U.S. patent application number 14/688400 was filed with the patent office on 2016-10-20 for medical food for patients with chronic liver disease.
The applicant listed for this patent is Michael Hudnall. Invention is credited to Michael Hudnall.
Application Number | 20160302451 14/688400 |
Document ID | / |
Family ID | 57128659 |
Filed Date | 2016-10-20 |
United States Patent
Application |
20160302451 |
Kind Code |
A1 |
Hudnall; Michael |
October 20, 2016 |
Medical Food for Patients with Chronic Liver Disease
Abstract
A medical food is provided. The medical food is configured
specifically for those having chronic liver disease to provide for
specific nutritional requirements caused by the chronic liver
disease. In some cases, the medical food contemplated herein may
achieve reversal of liver fibrosis.
Inventors: |
Hudnall; Michael;
(Scottsdale, AZ) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Hudnall; Michael |
Scottsdale |
AZ |
US |
|
|
Family ID: |
57128659 |
Appl. No.: |
14/688400 |
Filed: |
April 16, 2015 |
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A23L 33/16 20160801;
A61K 31/198 20130101; A61K 31/525 20130101; A23L 33/10 20160801;
A23V 2002/00 20130101; A23V 2002/00 20130101; A23V 2250/708
20130101; A23V 2250/712 20130101; A23V 2200/32 20130101; A23V
2250/0612 20130101; A23V 2250/1642 20130101; A23V 2250/21166
20130101; A23V 2250/161 20130101; A23V 2250/702 20130101; A23V
2250/0606 20130101; A23V 2250/0616 20130101; A23V 2250/1626
20130101; A23V 2250/7042 20130101; A23L 33/15 20160801; A23L 33/175
20160801; A23L 33/18 20160801; A23L 33/00 20160801; A23L 33/105
20160801 |
International
Class: |
A23L 1/29 20060101
A23L001/29 |
Claims
1) An ingestible composition for those having chronic liver disease
comprising: N-Acetyl Cysteine in a range of 500-5,000 mg;
Polyenylphosphatidylcholine in a range of 500-10,000 mg; and Alpha
Lipoic Acid in a range of 200-2,500 mg.
2) The ingestible composition of claim 1 further comprising at
least one of: L-Lysine; L-Arginine; Vitamin C; N-Acetyl
L-Carnitine; Betaine HCl; L-Glutamate; Turmeric; Proanthocyanidins;
Nigella sativa; Pantothenic acid; Benfotiamine; Magnesium; Vitamin
E; Cynara scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol;
Piper cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc;
Vitamin D3; Folate; Vitamin B12; Selenium; and Biotin.
3) The ingestible composition of claim 1 further comprising at
least one of: L-Lysine in a range of 400-5,000 mg; L-Arginine in a
range of 1,000-9,000 mg; Vitamin C in a range of 500-10,000 mg;
N-Acetyl L-Carnitine in a range of 250-3,000 mg; Betaine HCl in a
range of 300-20,000 mg; L-Glutamate in a range of 200-2,000 mg;
Turmeric in a range of 200-1,500 mg; Proanthocyanidins in a range
of 100-1,000 mg; Nigella sativa in a range of 50-400 mg;
Pantothenic acid in a range of 20-10,000 mg; Benfotiamine in a
range of 50-400 mg; Magnesium in a range of 50-800 mg; Vitamin E in
a range of 50-1,000 IU; Cynara scolymus in a range of 25-300 mg;
L-Glycine in a range of 50-3000 mg; Vitamin B1 in a range of 10-200
mg; Vitamin B2 in a range of 10-200 mg; Ubiquinol in a range of
30-1,000 mg; Piper cubeba in a range of 10-100 mg; Artemisia
absinthium in a range of 10-100 mg; Vitamin B3 in a range of
45-3,000 mg; Vitamin B6 in a range of 10-200 mg; Zinc in a range of
5-50 mg; Vitamin D3 in a range of 400-10,000 IU; Folate in a range
of 200-3,000 mcg; Vitamin B12 in a range of 200-3,000 mcg; Selenium
in a range of 100-600 mcg; and Biotin in a range of 50-2,000
mcg.
4) The ingestible composition of claim 1 further comprising:
L-Lysine; L-Arginine; Vitamin C; N-Acetyl L-Carnitine; Betaine HCl;
L-Glutamate; Turmeric; Proanthocyanidins; Nigella sativa;
Pantothenic acid; Benfotiamine; Magnesium; Vitamin E; Cynara
scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol; Piper
cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc; Vitamin
D3; Folate; Vitamin B12; Selenium; and Biotin.
5) The ingestible composition of claim 1 further comprising:
L-Lysine in a range of 400-5,000 mg; L-Arginine in a range of
1,000-9,000 mg; Vitamin C in a range of 500-10,000 mg; N-Acetyl
L-Carnitine in a range of 250-3,000 mg; Betaine HCl in a range of
300-20,000 mg; L-Glutamate in a range of 200-2,000 mg; Turmeric in
a range of 200-1,500 mg; Proanthocyanidins in a range of 100-1,000
mg; Nigella sativa in a range of 50-400 mg; Pantothenic acid in a
range of 20-10,000 mg; Benfotiamine in a range of 50-400 mg;
Magnesium in a range of 50-800 mg; Vitamin E in a range of 50-1,000
IU; Cynara scolymus in a range of 25-300 mg; L-Glycine in a range
of 50-3000 mg; Vitamin B1 in a range of 10-200 mg; Vitamin B2 in a
range of 10-200 mg; Ubiquinol in a range of 30-1,000 mg; Piper
cubeba in a range of 10-100 mg; Artemisia absinthium in a range of
10-100 mg; Vitamin B3 in a range of 45-3,000 mg; Vitamin B6 in a
range of 10-200 mg; Zinc in a range of 5-50 mg; Vitamin D3 in a
range of 400-10,000 IU; Folate in a range of 200-3,000 mcg; Vitamin
B12 in a range of 200-3,000 mcg; Selenium in a range of 100-600
mcg; and Biotin in a range of 50-2,000 mcg.
6) The ingestible composition of claim 1 wherein the composition is
divided into a plurality of capsules.
7) The ingestible composition of claim 2 wherein the composition is
divided into a plurality of capsules.
8) The ingestible composition of claim 6 wherein the composition is
divided into twenty four capsules.
9) The ingestible composition of claim 1 wherein the composition is
provided in a fluid mixture.
10) The ingestible composition of claim 1 wherein the composition
is provided in a powdered form.
11) A medical food composition selected to aid in a reversal of
liver fibrosis comprising: N-Acetyl Cysteine in a range of
500-5,000 mg; Polyenylphosphatidylcholine in a range of 500-10,000
mg; and Alpha Lipoic Acid in a range of 200-2,500 mg.
12) The medical food composition of claim 11 further comprising at
least one of: L-Lysine; L-Arginine; Vitamin C; N-Acetyl
L-Carnitine; Betaine HCl; L-Glutamate; Turmeric; Proanthocyanidins;
Nigella sativa; Pantothenic acid; Benfotiamine; Magnesium; Vitamin
E; Cynara scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol;
Piper cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc;
Vitamin D3; Folate; Vitamin B12; Selenium; and Biotin.
