[Pharmacotherapy for obesity]. / Farmacotherapie voor obesitas.

Obesity is a complex endocrine disease, mainly caused by environmental, behavioral and biological factors. Maintaining weight loss is extremely difficult due to the neuro-endocrine dysregulations that stimulate the body to return to the previous, increased, weight. Identifying underlying weight-gaining factors is needed, including medication-related, psychological and endocrine factors, as well as monogenic obesity. The cornerstone of treatment is optimization of lifestyle and all other contributing factors. Achieving at least 5% weight loss already has important health benefits. If combined lifestyle intervention (CLI) alone is not successful, pharmacotherapy or bariatric surgery can be added for patients with increased weight-related health risks. Recently, novel pharmacotherapy became available, among which, liraglutide 3 mg and the combination therapy naltrexone/bupropion, which leads to an additional 5-6% mean weight loss compared to CLI alone. For rare forms of obesity there are specific drugs that target defects in the regulation of hunger and satiety. Promising new pharmacotherapy for obesity is under development.

Obesity-associated T-cell and macrophage activation improve partly after a lifestyle intervention.

BACKGROUND: The relation between low-grade inflammation and metabolic dysfunction in obesity is not fully explored. OBJECTIVE: To evaluate immune parameters in the obese state and after a lifestyle intervention program. METHODS: Patients with obesity (n = 87) from an academic obesity clinic were compared with controls with regard to macrophage and T-cell activation (reflected by serum levels of soluble CD163 (sCD163) and soluble IL-2 receptor (sIL-2R), respectively), and an array of cytokines, chemokines, and growth factors. In addition, these parameters and regulatory T-cells (Treg), were studied in 27 patients who followed a 75-week lifestyle intervention (dietary advice, exercise, and psychoeducation). RESULTS: Mean sIL-2R and sCD163 levels were higher in patients than controls (sIL-2R:2884 ± 936 pg/ml vs. 2207 ± 813 pg/ml, p = 0.001; sCD163:1279 ± 580 pg/ml vs. 661 ± 271 pg/ml, p < 0.0001 respectively). Patients with metabolic syndrome (MetS) had higher sCD163 than those without (1467 ± 656 pg/ml vs. 1103 ± 438 pg/ml). Patients had higher IL-1ß, IL-1RA, IL-2, IL-4, IL-5, IL-6, IL-8, IL-9, IL-10, IL-15, IL-17A, MCP-1/CCL2, MIP-1α/CCL3, MIP-1ß/CCL4, G-CSF, GM-CSF, FGF, IFN-γ, and TNF-α than controls, whereas VEGF-A, PDGF-BB, and eotaxin were lower. Upon intervention, sIL-2R decreased while peripheral Treg frequencies increased within the reference range (p = 0.042 and p = 0.005 respectively). The sIL-2R decrease correlated to a decrease in waist circumference (rho = 0.388, p = 0.045) and in trend to a decrease in MetS components (rho = 0.345, p = 0.078). The Treg increase was unrelated to weight loss or metabolic improvement. Mean sCD163 did not change significantly upon intervention, nor did the cytokines, chemokines, and growth factors (except IP-10/CXCL10). CONCLUSION: In obesity, T-cell homeostasis improves after a lifestyle intervention. Immunologic alterations can occur independently of metabolic improvement.

[Obesity in the clinic room: diagnostics first, followed by effective treatment]. / Obesitas in de spreekkamer.

In clinical practice, relatively little attention is directed towards identifying underlying causes and contributing factors to weight gain in patients with obesity. However, recognising these "hidden fattening factors" is important as it can lead to more effective treatment strategies. In particular if underlying causes can be solved first, this could help to realise sustainable weight reduction. Besides the well-known lifestyle-related aspects, obesity may be caused or maintained by medication use, endocrine or hypothalamic disorders, monogenetic or syndromic diseases, and mental factors, which may require specific (medical) treatment. For lifestyle-related obesity, a combined lifestyle intervention (CLI) is a first step to combat obesity. This treatment comprises intensive guidance regarding healthy nutrition, physical activity, and behavioural psychology. In case of morbid obesity and insufficient effects of CLI after one year, weight-reducing medication or a bariatric intervention can be considered. This systematic strategy for diagnostics and treatment of obesity is illustrated by two clinical cases.

