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An increase in circulating levels of branched-chain amino acids during hemodialysis with regard to protein breakdown: three case reports

An increase in circulating levels of branched-chain amino acids during hemodialysis with regard... Background: Hemodialysis (HD) is a protein catabolic event. However, the amino acid (AA) kinetics during HD ses- sions involved in protein breakdown have not been well investigated in patients with and without diabetes mellitus (DM). Case presentation: Three patients (two patients with DM and one patient without DM) underwent fasting HD. Plasma levels of branched-chain AAs (BCAA; leucine, isoleucine, and valine), major non-essential AAs (alanine and glutamine, including glutamate), insulin, and ketone bodies were measured every hour during each HD session. After the start of the HD session, the plasma levels of insulin and all BCAAs dropped simultaneously. There was a significant subsequent increase in the plasma level of leucine and isoleucine levels, while valine levels remained constant. How- ever, the recovery in levels of BCAAs during HD indicated a profound amount of BCAAs entering the blood from body tissues such as muscles. BCAAs may have surpassed their removal by HD. Ketone body levels increased continuously from the start of the sessions and reached high values in patients with DM. Synchronous changes in insulin depletion and an increase in the levels of ketone bodies may indicate disruption of energy metabolism. Conclusions: This is the first report to demonstrate the time course of the changes in circulating levels of BCAAs and related metabolites in energy homeostasis during HD. An increase in BCAA levels during HD was found to be due to their transfer from the body tissue which suggested protein breakdown. Keywords: Branched-chain amino acids, Cell starvation, Diabetes mellitus, Glucose transporter, Hemodialysis, Insulin, Ketone bodies, Protein breakdown protein breakdown during HD have not been investigated Background in patients with and without diabetes mellitus (DM). Hemodialysis (HD) involves protein catabolism accom- In DM patients with various pathophysiological condi- panied by muscle proteolysis [1]. HD is associated with tions, including insulin resistance, response to HD ses- an increase in amino acid (AA) loss from blood, which sions regarding energy metabolism and AA behaviors induces muscle protein breakdown [2, 3]. However, differ from the response seen in non-DM patients [4–6]. detailed AA kinetics and mechanisms involved in skeletal In our previous study, we found that patients with DM often experienced serious “cell starvation” during HD *Correspondence: m-fujiwara@med.teikyo-u.ac.jp [6]. The rapid removal of insulin from the blood by HD Department of Internal Medicine, Nephrology, Teikyo University Chiba caused cell starvation (HD starvation), which accom- Medical Center, 3426-3, Anesaki, Ichihara, Chiba 299-0111, Japan Full list of author information is available at the end of the article panies an increase in the levels of ketone bodies due © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 2 of 9 to low glucose levels within the cell, even though there HD sessions. In Case 1 and 2, they refrained from insu- was sufficient glucose in the blood. Meanwhile, the AA lin injection during HD session: they underwent insulin behavior during the HD session has not been sufficiently injection with the intake of first meal after HD session. examined. In three (for two DM cases) and two (for a non-DM uTh s, we aimed to investigate the circulating AA case) sessions, plasma samples were collected from behaviors and profiles of insulin and ketone bodies dur - the blood tubing at the arterial site every hour during ing HD sessions in two patients with DM and one patient each HD session using a method reported in a previ- without DM. ous study [7]. For Case 2 and 3, we were not allowed to collect blood specimen because of anemic tendency Case presentation and methods in these patients. Therefore, we used dialysate as a sur - The characteristics of the three patients (Patients 1 rogate of plasma to measure KB levels as mentioned and 2 with DM, and Patient 3 without DM) are shown below. in Table  1. Among them, two patients (Cases 2 and Plasma levels of the following molecules were quan- 3) underwent online pre-dilution hemodiafiltration tified from the samples collected: major components of (HDF) as a regular treatment. All patients were in a non-essential AAs (NEAAs) (alanine [Ala], glutamine, stable condition and showed no signs of malnutrition. and glutamate), three branched-chain AAs (BCAAs) In all cases, the glucose concentration of the dialysate (leucine [Leu], isoleucine [Ile], and valine [Val]), immu- was at 100 mg/dL. They all had breakfast before HD or noreactive insulin (IRI), and ketone bodies (KB; includ- HDF sessions and received no exogenous AA during ing 3-hydroxy butyrate and acetoacetate). As glutamine Table 1 Characteristics of study patients Case 1 Case 2 Case 3 Primary CKD Rapidly progressive glomerulonephritis Diabetic kidney disease Chronic glomerulone- phritis Sex m m f Age (years) 76 64 72 Dialysis vintage (years) 12 1 11 BMI (kg/m ) 26 24 25 Weight (kg) 71 71 56.3 HD/HDF (h) HD, 4 h HDFpre, 5 h HDFpre, 5 h Creatinine (mg/dL) 11.3 9.7 9.4 Albumin (g/dL) 3.4 3.8 3.7 Hemoglobin (g/dL) 11 11 11 Hematocrit (%) 32 31 32 Glucose (mg/dL) 125 163 98 CRP (ng/mL) 0.04 0.01 0.1 Phosphate (mg/dL) 5.5 4.8 4.2 Potassium (mEq/L) 5.2 5.1 4.3 GA (%) 12.2 18.7 – GNRI 92 100 96 nPCR (g/kg/day) 0.91 1.0 1.1 Kt/V 1.65 1.39 2.1 Raid acting insulin (E) 3-3-3 5-5-4 – Dialyzer (material) NV-21U (PS) ABH-21P (PS) ABH-18P (PS) Substitution fluid volume (L) – 40 40 Dialysate flow rate (ml/min) 500 500 500 Blood flow rate (ml/min) 240 300 240 CKD chronic kidney disease, BMI body mass index, HD hemodialysis, HDF hemodiafiltration, HDFpre pre-dilution hemodiafiltration, CRP C-reactive protein, nPCR normalized protein catabolic rate, GA glycated albumin, GNRI geriatric nutritional risk index; The dialyzers were polysulfone (PS) (Toray Medical Co., Ltd, Tokyo Japan).: Data were averaged over three or two sessions F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 3 of 9 Fig. 1 Plasma levels of metabolites during sessions. Case 1 (DM A 900 patient, 3 sessions in 4-h HD). In each panel of Figs. 1, 2, and 3, A Ala, Glx Alanine (Ala) and glutamine including glutamate (Glx). B Leucine (Leu), isoleucine (Ile) and valine ( Val). C Immunoreactive insulin (IRI) and ketone bodies (KB). D Plasma glucose (PG). In C, the arrows along the left and right axis indicate the normal ranges of IRI and KB, respectively. The levels of KB in Fig. 2C and 2C were determined at 15 min, 30 min, 1 h, 2 h, 3 h and 4.5 h after the initiation of dialysis 300 (see text) Time (hrs) is easily converted to glutamate in normal laboratory 01234 5 Ala-1 Ala-2 Ala-3 settings [8], the sum of glutamine and glutamate levels Glx-1Glx-2 Glx-3 was evaluated as glutamine-glutamate (Glx) levels. The levels of IRI, AA, and glucose were determined using B 150 800 BCAA CLIA, HPLC, and enzymatic methods, respectively. The KB levels for Case 1 were determined using an enzy- matic method (LSI Medience Corp., Tokyo, Japan). The KB levels for Cases 2 and 3 were measured using dialysate collected at 15  min, 30  min, 1  h, 2  h, 3  h, and 4.5  h after the start of the sessions for determination by H-NMR spectroscopy (ECA, 600  MHz, JEOL. Co. LTD., Tokyo, Japan) and converted to plasma levels [5, Time (hrs) 6, 9, 10]. 