Activity of α-fucosidase and β-glucuronidase in serum and urine of patients administered parenteral nutrition

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Objective. 7RGHWHUPLQHWKHHIIHFWRISDUHQWHUDOQXWULWLRQDGPLQLVWHUHGWRLOOSDWLHQWVRQJO\FRFRQMXJDWHPHWDEROLVPE\ measuring serum and urinary activities of FUC and GLU.

Material and methods. %ORRGVDPSOHVDQGWKHGDLO\XULQHFROOHFWLRQZHUHWDNHQIURPSDWLHQWV¶ZKRKDGEHHQXQGHUJRLQJ SDUHQWHUDOQXWULWLRQIRUHLWKHURUGD\VDVZHOODVIURPDEDVHOLQHVDPSOH(Q]\PHDFWLYLWLHVLQVHUXPDQGXULQHZHUH determined by the method of =ZLHU]et al.

Results. 6HUXP)8&DFWLYLWLHVZHUHVLJQLILFDQWO\ORZHUDIWHUGD\VFRPSDUHGWRSZKHUHDV*/8DFWLYL-WLHVZHUHVLJQLILFDQWO\ORZHUDIWHUERWKDQGGD\VSDQGSUHVSHFWLYHO\FRPSDUHGWROHYHOVEHIRUH VWDUWLQJSDUHQWHUDOQXWULWLRQ*/8DFWLYLWLHVZHUHKRZHYHUKLJKHUDIWHUGD\VWKDQWKRVHDIWHUGD\VS,Q XULQH)8&DFWLYLWLHVZHUHVLJQLILFDQWO\GHFUHDVHGDIWHUGD\VFRPSDUHGWRGD\VDIWHUVWDUWLQJSDUHQWHUDOQXWULWLRQS 8ULQH*/8DFWLYLWLHVZHUHXQDIIHFWHGE\SDUHQWHUDOQXWULWLRQQRUZDVDQ\HIIHFWVHHQRQ)8&RU*/8DFWLYLWLHV when calculated per 1mg creatinine.

Conclusions. Serum FUC and GLU activities can be used for assessing the effect of parenteral nutrition on glycoconjugate PHWDEROLVP7KHVLJQLILFDQWGHFUHDVHVRIVHUXP*/8DFWLYLW\REVHUYHGDIWHUDQGGD\VPD\VHUYHWRLQGLFDWHWKDWWKH components of parental nutrition are appropriate and that the body has become suitably adapted to this form of nutrition. Key words:VHUXPXULQHĮIXFRVLGDVHȕJOXFXURQLGDVHSDUHQWHUDOQXWULWLRQ 675(6=&=(1,( :SURZDG]HQLH.OLQLF]QHOXEELRFKHPLF]QHREMDZ\QLHGRERUyZSRNDUPRZ\FKVWZDU]DMąNRQLHF]QRĞüZGURĪHQLDĪ\ZLH-QLDSR]DMHOLWRZHJRZFHOXRJUDQLF]HQLDNDWDEROL]PXZáDVQ\FKWNDQHNLVWZRU]HQLDZDUXQNyZXPRĪOLZLDMąF\FKFKRUHPX SU]HWUZDQLHNU\W\F]QHJRRNUHVXĮIXNR]\GD]D)8&LȕJOXNXURQLGD]D*/8VąHQ]\PDPLOL]RVRPDOQ\PLXF]HVWQLF]ą-F\PLZNDWDEROL]PLHJOLNRNRQLXJDWyZ2GFLQDMąIXNR]Ċ)8&OXENZDVJOXNXURQRZ\*/8RGQLHUHGXNXMąFHJRNRĔFD áDĔFXFKyZROLJRVDFKDU\GRZ\FK