High-dose chemotherapy with autologous haematopoietic stem cell support for relapsed or refractory primary CNS lymphoma: a prospective multicentre trial by the German Cooperative PCNSL study group.

To investigate safety and efficacy of high-dose chemotherapy followed by autologous stem cell transplantation (HCT-ASCT) in relapsed/refractory (r/r) primary central nervous system lymphoma (PCNSL), we conducted a single-arm multicentre study for immunocompetent patients (<66 years) with PCNSL failing high-dose methotrexate)-based chemotherapy. Induction consisted of two courses of rituximab (375 mg/m2), high-dose cytarabine (2 × 3 g/m2) and thiotepa (40 mg/m2) with collection of stem cells in between. Conditioning for HCT-ASCT consisted of rituximab 375 mg/m2, carmustine 400 mg/m2 and thiotepa (4 × 5 mg/kg). Patients commenced HCT-ASCT irrespective of response after induction. Patients not achieving complete remission (CR) after HCT-ASCT received whole-brain radiotherapy. Primary end point was CR after HCT-ASCT. We enrolled 39 patients; median age and Karnofsky performance score are 57 years and 90%, respectively. About 28 patients had relapsed and 8 refractory disease. About 22 patients responded to induction and 32 patients commenced HCT-ASCT. About 22 patients (56.4%) achieved CR after HCT-ASCT. Respective 2-year progression-free survival (PFS) and overall survival (OS) rates were 46.0% (median PFS 12.4 months) and 56.4%; median OS not reached. We recorded four treatment-related deaths. Thiotepa-based HCT-ASCT is an effective treatment option in eligible patients with r/r PCNSL. Comparative studies are needed to further scrutinise the role of HCT-ASCT in the salvage setting.

[Normoglycaemic ketoacidosis in pregnant patients with diabetes; early recognition is critical]. / Normoglykemische ketoacidose bij zwangere diabetici.

Diabetic ketoacidosis (DKA) during pregnancy is a rare but very serious complication that requires early recognition and treatment to prevent severe complications. Here we present three cases in which DKA occurred during normoglycaemia, demonstrating the importance of early recognition. In pregnancy, DKA can occur at lower blood glucose levels than usual due to several pregnancy-related factors, such as altered metabolism, increased insulin resistance, lower buffering capacity related to chronic hyperventilation and hunger. Symptoms that are common during pregnancy, such as vomiting, may be missed as a first sign of DKA. In patients with type 1 diabetes mellitus (especially those on continuous subcutaneous insulin infusion) insulin administration must never be discontinued, as this prevents lipolysis and ketone formation. Physicians and patients need to be aware of the risks and management of DKA in pregnancy.

Genetic associations in diabetic nephropathy: a meta-analysis.

AIMS/HYPOTHESIS: This meta-analysis assessed the pooled effect of each genetic variant reproducibly associated with diabetic nephropathy. METHODS: PubMed, EMBASE and Web of Science were searched for articles assessing the association between genes and diabetic nephropathy. All genetic variants statistically associated with diabetic nephropathy in an initial study, then independently reproduced in at least one additional study, were selected. Subsequently, all studies assessing these variants were included. The association between these variants and diabetic nephropathy (defined as macroalbuminuria/proteinuria or end-stage renal disease [ESRD]) was calculated at the allele level and the main measure of effect was a pooled odds ratio. Pre-specified subgroup analyses were performed, stratifying for type 1/type 2 diabetes mellitus, proteinuria/ESRD and ethnic group. RESULTS: The literature search yielded 3,455 citations, of which 671 were genetic association studies investigating diabetic nephropathy. We identified 34 replicated genetic variants. Of these, 21 remained significantly associated with diabetic nephropathy in a random-effects meta-analysis. These variants were in or near the following genes: ACE, AKR1B1 (two variants), APOC1, APOE, EPO, NOS3 (two variants), HSPG2, VEGFA, FRMD3 (two variants), CARS (two variants), UNC13B, CPVL and CHN2, and GREM1, plus four variants not near genes. The odds ratios of associated genetic variants ranged from 0.48 to 1.70. Additional variants were detected in subgroup analyses: ELMO1 (Asians), CCR5 (Asians) and CNDP1 (type 2 diabetes). CONCLUSIONS/INTERPRETATION: This meta-analysis found 24 genetic variants associated with diabetic nephropathy. The relative contribution and relevance of the identified genes in the pathogenesis of diabetic nephropathy should be the focus of future studies.