0 0 This study was approved by the Ethical Committee of Ile-1 Ile-2 Ile-3 Leu-1 Leu-2Leu-3 Teikyo University (TU-20-194), and informed consent Val-1Val-2 Val-3 was obtained from all the patients. C 40 IRI, KB Case 1: DM, male patient, three sessions of 4‑h HD 30 Figure  1A shows the time course of changes in the lev- els of Ala and Glx. The levels of these AAs decreased thorough removal from the plasma during the first hour of HD. Subsequently, the levels of Glx and Ala remained almost constant toward the end of the ses- sions. This behavior was similar in Case 2 (Fig.  2A) and Case 3 (Fig.  3A). However, the changes in BCAAs were Time(hrs) 0 0 different from those in the NEAAs (Fig.  1B). Although the levels of BCAAs decreased due to removal during IRI-1IRI-2 IRI-3 the first hour of HD sessions, dramatic increases in the KB-1 KB-2 KB-3 levels of Leu were observed, and the levels ultimately 200 almost recovered along with the simultaneous increase in Ile levels. Val levels remained constant and showed PG no decrease. Figure  1C shows the time-course changes in the IRI and KB levels. The IRI levels exhibited a sharp decrease in the first hour of HD. Thereafter, IRI values remained at the lower limit of the normal range (arrow along the left axis) [11]. In contrast, the KB lev- els continuously and dramatically increased, reaching a remarkably high value of 600 to1000 μM. These levels Time(hrs) were far higher than the upper limit of the normal range PG-1 PG-2 PG-3 (arrow along the right axis). The time course behaviors of the seven metabolite levels were reproduced in the three sessions. Leu, Ile (μM) IRI (mU/L) PG (mg/dL) Ala, Glx(μM) Val (μM) KB (μM) Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 4 of 9 A 900 A 900 Ala, Glx Ala, Glx Time(hrs) Time (hrs) 01234 5 Ala-1 Ala-2 Ala-1 Ala-2 Ala-3 Glx-1 Glx-2 Glx-1 Glx-2 Glx-3 B 150 800 B 150 800 BCAA BCAA Time (hrs) 0 0 Time (hrs) 0 0 Ile-1 Ile-2 Leu-1 Ile-1 Ile-2 Ile-3 Leu-1 Leu-2 Leu-3 Leu-2 Val-1 Val-2 Val-1 Val-2 Val-3 C 40 IRI, KB C 40 IRI, KB 20 400 0 0 0 0 IRI-1 IRI-2 KB-1 KB-2 IRI-1 IRI-2 IRI-3 D 200 KB-1 KB-2 KB-3 PG D 200 PG Time(hrs) 0 12345 PG-1 PG-2 Time(hrs) Fig. 3 Plasma levels of metabolites during sessions. Case 3 (non-DM patient, two sessions in 5-h HDF) PG-1 PG-2 PG-3 Fig. 2 Plasma levels of metabolites during sessions. Case 2 (DM patient, 3 sessions in 5-h HDF) PG(mg/dL) Leu, Ile (μM) IRI (mU/L) Ala, Glx(μM) Val (μM) KB (μM) Ala, Glx(μM) PG(mg/dL) IRI (mU/L) Leu, Ile (μM) KB (μM) Val(μM) F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 5 of 9 Figure 1D shows the time-course change in the level of (B) The levels of Ala and Glx decreased during the first plasma glucose (PG), which was almost constant. The PG hour and subsequently remained constant. levels were almost the same in Case 2 (Fig. 2D) and Case (C) IRI levels declined sharply between the first and 3 (Fig. 3D). second hours in all patients, and KB levels dramati- cally increased after the first hour in patients with DM. Case 2: DM, male patient, three sessions of 5‑h HDF (D) PG levels were almost constant. Figure  2B shows the time changes of BCAAs, which were also very similar to those in Fig.  1B. The dramatic In general, plasma levels of small molecules with- increase in Leu levels was also shown directly at the end out marked derivation (e.g., urea nitrogen) decrease of 5-h sessions, and the final levels recovered to slightly monotonously. Molecular weights of AAs and KB are above than the initial levels. Figure  2C illustrates the small and exist in free in serum, and thus, those should time changes in the levels of IRI and KB, in which whole be removed by diffusion during hemodialysis treatment. behaviors were similar through the sessions with a slower Nevertheless, in this case report, AAs were not decreas- decrease in IRI levels than those presented in Fig.  1C. ing monotonously (A, B) and KB was increasing dur- KB levels increased with time, and toward the end of the ing hemodialysis (C). We suppose that such behavior of sessions, they reached levels above the normal range. plasma AAs and KB levels during HD sessions suggests Among the three sessions in Case 2, five types of AAs that large amounts of AAs and KB were derived from showed highly reproducible time-course behaviors, and cells and such derivation from cells surpasses removal the time-course changes in the levels of IRI and KB were via dialyzer. reproduced. Because BCAA is an essential AA, which cannot be biosynthesized, and the patients had no exogenous Case 3: Non‑DM, female patient, two sessions of 5‑h HDF AA supply during the sessions, these increases are Figure 3B shows the time changes in the levels of BCAAs; supposed to originate from the free AA pool derived those of Leu and Ile somewhat differed from those pre - from muscle protein degradation. From our prelimi- sented in Figs.  1B and 2B. The levels of Leu and Ile nary observation, the two DM patients were more evi- decreased during the first or second hour from the start dent with their reproduced time course of changes, of the sessions and subsequently exhibited some fluctua - while the non-DM patient exhibited blunt behaviors tions in the time course, and the final levels that recov - of increase in Leu and Ile levels compared to the DM ered were lower than those in Figs. 1B and 2B. However, patients. These final levels did not reach their initial the changes in the levels of Val were remarkably similar levels. to those in Figs. 1B and Fig. 2B. Figure 3C represents the Ala and Glx constitute the two most important time changes in the levels of IRI and KB, in which IRI nitrogen carriers released from muscle, and Ala plays decreased during the second hour from the start of the an important role in the regulation of blood glucose sessions, similar to those seen in Fig. 2C. The changes in levels through the alanine-glucose cycle and glucone- the levels of KB in this case did not increase as much as ogenesis in the liver [12]. In the three cases, the