Cirrhosis, Liver
Conditions
Brief summary
Loss of skeletal muscle mass or sarcopenia is the most common and potentially reversible complication in cirrhosis that increases morbidity and mortality before, during and after liver transplantation. No proven treatments exist for the prevention or reversal of sarcopenia in cirrhosis, primarily because the mechanisms responsible for this are unknown. Based on compelling preliminary studies and those of the co investigator, investigators hypothesize that the mechanism of reduced skeletal muscle mass in cirrhosis is due to a myostatin mediated impaired mTOR (mechanistic target of rapamycin) signaling resulting in reduced protein synthesis and increased autophagy. Investigators further postulate that leucine, a direct stimulant of mTOR, will reverse the impaired mTOR phosphorylation in the skeletal muscle of cirrhotics. The consequent increase in protein synthesis reduced autophagy will result in an increase in skeletal muscle mass. Investigators will test these hypotheses by quantifying the response to acute and long term (3 month) administration of hydroxymethyl butyrate (HMB) enriched essential amino acid compared with an isonitrogenous isocaloric non-essential balanced amino acid mixture (does not stimulate protein synthesis) in cirrhotic patients. Fractional protein synthesis rate (FSR) in skeletal muscle, responses of the molecular regulatory pathways of skeletal muscle protein synthesis, and autophagy flux will be quantified in the acute and long term protocols. Tracer studies using L-\[D5\]-phenylalanine (Phe) as a primed constant infusion (prime 2µmol.kg-1.hr-1; constant 0.05 µmol.kg-1.hr-1) with and L \[ring-D2\] tyrosine, forearm plethysmography, and sequential skeletal muscle biopsies (total of 3 per study subject) will be used to quantify these outcomes. Anthropometric, clinical and body composition measures will be additional outcome measures for the long term intervention. Expression of regulatory signaling proteins, myostatin, IGF-1 (insulin like growth factor) , phospho-Akt, phospho-AMPK (activated protein kinase), phospho-mTOR and phospho-p70s6k will be quantified by Western immunoblots. Autophagy flux will be measured by quantifying expression of the autophagosome proteins.
Interventions
DIETARY_SUPPLEMENTHydroxy Methyl Butyrate
Hydroxy Methyl Butyrate
DIETARY_SUPPLEMENTBalanced Amino Acids
Balanced Amino Acids
Sponsors
The Cleveland Clinic
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
21 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
* Diagnosis of cirrhosis of the liver * Child-Pugh score of 5-8
Exclusion criteria
* Recent gastrointestinal bleeding (\<3m) * Active infection * Overt encephalopathy * Renal failure on dialysis * Pedal edema * Uncontrolled diabetes (HbA1C \> 7.9mg/dL) * Advanced cardiac, lung, kidney disease * Metastatic cancer * Medications that alter muscle protein metabolism * Pregnancy * Recent bowel resection or gastric bypass surgery, * INR \>1.7, platelets \<60,000/ml, serum creatinine \>2mg/dL * Medications that interfere with blood clotting
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Fractional Synthesis Rate of Skeletal Muscle | Day 0 to Day 90 | To test whether fractional synthesis of skeletal muscle proteins changes from baseline to 90 days with the administration of BAA or EAA/LEU. Fractional synthesis rate (FSR) of mixed muscle proteins will be calculated from the incorporation rate of the L- \[ring D5\] phenylalanine into the proteins and the free tissue phenylalanine enrichments using precursor product model: FSR= (∆Ep/t)/(∆Ec) x60x100 and expressed as %/hour. ΔEp is the increment in myofibrillar protein-bound L- \[ring D5\] phenylalanine enrichment, t is the time between the muscle biopsies. ∆Ec is the L- \[ring D5\] phenylalanine enrichments in the free intracellular pool in the muscle biopsies. |
Countries
United States
Contacts
Primary ContactAnnette Bellar
Outcome results
None listed