Wang XY, Li N, Gu J, Li WQ, Li JS. The effects of the formula of amino acids enriched BCAA on nutritional support in traumatic patients. World J Gastroenterol 2003; 9(3): 599-602 [PMID: 12632526 DOI: 10.3748/wjg.v9.i3.599]
Corresponding Author of This Article
Xin-Ying Wang, Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, China. wxinying@263.net
Article-Type of This Article
Clinical Research
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Xin-Ying Wang, Ning Li, Jun Gu, Wei-Qin Li, Jie-Shou Li, Medical School of Nanjing University, Research Institute of General Surgery, Jinling Hospital, Nanjing 210002, Jiangsu Province, China
ORCID number: $[AuthorORCIDs]
Author contributions: All authors contributed equally to the work.
Supported by the Natural Science Foundation of Jiangsu Province, China (No. BQ 2000014), and the Tenth Five-year Medicine Research Foundation in the CPLA (No. 01Z011)
Correspondence to: Xin-Ying Wang, Research Institute of General Surgery, Jinling Hospital, 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, China. wxinying@263.net
Received: August 13, 2002 Revised: September 5, 2002 Accepted: September 16, 2002 Published online: March 15, 2003
Abstract
AIM: To investigate the formula of amino acid enriched BCAA on nutritional support in traumatic patients after operation.
METHODS: 40 adult patients after moderate or large abdominal operations were enrolled in a prospective, randomly and single-blind-controlled study, and received total parenteral nutrition (TPN) with either formula of amino acid (AA group, 20 cases) or formula of amino acid enriched BCAA (BCAA group, 20 cases). From the second day after operation, total parenteral nutrition was infused to the patients in both groups with equal calorie and equal nitrogen by central or peripheral vein during more than 12 hours per day for 6 days. Meanwhile, nitrogen balance was assayed by collecting 24 hours urine for 6 days. The markers of protein metabolism were investigated such as amino acid patterns, levels of total protein, albumin, prealbumin, transferrin and fibronectin in serum.
RESULTS: The positive nitrogen balance in BCAA group occurred two days earlier than that in AA group. The serum levels of total protein and albumin in BCAA group were increased more obviously than that in AA group. The concentration of valine was notably increased and the concentration of arginine was markedly decreased in BCAA group after the formula of amino acids enriched BCAA transfusion.
CONCLUSION: The formula of amino acid enriched BCAA may normalize the levels of serum amino acids, reduce the proteolysis, increase the synthesis of protein, improve the nutritional status of traumatic patients after operation.
Key Words: $[Keywords]
Citation: Wang XY, Li N, Gu J, Li WQ, Li JS. The effects of the formula of amino acids enriched BCAA on nutritional support in traumatic patients. World J Gastroenterol 2003; 9(3): 599-602
Hypermetabolism and increased catabolism can be observed in traumatic patients after operation, which may result in severe disturbance of sugar, lipid and protein metabolism[1-4], companied with the changes on the levels of amino acids in serum[5,6]. How to adjust the formula of amino acids to improve the metabolism is an interesting project. There has been no data about formula of amino acid which is fit for nutritional support of patients after trauma yet[7-11]. The purpose of our study was to investigate the effects of the formula of amino acids enriched BCAA on nutritional support in traumatic patients after operation.
MATERIALS AND METHODS
Subjects
40 adult patients after moderate or large abdominal operations who needed total parenteral nutrition (TPN) for more than 6 days were enrolled in a prospective, randomly and single-blind-controlled study from multiple centers during the period from March 2000 to November 2000. The patients (21 males and 19 females) weighed 45-71 kg and were 20-70 years old without metabolic diseases, malnutrition and dysfunction of liver and kidney. The change of weight in each patient was less than 10% of that before disease. The patients were divided into two groups in random order, the control group (AA group) supplemented with the formula of amino acid (BCAA 22.8%) and the study group (BCAA group) with the formula of amino acid enriched BCAA (BCAA 35.9%).