13) The medical food composition of claim 11 further comprising at
least one of: L-Lysine in a range of 400-5,000 mg; L-Arginine in a
range of 1,000-9,000 mg; Vitamin C in a range of 500-10,000 mg;
N-Acetyl L-Carnitine in a range of 250-3,000 mg; Betaine HCl in a
range of 300-20,000 mg; L-Glutamate in a range of 200-2,000 mg;
Turmeric in a range of 200-1,500 mg; Proanthocyanidins in a range
of 100-1,000 mg; Nigella sativa in a range of 50-400 mg;
Pantothenic acid in a range of 20-10,000 mg; Benfotiamine in a
range of 50-400 mg; Magnesium in a range of 50-800 mg; Vitamin E in
a range of 50-1,000 IU; Cynara scolymus in a range of 25-300 mg;
L-Glycine in a range of 50-3000 mg; Vitamin B1 in a range of 10-200
mg; Vitamin B2 in a range of 10-200 mg; Ubiquinol in a range of
30-1,000 mg; Piper cubeba in a range of 10-100 mg; Artemisia
absinthium in a range of 10-100 mg; Vitamin B3 in a range of
45-3,000 mg; Vitamin B6 in a range of 10-200 mg; Zinc in a range of
5-50 mg; Vitamin D3 in a range of 400-10,000 IU; Folate in a range
of 200-3,000 mcg; Vitamin B12 in a range of 200-3,000 mcg; Selenium
in a range of 100-600 mcg; and Biotin in a range of 50-2,000
mcg.
14) The medical food composition of claim 11 further comprising:
L-Lysine; L-Arginine; Vitamin C; N-Acetyl L-Carnitine; Betaine HCl;
L-Glutamate; Turmeric; Proanthocyanidins; Nigella sativa;
Pantothenic acid; Benfotiamine; Magnesium; Vitamin E; Cynara
scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol; Piper
cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc; Vitamin
D3; Folate; Vitamin B12; Selenium; and Biotin.
15) The medical food composition of claim 11 further comprising:
L-Lysine in a range of 400-5,000 mg; L-Arginine in a range of
1,000-9,000 mg; Vitamin C in a range of 500-10,000 mg; N-Acetyl
L-Carnitine in a range of 250-3,000 mg; Betaine HCl in a range of
300-20,000 mg; L-Glutamate in a range of 200-2,000 mg; Turmeric in
a range of 200-1,500 mg; Proanthocyanidins in a range of 100-1,000
mg; Nigella sativa in a range of 50-400 mg; Pantothenic acid in a
range of 20-10,000 mg; Benfotiamine in a range of 50-400 mg;
Magnesium in a range of 50-800 mg; Vitamin E in a range of 50-1,000
IU; Cynara scolymus in a range of 25-300 mg; L-Glycine in a range
of 50-3000 mg; Vitamin B1 in a range of 10-200 mg; Vitamin B2 in a
range of 10-200 mg; Ubiquinol in a range of 30-1,000 mg; Piper
cubeba in a range of 10-100 mg; Artemisia absinthium in a range of
10-100 mg; Vitamin B3 in a range of 45-3,000 mg; Vitamin B6 in a
range of 10-200 mg; Zinc in a range of 5-50 mg; Vitamin D3 in a
range of 400-10,000 IU; Folate in a range of 200-3,000 mcg; Vitamin
B12 in a range of 200-3,000 mcg; Selenium in a range of 100-600
mcg; and Biotin in a range of 50-2,000 mcg.
16) The medical food composition of claim 11 wherein the
composition is divided into a plurality of capsules.
17) The medical food composition of claim 12 wherein the
composition is divided into a plurality of capsules.
18) The medical food composition of claim 16 wherein the
composition is divided into twenty four capsules.
19) The medical food composition of claim 11 wherein the
composition is provided in a fluid mixture.
20) The medical food composition of claim 11 wherein the
composition is provided in a powdered form.
Description
BACKGROUND
[0001] The present invention relates to medical food compositions.
More particularly, the present invention relates to a medical food
for patients with Chronic Liver Disease specifically formulated to
fulfill specific, distinctive dietary requirements of patients with
chronic liver disease. In some embodiments, the medical food
contemplated herein may reverse liver fibrosis.
[0002] Chronic Liver Disease (CLD) continues to rise in countries
worldwide and it is a growing problem in the US in particular. The
spectrum of CLD include, but is not limited to the predominate
hepatic diseases--hepatitis C (HCV) and hepatitis B (HBV) viruses,
non-alcoholic fatty liver disease (NAFLD) with associated
non-alcoholic steatohepatitis (NASH), and alcoholic liver disease
(ALD). All of these chronic liver conditions may lead to cirrhosis
and hepatocellular carcinoma (HCC). While new HCV antiviral drugs
are effective at eliminating the virus in 90% of HCV-infected
patients that receive them, the expense of these new drugs has
limited availability in the short term. Effective prophylactic HBV
vaccines have reduced the risk of HBV in this country, but HBV is
still a worldwide epidemic and anti-viral medications are only
prescribed in chronic at-risk HBV cases. Further, while we have
made medical advances in HCV antivirals and HBV vaccines, NAFLD and
NASH are on the rise in this country. The rampant epidemic of
obesity has led to significant rates of NAFLD affecting 17% to 33%
of individuals in the United States. It is estimated that six
million people have progressed to NASH. It is currently projected
that NASH patients will soon overtake HCV patients in the number of
liver transplantations performed every year.
[0003] CLD has been the subject of extensive studies over the
decades that add to our collective knowledge of hepatic
fibrogenesis, liver disease and the various means by which CLD
disrupts metabolism. CS Leiber was a pioneer in these areas,
performing many animal studies involving ALD, steatosis, cirrhosis
and the administration of phosphatidylcholine (PC) and/or SAMe to
correct CLD-associated metabolic disruptions and hepatic
fibrosis.
[0004] In a historical context, ten years ago valuable new types of
studies called metabolomic studies were begun and started being
reported in the literature. Since that time metabolomic studies
have become established as mainstream science. Metabolomics
involves a comparative analysis of global metabolic profiles
between two or more samples. Extensive metabolomic studies have
been performed on hepatobiliary diseases over the last ten years.
Metabolomic studies confirmed the findings of past CLD studies
documenting various disruptions of metabolism, including GSH
metabolism, PC metabolism, SAMe/homocysteine metabolism, one-carbon
metabolism, redox homeostasis, etc. seen in all patients with
CLD.
[0005] Metabolomic studies have also provided new and valuable
insights into CLD pathology, especially because these studies
specifically identify metabolic alterations and core metabolic
phenotype (CMP) changes associated with CLD. Metabolomics involve
high-throughput analytic chemistry combined with multivariate data
analysis to compile an unbiased, and often extensive profile of
small metabolites from various samples including animal models,
in-vitro hepatocytes, live human samples, serum, plasma, etc. The
focus of Metabolomic studies on the liver is at least partly due to
the fact that no other organ in the body has nearly as much
metabolic activity as the liver, so it is an obvious choice as an
organ to study changes in the metabolome associated with disease
states, in this case CLD.
[0006] The hepatic metabolome consists of a very complex collection
of small-molecule (<1.5 kDa) lipid and water-soluble metabolites
that interact in complex ways. The flux of these metabolites
provides information about genomic, proteomic and transcriptomic
activity that correlate with both normal and disease-altered
hepatic metabolism. Extensive Metabolomic analyses on CLD samples
over the last decade have identified specific metabolic/phenotypic
alterations associated with various forms of hepatobiliary disease
states. Not surprising, Leiber identified many of these same
CLD-disrupted pathways in his many historic liver disease
studies.
