Multi-frequency bioimpedance measurements of children in intensive care.

Bioimpedance spectroscopy is used to monitor the condition of the tissues of children staying in intensive care for the treatment of meningitis. The results are significant, with the angular frequency at maximum reactance lying between 1500 and 6400 x 10(3) rads(-1), whereas in a control group, this value does not exceed 900 x 10(3) rads(-1). The ratio between the specific conductance at zero and that at infinite frequency (this ratio is proportional to total body volume/volume of extracellular space) remains constant at 1.4 and equal to the ratio in the control group, despite infusions with physiological saline. The electrical parameters are associated with physiological ones and indicate that the membrane 'capacitance' decreases, as a result of the illness, from approximately 0.4 in the control group to 0.05 in the patient group. However, there is a time-delay between the onset of illness and the change in membrane capacitance. It is also found that the ratio between extracellular and intracellular specific conductivity in the group of patients and controls remains constant at approximately 4.3. The changes in the physiological and electrical parameters were compared with chemical parameters that were measured during the stay in intensive care.

The value of dextran 12,000 in ischemically damaged canine kidneys during machine perfusion.

The use of non-heartbeating (NHB) donor kidneys has led to the search for new methods of viability-testing. We investigated, in a canine model, the relationship between the filtration of dextran 12, 000 into urine and a certain period of warm ischemic time (WIT) during machine perfusion. Twenty-four canine kidneys were divided into three groups, sustaining 0 min, 30 min or 60 min of WIT. After cooling and flushing, the kidneys were perfused on a perfusion machine for 8 h. Three hundred milligrams of dextran 12,000 was added to the perfusate. In the perfusate, dextran and lactate dehydrogenase (LDH) concentrations were measured. Dextran concentrations were also analysed in urine. Intrarenal vascular resistance (IRR) was calculated from pressure and flow characteristics. The 30WIT group showed a higher dextran excretion rate than the other two groups. IRR and LDH measurements showed lower levels in the ischemic groups compared with the control group. Dextran 12,000 is not suitable as a viability test but does show interesting results regarding the low LDH and IRR levels in the ischemic groups.

Glutamine: the pivot of our nitrogen economy?

Glutamine serves as a shuttle of useful nontoxic nitrogen, supplying nitrogen from glutamine-producing (eg, muscle) to glutamine-consuming tissues. True production rates of glutamine are difficult to measure, but probably are less than 60 to 100 g/d for a 70-kg man. During catabolic stress increased amounts of glutamine are released from muscle, consisting of protein derived glutamine, newly synthesized glutamine, and glutamine losses from the intramuscular free pool. The large and rapid losses of free muscle glutamine are difficult to restore, presumably as a result of disturbances in the Na+ electrochemical gradient across the cell membrane. Whereas increased amounts of glutamine are released from muscle, glutamine consumption by the immune system (liver, spleen) also is enhanced. Thus, during catabolic stress changes occur in the flow of glutamine between organs. These changes are not necessarily reflected by alterations in the whole-body appearance rate of glutamine. In contrast with the gut, where glutamine is taken up in a concentration dependent manner, the immune system actively takes up glutamine despite decreased plasma concentrations. Supplementation with glutamine influences uptake by both the gut and the immune system, as evidenced by increased mucosal glutamine concentrations and gut glutathione production. There is evidence suggesting that this improves gut barrier function. Although the benefit of glutamine supplementation is most evident from experimental studies, clinical studies on the effect of glutamine do exist and suggest that glutamine supplementation has beneficial effects with regard to patient outcome.

Body composition in renal transplant patients: bioimpedance analysis compared to isotope dilution, dual energy X-ray absorptiometry, and anthropometry.

