the effect of muscular exercise on the blood ammonia
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1959
The effect of muscular exercise on the bloodammonia concentration in man. With particularreference to patients with Laennec's CirrhosisScott Ingram AllenYale University
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Recommended CitationAllen, Scott Ingram, "The effect of muscular exercise on the blood ammonia concentration in man. With particular reference topatients with Laennec's Cirrhosis" (1959). Yale Medicine Thesis Digital Library. 2334.http://elischolar.library.yale.edu/ymtdl/2334
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THE EFFECT OF MUSCULAR EXERCISE OH THE BLOOD AMMONIA CONCENTRATION
IN MAN
With Particular Reference To Patients With Laennec's Cirrhosis
by
Scott I. Allen, A.B. Nl
Pomona College, 1955
A Thesis Submitted to the Faculty of the
Yale University School of Medicine
In Candidacy for the Degree of
Doctor of Medicine
Department of Internal. Medicine
1959
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Acknowledgement
I wish to express my gratitude to Dr. H. 0.
Conn for his many helpful suggestions and
guidance during this investigation. I am
also indebted to Dr. M. Calabresi for his
help and laboratory facilities.
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1
THE EFFECT OF MUSCULAR EXERCISE ON THE BLOOD AMMONIA* CONCENTRATION
IN MAN
With Particular Reference To Patients With Laennec's Cirrhosis
Introduction
In 1925 Luck, Thacker, and Marrack reported high hlood ammonia
levels in epileptic patients after grand mal seizures (1), Although
they suspected that muscular exercise might be responsible for this
observation, they apparently excluded this possibility by their inability
to produce an increase in venous ammonia by exercise (stair running for
five minutes) in normal subjects. They were unable to satisfactorily
explain this phenomenon. In 192? Embden found the ammonia content of
isolated frog muscle preparations to be elevated after muscle activity (2).
He suggested that ammonia was formed during muscle contraction by the
deamination of adenylic acid. In addition he believed that this ammonia
remained within the muscle for the resynthesis of adenylic acid during
the resting phase. In the same year Parnas, Mozolowski, and Levinski
reported that the ammonia content of venous blood which drained the
exercising forearm was elevated In normal subjects (3). These investi¬
gators demonstrated that the ammonia which is liberated by fatiguing
muscle exercise escapes into tissue fluid and blood.
* Although it is realized that at pH 7.^ almost all amonia exists as ammonium ion, the term ammonia is used to represent the total ammonia- ammonium content.
1
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2
For many years after these investigations the effect of exercise
on ammonia metabolism was practically ignored. Recently in this country
Schwartz, Lawrence, and Roberts described elevated peripheral venous
ammonia levels following muscular exercise in normal subjects after
running and in patients after convulsions induced by electric shock
therapy (1). These investigators were interested in the possibility
that increases in blood ammonia following muscular exercise might be
a factor in the hyperpnea of exercise.
A brief review of ammonia metabolism might be helpful in order to
more fully appreciate the important role of muscle function on blood
ammonia concentration. The gastrointestinal tract is the most important
source of blood ammonia as a result primarily of the bacterial or enzy¬
matic action on ingested nitrogenous substances (5). Most of this ammonia
is liberated from urea which has diffused into the bowel by the action of
bacterial ureases. Bacterial amino acid oxidases liberate ammonia by the
deamination of amino acids derived from digested protein. The ammonia
is carried to the liver by the portal vein where much of the ammonia is
removed and is converted to urea and other nitrogenous substances. In
the presence of cirrhosis of the liver there is a decreased removal of
ammonia by the damaged liver (6). In addition much ammonia escapes hepatic
extraction by passing directly from the portal vein into the systemic
circulation through portasystemic collateral veins. This accounts for the
increased ammonia concentration frequently measured in peripheral venous
blood. The kidney which paradoxically is the main site of nitrogen excretion
has been demonstrated to be a source of endogenous ammonia production (5).
It has recently been recognized that the peripheral tissues, presumably
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muscle, are important sites for the removal of ammonia from the blood
in the presence of increased blood ammonia. Bessman and coworkers (7,8)
first demonstrated the peripheral uptake of ammonia in hepatic coma, and
recently a similar phenomenon was demonstrated in normal subjects (9).
Similar removel of ammonia by brain tissue has been noted (7,10). In
fasting normal subjects at rest arterial and venous ammonia values are
either in equilibrium or show a slight arterio-venous uptake.
In most patients with hepatic coma elevated levels of venous blood
ammonia have been reported. However, high levels of venous ammonia are
not always found in hepatic coma (11,12,13). Furthermore the alterations
in venous blood ammonia do not correlate well with the level of conscious¬
ness of the patient. Bessman and Bradley who demonstrated increased peripheral
arterio-venous ammonia differences in hepatic coma postulated that the
normal venous ammonia level observed in hepatic come, may be due to a
large uptake of ammonia by muscle tissue (8). They found a closer cor¬
relation between arterial ammonia levels and the neurological status of
patients in hepatic coma. Although the uptake of ammonia by peripheral
sites during hepatic coma has been observed by a number of authors, not
all cirrhotic patients in hepatic coma, demonstrate peripheral uptake. In
fact Summerskill, Wolfe, and Davidson have reported patients in the late
stages of hepatic coma in whom ammonia was released by peripheral tissue
despite high arterial concentrations (1M). Bessman end Mirick suggested
that the reduced muscle mass found in debilitated cirrhotics might explain
the poor uptake of ammonia occasionally seen in terminal hepatic coma. (15).
It is apparent that the status of peripheral ammonia removal may be important
in the genesis and prognosis of hepatic coma (10).
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Although it is generally agreed that ammonia intoxication does
not explain the pathogenesis of all cases of hepatic coma, it is
certainly true that the absorption of ammonisgenic substances from the
gastrointestinal tract may produce this syndrome. Hepatic coma with
hyperammonemia has been reported in subjects following porta-caval
shunts (16), gastrointestinal hemorrhage (1?), the administration of
high protein diet (18), urea (18), emmonium compounds (18), and methio¬
nine (19). The drugs acetazolemide (Diamox®))(20) and chlorothiazide
(Diuril®)(21) are also known to produce impending hepatic coma usually
associated with hyperammonemia although the mechanism of action is not
clearly understood. It has been suggested that Diamox may interfer with
the uptake of ammonia by peripheral muscle tissue (22).
The balance between the factors of production and removal of
ammonia from the blood is certainly more precarious in patients with
impaired liver function and increased portal collateral circulation.
Some preliminary work in this laboratory has suggested that patients
with Laennec's cirrhosis might release ammonia from muscle sources more
readily than other subjects after muscle exercise.
This investigation was undertaken to evaluate the effects of
muscular exercise on the release of blood ammonia from peripheral
tissues and particularly to compare this phenomenon in normal subjects
and in cirrhotic patients.
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Materials & Methods
Subjects
This investigation was carried out at the West Haven Veterans
Administration Hospital between May and October of 1958. The experi-
mental subjects were divided into three groups.
Group A consisted of 10 normal subjects 18 to 40 years of age who
were employed as doctors or technicians at the hospital. These volunteers
were younger and physically stronger than the patients in the other two
groups.
Group B included 31 ambulatory control patients 21 to 63 years
of age with a variety of benign non-hepatic diseases.
Group C consisted of 17 cirrhotic patients 31 to 6l years of age
in whom the diagnosis of Laermec's cirrhosis was established by histologic
methods. Most of these patients had experienced hepatic decompensation
at some time in the past as evidenced by Jaundice, ascites, esophageal
hemorrhage, or Impending coma. At the time of this study these patients
were capable of ambulation and were able to exercise with vigor equiva-
lent to the control patients.
Most of the subjects were in the postprandial state.
Exercise
In one series of observations each patient merely clenched his
fist vigorously at the rate of one per second against no resistance.
This type of exercise will be referred to as "fist clenches." In an
attempt to better standardize the amount of muscular exercise a spring
type hand grip exerciser known as a Power Gripper was utilized (Figure l).
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- 6 -
The Power Gripper was squeezed at the rate of one per second up to a
maximum of 100 contractions. This type of exercise will be referred
to as "power grips." A maximum of 100 "power grips” was sufficient
exercise to severely fatigue the forearm muscles of all normal subjects.
The longest duration of exercise was less than two minutes. Although all
subjects worked against the same spring resistance, some subjects squeezed
with more vigor than others. Various groups of subjects were studied
after 100 "fist clenches,” 50 "power grips," and 100 "power grips."