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One of the most important achievements in modern medicine has been the widespread use of parenteral QXWULWLRQDVDSDUWRIWKHSDWLHQWWUHDWPHQW>@ZKHQHYHU GLFWDWHGE\FOLQLFDOQHHG,QGHHGVLQFHWKHGLVFRYHU\RI blood circulation made by :LOOLDP+DUYH\LQWKH anatomical basis for vein transfusion has now included supplying patients with an adequate nutrition through SDUHQWHUDOPHDQV>@7KLVW\SHRIQXWULWLRQDOVXSSRUW LVWKXVEDVHGRQSURYLGLQJDOOWKHNH\GLHWDU\HOHPHQWV LQWKHFRUUHFWSURSRUWLRQVQHFHVVDU\IRUUDSLGFHOOXODU assimilation in maintaining adequate nutritional status RIWKHKXPDQERG\LQWHUPVRIERWKTXDOLW\DQGTXDQWLW\ >@,QSDWLHQWVXQGHUJRLQJOLYHUWUDQVSODQWVZLWKVKRUW ERZHOV\QGURPHSDUHQWHUDOQXWULWLRQFRQVWLWXWHVDOLIH VDYLQJWUHDWPHQW>@

One of the important benefits in adopting parenteral nutrition is in limiting the breakdown of the body’s RZQWLVVXHLQSURYLGLQJDQHQHUJ\VRXUFHWRJHWKHUZLWK assuring appropriate conditions for patients to survive WKHPRVWFULWLFDOPRPHQWVRIWKHLULOOQHVV>@

Glycoconjugates such as glycoproteins and gly-FROLSLGVIRUPDQLQWHJUDOSDUWRIFHOOXODUPHPEUDQHV DQGLQWHUVWLWLDOWLVVXHWKDWDUHPHWDEROLVHG>@E\ YDULRXV OLSDVHV SURWHDVHV DQG JO\FRVLGDVHV > @ Exoglycosidases in lysosomes metabolise glycocon-jugates by release simple sugar residues starting from WKHQRQUHGXFLQJHQGVRIROLJRVDFFKDULGHFKDLQV>@ 7KH HQ]\PH ĮIXFRVLGDVH )8&  (&  UHOHDVHV ĮIXFRVH >@ IURP ROLJRVDFFKDULGHV ZKLOVW ȕJOXFXURQLGDVH*/8(&LQVLPLODUID-VKLRQOLEHUDWHVJOXFXURQLGHVWKURXJKK\GURO\VLVRI glu-FXURQLFDFLGVOLQNHGWRDOFRKROVSKHQROVDQGFDUER[\OLF acidsZKLFKWDNHSDUWLQWKHGHWR[LILFDWLRQ>@ and hydrolysis of glycosaminoglycans in connective tissue. FUC demonstrates broad substrate specificity including

GHJUDGLQJFHOODQGPHPEUDQHJO\FRSURWHLQPXFLQ>@ and the oligosaccharide chains that constitute the sur-IDFHDQWLJHQVLQEORRGJURXSV$%DQG+>@,QGHHG lysosomal exoglycosidases have now been extensively studied due to their functions and widespread presence LQWLVVXHVDQGERGLO\IOXLGV>@

The study aims are to determine the effect of pa-renteral nutrition on the activity of FUC and GLU en-zymes in serum and urine as well as on glycoconjugate metabolism. These could therefore serve as a potential parameters/markers of assessing metabolic changes during parenteral nutrition.

0$7(5,$/$1'0(7+2'6 6XEMHFWVZHUHVLFNKRVSLWDOLVHGLQSDWLHQWV ZRPHQPHQDJHG\HDUVPHDQ“ \HDUVUHFHLYLQJSDUHQWHUDOQXWULWLRQDWWKH'HSDUWPHQW RI6XUJHU\DQG(QGRFULQRORJ\%LDO\VWRN0HGLFDO8QL-YHUVLW\+RVSLWDO7RDYRLGIDOVHSRVLWLYHVSDWLHQWVZLWK NLGQH\RUOLYHUGLVHDVHGLDEHWHVREHVLW\DQGDOFRKROLFV were excluded as these conditions are known to effect the activity of lysosomal exoglycosidases.

