Measurement of hepatic Ra UDP-glucose in vivo in rats: relation to glycogen deposition and labeling patterns.

We previously described an isotopic method for quantifying the rate of appearance of hepatic UDP-glucose (Ra UDP-Glc) and the direct entry of glucose into hepatic UDP-Glc in humans. Here, the method is tested in depth in rats. The basic principles are that dilution of labeled galactose in hepatic UDP-Glc, sampled noninvasively by the xenobiotic glucuronate (GlcUA) method, reveals Ra UDP-Glc. First, labeling patterns in secreted acetaminophen-GlcUA were compared with hepatic glycogen and plasma glucose by use of mass isotopomer distribution analysis from [2-(13)C]glycerol. Labeling was consistent with common precursor pools of glucose 6-phosphate and triose-phosphate for all end products studied in fasted and in intravenous glucose- and fructose-infused states. Next, [1-(3)H]galactose was administered. After a 24-h fast, Ra UDP-Glc was 25.0 +/- 1.7 mumol.kg body wt-1.min-1 and rose to 57.7 and 72.7 mumol.kg-1.min-1 at intravenous glucose infusion rates of 111 and 167-194 mumol.kg-1.min-1, respectively. Liver glycogen deposition correlated closely with Ra UDP-Glc (R2 = 0.76), although the turnover value was approximately 50% higher than the net deposition rate. In conclusion, the turnover of an intrahepatic metabolite, UDP-Glc, can be measured noninvasively, and Ra UDP-Glc correlates with liver glycogen deposition in rats.

An interdisciplinary, interagency, primary care approach to case management of the dually diagnosed patient with HIV disease.

The epidemic of dually diagnosed patients with HIV disease (HIV disease coexisting with substance abuse and/or mental illness) has become increasingly recognized. This phenomenon poses potential threats to the effectiveness of HIV primary care, even when delivered by expert clinicians. This article describes implementation strategies for the provision, documentation, and third party billing of interdisciplinary, interagency HIV primary care case management within the context of an academic medical center. Our approach, which is specific to our setting, has evolved as we have attempted to define an active role for the primary care physician as a member of the case management team.

Rate of glucose entry into hepatic uridine diphosphoglucose by the direct pathway in fasted and fed states in normal humans.

We used the glucuronate (GlcUA) probe technique to measure the rate of glucose entry into hepatic uridine diphosphoglucose (UDP-glc) by the direct pathway, to quantify the rate of appearance (Ra) of hepatic UDP-glc, and to calculate hepatic glucose cycling in vivo in normal humans. The direct pathway contribution to UDP-glc as determined by the ratio of [1-d1]-GlcUA to plasma [LD1]-glucose enrichments was minor (15% to 20%) in normal men after an overnight fast. After 9 hours of refeeding with intravenous (IV) glucose or an oral liquid formula meal each at a rate of 7 mg carbohydrate/kg/min, the direct pathway increased to 66.3% +/- 6.7% and 61.6% +/- 6.0% (mean +/- SE), respectively. Plasma glucose concentrations remained below 7.8 mmol/L and could not account for most of the variability in direct pathway contribution. The dilution of labeled [L-D1]-galactose in excreted acetaminophen-GlcUA was used to measure Ra UDP-glc, on the assumption that labeled galactose passes through the liver during its assimilation. Ra UDP-glc was 1.1 +/- 0.1 mg/kg/min after an overnight fast and increased to 2.0 +/- 0.1 with i.v. glucose and 2.6 +/- 0.2 with the oral liquid mixed meal. By combining the fractional glucose contribution with the Ra of hepatic UDP-glc, the rate of direct glucose entry into hepatic UDP-glc was 0.2 mg/kg/min (fasted) and increased to 1.3 to 1.6 (fed). This represented approximately 18% to 21% of systemic glucose disposal or 19% to 23% of the administered carbohydrate load during i.v. or oral refeeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of dronabinol on nutritional status in HIV infection.

OBJECTIVE: To examine the effect of dronabinol (delta-9-tetrahydrocannabinol) on appetite and nutritional status in patients with symptomatic HIV infection and weight loss. DESIGN: Double-blind, randomized, placebo-controlled, crossover trial with two five-week treatment periods separated by a two-week washout period. Patients received dronabinol 5 mg twice daily before meals or placebo. SETTING: A university-based HIV/AIDS clinic and a large infectious disease private practice largely devoted to care of patients with HIV. PARTICIPANTS: Twelve HIV-infected patients who had had at least a 2.25-kg weight loss participated in the study. Five patients completed the protocol, and seven withdrew (two because of drug intolerance, two because of disease progression, two because of noncompliance, and one because of experimental antiretroviral therapy). MAIN OUTCOME MEASURES: Main outcome measures included caloric intake, weight, percent body fat, serum prealbumin, and symptom distress. RESULTS: During dronabinol treatment, subjects experienced increased percent body fat (one percent, p = 0.04); decreased symptom distress (p = 0.04); and trends toward weight gain (0.5 kg, p = 0.13), increased prealbumin (29.0 mg/L, p = 0.11), and improved appetite score (p = 0.14). CONCLUSIONS: In a selected group of HIV-infected patients with weight loss, short-term treatment with dronabinol may result in improvement in nutritional status and symptom distress.