levels in Figs. 1C and 2C, but remained near the upper normal of Ala and Glx did not decrease throughout HD ses- range. In this case, the reproducibility of each metabo- sions after the first hour, but were maintained through lite between the two sessions was also confirmed, as long homeostasis [13]. They are non-essential AA with as behaviors in the levels of Leu and Ile had a little time biosynthesis that are closely interrelated with BCAAs, deviation. which could serve as amino group donors for the syn- thesis of Ala and Glx [14]. In this case report, growing levels of BCAA were suggested to provide a sufficient Discussion supply of amino groups for the synthesis of Ala and The results of present study were summarized as follows: Glx. As shown in Figs.  1C, 2C and 3C, IRI levels (A) BCAA levels decreased during the first or second decreased due to diffusion, convection, and adsorp- hours and subsequently did not decrease; however, tion by membranes [15]. In contrast to the decrease they were remarkably elevated toward the end of the sessions and the profiles were prominent in the patients with DM than the patient without DM. Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 6 of 9 in IRI levels, KB levels continuously increased. In this To understand such unique pathophysiology of case report, increases of KB levels were more evident HD starvation, “difference of glucose transporter” in the DM patients than in the non-DM patient, simi- expressed in different organ cell membranes should lar to BCAA behaviors. The former KB levels (Figs. 1C be considered. Glucose transporter GLUT4 (SLC2A4, and 2C) in the DM patients were elevated up to 600 to solute carrier family 2 facilitated glucose transporter 1000  μM, far higher than the upper limit of the nor- member 4) expressed in muscle cells and adipose tis- mal range (100  μM) (arrows in right axes in Figs.  1C, sue depends on insulin (insulin-sensitive organs), not 2C, 3C). Such high values reflect starvation [16, 17]. on glucose [21, 22]. Under insulin depletion caused Circulating KB appears during starvation when the by HD session primarily via adsorption of insulin on depletion of insulin induces free fatty acid release the dialyzer membrane [15], GLUT4 cannot be trans- from adipose tissue, and β-oxidation accelerates in the located on the surface of muscle and adipose tissue, liver [16, 17]. The latter KB levels (Fig. 3C) in the non- due to glucose poverty in these cells. Such cell starva- DM patient showed slight increase in time-course tion promotes adipose tissue lipolysis, which provides behavior; however, these levels maintained within the fatty acids to the liver through the bloodstream. Then, normal range indicated to be not starvation during the liver accelerates β-oxidation for converting fatty HD sessions. acids into ketone bodies, amount of which flowed into In this case report, we investigated the circulating AA blood with the consequence surpassing the continuous behaviors and profiles of insulin and ketone bodies dur - removal by HD (Figs. 1C, 2C, 3C). In contrast, the glu- ing HD sessions in two DM patients and one non-DM cose transporter GLUT2 (SLC2A2, solute carrier family patient to determine the effect of “HD starvation”. 2 facilitated glucose transporter member 2) expressed The comparison between HD starvation and conven - in the membranes of the liver and pancreas (β-cell) tional starvation (fasting starvation) is summarized in are dependent on glucose (glucose-sensitive organs), Table  2 [16–19]. A key similarity between the two is the not on insulin [23]. The relationship between glucose, extremely suppressed blood insulin level, whereas these insulin, and the organs is illustrated in Fig.  4. Because differed in expression time: fasting starvation deterio - the PG level is almost constant during each HD session rates gradually (20–36 h), and HD starvation deteriorates (Figs.1D, 2D and 3D), the liver and pancreas do not rapidly (1  h). The difference in the behavior of metabo - accelerate gluconeogenesis nor glucagon secretion [17] lites between the two states of starvation might reflect (Table 2). different liver statuses. In this context, the sharp increase in BCAA lev- In the present three cases, IRI levels remained very low els due to HD starvation (Figs.  1B, 2B, 3B) is inter- in the later stages of HD. This demonstrated that both preted as the distinct AA release from muscular cells DM and non-DM patients had only a small amount of via the autophagic procedure [24]. Basic adaptation endogenous insulin secretion stimulated by 100  mg/dL of autophagy is to activate for nutrient starvation, the dialysate glucose. As described above, more prominent mechanism is critically sensitive to the levels of AA and time-course changes in KB levels in patients with diabe- insulin, and the effect of insulin is greater in muscle than tes were coincident with insulin resistance often present liver [25]. in the groups [20]. Table 2 Comparison of time-course change in levels of metabolites between HD starvation and fasting starvation Metabolite and related pathway HD starvation Fasting starvation References regarding fasting starvation Blood glucose → ↓ Start of change 1 h 20–36 h Blood insulin ↓ ↓ Owen [16] Blood BCAA ↑ ↑ Felig [18], Owen [16], Schauder [19] Blood ketone bodies ↑ ↑ Owen [16], Watford [17] Hepatic glycogen → ↓ Watford [17] Blood alanine → ↓ Felig [18] Gluconeogenesis → ↑ Felig [18], Watford [17] The behaviors in lower three rows indicate difference of the liver status between two kind of starvation. In the right column, literatures referring to fasting starvation are depicted F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 7 of 9 Fig. 4 The schema of HD starvation. Arrows are flows of metabolites: Dashed arrows indicate sparse little or no amount. Insulin is adsorbed by dialysis membrane. Amino acids depletion induced by HD session increases number of autophagosomes in muscle The continuous increase in BCAA levels toward the (decrease initially and plateau thereafter). Except the ini- end of the HD session suggests that there were no pro- tial removal during the sessions, alanine levels could be found demands of the liver for BCAAs, suggesting that maintained by constant supply from plenty amounts of gluconeogenesis (transference of BCAA nitrogen to ala- BCAA and cessation of consume for gluconeogenesis. nine, a substrate for gluconeogenesis) is not accelerated. There are few studies regarding the change in AA con - In addition, “biotin deficiency” in HD patients [26, 27] centration in the blood during HD treatment; representa- could cooperatively suppress the gluconeogenesis dur- tive studies are summarized in Table 3. The plasma levels ing HD session, because biotin, a water-soluble vitamin, of AAs