Parenteral nutrition was intravenously administered LQDQDOOLQRQHKRXUSURFHGXUHXVLQJDLQIXVLRQSXPS for maintaining a constant rate of nutrient delivery. The nutrient admixture was made up at the hospital’s GLVSHQVDU\DQGSDWLHQWVUHFHLYHGW\SHVRIQXWULWLRQDO formulae as follows:

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Samples of serum and urine were obtained from SDWLHQWV DW  WLPH SRLQWV EHIRUH VWDUWLQJ SDUHQWHUDO QXWULWLRQEDVHOLQHDQGDQGGD\VWKHUHDIWHU7KH VDPSOHVZHUHWKHQVSXQIRUPLQXWHVDW[Jž& and supernatants were subsequently suitably aliquotted DQGVWRUHGLQHSSHQGRUIWXEHVDWž&UHDG\IRUXVH &RPSDULQJ)8&DQG*/8DFWLYLWLHVDIWHUDQGGD\V of parenteral nutrition with the baseline thus allowed any effects of the patient’s illness SHUVH on these enzyme activities to be excluded.

The times of sampling were in the first instance based on recommendations for monitoring parenteral nutrition at its early stages (ie. after 3-5 days) and FRPSDULQJWKHVHZLWKEDVHOLQHUHVXOWVWKHUHE\DOORZLQJ organ function to be assessed as well as any modifica-tions to the nutrient formulamodifica-tions to be made whenever UHTXLUHG>@,QDGGLWLRQVWXGLHVKDYHVKRZQWKDWDIWHU GD\VRISDUHQWHUDOQXWULWLRQLQUDWVWKHDFWLYLW\RI lysosomal exoglycosidases changes when measured LQOLYHUNLGQH\DQGVSOHHQKRPRJHQDWHV>@ $FWLYLWLHVRI)8&DQG*/8ZHUHPHDVXUHGLQGX-SOLFDWHE\WKHPHWKRGRI=ZLHU]HWDO>@DGDSWHGWR WKHPLFURWLWUHSODWHIRUPDW181&)RUWKH)8&WHVW WKHIROORZLQJZHUHDGGHGWRHDFKZHOO—/RI0 SKRVSKDWHFLWUDWH EXIIHU S+  DQG  —/  P0 SQLWURSKHQ\OĮIXFRS\UDQRVLGHVXEVWUDWH,QWKHFDVHRI WKH*/8WHVWWKHIROORZLQJZHUHDGGHG—/0 DFHWDWHEXIIHUS+ DQG—/P0QLWURSKHQ\O ȕ'JOXFXURQLGHVXEVWUDWH6LJPD6W/RXLV0R86$ )RUERWKWHVWVWKHVDPSOHYROXPHRIVHUXPRUXULQHZDV —/7KHPLFURSODWHPL[WXUHVZHUHWKHQLQFXEDWHGDQG PL[HGIRUPLQXWHVDWž&9DULVKDFNHU,QFXEDWRU '\QDWHFK7KHUHDFWLRQZDVVWRSSHGE\DGGLQJ—/ RI0ERUDWHEXIIHUS+ 7KHUHOHDVHGSQLWUR-SKHQROZDVGHWHFWHGE\LWVDEVRUEDQFHDWQPDQG the actual amounts were calculated from a calibration FXUYHXVLQJDPLFURSODWHUHDGHU(O[70%LR7HN ,QVWUXPHQWV,QF9HUPRQW86$7KHVWXG\KDGUHFH-LYHGDSSURYDOIURPWKH%LRHWKLFDO&RPPLVVLRQDWWKH %LDO\VWRN0HGLFDO8QLYHUVLW\1R5,

Statistical analyses were performed by $129$ and results were expressed as means and standard devia-WLRQV$YDOXHRIS”ZDVWDNHQDVEHLQJVLJQLILFDQW

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7KH PHDQ VHUXP )8& DFWLYLW\ QPROPOPLQ in patients before receiving parenteral nutrition was “FRPSDUHGWR“DQG “DIWHUDQGGD\VUHVSHFWLYHO\)LJXUHWKH GLIIHUHQFHEHWZHHQGD\VDQGEHLQJVLJQLILFDQWDW S$OVRWKHDFWLYLWLHVDIWHUERWKDQGGD\V ZHUHGHFUHDVHGZKHQFRPSDUHGWRWKHEDVHOLQH)LJXUH 1). Mean GLU activities in patient’s serum were found WREH“DWEDVHOLQHZKLFKZDVVLJQLILFDQWO\ KLJKHUZKHQUHVSHFWLYHO\FRPSDUHGWR“ SDQG“SDIWHUDQG GD\VRIUHFHLYLQJSDUHQWHUDOQXWULWLRQ)LJXUH7KH GLU activity after 5 days was found to be significantly ORZHUWKDQDIWHUGD\VSDOVRVKRZQLQ )LJXUH