Experiment protocols
TPN was infused with equal nitrogen and calorie through peripheral or central vein during more than 12 hours per day for 6 days, and began on the 2nd day after operation. The formula included nitrogen (0.2 g·kg-1d-1), non-protein calorie (NPC, 25 kcal·kg-1d-1), the ratio of NPC to N (125/1), the ratio of lipid to sugar (1/1-3/2).
Collection of samples
Serum samples from all patients were collected on the day before operation and on the 7th day after operation. The amino acid pattern, total protein, albumin, prealbumin, transferring and fibronectin in serum were detected.
Urine samples: 24-hour urine samples (total volume of urine from 6 am on the first day to 6 am on the second day) of 40 patients were collected from the day before operation to the 7th day after operation to analyze nitrogen balance.
Assays of amino acids, proteins and nitrogen balance
The amino acid pattern in serum was analyzed by the system of high liquid phase amino acid analysis (BECKMAN, USA): 126AA, 166 monitor, 232 reactor, 507 autoloador, golden data station. The total protein (TP) and albumin in serum were respectively detected by the automatic biochemistry analyzer. The serum prealbumin, transferrin, fibronectin were monitored with anti-Pa, anti-Tf, anti-Fn immuno-diffusion board. (Yuhuan reagent Co.) The nitrogen balance was analyzed with the method of Kjeldah1 to get the data of nitrogen content in urine.
Statistical analysis
All data were expressed as mean ± SD. Comparisons between two groups were performed using an unpaired Student’s t test. Differences were considered statistically significant when P < 0.05.
RESULTS
General clinical data
The age, sex, weight diagnosis and operation of patients were presented in Table 1, and showed the data comparable in both groups.
Table 1 The comparability of patients’ age, sex and operation.
Group
Case
Age(y)
Sex(M/F)
Weigh before operation(kg)
Colectomy
Enterectomy
Miles
Rectal cancer anterior-rectal resection
Aborminal trauma
Digestive tract tumor resection
AA
20
20-75
9/11
59.58 ± 12.28
9
4
2
1
1
3
BCAA
20
20-75
12/8
60.38 ± 9.83
7
5
0
2
5
1
Nitrogen balance
As shown in Figure 1, the negative nitrogen balance was observed from all patients in both groups after operation, which was significantly improved after TPN infusion. The positive nitrogen balance in study group occurred on the third day after operation, which was earlier two days than that in the control group. On the sixth day after operation, the nitrogen balance in the study group is obviously better than that in the control group (P < 0.05).
Figure 1 Nitrogen balance after infusion in two groups.aP < 0.05 vs the control group.
Serum levels of prealbumin, fibronectin, and transferrin
The serum levels of prealbumin, fibronectin, and transferring have no significant difference beween two groups (Table 2).
Table 2 The changes of prealbumin, fibronectin and transferrin in two groups.
Group
Case
Before transfusion -x±s
After transfusion -x±s
Difference -x±s
P value
Prealbumin (g/L)
I
20
0.467 ± 0.294
0.449 ± 0.305
-0.018 ± 0.091
0.305
II
20
0.296 ± 0.239
0.297 ± 0.250
0.001 ± 0.048
Fibronectin (g/L)
I
20
2.200 ± 0.752
2.112 ± 0.789
-0.085 ± 0.344
0.128
II
20
2.201 ± 0.792
2.345 ± 1.052
0.144 ± 0.735
Transferrin (g/L)
I
20
0.316 ± 0.171
0.335 ± 0.179
0.019 ± 0.211
0.970
II
20
0.276 ± 0.107
0.296 ± 0.524
0.018 ± 0.116
Serum levels of albumin and total protein
There is significant difference before and after study in the serum levels of albumin and total protein of two groups. As shown in Figure 2, contrast to the study group, the serum levels of total protein and albumin decreased greatly in the control group after operation (P < 0.05).
Figure 2 The changes of total protein and albumin after infusion in two groups.aP < 0.05 vs the control group.