Blood Specimens
Twenty milliliter syringes were prepared by wetting the barrel of
the syringe with Upjohn heparin (1000 units/ml,). All excess heparin
was expressed from the syringe leaving only the heparin filling the
"dead space." A lateral antecubital vein was usually selected for veni¬
puncture . A soft rubber tourniquet was used to distend the vein momentarily
for the venipuncture. Then the tourniquet was released and the baseline
blood specimen was drawn without venous stasis. The subjects were not
permitted to squeeze or pump their fists prior to or during the blood
collection. A three-way stopcock attached to the needle was closed and
the needle was then secured in the vein with adhesive tape. Immediately
after exercise another sample was drawn without stasis. Then 0.5 ml. of
heparin (1000 units/ml.) was injected into the stopcock to prevent clotting
in the needle. At the end of fifteen minutes after discarding 5 ml. of
blood another sample was drawn without tourniquet. Arterial ammonia samples
were obtained through an 18 gauge Cournand indwelling needle from either
a femoral or a brachial artery. All blood specimens were analyzed for
ammonia within ten minutes after drawing the samples.
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Methods
The blood ammonia was determined according to the method of
Seligeon and Hirahara (23). In this laboratory this method has been
modified in the following respects. Two steel rods instead of three
were placed in each diffusion bottle. The Kessler reagent of Vanselow
was diluted 1:10 instead of 1:20 with distilled water. The ammonium
sulfate standard and the unknown blood samples were determined in
triplicate instead of duplicate. The mean venous ammonia level for
normal subjects in this laboratory was 102^:23 micrograms per
100 ml. with a range of 67-1^2. The abbreviation ^ gn$ will be used
throughout this communication.
Blood oxygen saturation and carbon dioxide content were determined
according to the method of Peters and Van Slyke (2l). Serum sodium and
potassium were determined with a Baird flame photometer. Serum chloride
was determined by the method of Shales and Shales (25). Serum magnesium
was determined by a modification of the method of Orange and Rhein (26).
Serum glutamic oxaloacetic transminase (SCOT) was measured by the Sigma
Chemical Company's colorimetric procedure (27). Blood pH was measured
with a Cambridge Model R pH meter.
Discussion of Methods.
During the period of this investigation the mean and range for
venous blood ammonia in normal subjects was noted to be elevated above
the levels previously observed in this laboratory. In a series of ten
normal subjects the mean venous ammonia was l6l± 12jugra$ with a range
of 1^1-184^, gaff, . The explanation for this rise in the mean venous blood
ammonia was not established until after the conclusion of this study.
- V -
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- 8 -
Investigation subsequently revealed that the Upjohn heparin (1000 units/mi.)
used throughout this study was responsible for the higher ammonia values.
The earlier range of normal had been established using Liquaemin^)
(Organon).
Comparative analysis using these two commercial heparin preparations
revealed that the use of the Upjohn product invariably resulted in higher
hlood ammonia values than the Organon preparation. The roe an difference in
twenty-five hlood specimens, each performed in triplicate, was 30U€>®$
and ranged from 4 to 70 Jign#. It is ironic to note that three additional
commercial heparin preparations, which were similarly evaluated, did not
differ significantly from the results obtained with the Organon heparin.
The Upjohn product hy direct analysis liberated approximately 10
times as much M^-N as did the Organon preparation (1500{xgntf vs lOjugn^)*
Measurement hy weight showed that the amount of heparin required to fill
the dead space of a 20 ml. syringe varied from 0.15 to 0.18 ml. Since
10 to 12 ml. of blood were withdrawn, approximately 1.5$ of this total
volume was heparin, which would account for more than 20p.gm$ of MET ,-N
when the Upjohn product was used.
It is apparent that variations in the amount of heparin employed
might effect comparative blood ammonia values. The effect of the heparin
may explain some of the discrepancies observed in the values for venous
hlood ammonia drawn simultaneously from both arms of the seme patient
(Table III and IV). Since this study is concerned primarily with relative,
ratter than absolute, changes in blood ammonia values before and after
exercise, the data obtained in this study is valid. The random distribution
- 8 -
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- 9 -
of the adverse effect of the heparin among the experimental subjects
permits reliable statistical analysis.
Results
Mild Exercise
In a preliminary series of 10 control patients and 7 cirrhotic
patients venous blood samples were drawn for ammonia determination from
the antecubital vein of the exercising arm before and immediately after
100 "fist clenches" at the rate of one per second. The results are shown
in Table I and Figure 2. Only one patient (J.P.) in the control group
showed a significant elevation in venous ammonia with this mild exercise.
Five cirrhotic patients showed elevations in excess of UO/lgmfjL Two
cirrhotic patients (W.C. and F.N.) did not show a significant rise in
venous ammonia with this mild exercise. The mean elevations in venous
ammonia, was 0± 20ju.gn$ in the control group and 43±22>*.gm$ in the
cirrhotic group. The difference between the elevation of the means of
the two groups is statistically significant with a P value of 0.001.
This exercise study indicated a greater increase in ammonia content in
venous blood of cirrhotic patients following mild muscular effort as
compared to control patients. Although the resting blood ammonis level
was higher in cirrhotic patients, there was no relationship between the
initial ammonia concentration and the absolute or percentage rise in the
blood ammonia.
Moderate Exercise
In a series of six control patients and seven cirrhotic patients
r,. • j-tt Inner.** ' trow- n£? t. * } O J >/. o . <* ..f.s 'jo
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10
Table I
Venous Blood Ammonia in the Exercising Arm Before and After 100 11 Fist Clenches”
Control Patients Before Exercise After Exercise Difference
1. J.P. 121 167 46 2. E.F. 111 113 2 3- W.F. 110 107 "3 4. L.K. 145 130 -15 5- J.C. 151 137 -14 6. F.J. 126 135 9 7. P.H. 155 153 - 2 8. L.C. 102 - 103 1 9- R.C. 120 126 6
10. J.D. 133 102 -31 Mean 127 127 0 S.D. ±21 ±24 ■r 20
Cirrhotic Patients Before Exercise After Exercise Difference
1. E.C. 114 164 50 2. L.C. 129 169 40 3- F.N. 156 166 10 4. W.C. 150 14? - 3 5- C.M. 206 300 94 6. H.W. 157 206 49 7. s.s. 147 214 67
Mean 151 195 43 S.D. ± 26 ± 47 ± 22
01
I iXcfrT
nj • >i *»* A >© -• I -
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■ rr •• ■ J • - : i j' :. . i . ■ .•->"•
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FIG. 2
Venous Blood Ammonia in the Exercising Arm Before and After
IOO Fist Clenches.
Mean
NH3
^gm per
100ml
Control Patients
Cirrhotic Patients
| | BEFORE
^ AFTER
O
1
<
» { ) (
11
venous ammonia samples were collected from the exercising arm before
and immediately after 50 "power grips" at one per second. The results
are shown in Table II and Figure 3. Although two control patients
showed rises of 35 and 36ug®$, all cirrhotic patients demonstrated
rises of more than 46p-gm$> with this moderate exercise. There was a
mean rise of 5p.gn$ in the control group and a mean rise of 80p.ga$ in
the cirrhotic group. The difference between these means is statistically
significant with a P value of 0.001. These results with moderate exercise
confirm the results from the 100 "fist clench” experiments. These findings
suggest that cirrhotic patients may have a greater tendency than non¬
cirrhotic patients to liberate ammonia from muscle sites with moderate
degrees of exercise.
Fatiguing Exercise
In a series of 10 normal subjects, 10 control patients without liver
disease, and 10 cirrhotic patients a needle was placed in an antecubitsl
vein of each arm. Venous samples for ammonia determination were drawn
simultaneously from both extremities before exercise of one forearm,
immediately after, and fifteen minutes after exercise. The exercise
consisted of 100 "power grips" at one per second.
The results for venous blood ammonia from the exercising arm are
shown in Table III and Figure 1. The mean blood ammonia values before
exercise were not significantly different in the three groups although
one cirrhotic patient (C.M.) had a baseline blood ammonia of 276|xgm$.
