Role of Branched Chain Amino Acids in the Management of Hepatic Encephalopathy

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1 World Journal of Medical Sciences 3 (2): 60-64, 2008 ISSN IDOSI Publications, 2008 Role of Branched Chain Amino Acids in e Management of Hepatic Encephalopay Aftab Ahmed Soomro, Bikha Ram Devrajani, Rafi A. Ghori, Haresh Lohana and G. Ali Qureshi 1 Department of Medicine, Liaquat University of Medical and Heal Sciences Hyderabad/Jamshoro, Pakistan 2 Department of Biochemistry, University of Heal Sciences, Khayabane Jamia Punjab, Lahore, Pakisan Abstract: To know e association of branched chain amino acids (BCAA) in e management of hepatic encephalopay. Prospective, comparative, non randomized open study. This study was conducted in Medical Unit-4, LUMHS, Hyderabad, Pakistan from January 2007to October 2007 in indoor patients. Forty Eight (48) cases of chronic hepatic encephalopay were included for e study.24 patients were kept on branch chain amino acids and 24 patients were on control group. All investigations were done in all cases for e diagnosis and e classification of Chronic Liver Diseases (CLD) including ammonia and serum albumin level. Serum Ammonia and serum albumin level on admission day and six day and after four mons were done. Recovery and reoccurrence of hepatic encephalopay were compared on patients who were on brand chain amino acids given initially intravenously en kept on oral amino acids wi ose of control group wiout aminoleban. Those who were on aminoleban showed early improvement and recovery from hepatic encephapay and subsequently on follow up visits at four mons. Ammonia level which was initially raised decreased subsequently on six day and on fou mon. And eir albumin level also increased at four mon follow up compared to patients who did not received aminoleban. On grounds of above study we recommended branched amino acids for e treatment and prevention of chronic hepatic encephalopay. Key words: Hepatic Encephalopay % Chronic Liver Disease % Aminoleban % Branched chain Amino Acids INTRODUCTION low in amino acids as a preparation of treating hepatic encephalopay[7]. The Major mechanism of hepatic encephalopay Severe HE may be reversed by a nutritional approach due to liver cirrhosis currently attracting involves e based on e administration of consistent amount of intoxication and neurotransmitter eories [1,2]. The BCAA [1]. representative agents of intoxication are ammonia, Malnutrition is a common feature of chronic liver meaneiol, phenol and short chain fatty acids. The failure CLF. Nutrient requirement is increased because of neurotransmitter eory can be divided into e presence of a hypercatabolic state [2]. moreover food following two categories depending upon e types of digestion and e absorption are often incomplete [3]. amino acids as e amino acid-neurotransmitter eory The increased muscle protein degradation coupled and gamma aminobutyric (GABA) eory [3,4]. Fischer wi impaired liver function induces a profound alteration and Baldessarini, proponents of e amino acid of e plasma AA pattern characterized by an elevation in neurotransmitter eory. In patients suffering from hepatic aromatic amino acid AAA phenylalanine (PHE), tyrosine encephalopay plasma concentration of aromatic amino (TYR) and tryptophan (TRP) and a reduction in branched acids (AAA) such as phenylalanine, tyrosine and free amino acids AA (BCAA), valine (VAL), leucine (LEU) and tryptophan, as well as meionine, aspartic acid and isoleucine (ILEU) level [18]. These changes in e plasma glutamic acid are elevated where as branched amino acids AA profile very likely play a key role in e paogenesis (BCAA s) such as leucine, isoleucine and valine are of HE and may erefore be responsible for e protein decreased [5]. These researchers suggested at e intolerance seen in CLF patients [19]. Plasma and brain condition would be improved if e plasma amino acids accumulation of AAA may in fact cause a severe were normalized [6]. They en developed an amino acid impairment of brain neurotransmitter synesis, in turn solution (Fischer s solution) enriched in BCAA s and causing HE [20,21]. The decrease in plasma BCAA, which Corresponding Auor: Prof. G.Ali Qureshi, Department of Biochemistry, University of Heal Sciences, Khayaban-i- Jamia Punjab, Lahore, Pakistan 60

