# Presentation: 731386

## The Role of Glutathione in Cell Defense, with References to Clinical Deficiencies and Treatment

- Thomas A. Kwyer, M.D.

## Glutathione Precursors: Amino Acids

- L-Glutamate
- L-Cysteine
- the rate-limiting substrate
- cystine (cysteine=cysteine) is an ideal form of cysteine for glutathione synthesis
- Glycine

## Glutathione: L-glutamylcysteinylglycine

- DNA synthesis and repair
- Protein synthesis
- Prostaglandin synthesis
- Amino acid transport
- Metabolism of toxins and carcinogens
- Immune system enhancement
- Prevention of oxidative cell damage
- Enzyme activation
- Lomaestro, B. Ann Pharmacother, 1995 Dec;(12):1263 -73.

## Immunonutrition in the Critically Ill: a Systematic Review of Clinical Outcomes (12 studies with 1,557 subjects, 1,482 of whom were analyzed)  

- “*Objective: *To perform a meta-analysis addressing whether enteral nutrition with immune-enhancing feeds benefit critically     ill patients after trauma, sepsis, or major surgery.”
- “Main outcome measures were mortality, infection,ventilator   days, intensive care unit stay, hospital stay, diarrhea days,   calorie intake and nitrogen intake.”
- Beale, R., Crit. Care Med. 1999, Dec.;27(12):2799-805.

## Immunonutrition in the Critically Ill: a Systematic Review of Clinical Outcomes (Summary)

**BENEFITS:**
**Infection: a significant reduction in the relative risk of acquiring infection. **
**Ventilator Days: a significant reduction overall.**
**Hospital Length of Stay**: **the reduction in hospital LOS was significant.**
**SAFETY:**
**No increase in side effects of feeding was reported in patients receiving immunonutrition.**

## Effect of Immune Enhancement on Length of Therapeutic Intervention in Severe Abdominal Trauma

## Effect of Immune Enhancement on Total Hospitalization Cost in Severe Abdominal Trauma

## Effect of Immune Enhancement on Total Hospital Days in Severe Abdominal Trauma

## Pathogenesis of Glutathione Deficiency: Cytokine Selection (Slide 1)

- “_Glutathione Levels in Antigen-presenting Cells Modulate Th1 Versus Th2 Response Patterns_.”  (Title of Article)
- “...the **Th1 pattern** is characterized by interleukin 12 (IL-12) and interferon  (IFN-) production and the up-regulation cell-mediated, e.g.,**delayed hypersensitvity**, (DTH) responses.”
- “The **Th2 response** pattern is characterized by IL-4 and IL-10 production and up-regulation of a variety of **antibody responses**.”
- Peterson, J., Proc. Natl. Acad. Sci. U S A 1998, Mar. 17;95(6): 3071-3076.

## Pathogenesis of Glutathione Deficiency: Cytokine Selection (Slide 2)

- “Antigen-presenting cells (APC) -- macrophages, dendritic cells, and B cells -- are central to the development of either Th1 or Th2 immunity because **antigen presentation and recognition are required to initiate responses**.”
- “...**GSH depletion** inhibits Th1-associated cytokine production and/or **favors Th2-associated responses**.”
- Peterson, J., Proc. Natl. Acad. Sci. U S A 1998, Mar. 17;95(6): 3071-3076.

## “Defective Antigen Processing Correlates with a Low Level of Intracellular Glutathione” 

- “Therefore, low intracellular glutathione levels in antigen-presenting cells correlate with defective processing of antigen with disulfide bonds, indicating that this thiol may be a _critical_ factor in regulating productive antigen processing.”
- Short, S., Eur. J. Immunol. 1996, Dec;26(12):3015-3020.
- _Most antigens are proteins with disulfide bonds. GSH reduces disulfide bonds.  Low GSH prevents disulfide bond reduction._
- 1. RSSR’ + GSH  RSH + GSSR’
- 2. GSSR’ + GSH  GSSG + R’SH

## “Lymphocyte Proliferation in Glutathione-depleted Lymphocytes: Direct Relationship Between Glutathione Availability and the Proliferative Response”

- “Lymphocyte proliferation in response to mitogenic lectins is directly dependent upon glutathione (GSH) availability.”
- “...the restoration of lymphocyte proliferation by exogenous GSH is more closely linked to effects on intracellular rather than extracellular GSH.”
- “These studies confirm the importance of intracellular GSH in lymphocyte proliferation.”
- Hamilos, D., Immunopharmacology, 1989, 18;223-235.