All 30 subjects showed an elevated venous blood ammonia immediately after
exercise. The smallest rise was 25in a normal subject (A.P.) The
largest rise was 320^.gm# in a control patient (A.S.). Although the
- IX
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- 12
Table II
Venous Blood Ammonia In the Exercising Arm Before and After 50 "Power Grips”
Control Patients Before Exercise After Exercise Difference
1. L.C. 15k 136 -18 2. R.C. 156 191 35 3- A .H. 128 127 - 1 b. G.E. lb 3 132 - 9 5- A.T. lb3 130 -13 6. J.B. 151 18? 36
Mean lb5 151 5 S.D. ±6 ±30 ±2b
Cirrhotic Patients Before Exercise After Exercise Difference
1. D.S. 11+9 21+7 98 2. S.S. 117 193 1+6
3- L.S, 11+7 211 61+ b. J.K. 150 232 82 > • W.C. 1^3 213 70 6. W.P. 108 2l+9 Ibl 7. C.M. 198 258 61+
Mean 1^ 229 80 S.D. ±15 ±21 ±35
- £1 -
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FIG. 3
Mean NH3
/igm per
100 ml
Venous Blood Ammonia in the Exercising Arm Before and After
50 Power Grips.
300-
Control Patients
Cirrhotic Patients
| | BEFORE
T7jI AFTER
o
(
(
1 )
) )
- 13 -
Table III
Venous Blood Ammonia in the Exercising Arm Before and After 100 "Power Grips"
Normal Subjects Before Exercise After Exercise 15 Minutes After Ex.
1. S.A. 150 373 352 2. M.S. 144 276 207 3- A.P. 168 193 191 4. A.S. 180 249 —
5- J.D. 156 348 221 6. P.M. 184 240 160 7. T.A. 153 256 173 8. S.N. 154 180 150 9. J.O. 144 209 164
10. H.C. 172 216 «...
Mean T6T 254 ~20E S.D. ±12 ±64 t 51
Control Patients
1. A.S. 110 430 284 2. K.K. 179 247 ---
3- E.W. 159 230 171 4. W.F. 158 377 263 ^ * B.L. 110 200 169 6. C.W. 158 346 161 7. J.D. 156 275 230 8. R.S. 170 230 153 9- F.G. 124 211 169
10. L.L. 116 177 -- -
Mean 144 272 200 S.D. •±51 ±82 t 51
Cirrhotic Patients
1. H.V. 223 394 264 2. W.C. 135 258 188 3* C.M. 276 330 320 4. H.W. 196 313 204 C. J • s.s. 197 275 300 6. L.S. 116 232 139 7. D.S. 104 305 - ~ *- 8. J.W, 130 310 9. J.S. 139 207 ---
10. S.P. 117 231 Mean 163 ~28S 233 S.D. £44 a:54 ±65
.zA
- i -
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FIG. A
Venous Blood Ammonia in the Exercising Arm Before and After
IOO Power Grips.
□ before EXERCISE ^2 IMMEDIATELY after exercise
■ (5 MIN. AFTER EXERCISE
(
( )
- Ik
cirrhotic group exhibited a slightly higher mean elevation in venous
blood ammonia in the exercising arm immediately after exercise, the
difference between the three groups is not statistically significant.
Although most subjects still had an elevated venous blood ammonia
level in the exercising arm at fifteen minutes after exercise, in one
or two subjects of each group the venous ammonia concentration had
returned to the pre-exercise level. At fifteen minutes the mean venous
blood ammonia in the exercising arm was not significantly different in
the three groups.
The results for the resting arm in the 100 "power grip" exercise
study are shown in Table IV and Figure 5- The mean venous ammonia values
in the resting arm immediately after exercise and fifteen minutes after
exercise were not significantly different from the pre-exercise values.
This experiment indicates that when the forearm was exercised to
fatigue there occurred a large but variable elevation of the venous
ammonia of the exercising arm, but there was no significant change in
venous blood ammonia in the resting arm. The similarity of the response
to fatiguing exercise in the three groups as opposed to less rigorous
exercise suggests that cirrhotic patients liberate ammonia at lesser
degrees of muscular exertion. When the exercise is carried out to the
stage of fatigue, however, both cirrhotics and non-cirrhotics respond
identically.
Arterial-Venous Ammonia Values
In three control patients and two cirrhotic patients venous blood
ammonia levels were obtained from the exercising arm before and immediately
after 100 "power grips.” Simultaneous arterial samples were obtained from
.;joudv ni aol J r.ve.:. ■■ a' ft i&rfelri fi fcfttlri trix« 011013 ©iforivtlo
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- 15 -
Table IV
Venous Blood Ammonia in the Besting Arm Before and After 100 "Power Grips"
Normal Subjects Before Exercise After Exercise 15 Minutes .
1. S.A. « « w 172 ...
2. M.S. 153 178 166 3- A.P. 165 187 I65 1. A.S. 176 196 5. J.D. 183 178 201 6. P.M. 220 208 160 7- T.A. ll2 ll2 135 8. S.N. 153 113 121 9. J.O. 13^ 132 111
10. H.C. 118 111 « •«.
Mean ~l&2 167 157 S.D. ±32 ±33 ±22
Control Patients
1. A.S. 111 127 «
2. K.K. 176 179 - --
3- H.W. 172 169 169 1. W.F. 180 183 I83 5. B.L. 113 108 ---
6. c.w. 161 ---
7. J.D. 15I 161 151 8. R .S. 167 116 150 9- F.G. 1I2 133 137
10. L.L. 126 120 -
Mean 151 TW T5F S.D. ±22 ±31 ±18
Cirrhotic Patients
1. H.V. ... 2. w.c. 111 150 170 3- C.M. 2l5 255 225 1. H.W. 182 181 173 5- s.s. 180 163 168 6. L.S. 101 112 137 7. 8
D.S. •T W
129 131
9. J.S. <o> aa am
10. S.P. - aa,
Mean 171 175 S.D. ±17 ± 51 £ 28
VI eltiflT
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FIG. 5
Venous Blood Ammonia in the
Resting Arm Before and After IOO Power Grips.
Normal Subjects
200-
Mean
NH3
100- per
100ml.
Control Patients Cirrhotic Patients
□ before exercise Y7[ IMMEDIATELY AFTER EXERCISE
15 MIN. AFTER EXERCISE
o
{
( } )
)
) (
(
- 16 -
either a brachial or a femoral artery. The results are shown in
Table V. After exercise the venous ammonia levels rose significantly
in each patient as has been shown in earlier studies. The mean elevation
in systemic ammonia measured in arterial blood was 11 jagm$ which is
within the limits of experimental error for the ammonia determination.
The 8rterio-venous difference in blood ammonia after exercise ranged
from -66 to -15l|ugn$ but did not correlate with the pre-exercise
arterial or venous levels. In these five patients a marked elevation
in peripheral venous ammonia from the exercising extremity was demon¬
strated without significant change in the systemic arterial ammonia
concentration. It is conceivable that the slight rise in arterial
ammonia concentration which occurred in two of the patients resulted
from the high ammonia concentration of the venous blood from the
exercising arm.
Effect of Acetazolamide
Nine cirrhotic patients in whom the effect of exercise was studied
were restudied within one week to evaluate the effect of acetazolamide
(Diamox^) on this phenomenon. Two hundred fifty milligrams of Diamox
was given orally 13 hours prior to exercise and two hundred fifty
milligrams of Diamox was given one hour prior to exercise. Venous blood
ammonia samples were obtained in the exercising arm before and immediately
after 100 '’power grips.” The exercise response of these nine cirrhotic
patients with and without Diamox is shown in Table VI and Figure 6. The
mean venous ammonia level before exercise was not significantly different
after the ingestion of 500 mgm. of Diamox than it had been previously.
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- IT -
Table V
Arterial Blood Ammonia Before and After 100 "Power Gripe”
Before Exercise After Exercise Change
1. R.K, Control 96 119 23 2. *L.A.
11 246 273 27 3. W.D. f!
123 128 5
4. J.S. Cirrhotic 129 131 2 a ✓ • W.P. 11 182 179 - 3
Mean 11 S.D. ±13
Venous Blood Ammonia in the Exercising Arm Before and After 100 Power Grips
Before Exercise After Exercise Change
1. R.K. Control 121 298 177 2. *L.A . ft 190 310 120
3. W.D. 11 119 210 91
4. J.S. Cirrhotic 139 207 68 5- W.P. ff 143 291 148
Mean 121 S.D. ±43
Arterio-Venous Ammonia Difference in the Exercising Arm Before and After 100 Power Grips
A-V diff. Before A-V diff. After Change
1. R.K. Control - 25 -179 -154 2. *L.A . If
56 - 37 - 93 3- W.D. H 4 - 82 - 86 4. J.S. Cirrhotic - 10 - 76 - 66 5. W.P. 11
39 -112 -151 Mean -110
S.D. ±35
* L.A. had ingested 3 grams of HH.C1 45 minutes prior to this study.
