Fine vs. coarse complete all-in-one admixture infusions over 96 hours in rats: fat globule size and hepatic function.

BACKGROUND & AIMS: The United States Pharmacopeia (USP) has adopted Chapter <729> that set two globule size limits for all lipid emulsions with the mean droplet size at no >500 nm, while large-diameter fat globules as the percent fat>5 microm or PFAT(5) must be <0.05%. A quantitative risk assessment of toxicity from the intravenous infusion of all-in-one (AIO) admixtures made from a lipid emulsion that meets USP standards (fine) vs. one that does not (coarse), was conducted. METHODS: Two separate 96-h infusion studies in rats receiving nutritionally complete AIOs made from a fine (F) vs. a coarse (C) 20% starting lipid emulsion (SLE) with either 18 or 36% as fat calories were performed. The animals were equally divided in each (18% fat, n=18; 36% fat, n=22) to receive AIOs made from F or C lipids. PFAT(5) levels were measured at the outset and every 24h at the change of infusions and blood levels of liver enzymes AST and GST, and serum triglycerides (TG) were measured at the end of study. RESULTS: On average, the starting PFAT(5) values for infusions of F-AIOs were 0.018+/-0.007 (n=48) vs. C-AIOs at 0.183+/-0.026% (n=48), whereas the 24-h average was 0.234+/-0.211% (n=168) vs. 1.033+/-0.224% (n=180), respectively. No significant differences in the blood-based parameters were noted in rats between F-AIOs and C-AIOs in the studies comparing 18 or 36% of fat calories, respectively. When the data were combined into all F- vs. all C-AIOs, AST was significantly higher in C-AIOs (157+/-41) vs. F-AIOs (130+/-37), p=0.036. TG was lower in C (69+/-37) vs. F (106+/-70), nearly reaching statistical significance (p=0.056) with no differences in GST levels for C (21+/-9) vs. F (17+/-9), p=0.199. When stratified according to a PFAT(5) of 0.4%, C-AIOs were significantly higher than F-AIOs for AST (157+/-41 vs. 130+/-37, p=0.004), and TG was significantly lower in C- vs. F-AIOs (67+/-36 vs. 117+/-71, p=0.022), respectively. CONCLUSIONS: Coarse lipid emulsions that fail pharmacopeial limits produce less stable AIOs and are associated with evidence of worsened hepatic injury.

Physicochemical stability of intravenous lipid emulsions as all-in-one admixtures intended for the very young.

BACKGROUND & AIMS: Intravenous lipid emulsions (IVLEs) are unstable when growth of lipid droplets into large fat globules is detected by appropriate particle sizing techniques. Specifically, instability is evident when the volume-weighted percent fat (PFAT)>5 microm exceeds 0.4% of the total lipids present. This represents an approximate 10-fold increase in the population normally present in the large-diameter tail of stable lipid emulsions. The composition of the oil phase of an IVLE, however, has been shown to exhibit different stability characteristics. We investigated the stability of various IVLEs containing physical mixtures of medium-(MCT) and/or long-chain triglycerides (LCT) in three different all-in-one (AIO) admixtures intended for neonatal and infant patients. METHODS: The 20% (w/v) IVLEs used in this study were composed of the following oils (by weight): 1). 1:1-soybean/safflower (SS); 2). 1:1-MCT:soybean (MS); and 3). 5:4:1-MCT:soybean:fish (MSF). Stability was assessed by light obscuration or light extinction to count large fat globules, and by aided (microscopic) and unaided (naked eye) visual assessments for up to 48 h at room temperature. RESULTS: The stability of SS-based admixtures significantly and rapidly deteriorated in one of the three AIO compositions studied, whereas the AIOs made from MS or MSF were stable for all formulations. CONCLUSION: The results suggest that AIOs made from MCT/LCT-containing IVLEs are more stable than those made from pure LCTs.

