
degree in acutely catabolic patients. These increases are
seen almost immediately and last as long as 20 days after
the onset. Carbohydrate loads will suppress glycerol
turnover in acutely catabolic patients just as in depleted
or normal subjects, yet they have little suppressive effect
on FFA turnover. The effects of acute catabolism are to
increase triglyceride hydrolysis and fat mobilization
more than fat oxidation. Reesterification of fatty acids,
or substrate cycling of triglycerides, is increased as much
as 4-fold and remains high even with sustained hyper-
caloric administration of glucose. Wolfe and co-workers47
found the increase in triglyceride recycling to occur pri-
marily in adipose tissue. The total amount of recycling
accounted for a minimum of 10% of the increase in whole
body energy expenditure seen in a pediatric population
of burn patients.
The acute catabolic state is associated with an increase
in gluconeogenesis, which is resistant to suppression by
glucose infusion. A parallel change is seen in fat oxida-
tion, which is increased at any given level of glucose
infusion when compared with that of undernourished or
Downloaded from pen.sagepub.com at PENNSYLVANIA STATE UNIV on May 18, 2016
inormal subjects. Ketoadaptation does not occur readily
ias compared with simple starvation. The process by
iwhich this occurs and the underlying mechanisms are
]not well elucidated.
Plasma FFA flux is linearly related to plasma FFA
< concentrations in normal dogs and man. However, the
iFlux of substrates such as glycerol and fatty acids cannot
1be predicted from the plasma concentration in the pres-
< ence of an acutely catabolic state. Kinetic measurements
< are therefore necessary to evaluate alterations in lipid
metabolism during the chronic and acute illness and how
they are further influenced by the fasted and fed states.
Robin and coworkers48 studied depleted and acutely in-
:jured patients on limited glucose intake or TPN, using
[14C]palmitate and indirect calorimetry. When receiving
TPN, the REE rose from 109 to 119% and from 89 to
103% of predicted in injured and depleted patients. FFA
flux was not affected while FFA oxidation and net fat
oxidation decreased by 60%. The proportion of the net
fat oxidation derived from immediate oxidation of cir-
culating FFA was approximately 35%. The results indi-
cate that with glucose-based TPN, there is a discrepancy
between suppression of FFA production and oxidation.
In addition, sources of fatty acid which are not in rapid
equilibrium with circulating FFA contribute substan-
tially to whole body fat oxidation (see Fig 4).
There is growing evidence that the lipid composition
of cell membranes can be manipulated by dietary treat-
ment and therefore has the potential to influence many
aspects of cell function.49 The changes in phospholipid
fatty acid composition reflect the composition of the fat
consumed because the turnover of membrane fatty acids
is rapid. Coconut oil-fed rats have more saturated fatty
acids in the membranes than do rats fed either corn,
safflower, or menhaden oils. This change in membrane
fatty acid saturation can result in a change in membrane
fluidity or the degree of ordering and motion of the
hydrocarbon core of the lipid bilayer. Intake of a more
saturated fatty acid mixture results in a less fluid cell
0---~ ~~..-. ,-_..--...--.
FIG. 4. Contribution of fat oxidation to caloric expenditure. Results
of a clinical study are shown in which the free fatty acid oxidation
(isotopic palmitate) is compared with the net fat oxidation (indirect
calorimetry), Note that the free fatty acid oxidation is only approxi-
mately one-third of the net fat oxidation. 0, REE; E3, net fat oxidation;
E, free fatty acid oxidation. See Robin and co-workers.48

membrane and an altered environment for the proteins
of the membrane.
Cellular membranes serve as geographic boundaries
for the cell and its compartments and have in addition
metabolic control properties. They are the &dquo;gatekeepers&dquo;
of the cells.&dquo; They regulate the influx and efflux of
nutrients, substrates, hormones, and metabolic products
produced or used by the cell in the course of its metabolic
activity. In the plasma membrane, receptors embedded
in the membrane have a similar function because they
control the entry of nutrients or hormones into the cell.