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- 18 -
Table VI
Diamox Study
Venous Blood Ammonia in the Exercising Arm Before and After 100 ’’Power Grips”
Cirrhotics without Before Exercise After Exercise Difference Diamox
1. w.c. 135 258 123 2. C.M. 276 330 54
3- s.s. 197 275 78 4. L.S. 116 232 116 5. J.S. 139 207 68 6. D.S. 104 305 201 7. J.W. 130 310 180 8. J.K. 167 313 146
9- W.P. 143 291 148 Mean 156 "280 124" S.D. £55 ±42 ± 40
Cirrhotics after Before Exercise After Exercise Difference 500 mgm. Di8tnox
1. W.C, 145 261 116 2. C.M. 256 285 29 3. s.s. 215 225 10 4. L.S. 151 370 219 5. J.s. 161 235 74 6. D.S. 108 269 157 7 . J .W. 147 314 167 8, J.K. 211 324 113 9. W.P. 138 281 143
Mean 170 “285 115 S.D. *48 ±59 ±65
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FIG. 6
Venous Blood Ammonia In the Exercising Arm Before and After
100 Power Grips.
Cirrhotics
300-
Mean
NH3 /xgm per
100ml.
200-
00-
Cirrhotics "Diamox"
| | BEFORE
^ AFTER*
{
i ) )
(
(
) )
- 19 -
Neither the exercise-induced rise in blood ammonia nor the mean base¬
line blood ammonia level was altered by the administration of 500 mgm.
of Diamox. It is interesting to note that although there is a wide
individual variation, the elevation in venous ammonia following exercise
was quite reproducible in the same patients with and without Diamox.
Although one patient (D.S.) developed a transitory flapping tremor five
hours after the second dose of Diamox, a repeat venous blood ammonia at
this time was only 148 M-grafif>. Diamox apparently had no significant effect
on the peripheral release of ammonia after fatiguing muscular exercise.
Hydrogen Ion Concentration, Oxygen Saturation, and Electrolytes
In a series of five control patients and four cirrhotic patients
venous samples were obtained for blood pH, oxygen saturation, and serum
electrolytes before and immediately after 100 "power grips.” The results
are shown in Table VII and Figure 7-
A.11 subjects showed a fall in venous blood pH following exercise.
The mean blood pH fell from 7.40 to 7.28. This change is statistically
significant with a P value of 0.01.
Six patients including the five control patients showed a decrease
in oxygen saturation following exercise. In one cirrhotic patient (W.P.)
it remained unchanged, and in another cirrhotic patient (J.W.) it became
elevated. The mean venous oxygen saturation fell from 66$ to 55$. This
fall is statistically significant with a P value of 0.05.
All of the patients showed a rise in venous C0? content following
exercise. The mean C0?content changed from 23.0 to 25.1 rnEq/l after
exercise. This change is statistically significant with a P value of 0.001.
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20
Table VII
Venous Blood pH, Oxygen Saturation, and. Electrolytes in the Exercising Arm Before and After 100 ’’Power Grips’’
HYDROGEN ION CONCENTRATION
Subject pH Before pH After Differen
1. L.L. (Control) 7.40 7-37 -.03 2. H.C.
!« 7-3 8 7.22 -.16
3- w.s. ft
7.40 7.34 -.06 4. J.D.
ff 7-38 7.32 -.06
5 • W.D. tt
7.38 7.32 -.06 6. J.S. (Cirrhotic) 7.^5 7.22 -•23 7. D.S.
ft 7.44 7.25 -.19 8. W.P.
tf 7.^0 7.25 -.15
9- J.W. If
7.41 7.23 -.18 Mean 7-40 7.28 -.12 S.D. ±.03 t.06 ±.08
Subject
OXYGEN SATURATION (Vol. per 100 ml.)
^2 Sat. Og Sat. Difference Before After
j •
4.
5-
6. 7. 8.
L.L. (Control) 52.1 H.C.
ff 77.6
W.S. ff
69. J.D. If 60.9 W.D.
ff 68. J.S. (Cirrhotic) 82.6 J.W. ff 58. W.P. »!
62. Mean S.D. ±12.
44.8 - 7-3 56.3 -21.3 53. -l6.
45. -15.9 64. - 4.
52.5 -30.1 64. 6. 62. 0. 55-2 -11.1
±9. 112.
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21
Table VII Continued
SERUM SODIUM (mEq. per liter)
Subject Na Before Na After Difference
1. L.L. (Control) 141 142 1 2. H.C.
If 140 144 4 3. W.S.
11 138 140 2
4. J.D. II 134 140 6
5- W.D. n 138 140 2
6. J.S. (Cirrhotic) 136.5 138 1.5 7. D.S.
Iff 126 128 2 8. W.P. Iff
132 132 0
9. J.W. Iff
137 137.5 0.5 Mean 135.8 137.9 2.1 S.D. ±5.6 r 5.2 ±2.2
SERUM POTASSIUM (mEq. per liter)
Subject K Before K After Difference
1. L.L. (Control) 4.75 4.50 »0.25 2. H.C.
Iff 4.25 4.25 0.0
3. W.S. Iff
M ^•5 0.2 4. J.D.
11
4.5 5.0 0.5 e; ^ * W.D.
11 4.25 4.5 0.25 6. J.S. (Cirrhotic) 4.5 4.5 0.0 7. D.S.
11
3.3 3.4 0.1 8. W.P. 19 4.5 4.5 0.0 9- J.W.
11
1-3 M 0.0 Mean ~1.29 TT38 0.09 S.D. ±.55 ±.46 ±.02
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22
Table VII Continued
SERUM CARBON DIOXIDE (rriEq. per liter)
Subject COg Before C02 After Difference
1. L.L. (Control) 24.8 27.9 3-1 2. H.C.
If 22.2 26.0 3.8
3- w.s. 11 22.5 23.5 1.0
4. J.D. ff 23-6 26.1 2.5
K > • W.D. tf
24.1 25.3 1.2 6. J.D. (Cirrhotic) 21.9 24.5 2.6
7. D.S. If
25-3 26.6 1.3 8. W.P.
If 20.0 20.4 0.4
9- J.W. ff
22.5 25.1 3.1 Mean 23.0 25.1 2.1 S.D. ±2.1 £2.7 ±1.1
SERUM CHLORIDE (mEq. per liter)
Subject Cl Before Cl After Difference
1. L.L. (Control) 102.8 102.8 0.0 2. H.C. 106.9 102.9 - 4.0
3. W.S. 92.3 92.7 0.4 4. J.D. 97-6 97.6 0.0
5- W.D. 99.8 100. 0.2 6. J.S. (Cirrhotic) 102.9 102.7 - 0.2 7. D.S. 109.5 107.7 - 2.2 8. W.P. 94.7 94.9 0.2 9. J.W. 93.8 94.0 0.2
Mean 100.0 99.5 * 0.5 S.D. ±7.3 ^6.7 ±1.4
-
6 uailncO X. \' vie sT
' i j . :J : •... x.
OOflKM 6-lOtQg s!.,) :*• jy i: .
(Icin'' ) . ; • u.
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c.x M'S e.":c; II
. . - ■.
X.dS . t
Si . X F. *3 X. 49 11
. . w
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. . " ■ V
c.o r . . X .?■
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C.O . y;. .oo: G. X'V . . ■’
T.'-.OX • . SO ( no.)
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FIG. 7
mEq./l
mEq./l
Venous Electrolytes, pH, and Oxygen Saturation in the
Exercising Arm Before and After
100 Power Grips.
! )
J
1
) )
- 23 -
There was no significant change in serum sodium, potassium, or
chloride following exercise. The slight changes in these parameters
are within experimental error.
Serum Glutamic Oxaloacetic Transaminase
In a series of three control patients and three cirrhotic patients
serum glutamic oxaloacetic transaminase (SGOT) determinations were done
on venous blood from the exercising arm before and immediately after
100 "power grips." The results are shown in Table VIII. Although two
cirrhotic patients had baseline SGOT levels above the normal limit of
40 units, no significant change in SGOT was observed in the venous
blood following exercise. The differences observed are within the
experimental error for the determination.
