,

Boyd

E.

Robert

Terry,4 L.

M.D.,

Wixom,7

William

K. Yamanaka,5

Ph.D.,

described

in

leukocyte

differential

counts,

a companion were

unchanged

counts,

hemoglobin

decline

after

rise

in

the

serum

During

the

triglyceride

plasma

lipid

acids The

insertion

mild

fractions,

blood

The

responses

acid

to be related

in Am.

one

to become

a major

The plasma

human

J. Clin.

amino

therapeutic

acids,

have

provided the essential amino acids and nonspecific nitrogen. Sterile vitamins, electrolytes, and trace elements are included. Considerable research has been focused on preparations of lipid emulsions as a source of calories and essential fatty acids (EFA).

earlier

cottonseed

oil emulsion

caused

adverse complications (2, 5) and was withdrawn from clinical use by the Food and Drug Administration. By contrast, Hallberg et al. reported the efficacy of a soybean oilphosphatide emulsion in a 4-year clinical

900

The

American

Journal

of Clinical

lipids

during

and

positive

urinary

marrow

response

prolonged

1

owing

From

parenteral

a slow

in the

the

main

other

deficiency

fatty

need

acid.

during

by

anemia

nutrition

four

in linoleic

intake

The

with

observed.

whereas

acid

A mild

to the rise

decrease

glucose

cortisol.

were

Within

markedly, fatty

high

erythrocyte

began

hemosiderin

mainly

a similar

essential

to the

the

of histidine.

declined.

declined

and decreased

30: 900-909,

deletion

counts,

hemoglobin

volume

the

showed

to the

responses

However,

increased,

acid

leukocyte

before

total cholesterol fraction

insulin,

Nutr.

approach for selected human patients (2-4). Glucose or sometimes other carbohydrates have served as the main caloric source. Casein or fibrin hydrolyzates, or more recently

of crystalline

plasma

plasma

total

corpuscular

bone

and

in timing

alimentation.

observed

haptoglobin,

and arachidonic

Total intravenous (I .V.) alimentation by central venous delivery, initiated by Dudrick et a!. (1), has developed rapidly in re-

An

and

corpuscular

experiment.

mean

catheter,

phospholipid

elevated

72-day

and

capacity,

the total

erythrocyte

seems

serum

binding whereas

linoleic

glucose,

investigation.

in

iron

overall

intravenous

periods,

intravenous

normal

the

including

and mean

hemoglobin,

hematocrit,

component,

anemia

lipid-free

total

responses,

corpuscular

during

of the

intravenous

increased.

Hematological

mean

decrease

iron,

plasma

paper.

concentration,

reticulocytes,

normal

mixtures

Ph.D.,

An experiment with a normal man on intravenous alimentation for 48 days was to test for the nutritional role of histidine . The metabolic nitrogen response was

concentration

years

L. Anderson,6

Ph.D.

ABSTRACT performed

cent

Helen

vein and

the

were

a

hormonal

further

direct

1977.

the

Departments

of Biochemistry

and Sur-

gery, School of Medicine and Department of Human Nutrition, College of Home Economics, University of Missouri-Columbia, 2

Supported

Columbia,

by National

Missouri

Institutes

65201.

of Health

Re-

search Grants AM-12608 and AM-15832 and Clinical Research Center Grant RR-00287-08 and gifts from McGaw Laboratories. Presented in part at the annual meeting of the American Institute of Nutrition, April 7 to 12, 1974, Atlantic City, New Jersey. Additional data, indicated by an asterisk in the

text, have been deposited with the National Auxiliary Publications Service of the American Society for Information Service. Associate Professor of Surgery, Department of Surgery, School of Medicine. 5Associate Professor of Human Nutrition, School of Home Economics, University of Washington, Seattle, Washington 98196. #{176}Associate Professor of Nutrition, Department of Human Nutrition, Foods and Food Systems Management, College of Home Economics. 7Professor of Biochemistry, Department of Biochemistry, School of Medicine to whom reprint requests should be addressed.

Nutrition

30: JUNE

1977,

pp. 900-909.

Printed

in U.S.A.

Downloaded from https://academic.oup.com/ajcn/article-abstract/30/6/900/4650323 by East Carolina University user on 13 January 2019

Total parenteral nutrition with selective histidine depletion in man II. Hematological, and hormonal responses1-3

RESPONSES

trial via

with over 2,700 (6, 7). Because

available

,

the calories

and

Burr

recognized

the

in the I .V. (8) earlier

were (1).

rat’s

need

for EFA, and later Hansen and Holman and their respective associates found that the orally fed human infant needed a source of

EFA

(9,

10).