[0007] Strikingly, hepatic metabolic alterations to the phenotype
associated with CLD all exhibit a similar, almost identical global
profile. In other words, CLD progresses in similar patterns defined
by similar epigenetic alterations in metabolic activity, regardless
of the etiology of the disease. The profile of these combined
alterations make up a specific "Core Metabolic Phenotype" (CMP) in
patients with CLD. According to Beyoglu et al (cited herein),
[0008] "Whether provoked by obesity and diabetes, alcohol use or
oncogenic viruses, the liver develops a core metabolomic phenotype
(CMP) that involves dysregulation of bile acid and phospholipid
homeostasis. The CMP commences at the transition between the
healthy liver (Phase 0) and NAFLD/NASH, ALD or viral hepatitis
(Phase 1). This CMP is maintained in the presence or absence of
cirrhosis (Phase 2) and whether or not either HCC or CCA (Phase 3)
develops. Inflammatory signaling in the liver triggers the
appearance of the CMP. Many other metabolomic markers distinguish
between Phases 0, 1, 2 and 3. A metabolic remodeling in HCC has
been described but metabolomic data from all four Phases
demonstrate that the Warburg shift from mitochondrial respiration
to cytosolic glycolysis foreshadows HCC and may occur as early as
Phase 1. The metabolic remodeling also involves an upregulation of
fatty acid .beta.-oxidation, also beginning in Phase 1. The storage
of triglycerides in fatty liver provides high energy-yielding
substrates for Phases 2 and 3 of liver pathology."
[0009] A comprehensive review of metabolomics studies show that all
forms of CLD similarly present the following CMP-associated
changes: [0010] extreme oxidative stress, [0011] increased
.beta.-oxidation of fatty acids, [0012] a shift from aerobic
respiration to anaerobic glycolysis, [0013] increased
glutathione/cysteine/thiol cycling, [0014] dysregulation of
phospholipid and bile acid homeostasis and [0015] increased storage
of cytosolic fatty acids and triacylglycerides in fatty liver.
[0016] Most of these CMP-associated metabolic alterations involve
up-regulated biosynthetic pathways whose end-products experience
greater utilization and consumption. CLD-induced up-regulated
biosynthetic pathways experience greater flux of metabolites, while
the biosynthetic end-products of these pathways experience
decreased availability or depletion due to greater utilization.
Increased cycling of CMP-upregulated metabolites, therefore, is
regarded as increased metabolic demand associated with CLD.
[0017] In other words, CLD causes alterations to the phenotype of
the host by altering and up-regulating specific
metabolic/biosynthetic pathways. The combined metabolic alterations
induced by CLD create increased metabolic demand and utilization
for CMP-upregulated metabolites and nutrients. Increased metabolic
demand translates into increased nutritional requirements for these
metabolites. Therefore, increased metabolic demands associated with
CMP-upregulated metabolites define the new distinctive nutritional
requirements of CLD patients.
[0018] Identification of these CLD-altered metabolic/biosynthetic
pathways is necessary to develop a science-based medical food. The
term medical food, as defined in section 5(b) of the Orphan Drug
Act (21 U.S.C. 360ee (b) (3)) is "a food which is formulated to be
consumed or administered enterally under the supervision of a
physician and which is intended for the specific dietary management
of a disease or condition for which distinctive nutritional
requirements, based on recognized scientific principles, are
established by medical evaluation."
[0019] Therefore, what is needed is a medical food for CLD patients
that supplies appropriate amounts of specific nutrients for which
CLD patients experience greater demand and utilization. This
medical food for CLD patients will support their new distinctive
nutritional requirements.
SUMMARY
[0020] The subject matter of this application may involve, in some
cases, interrelated products, alternative solutions to a particular
problem, and/or a plurality of different uses of a single system or
article.
[0021] In one aspect, an ingestible composition is provided. The
composition may comprise N-Acetyl Cysteine in a range of 500-5,000
mg; Polyenylphosphatidylcholine in a range of 500-10,000 mg; and
Alpha Lipoic Acid in a range of 200-2,500 mg. This composition may
be divided into individual serving sizes for administration. In a
further aspect, the composition may further comprise at least one
of L-Lysine; L-Arginine; Vitamin C; N-Acetyl L-Carnitine; Betaine
HCl; L-Glutamate; Turmeric; Proanthocyanidins; Nigella sativa;
Pantothenic acid; Benfotiamine; Magnesium; Vitamin E; Cynara
scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol; Piper
cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc; Vitamin
D3; Folate; Vitamin B12; Selenium; and Biotin.
[0022] In another aspect, medical food composition selected to aid
in a reversal of liver fibrosis is provided. The composition may
comprise N-Acetyl Cysteine in a range of 500-5,000 mg;
Polyenylphosphatidylcholine in a range of 500-10,000 mg; and Alpha
Lipoic Acid in a range of 200-2,500 mg. This composition may be
divided into individual serving sizes for administration. In a
further aspect, the composition may further comprise at least one
of L-Lysine; L-Arginine; Vitamin C; N-Acetyl L-Carnitine; Betaine
HCl; L-Glutamate; Turmeric; Proanthocyanidins; Nigella sativa;
Pantothenic acid; Benfotiamine; Magnesium; Vitamin E; Cynara
scolymus; L-Glycine; Vitamin B1; Vitamin B2; Ubiquinol; Piper
cubeba; Artemisia absinthium; Vitamin B3; Vitamin B6; Zinc; Vitamin
D3; Folate; Vitamin B12; Selenium; and Biotin.
BRIEF DESCRIPTION OF THE FIGURE
[0023] FIG. 1 provides a flow chart of an embodiment of use of the
medical food of the present invention.
DETAILED DESCRIPTION
[0024] The present medical food composition accomplishes the need
of providing CLD patients with their new distinctive nutritional
requirements. The present invention is a new medical food intended
to fulfill the specific dietary requirements of patients with CLD
for which distinctive nutritional requirements, based on
established epigenetic, metabolomic and other types of scientific
research, are established.
[0025] The composition of the present invention is referred to
herein as a "medical food" or the "medical food of the present
invention." This term is intended to apply to the composition
discussed for the treatment contemplated. However, it should be
understood that the composition of the present invention may be
used as a dietary supplement formula, as well as a drug (such as an
FDA approved drug) formula.
[0026] The complex list of metabolites that are required to
stabilize these interlinked up-regulated metabolic pathways can
only be provided by a strategic and comprehensive medical food. The
complex balance between the medical food's numerous nutrients and
the medical food's requirement of continuous administration three
times per day could not be reasonably provided by simple
alterations of diet alone.
[0027] In a particular embodiment, the medical food may be
administered orally in divided doses of eight capsules taken three
times a day (morning, afternoon, and evening) for a total of twenty
four capsules daily. However, it should be understood that the
formulation may also be supplied as a liquid drink, tablet, powder,
gel, emulsion, micelles, liposomes, and the like.
[0028] Further, CLD is not a nutrient deficiency disease like
scurvy or pellagra, in which the supplementation of a particular
deficient nutrient or dietary supplement may correct symptoms
caused by deficiencies of a person's normal nutritional
requirements. Similarly, ALD does not simply alter the metabolism
of the patient while he is drinking. Rather the abuse of alcohol
may change the patient's metabolism in the long-term and alter his
nutritional requirements in ways that require fulfillment even
after the patient has quit drinking. The medical food is designed
to address and correct the results of unfulfilled nutritional
requirements in CLD patients.
[0029] The medical food satisfies the new distinctive nutritional
requirements of CLD patients with a comprehensive list of required
metabolites designed to fortify and balance all CMP interlinked and
up-regulated metabolic pathways associated with patients with CLD.
Research shows that these linked CMP-upregulated biosynthetic
pathways experience concurrent increased demand and utilization.
Therefore, a comprehensive and balanced approach is necessary in
order to fulfill the new distinctive nutritional requirements of
CLD patients.