Serum Magnesium
In four control patients and three cirrhotic patients serum
magnesium levels were obtained on venous blood from the exercising
arm before and immediately after 100 "power grips." The results are
shown in Table IX. No significant change in serum magnesium concentration
was noted following muscular exercise.
Discussion
The significance of the liberation of ammonia by muscular exercise
is not clear. It has been observed that in the resting state the peripheral
arterial and venous ammonia levels are in equilibrium or show a small
uptake by the tissues of the extremities. With muscular activity large
amounts of ammonia are released Into the systemic circulation. It must
o,7 - . ul o (straps a.c wjfrst&do itaeo .Richie ©tt went 'isriT
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- 24 -
Table VIII
Serum Glutamic Oxaloacetic Transaminase in the Exercising Arm Before and After 100 "Power Grips"
Subject Before Exercise After Exercise Difference
1. E.B. (Control) 31* 3^ 0 2. W.D.
!I 12 12 0
3. F.R. It
13 15 2 4. L.S. (Cirrhotic) 34 36 2 5. D.S.
It 100 100 0
6, A.C. If
58 63 5
Table IX
Serum Magnesium in the Exercising Arm Before and After
100 "Power Grips"
SERUM MAGNESIUM (mEq, per liter)
Subject Mg Before Ex. Mg After Ex. Difference
1. C.W. (Control) 1.8 1.8 0.0 2. W.D. 1.8 1.8 0.0 3. L.C. 1.9 1.8 - 0.1 4. L. L. " 1.7 1.7 0.0 5. S.S. (Cirrhotic) 1.6 1.6 0.0 6. J.B. " 1-3 1.3 0.0 7. L.S. ” 1.9 1.9 0.0
• ••
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- 25 -
be assumed that during normal daily activities the release of ammonia
during muscular activity is balanced by the extraction of ammonia by
peripheral tissues. Furthermore the liberation and extraction of ammonia
by the extremities is a relatively small part of the maintenance of the
overall ammonia equilibrium In the body in normal subjects.
These observations have several important practical aspects in
the management of patients with advanced liver cirrhosis. The first
of these concerns the value of bed rest in the treatment of liver
disease. The muscles appear to play a major role in the maintenance
of normal systemic blood ammonia concentrations when faced with increased
intake of ammonia or decreased hepatic capacity for its removal. The
uptake of ammonia by the peripheral tissues has been shown to occur in
both normal subjects and in patients with impending hepatic coma, as
systemic venous ammonia levels rise. This extraction of ammonia by
muscles has been interpreted as an attempt to maintain normal systemic
ammonia concentrations (7,10). When the capacity of the peripheral
tissues to take up ammonia is surpassed, terminal hepatic coma appears
to develop. Since muqcular activity is accompanied by the release of
ammonia into the systemic circulation, superficially this implies that
muscular exercise may be harmful in liver disease, in general, and in
impending hepatic coma in particular where small additional increments
of ammonia may be quite toxic. Until there is a more complete understanding
of these phenomena, it would appear wise to employ complete rest as part
of the regimen of therapy for impending hepatic coma.
The observation that even insignificant degrees of exercise may
release large quantifies of ammonia suggests the use of certain precautions
i aaftfiTltfoidB v.i; *50<i • / • • f
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ie.faJta v . « . ua . b J b
.. ;<tJ s . v,;w a. .'. : -:r one . fine-■■Tin:- t-coj.-n Din:-., lav,* J rvoion 10
; • < ■ • I. • ■ ■ j n
■f'■ f irworfs need eari i.j i :<■;I • .. - ) :,c •jj;noC!^e> lo u
• • . tt . 1 "
tnc > io olfJT . ®aJt*3c alovai
: J . a ■
. - i . ' J oa looms
. oc sg© -I - -■ /ail
‘•■v .. j . •: im>c . no ■ •: yflvtfoa isluosw - lJi . colavoi of
. . .i ; ■ • • -
jo ’• nl . -3 '!>»!: * •11 nJt lulm •rt er -..lone a •• -.ujoeu-n
■ j tl .. I ■' /■ ■ >1 .nfc ■" ■
mi rr ■ ac a r on ...-wri 1 •/ ■ . 7>' .■ 1- !•."• • • ‘ i • -.tftv "i
• j is od v rOTC.r; ■
. • o oir K r,; . , ' - c ; >; -.r r i '.o i > laei oof io
' o )•. ... j • ..'{i;.,! oil ;i va jtv' noi vm .ro ri ?
ao J. u *r rtJrj- ') io nu .•■1 ~.?seww-. -Inormr i j o M.tli'up ogisX
- 26 -
in the withdrawal of venous blood. The patient is frequently requested
to clench his fist repeatedly in order to facilitate the filling of
peripheral veins. Since as few as 50 fist clenches can cause significant
elevations of the venous ammonia in cirrhotic patients, such exercise
must be assiduously avoided. Although some investigators have recognized
this artifact, it is certain that it has not been universally appreciated.
It is interesting to note that one group of workers who noted surpris¬
ingly high venous ammonia values in newborn infants, attributed these
results, at least in part, to the activity of the infants during the
collection of the blood (28).
The data presented in this study confirms earlier work which
demonstrated increased ammonia levels in the veins which drain exer¬
cising muscle. After mild and moderate exercise cirrhotic patients
showed increased ammonia content in venous blood immediately following
exercise compared to control patients. After more severe fatiguing
muscular exercise, however, the elevation in venous blood ammonia was
similar in cirrhotic and control patients.
The explanation for this difference is unknown. It is interesting
to speculate that in the cirrhotic fproup of patients who had a higher
mean blood ammonia concentration, the ammonia binding sites of the
peripheral tissues were more nearly saturated and might liberate ammonia
more readily than in normal subjects. Certainly in patients in hepatic
coma arterio-venous ammonia differences increase as the arterial ammonia
level rises until final decompensation develops accompanied by the
release of ammonia from the extremities (10). This has been interpreted
to mean that the complete saturation of the peripheral tissue capacity
jj, :,u,; - - in l moltad'T .hocLti ww-v "o s-i ni
5.11X11 ■ tlJtOBl Q ■ tti
: i ' ’ ’ <* 1' - '
• ■: ' ■■ ■ ' t l J 1 :
■ ,t<&u*ovixl aaoe fauoteik . • ^
. bet<■ tstyixiqs- iwtau aeac lent : • ' it tssii r ; .*voo si "i -■■iil’xe 3irt't
. . ■ ■ 9 ■ -n a.ttwmta - ‘
j ta ni mo a til ' ' - 1 u
• . - • ' •
. {>• ,) r,ooi . y ' ) ncjinniioo
in* ••• •■ ■..' -ioi.L'i!-i ijJWilnoc s*-'* nl i-**0**' 'i": eril
• . p. . ' . flft » •• - ' •'
, : , -; ► &i i ■ ■ • - ■’ '
. . io't V. ,:.<Dold -uo.n v n.t tfnrrfnos :i.nom.P U awnt :
• . , # ' I ■ ' - •
, ,• , ... ? vmH^A trttioi©xe -xaiiiDetfB
. jtfn.io-ag io*xia > .n* ol Joe-nip ui .u.-i.
. _ • aaoatkm - - ■ : ■ - j ;l ; - 1
. -.vo-:--;; *iit at <t*f& " 0*
jaJ- )c jtia •^ni.fertid einoofflB aril tooXv arihiaoao sinofl:m.B fiooXcf a^as
■ - ■ a ■ • ■ ; *
at Kta,lt*q. at i±atet-seO .et06{,r.u-. . stfln.cn at art* xLllxvi worn
x i-r j , rtt kb .^Beaaai ®oc-fi*n..>rUfc Blncaw® anonev-oi'sojfn a®°°
< D ■ ’ ' '
C«x) $ ' "TC
xcM: ,c *u, *lt i-ioriciioc ocU lo ncltf^ulPn aiU lari? n«« o/
- 27 -
to bind ammonia has occurred. Since most of the ammonia determinations
in this study were performed in the postprandial state, it is conceivable
that the peripheral sites might be more nearly saturated with ammonia in
the cirrhotic group. Unfortunately, this study does not directly answer
these questions.
Some of the results observed in this study may be accounted for
on the basis of the abnormal flow patterns which occur in cirrhotic
patients. Palmar erythema which is frequently found In cirrhotic patients
is thought to represent arterio-venous anastomoses in the hand. Silverstein
first showed that the abnormally low arterio-venous difference of oxygen
saturation in cirrhotic patients with palmar erythema could be reverted
to normal by exclusion of the hand from the forearm circulation (29).