Whether multifrequency bioelectrical impedance analysis (MF-BIA), a relatively new method for measuring body composition, is also applicable for accurate body composition measurements in renal transplant (RTx) patients is not known. Therefore, the use of MF-BIA is validated in 77 RTx patients with a stable renal function at least 2 yr posttransplantation. MF-BIA is compared to isotope dilution techniques for measurement of body water compartments, and to dual energy x-ray absorptiometry (DEXA) and anthropometry for measurement of fat and fat free mass. Finally, DEXA and anthropometry are compared to each other. Method agreement is assessed by intraclass correlation coefficients (ICC) and plotted by Bland and Altman analysis. MF-BIA significantly underestimates total body water (TBW, 0.7+/-2.1 L) and overestimates the extracellular water (ECW, 3.3+/-1.8 L) compared to isotope dilution; the ICC between both techniques is 0.943 for TBW and 0.846 for ECW. The percentage body fat (BF) measured by MF-BIA is significantly higher than both BF measured by DEXA (3.4+/-4.7%) or by anthropometry (5.5+/-5.2%). The ICC between MF-BIA and DEXA is 0.887 and between MF-BIA and anthropometry 0.856. BF measured by DEXA is significantly higher than BF measured by anthropometry (2.1+/-4.4%); their ICC is 0.913. In conclusion, MF-BIA seems to be suitable for measurement of TBW in RTx patients; however, method agreement between isotope dilution and MF-BIA for the measurement of ECW is not satisfactory. In the assessment of fat and fat free mass, the reliability of MF-BIA appears to be questionable. Method agreement between DEXA and anthropometry seems to be slightly better.

Determination of total body water by multifrequency bio-electric impedance: development of several models.

Multifrequency bio-electronic impedance analysis (MF BIA) measurements are taken from a heterogeneous group of patients, varying in size between obese and slim. The measuring system uses four electrodes: two current and two potential electrodes. Three new models are developed to calculate total body water (TBW) from the BIA data, and the resulting TBW values are compared with TBW determined by D2O dilution. The results demonstrate that the most simple model provides the best TBW values. For individual patients, TBW can be determined by means of bioimpedance measurement with an accuracy of 3 litres. In the most simple model (model 1), the body is electrically represented by a cylinder, and corrections are made for the amount of fat. This is an extension of the model used by Xitron. In the more advanced models (2 and 3), the body is represented by a cylinder for the trunk, and truncated cones represent the arms and legs. In model 2, delta TBW amounts to 3 litres. It is shown that the resistance of the trunk is proportional to the square root of the length. In model 3, it is assumed that subcutaneous fat is a poor conductor of electric current. An equation is developed that describes the partition of subcutaneous fat, and the fat layer is then removed from the cones representing arms and legs and from the cylinder that models the trunk.

Absence of glutamine isotopic steady state: implications for the assessment of whole-body glutamine production rate.

1. During infusion of [5-15N]glutamine in patients with gastrointestinal cancer we unexpectedly observed a gradual decrease in time of the appearance rate (Ra) of glutamine in plasma. Here we investigate whether the failure to achieve a plateau isotopic enrichment in plasma is, among other factors, due to incomplete equilibration of the glutamine tracer with the large intramuscular free glutamine pool.2. Plasma and intramuscular glutamine enrichment were measured during 6-11 h infusions of L-[5-15N]glutamine and L-[1-13C]glutamine in post-absorptive patients admitted to hospital for elective abdominal surgery. L-[1-13C]Leucine and L-[ring-2H5]phenylalanine were infused to measure the proportion of glutamine appearing in plasma directly due to its release from protein.3. The glutamine tracer entered muscle, but the rise in intramuscular glutamine enrichment was small, presumably as a result of the enormous size of the intramuscular glutamine pool and the limited speed of entry of glutamine into muscle. In each patient the intramuscular glutamine enrichment was lower than that in plasma (P<0.001), and both increased with tracer infusion time (P<0.001), indicating incomplete equilibration of the glutamine tracer.4.A comparison of the results obtained by the two glutamine tracers indicated that recycling of the nitrogen label contributed to about 15% of the decrease in Ra.5. There was a gradual reduction in the glutamine release from proteolysis, which contributed to 16-21% of the decline in Ra.6. We conclude that slow equilibration of the glutamine tracer with the large muscle glutamine pool significantly contributes to the absence of isotopic steady state. Consequently, the appearance rate of glutamine in plasma measured during short tracer infusion periods (hours) considerably overestimates the whole-body glutamine flux.