## Pathogenesis of Glutathione Deficiency in the Immune Response: Summary

**Glutathione levels in antigen-presenting cells modulate Th1 versus Th2 response patterns.**
**Antigen presentation and recognition are required to initiate immune responses.**
**Key events that determine whether IFN-******** is produced occur almost immediately.**
**IFN-******** production predominates when GSH levels are high.**
**GSH depletion may play a **_**key**_** role in exacerbating HIV and other infectious diseases in which Th2 predominance is an important aspect of the disease pathology.**

## Pathogenesis of Glutathione Deficiency and Apoptosis: AIDS (Slide 1)

- “_**Glutathione Deficiency is Associated with Impaired Survival in HIV Disease**_.”  (Title of Article from Stanford)
- “The crucial connection revealed here between GSH deficiency and survival in HIV disease was foreshadowed by several studies.”
- Survival in all HIV+: **GSB******** 0.91 = 90%, GSB******** 0.91 = 32%.**
- Survival in CD4  200: **GSB******** 1.05 = 87%, GSB******** 1.05 = 17%.**
- Herzenberg, L, Proc. Natl. Acad. Sci. U S A 1997, Mar. 4;94(5): 1967-1972.

## Pathogenesis of Glutathione Deficiency and Apoptosis: AIDS (Slide 2)

- “_Type 1 and Type 2 Cytokines in HIV Infection -- a Possible Role in Apoptosis and Disease Progression._” (Title of Article)
- “...a strong type 1/weak type 2 cytokine production profile was observed in HIV-seropositive patients with delayed or absent disease progression, whereas progression of HIV infection was characterized by a weak type 1/strong type 2 cytokine production profile.”
- Clerici, M., Ann. Med. 1997, Jun.;29(3):185-188.

## Pathogenesis of Glutathione Deficiency and Apoptosis: AIDS (Summary)

**Glutathione Deficiency is Associated with Impaired Survival in HIV Disease.**
**Survival in all HIV+:** **GSB******** 0.91 = 90%, GSB******** 0.91 = 32%.**
**Survival in CD4******** 200:** **GSB******** 1.05 = 87%, GSB******** 1.05 = 17%.**
**Antiretroviral therapies will not successfully eradicate HIV and HIV-seropositive patients will not be ultimately cured unless therapies aimed at restoring the immune system are associated with the antiretroviral drugs currently employed.**

## Benefits of Glutathione Enhancement in Disease or Stress: Pulmonary Disease 

- “We describe a case of a patient who had obstructive lung disease responsive to corticosteroids, and low whole blood GSH levels.”
- “After 1 month of supplementation with a whey-based oral supplement designed to provide GSH precursors, whole blood **GSH levels and pulmonary function increased significantly and dramatically**.”
- Lands, L., J. Appl. Physio. 1999, Oct.;87(4):1381-5.

## Benefits of Glutathione Enhancement in Disease or Stress: Pulmonary Disease

- Relationship to Immunocal® intake:
- Time 6 on Immunocal® 1 month.
- Time 7 off Immunocal®.
- Time 8 back on Immunocal®.
- Immunocal® significantly and dramatically increased pulmonary function.

## Method of Intracellular GSH Enhancement: Undenatured Whey Protein Concentration

- Contains highly concentrated amounts of cystine (cysteine = cysteine) because of a new Pasteurization technique which preserves the disulfide bond between the two cysteines.
- The naturally occurring constituent heat labile proteins found in “Mother’s Milk” that imparts immune enhancement.
- Dose: 10 - 40 grams per day for adults and 1⁄2 gram/Kg for infants and young children up to 40 Kg.
- High dose to reverse cachexia: up to 120 grams has been reported (anecdotal) to **increase total body weight 15% in two weeks** in a near death AIDS patient with cachexia.