2 compete wi AAA for e blood brain transport [22], contributes greatly to e accumulation of AAA in e brain [17]. Fischer and colleagues have proposed an AAA mixture. BCAA are metabolically very active. In e peripheral tissues ey may be oxidized to produce energy [24] or may be act as antictabolic factors (particularly leucine) by stimulating e synesis and reducing e degradation of muscle protein [25,26]. Indeed, in patients wi chronic liver failure (CLF) i.v. BCAA decrease AA and ammonia plasma concentrations [27]. BCAA, by competing wi AAA for blood brain transport [22], may reduce brain entry of AAA. Since e first report by Fischer et al [22] a large number of aneedotal studies have been carried out which clearly show at severe HE may rapidly reversed by e i.v. administration of AA mixtures enriched wi BCAA [29,33]. These findings have been subsequently confirmed by at least 5 randomized, controlled trials [34]. PATIENTS AND METHODS In bo groups i.e. group I on conventional erapy and group II on conventional as well as on BCCA,eir status regarding proombin time, Albumin level and serum ammonia level in patients were as follows: The difference of Prorombin time in 8 patients was 3 to 6 seconds from control where as > 6 seconds in 6 patients were noted in each group.in bo group out of 24 patients S. albumin level was <2.8mg/dl seen in 16 patients and S. albumin level between 2.8 and 3.1mg/dl were noted in remaining 6 patients. S. albumin and S. ammonia level were done on admission day, on 6 day and at 4 mons in bo groups. Data Analysis: The data were evaluated in SPSS version 16.0 e Fisher s exact and Pearson s chi-square test was applied among e categorical variable and independent samples T test was applied to compare e means among continuous variable. The p value < 0.05 was considered as statically significant level. RESULTS The patients wi decompensated Liver cirrhosis Recovery and recurrence of hepatic encephalopay (LC), who met e following study criteria were were compared on patients who were on BCAA given enrolled in e patient study.:all e cases of hepatic initially intravenously an orally wi ose of group encephalopay Grade II coma or a history of hepatic wiout BCAA. Those who were on BCAA showed early encephalopay having HBV and HCV. Bo males and improvement and recovery and subsequently on follow females were enrolled. Before e start of e study an up visits at four mons. They not only showed informed consent was obtained from e patients. improvement as for as eir ammonia level is concerned Out of 48 patients enrolled, ey were divided which was initially raised but ammonia level decreased into two groups Group-1 and Group 2, 24 patients were subsequently at 6 day and on four mon follow up. kept in each group. Group 1(24 patients) were kept on Their albumin level also increased from eir initial reading conventional treatment and Group 2 received bo noticed at four mons follow up, compared to patients conventional as well as branched chain amino acids.in who did not received BCAA. Patients in group-2 was ion Group 1 kept on conventional erapy, out of 24 patients, BCAA showed early improvement and recovery and 17 were males 7 were females and in Group 2 on subsequently on follow up visit at four mons.patients conventional as well as on BCAA out of 24 patients, 17 on BCAA showed improvement which initially wiout were males and 07 were females. As for age distribution is BCAA was raised but on six day and four mons concerned again ey were divided into two groups. 1 and follow up it reduced significantly. Albumin level which 2, Group 1 on conventional erapy were kept as under: was initially low eier remain stabilized or in few patients 10 patients from age from while in 2 were it also raised. The mortality rate in group 2 patients chosen over 50 years of age.# In Group 2, who were kept compared to group 1 was also significantly low. on BCAA as well as conventional erapy eir ages and The results are as follows, In first week hospital stay numbers are: from patients were 12 in in group I patients in comparison to group II patients was numbers and patients above 50 years of age were 2 in more an seven days (group 1 = 8 patients 33.3% and number The above 48 patients were diagnosed on e group 2 = 0 patients). P value < patients from bases of clinical history / examination / laboratory group 2 remained hospitalized for 14 days while only one parameters including prorombin time, serum albumin patient remain in hospital for 14 days (group 2 = 1 patient and serum ammonia level. {14.2%} and in group 1 {33.3%}). Those who remained 61