Figure 1. Serum FUC activity in patients receiving parenteral QXWULWLRQ31

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The corresponding results for urine were a FUC DFWLYLW\ QPROPOPLQ RI  “ DW EDVHOLQH DQG“DQG“DIWHUDQGGD\V UHVSHFWLYHO\RISDUHQWHUDOQXWULWLRQ)LJXUHZKHUH WKHDFWLYLW\DIWHUGD\VZDVVLJQLILFDQWO\ORZHUWKDQ DIWHUGD\VS8ULQDU\*/8DFWLYLWLHVGLG not show any significant differences between any of the time points although a small upward trend was noticed DV IROORZV  “ EDVHOLQH  “

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GD\VDQG“GD\V)LJXUH:KHQ FUC activity in urine was corrected for creatinine then also there were no significant differences between time SRLQWVQPROPOPLQPJFUHDWLQLQHLH“ EDVHOLQH“GD\VDQG“ GD\V)LJXUH)XUWKHUPRUHVLPLODUILQGLQJVIRUXULQD-ry GLU activity were seen with the creatinine correction DVIROORZV“EDVHOLQH“ GD\VDQGGD\VDVVKRZQLQ)LJXUH Parenteral nutrition had no effect on urinary creatinine FRQFHQWUDWLRQ)LJXUH

Figure 3. Urine FUC activity in patients receiving parenteral QXWULWLRQ31

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Figure 5. Urine FUC activity per 1mg creatinine in patients UHFHLYLQJSDUHQWHUDOQXWULWLRQ31

Figure 6. Urine GLU activity in patients per 1mg creatinine UHFHLYLQJSDUHQWHUDOQXWULWLRQ31

Figure 7. Urine creatinine concentrations in patients rece-LYLQJSDUHQWHUDOQXWULWLRQ31

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Parenteral nutrition is a relatively new method of clinical treatment if patients are malnourished or at risk of malnutrition whenever intravenous administration RIDSSURSULDWHQXWULHQWVDUHPHGLFDOO\UHTXLUHG>@)RU LQVWDQFH LW LV DGRSWHG DIWHU VXUJHU\ ZKHQ PHWDEROLF activity becomes elevated due to the body’s response to injury and associated trauma. These factors contribute to an increased basal energy expenditure and protein re- TXLUHPHQWPHGLDWHGE\ERWKWKHLPPXQHDQGQHXURHQ-GRFULQHV\VWHPV>@,QUHDFWLRQWRSDLQEORRGORVVDQG RUJDQGDPDJHWKHK\SRWKDODPLFSLWXLWDU\DGUHQDOD[LV EHFRPHVDFWLYDWHGZLWKDQLQFUHDVHGUHOHDVHRI$&7+ growth hormone and prolactin. As a consequence of in-MXU\PHWDEROLFFKDQJHVDOVRRFFXUZLWKLQFUHDVHGOHYHOV RIFRUWLVROFDWHFKRODPLQHVDQGJOXFDJRQUHIOHFWLQJWKH LQFUHDVHGEDVDOH[SHQGLWXUHRIHQHUJ\>@3DUW of the inflammatory response to surgery and trauma is SURWHRO\VLVRIVWUXFWXUDOSURWHLQHJPXVFOHHIIHFWHG E\WKHLQFUHDVHGVHFUHWLRQRILQWHUOHXNLQV,OĮȕ Many studies have confirmed the relationship between malnutrition and untoward outcomes following surgery. It is seen that patients receiving adequate nutrition are able to better tolerate surgical procedures and recover PRUHUDSLGO\WKDQWKRVHWKDWDUHPDOQRXULVKHG>@

