[Nutritional support in cardiac cachexia].
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C57BL/6J mice bearing a low or undifferentiated rapidly growing tumor were treated daily with either i.p. injections of the recombinant cytokines interleukin(IL)-1 alpha, IL-1 beta (21 ng/g), and tumor necrosis factor alpha (21 ng/g) or s.c. injections of cyclosporin A (60 micrograms/g) or indomethacin (1 micrograms/g). In some experiments, indomethacin was administered in the drinking water corresponding to the amount of s.c. injections. Survival and the time course of tumor growth and food and water intake were measured. The nutritional state (body composition) of the animals was registered at spontaneous death in the course of tumor disease. Indomethacin prolonged survival from 14 +/- 1 to 22 +/- 1 days in tumor-bearing mice when administered either in the drinking water or as s.c. injections. This effect, which was due to tumor growth inhibition, was equally effective irrespective of whether indomethacin was instituted on Day 1, 5, 7, or 9 following tumor implantation. Indomethacin did not inhibit tumor cell growth in vitro. Indomethacin-treated tumor-bearing mice were also less anorectic than untreated tumor-bearing mice, and their nutritional state, particularly lean body mass, was significantly improved by indomethacin at doses (1 micrograms/g) that did not influence the food intake or body composition in non-tumor-bearing mice. At spontaneous death, indomethacin-treated tumor-bearing mice had a significantly larger tumor burden when accounting for their degree of malnutrition as compared with untreated tumor bearers. Indomethacin did not decrease the elevation in hepatic concentrations of RNA seen in response to tumor progression. Adherent peritoneal macrophages from tumor-bearing mice had a lower prostaglandin E2 synthesis compared with macrophages from non-tumor-bearing controls in the basal state (1100 +/- 150 pg/10(6) cells versus 3700 +/- 922 pg/10(6) cells). Lipopolysaccharide stimulated macrophages from tumor-bearing mice to produce significantly more prostaglandin E2 in vitro compared with control macrophages (39,500 +/- 4208 pg/10(6) cells versus 12,500 +/- 4330 pg/10(6) cells).(ABSTRACT TRUNCATED AT 400 WORDS)
With the euglycemic clamp technique, we evaluated the effects of graded doses of insulin on glucose turnover rates and forearm lactate balance in five weight-losing patients with cancer before surgery and five age- and weight-matched healthy volunteers (control subjects). Insulin was infused sequentially at increasing rates of 0.5 (low physiologic), 1.0 (high physiologic), and 4.0 (supraphysiologic) mU/kg.min for 120 minutes each. Concurrently, rates of glucose appearance and disappearance were derived from [3-3H] glucose infusion. The mean postabsorptive rate of glucose appearance in patients (2.9 +/- 0.1 mg/kg.min) was significantly higher (p less than 0.02) than that of control subjects (1.98 +/- 0.16 mg/kg.min). Complete suppression of endogenous glucose production occurred at high physiologic insulin concentrations. With progressive insulin infusion, the rate of glucose disappearance increased to 3.6 +/- 1.2, 8.7 +/- 0.8, and 13.7 +/- 1.1 mg/kg/min in control subjects and 2.9 +/- 0.4, 5.3 +/- 0.3, and 10.9 +/- 0.9 mg/kg.min in patients, significantly different from that of control subjects (p less than 0.05) during the intermediate (high physiologic) insulin infusion. A comparable slight increase in arterial plasma lactate concentration was observed in both groups with progressive hyperinsulinemia. Baseline peripheral lactate flux was identical in patients (-272 +/- 56 nmol/100 gm.min) and in controls (-271 +/- 57 nmol/100 gm.min). Progressive physiologic hyperinsulinemia resulted in significantly (p less than 0.05) augmented peripheral lactate efflux in patients (-824 +/- 181 nmol/100 gm.min) compared with control subjects (-287 +/- 64 nmol/100 gm.min). Supraphysiologic insulin abolished this increased lactate efflux in patients. Postabsorptive rates of endogenous glucose appearance in weight-losing patients with cancer were elevated, but complete suppression was achieved with insulin concentrations in the physiologic range. Total body glucose use was diminished in these patients, consistent with a state of insulin resistance. This impaired insulin action on peripheral glucose use was associated with an increase in peripheral lactate release in patients.
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The effect of substitution of the carbohydrate component of the diet by calories derived from fish oil on host body weight loss and tumor growth rate has been studied in an experimental colon adenocarcinoma (MAC16). This tumor produces extensive host weight loss and reductions in both total body fat and muscle dry weight, without a reduction in food intake. Diets containing fish oil significantly reduced host body weight loss, with almost complete protection occurring when the fish oil comprised 50% of the calories, without an alteration of total calorie consumption or nitrogen intake. There was also a significant reduction in tumor growth rate, although the reduction in host weight loss was greater than might be expected from a smaller tumor burden. The reduction of host body weight loss was associated with an increase in total body fat and muscle mass. The effect appears specific to the type of fat since comparable results were not obtained with a gamma-linolenic acid-enriched diet. When compared with cyclophosphamide and 5-fluorouracil the fish oil diet exerted a similar antitumor effect at the maximum dose. Whereas the antitumor effect of the former agents was achieved with considerable host toxicity, the latter produced no toxicity and almost completely abolished the cachectic effect of the tumor. These results suggest that fish oil is a nontoxic, highly effective anticachectic agent with the added advantage of antitumor activity.
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Several lines of investigation suggest that the endogenous synthesis of cachectin contributes to the host changes that occur in cancer. Although serum appearance of cachectin in tumour-bearing animals and patients with cancer cannot be measured with current techniques, there is accumulating evidence to suggest that tissue macrophage production of cachectin is accelerated in organisms with tumours. Production of cachectin, coupled with the simultaneous synthesis of other cytokines that act synergistically with cachectin may explain many of the host changes in the absence of detectable circulating levels.
Animals transplanted with the MAC16 colon adenocarcinoma showed a loss of body weight as the tumor weight increased, without a reduction in food intake. Both adipose tissue and muscle mass decreased in tumor-bearing animals, although loss of body fat exceeded that of muscle mass for given tumor weight. Urinary nitrogen excretion was significantly elevated when the weight loss did not exceed 3 to 4 g, but above this weight loss there was a conservation of nitrogen and the excretion level fell to or below that found in non-tumor-bearing animals. The presence of a tumor alone was not sufficient to account for the elevated nitrogen excretion, since animals bearing a related colon adenocarcinoma (MAC13) that did not induce weight loss had a nitrogen excretion pattern similar to that of non-tumor-bearing controls. Feeding an isocaloric isonitrogenous diet in which 80% of the calories were supplied as medium chain triglycerides, which significantly elevated plasma levels of ketone bodies, reduced both tumor weight and host weight loss and restored both the nitrogen balance and urea excretion to that of non-tumor-bearing animals. The plasma levels of amino acids, which were reduced in the cachectic state, were also restored to control values in animals fed the medium chain triglyceride diet. These results suggest that excessive nitrogen catabolism in the cachectic state can be prevented by suitable dietary modification.
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