Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with an increased death risk from cardiovascular diseases. However, while even minor renal dysfunction is an independent predictor of adverse cardiovascular prognosis, PEW becomes clinically manifest at an advanced stage, early before or during the dialytic stage. Mechanisms causing loss of muscle protein and fat are complex and not always associated with anorexia, but are linked to several abnormalities that stimulate protein degradation and/or decrease protein synthesis. In addition, data from experimental CKD indicate that uremia specifically blunts the regenerative potential in skeletal muscle, by acting on muscle stem cells. In this discussion recent findings regarding the mechanisms responsible for malnutrition and the increase in cardiovascular risk in CKD patients are discussed. During the course of CKD, the loss of kidney excretory and metabolic functions proceed together with the activation of pathways of endothelial damage, inflammation, acidosis, alterations in insulin signaling and anorexia which are likely to orchestrate net protein catabolism and the PEW syndrome.

Apoptosis and myostatin are major mediators of muscle atrophy and might therefore be involved in the wasting of uremia. To examine whether they are expressed in the skeletal muscle of patients with chronic kidney disease (CKD), we measured muscle apoptosis and myostatin mRNA and their related intracellular signal pathways in rectus abdominis biopsies obtained from 22 consecutive patients with stage 5 CKD scheduled for peritoneal dialysis. Apoptotic loss of myonuclei, determined by anti-single-stranded DNA antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assays, was significantly increased three to fivefold, respectively. Additionally, myostatin and interleukin (IL)-6 gene expressions were significantly upregulated, whereas insulin-like growth factor-I mRNA was significantly lower than in controls. Phosphorylated JNK (c-Jun amino-terminal kinase) and its downstream effector, phospho-c-Jun, were significantly upregulated, whereas phospho-Akt was markedly downregulated. Multivariate analysis models showed that phospho-Akt and IL-6 contributed individually and significantly to the prediction of apoptosis and myostatin gene expression, respectively. Thus, our study found activation of multiple pathways that promote muscle atrophy in the skeletal muscle of patients with CKD. These pathways appear to be associated with different intracellular signals, and are likely differently regulated in patients with CKD.

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Background The aim of this systematic review and meta-analysis was to assess the effect of anesthesia maintenance with volatile agents compared with propofol on both short- and long-term mortality (primary outcomes) and major clinical events in adults undergoing cardiac surgery with cardiopulmonary bypass. Methods Randomized clinical trials on the effects of current volatile anesthetics versus propofol in adults undergoing cardiac surgery with cardiopulmonary bypass were searched (1965 to September 30, 2019) in PubMed, the Cochrane Library, and article reference lists. A random effect model on standardized mean difference for continuous outcomes and odds ratio for dichotomous outcomes were used to meta-analyze data. Results In total, 37 full-text articles (42 studies, 8,197 participants) were included. The class of volatile anesthetics compared with propofol was associated with lower 1-yr mortality (5.5 vs. 6.8%; odds ratio, 0.76 [95% CI, 0.60 to 0.96]; P = 0.023), myocardial infarction (odds ratio, 0.60 [95% CI, 0.39 to 0.92]; P = 0.023), cardiac troponin release (standardized mean difference, −0.39 [95% CI, −0.59 to −0.18], P = 0.0002), need for inotropic medications (odds ratio, 0.40 [95% CI, 0.24 to 0.67]; P = 0.0004), extubation time (standardized mean difference, −0.35 [95% CI, −0.68 to −0.02]; P = 0.038), and with higher cardiac index/output (standardized mean difference, 0.70 [95% CI, 0.37 to 1.04]; P < 0.0001). The class of volatile anesthetics was not associated with changes in short-term mortality (1.63 vs. 1.65%; odds ratio, 1.04 [95% CI, 0.73 to 1.49]; P = 0.820) and acute kidney injury (odds ratio, 1.25 [95% CI, 0.77 to 2.03]; P = 0.358). Conclusions In adults undergoing cardiac surgery with cardiopulmonary bypass, the class of volatile anesthetics was superior to propofol with regard to long-term mortality, as well as to many secondary outcomes indicating myocardial protection. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Amino acids are classically considered as the building blocks for the synthesis of proteins. Besides this, some of them play a major role in other functions, such as regulation of protein turnover and signal transduction, transport of nitrogen and carbon across the organs, or neurotransmission. The unique characteristics of amino acids are the presence of a free amino group in the α‐carbon and a free carboxyl group. The amino acids differ from each other with respect to their side‐chains. The amino acids are classified into subgroups according to their similarity in carbon skeleton, substituent groups or a common metabolic pathway. The biosynthesis of amino acids involves several biochemical pathways in which amino acids are assembled from other precursors. The biosynthesis of amino acids is distinct from that involving lipids or carbohydrates because it includes the use of nitrogen. Key Concepts: Amino acids are classically considered as the building blocks from which proteins are synthesised. Besides this, some of them play a major role in the regulation of protein turnover and signal transduction, transport of nitrogen and carbon across the organs, and neurotransmission. The biosynthesis of amino acids involves several biochemical pathways in which amino acids are assembled from other precursors. The biosynthesis of amino acids is distinct from that involving lipids or carbohydrates because it includes the use of nitrogen. The fixation of nitrogen is a process that converts atmospheric nitrogen to a form that can be used biologically. The pathways for the synthesis of essential amino acids are present only in microorganisms and plants. Nine of 12 nonessential amino acids are synthesised from amphibolic intermediates, whereas three amino acids (tyrosine, cysteine and hydroxylysine) derive from essential amino acids. Amino acid transaminases, glutamate dehydrogenase and glutamine synthetase play a central role in the synthesis of nonessential amino acids. The major pathway by which ammonia is incorporated into amino acids is through the reductive amination of α‐ketoglutarate to glutamate. Ammonia is highly toxic for animals. Glutamine is a nontoxic carrier of ammonia. In the human adult as much as 200–250 g of proteins are degraded daily, and their constituent amino acids are in large part reutilised in protein synthesis. Amino acid deficiency states can result if any of the essential amino acid is present in inadequate amounts or omitted from the diet. Alanine, glutamate and glutamine are crucial links between energy and protein metabolism. Moreover, glutamine and alanine biosynthesis in the peripheral tissues (muscle) provides a means for the transport of carbon to the liver for gluconeogenesis and nitrogen for ureagenesis. There are several nonprotein functions of amino acids, such as the biosynthesis of purines and pyrimidines, which involve more nonessential than essential amino acids.

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