Increased de novo hepatic lipogenesis in human immunodeficiency virus infection.

We measured de novo lipogenesis in human immunodeficiency virus (HIV) infected men using a newly developed stable isotope method. HIV-infected subjects with a history of weight loss (n = 17, mean weight loss 14.9 +/- 3.2 kg), asymptomatic HIV-seropositive subjects with normal CD4 T-cell counts (n = 7) and healthy HIV seronegative controls (n = 11) were studied. Hepatic lipogenesis was determined by infusion of [2-13C]-acetate, using the recently described xenobiotic probe technique with mass isotopomer analysis. Hepatic acetyl-coenzyme A enrichment was measured by high performance liquid chromatography/mass spectrometry of secreted sulfamethoxazole-acetate, with measurement of incorporation into very low density lipoprotein-fatty acids by gas chromatography-mass spectrometry. Circulating tumor necrosis factor (TNF), interleukin-1 (IL-1), interferon alpha (IFN alpha), insulin, and triglycerides were measured concurrently, and 7-day weighed food records were performed. De novo hepatic lipogenesis was increased 3- to 4-fold in HIV-infected subjects with weight loss compared to normal controls (P < 0.05 for palmitate and stearate in both overnight-fasted and fed states), and was also significantly increased in asymptomatic HIV seropositive subjects. Circulating TNF and IL-1 were not measurable in any subject (detection limit 2 pg/ml for IL-1 and 20 pg/ml for TNF). Serum IFN alpha was measurable in 11 out of 17 subjects with wasting and correlated significantly with de novo lipogenesis in overnight-fasted but not fed states. Serum IFN alpha was unmeasurable in asymptomatic HIV-infected subjects despite elevated lipogenic rates. Serum triglyceride concentrations were elevated in subjects with weight loss (2.09 +/- 0.28 mmol/L) and asymptomatic HIV-positives (1.34 +/- 0.34 mmol/L) in comparison to controls (0.67 +/- 0.08 mmol/L), and correlated with lipogenesis. Food intake correlated inversely with lipogenesis in the overnight-fasted state. We conclude that HIV infection is characterized by abnormal fat anabolism. This applies to subjects with reduced lean body mass and to asymptomatic HIV-positive subjects with normal T-cell counts. The former observation may have implications for the pathophysiology and treatment of the wasting syndrome. The latter observation is consistent with activation of the immune response and a state of viral nonlatency in early HIV disease.

Effects of recombinant monokines on hepatic pyruvate dehydrogenase, pyruvate dehydrogenase kinase, lipogenesis de novo and plasma triacylglycerols. Abolition by prior fasting.

1. The effects of recombinant human tumour necrosis factor alpha (TNF) and murine interleukin-1 alpha (IL-1) on the activation state of the hepatic pyruvate dehydrogenase complex (PDHa), the activity of mitochondrial PDH kinase, hepatic lipogenesis de novo and plasma triacylglycerol (TG) concentrations were studied. 2. Monokine effects depended upon prior nutritional state. In rats fasted for 20 h or 45 h before monokine administration and refeeding (orally or with intravenous glucose), PDHa, TG and hepatic lipogenesis were not increased. In rats fed ad libitum, treatment with TNF plus IL-1 increased the contribution of hepatic lipogenesis to circulating TG to 550% of control values (P = 0.03) and plasma TG concentrations to 159% (P = 0.02), whereas PDHa increased slightly to 120% (P = 0.02) and liver glycogen content fell to 45.8% (P = 0.05) of control values. 3. Intrinsic hepatic PDH kinase activity was not changed by monokine treatment in rats fed ad libitum. 4. The increased lipogenesis de novo showed no correlation (r2 = 0.05, not significant) with hepatic PDHa in individual animals fed ad libitum. 5. In conclusion, these results suggest that monokines increase pyruvate flux through hepatic PDH in vivo in rats fed ad libitum primarily by mechanisms other than covalent modification of PDH. Prior nutritional status exerts a permissive effect for monokine stimulation of PDHa and lipogenesis, consistent with a substrate-mediated action, but the mechanism of this permissive effect remains uncertain.

Use of mass isotopomer distributions in secreted lipids to sample lipogenic acetyl-CoA pool in vivo in humans.