A new method for plasma volume measurements with unlabeled dextran-70 instead of 125I-labeled albumin as an indicator.

A method has been developed to determine plasma volume with dextran-70 without the use of a fluorescent label. The results obtained are compared to those found using the 125I-labeled albumin method, which is taken as the gold standard. The CV of the method is about 5%, compared to 3% with the gold standard. It is shown to be of use for the determination of an increase in plasma volume during pregnancy.

Mechanism of volume adaptation in the awake early pregnant rat.

The objective of the present study was to determine whether the increase in plasma volume (PV) during pregnancy is established by fluid retention or by a shift within the extracellular fluid volume (ECFV) from the interstitium toward the intravascular compartment. To this end, we simultaneously, measured total body water, (TBW), ECFV, and PV together with the hematocrit (Hct) and plasma osmolality 4, 8, and 12 days postsurgery in chronically instrumented pregnant (P) and nonpregnant (NP) rats. The P rats were instrumented with a catheter in the femoral artery on day 1 postconception. In the NP group, neither TBW nor ECFV and PV had changed consistently on days 8 and 12 postsurgery relative to day 4. In contrast, in the P animals, TBW, ECFV, and PV had increased by 16, 24, and 20%, respectively, by day 12 relative to day 4. To evaluate whether PV had increased in concert with an overall rise in TBW or as a result of a fluid shift at the cost of the interstitial fluid volume, we calculated the relative size of each fluid compartment on three consecutive measurement sessions. In the NP group, TBW, presented as percentage of maternal weight (%MW) as well as ECFV (%TBW) and PV (%ECFV) had not changed consistently throughout the measurement period. In the P animals, TBW (%MW) was slightly higher on day 12 compared with day 4, but ECFV (%TBW) and PV (%ECFV) had not changed significantly. Finally, in the NP group, Hct had not changed, whereas, in the P animals, Hct was 10% lower on days 8 and 12 compared with day 4. Plasma osmolality did not change consistently in either group during the course of the experimental period. The gradual synchronous increase in all fluid compartments, without consistent change in their relative distribution, suggests that, in normal rat pregnancy, PV expansion is primarily achieved by fluid retention rather than by a redistribution of the ECFV.

Gut permeability, intestinal morphology, and nutritional depletion.

Nutritional depletion increases the risk for postoperative complications. The intestinal barrier may be important in the underlying pathophysiologic mechanism. In this study, 26 patients were evaluated to determine whether nutritional depletion was related to gut integrity and intestinal morphology. Nutritional depletion was estimated by calculating percentage ideal body weight (PIB) or percentage ideal fat free mass (PIFFM). To assess gut integrity, a lactulose/mannitol (L/M) test was performed. Duodenal biopsies were taken, and villous height, crypt depth, number of IgA-producing plasma cells, intraepithelial lymphocytes (IELs), and proliferating index were determined. The L/M ratio was increased, and villous height was decreased in depleted patients. Depletion was not associated with differences in the number of immune cells or proliferating index. The number of IgA-producing plasma cells was positively correlated with the L/M ratio. This study shows that nutritional depletion is associated with increased intestinal permeability and a decrease in villous height.

Glutathione S-transferase as predictor of functional outcome in transplantation of machine-preserved non-heart-beating donor kidneys.