The change in the pattern of serum amino acid
The concentration of valine was notably increased (P = 0.02642) and that of arginine was markedly decreased (P = 0.0412) in the study group after the formula of amino acids enriched BCAA infusion when compared with the control group. In the study group, the concentrations of valine, threonine, alanine, methionine, histidine, phenylalanine and BCAA are higher after infusion than those before transfusion (P < 0.05). In the control group, the concentrations of glycine, histine and phenylalanine are higher after infusion than those before infusion (P < 0.05). (Table 3).
Table 3 The changes of the amino acid pattern in serum after infusion.
Group
Case
Before infusion -x±s
After infusion -x±s
P value
Difference -x±s
P value
Asparagic acid(umol/L)
I
20
0.0748 ± 0.0672
0.0942 ± 0.0789
0.2580
0.0194 ± 0.0638
0.8728
II
20
0.0633 ± 0.0413
0.0797 ± 0.0558
0.0999
0.0164 ± 0.0360
Threonine (umol/L)
I
20
0.1973 ± 0.1554
0.2829 ± 0.2147
0.0354
0.0856 ± 0.1424
0.2415
II
20
0.1549 ± 0.0863
0.3154 ± 0.2331
0.0065
0.1601 ± 0.1943
Serine (umol/L)
I
20
0.2320 ± 0.1455
0.2600 ± 0.1701
0.4696
0.0279 ± 0.1456
0.5872
II
20
0.1981 ± 0.1305
0.2518 ± 0.1576
0.0759
0.0537 ± 0.1086
Glutacid (umol/L)
I
20
0.2619 ± 0.2755
0.2829 ± 0.2146
0.8237
0.0209 ± 0.3574
0.3334
II
20
0.2718 ± 0.2409
0.4212 ± 0.3217
0.1275
0.1493 ± 0.3570
Glycine (umol/L)
I
20
0.3844 ± 0.2695
0.5402 ± 0.3608
0.0173
0.1558 ± 0.2237
0.9325
II
20
0.3722 ± 0.2207
0.5193 ± 0.3565
0.1028
0.1471 ± 0.3265
Alanine (umol/L)
I
20
0.5067 ± 0.3043
0.5737 ± 0.4167
0.5325
0.0669 ± 0.4053
0.1322
II
20
0.4382 ± 0.2862
0.7291 ± 0.5371
0.0111
0.2908 ± 0.3849
Valine (umol/L)
I
20
0.2959 ± 0.2188
0.2722 ± 0.2168
0.6596
-0.0237 ± 0.2038
0.0264
II
20
0.2601 ± 0.1494
0.4599 ± 0.3765
0.0249
0.1999 ± 0.3082
Cysteine (umol/L)
I
20
0.0138 ± 0.0180
0.0209 ± 0.0182
0.1043
0.0057 ± 0.0127
0.9373
II
20
0.0300 ± 0.0202
0.0350 ± 0.0244
0.5238
0.0050 ± 0.0296
Methionine (umol/L)
I
20
0.0472 ± 0.0361
0.0590 ± 0.0498
0.3292
0.0118 ± 0.0452
0.4447
II
20
0.0282 ± 0.0222
0.0516 ± 0.0440
0.0253
0.0234 ± 0.0362
Isoleucine (umol/L)
I
20
0.1030 ± 0.0728
0.1298 ± 0.0874
0.1973
0.0268 ± 0.0766
0.7457
II
20
0.0825 ± 0.0586
0.1181 ± 0.0914
0.0730
0.0356 ± 0.0711
Leucine (umol/L)
I
20
0.2368 ± 0.1699
0.2496 ± 0.1694
0.7556
0.0128 ± 0.1557
0.3377
II
20
0.1770 ± 0.1113
0.2399 ± 0.1674
0.0698
0.0629 ± 0.1242
Tyrosine (umol/L)
I
20
0.0774 ± 0.0511
0.0787 ± 0.0631
0.9380
0.0014 ± 0.0659
0.7263
II
20
0.0584 ± 0.0378
0.0677 ± 0.0528
0.5343
0.0093 ± 0.0563
Phenylalanine (umol/L)
I
20
0.0897 ± 0.0960
0.1572 ± 0.1323
0.0289
0.0675 ± 0.1074
0.9835
II
20
0.0736 ± 0.0518
0.1418 ± 0.1277
0.0138
0.0683 ± 0.0939
Lysine (umol/L)
I
20
0.1888 ± 0.1780
0.2311 ± 0.1984
0.3706
0.0422 ± 0.1767
0.6928
II
20
0.1124 ± 0.1226
0.1836 ± 0.2403
0.2280
0.0712 ± 0.2187
Histidine (umol/L)
I
20
0.2517 ± 0.1691
0.2885 ± 0.2054
0.2654
0.0368 ± 0.1227
0.2958
II
20
0.1907 ± 0.1041
0.2756 ± 0.1778
0.0196
0.0850 ± 0.1249
Arginine (umol/L)
I
20
0.1214 ± 0.2102
0.2534 ± 0.5048
0.1584
0.1320 ± 0.3433
0.0412
II
20
0.2038 ± 0.4115
0.0480 ± 0.0678
0.1459
-0.1559 ± 0.3921
BCAA (umol/L)
I
20
0.6358 ± 0.4556