[0030] Each medical food daily dose is split into three separate
administrations in order to satisfy the constant increased
nutritional requirements of CLD patients. The medical food's
3.times. daily administration is designed to achieve optimal
periods of homeostasis in CMP-disrupted systems for as long as
possible throughout the day. Once or twice daily administrations of
medical food will not be as effective as the present invention's
three-time-daily administration, even with the same total daily
amount. This is because the medical food of the present invention
is designed to provide increased nutrient delivery to the cells of
CLD patients in an optimal manner throughout the day, and a
three-time-daily administration is necessary to achieve this
purpose.
[0031] The medical food has identified all known metabolic pathways
demonstrating CMP up-regulation in CLD. Fulfilling the new
distinctive nutritional requirements for CLD patients is
accomplished by supplying the necessary balanced amounts of
critical nutrients and metabolites for increased flux into
CMP-associated up-regulated pathways.
[0032] The present invention is a medical food that fulfills new
distinctive nutrient requirements for patients with CLD. Medical
foods are not drugs and by regulation may contain only GRAS
(Generally Recognized As Safe) ingredients. Every ingredient in the
medical food is classified as GRAS by the FDA. Further, each
ingredient in the medical food formula is in proper balance and
proportion for safe administration. The medical food GRAS
ingredients are required to provide nutritionally balanced support
for CMP up-regulated metabolic/biosynthetic/antioxidant pathways
and homeostatic activity in CLD patients.
[0033] The medical food is not intended to treat or cure CLD.
Rather, the medical food for chronic liver disease of the present
invention is intended to satisfy the new distinctive nutritional
requirements of CLD patients. Our intention is for the present
invention's status as a medical food to be satisfied by even the
FDA's narrowest interpretation of the statute. In the present
clinical setting, there is evidence of a need for such a
science-based medical food for CLD patients.
Core Metabolic Phenotype Comprehensively Identifies CLD-Altered
Metabolic/Biosynthetic Pathways
[0034] As shown below, all CLD exhibit very similar changes to core
metabolic phenotype (CMP), regardless of CLD etiology. Specific
studies will demonstrate that the same list of CMP-associated
metabolic alterations occur in each and every type of CLD. The
purpose of this exercise is to establish that due to the very
similar nature of these CLD-induced metabolic disruptions, all
patients with CLD experience the same disrupted metabolic pathways.
These disrupted metabolic pathways define the new distinctive
nutritional requirements for patients with CLD. It is therefore
appropriate to fulfill the new distinctive nutritional requirements
of CLD patients by providing the same medical food formula, because
the medical food of the present invention addresses the same
disrupted metabolic pathways present in every form of CLD,
regardless of the etiology. The medical food accomplishes this by
providing a balanced and comprehensive medical food formula with
scientific justification and up-coming human clinical trials.
[0035] CMP is associated with the following global changes in the
metabolome of CLD patients: [0036] Dis-regulation of phospholipid
metabolism, as well as cholesterol and bile acid homeostasis,
[0037] Increased storage of cytosolic triglycerides and fatty acids
accompanied with altered .beta.-oxidation of fatty acids, [0038] A
shift from aerobic respiration to anaerobic glycolysis, [0039]
Increased utilization of thiol-containing metabolites including
increased glutathione/cysteine cycling,
[0040] CMP-associated metabolic changes listed above combine to
create extreme oxidative stress, which the evidence has been well
documented in all CLD. Therefore, as stated above, the rest of Part
A will be dedicated to establishing the new CMP-associated
distinctive nutritional requirements of CLD patients.
[0041] The discussion about how to fulfill the new distinctive
nutritional requirements of CLD patients will take place in Part B,
below.
1. CMP is Associated with Disruption of Phospholipid, Cholesterol
and Bile Acid Homeostasis
Phosphatidylcholine (PC) Homeostasis
[0042] Many Metabolomic studies have focused on CMP-associated
changes in the lipidome of CLD patients. It has long been known
that lipid metabolism experiences widespread disruption in patients
with CLD and that these metabolic changes are associated with
distinct changes in specific metabolic biomarkers. Of particular
interest to metabolomic researchers has been CMP-associated
disruption of PC homeostasis. It has been demonstrated in a variety
of studies that all types of CLD patients experience decreased PC
availability due to increased utilization and/or impaired synthesis
in patients with CLD.
[0043] For example, a meta-analysis that examined a large body of
metabolomic hepatobiliary studies involving patients with all types
of CLD documented that lysophosphatidylcholine species (LPCs) were
universally depressed while bile acids were found elevated in all
forms of CLD. Thus, the study concluded that "It would appear that
depressed LPCs and elevated bile acids in serum represent a
phenotype of hepatitis and cirrhosis independent of etiological
origin . . . ."
Cholesterol and Bile Acid Homeostasis
[0044] Similarly, CLD-associated CMP changes cause elevated levels
of cholesterol and bile acids. Increased cholesterol infiltration
of the mitochondrial membrane has been associated with
mitochondrial GSH depletion. Bile acids are created from
cholesterol and bile acids are found elevated in patients with
CLD.
[0045] Glycochenodeoxycholic acid (GCDCA) is the main toxic
component of bile acid and elevated GCDCA has been shown to be
significantly associated with decreased mitofusin 2 (Mfn2) gene
expression. Decreased Mfn2 is associated with many
mitochondrial-related diseases. This was demonstrated in a study
conducted by Chen et al in which normal human hepatocytes induced
by GCDCA showed significant decreased in Mfn2 activity resulting in
mitochondrial damage. However, this mitochondrial damage was
reversed in the lab by stimulating overexpression of Mfn2.
1a. Non-Alcoholic Fatty Liver Disease (NAFLD)--Disruption of PC,
Cholesterol and Bile Acid Homeostasis
PC Homeostasis
[0046] NAFLD exhibits CMP-associated disruption of PC biosynthetic
pathways. A study comparing human steatotic livers versus
non-steatotic livers showed elevated PC metabolites in steatotic
livers, indicating increased activity in the PC biosynthetic
pathway. Another research study documented rodents who were fed
diets that induced fatty liver experienced up-regulated utilization
of PC, choline, betaine, and trimethylamine N-oxide. Other human
and animal studies have shown PC disruption in NAFLD.
[0047] Increased catabolism of PC and phosphatidylethanolamine (PE)
species in the liver by phospholipases A1 and A2 release free fatty
acids that require .beta.-oxidation in the mitochondria. If these
hepatic fatty acids are not adequately oxidized by
.beta.-oxidation, then the unused fatty acids will be repackaged in
the liver as hepatic triacylglycerols, creating hepatic steatosis
(NAFLD) and setting the stage for NASH.
[0048] Metabolomic studies show that CMP-associated disruption of
PC homeostasis and elevated triacylglycerol production are not
simply an intracellular accumulation of fat in the liver but rather
a large-scale translocation of lipid stores. Decreased PC
availability and increased PC utilization may contribute to
increased cholesterol and fatty acid infiltration into cellular and
mitochondrial membranes, which may in turn affect mitochondrial
glutathione (GSH) transport.
Cholesterol and Bile Acid Homeostasis
[0049] In human and animal studies NAFLD causes an increase in
lipid species in the liver and serum/plasma, including cholesterol
esters and various bile salts. However, NAFLD is marked by less
hepatic inflammation, and therefore less bile acids disruption than
NASH.
1b. Non-Alcoholic Steatohepatitis (NASH)--PC, Cholesterol and Bile
Acid Homeostasis
PC Homeostasis
[0050] NASH is defined as advanced-stage NAFLD accompanied by high
inflammatory activity. As much as 67%-80% of NAFLD patients may
remain as benign fatty liver with minimal progression to cirrhosis
and normal mortality rates compared to the general population.