Collins

et a!. (1 1) observed

the first EFA deficiency in two adult patients. One patient with the short bowel syndrome received lipid-free parentera! solutions for 100 days and developed a skin rash, hypertrig!yceridemia, serum EFA deficiency, and increased serum 5,8,1 1-eicosatrienoic acid; several infusions of soybean lipid emulsions reversed these symptoms. This patient developed a refractory anemia that was not due to deficiency of iron, cyanocobalamin or folic acid; after lipid infusion, erythrocyte production returned to near normal. An anemia associated with EFA deficiency has also been observed with beagle puppies (12). Later, the EFA deficiency in infants induced by lipid-free I.V. alimentation (13-15) was reversed by daily oral doses of methyl linoleate (13), intravenous soybean oil emulsions (14), or oral

feeding malnourished lipid-free

by oral

(15).

The

EFA

adults parenteral

safflower

deficiency

in four

after 6 to 8 weeks of nutrition was reversed

oil (16).

Hypercatabolic,

and

Experimental

plan

methods

The subject, oral diet, lipid-free IV. intake and experimental plan are described in a companion paper (8). At the time of this 1972 experiment IV. lipid emulsions were not available for fat of a normal man was tentatively the EFA during the IV. periods. Analytical Triplicate

the heme

clinical use; the depot assumed to provide

procedures fingertip

profiles

blood

with

samples

a Coulter

the

IN

Clinical

ADULT

Pathology

and The

901

Laboratory.

total iron binding capacity ical Chemistry Laboratory nodiffusion and the two were performed ogy Laboratory.

MAN Serum

were determined (19). Haptoglobin

iron

and

in the Clinby immu-

bone evaluated 51Cr-tagged

marrow examinations in the Clinical Patholred cell volume (20) volume (21) were performed

and tThIlabeled albumin by the Nuclear Medicine Service. The plasma lipids were extracted with chloroformmethanol (1 : 1 ) (22), separated into the four indicated classes by silicic acid column chromatography (23), methylated with 1 % H2SO4 in CH3OH (22), and analyzed by gas-liquid chromatography (Bendix model 2500 chromatograph) (24). The mono -and diglyceride fraction also included a small amount of free fatty acids. An internal fatty acid standard (17:0) was used to quantitate the total fatty acids during the chromatographic analysis. After washing of the packed erythrocytes three times with normal saline, they were extracted and analyzed as described above for the plasma lipids. Glucose was measured by the Technicon autoanalyzer SMA-6-60 and cortisol by a fluorometric method (25) in the Clinical Pathology Laboratory. Insulin was measured by a radioimmunoassay (26) by Mr. Jack England and Dr. Robert L. Jackson, Department of Child Health.

Results Hematological

data

The total leukocyte count (Fig. 1) did not change during the 72-day experiment; the slope of the linear regression equation for the leukocyte measurements, y(103/mm3) = -0.029 x (days) + 7.1 was insignificant and the overall mean ± SD (5.9 ± 0.9) was in the normal range The mean ± SD and the slope for the differential counts were: bands (0.7 ± 1 .1 + 0.018), neutrophils ,

.

.

thermally burned patients on I.V. alimentation developed an EFA deficiency which was effectively treated with I.V. lipid emulsion (17, 18). In contrast to the above conditions of stress, this paper reports an experiment which demonstrated the rapid development of a chemical EFA deficiency in a normal adult man receiving lipid-free I.V. alimentation.

Materials

INTAKE

were

analyzed

for

Counter

model

S in

%,

(59.0 ± 8.0, -0.130), lymphocytes (32 ± 7.0, +0.123), monocytes (4.5 ± 0.015), eosinophils (2.9 ± 1 .9, -0.012), and basophils (1 .0 ± 1 .2, +0.005). All 2.5,

-

means were within the usually accepted norma! ranges. Because the slopes approached zero, the experimental treatment had no effect on the differential leukocyte counts. The reliability of hematological responses was increased by triplicate analyses and frequent measurements. Results were examined by analysis of variance* and linear regression analysis with primary reliance on the sign of the slope, rather than its numerical magnitude. The total erythrocyte count (Fig. 1) was normal in period I, then declined slowly but significantly, with negative slopes for periods II through VI, and then increased to a positive slope in oral period

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in the present experiment by glucose as described

Burr

HISTIDINE-FREE

infusions in Scandinathis product was not

for our use

solution supplied

TO

902

TERRY

ET

AL.

c

‘H’II

TIP4 (days)

FIG. 1. Hematological results during oral and intravenous alimentation. The vertical dashed lines depict the 48 days of total parenteral nutrition within the overall 72-day experiment. The stippled vertical bands, here and in Figure 6, denote the deletion of lysine (period III) or histidine (period V) from the complete amino acid intake; the horizontal bands denote the normal human range for the component. Other details of the experimental design may be found in the previous paper (8). The numbers above the line denote the slope from a linear regression equation for the indicated time period. For the three erythron measurements, significant differences (P < 0.05) in the slopes are indicated where the superscript letters differ.