Further, the hormone receptors of a plasma membrane
may bind a given hormone and elicit a cascade of reac-
tions characteristic of the hormone effect without per-
mitting the entry of the hormone itself into the cytosolic
compartment. Insulin binds to its receptor and in so
doing elicits the cascade of events described earlier. Once
bound by the receptor site, the insulin is inactivated and
brought into the cell by pinocytosis for further degrada-
tion. This is in contrast to steroids and thyroxine which
must enter the cell to bind to receptors. The gatekeeping
property of the membrane is vested in the structure and
function of the various transporters, receptors, and bind-
ing proteins embedded in the lipid constituents of the
membrane.
Lipids have surfaced as potent and diverse modulators
of cell function, over and beyond the membrane compo-
sition just mentioned. Lipids may serve as ligands for
cell-surface receptors, as anchors for membrane-associ-
ated proteins, and as &dquo;second messengers. 1150 Some func-
tions involve complex lipids directly; however, many
other functions involve cleavage of membrane lipids to
yield the various prostaglandins, diacylglycerols which
activate protein kinase C, a choline derivative which is
converted into a platelet-activating factor, together with
new roles for membrane lipids which are constantly
appearing. Membrane lipid functions present an obvious
link between nutrition and cell behavior and offer a
tremendous potential for understanding and controlling
the response to disease and injury.
Fat emulsions are currently included in the intrave-
nous regimen of patients requiring parenteral nutrition
to provide both energy and essential fatty acids. In these
preparations, triglycerides are emulsified by phospho-
lipids. The amount of phospholipid is variable among the
available emulsions yet is always in excess of what is
needed for emulsifying the triglycerides. Therefore, fat
emulsions can be considered as composed of two different
kinds of particles: triglyceride-rich particles (resembling
chylomicrons and very-low-density lipoproteins) and
phospholipid-rich particles (which resemble liposomes).
Carpentier and co-workers51 have emphasized the im-
portance of recognizing that the composition of various
lipid emulsions may influence biologic function in differ-
ing ways. The metabolism of the triglyceride-rich parti-
cles, which contain no apoproteins or cholesterol esters
and only traces of free cholesterol. includes high affinity
for apoproteins which resembles that of chylomicrons.
The triglyceride fatty acid composition affects the active-
ity of LPL and the rate of accumulation of fatty acids in
the plasma. Active shifts of core components hale been
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155S
demonstrated between triglyceride-rich particles of an
<
emulsion and endogenous cholesterol-rich lipoproteins.
<
°
While endogenous lipoproteins are remodeled by lipid
infusions, the exogenous lipid particles are also involved
:in the plasma transport of cholesterol.
A portion of phospholipid present in fat emulsions
,surrounds the core of trigly ceride-rich particles while the
rest, sometimes referred to as the phospholipid excess,
can be separated as liposomes. The proportion of the
liposomal population is much greater in 10% emulsions
containing 12 g/liter of phospholipids and 100 g/liter of
triglycerides compared with 20% emulsions containing
also 12 g/liter of phospholipids but 200 g/liter of triglyc-
erides. Because the phospholipase activity of plasma is
relatively low compared with the triglyceride lipase ac-
tivity, it is common to observe marked and prolonged
increases in plasma phospholipid concentrations during
and after infusion of 10% emulsions, even at moderate
rates.
Carpentier and coworkers51 have also observed that
liposomal phospholipids can delay the clearance of tri-
glyceride-rich particles, probably by competing for bind-
ing to endothelial LPL. It is known that phospholipids
have a high affinity for free cholesterol and such com-
plexes may explain the &dquo;lipoprotein X&dquo; isolated from the
plasma of cholestatic patients. 52 The rise in plasma free
cholesterol observed during infusions of phospholipid-
rich particles is not likely to be due to the cholesterol
infused, but it comes from membranes of circulating
erythrocytes. Analysis of red blood cell membranes dem-
onstrated concomitant increase in phospholipid con-
a
tent and decrease in the free cholesterol of the mem-
a
brane which were directly related to the phospholipid
intake.
CONCLUSION
The effectiveness of nutritional support is more the
result of the underlying metabolic state of the patient
than of the particular diagnosis.53 Thus, the search for
the mechanisms underlying the metabolic state of the
patient is of direct importance to nutritional manage-
ment. However, the focus must be widened to explore
further the transition from the fasted to the fed state
and how catabolic stimuli modify this transition. A log-
ical extension is to search for nutrients with specific
actions on certain cells which may lead to pharmacologic
ways of aiding convalescence.
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