However, approximately 20%-33% of NAFLD patients may progress to
NASH.
[0051] In both NASH and in NAFLD, triacylglycerols and several
fatty acids are shown to be elevated in the liver, while various
other fatty acids and lysophosphatidylcholine (LPC) show decreased
levels in plasma. Metabolic studies of NAFLD and NASH showed global
changes to lipid profiles in both diseases with only a few
differences between them--a comparative analysis showed only three
phospholipid species with significant changes in serum
concentrations in NASH compared with NAFLD. A recent study noted
decreased levels of LPC and increased bile acids associated with
NASH were not demonstrated in mere steatosis (NAFLD). Differences
between NAFLD and NASH appear to be due to the inflammatory
component of NASH; this inflammatory component is absent in fatty
liver (NAFLD).
[0052] A similar study found that Lysophosphatidylcholine
acyltransferases (LPCAT), which convert LPC to PC were up-regulated
in NASH with a 200%-400% increase in hepatic LPCAT1, LPCAT2, and
LPCAT3 mRNAs. A mechanism proposed by Gonzalez et al suggested that
hepatic inflammation causing activation of TNF.alpha. and TGFb1 in
turn cause increased hepatic LPCAT activity resulting in lower
serum LPC levels.
Cholesterol and Bile Acid Homeostasis
[0053] As noted above, the inflammatory component of NASH may be
linked to fatty acids transported to the liver from visceral
adipose. NASH-associated inflammation is also linked to bile acid
disruption in the liver. Gonzalez et al suggested " . . . the
decline in serum LPC and rise in serum bile acids are a signature
of the inflammatory component of NASH, rather than the steatotic
component." Furthermore, they suggested that hepatic inflammation
involving TNF.alpha. and TGFb1 activation in the liver causes
disruption to bile acids, documenting that the enzymes that uptake
the bile salts into the hepatocytes were highly down-regulated, and
the transporters that export bile acids from the liver were highly
up-regulated in NASH.
1c. Alcoholic Liver Disease (ALD)--PC, Cholesterol and Bile Acid
Homeostasis
PC Homeostasis
[0054] ALD has long been implicated in disrupted PC metabolism. A
study on cirrhotic patients reported that whether cirrhosis was due
to alcohol or HBV, there was a decrease in serum LPC of cirrhotic
patients compared to healthy volunteers. Animal studies have shown
that alcohol exposure may produce pathologies that correlate with
NASH. A study on alcoholic micropigs initially showed increased
hepatic triglycerides, and then after six months demonstrated
inflammation, steatosis and fibrosis. The authors concluded that
increased lipid synthesis and reduced LPC synthesis and export were
responsible for the accumulation of hepatic triglycerides in ALD.
In another study on athymic nude mice gavaged with 5% to 40%
ethanol solutions, the findings showed the mice developed a mild
hepatic hemorrhage and serum PC was elevated. There was a decrease
in saturated and monounsaturated LPC, but polyunsaturated LPC was
elevated.
Cholesterol and Bile Acid Homeostasis
[0055] Metabolomic ALD studies show that ALD-induced cirrhosis is
associated with higher bile acids and lower LPCs (92,94) in a
manner almost identical with non-alcoholic and HBV-induced
cirrhosis.
1d. HBV and HCV--PC, Cholesterol and Bile Acid Homeostasis
PC Homeostasis
[0056] PC biosynthesis is known to be disrupted in both HCV and
HBV. A Metabolomic study in China studied HBV patients with
deteriorating liver function demonstrated disrupted PC levels. The
study describes decreased PC species combined with an elevation of
toxic bile acids, glycochenodeoxycholic acid (GCDCA). Another
Chinese study reported similar results when examining the
progression of chronic HBV to cirrhosis. The same phenomena are
also seen in NALFD/NASH, cirrhosis and HCC. An animal study
indicated that HCV alters many pathways in the liver with
significant changes in LPCs and bile acids, as well as carnitine
esters, fatty acids, and LPEs.
[0057] A study conducted by Metabolon Inc., in association with the
University College Dublin showed the global effects on the hepatic
metabolome of HCV infection. Comparative analysis of 250
metabolites of normal hepatocytes was compared to the same panel of
metabolites from HCV-infected hepatocytes. The study demonstrated
specific changes in metabolism in HCV-infected hepatocytes at 24,
48 and 72 hours, disrupting many different metabolic pathways as a
result of HCV infection, most notably fatty acid, phospholipid,
GSH, amino acid, nucleotide and methylthioadenosine metabolism. The
study showed altered flux through both PC biosynthetic pathways
(PEMT and CDP-choline), as well as alteration to all the other
CMP-associated pathways.
Cholesterol and Bile Acid Homeostasis
[0058] HCV disrupts many aspects of lipid metabolism. Lipids are
necessary for HCV viral assembly and secretion. HCV replication
modulates host cell lipid metabolism dramatically to enhance its
replication. The HCV life cycle requires numerous lipids, which
have been shown to be essential modulators of the HCV viral
lifecycle.
[0059] HCV disrupts cholesterol metabolism by causing proteolytic
cleavage of sterol regulatory element binding proteins (SREBPs),
thereby inducing steatosis. Bile acids are derived from cholesterol
and HCV disrupts bile acid metabolism as well as cholesterol
metabolism.
[0060] Apolipoprotein and VLDL synthesis is altered in HCV and
HCV-infected hepatocytes showed increased production of cholesterol
and sphingolipids, both of which HCV utilizes to aid in virion
maturation and infectivity. Cholesterol-depleted or
sphingomyelin-hydrolysed virus had a negative impact on
infectivity. Metabolomic analysis of HCV-infected hepatocytes
showed a significant increase in cholesterol and various sphingoid
bases.
[0061] An animal study was performed in HCV-infected tree shrews,
which showed increased bile acids and decreased PC availability;
both are hallmarks of CLD-induced CPM alterations. Further, it has
been established that HBV, HCV, and NASH all trigger similar
metabolomics alterations involving hepatic inflammation-mediated
changes to bile acid metabolism. Serum bile acids have been found
to be higher in patients with severe fibrosis as compared to
patients with moderate fibrosis.
[0062] A Metabolomic study on HCV-infected human hepatocytes showed
that HCV impaired VLDL production and secretion, which in turn may
add to the accumulation of hepatic triglycerides due to decreased
VLDL packaging of triglycerides for hepatic export.
[0063] A recent HBV metabolomic study noted a decline in serum PC
species and also elevated GCDCA levels, one of the main toxic
components of bile acids, in HBV-infected patients. Serum bile
acids have also been found to be elevated in HCV patients. As
mentioned previously, Mitofusin2 (Mfn2) gene expression regulates
mitochondrial morphology and signaling. A recent study showed that
one of the signature toxic components of bile acids, GCDCA,
decreases the expression of Mfn2. Further, stimulation in the lab
of overexpression of Mfn2 " . . . effectively attenuated
mitochondrial fragmentation and reversed the mitochondrial damage
observed in GCDCA-treated . . . " hepatocytes.
[0064] This line of research demonstrates how disruption of PC
metabolism affects other CMP-associated pathways in various
ways--increased SAMe flux into the up-regulated PC pathway in the
liver has a negative effect on flux of SAMe into the GSH pathway.
Decreased GSH contributes to the disruption of redox homeostasis
and the creation of extreme oxidative stress in patients with CLD.