Integrin stimulation-induced hypertrophy in neonatal rat cardiomyocytes is NO-dependent.

Prolonged myocardial stretch typically leads to hypertrophy of cardiomyocytes. As integrins are cellular receptors of stretch, we hypothesize that integrin stimulation induces cardiomyocyte hypertrophy. Integrins of neonatal rat cardiomyocytes (NRCMs) were stimulated with a peptide containing the Arg-Gly-Asp (RGD) sequence for 24 h. For comparison, alpha(1)-adrenergic stimulation by phenylephrine (PE) for 24 h was applied. Saline-treated NRCMs were used as control. The hypertrophic response was quantified by measuring cell surface area (CSA). Phosphorylation of NO-synthase-1 (NOS1) was assessed by immunocytochemistry. CSA was increased by 38% (IQR 31-44%) with RGD and by 68% (IQR 64-84%) with PE versus control (both P < 0.001). NOS-1 phosphorylation was increased by 61% with RGD and by 21% with PE versus control (both P < 0.01). A general NOS-inhibitor (L-NAME) inhibited RGD-induced hypertrophy completely, but had no significant effect on PE-induced hypertrophy. Administration of NO-donor to NRCMs co-incubated with RGD + L-NAME partly restored hypertrophy (to 62% of the hypertrophic effect of RGD alone), but had no effect if incubated with PE + L-NAME. Ryanodine and BAPTA-AM inhibited RGD-induced hypertrophy completely but not that induced by PE. Integrin stimulation of NRCMs by RGD leads to hypertrophy, likely by activation of NOS-1. Abrogation of RGD-induced hypertrophic response upon NOS-inhibition and rescue of this hypertrophic effect by NO-donor suggest that integrin stimulation-induced hypertrophy of NRCMs is NO-dependent.

Release kinetics of intact and degraded troponin I and T after irreversible cell damage.

PURPOSE: We characterized the release kinetics of cardiac troponin I and T in relation to lactate dehydrogenase (LDH) from cardiomyocytes before and after the transition from reversible to irreversible cell damage. METHODS: Cardiomyocytes were exposed to mild metabolic inhibition (1 mmol/L sodium azide) to induce a necrotic cell death process that is characterized by a reversible (0-12 h) and irreversible phase (12-30 h). At various time intervals cells and media were collected and analyzed for LDH activity, intact cTnI and cTnT, and their degradation products. RESULTS: During the first 12 h of metabolic inhibition, cell viability was unchanged with no release of intact cTnI and cTnT nor their degradation products. Between 12 and 30 h of azide treatment, cardiomyocytes showed progressive cell death accompanied by release of intact cTnI (29 kDa), intact cTnT (39 kDa), four cTnI degradation products of 26, 20, 17 and 12 kDa, and three cTnT degradation products of 37, 27 and 14 kDa. Possibly due to degradation, there is progressive loss of cTnI and cTnT protein that is obviously undetected by the antibodies used. CONCLUSIONS: Metabolic inhibition of cardiomyocytes induces a parallel release of intact cTnI and cTnT and their degradation products, starting only after onset of irreversible cardiomyocyte damage.

Release of cardiac troponin I from viable cardiomyocytes is mediated by integrin stimulation.