Circulating ghrelin concentrations are lowered by intravenous glucose or hyperinsulinemic euglycemic conditions in rodents.

Ghrelin is a peptide secreted mainly by gastric parietal cells that may play a role in appetite regulation. Circulating ghrelin is abruptly lowered by food intake, but factors involved in ghrelin regulation remain unclear. The aim of this study was to determine whether intravenous glucose infusion lowers ghrelin, and to determine whether glucose, insulin or some measure of insulin action best predicts the effect of feeding on ghrelin. Rats were infused over 3 h with either A. saline (controls); B. dextrose to steady state blood glucose approximately 16.7 mM, or C. insulin 7.5 mU/kg x min, plus dextrose as needed to clamp to euglycemic basal concentrations. During 3 h of infusion, group B had significantly greater (P<0.01) glucose, 17.4+/-0.3 mM, than groups A (6.6+/-0.3) or C (6.1+/- 0.2). Groups B and C had hyperinsulinemia at the end of the 3 h infusion (894+/-246, 804+/-156 pM) compared with saline-infused (222+/-24 pM, P<0.01). Ghrelin concentrations were reduced (P<0.01) in both hyperinsulinemic groups (B=85+/-2; C=103+/-0.6 pM) versus controls (163+/-9). Ghrelin was strongly correlated with insulin (r=-0.68), glucose infusion rate (r=-0.75) and free fatty acids (r=0.67), when all 3 groups were combined, although only the 2 latter variables were independent predictors of ghrelin. In conclusion, neither a rise in blood glucose nor presence of nutrient in the stomach is required for the effect of feeding on ghrelin. The data suggest that whole body insulin responsiveness plays either a direct or indirect role in meal-related ghrelin inhibition.

Inflammatory mediators in patients receiving long-term home parenteral nutrition.

This study was designed to examine circulating and urine cytokine levels in patients receiving long-term home total parenteral nutrition (TPN) support. Twelve patients who had been receiving home TPN for more than 1 year (range, 1.3-19.5 years) were enrolled for study. To avoid the potential confounding effects of intercurrent infection, patients were studied during periods of clinical stability without clinical evidence of infection. Ten normal healthy volunteers served as controls. Serum levels of albumin and C-reactive protein, temperature, body weight, and blood white cell counts were determined. The levels of soluble tumor necrosis factor receptor II (sTNF-RII) and interleukin 6 (IL-6) were measured in serum and 24-hr urine. The results showed that the concentrations of sTNF-RII and IL-6 in 24-hr urine and serum were significantly higher in patients, indicating that long-term home TPN may be associated with a persistent low-grade inflammatory state.

Sites of conditional essential fatty acid deficiency in end stage liver disease.

BACKGROUND: End stage liver disease (ESLD) is a devastating illness. Its protean manifestations involve many different aspects of disturbed hepatic function. One consequence of ESLD is a decrease in plasma levels of very long chain polyunsaturated fatty acids (VL-PUFAs), particularly arachidonic acid (AA) and docosahexaenoic acid (DHA), the former important for eicosanoid metabolism and the latter for retinal and brain membrane structure. The purpose of this study was to define the VL-PUFA changes in liver disease by comparing plasma and tissue levels of VL-PUFAs in controls to patients with ESLD. METHODS: Fatty acid profiles from plasma, red blood cell (RBC) membranes, muscle, liver, and fat tissue from ESLD patients undergoing liver transplants were measured and compared with control patients undergoing elective liver resection. RESULTS: Fatty acid profiles from plasma and RBC membranes showed significant decreases in AA and DHA levels in patients with ESLD compared with controls. However, there were no significant differences in tissue fatty acid composition between ESLD patients and controls. CONCLUSIONS: ESLD affects the liver's ability to maintain circulating levels of AA and DHA, and thereby presumably RBC membrane levels. However, solid tissues appear not to be affected by ESLD. Although the mechanism for these changes remains to be defined, it is consistent with hepatic impairment of elongation and desaturation to produce VL-PUFA for transport. The present results also suggest that dietary interventions to include preformed VL-PUFA rather than their precursors, linoleic and alpha linolenic acid, would be needed to normalize plasma VL-PUFA levels in patients with ESLD.