Non-heart-beating (NHB) donors are a valuable source of kidneys for transplantation. The organs, however, sustain substantial warm ischemic damage that may jeopardize the transplantability and result in nonfunction of the grafts. Quantification of warm ischemic time (WIT) and prediction of transplant outcome are essential for the use of NHB donor organs. During machine preservation (MP) the viability of NHB donor kidneys was evaluated through calculating intrarenal vascular resistance and determining lactate dehydrogenase and alpha-glutathione S-transferase (alphaGST) in the perfusate. Thirty-seven functioning (F) and nine nonfunctioning kidneys (NF) were compared. WIT was longer in NF; serum creatinine, donor age, and preservation time were not different. WIT correlated well with alphaGST after 4 and 8 hr of MP (r=0.353, P=0.009, and r=0.346, P=0.011, respectively). When compared with F, intrarenal vascular resistance was increased in NF after 4 and 8 hr of perfusion (P<0.05); at all time points, alphaGST levels were elevated in NF (P<0.05). Lactate dehydrogenase activity was not different between the groups, but could identify immediate functioning grafts within the F group. In conclusion, alphaGST levels correlated strongly with WIT and were also able to distinguish NF from F grafts. alphaGST can adequately predict the functional outcome of NHB donor grafts before transplantation; levels of alphaGST can be used to define reliable safety margins for viability. Therefore, MP is useful in evaluating the viability of NHB donor kidneys, and the parameters discussed will help to select nonviable grafts from this valuable pool of kidneys for transplantation.

Determination of total body water by a simple and rapid mass spectrometric method.

A rapid and inexpensive method was developed to determine deuterium enrichment in body fluids. This is achieved by converting water into acetylene. To vacutainer tubes a small amount of calcium carbide is added. The tubes are evacuated and 25 microliters of sample are injected through the stopper. The reaction takes place spontaneously at room temperature in a few seconds. Enrichment at mass 27 compared with mass 26 can be determined by continuous flow isotope ratio mass spectrometry without any interference from the carrier gas helium. A series of D2O samples diluted with increasing amounts of H2O is prepared at the time of measurement of the biological samples and the measured ratios are used to calculate the isotope dilution of the unknown. The relative error of the method is 1.6% when a dose of 25 ml kg-1 is administered to the patient. The method was compared with two different methods in use in other laboratories, by a published method The means of the differences were -0.1 and 0.08 1, respectively, with standard deviations of 0.63 and 3.0.

An improved bromide assay for the estimation of extracellular water volume by capillary gas chromatography.

A sensitive bromide determination has been developed that consists of the following steps: isolation (purification) of bromide; oxidation of bromide to bromine with potassium permanganate and subsequent reaction with acetone, to give the volatile bromoacetone; quantification of bromoacetone by capillary gas chromatography. The method can also be used with small sample volumes appropriate for paediatric applications. Thermodynamic arguments are used to calculate the equilibria involved. The accuracy and reproducibility of the method have been determined. Finally, the bromide space of six volunteers was determined and the clearance of the bromide by the kidneys was investigated.

Glutamine and the preservation of gut integrity.

Parenteral glutamine dipeptide improves nitrogen balance in postoperative patients on total parenteral nutrition (TPM). Animal studies show that the structure and function of the gut is preserved by glutamine. It is not known if this is the case in human beings. 20 patients admitted to hospital for total parenteral nutrition were randomly allocated to receive parenteral nutrition enriched with glycyl-L-glutamine (Gln TPN), or standard parenteral nutrition (STPN). Mucosal biopsy specimens were taken from the second part of the duodenum before starting parenteral nutrition, and after two weeks. The ratio between the urine concentrations of lactulose and mannitol after enteral administration was used to measure intestinal permeability. After two weeks of parenteral nutrition in the GlnTPN group, intestinal permeability was unchanged, whereas permeability in the STPN group increased. Villus height was unaltered in the GlnTPN group but in the STPN group it decreased. The addition of glutamine to parenteral nutrition prevents deterioration of gut permeability and preserves mucosal structure.

Circulatory models in assessment of cardiac enzyme release in dogs.

Cardiac ischemia causes interstitial leakage of cellular enzymes followed by release of these enzymes into plasma. Quantitative interpretation of these data requires a specific circulatory model, and the performance of such models was investigated. Plasma activities of cardiac enzymes were measured for increasingly abrupt forms of ischemic heart injury in the dog: 1) permanent ligation of the left anterior descending coronary artery (LAD); 2) reperfusion after 2 h of ligation of the LAD; and 3) calcium-free perfusion of the LAD during 10 min (calcium-paradox injury). Release into plasma of a rapidly (41%/h) and a slowly (2.2%/h) catabolized enzyme was calculated from the plasma activities, using a detailed circulatory model with compartments for heart, plasma, muscle, skin, and viscera. The time course of cellular enzyme leakage into interstitial space in the heart was calculated from release into plasma and a range of reported values for transendothelial permeability. Simplification to one- and two-compartment models introduced, respectively, 10 and 2% error in calculated cumulative release. Considering the other sources of error, this implies adequate performance of the two-compartment model. Protein washout from the heart is strongly influenced by expansion of interstitial protein space with dead myocyte volume and depends on the microheterogeneity of necrotic tissue areas. Accelerated release of enzymes into plasma after reperfusion reflects accelerated cellular leakage rather than enhanced washout.