Elevated cardiac troponin-I (cTnI) levels have been demonstrated in serum of patients without acute coronary syndromes, potentially via a stretch-related process. We hypothesize that this cTnI release from viable cardiomyocytes is mediated by stimulation of stretch-responsive integrins. Cultured cardiomyocytes were treated with (1) Gly-Arg-Gly-Asp-Ser (GRGDS, n = 22) to stimulate integrins, (2) Ser-Asp-Gly-Arg-Gly (SDGRG, n = 8) that does not stimulate integrins, or (3) phosphate-buffered saline (control, n = 38). Cells and media were analyzed for intact cTnI, cTnI degradation products, and matrix metalloproteinase (MMP)-2. Cell viability was examined by assay of lactate dehydrogenase (LDH) activity and by nuclear staining with propidium iodide. GRGDS-induced integrin stimulation caused increased release of intact cTnI (9.6 +/- 3.0%) as compared to SDGRG-treated cardiomyocytes (4.5 +/- 0.8%, p < 0.001) and control (3.0 +/- 3.4%, p < 0.001). LDH release from GRGDS-treated cardiomyocytes (15.9 +/- 3.8%) equalled that from controls (15.2 +/- 2.3%, p = n.s.), indicating that the GRGDS-induced release of cTnI is not due to cell necrosis. This result was confirmed by nuclear staining with propidium iodide. Integrin stimulation increased the intracellular and extracellular MMP2 activity as compared to controls (both p < 0.05). However, despite the ability of active MMP2 to degrade cTnI in vitro, integrin stimulation in cardiomyocytes was not associated with cTnI degradation. The present study demonstrates that intact cTnI can be released from viable cardiomyocytes by stimulation of stretch-responsive integrins.

Integrin stimulation induces calcium signalling in rat cardiomyocytes by a NO-dependent mechanism.

The myocardial stretch-induced increase in intracellular [Ca(2+)] ([Ca(2+)](i)) is considered to be caused by integrin stimulation. Myocardial stretch is also associated with increased nitric oxide (NO) formation. We hypothesised that NO is implicated in calcium signalling following integrin stimulation. Integrins of neonatal rat cardiomyocytes were stimulated with a pentapeptide containing the Arg-Gly-Asp (RGD) sequence. [Ca(2+)](i) was measured with Fura2, [NO](i) was measured with DAF2 and phosphorylation of focal adhesion kinase (FAK) was monitored with immunofluorescence techniques. Integrin stimulation increased both [NO](i) and [Ca(2+)](i), the latter response being inhibited by ryanodine receptor-2 (RyR2) blockers and by N(G)-monomethyl-L-arginine (L-NMMA), an inhibitor of NOS, but resistant to GdCl(3), diltiazem and wortmannin. Integrin-induced intracellular Ca(2+) release thus appears to be independent of the influx of extracellular Ca(2+) and phosphatidylinositol-3 kinase activity. In addition, integrin stimulation induced phosphorylation of FAK. Our results provide evidence for an integrin-induced Ca(2+) release from RyR2 which is mediated by NO formation, probably via FAK-induced NOS activation.

Relationship between vitamin E requirement and polyunsaturated fatty acid intake in man: a review.

