Albumin Catabolic Rate Measured by a Stable Isotope

Study Overview
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Brief Summary
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The goal of this physiological study is to compare albumin catabolic rate measured by a stable isotope labeled amino acid in healthy volunteers and in patients with liver disease. At steady state synthesis and catabolism or degradation are equal. The primary questions it aims to answer are: Is albumin catabolic rate lower in patients with liver disease? Is albumin catabolic rate measured by stable isotopes in volunteers like historical controls measured by radio-iodinated albumin at the investigator's laboratory or elsewhere? Subjects will be given an oral dose of the deuterium labeled amino acid phenylalanine that will be incorporated by the liver in newly synthetized albumin molecules, and blood samples will be taken over 12 weeks to determine the catabolic rate of albumin.

Detailed Description
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This study is part of a greater research program investigating the clinical use of albumin infusions in surgery, liver disease and states of critical illness. Indications are still under debate after more than 70 years of use. Good methodology for assessment of synthesis or degradation can be of immense value in these situations. The gold standard to assess albumin turn-over is to use radio-iodine labeled albumin and take blood samples over several weeks. This method is however associated with many regulatory difficulties and possibly also methodological flaws. Intravenous injection of deuterium labeled D5-phenylalanine has been used for snap-shot assessment of albumin synthesis, but in this study the stable isotope tracer will be given orally. The idea is that a large dose of labeled phenylalanine will over-flow all body compartments and thus in the liver be incorporated in the newly synthetized albumin molecules. After a short time period there is no more tracer in the amino acid pool and the disappearance of labeled albumin molecules can then be used to measure the albumin disappearance rate, that is equal to the catabolic rate and in steady state also equal to the synthesis rate. The investigaors believe that by this new method it is possible to overcome some of the issues of radio-iodinated albumin: 1) no radiation, 2) no risk that the tracer leaves from the albumin molecule ahead of the catabolism of the albumin molecule, 3) no risk that the half-life of the albumin molecule is damaged by the labeling process, 4) a potential to measure turn-over of other long-lasting proteins. Quantitative measurement of enrichment of isotopically labeled phenylalanine is done using gas chromatography-mass spectrometry at the Karolinska Stable Isotope Core where Olav Rooyackers is the laboratory director. Quantification of total phenylalanine (the precursor) is performed by mass spectrometry against an internal standard. The albumin molecule binds to free acid radicals (scavenger function) with its sulfhydryl group in the Cys-34 position (human mercaptoalbumin). During oxidative stress, the sulfhydryl group is oxidized to sulfinic acid (human non-mercaptoalbumin 1, HNA 1). This is a reversible process. Upon continued oxidation, sulfonic acid is formed, which appears to be irreversible (human non-mercaptoalbumin 2, HNA2). The result is a damaged albumin molecule that has lost its scavenger function. Oxidative stress with high levels of HNA2 may have a decisive role in the pathogenesis of severe liver failure. There is no data in the literature regarding changes in oxidized albumin over time. The investigators will try to model albumin turnover by looking at how these fractions and the proportions between them change over time. Previous results, suggesting that the amount of oxidized albumin is higher in patients with liver cirrhosis [Oettl 2013], will be reproduced. Finally, the association between albumin oxidation and albumin catabolic rate will be described. The statistical analysis plan including the determination of the number of study subjects is included in the attached study plan.

Official Title
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Albumin Catabolic Rate Measured by a Stable Isotope

Conditions
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Liver Disease Chronic

Intervention / Treatment
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* Other: stable isotopes


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Healthy volunteers: males and females >= 40 years (to be more like the anticipated age of the liver patients) good peripheral blood vessels written informed consent Patients with liver cirrhosis: known compensated liver cirrhosis with radiological or endoscopic signs of portal hypertension, such as varices, splenomegaly, or shunts. written informed consent Exclusion Criteria: Planned surgical procedure within 3 months (due to possible blood loss i.e. loss of tracer) Pregnancy at dosing Phenylketonuria Participating in other study with stable isotopes within 60 days. Circumstance that causes the responsible researcher to assess the research person's participation as inappropriate

Ages Eligible for Study
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Minimum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Patients with liver disease<br>patients with chronic liver disease will receive a oral dose of a stable isotope labeled amino acid, 2H5-Phenylalanine, (45 mg/kg body weight 50% MPE). Blood samples will be taken over 12 weeks. | Other: stable isotopes<br>* The tracer 2H5-phenylalanine is an essential amino acid labeled with deuterium that is a stable isotope, i.e. no radiation is emitted, but the tracer can still be assessed by a combination of gas chromatography and mass spectrometry. The tracer has no measurable effects, but are used for assessment of human physiology.<br>|
| Experimental: Healthy volunteers with no signs of liver disease<br>Healthy volunteers with no signs of liver disease will receive a oral dose of a stable isotope labeled amino acid, 2H5-Phenylalanine, (45 mg/kg body weight 50% MPE). Blood samples will be taken over 12 weeks. | Other: stable isotopes<br>* The tracer 2H5-phenylalanine is an essential amino acid labeled with deuterium that is a stable isotope, i.e. no radiation is emitted, but the tracer can still be assessed by a combination of gas chromatography and mass spectrometry. The tracer has no measurable effects, but are used for assessment of human physiology.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Albumin degradation rate by stable isotope | The disappearance rate of 2H5-phenylalanine labeled albumin over time, that is the catabolic rate of albumin, will be measured in both study groups in blood samples over 12 weeks, and the study groups compared. | 12 weeks | 
| Albumin degradation rate by different methods | Healthy volunteers will be compared to historical controls from our laboratory where albumin degradation rate was measured by radio-iodinated human serum albumin. | 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Albumin synthesis rate | We will compare the oral flooding dose with historical controls where the isotope was given intravenously at our laboratory for measurement of albumin synthesis rates in volunteers and patients with liver disease. | 120 minutes | 
| Albumin degradation by modeling different fractions of oxidized albumin over time | During the life span of the albumin molecule more and more oxidation appears. The doubly oxidized molecule can no longer reverse to unoxidized albumin. We want to investigate if rations of labeled to unlabeled fractions of the different forms of oxidized albumin can be used for modeling albumin degradation rate | 12 weeks | 
| Correlation between oxidation and degradation rate of albumin | Oxidation of albumin molecules has been reported to be increased in liver disease. We want to see if there is a correlation between oxidation fraction and albumin degradation rate. | 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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albumin catabolism