A network thermodynamic model of the concentrating properties of the rabbit/rat kidney in the steady state using the electronic network simulation program SPICE.

A model for the simulation of the diluting and concentrating properties of the rabbit and rat kidney is developed. Translation of the physical model into an electronic one brings the model into a form that can be handled by the electronic network simulation program SPICE. The steady state responses of both kidneys to various inputs are calculated under certain conditions.

Estimation of fetal lung maturity by assessment of lamellar body particle concentration.

The concentration of lamellar bodies expressed as the optical density at 700 nm in amniotic fluid samples was calculated after centrifugation of the samples to obtain the lamellar bodies in a relatively pure form. The lamellar body concentrations obtained were compared with lecithin-sphingomyelin (L/S) ratios from the same samples. The advantages of the method compared with the L/S ratio are discussed as is the dependence on total volume that the method shares with all other procedures which depend on the measurement of a single concentration.

Role of maternal glucose as a metabolic substrate for the guinea pig conceptus.

Our study in pregnant guinea pigs was designed to determine whether the modest fractional contribution of glucose to the late-pregnant uterine caloric uptake was due to inadequate uterine glucose supply or to diminished uterine glucose demand. To this end, uterine uptake of glucose, O2, and lactate was measured in 27 late-pregnant guinea pigs with a wide range of litter sizes. A group of 11 mid-pregnant guinea pigs served as a reference. The fractional uterine uptake of glucose in mid- and late-pregnancy was 90 and 45%, respectively, confirming the indirect data calculated from different studies. In late pregnancy, uteroplacental blood flow (microspheres, -40%) as well as arterial glucose concentration (-30%) had decreased relative to mid-gestation, giving rise to a 60% lower wt-specific uterine glucose supply and a 21% lower wt-specific uterine glucose uptake. Inasmuch as fetal and placental glycogen stores become rapidly depleted after the 50th day of pregnancy, the lower uterine glucose uptake in late pregnancy appears to reflect inadequate uterine glucose supply rather than diminished fetal glucose demands. In late pregnancy, uterine caloric demand per kg is about 60% more than in mid-gestation, most likely associated with accelerated fetal fat accretion. Inasmuch as the latter appears to be mostly fueled by nonglucose fat precursors, it could explain why the glucose fraction of the uterine caloric uptake in late pregnancy has decreased by 50% instead of 21% as compared to mid-gestation. The reduction in arterial glucose concentration in late pregnancy was independent of litter size suggesting this phenomenon is to be a maturational adaptation rather than a sign of inadequate maternal glucose production.

Thermodynamic network modelling of transfer across the perfused guinea-pig placenta, using SPICE.

The response of the dually perfused guinea pig placenta to bolus inputs of the marker substances 125I-albumin and tritiated water is used to model vascular placental topology and membrane characteristics. This is accomplished by generating a thermodynamic network containing ten adjustable variables describing flow and transfer quantitatively. After translation of the network into an electronic circuit the parameter values are determined with the use of the SPICE program. The results are then used to estimate unknown physiological variables like shunted flow, membrane permeabilities, etc. This model has potential usefulness in the study of those areas of placental physiology in which transient analysis is required.

Serum water determination by means of microwave evaporation.

A novel method is described for the determination of serum water using a microwave oven. The sources of experimental errors were analysed. Serum samples from two hundred patients were analysed for sodium, water and protein, and the data were used to calculate serum sodium molalities. A possible correlation was investigated between serum water content and protein concentration. The results were compared with those in the literature.