were measured before and after each HD session, plays a key role as a coenzyme in reaction from pyruvate and the lack of decline in plasma EAA levels during the to oxaloacetic acid located at the start of the gluconeoge- sessions has already been reported [2, 3, 8, 28–32]. How- netic pathway. ever, the mechanism underlying EAA behavior remains The circulating levels of BCAAs are balanced by their unclear because plasma AA levels at intermediate time appearance and disappearance in the blood. In this con- during the session are yet to be observed. dition, an increase in supply and decrease in demand In summary, it is noted that the BCAA increase was (consumption) of BCAA leads its circulating levels to ele- triggered by IRI depletion and was accompanied by an vation, and concomitantly, the amount missing of BCAA elevation in KB levels. The synchronous time course during HD into the dialysate is expected to increase. changes in these metabolite levels represented disrup- Therefore, an increase in plasma levels of BCAAs dur - tion of homeostasis in protein and energy induced by HD ing HD is suspected to be harmful from the viewpoint of starvation. In this case report, these behaviors were more nutrient homeostasis. evident in the DM patients than in the non-DM patient. Regarding HD starvation, an increase in plasma BCAA This is the first case report to show the time course of the levels (Figs.  1B, 2B, 3B) supposed to be produced by changes in circulating BCAAs in detail and clearly dem- the breakdown of muscle protein indicates disruption onstrated an increase in BCAA levels at an early time in of homeostasis during HD in not only protein but also the sessions. The consequence was the dramatic increase energy, because such high amounts of BCAAs are not in BCAA which suggested to induce skeletal protein available for energy generation due to the suppression of breakdown. Present our finding is preliminary but novel gluconeogenesis. Such suppression of gluconeogenesis and the larger study is warranted in near future. could explain the time-course behavior of alanine levels Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 8 of 9 Table 3 Selected studies of plasma amino acids measurement during HD treatment Author Measured No. of AA Meal HD/HDF (h) Etiology (N) kT/V Blood flow Surface area Dialysate Membrane Study aim (reference) timing measured supplement during rate (mL/ of dialyzer glucose (mg/ (N) AA kinds HD min) (m ) dL) Ikizler [28] B, A 25 No No HD (4 h) D(3), ND(6) 1.5 300–400 1.8 Not described PS, PMMA CU Functional comparison of membranes (between PS, PMMA and CU) Navarro [3] B, A 22 Yes, no no HD (4 h) ND(10) 1.23 300 1.7 100 PAN Evaluation of the effect of intradialytic amino acid solution supply Gil [29] B, A 21 No No HD D(3), ND(7) 1.52 2, 50, 300 1.4 Not described PAES Functional comparison of membranes (between high flux and low flux) Fujiwara [8] B, A 28 Yes, no No HDF (5 h) D(2) 1.7 240 2.1 100 PS Evaluation of the effect of intradialytic amino acid solution supply Murtas [30] B, A 20 No No HD,HDF(4 h) ND(10) 1.37 240 1.8 100 PS Functional comparison of modalities (between HD and HDF) Murtas [31] B 20 No No HD,HDF(4 h) ND(10) 1.37 Not described 1.8 100 PS Functional comparison of modalities (between HD and HDF) Hendriks [32] B, A 22 No Yes HD (4 h) D(2), ND(8) Not described 300–400 1.7, 2.2 100 PS (7) PAES (3) Evaluation of the effect of food intake AA amino acids, B before HD, A after HD, D diabetic, ND non-diabetic, PS polysulfone, PMMA polymethylmethacrylate, CU cuprophane, PAN polyacrylonitrile, PAES polyarylethersulfone F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 9 of 9 Abbreviations 10. Ando I, Takeuchi K, Oguma S, et al. H NMR spectroscopic quantification HD: Hemodialysis; HDF: Hemodiafiltration; AA: Amino acid; BCAA : Branched- of plasma metabolites in dialysate during hemodialysis. Magn Reson Med chain amino acid; EAA: Essential amino acid; NEAA: Non-essential amino acid; Sci. 2013;12(2):129–35. DM: Diabetes mellitus; IRI: Immunoreactive insulin; KB: Ketone bodies; Ala: 11. Iwase H, Kobayashi M, Nakajima M, Takatori T. The ratio of insulin to Alanine; Glx: Glutamine, and glutamate; Leu: Leucine; Ile: Isoleucine; Val: Valine. C-peptide can be used to make a forensic diagnosis of exogeneous insulin overdosage. Foren Sci Intern. 2001;115:123–7. Acknowledgements 12. Raj DSC, Welbourne T, Dominic EA, et al. Glutamine kinetics and protein Not applicable. turnover in end-stage renal disease. Am J Physiol Endcronol Metab. 2005;288:E37-46. Authors’ contributions 13. Bröer S, Bröer A. 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Biotin ameliorates muscle cramps of hemodialysis patients: a prospective trial. Tohoku J Exp Med. 2012;227:217–23. 27. Fujiwara M, Ando I, Yagi S, et al. Plasma levels of biotin metabolites References are elevated in hemodialysis patients with cramps. Tohoku J Exp Med. 1. Lim VS, Ikizler TA, Raj DSC, Flanigan MJ. Does hemodialysis increase pro- 2016;239(4):263–7. tein breakdown? Dissociation between whole-body amino acid turnover 28. Ikizler TA, Flakoll PL, Parker RA, Hakim RM. Amino acid and albumin losses and regional muscle kinetics. J Am Soc Nephrol. 2005;16:862–8. during hemodialysis. Kidney Int. 1994;46:830–7. 2. Ikizler TA, Pupim LB, Brouillette JR, et al. Hemodialysis stimulates muscle 29. Gil HW, Yang JOY, Lee EM, Choi JS, Hong SY. The effect of dialysis mem- and whole body protein loss and alters substrate oxidation. Am J Physiol brane flux on amino acid loss in hemodialysis patients. J Korean Med Sci. Endocrinol Metab. 2002;282:E107–16. 2007;22:598–603. 3. 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Hendriks FK, Smeets JSJ, Broers NJH, et al. End-stage renal disease bolic responses during hemodialysis determined by quantitative 1H NMR patients lose a substantial amount of amino acids during hemodialysis. J spectroscopy. J Pharm Biomed Anal. 2015;111:159–62. Nutr. 2020;31:1160–6. 6. Fujiwara M, Ando I, Satoh K, et al. Biochemical evidence of cell starvation in diabetic hemodialysis patients. PLoS ONE. 2018;13:e0204406. Publisher’s Note 7. Yamamoto H, Kondo K, Tanaka T, et al. Reference intervals for plasma- Springer Nature remains neutral with regard to jurisdictional claims in pub- free amino acid in a Japanese population. Anna Clin Biochem. lished maps and institutional affiliations. 2016;53:357–64. 8. Fujiwara M, Ando I, Nemoto T, et al. Amino acid kinetics in diabetic patients during hemodiafiltration performed under intradialytic parenteral amino acid nutrition: a preliminary study. J Jpn Soc Dial Ther. 2019;52:457–62. 9. Ando I, Hirose T, Nemoto T, et al. Quantification of molecule in H-NMR metabolomics with formate as a concentration standard. J Toxicol Sci. 2010;35(2):253–6. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Renal Replacement Therapy Springer Journals