Vitamin E is the general term for all tocopherols and tocotrienols, of which alpha-tocopherol is the natural and biologically most active form. Although gamma-tocopherol makes a significant contribution to the vitamin E CONTENT in foods, it is less effective in animal and human tissues, where alpha-tocopherol is the most effective chain-breaking lipid-soluble antioxidant. The antioxidant function of vitamin E is critical for the prevention of oxidation of tissue PUFA. Animal experiments have shown that increasing the degree of dietary fatty acid unsaturation increases the peroxidizability of the lipids and reduces the time required to develop symptoms of vitamin E deficiency. From these experiments, relative amounts of vitamin E required to protect the various fatty acids from being peroxidized, could be estimated. Since systematic studies on the vitamin E requirement in relation to PUFA consumption have not been performed in man, recommendations for vitamin E intake are based on animal experiments and human food intake data. An intake of 0.6 mg alpha-tocopherol equivalents per gram linoleic acid is generally seen as adequate for human adults. The minimum vitamin E requirement at consumption of fatty acids with a higher degree of unsaturation can be calculated by a formula, which takes into account the peroxidizability of unsaturated fatty acids and is based on the results of animal experiments. There are, however, no clear data on the vitamin E requirement of humans consuming the more unsaturated fatty acids as for instance EPA (20:5, n-3) and DHA (22:6, n-3). Studies investigating the effects of EPA and DHA supplementation have shown an increase in lipid peroxidation, although amounts of vitamin E were present that are considered adequate in relation to the calculated oxidative potential of these fatty acids. Furthermore, a calculation of the vitamin E requirement, using recent nutritional intake data, shows that a reduction in total fat intake with a concomitant increase in PUFA consumption, including EPA and DHA, will result in an increased amount of vitamin E required. In addition, the methods used in previous studies investigating vitamin E requirement and PUFA consumption (for instance erythrocyte hemolysis), and the techniques used to assess lipid peroxidation (e.g. MDA analysis), may be unsuitable to establish a quantitative relation between vitamin E intake and consumption of highly unsaturated fatty acids. Therefore, further studies are required to establish the vitamin E requirement when the intake of longer-chain, more-unsaturated fatty acids is increased. For this purpose it is necessary to use functional techniques based on the measurement of lipid peroxidation in vivo. Until these data are available, the widely used ratio of at least 0.6 mg alpha-TE/g PUFA is suggested. Higher levels may be necessary, however, for fats that are rich in fatty acids containing more than two double bonds.

Protection of myocytes against free radical-induced damage by accelerated turnover of the glutathione redox cycle.

The primary defence mechanism of myocytes against peroxides and peroxide-derived peroxyl and alkoxyl radicals is the glutathione redox cycle. The purpose of the present study was to increase the turnover rate of this cycle by stimulating the glutathione peroxidase catalysed reaction (2GSH-->GSSG), the glutathione reductase catalysed reaction (GSSG-->2GSH), or both. Neonatal rat heart cell cultures were subjected to a standardized protocol of oxidative stress using 80 mumol.l-1 cumene hydroperoxide (CHPO) for 0-90 min. The consequences of this protocol were described in terms of cellular concentrations of GSH, GSSG, NADPH and ATP, formation of malondialdehyde (MDA), release of GSSG and of ATP catabolites, depression of contraction frequency, cellular calcium overload, and enzyme release. Trolox-C, an analogue of vitamin E, accelerated the glutathione peroxidase reaction leading to lowering of GSH concentration and the GSH/GSSG ratio, less MDA formation, diminished negative chronotropy, delayed calcium overload, and less enzyme release. Glucose was used to accelerate the glutathione reductase reaction by supplying NADPH, leading to higher GSH concentration and a higher GSH/GSSG ratio, less MDA formation, diminished negative chronotropy, unchanged development of calcium overload, and less enzyme release. As a full turn of the glutathione redox cycle involves both the peroxidase and the reductase reactions, the combination of Trolox-C and glucose was superior to either of the two alone: 90 min following addition of CHPO together with Trolox-C and glucose, the GSH concentration and the GSH/GSSG ratio were almost normal, MDA formation was extremely low, calcium overload was markedly delayed, and enzyme release hardly occurred at all. Cells remained beating in the observation period of 30 min. We conclude that the capacity of the glutathione redox cycle to withstand oxidative stress can be increased by stimulation of either the peroxidase reaction or the reductase reaction, and that optimal redox cycling is achieved by stimulation of both reactions.

Desferrioxamine protects myocytes against peroxide-induced myocyte damage without affecting glutathione redox cycle turnover.