In a vicious circle, extreme oxidative stress then further oxidizes
existing GSH stores, causing increased GSH cycling. Similarly,
decreased PC affects choline metabolism, which in turn controls
cholesterol metabolism and bile acid homeostasis. An increase in
bile acids creates an increase in GDCDA from toxic bile acids. As
mentioned above, GDCDA exacerbates extreme oxidative stress by
negatively affecting Mfn2 gene expression. Therefore, disruption of
PC availability affects the GSH pathway, and all linked
up-regulated CMP pathways contribute to extreme oxidative stress,
which is the hallmark of CLD.
2. CMP is Associated with Increased Storage of Cytosolic
Triacylglycerides (TGL) in Fatty Liver and Altered .beta.-Oxidation
of Fatty Acids (FA) 2a. Non-Alcoholic Fatty Liver Disease
(NAFLD)--Triacylglycerides (TGL) and Fatty Acids (FA) Accumulation
in the Liver
[0065] Visceral adipose supplies fatty acids to the liver for
.beta.-oxidation. PC catabolism is also considered a source of
fatty acids for hepatic .beta.-oxidation. Studies indicate that
increased levels of hepatic triacylglycerols are also seen in
CMP-associated CLD and that those triacylglycerols may be exported
from adipose tissue.
[0066] Studies have also indicated that visceral adipose, known for
being highly inflammatory, may be responsible for exporting the
inflammatory component which distinguishes NAFLD from the
inflammatory state of NASH.
[0067] In fact, both visceral adipose and up-regulated PC
metabolism are considered sources of hepatic fatty acids associated
with increased hepatic triacylglycerols. Increased catabolism of PC
by phospholipases A1 and A2 in the liver release free fatty acids.
These free fatty acids require .beta.-oxidation in the mitochondria
of hepatocytes. Un-oxidized fatty acids are repackaged as hepatic
triacylglycerols, creating NAFLD and setting the stage for
NASH.
[0068] As noted in section 1b, NAFLD is considered to be the
physical manifestation of metabolic syndrome in the liver.
Metabolomic studies have found increased lipid species
triacylglycerides and diacylglcerides in both liver and blood
samples of NAFLD patients.
2b. Non-Alcoholic Steatohepatitis (NASH)--Triacylglycerides (TGL)
and Fatty Acids (FA) Accumulation in the Liver
[0069] NAFLD and NASH are both characterized by changes in the
cellular lipid profile. NASH is NAFLD with a major inflammatory
component. For years researchers have been searching for the cause
of NASH-associated hepatic inflammation, and new studies theorize
that adipose tissue, which is intrinsically pro-inflammatory, may
be the origin of hepatic inflammation. As mentioned previously,
Lipidomic studies show similar significant lipid metabolic
disruption in both NASH and NAFLD with only small differences in
three PC species to distinguish the two. In NASH as well as NAFLD,
triacylglycerols and several fatty acids were shown to be elevated
in plasma, while various other fatty acids showed decreased levels
in plasma. Other studies also showed that NASH patients with
cirrhosis show reduced cellular carnitine levels, which may
negatively affect .beta.-oxidation of fatty acids in the
mitochondria.
2c. Alcoholic Liver Disease (ALD)--Triacylglycerides (TGL) and
Fatty Acids (FA) Accumulation in the Liver
[0070] Early on, Leiber found a correlation with ethanol intake and
the accumulation of hepatic fatty acids and triglycerides. Leiber
also showed that ethanol has extreme effects on lipid peroxidation.
Metabolomic studies suggest that hepatic fatty acids and
triacylglycerides increase and plasma fatty acids and PC species
decrease in ALD.
2d. HBV and HCV--Triacylglycerides (TGL) and Fatty Acids (FA)
Accumulation in the Liver
[0071] In Section 1 we showed that CLD-associated CMP exhibits
up-regulated cholesterol utilization, which supplies the liver with
fatty acids from PC catabolism. These PC-derived hepatic fatty
acids require .beta.-oxidation or they will be re-packaged as
hepatic triacylglycerols, contributing to fatty liver. We have
shown in Section 1d above that both HCV and HBV infections affect
PC metabolism and increase hepatic fatty acids and
triacylglycerides.
[0072] We also discussed that visceral adipose is also a source for
both hepatic fatty acids and hepatic triacylglycerols. The
HCV-infected tree shrew study (Tupaia belangeri chinensis)
suggested that HCV causes alterations in carnitine esters and fatty
acids.
[0073] HCV patients have been shown to have low levels of carnitine
species, which impairs .beta.-oxidation of fatty acids. An
extensive metabolomics study on HCV-infected hepatocytes showed
that HCV infection causes an increase in lipid content within
hepatocytes, or liver steatosis. Steatosis is the accumulation of
intracellular fatty acids in the liver, and it has been associated
with HCV infection, increased oxidative stress and progression to
liver cirrhosis. HCV causes proteolytic cleavage of sterol
regulatory element binding proteins (SREBPs), thereby increasing
cholesterol and inducing steatosis.
[0074] Further, fatty acid oxidation is disrupted during HCV
infection and it is associated with HCV-induced metabolic
L-Carnitine deficiency. A metabolomic analysis of HCV-infected
hepatocytes showed that HCV disrupts fatty acid .beta.-oxidation
and fatty acid transport to the mitochondria. The study also showed
that HCV-infected hepatocytes have an increase in fatty acid
concentration and a decrease in mediators of fatty acid transport.
Acyl-carnitine (necessary for fatty acid transport to the
mitochondria from the cytosol) and proper mitochondrial function
have been shown to be depleted in HCV. Further, the metabolomic
study showed a significant decrease in coenzyme A (CoA),
pantothenic acid, acetylcarnitine and a number of carnitine
derivatives at 48 and 72 hours post-infection, indicating that
fatty acid transport to the mitochondria may also be disrupted.
3. CMP is Associated with a Shift from Aerobic Respiration to
Anaerobic Glycolysis (Warburg Shift)
[0075] In the Introduction, we described the new distinctive CMP as
it progresses through the different phases of CLD. One of the
CMP-associated changes we noted was the "Warburg shift", which
involves a shift in metabolism from aerobic respiration to
anaerobic glycolysis. This shift to anaerobic glycolysis has
usually been associated with HCC, but recent metabolomic studies
have shown that the shift happens early in all CLD.
[0076] As stated previously, the shift from aerobic oxidative
phosphorylation to cytosolic anaerobic glycolysis is a hallmark of
CLD-associated CMP. The Warburg shift is associated with
alterations of metabolic pathways that are linked to both cell
proliferation and nutrient acquisition, while the shift to
anaerobic glycolysis comes at the expense of ATP production.
3a, 3b. NAFLD and NASH--Warburg Shift
[0077] Insulin resistance is associated with NAFLD/NASH. In mice,
insulin is reported to activate pyruvate kinase M2, which is the
enzyme that triggers cytosolic glycolysis involved in the Warburg
shift. The shift from aerobic respiration to anaerobic glycolysis
results in the production of lactate and alanine from pyruvate. The
Warburg shift occurs as early as Phase 1 in NAFLD/NASH
progression.
3c. ALD--Warburg Shift
[0078] ALD progresses towards a shift in aerobic respiration to
anaerobic glycolysis along the parallel path of fibrosis/cirrhosis,
CMP expression and HCC development.
3d. HBV and HCV--Warburg Shift
[0079] Metabolomic studies have documented the Warburg shift occurs
in all types of CLD, including HBV and HCV as early as phase one,
long before the appearance of HCC.
[0080] Furthermore, HCV has been found to shift metabolism from
aerobic respiration towards the pentose phosphate pathway. The
pentose phosphate pathway is a parallel pathway with anaerobic
glycolysis. In other words, the pentose phosphate pathway creates
NADPH and five-carbon sugars, which are then oxidized by glycolysis
in HCV patients.