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Understanding the biochemical basis of compli-cations arising from parenteral nutrition is vital for HQVXULQJ HLWKHU WKDW SUHYHQWLRQ LV HIIHFWLYH DQ HDUO\ diagnosis can be made and that such complications can EH WUHDWHG >@ 0HDVXULQJ O\VRVRPDO H[RJO\FRVLGDVH activity of the FUC and GLU enzymes that metabolise JO\FRFRQMXJDWHVVXFKDVJO\FRSURWHLQVJO\FROLSLGVDQG SURWHRJO\FDQV>@FDQDOORZFKDQJHVLQWKHLUPHWDER-lism to be evaluated in sick patients receiving parenteral QXWULWLRQ ,QGHHG WKH SUHVHQWHG VWXG\ GHPRQVWUDWHG some significant changes in serum FUC and GLU ac-WLYLWLHVRIVXFKSDWLHQWVZKHUHVLJQLILFDQWGHFUHDVHVRI )8&DFWLYLW\ZDVREVHUYHGDIWHUGD\VRISDUHQWHUDO nutrition compared to 5 days. The study also showed significantly lower serum GLU activity after 5 days of SDUHQWHUDOQXWULWLRQFRPSDUHGWREDVHOLQHZKHUHDV*/8 DFWLYLW\DIWHUGD\VZDVVLJQLILFDQWO\KLJKHUWKDQDIWHU GD\V)LJXUHVDQG

These observed changes in lysosomal exoglyco-sidase activities found in serum may be the result of structural changes in tissue and organs. Animal studies on the short-term effect of parenteral nutrition on rat OLYHUV VKRZHG WKDW EORRG YHVVHOV FRQWDLQHG VWDJQDQW EORRGDJJORPHUDWHGOHXFRF\WHVLQFDSLOODULHVLQFUHDVHG numbers of lysosomes and macrophage fat storage as well as increased activities of enzymes in homogenates VXFKDV1DFHW\OȕKH[RVHDPLQLGDVH+(;ȕJDODF-WRVLGDVH*$/*/8DQG&DWKHSVLQ'>@ According to studies by 3RULDGNRYDand 9DVLOHYD> @WKHLQFUHDVHGDFWLYLW\RIO\VRVRPDOHQ]\PHVPD\ reflects the body’s way of adapting to a deficiency of certain nutrients or is a reflection of lysosomal enzymes involved in the reconstruction of tissues and organs.

7KDQNVWRUHFHQWVWXGLHVWKHUHODWLRQVKLSVEHWZHHQ pathological changes in cellular structure and bioche-mically defined disorders of metabolism are now better understood. There has also been an increase in the num-ber of non-invasive and high sensitive methods used IRUDVVHVVLQJNLGQH\IXQFWLRQ>@7KXVRQHRIVWXG\ aims was to determine whether changes in urinary FUC and GLU activity occur whenever parenteral nutrition is administered to patients. In normally functioning NLGQH\VH[RJO\FRVLGDVHVGRQRWFURVVWKHJORPHUXODU PHPEUDQH ILOWHU EDUULHU ZKHUH SURWHLQV !  N' DUH UHWDLQHGLQWKHEORRGFLUFXODWLRQ>@1HYHUWKHOHVVLQ this case both FUC and GLU activity has been detected LQXULQH>@GHPRQVWUDWLQJWKDWWKHVHHQ]\PHVDUH released therein by other means than cellular breakdown RUPHPEUDQHGDPDJHDVUHVXOWLQJIURPDQ\GLVHDVHG states. The presence of these enzymes in urine may be due to the natural process of urethral sloughing or an exocytosis of these enzymes from kidney tubules into the urine.

Animal studies on rats receiving parenteral nutrition have shown that after 9 days blood becomes stagnant

LQYHVVHOVOHXNRF\WHLQILOWUDWHVLQWRFRQQHFWLYHWLVVXH and glomerular dystrophy and partial sclerosis occurr >@7KHVHPRUSKRORJLFDOFKDQJHVPD\EHFRQVLGHUHG as causing the activities of lysosomal enzymes to chan-JH6WXGLHVRQKXPDQNLGQH\IXQFWLRQEDVHGRQ+(; 1DFHW\Oȕ'KH[RVDPLQLGDVHDFWLYLW\LQXULQH> @UHYHDOWKDWORQJWHUPSDUHQWHUDOQXWULWLRQ!PRQ-ths) lead to increased HEX activity in the urine which is a marker of renal tubule dysfunction. The aetiology of kidney dysfunction during parenteral nutrition can EHE\QHFURVLVRIWKHJORPHUXOLH[FHVVLYHSURWHLQLQ-WDNHEDFWHULDOLQIHFWLRQDQGWKHQHSKURWR[LFLW\FDXVHG by certain nutrient components such as chromium and FDGPLXP>@