Fisher and coworkers confirmed these studies and demonstrated a decreased
arterio-venous ammonia difference in cirrhotic patients with palmar
erythema (30). After exclusion of the palmer circulation in these patients
the arterio-venous difference returned to normal. Exclusion of the hand
in cirrhotic patients without palmer erythema, however, resulted in no
significant change in oxygen saturation or ammonia content. Presumably
during exclusion of the hand, arterial blood passes through the capillary
bed instead of directly entering the venous system through the arterio¬
venous shunts In the palm. Thus the arterio-venous shunting of blood
"around1’ the muscle tissue might result in higher post-exercise ammonia
values in cirrhotic patients with palmar erythema than in other subjects.
This difference might possibly explain why cirrhotic patients appear to
liberate ammonia at lower exercise levels than do normals.
ejbn ■ rife) t> tl-ocj , wt * «t * wm o?
.. , ; ■ • Ti sinJ (it
Hi slaeowe eica -'.o yri^JLa u*i ifetaec ^'
.i(,v .fj,. <m±Sw 1 lea eoob -■* :* t\Le&*<w&to\c&} .qirc-s* oiioifTxio edl
. in J: :i: •.• r ." t
. . . , . I J ■ ' " • : •' : 0
. ■ • • •...•• v. . •: ■■■ -
,.m i, ■«: olJoitolo ai ten** imttpvii i .w*ti*y,r<s imlrt .Bitaottoc
-
n .. , x > •( • ■»atne**.£f> ^yoa&v-oiTs.t'ta vol tllittivtad.t s> * 1 tav-. r!.. l£"i. i
jt> •/:» imls? tin * sSa»it*q i : ■ . w&inutfa
■ J .-'■••
-_■ . • aft • •,, no i .. >n i t ' ■ ■ " *6 " '*■ ,i!
to _
• ••' rrotsaiol* 'ial'iA .(Of) fisodlx*1^
0 j a eanoieftli £> euoaev-
en n ‘ ftojiu: o-x t<xavstfod t nw^dlv/io *XJ5smisc * ••rorflelnoltsc otJcdTrxio n*
,n . ■ . ■ - - • «*&> ^Dliin^ta
v-i ilic r> erSl (fetroirf* 33onsq ioold ttei'*i ed* ’it notai/Iox© aol-su*
• n . ancfrev - ©ill SQi-V. *:v> %L&**>lU ' .. .
j a |aa fcrt^M ' ■ • ' ttpm
. t. ,. : j..um Irifciiw ©weelJ il&Um
a t ' ■•" ' - ■• ' ' ' ': ' *
r 7 ~ . ;:r •• ;-«w: r -cj -.Ut 'vilo >ytir n.'*’I:;xv \.i.d±*• =?o<? irtixu eonvv-.ittx ai. 1
. lftcnon :-.ft nartl aj.*v*I : i -^x, vnroi 1 tOtom* oStn^SU
- 28 -
Only six of seventeen cirrhotic patients studied herein had
palmar erythema. In these patients there seemed to be no correlation
between the presence of palmar erythema and the degree of response
of blood ammonia following exercise.
It is of interest that Abelmann and Hutcheson were able to demon¬
strate greater peripheral blood flow in the lower extremities of
cirrhotic patients both at rest and during exercise (31)* A rapid blood
flow with increased arterio-venous shunting might have several effects
on the ammonia content of venous blood after exercise. In addition to
the effect of shunting arterial blood directly into the venous system,
other possible effects might be postulated. A greater blood flow might
dilute the ammonia liberated after exercise and actually result in
lower venous ammonia values than would occur with equivalent exercise
and a smaller total blood flow. Since it has been observed that maximum
elevations in venous blood ammonia may not occur for several minutes
after the cessation of exercise (*+), the rate of blood flow may be
important in determining when peak elevations in venous blood ammonia
appear in antecubital venous blood. Certainly blood flow measurement
would be helpful in interpreting the results observed in this study.
Some authors have suggested that there is a direct relationship
between the oxygen saturation and the ammonia concentration of blood.
Iber and Chalmers oxygenated venous blood in vitro and found significant
rises in ammonia content (32). Faloon and his associates demonstrated a
rise in blood ammonia, after passage through the lungs, which again
suggested this possibility {33)• However, recent evidence by Beartl et al.
indicates that oxygen saturation per se does not directly alter the ammonia
of blood (3l).
ni -■ : j . i t : r ' i d 1 ;o ' n
i j;j-,r ic: '.a a o.. • -r: xij ..da .'.trc n. . ’X'wi.sq
. ...JC. ;v> nr (B riTi’.'i !’q :o o-.rr.. >C:*tq o :i v\/ic
. : ..ai'v - : ••• r< U.
-aoi»»i) od :■<i c ’> cxiW croi ••foljuE In.8 nnwiXatf^ dn/:d '-‘.el ai to si dl
■ ... ©darrda
. ( : -i.
• - ■ . . vast t -1
•j noidii -i. . - io- jr*>oit o • ' d dnoo -rtf no
. P aXStmdB \o ®£d
i j . d Li. . . ■ . j . . . -
■ r. i ■ . ' if
. : , ,J. ■ iuew 1! ,1J rJ- Wt ' 1. ’ ' •
• , - ■ " v- :
• e&SQffltt» t>:;oj.cf swone* Si -r.ncidr.v p
ac von cooid do vJ«•. arid- ,(A) wivs**© 1o noidnaaao .rid Pet’ka
- ■ - _ ■ ■ - ■ . Way Ri "
il n ili • & stride' * edn t fiJ 1 • - • "
i-tinoidfi to&tlk s <»1 ®*©fid d b-od •:• <2S$8»© ©v&ri t-sorida* as»3
•to noia -dn. - its • as aoidowdea n^xo o.*t flMMtstf
_ ;j • • r ; • ;.auo'.t .or o*sdiv atx . ksjobov od.eaie5i.vtc a'Jeoues.iO
a be • idancfflei oedriooeeu elri Jar .( ) dfl«dno^ ai ©Mi*
B : . lilw % :.y:nul l'd tX'-.uo'srld *K»dt * , filnom&ns .■.•■ oir ni -■• - *
j-. ;. . . • *0 •i • ( .* ) .■.J' liidl&f.'OC oi*\d •'
.rid *. j.. >■ v.Idoo'.tifc "on e -b yo *«jq tioidc*5.;;ds0 ae^^xc d'•’•rid ©edcolyni
. (Af ) .ool-.i 'to
- 29 -
There are broad variations in the venous drainage pattern from
the muscle mass in the forearm. It has been estimated that at least
80$ of the total blood flow in the forearm is from muscular sites (35).
Local exercise increases the blood flow in an extremity, presumably
due to vasodilatation of vessels chiefly in muscle tissue (36). Much
of the blood from the muscles joins the superficial venous system
through a large communicating vein at the antecubital space. Although
the composition of antecubital venous blood varies according to the
proportion of blood from cutaneous and muscle sites, this factor has
been assumed to vary in a random fashion.
Systemic arterial ammonia levels did not change appreciably
immediately after exercise. This stability of the arterial blood ammonia
in the presence of considerable peripheral release of ammonia suggests
a rapid dilution or clearance of the released ammonia in the five sub¬
jects studied. In this regard, it is of interest that the venous blood
ammonia level in the opposite resting arm did not increase significantly
in a series of subjects after severe exercise of a forearm.
Diamox, which has been implicated in the precipitation of hepatic
coma, has been shown to block the peripheral uptake of ammonia by
peripheral tissues tk the extremity (22). This observation suggested
that the carbonic anhydrsse inhibitor Diamox might also alter the
peripheral release of ammonia following exercise in cirrhotic patients.
In this study Diamox had no demonstrable effect on the peripheral release
of ammonia following exercise.