Measurement of hepatic fatty acid (FA) and cholesterol synthesis has been limited by lack of access to the precursor pool, cytosolic acetyl-CoA. We present a method for inferring the enrichment of the true hepatic lipogenic precursor pool in humans using the frequency distribution of mass isotopomers within enriched circulating polymers of acetyl-CoA [very low-density lipoprotein (VLDL)-palmitate, VLDL-stearate]. Human subjects were infused intravenously (n = 16) with [1-13C]- or [2-13C]acetate. Oral sulfamethoxazole (SMX) was administered concurrently, and the acetylated conjugate (SMX acetate) was used to estimate independently the hepatic cytosolic acetyl-CoA enrichment. Isotopomer frequencies in VLDL-FA were determined by gas chromatography-mass spectrometry, whereas high-performance liquid chromatography-mass spectrometry was used to measure enrichments in SMX acetate. Based on the excess M2/excess M1 ratio in VLDL-FA, calculated acetyl-CoA enrichments were 5.59 +/- 0.33 molar percent excess (MPE), whereas SMX acetate enrichments were 5.38 +/- 0.31 MPE (the 2 methods were not significantly different). Mass isotopomer-calculated and SMX acetate-measured estimates of acetyl-CoA enrichments correlated very closely in individual subjects (r2 = 0.93; P less than 0.0001). De novo hepatic lipogenesis can be measured using isotopomer-calculated precursor enrichments compared with measured incorporation in specific isotopomers of VLDL-FA. In summary, excess isotopomer frequencies in secreted lipids provide a non-invasive technique for estimating hepatic cytosolic acetyl-CoA enrichments in humans in vivo and correlate closely with enrichments observed using the xenobiotic probe technique. Isotopomeric distributions represent a new strategy for accurate measurement of macromolecule synthesis that may be applicable to other classes of molecules besides lipids.

Sampling the lipogenic hepatic acetyl-CoA pool in vivo in the rat. Comparison of xenobiotic probe to values predicted from isotopomeric distribution in circulating lipids and measurement of lipogenesis and acetyl-CoA dilution.

The acetylation of xenobiotics may provide a means for sampling hepatic cytosolic acetyl-CoA in vivo for isotopic studies of lipogenesis. Here, we test the accuracy of acetylated-sulfamethoxazole (SMX) in representing the true precursor pool for hepatic lipogenesis by comparison to a mathematical technique for estimating acetyl-CoA enrichment using the mass isotopomer distribution in circulating lipids. We then go on to measure hepatic fatty acid synthesis in intact rats using stable and radioisotopes. Specific activities and enrichments of SMX-acetate (the latter determined by high performance liquid chromatography-mass spectrometry) were monitored during fasting and refeeding. The dilution rate of hepatic acetyl-CoA relative to infused 13C- or 14C-acetates was 0.158-0.200 mmol/kg body weight/min during fasting, and did not increase significantly in rats refed with intravenous glucose at 25-30 mg/kg/min or refed ad libitum with chow, suggesting little additional input of acetate units. Plasma beta-hydroxybutyrate specific activity was much lower than SMX-acetate. The isotopomeric frequency distributions in circulating very low density lipoprotein (VLDL)-palmitate and VLDL-stearate were used to estimate the enrichment of the true precursor, hepatic acetyl-CoA, from a model based on the binomial distribution. The calculated acetyl-CoA values (7.28 +/- 0.49 molar percent excess (n = 16] based on isotopomeric frequencies were very close to measured SMX-acetate enrichments (7.44 +/- 0.41 molar percent excess (n = 21] and values within individual animals (n = 14) correlated very well (r2 = 0.90, p less than 0.0001). The contribution of VLDL-fatty acid by the de novo lipogenic pathway was similar using the stable isotope approach or radioisotopes (only 1-2% in fasted or intravenous glucose refed rats, 5% in chow refed). Combining fractional de novo lipogenesis values with absolute de novo lipogenesis rates allows estimation of total VLDL-triglyceride synthesis. In conclusion, the xenobiotic acetylation technique provides continuous access to the lipogenic hepatic acetyl-CoA pool in vivo and permits measurement of fatty acid synthesis. Isotopomer ratios in secreted lipids provide another method for estimating true precursor acetyl-CoA enrichments.

Fraction of hepatic cytosolic acetyl-CoA derived from glucose in vivo: relation to PDH phosphorylation state.