A significant decrease in urinary FUC activity was IRXQGLQWKHSUHVHQWHGVWXG\DIWHUGD\VRIUHFHLYLQJ SDUHQWHUDOQXWULWLRQFRPSDUHGWRGD\V)LJXUH,Q order to account for the state of diuresis affecting enzy-PHDFWLYLWLHVWKH)8&DQG*/8UHVXOWVZHUHFRUUHFWHG IRUXULQDU\FUHDWLQLQH>@&RQFHQWUDWLRQVRIWKHODWWHU are directly related to muscle mass and the efficiency of renal function which significantly decrease during fasting as well as in acute or chronic kidney dysfunction >@7KHFXUUHQWVWXG\VKRZHGWKDWUHQDOH[FUHWLRQRI creatinine does not significantly change during when SDUHQWHUDOQXWULWLRQLVDGPLQLVWHUHGDWGD\V)LJXUH 7). It was found that when FUC and GLU activities are WKHQFHVRFRUUHFWHGSHUPJFUHDWLQLQHWKHQDFWLYLWLHV of these enzymes over this time period are independent RIZKHWKHUSDUHQWHUDOQXWULWLRQLVDGPLQLVWHUHGRUQRW )LJXUHVDQG7KXVWKRVHSDWLHQWVUHFHLYLQJSD-UHQWHUDOQXWULWLRQLQWKHVKRUWWHUPH[HUWVRQO\DVPDOO effect on renal filtration and the lysosomal metabolism of exoglycosidases present in kidney tubules. At the VDPHWLPHFKDQJHVLQRWKHURUJDQIXQFWLRQLQZKLFK WKHVHHQ]\PHVDUHV\QWKHVLVHGHOLPLQDWHGRUGHJUDGHG cannot be ruled out which may thereby affect their ac-WLYLWLHVLQVHUXPDQGVXEVHTXHQWO\XULQH>@

)RUVXUJLFDORSHUDWLRQVWKHSULQFLSDODLPRIQXWULWLR-nal therapy/treatment around this time is to decrease the ULVNRIFRPSOLFDWLRQVVRDULVLQJFKLHIO\SRVWRSHUDWLYH LQIHFWLRQVSURYLGLQJPHWDEROLFVXSSRUWGXULQJVXUJLFDO LQGXFHGPHWDEROLFVWUHVVDFFHOHUDWLQJZRXQGKHDOLQJ DQGDUHWXUQWRQRUPDOJDVWURLQWHVWLQDOIXQFWLRQ>@ When assessing the metabolism of glycoconjugates it might therefore be useful to determine the activities of lysosomal exoglycosidases present in the serum.

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1. Parenteral nutrition decreases glycoconjugate meta-bolism which is reflected by decreased serum FUC DFWLYLW\DIWHUGD\VRILWVDGPLQLVWUDWLRQ,WDOVR significantly decreases serum GLU activity in

K. Raczkowska, S.D. Szajda, K. Raczkowski et al.

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tients receiving parenteral nutrition after both 5 and GD\VFRPSDUHGWREDVHOLQHZKHUH*/8DFWLYLW\ ZDVVLJQLILFDQWO\KLJKHUDIWHUGD\VWKDQGD\V 8ULQDU\)8&DFWLYLW\VLJQLILFDQWO\IHOODIWHUGD\V of receiving parenteral nutrition compared to 5 days.  ,QRUGHUWKDWDUHWXUQLVPDGHWREDVHOLQHOHYHOVRI VHUXP*/8DFWLYLW\DIWHUGD\VIURPUHFHLYLQJSD-UHQWHUDOQXWULWLRQDQDSSURSULDWHO\EDODQFHGPL[WXUH of nutrient components needs to be administered. The body also needs the ability of being able to adapt to this form of nutrition.

3. The administration of short-term parenteral nutrition has little effect on renal filtration and lysosomal exoglycosidases present in kidney tubules.

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