An increase in circulating levels of branched-chain amino acids during hemodialysis with regard to protein breakdown: three case reports

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Abstract

Background: Hemodialysis (HD) is a protein catabolic event. However, the amino acid (AA) kinetics during HD ses- sions involved in protein breakdown have not been well investigated in patients with and without diabetes mellitus (DM). Case presentation: Three patients (two patients with DM and one patient without DM) underwent fasting HD. Plasma levels of branched-chain AAs (BCAA; leucine, isoleucine, and valine), major non-essential AAs (alanine and glutamine, including glutamate), insulin, and ketone bodies were measured every hour during each HD session. After the start of the HD session, the plasma levels of insulin and all BCAAs dropped simultaneously. There was a significant subsequent increase in the plasma level of leucine and isoleucine levels, while valine levels remained constant. How- ever, the recovery in levels of BCAAs during HD indicated a profound amount of BCAAs entering the blood from body tissues such as muscles. BCAAs may have surpassed their removal by HD. Ketone body levels increased continuously from the start of the sessions and reached high values in patients with DM. Synchronous changes in insulin depletion and an increase in the levels of ketone bodies may indicate disruption of energy metabolism. Conclusions: This is the first report to demonstrate the time course of the changes in circulating levels of BCAAs and related metabolites in energy homeostasis during HD. An increase in BCAA levels during HD was found to be due to their transfer from the body tissue which suggested protein breakdown. Keywords: Branched-chain amino acids, Cell starvation, Diabetes mellitus, Glucose transporter, Hemodialysis, Insulin, Ketone bodies, Protein breakdown protein breakdown during HD have not been investigated Background in patients with and without diabetes mellitus (DM). Hemodialysis (HD) involves protein catabolism accom- In DM patients with various pathophysiological condi- panied by muscle proteolysis [1]. HD is associated with tions, including insulin resistance, response to HD ses- an increase in amino acid (AA) loss from blood, which sions regarding energy metabolism and AA behaviors induces muscle protein breakdown [2, 3]. However, differ from the response seen in non-DM patients [4–6]. detailed AA kinetics and mechanisms involved in skeletal In our previous study, we found that patients with DM often experienced serious “cell starvation” during HD *Correspondence: m-fujiwara@med.teikyo-u.ac.jp [6]. The rapid removal of insulin from the blood by HD Department of Internal Medicine, Nephrology, Teikyo University Chiba caused cell starvation (HD starvation), which accom- Medical Center, 3426-3, Anesaki, Ichihara, Chiba 299-0111, Japan Full list of author information is available at the end of the article panies an increase in the levels of ketone bodies due © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 2 of 9 to low glucose levels within the cell, even though there HD sessions. In Case 1 and 2, they refrained from insu- was sufficient glucose in the blood. Meanwhile, the AA lin injection during HD session: they underwent insulin behavior during the HD session has not been sufficiently injection with the intake of first meal after HD session. examined. In three (for two DM cases) and two (for a non-DM uTh s, we aimed to investigate the circulating AA case) sessions, plasma samples were collected from behaviors and profiles of insulin and ketone bodies dur - the blood tubing at the arterial site every hour during ing HD sessions in two patients with DM and one patient each HD session using a method reported in a previ- without DM. ous study [7]. For Case 2 and 3, we were not allowed to collect blood specimen because of anemic tendency Case presentation and methods in these patients. Therefore, we used dialysate as a sur - The characteristics of the three patients (Patients 1 rogate of plasma to measure KB levels as mentioned and 2 with DM, and Patient 3 without DM) are shown below. in Table  1. Among them, two patients (Cases 2 and Plasma levels of the following molecules were quan- 3) underwent online pre-dilution hemodiafiltration tified from the samples collected: major components of (HDF) as a regular treatment. All patients were in a non-essential AAs (NEAAs) (alanine [Ala], glutamine, stable condition and showed no signs of malnutrition. and glutamate), three branched-chain AAs (BCAAs) In all cases, the glucose concentration of the dialysate (leucine [Leu], isoleucine [Ile], and valine [Val]), immu- was at 100 mg/dL. They all had breakfast before HD or noreactive insulin (IRI), and ketone bodies (KB; includ- HDF sessions and received no exogenous AA during ing 3-hydroxy butyrate and acetoacetate). As glutamine Table 1 Characteristics of study patients Case 1 Case 2 Case 3 Primary CKD Rapidly progressive glomerulonephritis Diabetic kidney disease Chronic glomerulone- phritis Sex m m f Age (years) 76 64 72 Dialysis vintage (years) 12 1 11 BMI (kg/m ) 26 24 25 Weight (kg) 71 71 56.3 HD/HDF (h) HD, 4 h HDFpre, 5 h HDFpre, 5 h Creatinine (mg/dL) 11.3 9.7 9.4 Albumin (g/dL) 3.4 3.8 3.7 Hemoglobin (g/dL) 11 11 11 Hematocrit (%) 32 31 32 Glucose (mg/dL) 125 163 98 CRP (ng/mL) 0.04 0.01 0.1 Phosphate (mg/dL) 5.5 4.8 4.2 Potassium (mEq/L) 5.2 5.1 4.3 GA (%) 12.2 18.7 – GNRI 92 100 96 nPCR (g/kg/day) 0.91 1.0 1.1 Kt/V 1.65 1.39 2.1 Raid acting insulin (E) 3-3-3 5-5-4 – Dialyzer (material) NV-21U (PS) ABH-21P (PS) ABH-18P (PS) Substitution fluid volume (L) – 40 40 Dialysate flow rate (ml/min) 500 500 500 Blood flow rate (ml/min) 240 300 240 CKD chronic kidney disease, BMI body mass index, HD hemodialysis, HDF hemodiafiltration, HDFpre pre-dilution hemodiafiltration, CRP C-reactive protein, nPCR normalized protein catabolic rate, GA glycated albumin, GNRI geriatric nutritional risk index; The dialyzers were polysulfone (PS) (Toray Medical Co., Ltd, Tokyo Japan).: Data were averaged over three or two sessions F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 3 of 9 Fig. 1 Plasma levels of metabolites during sessions. Case 1 (DM A 900 patient, 3 sessions in 4-h HD). In each panel of Figs. 1, 2, and 3, A Ala, Glx Alanine (Ala) and glutamine including glutamate (Glx). B Leucine (Leu), isoleucine (Ile) and valine ( Val). C Immunoreactive insulin (IRI) and ketone bodies (KB). D Plasma glucose (PG). In C, the arrows along the left and right axis indicate the normal ranges of IRI and KB, respectively. The levels of KB in Fig. 2C and 2C were determined at 15 min, 30 min, 1 h, 2 h, 3 h and 4.5 h after the initiation of dialysis 300 (see text) Time (hrs) is easily converted to glutamate in normal laboratory 01234 5 Ala-1 Ala-2 Ala-3 settings [8], the sum of glutamine and glutamate levels Glx-1Glx-2 Glx-3 was evaluated as glutamine-glutamate (Glx) levels. The levels of IRI, AA, and glucose were determined using B 150 800 BCAA CLIA, HPLC, and enzymatic methods, respectively. The KB levels for Case 1 were determined using an enzy- matic method (LSI Medience Corp., Tokyo, Japan). The KB levels for Cases 2 and 3 were measured using dialysate collected at 15  min, 30  min, 1  h, 2  h, 3  h, and 4.5  h after the start of the sessions for determination by H-NMR spectroscopy (ECA, 600  MHz, JEOL. Co. LTD., Tokyo, Japan) and converted to plasma levels [5, Time (hrs) 6, 9, 10]. 