We measured the contribution of glucose to hepatic cytosolic acetyl-CoA in vivo in rats and compared it with the phosphorylation state of a potentially regulatory enzyme complex [pyruvate dehydrogenase (PDH)]. Xenobiotic probes were used to sample hepatic cytosolic acetyl-CoA [acetylated sulfamethoxazole (SMX)] and UDP-glucose (glucuronidated acetaminophen) in vivo during [U-14C]glucose infusions. Percent active (dephosphorylated) form of PDH (PDHa) was determined on freeze-clamped liver. First, we confirmed using liver cell elutriation that acetylation of SMX occurs in parenchymal hepatocytes. Next, the fraction of cytosolic acetyl-CoA derived from [14C]glucose in vivo was shown to depend on dietary state. Specific activity of acetyl-CoA relative to plasma glucose or hepatic UDP-glucose was lower after 48 h fasting than after overnight fasting, and glucose refeeding (25 mg.kg-1.min-1 iv) maximally increased [14C]-glucose fractional contribution to acetyl-CoA within 2 h in the overnight-fasted but not in the prolonged fasted group. Hepatic PDHa demonstrated a similar but not identical pattern. The isotopic and enzymatic parameters showed significant correlations (r2 = 0.61 in 48-h fasted-refed group, r2 = 0.28 in overnight-fasted refed group), although [14C]glucose contribution to acetyl-CoA increased disproportionately compared with PDHa as refeeding progressed. The indirect pathway of UDP-glucose synthesis correlated inversely with the fractional contribution of glucose to acetyl-CoA. In summary, the fraction of hepatic acetyl-CoA derived from glucose in vivo is influenced by acute and chronic dietary factors and is only partially explained by PDHa. Regulation of the carbon source of hepatic acetyl-CoA in vivo and interactions suggested by these results (e.g., glucose-fatty acid cycle; branch-point regulation of glucose recycling) can be addressed in a quantitative fashion using this experimental framework.

Measurement of de novo hepatic lipogenesis in humans using stable isotopes.

Direct measurement of de novo lipogenesis has not previously been possible in humans. We measured de novo hepatic lipogenesis in normal men by means of stable isotopes and by combining the acetylated-xenobiotic probe technique with mass isotopomer analysis of secreted very low density lipoprotein-fatty acids (VLDL-FA). Sulfamethoxazole (SMX) was administered with [13C]acetate during an overnight fast followed by refeeding with intravenous glucose (7-10 mg/kg of weight per min), oral Ensure (7-10 mg of carbohydrate/kg of weight per min), or a high-carbohydrate mixed-meal breakfast (3.5 g of carbohydrate/kg of weight). Respiratory quotients remained less than 1.0. High-performance liquid chromatography/mass spectrometry-determined enrichments in SMX-acetate attained stable plateau values, and hepatic acetyl-coenzyme A (CoA) dilution rate did not increase with refeeding (approximately 0.024 mmol/kg per min). The fraction of VLDL-palmitate derived from de novo lipogenesis was only 0.91 +/- 0.27% (fasted) and 1.64-1.97% (fed). For stearate, this was 0.37 +/- 0.08% and 0.47-0.64%. Precursor enrichments predicted from isotopomer ratios were close to measured SMX-acetate enrichments, indicating that SMX-acetate samples the true lipogenic acetyl-CoA pool. Stearate synthesis was less than palmitate and the two did not move in parallel. Estimated total VLDL-FA synthesis is less than 500 mg/day. Thus, de novo hepatic lipogenesis is a quantitatively minor pathway, consistent with gas exchange estimates; fatty acid futile cycling (oxidation/resynthesis) is not thermogenically significant; and synthesis rates of different nonessential fatty acids by human liver are not identical in nonoverfed normal men. The contribution and regulation of de novo lipogenesis in other settings can be studied using this technique.

Liquid chromatography/mass spectrometry of plasma glucose and secreted glucuronate for metabolic studies in humans.

Negative ion thermospray liquid chromatographic/mass spectrometric methods have been developed for the determination of isotopic enrichments for glucose and acetaminophen-uridine diphosphate glucuronate from (1-2H1)glucose, (1-2H1)galactose and (2-13C)acetate in humans. The error of estimate ranged from below 1% to 5%. The advantages of the method include fast analysis (up to 35 per hour), eased sample preparation, good precision, sensitivity comparable with gas chromatography/mass spectrometry and better than with isotope ratio mass spectrometry.

Ten years of experience with semen cryopreservation by cancer patients: follow-up and clinical considerations.

Antineoplastic damage to the testicular germinal epithelium with accompanying infertility or subfertility is now a recognized indication for the use of sperm banking. Thus, issues concerning quality of life now compete with questions of survival in decisions made in oncologic settings. In an attempt to learn what concerns patients who use semen preservation facilities, a 10-year retrospective study was undertaken. Registered mail and phone solicitation was used to determine follow-up characteristics of self-referred male cancer patients who voluntarily banked semen at a private facility before they began cancer treatment. The difficulties encountered in conducting follow-up on this group of patients raise questions about sperm banking practices by cancer populations.