4. CMP is Associated with GSH Depletion, Increased Consumption of
Thiol-Containing Metabolites, Extreme Oxidative Stress and Altered
One-Carbon Metabolism
[0081] CLD of all etiologies are associated with CMP-induced
hepatic extreme oxidative stress. Glutathione is the master
controller of cellular redox status, maintaining and regulating the
redox status of cellular enzymatic and non-enzymatic
(small-molecule) antioxidants. CLD-associated depletion of GSH may
cause depletion of all linked cellular antioxidants that are
normally maintained and regulated by GSH.
4a, 4b. NAFLD and NASH--Altered Homocysteine/Glutathione/One-Carbon
Metabolism
[0082] Metabolomic analyses on a variety of types of NAFLD samples
have been performed on animal models, living human subjects and
human tissue samples. One common finding is that
cysteine-glutathione disulfide and both oxidized and reduced
glutathione were depressed in the liver and serum/plasma, and this
condition is associated with extreme oxidative stress in patients
with NAFLD/NASH.
[0083] The progression of steatosis (NAFLD) to steatohepatitis
(NASH) involves the sensitization of hepatocytes through oxidative
stress to cytokine-induced apoptosis and the importation of
inflammatory fatty acids from adipose tissue. Depletion of
mitochondrial glutathione (mGSH) is associated with cholesterol
infiltration of mitochondrial membranes, which lowers transmembrane
potential, and which in turn inhibits the transport of cytosolic
GSH into the mitochondrial membrane. Glutathione depletion has been
found to be involved with hepatic stellate cell activation.
[0084] One of the most common research models for inducing
steatosis is the methionine and choline deficient diet (MCD). MCD
is associated with steatosis, mitochondrial dysfunction,
hepatocellular injury, oxidative stress, inflammation, and
fibrosis. One study analyzed the contributions of both the
methionine deficient diet (MD) and the choline deficient diet (CD)
to total MCD pathogenic effect. They found that MD reproduced most
of the deleterious effects of the total MCD, while CD caused mainly
steatosis, with a rise in hepatic FA and TGL accumulations, but
without much of the other deleterious effects associated with
MCD.
[0085] The study found that S-adenosylmethionine (SAMe) and
glutathione (GSH) depletion in the mitochondria precede the
observed effects due to decreased mitochondrial membrane fluidity
associated with a lower
phosphatidylcholine/phosphatidylethanolamine ratio. GSH or SAMe
therapy restored GSH in the mitochondria and ameliorated
hepatocellular injury in mice fed either a MCD or MD diet.
4c. ALD--Altered Homocysteine/Glutathione/One-Carbon Metabolism
[0086] Alcohol toxicity has also long been linked to
folate/homocysteine or one-carbon metabolism disruption. Early
research established significant ethanol-associated glutathione
depletion and oxidative stress, altered methionine metabolism,
altered folate/homocysteine/one-carbon metabolism, malnutrition,
and increased Kupffer cell activation. Alcohol induced oxidative
stress and inflammation has been shown to exacerbate the
progression of the disease.
[0087] Changes in gene expression can be accomplished through
alterations in DNA coding sequence. Changes in gene expression and
phenotype may also be caused by other mechanisms. Epigenetics is
the study of these heritable changes. DNA can be modified
epigenetically by DNA methylation, histone modifications, and
RNA-based mechanisms. Recent studies have focused on epigenetic
features, transcriptional factors and signaling pathways associated
with chronic ALD. These new studies provide greater nuanced
perspectives of ALD/CLD disease pathology. Consumption of ethanol
causes epigenetic changes (CMP) that contribute to ALD. In an
extensive study, ethanol affected metabolism of methionine and
thereby DNA methylation. ALD is associated with GSH depletion in
the mitochondria. Studies show that ALD-induced mitochondrial GSH
depletion is associated with cholesterol-enrichment of the
mitochondrial membrane, which leads to impairment of GSH transport
of cytosolic GSH into the mitochondria in both ALD and
NAFLD/NASH.
4d. HBV and HCV--Altered Homocysteine/Glutathione/One-Carbon
Metabolism
[0088] Both HCV and HBV induce hepatic oxidative stress. The
mechanisms for increasing oxidative stress in both pathologies are
well known. These mechanisms involve epigenetic changes caused by
viral proteins interacting with both mitochondria and endoplasmic
reticulum (ER) to increase mitochondrial reactive oxygen species
(ROS) generation. HCV core expression inhibits electron transport
at Complex I, and increase Complex I ROS production. They also
induce depletion of mitochondrial GSH, increase mitochondrial
membrane permeability and impair various antioxidant defense
mechanisms.
[0089] A metabolomic study on HCV-infected hepatocytes showed
changes to the GSH pathway at 24, 48 and 72 hours, demonstrating
that HCV caused six or seven specific epigenetic changes to the
metabolome. These findings are consistent if not identical with the
phenotypic expression of the CMP seen in all forms of CLD.
[0090] HCV-mediated mitochondrial disruption is a causative factor
in GSH depletion and the creation of extreme oxidative stress. HCV
has been shown to create replication sites in the mitochondrial
membrane that damages mitochondrial form and function. HCV has also
been shown to disrupt the GSH metabolic pathway, causing greater
utilization of GSH and disrupted biosynthesis. HCV-impaired GSH
biosynthesis contributes to a large increase in ROS generation that
further contributes to mitochondrial GSH depletion.
5. CLD/CMP-Associated Extreme Oxidative Stress and Fibrogenesis
[0091] CLD causes extreme oxidative stress as a result of
CMP-associated metabolic disruptions and unfulfilled distinctive
nutritional requirements. NASH, ALD, HCV, and HBV all have been
associated with extreme oxidative stress. CLD-induced metabolic
changes increase ROS and NOS levels, which disrupt redox
homeostasis and create extreme oxidative stress. Depletion of GSH
results in the inability to counteract oxidative-mediated insults
to cellular systems, resulting in irreversible cellular
degeneration and cell death. GSH depletion and CLD-associated
oxidative stress may damage mitochondria form and function.
Furthermore,
non-enzymatic small molecule antioxidants and antioxidant minerals
are both depleted as a result of CLD-induced oxidative stress, GSH
depletion and cirrhosis.
[0092] GSH is the main regulator of cellular redox homeostasis and
redox signal transduction. Under normal metabolism, cellular redox
status is maintained and regulated by the glutathione redox couple
GSH:GSSG (GSSG is an oxidized form of GSH), along with the
NADPH/NADP+ and Trx-SH/Trx-SS redox couples. Redox balance is
involved in cellular signal transduction, and small changes in the
GSH:GSSG ratio are involved in the fine-tuning of signal
transduction in physiological events such as cell cycle regulation
and other processes.
[0093] The interaction of GSH and the free-thiol in cysteine
residues forms a mixed disulfide that is reversibly formed through
protein-S-glutathionylation to protect proteins from irreversible
oxidative stress. Protein-S-glutathionylation is an important
mechanism for post-translational regulation of a large list of
regulatory, structural and metabolic proteins that play roles in
cell signaling and metabolic pathways. Protein-S-glutathionylation
production requires a reactive cysteinyl residue, present at
physiological pH in the thiolate form. Under oxidative stress,
these cysteinyl residues may be oxidized and react with GSH leading
to a glutathionylated-cysteine derivative. Both GSSG and
S-glutathionylated proteins may be catalytically reduced back to
GSH, while they both may also be reduced back to GSH
non-enzymatically.