0 0 This study was approved by the Ethical Committee of Ile-1 Ile-2 Ile-3 Leu-1 Leu-2Leu-3 Teikyo University (TU-20-194), and informed consent Val-1Val-2 Val-3 was obtained from all the patients. C 40 IRI, KB Case 1: DM, male patient, three sessions of 4‑h HD 30 Figure  1A shows the time course of changes in the lev- els of Ala and Glx. The levels of these AAs decreased thorough removal from the plasma during the first hour of HD. Subsequently, the levels of Glx and Ala remained almost constant toward the end of the ses- sions. This behavior was similar in Case 2 (Fig.  2A) and Case 3 (Fig.  3A). However, the changes in BCAAs were Time(hrs) 0 0 different from those in the NEAAs (Fig.  1B). Although the levels of BCAAs decreased due to removal during IRI-1IRI-2 IRI-3 the first hour of HD sessions, dramatic increases in the KB-1 KB-2 KB-3 levels of Leu were observed, and the levels ultimately 200 almost recovered along with the simultaneous increase in Ile levels. Val levels remained constant and showed PG no decrease. Figure  1C shows the time-course changes in the IRI and KB levels. The IRI levels exhibited a sharp decrease in the first hour of HD. Thereafter, IRI values remained at the lower limit of the normal range (arrow along the left axis) [11]. In contrast, the KB lev- els continuously and dramatically increased, reaching a remarkably high value of 600 to1000 μM. These levels Time(hrs) were far higher than the upper limit of the normal range PG-1 PG-2 PG-3 (arrow along the right axis). The time course behaviors of the seven metabolite levels were reproduced in the three sessions. Leu, Ile (μM) IRI (mU/L) PG (mg/dL) Ala, Glx(μM) Val (μM) KB (μM) Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 4 of 9 A 900 A 900 Ala, Glx Ala, Glx Time(hrs) Time (hrs) 01234 5 Ala-1 Ala-2 Ala-1 Ala-2 Ala-3 Glx-1 Glx-2 Glx-1 Glx-2 Glx-3 B 150 800 B 150 800 BCAA BCAA Time (hrs) 0 0 Time (hrs) 0 0 Ile-1 Ile-2 Leu-1 Ile-1 Ile-2 Ile-3 Leu-1 Leu-2 Leu-3 Leu-2 Val-1 Val-2 Val-1 Val-2 Val-3 C 40 IRI, KB C 40 IRI, KB 20 400 0 0 0 0 IRI-1 IRI-2 KB-1 KB-2 IRI-1 IRI-2 IRI-3 D 200 KB-1 KB-2 KB-3 PG D 200 PG Time(hrs) 0 12345 PG-1 PG-2 Time(hrs) Fig. 3 Plasma levels of metabolites during sessions. Case 3 (non-DM patient, two sessions in 5-h HDF) PG-1 PG-2 PG-3 Fig. 2 Plasma levels of metabolites during sessions. Case 2 (DM patient, 3 sessions in 5-h HDF) PG(mg/dL) Leu, Ile (μM) IRI (mU/L) Ala, Glx(μM) Val (μM) KB (μM) Ala, Glx(μM) PG(mg/dL) IRI (mU/L) Leu, Ile (μM) KB (μM) Val(μM) F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 5 of 9 Figure 1D shows the time-course change in the level of (B) The levels of Ala and Glx decreased during the first plasma glucose (PG), which was almost constant. The PG hour and subsequently remained constant. levels were almost the same in Case 2 (Fig. 2D) and Case (C) IRI levels declined sharply between the first and 3 (Fig. 3D). second hours in all patients, and KB levels dramati- cally increased after the first hour in patients with DM. Case 2: DM, male patient, three sessions of 5‑h HDF (D) PG levels were almost constant. Figure  2B shows the time changes of BCAAs, which were also very similar to those in Fig.  1B. The dramatic In general, plasma levels of small molecules with- increase in Leu levels was also shown directly at the end out marked derivation (e.g., urea nitrogen) decrease of 5-h sessions, and the final levels recovered to slightly monotonously. Molecular weights of AAs and KB are above than the initial levels. Figure  2C illustrates the small and exist in free in serum, and thus, those should time changes in the levels of IRI and KB, in which whole be removed by diffusion during hemodialysis treatment. behaviors were similar through the sessions with a slower Nevertheless, in this case report, AAs were not decreas- decrease in IRI levels than those presented in Fig.  1C. ing monotonously (A, B) and KB was increasing dur- KB levels increased with time, and toward the end of the ing hemodialysis (C). We suppose that such behavior of sessions, they reached levels above the normal range. plasma AAs and KB levels during HD sessions suggests Among the three sessions in Case 2, five types of AAs that large amounts of AAs and KB were derived from showed highly reproducible time-course behaviors, and cells and such derivation from cells surpasses removal the time-course changes in the levels of IRI and KB were via dialyzer. reproduced. Because BCAA is an essential AA, which cannot be biosynthesized, and the patients had no exogenous Case 3: Non‑DM, female patient, two sessions of 5‑h HDF AA supply during the sessions, these increases are Figure 3B shows the time changes in the levels of BCAAs; supposed to originate from the free AA pool derived those of Leu and Ile somewhat differed from those pre - from muscle protein degradation. From our prelimi- sented in Figs.  1B and 2B. The levels of Leu and Ile nary observation, the two DM patients were more evi- decreased during the first or second hour from the start dent with their reproduced time course of changes, of the sessions and subsequently exhibited some fluctua - while the non-DM patient exhibited blunt behaviors tions in the time course, and the final levels that recov - of increase in Leu and Ile levels compared to the DM ered were lower than those in Figs. 1B and 2B. However, patients. These final levels did not reach their initial the changes in the levels of Val were remarkably similar levels. to those in Figs. 1B and Fig. 2B. Figure 3C represents the Ala and Glx constitute the two most important time changes in the levels of IRI and KB, in which IRI nitrogen carriers released from muscle, and Ala plays decreased during the second hour from the start of the an important role in the regulation of blood glucose sessions, similar to those seen in Fig. 2C. The changes in levels through the alanine-glucose cycle and glucone- the levels of KB in this case did not increase as much as ogenesis in the liver [12]. In the three cases, the levels in Figs. 1C