Physicochemical assessments of parenteral lipid emulsions: light obscuration versus laser diffraction.

The United States Pharmacopeia (USP) has proposed a new Chapter <729> entitled 'Globule Size Distribution in Intravenous Emulsions' that is intended to identify methods for analyzing the stability of lipid emulsions. We studied the differences between particle-sizing instruments when analyzing the physicochemical stability of a parenteral nutrition mixture compounded with intravenous lipid emulsion, known as an all-in-one mixture. As the growth of lipid droplets, i.e. coalescence, signals an irreversible change in emulsion stability, we focused our investigation on the large diameter tail (>5 microm) of the globule size distribution. Of the four proposed methods, droplet size was studied over a range of mixture stabilities using a low osmolality parenteral nutrition formula employing both light scattering and light obscuration techniques. In addition, the same mixtures were also freshly prepared, and then spiked with a known amount of 5 microm latex spheres. The response obtained from the light obscuration technique was linear and detected both unstable and latex-spiked mixtures in every case for droplets or particles >5 microm. The results of the laser diffraction method were non-linear and overestimated, was less sensitive or missed entirely, globules or particles in the large diameter tail of the dispersion. The results demonstrate that light obscuration is superior to laser diffraction in identifying unstable intravenous fat emulsions.

Physicochemical stability assessments of lipid emulsions of varying oil composition.

BACKGROUND AND AIMS: Intravenous lipid emulsions have been shown to be unstable when the percent fat >5 microm (PFAT >5 microm) exceeds 0.4% by weight of the total fat present. We investigated the physicochemical stability of a standard low amino acid and carbohydrate mixture containing electrolytes when combined with four different commercial intravenous lipid emulsions of varying oil composition. METHODS: The 20% (w/v) lipid emulsions studied were composed of the following oils (by weight): 1) 1 : 1 soybean/safflower (SS); 2) 100% soybean (S); 3) 1 : 1 soybean/MCT (SM) and 4) 4 : 1 olive/soybean (OS). Physicochemical stability was assessed by light obscuration or extinction using a single-particle optical sensing technique to detect growth of fat globules in the large diameter tail (>1 microm) of the droplet size distribution and by visual analyses for evidence of phase separation. RESULTS: The physicochemical stability of SS and S-based all-in-one mixtures significantly deteriorated over time when compared to the mixtures made from SM and OS. In addition, of the four mixtures studied that contained SS (n=2) and S (n=2), only one of each bag studied showed visually obvious destabilization by the presence of free oil from phase separation, despite highly abnormal changes in the globule size distribution of all four preparations. CONCLUSION: The results suggest that all-in-one mixtures composed of either soybean oil alone or in combination with safflower oil are less stable than those mixed with either MCT or olive oil which also contain sodium oleate that can act as co-emulsifying agent.

Cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS).

This study examined the effects of a liquid meal on cholecystokinin (CCK) secretion in patients with severe short bowel syndrome (SSBS) receiving home total parenteral nutrition (TPN) support for 5-19 years after massive small bowel resection. Five patients with SSBS due to superior mesenteric artery or vein thrombosis were included. Five healthy volunteers served as controls. Blood was drawn before and 1 hr following consumption of 250 ml of a liquid diet containing 232 kcal with 8 g fat and 8 g protein. Plasma CCK activity was evaluated by amylase bioassay. All patients had stable weight with a normal BMI and serum albumin level, although there were mild abnormalities in their liver function tests. CCK secretion after stimulation was significantly decreased in patients. These results suggest that reduction in intestinal length influences CCK secretion in response to meal stimulation in SSBS patients.