VII. Period VI, with histidine intake, showed no significant change from the preceding period V, without histidine inclusion. A quite similar pattern is shown in the slopes of linear regression equations for hemoglobin and hematocrit (Fig. 1); further

evaluation

by analysis

of variance

showed

a

significant stepwise decline in hemoglobin from periods Ito III-IV, V, and VI.* Slopes of these three indices for combined periods II and IV were not significantly different from those shown for combined periods II, III, and IV in Figure 1. These stepwise statistical analyses suggest that the anemia started on day 10 with the initiation of intravenous alimentation, and not at day 25 with the omission of histidine. Further evaluation may be found in the “Discussion”.

With

respect

to

the

blood

indices,

the

mean corpuscular hemoglobin (MCH)* and the mean corpuscular hemoglobin concentration (MCHC)* were constant throughout periods of the experiment (overall means = 32.0 pg ± 1.1; 35.2% ± 1.4, respectively). The mean corpuscular volume (MCV) declined slowly from period I (93.53 ± 2.4)

to period

VI (89.6

±

1.7)

(P < 0.05).*

The anemia was associated with a minor rise in reticulocytes and reticulocyte index at two periods (Fig. 1), one late in the histidine-free period and one in the histidinereplete period; correlation of the reticulocytosis with histidine intake is inconclusive. Serum haptoglobins (Figs. 1 and 2) were

normal clined

in oral in

hemosiderin riod (Fig.

I.V.

periods periods

was positive 1). Both serum

I and

VII,

but

V and

VI.

Urinary

de-

in the last I .V. peiron (149 g/100

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TE IN DEX

RESPONSES

TO

HISTIDINE-FREE

ml; normal range = 60 to 150 j.tg/100 ml) and total serum iron binding capacity (346 pg/100 ml; normal range = 250 to 350 pg/ 100 ml) on day 45 (period V) were normal.

synchronous tion, and

the

myelopoiesis, presence

of

platelet stainable

produciron.*

The sole difference in the two samples were a slight shift in the myeloid/erythroid (M/E) ratio from 2.5:1 to 1.3:1. On day 46 in period V, use of 51Cr-tagged red cells provided a red cell volume of 1,849 ml

(22

ml/kg)

range of 2,180 determination showed volume,

range ments

as compared

330 the

±

of

with

a normal

ml. A simultaneous SSIlabeled plasma

3117 ml (38 ml/kg) for the plasma which was also within the normal (3,270 ± 490 ml). Such measureeliminate hemodilution as a cause of

the

IN

mild

folic

anemia.

acid,

tamin

ADULT

MAN

The

vitamin

E exempt

daily

mild

a nutritional

information

anemia

Indices

was

of lipid

intake

B12, pyridoxine,

the etiology of the anemia. urinary hemosiderin and hematological

903

of

iron,

and

deficiency

The presence the accumulated suggest

that

vias

of the

hemolytic. metabolism

The effect of I.V. alimentation on lipid metabolism was assessed by three approaches after completion of the 72-day experiment. Plasma lipids were extracted, separated into the four indicated classes (Fig. 3), analyzed by gas-lipid chromatography, and evaluated statistically as described in the legend of Figure 3. Total plasma cholesterol (Fig. 3, left graph) declined significantly during the I.V. periods, probably owing to the absence of exogenous cholesterol intake. The total fatty acids present as cholesterol esters decreased within the same time interval, although not sig-

FIG. 2. Immunodiffusion of haptoglobin. The center well of the Ouchterlony plate contained the haptoglobin antibody; the control serum and experimental sera, designated by the number of the experimental day, were placed in the peripheral wells. The plate was incubated overnight and stained for protein.

Ora)

ravenous

Ora(

)ntravenous

Ora( **

E

2OO

ro(

4OOTotac1ds\

\#{231}este/

E fl

z 0

‘no

adds

holesterol

z

esters

2OO

I

trig(yceresi

o-&g(erides

C-)

z

1phospho$pid

0

‘‘0

_-I-

I

20

40 TIME (days)

60

20

40

60

TIME (days)

FIG. 3. Plasma cholesterol and total fatty acid concentrations. The two to four analyses in the two oral periods were compared with the six of 14 analyses in the I .V. periods by analysis of variance. The level of statistically valid differences are indicated by asterisks: * = P < 0.05, ** = P