and 2C, but remained near the upper normal of Ala and Glx did not decrease throughout HD ses- range. In this case, the reproducibility of each metabo- sions after the first hour, but were maintained through lite between the two sessions was also confirmed, as long homeostasis [13]. They are non-essential AA with as behaviors in the levels of Leu and Ile had a little time biosynthesis that are closely interrelated with BCAAs, deviation. which could serve as amino group donors for the syn- thesis of Ala and Glx [14]. In this case report, growing levels of BCAA were suggested to provide a sufficient Discussion supply of amino groups for the synthesis of Ala and The results of present study were summarized as follows: Glx. As shown in Figs.  1C, 2C and 3C, IRI levels (A) BCAA levels decreased during the first or second decreased due to diffusion, convection, and adsorp- hours and subsequently did not decrease; however, tion by membranes [15]. In contrast to the decrease they were remarkably elevated toward the end of the sessions and the profiles were prominent in the patients with DM than the patient without DM. Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 6 of 9 in IRI levels, KB levels continuously increased. In this To understand such unique pathophysiology of case report, increases of KB levels were more evident HD starvation, “difference of glucose transporter” in the DM patients than in the non-DM patient, simi- expressed in different organ cell membranes should lar to BCAA behaviors. The former KB levels (Figs. 1C be considered. Glucose transporter GLUT4 (SLC2A4, and 2C) in the DM patients were elevated up to 600 to solute carrier family 2 facilitated glucose transporter 1000  μM, far higher than the upper limit of the nor- member 4) expressed in muscle cells and adipose tis- mal range (100  μM) (arrows in right axes in Figs.  1C, sue depends on insulin (insulin-sensitive organs), not 2C, 3C). Such high values reflect starvation [16, 17]. on glucose [21, 22]. Under insulin depletion caused Circulating KB appears during starvation when the by HD session primarily via adsorption of insulin on depletion of insulin induces free fatty acid release the dialyzer membrane [15], GLUT4 cannot be trans- from adipose tissue, and β-oxidation accelerates in the located on the surface of muscle and adipose tissue, liver [16, 17]. The latter KB levels (Fig. 3C) in the non- due to glucose poverty in these cells. Such cell starva- DM patient showed slight increase in time-course tion promotes adipose tissue lipolysis, which provides behavior; however, these levels maintained within the fatty acids to the liver through the bloodstream. Then, normal range indicated to be not starvation during the liver accelerates β-oxidation for converting fatty HD sessions. acids into ketone bodies, amount of which flowed into In this case report, we investigated the circulating AA blood with the consequence surpassing the continuous behaviors and profiles of insulin and ketone bodies dur - removal by HD (Figs. 1C, 2C, 3C). In contrast, the glu- ing HD sessions in two DM patients and one non-DM cose transporter GLUT2 (SLC2A2, solute carrier family patient to determine the effect of “HD starvation”. 2 facilitated glucose transporter member 2) expressed The comparison between HD starvation and conven - in the membranes of the liver and pancreas (β-cell) tional starvation (fasting starvation) is summarized in are dependent on glucose (glucose-sensitive organs), Table  2 [16–19]. A key similarity between the two is the not on insulin [23]. The relationship between glucose, extremely suppressed blood insulin level, whereas these insulin, and the organs is illustrated in Fig.  4. Because differed in expression time: fasting starvation deterio - the PG level is almost constant during each HD session rates gradually (20–36 h), and HD starvation deteriorates (Figs.1D, 2D and 3D), the liver and pancreas do not rapidly (1  h). The difference in the behavior of metabo - accelerate gluconeogenesis nor glucagon secretion [17] lites between the two states of starvation might reflect (Table 2). different liver statuses. In this context, the sharp increase in BCAA lev- In the present three cases, IRI levels remained very low els due to HD starvation (Figs.  1B, 2B, 3B) is inter- in the later stages of HD. This demonstrated that both preted as the distinct AA release from muscular cells DM and non-DM patients had only a small amount of via the autophagic procedure [24]. Basic adaptation endogenous insulin secretion stimulated by 100  mg/dL of autophagy is to activate for nutrient starvation, the dialysate glucose. As described above, more prominent mechanism is critically sensitive to the levels of AA and time-course changes in KB levels in patients with diabe- insulin, and the effect of insulin is greater in muscle than tes were coincident with insulin resistance often present liver [25]. in the groups [20]. Table 2 Comparison of time-course change in levels of metabolites between HD starvation and fasting starvation Metabolite and related pathway HD starvation Fasting starvation References regarding fasting starvation Blood glucose → ↓ Start of change 1 h 20–36 h Blood insulin ↓ ↓ Owen [16] Blood BCAA ↑ ↑ Felig [18], Owen [16], Schauder [19] Blood ketone bodies ↑ ↑ Owen [16], Watford [17] Hepatic glycogen → ↓ Watford [17] Blood alanine → ↓ Felig [18] Gluconeogenesis → ↑ Felig [18], Watford [17] The behaviors in lower three rows indicate difference of the liver status between two kind of starvation. In the right column, literatures referring to fasting starvation are depicted F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 7 of 9 Fig. 4 The schema of HD starvation. Arrows are flows of metabolites: Dashed arrows indicate sparse little or no amount. Insulin is adsorbed by dialysis membrane. Amino acids depletion induced by HD session increases number of autophagosomes in muscle The continuous increase in BCAA levels toward the (decrease initially and plateau thereafter). Except the ini- end of the HD session suggests that there were no pro- tial removal during the sessions, alanine levels could be found demands of the liver for BCAAs, suggesting that maintained by constant supply from plenty amounts of gluconeogenesis (transference of BCAA nitrogen to ala- BCAA and cessation of consume for gluconeogenesis. nine, a substrate for gluconeogenesis) is not accelerated. There are few studies regarding the change in AA con - In addition, “biotin deficiency” in HD patients [26, 27] centration in the blood during HD treatment; representa- could cooperatively suppress the gluconeogenesis dur- tive studies are summarized in Table 3. The plasma levels ing HD session, because biotin, a water-soluble vitamin, of AAs were measured before