0.6516 ± 0.4014
0.8631
0.0158 ± 0.3494
0.0785
II
20
0.5196 ± 0.3128
0.8180 ± 0.6279
0.0325
0.2984 ± 0.4869
DISCUSSION
The trauma caused by moderate or large operation may result in disturbance of glucose, lipid and protein metabolism including hypermetabolism and increased catabolism, which may lead to acute protein malnutrition, decline of immunological function and dysfunction of multiple organs[12-16]. It was reported that the supplement of the special amino acids such as arginine, BCAA and glutamine would improve recovery of patients[17-24]. Our present study was to observe the effect of the formula of amino acids enriched BCAA on patients after trauma.
In this study, we began to supplement the application of the formula of amino acid enriched BCAA on day 2 after operation to correct patients’ hypermetabolism, to normalize the pattern of plasma amino acid concentrations and to improve recovery of patients. BCAA(valine, leucine, isoleucine) can be used as the substrate for energy and glyconeogenesis and as the muscle protein regulator. BCAA can increase the intake of energy by means of oxidization into energy in the tissues without aggran dizin g the burd en of the liver . As glyconeogenesis substrate, BCAA can also be oxidized in body and produce much energy by the mechanism of circulation between oxidation and alanine synthesis[25-28]. The valine, leucine and isoleucine per gram molecular can produce 42, 43 and 32 gram molecular ATP respectively, which can supply a lot of energy to the body. The character as the source of energy for these 3 amino acids is that their first carbon can be oxidized and produce phosphate of high energy without glutamic acid, which is helpful for the decline of mechanism of producing energy with glutamic acid during trauma and stress. Because BCAA is mainly metabolized in muscle, the application of the formula of amino acid enriched BCAA can decrease the decompose of visceral protein such as muscle and liver proteins, prevent the loss of amino acids from muscle, correct negative balance, improve protein synthesis and regulate serum amino acids. In addition our results demonstrated the effect was dependent on the dose of BCAA.
Under the stress of trauma, the decompose of muscle protein seriously increases and produces a lot of free amino acids[29-33], and hyperphenylalaninaemia appears. The ratio of phenylalanine to tyrosine (phe/tyr) rises and the ratio of BCAA to aromatic amino acid (AAA) descents after trauma because of the dysfunction of liver[34,35]. The low dose of phenylalanine and the high dose of BCAA in the formula of amino acid enriched BCAA can also improve the pattern of serum amino acids after trauma.
In summary, the nitrogen balance, the synthesis of acute phase proteins and visceral proteins and the pattern of serum amino acid concentrations were measured and compared with two groups after six days of TPN after trauma. Our results demonstrated that the formula of amino acid enriched BCAA could normalize of serum amino acid levels, reduce proteolysis, increase protein synthesis and improve nitrogen balance.
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