Changes in other parameters such as venous pH, oxygen saturation,
electrolytes, serum glutamic oxaloacetic transaminase were measured
-
,:0*.; ,r. eni-'ll :.y -nov Adi .ni sxmi-J ex**.".? o• •- v. o •*>
- , j «,:•! > tK,™ -tii i.j^botio! mf ni. z&m •-loearo ad*
... . • . . yf ■ ■ ; : . ■ 0 . ’■ ■ $g i &
Y> . y ,. # jtm-nJx* an at woII fcoolrf erf* e'aaeOToni oai:•■■»« -^oj
fi .{, ) ,,u; li •».' JtuMf o.i Utelrfo «?xoHS,.v lo ijclTf,r*iii3oe®v.o* aui
. .1 1 .' M — ‘ 1
nia ttt * * 1
. , - ■ ' ■ • ■ ' !
f. .. .,■■;■ . i;.j• . -j-•.!:• u.-j auoex7£‘*wo MO-ft O' .0 n>Ltocg-;:
:■ . r •' * ni 'v oi i? r -
r ■ ■ ' ' ‘
. „ ■ . - / . ‘ ' '• '
in ■ to . .* !»• - H " ’ : ®J
, t ■ t A. - ° « ■ '
,oid ircnev «<u Jarf* i*.vx*:?ai to si *i t *W* al • ; **&**■> a?0®t
:■ - ' '■ « J :; ’
• , . ' - -. • J ■ ■ ; u ' ' ■' ® •’
; j .(( *xc aoi7-’JloIvomo &■•:■■> ni Owod e’cl *.i *iriw
.. *1 .. ** -■ mi ■ •-
■ °-
e 7 ,J.« 9 tdHJt" so-IT Slid **«i tot dUlOttBO ,,,t ***
uorfnto ni •fttDf- *e gnivc.i.l Lx.®." to 8W^1
■ , - , ; B ' ■' * '
jg.j -7*7e; i.j .aivolioi .’in .••flan# •>
.n,.*t,- . n .\.:;o , ■ w*,. « t1™*- WW ni <■
,■ ,.,V oeootawamd old > u' tnta ,a»*xiC^=^
- 30
before and immediately after exercise in order to acquire data which
might shed additional light on the significance and mechanism of the
peripheral release of ammonia with exercise.
Venous blood pH decreased immediately after exercise in all
patients in this study. It has been suggested that blood pH may be
Important in the toxicity of ammonia (37, 38, 39). Ammonium salts are
thought to be more toxic in the presence of alkalosis due to enhanced
permeability of the blood-brain barrier to ammonia. In addition, in
alkalosis the venous ammonia may be relatively low In spite of high
arterial levels due to Increased tissue uptake (39)* In acidosis the
reverse holds true. Recent studies by Stabenau et al. have demonstrated
the importance of the pH gprsdient between the blood and the intracellular
tissue in the distribution of ammonia (10). Their investigations confirmed
the theoretic concept that ammonia tends to diffuse from the more alkaline
to the more acid compartment. In view of the relative intracellular acid¬
osis of muscle during and after exercise, it is apparent that the observed
changes in venous ammonia concentration could not be explained by the pH
gradient alone. It seems apparent that large amounts of ammonia are
actually formed during the energy-yielding reactions of muscular activity.
The venous oxygen saturation was observed to fall In six patients
immediately after muscular exercise. Two of the cirrhotic patients did
not exhibit a fall in oxygen saturation after exercise. One of these
patients (W.P.) had significant palmar erythema. It seems unlikely that
changes in venous oxygen saturation per se explain the rises in venous
ammonia found immediately after exercise. Nevertheless the relation of
• -: - tlflgl < - i [jsnoiJlH>a 6eris iibtlw
, ■•» *tr:e :'jr ±r»< H 1Vi'S ’C
,; *j • 2 y; . : : if ' Q t< • : ’ J'
■ c <,o : r Mr ro. m>-•' • <* *1 -Y.'^ >*«** «£*noi*.*K.
I ■ ( . ) 1
,- nil. n. ,;•)• i; '•■ oij .y j fjO'T-. e 5'ic 'i i ni oix'.t oi / yjoili
n<j . /•■; t • ; ■ -•■' ni anf*- booitf to
j ... rjj; - ^..gvUf id y. ■ Inoah* -;.icn?v o/.i i- o.i
l,r0oi . ( ) ewtsiJ bseftenoni oJ- 6wl
..• sne« I • J '•
. ■ ri' i oid or 1 aBewted :>«■ *•.:••••• Sc . ■> j- -
• ■ : ) j- .' ■ ■ W ■ tmmM
- r ■ . if til ;; •; (6c i ' 1 • ' • 1 - ' °®d'
a t . ■ • . ft* a tlUXBfr ion • - 0:
... * • a®
i• ;,ri .;on - 1 ':o • . 0 • • • . •'
• . , SfOfB ■ .i ■ ’■-■•' • ' ■
i i 1 ■ ' t% . r Mfc* - - •
h ' < ' . o I. J /•■ , ' J ' ■ . OOI1
. , . H - F>ei£>*s»x,p iriuvcan
j ',o jfi . -e io'iaxo Tytt p noi.tcic/Be n ’oc^o ill 1*- -l s fditixw ten
j ncr j ■ (■ • )
r.; 1-: t j riliHcxo >v noit-nui^e fl®|j . ;i
, , i esD ? ■ . - ™° ■ ■
- 31 -
oxygen supply to the production of ammonia by muscle tissue is important
and will be discussed later.
Venous blood CO..., content increased immediately after exercise in
all patients as was anticipated. There were no consistent changes in
venous sodium, potassium, chloride, or nngnesium following exercise.
In order to investigate the possibility that ammonia might be
released from muscle sites by the process of transamination, SGOT levels
were studied in venous blood before and immediately after exercise. No
significant changes were found.
A mechanism for the elevation of blood ammonia with muscle contrac¬
tion was worked out by Embden and Farms beginning in 1927- Embden
discovered the substance adenylic acid in extracts of frog muscle at
rest (2). After muscle contraction he found a decrease in adenylic
acid and an increase in inosinic acid. He suggested that adenylic acid was
deaminated to inosinic acid during muscle contraction with the concomi¬
tant liberation of one mole of ammonia. Embden thought that the ammonia
remained in the muscle for reamimtion during the during the resting
phase.
Perms and coworkers established that ammonia escapes into tissue
fluid and venous blood following muscle contraction (3). In addition he
found that muscle forced to contract to the point of fatigue gave off
an amount of ammonia exactly equivalent to the amount of adenine nucleo¬
tide converted to inosinic acid (ll). However, he found that muscle forced
to contract occasionally under conditions which avoid fatigue liberates
more ammonia than can be accounted for on the basis of the above trans¬
formation. He concluded that the extra ammonia was derived from adenine
nucleotide which had been regenerated between experimental contractions.
irr r cocci d u ... U ■■tncm-'i to nc tJ-. uIonq rM ct \Iqcur a ;ruc
,'J t. J iv 3C>fC jt.r ei J. .Civ
ri» •_ ■ -i v,i t I. a.fwjt -O. .•. ii .tn-'Jnoo iJ toolc zjcctoV
r. Bflt 0 on eiev ©ierfT . be*«crl?Jbtnfl a** an etaaidaq XI*
■ • tsu ‘ • < . «‘ >
,( ,• - .in-. -Xootw< Xr :* o* iei/r.o al
j _c, 2 .J gji ■ ,. ■ i " BlflWB '• ; ’• .
)W © WOW * ai *13W
. a.-.- t >* v; ;o%'rr d ;/a ol i resli
.. J.Q ]’w Blaoatta ■ > • ■ ■>■ ■ n .■
r • . - • «d r- ; erf?, ru ; Y,( Xuo tK-. -eov «? w noi;
. .• T - S -x © nJ t >1 BU • ' ; ■ " • ** ' ' w '
■ .,. : ... • x 3 m 4 .(s> #er
• 3 ire © laieofl. al w* al i *
.. i . if1. . ^ j ij'Lw n ./m.dio-'.rJ6i -rtltub ' tes? .’nlsont >' X b©^ ?alflje&b
- , MB • " ' •' ' •:
■ .. - .. - ■ : 00 X ■ • ' a’: ■'
.©S^riq
c fl . ■ • • n
r, ( s n J c i Bln £©* * ° r n
V;o sir , .w«.XJ<r *io Jnloa ©rf* cX to^aoo o* be *>1 eloeiw tedl baaoi
v \ nxn'je : ‘to jm ©rf* oJ tnoisvliiys VHinow;*?. lo tnu-.v: ■ n-
x . ■ -
■ s fclov ■ ■ iiil«© ■ » tw -* -
, 1 ,v . ■ ■ ' ' .- 1 xnu • f 'J
■•iJ-n • lire* ; i >vX*t0b r'-w elaonano miy.Q ^ri-X ubtuLoaoo ©H .noi’lxwiol
a.lj-) -.Xaos i ;n «:ivyk© neowXed hot ..lenev©1 need btn ci-idv sbitoelotm
- 32 -
Parnas and his group found that substances like iodoacetlc acid
and sodium fluoride which are known to inhibit the anaerobic break¬
down of glycogen to lactate increased ammonia production from isolated
muscle preparations after exercise and decreased lactate formation (h2).