Sustained endotoxemia leads to marked down-regulation of early steps in the insulin-signaling cascade.

OBJECTIVES: To determine the effects of sustained, 3-day endotoxin infusion on early steps of the insulin-signaling pathway in rat liver and skeletal muscle in vivo; to examine insulin signaling in well-established acute endotoxin models of insulin resistance. DESIGN: Prospective, controlled animal study. SETTING: University research laboratory. SUBJECTS: Male Sprague-Dawley rats: 24 in the 3-day endotoxin study, 22 in each acute endotoxin study. INTERVENTIONS: In prolonged endotoxemia studies, endotoxin (1 mg.kg-1.24 hrs-1) was administered via jugular venous catheter for 74 hrs. Insulin was then injected, and liver and skeletal muscle were removed after 5 mins. In acute endotoxemia studies, an endotoxin bolus (1 mg/kg) was administered, and insulin-signaling responses were studied after 4 hrs. MEASUREMENTS AND MAIN RESULTS: In liver of rats with sustained endotoxemia, there were significant decreases in insulin-stimulated tyrosine phosphorylation of insulin receptors (74%), insulin receptor substrate (IRS)-1 (74%), and IRS2 (53%); binding of the p85 subunit of phosphatidylinositide 3-kinase to IRS1 (80%); and IRS1-precipitable phosphatidylinositide 3-kinase activity (>90%). These findings were associated with significant reductions in abundance of insulin receptors (37%), IRS1 (60%), and IRS2 (23%). Signaling in skeletal muscle was similarly affected, with reduced IRS1 phosphorylation (49%), IRS1 abundance (50%), and binding of p85 to IRS1 (57%). Insulin signaling 4 hrs after endotoxin administration was not different from controls. CONCLUSIONS: Prolonged endotoxemia is associated with marked deficits in early steps of the insulin-signaling pathway, which are at least partly explained by reduced abundance of the insulin receptor and IRS proteins. Signaling defects were not evident 4 hrs after endotoxin administration under conditions of adequate nutrition, indicating that insulin resistance develops gradually, may require concomitant malnutrition, and is not reversed by the development of endotoxin tolerance.

Stress-induced hyperglycemia.

Stress hyperglycemia is common and likely to be associated with at least some of the same complications as hyperglycemia in true diabetes mellitus, such as poor wound healing and a higher infection rate. The predominant cause is the intense counterregulatory hormone and cytokine responses of critical illness, often compounded by excessive dextrose administration, usually as TPN. Although randomized data suggesting benefit of controlling hyperglycemia in hospitalized patients are paltry, prospective controlled trials are feasible and should be initiated. In the interim, the practice at the authors' institution is to use insulin to lower plasma glucose concentrations to a safe range of 150 mg/dL to 200 mg/dL in all patients.

Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications--a randomized clinical trial.

OBJECTIVE: To determine whether the frequency rate of hyperglycemia and infectious complications can be reduced by an underfeeding strategy in patients requiring total parenteral nutrition (TPN), without deleterious effects on nitrogen balance. DESIGN: Prospective, randomized, controlled nonblinded trial. SETTING: A university-affiliated teaching hospital with a dedicated TPN service. PATIENTS: TPN was initiated in 40 adult patients and continued for > or =5 days. INTERVENTION: Two different TPN feeding strategies were compared: hypocaloric feeding (1 L containing 70 g protein and 1000 kcal) and standard weight-based regimen, begun in similar amounts initially, but advanced in increments toward 25 kcal and 1.5 g protein/kg dry (or adjusted ideal) weight. MEASUREMENTS AND MAIN RESULTS: We evaluated the frequency rate of hyperglycemia, average blood glucose, numbers and types of infections while receiving nutritional support and nitrogen balance after 5 days of TPN. There were significant differences between the quantities of calories, dextrose, fat, and protein provided to the two groups. However, average blood glucose, frequency rate of hyperglycemia, and infection rates (from intravenous catheter, pneumonia, and wound/abdominal collection) were similar in each group. The control group showed a trend toward a higher insulin requirement. Nitrogen balance, only available as a subset, was significantly more negative in the hypocaloric group. CONCLUSIONS: Provision of TPN to a goal of 25 kcal/kg was not associated with more hyperglycemia or infections than a deliberate underfeeding strategy. A regimen of 1.5 g/kg protein in conjunction with 25 kcal/kg did, however, provide significant nutritional benefit in terms of nitrogen balance in comparison with hypocaloric TPN.