The primary defense mechanism of myocytes against peroxide-derived free radicals is the glutathione redox cycle. The purpose of the present study was to investigate whether desferrioxamine protects myocytes against peroxide-induced cell damage, and if so, whether the turnover rate of the glutathione redox cycle is involved in this protection. Neonatal rat heart cell cultures were subjected to a standardized oxidative stress by a 90 min incubation with 80 mumol/l cumene hydroperoxide. The consequences of this stress protocol were described in terms of cellular concentrations of GSH, GSSG, ATP, ATP-catabolites, and Ca2+, formation of malondialdehyde to quantify lipid peroxidation, and enzyme release to quantify the relative number of irreversibly injured cells. Following pretreatment of cell cultures with 10 mmol/l desferrioxamine mesylate for 1 h, 80 mumol/l cumene hydroperoxide caused less malondialdehyde formation (at 90 min: 0.34 v 2.35 nmol), less ATP depletion (at 60 min: 16.7 v 3.6 nmol), less Ca2+ overload (at 30 min: 40 v 1500 nM) and less enzyme release (at 90 min: 4.6 v 60.5% of the cells) compared to cell cultures subjected to cumene hydroperoxide without pretreatment. However, in desferrioxamine pretreated cell cultures cumene hydroperoxide caused cellular GSH depletion (at 60 min: 19.5 v 20.8 nmol) and GSSG efflux (at 60 min: 6.3 v 6.0 nmol) which was not different from cell cultures subjected to cumene hydroperoxide without pretreatment. Added to the finding that in a cell-free system cumene hydroperoxide is a substrate for glutathione peroxidase, we conclude that desferrioxamine, by chelating free iron ions (1), prevented the formation of cumene alkoxyl and peroxyl radicals associated with protection of the myocytes, and (2) did not diminish rapid glutathione redox cycling leading to GSH depletion and GSSG efflux.

Buthionine sulfoximine reduces the protective capacity of myocytes to withstand peroxide-derived free radical attack.

Mammalian heart myocytes have a limited capacity to withstand the deleterious effects of free radical generating compounds. To assess the role of the glutathione redox cycle relative to this capacity, rat heart cell cultures were subjected for 90 min to 80 mumol/l cumene hydroperoxide (CHPO) without and with prior glutathione depletion by buthionine sulfoximine. Preincubation of cultures with 125 mumol/l buthionine sulfoximine for 2 h and 17 h caused a reduction of glutathione by 33% and 82%, respectively, without concomitant increase of glutathione disulfide. Subsequent incubation with CHPO for 90 min caused slowing of NADPH consumption (in the first 20 min 27 pmol vs 68 pmol without pretreatment with buthionine sulfoximine for 17 h), which indicates that glutathione depletion reduced the turnover rate of the glutathione redox cycle. Pretreatment with buthionine sulfoximine for 17 h exaggerated the negative chronotropic effects of CHPO: the time elapsed to 50% of baseline contraction frequency fell from 5.7 +/- 1.4 min without buthionine sulfoximine to 3.7 +/- 0.4 min after pretreatment with buthionine sulfoximine (P < 0.02). The severity of CHPO-induced lipid peroxidation as assessed by malondialdehyde formation (2.23 +/- 0.51 vs 0.99 +/- 0.05 nmol in the first 20 min; P < 0.05) was increased by buthionine sulfoximine pretreatment, as was the extent of cell necrosis as assessed by release of alpha-hydroxybutyrate dehydrogenase (39.5 +/- 5.1 vs 29.0 +/- 12.9% in the first 45 min). A "sublethal" dose of 10 microM CHPO for 60 min caused no substantial HBDH release, no formation of malondialdehyde, and no exhaustion of cellular GSH (35 nmol/U HBDHt = 0). However, following pretreatment with buthionine sulfoximine, 10 microM CHPO for 60 min produced 12% HBDH release and extensive lipid peroxidation (1.95 nmol malondialdehyde/U HBDHt = 0). As the deleterious effects of CHPO were aggravated by glutathione depletion, we conclude that the glutathione redox cycle plays a major role in the protection of myocytes against peroxide-induced free radical attack.