## Cystine: the Preferred Substrate for Optimal Glutathione Synthesis and Immune Enhancement  

- Hepatic Nitrogen Metabolism: Cysteine from muscle catabolism arrives in the liver in the form of cystine.  Enteral feeding of cystine takes advantage of this well-developed metabolic pathway that is also utilized when digesting breast milk which has well documented and indisputable immune enhancing properties.
- Antigen Presenting Cells: Prefer cystine for GSH synthesis which is required to initiate the immune response then feed lymphocytes cysteine as an immunoregulatory signal.
- Astrocytes: Prefer cystine for GSH synthesis and feed cysteine to neurons to protect against neurodegenerative diseases.

## Proton Donation is the Basis for Preservation of the Amino Acid Pool (Positive Nitrogen Balance)  (Dröge, W, FASEB J., 1997 Nov.;11(13):1077-89)

## Proton Donation: the Sulfur of Glutathione can give up a Proton (H+) 

- GSH + GSH  GSSG + 2H+

## Pathogenesis of Cystine Deficiency: Wasting Syndromes (Slide 1)

- “_Role of Cysteine and Glutathione in HIV Infection and Other Diseases Associated with Muscle Wasting and Immunological Dysfunction_.”  (Title of Article)
- “Evidence suggests that 1) the cystine level is regulated primarily by the normal postabsorptive skeletal muscle protein catabolism, 2) the cystine level itself is a physiological regulator of nitrogen balance and body cell mass...”
- Dröge, W., FASEB J. 1997, Nov;11(13):1077-89.

## Pathogenesis of Cystine Deficiency: Wasting Syndromes (Slide 2)

- AIDS, sepsis, major injury, trauma, cancer, chronic fatigue syndrome, Crohn’s disease, ulcerative colitis, and athletic over-training are associated with:
- low cystine,
- low glutamine,
- elevated glutamate,
- increased urea production, and
- reduced natural killer (NK) cell activity.

## Pathogenesis of Cystine Deficiency: Wasting Syndromes (Slide 3)

**This diagram demonstrates the relationship between cystine and nitrogen balance to be as follows:**
-  ****** ****Cystine.**
-  ****** ****Protons (H****+****).**
-  ****** ****Bicarbonate (HCO****2****-****).**
-  ****** ****Carbamoylphosphate.**
-  **Ammonium ion (NH4****+****) is   saved.**
**This results in positive nitrogen balance with maintenance or increase in weight.**

## Pathogenesis of Cystine Deficiency: Wasting Syndromes (Slide 4)

**This diagram demonstrates the relationship between cystine and nitrogen balance to be as follows:**
** ******** ****Cystine.**
** ******** ****Protons (H****+****).**
** ******** ****Bicarbonate (HCO****2****-****) .**
** ******** ****Carbamoylphosphate.**
** ****Ammonium ion (NH4****+****) is saved.**
**This results in negative nitrogen balance with decrease in weight and possible cachexia.****	****	**

## Glutathione Precursor Transport: Cystine is Preferred form of Cysteine for GSH Synthesis

- Cystine (cysteine=cysteine) is the preferred form of cysteine for macrophages and astrocytes.
- “Macrophages consume cystine...”                     Gmunder, H., Macrophages Regulate Intracellular Glutathione Levels of Lymphocytes.  Cell. Immunol., 1990, Aug.; 129(1): 32-46.
- “These results demonstrate that astroglial cells prefer cystine...”  Kranich, O., Glia, 1998, Jan.;22(1): 11-8.

## Glutathione Depleting Agents

- Smoking.
- Alcohol.
- Caffeine.
- Acetaminophen.
- Drugs.
- Vigorous exercise.
- x-, - and UV radiation
- Xenobiotics.

## Total Parenteral Nutrition: the Road to Enteral Atrophy, Leaky Gut Syndrome and Pneumonitis 

- Enterocyte nutrient transport is one way: from the gut to the cell to the capillary.
- Enterocytes cannot transport nutrients from the blood vessel.
- Enterocytes starve as the rest of the body is fed by way of the vasculature.
- Enterocytes pull away from each other as a consequence of gut atrophy.

## Total Parenteral Nutrition: the Road to Enteral Atrophy, Leaky Gut Syndrome and Pneumonitis

- Bacteria slip between the atrophying enterocytes.
- Bacteria enter lymph nodes and then gain access to thoracic duct.
- The thoracic duct emtpies into the blood flowing toward the right heart and into the pulmonary circulation.
- Atrophic gut cannot generate sufficient amounts of secretory IgA.
- The lungs are also compromised and pneumonitis frequently occurs due to constant seeding and lack of IgA.