3 more an 14 days were 16 from group 1 (66.7%) and 6 Recent interests focused on e timing of from group 2 (25.0%). The P value < which is administration of BCAA since day time BCAA is usually significant. consumed by energy generation for physical exercise of As for as serum ammonia level is concerned in group skeletal muscle in liver cirrhosis. Nocturnal BCAA seem 1 on conventional erapy it was raised to /- 7.89, to be more favorable as source of protein synesis on six day / and at 4 mons / by giving higher nitrogen balance [22]. Abnormal While in group 2 on BCAA initially it was / , amino acids metabolism in Liver cirrhosis (LC) can be On six day / on 4 mons / , characterized by decreased concentration of BCAA wi P value < which is higly significant. Serum and increased concentration of aromatic amino acids Albumin level initially in 16 patients from group 1 and (AAA). In hepatic failure, e metabolism of AAA s and from group 2 was < 2.8 (66.7%) in each group and in meionine is lowered, leading to elevated concentrations 8 patients it remain more an 2.8 to 3.1 i.e. 33.3% in each in e blood [16]. In contrast in e muscles e catabolism group. However in patients on BCAA eier it remain of BCAA s is accelerated, resulting in a decrease in e near 3.1 or slightly raised at 4 mons. Mortality in group concentration of BCAA s [5.] Consequently, Fischer s 2 compared to group 1 was significantly decreased. Alive ratio diminishes and e uptake of AA increased into group 1 = 3 (12.5%) and in group 2 = 10 (41.9%) P value brain [6,7]. This increased uptake leads to an increase in <0.04. Patients died from group 1 = 21 patients (67.5%) number of neurotransmitters causing encephalopay. while in group 2 = 14 patients died (58.3%) P value <0.04 The AA solution at was developed by Fischer and which is significant. Baldessarini 1 for e purpose of normalizing e amino acid balance can bring about a rapid symptomatic DISCUSSION improvement in patients. The solution has been widely used in e treatment of hepatic failure [9,12]. Protein energy malnutrition (PEM) is a common Administration is restricted only to intravenous infusion, manifestation in cirrhotic patients wi reported however, which limits e patients can be treated incidences as high as 65-90%. In cirrhosis, protein predominantly in patients. Such intravenous infusion are malnutrition is usually represented by reduced serum inconvenient for e patient wi mild and moderate albumin level and by decreased skeletal muscle volume encephalopay, [8,9,17]. In our study, long term clinical (muscular protein). PEM affects largely e outcome of experiments was designed so at e uselessness of patients by determining bo eir quality of life and aminoleban in treating patients wi hepatic failure can be survival. As an intervention for energy malnutrition, identified more clearly. The neuropsychic symptoms and frequent meal or late evening snack has recently been performance status also improved significantly in recommended [11,13]. Patients wi low plasma BCAA patients. Many patients were eventually able to undertake have low serum albumin levels and ose wi high BCAA normal daily life wiout assistance. This may represent have high albumin [5]. Hyperammonemia is a common an improvement in e quality of life. The prognosis of LC manifestation of cirrhotic patients due to impaired hepatic is dependent on various factors such as total bilirubin capacity to detoxicated ammonia. Instead, skeletal and albumin in e serum, ascites and encephalopay as muscles and, to a lesser extent e brain clear blood well as nutritional