Parnas suggested that a failure of any part of the energy producing
part of muscle promoted the increased deamination of adenine compounds.
A summary of current concepts about the enzymatic reactions involved
in the transfer of energy for muscle contraction may clarify these
relationships (h3). The conventional symbols* for high energy phosphate
compounds will be used throughout this discussion.
ATP is thought to be the immediate source of energy for muscle
contraction according to Reaction I.
I. ATP --* ADP f- Phosphate
Muscle is unusual in comparison with other tissues because large amounts
of energy must be delivered almost instantaneously. The amount of ATP in
resting skeletal muscle is insufficient to last for more than one half
second of intense activity. Consequently the muscle is endowed with
two well described mechanisms for the rapid regeneration of ATP. In the
first of these creatine kinase catalyzes the transfer of phosphate from
phosphocreatine to ADP to allow the resynthesis of ATP according to
Reaction II.
* ATP -- Adenosine Triphosphate ADP -- Adenosine Diphosphate AMP -- Adenosine Monophosphate or Adenylic Acid
. ■ : ; soon , • . ' ba rr
_ . do" a j li'.ai A r ‘i'1 ii .1 A i >■ i. u\ o :..i-
; ; v , a I • F .
•• n ' if. ■ ■ . j . m
i c . •• ■ j ■ ... &*fwJLi&1 b t •riJ • tfoeggn
l . , . , : : a' ■ j fl: . 1 ■ ■ ■ • • ■ - ‘
■ - 1 i ■ J • fXI R
if:r ;, -■ v i fK .* J-r "-,:Jno- '.i oBjjWf not \yzoa* lo lelf-ar-xt al
• ( ) '
‘ i ■ - , . ti
:'i ,-\ n.'i lo sW■ &JU'itBunaiir •> o* J•»' : r> ’J ^
. ; a.- tta t*! oJ rl *scoo • nr jfc* :.jrc-tw.o
. ...
wire i }; - . i ‘ :
A XfO 'u j ■ 1 : '
, !i : i li si J** 1
j; ;ur if “ v Jyi jUi. ifciic-J ici- Jiii tuoj
j , . n j ' i • J >t 'tci • wilt
j ( ,,( ■ • .j ■ a •% I- • t- ■ $nl a-nlt■ >• j : '•
, lo ' -• f: > '.r . o i I ■ ' ■ / : . j • u
. i v nc i* -?»f.
.j- irr -.crv^l-xT '• ' — ^T>. * fjrtii 'OOi \
j-.ly.rf \ ”c j- • sqf odccrr A :i' -mt-'r-h —
- 33 -
II. ADP -b Phosphocreatine ^ ATP 4- Creatine 4- Phosphate
In the second muscle glycogen is metabolized according to the Myerhof-
Embden glycolytic scheme to yield lactic acid and three moles of ATP
(Reaction III).
III. 3ADP -P Glycogen ~c-—^ 3^TP 4 2Lactic Acid
Even in the presence of abundant oxygen the contraction of muscle
results in the production of much lactic acid. When the total supply
of glycogen and phosphocreatine is exhausted under anaerobic conditions,
ATP is degraded to inosinic acid according to Reactions I, IV and V.
I. ATP ^^ ADP Hh Phosph8 te
IV. 2ADP -* ATP 4~ AMP 4 Phosphate
V. AMI' Inosinic Acid -f Ammonia
m2 OH
m3
In contrast to Reactions I through IV which involve the transfer of high
energy phosphate bonds. Reaction V the deamination of adenylic acid is
not important in energy transfer. The significance of this reaction in
muscle metabolism is unknown.
There are some interesting experiments relating ammonia toxicity
to a decreased synthesis of acetylcholine. Torda and Wolff collected
blood serum from the working arm of humans end noted that this serum
.II
■ j l> tlJbiooo . Lodntem i . iM j <
me i-r: . L'-'-i bleJhc o.r aorefi . n
. (II noil- )
f • . ' i • . • •> S3 • ■ -
vjf.T ■ > n: :. j" • hio i? tap nur to ©ones)/CU ai at. -,3
I
■ - n • jj i . ■ aegoot
... ,noi j-.-'; • od 161000 olaieofti ol 6©fc»ig©6
U-. IT k
etBfiqBOiti - \M.< -r iuAc; . I
HinotuwA. 61 o I oiat«onl -v SMA .
o *j /• • t o' i ■ ■ J.-; - >i ioirlv' VI r- uo*-\ )• no‘ f :-■ ot trtpi.tno al
t! ' oJt-L .n©-. To noiv n.Ni 00 urfJ- V aoitruoR .elnoc! eJerfcxoxq; Haiono
fli nojtt < o >1 • 1 in i p; f1 ■ • a ;' -• r 0 1011
.ci :m-nu 1 n- Hoc I- -t oio jj.it
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t; -jj.;Q-. -I’iioW !:a!* ibiof en.tlr riolVoofi to cieonta^s 6©bp«ioo6 a ot
jtrft t 1 i • Ion * ii : ai "tnd To mif gnll£"tow exit crjoil erwi^e boold
- 3*4 -
decreased the synthesis of acetylcholine from isolated muscle preparations
which were stimulated electrically along its motor nerve (44), Ammonium
salts had a similar effect on muscle preparations resulting in a curare
like paralysis at the nyoneural Junction. It is intriguing to speculate
that the ammonia released by the deamination of adenylic acid may be
partially responsible for the signs of fatigue following muscle contrac¬
tion. Recently Ulshafer has likewise postulated that ammonium salts
interfere with acetylcholine synthesis in the brain with the resultant
production of the signs of hepatic come (45).
The mechanism of the resynthesis of ATP from inosinic acid is not
well understood. Inosinic acid probably serves as a precursor for
adenylic acid. In vivo experiments in rats show the rapid incorporation
of N'5'" labeled ammonium salts into the 6-amino group of adenylic acid (43).
Since much ammonia escapes from muscle tissue during exercise, other
sources of nitrogen may be important in the regeneration of ATP from
inosinic acid during the resting phase after fatiguing exercise.
The peripheral release and uptake of ammonia is an interesting
but neglected area of ammonia metabolism with important implications
relating to the mechanism and clinical management of patients In impending
hepatic coma. These studies on the peripheral release of ammonia suggest
many facets for further Investigation.
Summary and Conclusions
Venous blood, ammonia, content was studied following graded amounts
of muscular exercise of a forearm in normal subjects, control patients
no 11
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- 35 -
without liver disease, and cirrhotic patients. After mild and moderate
exercise the cirrhotic patients demonstrated increased ammonia content
in venous blood immediately following exercise compared to control
patients. After severe fatiguing exercise both control and cirrhotic
patients exhibited equivalent elevations in venous blood ammonia
immediately following exercise. No significant change was noted in
the venous blood ammonia level in the opposite resting forearm. Arterial
blood ammonia levels did not change significantly in five subjects after
severe muscular exercise.
Changes in oxygen saturation, pH, serum electrolytes, and serum
glutamic oxaloacetic transaminase were studied in venous blood before
and immediately after severe exercise of a forearm. There was a signifi¬
cant decrease in the mean oxygen saturation, pH, and carbon dioxide
content. There were no changes observed in serum sodium, potassium,
magnesium, and serum glutamic oxaloacetic transaminase.
The drug acetazolamide did not seem to alter the peripheral
release of ammonia in cirrhotic patients during muscle exercise.
Ammonia is released from muscle during muscular exercise from the
breakdown of adenine monophosphate to inosinic acid during the utilization
of adenosine triphosphate as a source of energy.
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- 36 -
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..a
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- 37 -
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V'
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- 38 -
26. Orange, M., and Rhein, H. C. Microestimstion of magnesium in "body fluids. J. Biol. Chem. l8£: 379-386, 1951.
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38. Lawrence, W., Jr., Jacquez, J. A., Dienet, S. G., Poppell, J. W., Randall, E. T., and Roberts, K. E. The effect of changes in blood pH on the plasma total ammonia level. Surgery 42: 5O-6O, 1957*
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1+3. White, A., Handler, P., Smith, E. L., and Stetten, D., Jr., Principles of Biochemistry, New York, McGraw-Hill, 1954.
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