Comparison of growth and fatty acid metabolism in rats fed diets containing equal levels of gamma-linolenic acid from high gamma-linolenic acid canola oil or borage oil.

We have utilized transgenic technology to develop a new source of gamma-linolenic acid (GLA) using the canola plant as a host. The aim of the present study was to compare the growth and fatty acid metabolism in rats fed equal amounts of GLA obtained from the transgenic canola plant relative to GLA from the borage plant. Young male Sprague-Dawley rats (n = 10/group) were randomized and fed a purified AIN93G diet (10% lipid by weight) containing either a mixture of high GLA canola oil (HGCO) and corn oil or a control diet containing borage oil (BO) for 6 wk. GLA accounted for 23%, of the triglyceride fatty acids in both diets. Growth and diet consumption were monitored every 2-3 d throughout the study. At study termination, the fatty acid composition of the liver and plasma phospholipids was analyzed by gas chromatography. The growth and diet consumption of the HGCO group were similar to the BO group. There were no adverse effects of either diet on the general health or appearance of the rats, or on the morphology of the major organs. There was no significant difference between the diet groups for total percentage of n-6 polyunsaturated fatty acids present in either the total or individual phospholipid fractions of liver or plasma. The relative percentage of GLA and its main metabolite, arachidonic acid, in each phospholipid fraction of liver or plasma were also similar between groups. The percentage of 18:2n-6 in liver phosphatidylethanolamine and phosphatidylinositol/serine was higher (P < 0.05) and 22:5n-6 was lower in the HGCO group than the BO group. This finding could be attributed to the higher 18:3n-3 content in the HGCO diet than the BO diet. Results from this long-term feeding study of rats show for the first time that a diet containing transgenically modified canola oil was well-tolerated, and had similar biological effects, i.e., growth characteristics and hepatic metabolism of n-6 fatty acids, as a diet containing borage oil.

Metabolic effects of insulin and insulin-like growth factor-I in endotoxemic rats during total parenteral nutrition feeding.

The effects of insulin and insulin-like growth factor-I (IGF-I) on protein, energy, and glucose metabolism were examined in endotoxemic rats receiving total parenteral nutrition (TPN) for 3 days. The endotoxemic model was induced by constant infusion of lipopolysaccharide (1 mg/kg x d) for 3 days. The TPN regimen provided 200 kcal/kg x d and 1.5 g protein/kg x d. The dosage of insulin (5 mU/kg x h) and IGF-I (20 microg/kg x h), either alone or in combination, was chosen to maintain normal levels of leucine and glucose in plasma during feeding. One normal control and 4 endotoxemic groups with different treatments (saline, IGF-I, insulin, or IGF-I and insulin) were included. The effects of endotoxin were compared between the group receiving endotoxin alone and normal controls, and the effects of insulin and IGF-I were compared within the endotoxemic groups. The results show that endotoxin significantly increased the mortality and induced a hypermetabolic state, and nutrition alone could not overcome the catabolism induced by endotoxin. However, administration of insulin and IGF-I enhanced protein preservation in muscle tissue in endotoxemic rats during TPN. This effect was greater for insulin either alone or in combination with IGF-I. Insulin also significantly reduced the mortality. There were no additive effects of these two anabolic hormones on any measured parameter in these experimental conditions.