Effects of glucose, Trolox-C, and glutathione disulphide on lipid peroxidation and cell death induced by oxidant stress in rat heart.

OBJECTIVE: The aim was to find effective protection of myocytes against peroxide induced damage in terms of preservation of contractile activity, protection against lipid peroxidation, and protection against cell death. METHODS: The components of the glutathione redox cycle, the production of malondialdehyde, cell contractions, and enzyme release from myocytes were measured in cultured neonatal rat heart cells before and after administration of cumene hydroperoxide, 80 mumol.litre-1. The protective action was tested of (1) glucose (10 mmol.litre-1) which stimulates the production of NADPH; (2) Trolox-C (0.16 mmol.litre-1) which is a water soluble analogue of alpha tocopherol and a scavenger of free radicals; and (3) GSSG (0.6 mmol.litre-1) which increases the intracellular concentrations of GSH and GSSG. RESULTS: Although the three substances tested were equally effective in reducing the formation of malondialdehyde, exogenous GSSG afforded only slight protection against cumene hydroperoxide induced cell death, whereas glucose and Trolox-C were highly effective protectors. The depressant effect of cumene hydroperoxide on beating frequency was not influenced by preincubation with GSSG, nor by coadministration of glucose, but Trolox-C was able to diminish the negative chronotropic action of cumene hydroperoxide. CONCLUSIONS: Effective protection against cumene hydroperoxide induced lipid peroxidation is not associated per se with effective protection against cumene hydroperoxide induced loss of beating frequency and cell death.

A method to quantitate cell numbers of muscle cells and non-muscle cells in homogenised heart cell cultures.

Neonatal rat heart cell cultures are popular research models in cardiovascular investigations. A major disadvantage is the variable contribution of non-muscle cells to the cultures. As biochemical and pharmacological quantities are generally measured in homogenised cultures, we looked for a method to calculate numbers of muscle cells and non-muscle cells per culture after homogenisation. By means of a model based on the presence of one diploid nucleus per myocyte and per non-muscle cell, a nuclear DNA content of 7.5 pg, and a constant ratio of DNA content and sum of the lactate dehydrogenase isoenzymes LDH-4 and LDH-5 (DNA/LDH4+5 = 11.6 +/- 1.5 micrograms.U-1) in non-muscle cells, we calculated that in 21 neonatal rat heart cell cultures, cultured for 0-6 days, the number of muscle cells was 1.5 X 10(6) per culture, independent of time; and the number of non-muscle cells was low at day 0 (1.6 X 10(5) per culture), increasing to 4 X 10(6) per culture at day 6. Based on a time dependent increase in lactate dehydrogenase content per muscle cell we showed that muscle cells in culture underwent progressive hypertrophy: in 6 days myocyte volume increased fourfold. Thus, by measurement of DNA content and the activities of lactate dehydrogenase and its isoenzymes in a homogenised culture the cellular composition of the culture can be assessed quantitatively.

Recognition and quantification of myocardial injury by means of plasma enzyme and isoenzyme activities after cardiac surgery.

Serial plasma enzyme determinations were carried out in 32 patients who underwent cardiac surgery with the aid of extracorporeal circulation. Plasma creatine kinase (CK), the cardiospecific isoenzyme of CK (CKMB), and alpha-hydroxybutyrate dehydrogenase (HBDH) were determined from the onset of surgery up to 100 to 120 hours after operation. From the plasma enzyme activities, the total amount of enzyme released by the injured heart into the circulation could be calculated using mathematical equations solved numerically by means of a computer. The calculated amount of CK, CKMB, and HBDH released by the heart correlated well with (1) postoperative mortality, and (2) peak activities of the respective enzymes. The calculated amount of any of the 3 enzymes released showed poor or no correlation with (1) electrocardiographic criteria of myocardial infarction, (2) duration of cardiopulmonary bypass, and (3) duration of total aortic cross-clamping. This study shows that the extent of myocardial injury after surgery can be assessed quantitatively using the calculated amounts of enzyme released, as well as using peak plasma activities of CKMB and HBDH.