and after each HD session, plays a key role as a coenzyme in reaction from pyruvate and the lack of decline in plasma EAA levels during the to oxaloacetic acid located at the start of the gluconeoge- sessions has already been reported [2, 3, 8, 28–32]. How- netic pathway. ever, the mechanism underlying EAA behavior remains The circulating levels of BCAAs are balanced by their unclear because plasma AA levels at intermediate time appearance and disappearance in the blood. In this con- during the session are yet to be observed. dition, an increase in supply and decrease in demand In summary, it is noted that the BCAA increase was (consumption) of BCAA leads its circulating levels to ele- triggered by IRI depletion and was accompanied by an vation, and concomitantly, the amount missing of BCAA elevation in KB levels. The synchronous time course during HD into the dialysate is expected to increase. changes in these metabolite levels represented disrup- Therefore, an increase in plasma levels of BCAAs dur - tion of homeostasis in protein and energy induced by HD ing HD is suspected to be harmful from the viewpoint of starvation. In this case report, these behaviors were more nutrient homeostasis. evident in the DM patients than in the non-DM patient. Regarding HD starvation, an increase in plasma BCAA This is the first case report to show the time course of the levels (Figs.  1B, 2B, 3B) supposed to be produced by changes in circulating BCAAs in detail and clearly dem- the breakdown of muscle protein indicates disruption onstrated an increase in BCAA levels at an early time in of homeostasis during HD in not only protein but also the sessions. The consequence was the dramatic increase energy, because such high amounts of BCAAs are not in BCAA which suggested to induce skeletal protein available for energy generation due to the suppression of breakdown. Present our finding is preliminary but novel gluconeogenesis. Such suppression of gluconeogenesis and the larger study is warranted in near future. could explain the time-course behavior of alanine levels Fujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 8 of 9 Table 3 Selected studies of plasma amino acids measurement during HD treatment Author Measured No. of AA Meal HD/HDF (h) Etiology (N) kT/V Blood flow Surface area Dialysate Membrane Study aim (reference) timing measured supplement during rate (mL/ of dialyzer glucose (mg/ (N) AA kinds HD min) (m ) dL) Ikizler [28] B, A 25 No No HD (4 h) D(3), ND(6) 1.5 300–400 1.8 Not described PS, PMMA CU Functional comparison of membranes (between PS, PMMA and CU) Navarro [3] B, A 22 Yes, no no HD (4 h) ND(10) 1.23 300 1.7 100 PAN Evaluation of the effect of intradialytic amino acid solution supply Gil [29] B, A 21 No No HD D(3), ND(7) 1.52 2, 50, 300 1.4 Not described PAES Functional comparison of membranes (between high flux and low flux) Fujiwara [8] B, A 28 Yes, no No HDF (5 h) D(2) 1.7 240 2.1 100 PS Evaluation of the effect of intradialytic amino acid solution supply Murtas [30] B, A 20 No No HD,HDF(4 h) ND(10) 1.37 240 1.8 100 PS Functional comparison of modalities (between HD and HDF) Murtas [31] B 20 No No HD,HDF(4 h) ND(10) 1.37 Not described 1.8 100 PS Functional comparison of modalities (between HD and HDF) Hendriks [32] B, A 22 No Yes HD (4 h) D(2), ND(8) Not described 300–400 1.7, 2.2 100 PS (7) PAES (3) Evaluation of the effect of food intake AA amino acids, B before HD, A after HD, D diabetic, ND non-diabetic, PS polysulfone, PMMA polymethylmethacrylate, CU cuprophane, PAN polyacrylonitrile, PAES polyarylethersulfone F ujiwara et al. Renal Replacement Therapy (2022) 8:1 Page 9 of 9 Abbreviations 10. Ando I, Takeuchi K, Oguma S, et al. H NMR spectroscopic quantification HD: Hemodialysis; HDF: Hemodiafiltration; AA: Amino acid; BCAA : Branched- of plasma metabolites in dialysate during hemodialysis. Magn Reson Med chain amino acid; EAA: Essential amino acid; NEAA: Non-essential amino acid; Sci. 2013;12(2):129–35. DM: Diabetes mellitus; IRI: Immunoreactive insulin; KB: Ketone bodies; Ala: 11. Iwase H, Kobayashi M, Nakajima M, Takatori T. The ratio of insulin to Alanine; Glx: Glutamine, and glutamate; Leu: Leucine; Ile: Isoleucine; Val: Valine. C-peptide can be used to make a forensic diagnosis of exogeneous insulin overdosage. Foren Sci Intern. 2001;115:123–7. Acknowledgements 12. Raj DSC, Welbourne T, Dominic EA, et al. Glutamine kinetics and protein Not applicable. turnover in end-stage renal disease. Am J Physiol Endcronol Metab. 2005;288:E37-46. Authors’ contributions 13. Bröer S, Bröer A. Amino acid homeostasis and signaling in mammalian MF and IA conceived and analyzed the data. MF wrote the draft of the manu- cells and organisms. Biochem J. 2017;474:66. script. YI, YS, and HT revised the manuscript critically for important intellectual 14. Harper AE, Miller RH, Block KP. Branched-chain amino acid metabolism. content. All authors read and approved the final manuscript. Annu Rev Nutr. 1984;4:409–545. 15. Abe M, Kalantar-Zadeh K. Haemodialysis-induced hypoglycaemia and Funding glycaemic disarrays. Nat Rev Nephrol. 2015;11:302–14. This study received no specific funding. 16. Owen OE, Felig P, Morgan AP, Wahren J, Cahil GF. Liver and kidney metabolism during prolonged starvation. J Clin Invest. 1969;48:574–83. Availability of data and materials 17. Watford M: Starvation. Metabolic changes. In: eLS. Wiley: Chichester. 2015. The data and materials were all included in the manuscript. 18. Felig P, Owen E, Wahren J, Cahill DF Jr. Amino acid metabolism during prolonged starvation. J Cli Invest. 1969;48:584–94. 19. Schauder P, Herbertz L, Langenbeck U. Serum branched chain amino and Declarations keto acid response to fasting in humans. Metabolism. 1985;34:58–61. 20. Rahhal MN, Ghraibeh NE, Rahimi L, Ismal-Beigi F. Disturbances in insulin- Ethics approval and consent to participate glucose metabolism in patients with advanced renal disease with and This study was approved by the Ethical Committee of Teikyo University ( TU- without diabetes. J Clin Endocrinol Metab. 2019;104:4949–66. 20-194), and informed consent was obtained from all the patients. 21. Bell G, Kayano T, Buse J, et al. Molecular biology of mammalian glucose transporters. Diabetes Care. 1990;13:198–208. Competing interests 22. Watson RT, Kanzaki M, Pessin JE. Regulated membrane trafficking of the The authors declare no competing interests. insulin-responsive glucose transporter 4 in adipocytes. 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Journal

Renal Replacement TherapySpringer Journals

Published: Jan 6, 2022

Keywords: Branched-chain amino acids; Cell starvation; Diabetes mellitus; Glucose transporter; Hemodialysis; Insulin; Ketone bodies; Protein breakdown

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