condition [18].Malnutrition has been ammonia by incorporating ammonia in e process of reported to be one of e major risk factors responsible for glutamine production from glutamate. The precursor e dea due to hepatic failure [19,20]. The patients glutamine requires BCAA for its synesis. Thus, when receiving aminoleban EN were still alive at e end of 6- exposed to hyperammonemia, skeletal muscle take up mons study period. Consequently Aminoleban EN was BCAA from e plasma to enhance eir ability to degrade considered to be effective in prolonging e life span of ammonia [16]. In contrast, cirrhotic patients lose hepatic patients wi decompensated LC. BCAA are known for storage of glycogen due to liver atrophy and also get eir use an energy source. They also compete for entry resistant to insulin in eir peripheral tissues. Majority of across e blood brain barrier [21] wi neutral amino such BCAA oxidation is supposed to occur in skeletal acids at are precursors of monoamines [22], act as muscles and contribute to enhanced uptake of BCAA detoxicants for ammonia and accelerated protein from plasma by skeletal muscles [17]. synesis in muscle while inhibiting e break down of 62

4 Table 1: Demographic profile of e patients (n = 48) Age (in years), Mean±SD (Range) 41.2±7.2(30 55) Gender: Male 34(70.8%) Female 14(29.2%) Age distribution: 30 to 39 20(41.6%) 40 to 49 24(50%) 50 and above 4(8.4%) Table 2: Investigations of e patients done during eir hospital stay and follow up Prorombine Time 3 to 6 18(75.0%) 18(75.0%) NS > 6 6(25.0%) 6(25.0%) Serum Albumin < (66.7%) 16(66.7%) NS 2.8 to 3.1 8(33.3%) 8(33.3%) Table 3: Hospital stay, mortality and observations Group 1 treatment Group II treatment & BCAA Parameter (n = 24) (n = 24) P value Hospital stay: Mortality: 1 to 7 days 0 8(33.3%) < 0.001* 8 to 14 days 8(33.3%) 1(4.2%) > 14 days 16(66.7%) 6(25.0%) Alive 3(12.5%) 10(41.7%) 0.04 Dead 21(87.5%) 14(58.3%) Recurrence of Hepatic Coma (observed during 4 mons) Up to 4 times 3(12.5%) 0 Up to 3 times 6(25.0%) 2(8.3%) Upto 2 times 9(37.5%) 3(12.5%) One time 2(8.3%) 2(8.3%) Nil 4(16.7%) 17(70.8%) * P value is statistically highly significant Table 4: Serum Ammonia level of patients Group 1 treatment Group II treatment & BCAA Parameter (n = 24) (n = 24) P value Serum ammonia level: Initial ± ± On 6 Day 70.4 ± ± 8.16 < 0.001* On 4 mons ± ± < 0.001* Results are expressed as Mean ± Standard Deviation * P value is statistically highly significant muscular protein. In conclusion, long term administration of e enteral amino acid nutrient, aminoleban EN, led to nutritional improvement wi little adverse reactions as well as e improvement of e quality of life and performance status. Aminoleba EN was us able to prolong e life span of patients wi decompensated LC. CONCLUSION In advanced liver cirrhosis long term nutritional supplements wi oral BCAA is useful to prevent progressive hepatic failure and improves surrogate markers and heal status. It also raises plasma albumin level, improves quality of life of patient and decrease incidence of subsequent hepatic encephalopay in ese patients. From our study it is observed at nutritional factor plays a significant role bo in e paogenesis as well as management of hepatic encephalopay. The administration of solution rich in BCAA leads to mental recovery from acute hepatic encephalopay in patients wi liver cirrhosis. REFERENCES 1. Fischer, J.E., et al False neurotransmitters and hepatic failure. Lancet, 2: Cangiano, C., et al Plasma level of false neurotransmitters across e brain in portal-systemic encephalopay. EUr J clin Invest, 12: Fischer, J.E., et al The role of plasma amino acids in hepatic encephalopay. Surgery, 78: Fischer, J.E., et al The effect of normalization of plasma amino acids on hepatic encephalopay in man. Surgery, 80: Fischer, J.E., N. Yoshimura, N. Aguirre A., et al Plasma amino acids in patients wi hepatic encephalopay. Effect of amino acid infusion Am. J. surg., 127: Karnosfsky, D.A., W.H. Abelmann, L.F. Craver, et al The use of nitrogen mustard in e palliative treatment of carcinoma. Cancer, 1: Swart, G.R., J.W.O. Van Den Berg, J.L.D. Wattimena, et al, Elevated protein requirements in cirrhosis of liver investigated by whole body protein turnover studies. Clin Sci., 75: Cerra, F.B., Hypermetabolism, organ failure and metabolic support. Surgery, 101: Christensen, E., P. Schelichting, L. Fauerholdt, et al Prognostic value of child-turcotte criteria in medically treated cirrhosis. Hepatology, 4:

5 10. Pardridge, W.M., Kinetics of competitive 23. Rossi Fanelli, F., et al Phenyleanolamine and inhibition of neutral amino acid transport across e octopamine in hepatic encephalopay. Dekker, blood brain barrier. J. neurochemist, 28: 103. New York, pp: Jellinger, K., P. Riederer, G. kleinbereger, et al Pardridge, W.M. et al, The regularity of Brain monoamines in human hepatic aminoacid availability in brain. In nutrition in encephalopay. Acta Neuropaol (Berlin), 43: 63. brain,raven New York, pp: Hayashi, M., H. Ohnishi, Y. Kawade et al Oddessey, R., et al, Oxidation of luecine by rat Augmented utilization of branched chain amino skeletal muscle, Am. J. Physiol., 223: acids by skeletal muscle in decompensated liver 26. Sherwin, R.S., Effect of starvation on e cirrhosis in special relation to ammonia turnover and metabolic response to leucine, J.C. detoxification. Gastroenterology Jpn., 16: 64. Invest, 21: Yoshida, T., Y. Muto, H. Moriwaki and M. Yamato, 27. Freund, H.R., et al Nitrogen sparing Effect of long- term oral supplementation mechanism of slightly administered branched wi branched-chain amino acid granules on e chain aminoacid in e injured rat, Surgery, 90(2): prognosis of l I liver cirrhosis, J. Gastroenterol., : Cerra, F.B., et al A multicenter trial of 14. A.S.P.E.N Board of Directors and e clinical branched chain enriched amino acid infusion guidelines task force. Guidelines for e use of (FO80) in hepatic encephalopay (HE), Hepatology, parenteral and enteral nutrition in adult and pediatric 2: patients. Liver disease, JPEN 26: 65sa-68sa. 29. Fiaccadori, F., et al Branched chain amino 15. Yamauchi, M., K. Takeda, K. Sakamoto, M. Ohata acids enriched solution in e treatment of and G. Toda, Effect of oral branched clain encephalopay: A controlled trial. In hepatic amino acid supplementation in e late evening on encephalopay in Chronic Liver Failure, Plenum e nutritional state of patients wi liver cirrhosis, New York, pp: hepatol. Res., 21: Strauss, E., et al A randomized controlled 16. Nakaya, Y., N. Harada, S. Kkakui, K. Okada, clinical trial for e evalution of e efficacy of an A. Takahashi, J. Inoi and S. Ito, Severe enriched branched chain amino acid solution catabolic state after a prolonged fasting in cirrhotic compared to neomycic in hepatic encephalopay, patients: effect of oral branched- chain amino acid 3: 863 (abstact). enriched nutrient mixture, J. Gastroenterol., 31. Gluud, C., et al Preliminary treatment results 37: wi branched chain amino acid infusion to 17. Yamato, Y. Muto, T. Yoshida, M. Kato and patients wi hepatic encephalopay, Scan. J. H. Moriwaki, clearance rate of plasma branched- Gastroentrol., 18(suppl.86): chain amino acids correlates significantly wi 32. Yushida, et al Nutiitional assessment and Blood ammonia level in patients wi liver erapy in patients wi hepatitis, KAN TAN SUI, cirrhosis,hepatol. Res., 3: : Owen, O.E., et al, Nature and quality of 33. Yoshid, T., Effects of oral supplementation fuels consumed in patients wi alcoholic cirrhosis, wi BCCA-G on e prognosis of liver cirrhosis, J. Clin Invest, 72: JJPEN, 14: Casino, A., et al Plasma and cerebrospinal 34. Jchida, F., et al Clinical study of enteral amino fluid aminoacid patterns in hepatic encephalopay, acid nutrients in decompensated liver cirrhosis Dig. Dis. Sci., 27: wi hepatic encephalopay, Acta Hepatol 20. Casino, A., et al Plasma aminoacid and Japonica, 29: imbalalance in patients wi liver disease, Am. J. 35. Manchesini, G., et al Nutritional Dig. Dis., 23: supplementation wi branched chain amino acids 21. Rossi Fanelli, F., et al Aminnoacids in hepatic in advanced cirrhosis,a double blind randomized encephalopay, Prog Nneurobiol., 28: trial. Gastroenterology, 2(124): Fischer, J.E., et al False neurotransmitters and hepatic failure, Lancet, 2:

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