[0094] Protein-S-glutathionylation is an important mechanism for
post-translational regulation. Regulatory, structural and metabolic
proteins that react with GSH to form S-glutathionylated proteins
are involved in cell signaling and the regulation of cellular
metabolic pathways.
[0095] Disruption of GSH-controlled cellular redox homeostasis
increases oxidative stress. Disruption of GSH homeostasis has been
implicated in the pathogenesis and progression of many human
diseases. Decreased GSH levels contributing to oxidative stress
have been associated with aging, neurodegeneration, inflammation,
and infections.
[0096] Besides countering ROS-associated oxidative stress, GSH is
also critically involved in mediating the susceptibility of nitric
oxide (NO) and NO derivatives in the body. GSH is involved in
countering Reactive Nitrogen Species (RNS) associated oxidative
stress and counteracting RNS-mediated damage. CLD increases ROS and
NO levels, which disrupt redox homeostasis and create extreme
oxidative stress. As mentioned above, depletion of GSH results in
the inability to counteract oxidative stress and NO-mediated
insults to hepatic cellular systems, resulting in irreversible
cellular degeneration and cell death.
[0097] Extreme hepatic oxidative stress and oxidative
stress-mediated hepatic inflammation trigger the separate process
of liver fibrogenesis. Hepatic fibrogenesis involves a process
whereby CMP-associated oxidative stress triggers the conversion of
normally quiescent hepatic stellate cells into active
collagen-secreting myofibroblasts.
Part B: The Medical Food Contemplated Herein Fulfills the New
Distinctive Nutritional Requirements for Patients with CLD
[0098] In Part A we established that all forms of CLD create
distinctive epigenetic changes in the phenotype and alterations of
metabolism in patients with CLD. We also established that these
changes are similar, and in most cases identical in all forms of
CLD, regardless of the disease etiology. Extensive metabolomic
studies on all forms of hepatobiliary diseases have collectively
labeled these new distinctive metabolic/phenotypic changes as the
new Core Metabolic Phenotype (CMP) for CLD patients.
[0099] As noted previously, these CMP phenotypic changes are very
similar in all CLD, whether they involve epigenetic changes and/or
metabolic alterations associated with chronic ALD, NAFLD, NASH or
oncogenic viruses like HCV or HBV. These CMP-associated changes
result in the up-regulation of specific biosynthetic metabolic
pathways, which increases the metabolic demand for metabolites and
end-products involved in those biosynthetic pathways.
[0100] A person's complete nutritional requirements are defined as
the sum of a person's combined metabolic demands. Therefore the new
distinctive nutritional requirements of CLD patients must factor in
increased demand for metabolites and end-products of up-regulated
biosynthetic pathways associated with CLD.
[0101] A medical food for CLD patients must strategically identify,
coordinate and supply the proper amount and balance of metabolites
necessary to fulfill the new distinctive nutritional requirements
of CLD patients. Disrupted CMP-associated metabolic pathways are
listed below: [0102] Dis-regulation of phospholipid metabolism and
membrane phospholipid reallocation, [0103] Dis-regulation of
cholesterol and bile acid homeostasis, [0104] Increased storage of
cytosolic triglycerides and fatty acids accompanied with altered
.beta.-oxidation of fatty acids, [0105] A shift from aerobic
respiration to anaerobic glycolysis, [0106] Increased utilization
of thiol-containing metabolites including increased
glutathione/cysteine cycling, increased SAM/SAH/methionine cycling
and increased one-carbon methylation metabolism
[0107] The CMP-related metabolic alterations listed above involve
up-regulation and increased cycling of metabolites involved in the
following up-regulated biosynthetic pathways: [0108] The GSH
pathway as well as other GSH-linked antioxidant systems, including
cellular small molecule non-enzymatic antioxidants and
mitochondrial metabolites [0109] Both phosphatidylcholine (PC)
biosynthetic pathways (PEMT and CDP-choline) and mitochondrial
metabolites associated with mitochondrial membrane form, function
and transmembrane potential [0110] The SAM/SAH/methionine cycle
with associated one-carbon methylation metabolism [0111] Amino acid
metabolism
[0112] There is ample evidence that depletion of biosynthetic
metabolites in one CLD-altered pathway may exacerbate other
existing CLD-altered pathways. This is due to the fact that
CLD/CMP-altered biosynthetic pathways are interlinked and most of
these up-regulated pathways draw directly on SAMe stores. These
interlinked pathways include the GSH and PC pathways as well as the
SAM/SAH/methionine cycle and one carbon metabolism. Nutritional
depletion of key nutrient metabolites in these interlinked
metabolic pathways may have a synergistic effect on promotion of
extreme oxidative stress, which is the hallmark of CLD.
[0113] As noted in Section A, extreme hepatic oxidative stress and
oxidative stress-mediated inflammation trigger the process of
hepatic fibrogenesis. Fibrogenesis involves the conversion of
hepatic stellate cells into myofibroblasts. Myofibroblasts secrete
collagen into the extracellular spaces of the liver, resulting in
fibrosis and cirrhosis.
[0114] While liver fibrosis was once considered irreversible,
modern studies have demonstrated that once the trigger to
fibrogenesis (extreme oxidative stress) is switched off,
myofibroblasts apoptosis may occur while hepatic stellate cells
remain quiescent and the process of collagen resorption may then
proceed at a fairly constant rate. The process of collagen
resorption is well established and has been demonstrated in
numerous animal and human CLD studies.
[0115] SAMe is the most ready methyl donor of all the one-carbon
methylation donors, so it is no surprise that all CMP up-regulated
biosynthetic pathways similarly draw on SAMe. SAMe is also involved
in the transsulfuration pathway in GSH synthesis. Further, there is
a large body of existing current and historical studies involving
exactly these same CMP metabolic pathway alterations and the
interlinked effects that one altered pathway may have on other CMP
pathways. Dr. C. S. Leiber was a pioneer in this area and performed
a series of seminal studies on ALD and liver cirrhosis.
[0116] CMP alterations establish a vicious positive feedback loop
regarding CLD-induced oxidative stress: CMP-altered metabolic
pathways create extreme oxidative stress, and extreme oxidative
stress negatively affects the altered CMP metabolic pathways.
Extreme oxidative stress causes increased oxidation of: PC to
oxidized PC; methionine to methionine sulfate; homocysteine to
homocystine; cysteine to cystine; GSH to GSSG., GCDCA in bile acid,
and proteins to PrS-SC, PrS-SG, and PrS-SCG. These oxidized
metabolites require reduction to reactivate their healthy roles in
metabolism. Accumulation of oxidized forms of these metabolites may
have negative implications for health. For instance, oxidized PC
may cause apoptosis in macrophages and affect cell viability.
[0117] A recent review of GSH studies concluded that, "Conditions
characterized by increased ROS levels may require not only enhanced
GSH action to maintain redox status, but also augmented energy
supply and precursors to replace/enhance GSH content and/or
transport it to the places where it is needed". Further, extreme
oxidative stress may decrease SAMe availability, which contributes
to DNA hypomethylation and oxidation. DNA hypomethylation may
induce and/or exacerbate further alterations to CMP gene
expression. Extreme oxidative stress has been identified as a
trigger to hepatic stellate cell conversion in the process of
hepatic fibrogenesis.
[0118] PC supplementation has also been studied in CLD, as has SAMe
supplementation. While animal studies have shown promise, human
studies targeting individual metabolites have been inadequately
controlled and have shown mainly inconclusive results. There have
been calls for human clinical trials involving combinations of
these CLD up-regulated metabolites.
[0119] The medical food clinical trials will demonstrate that its
treatment serves to decrease oxidative stress and/or re-establish
redox homeostasis in study patients. This in turn will
down-regulate fibrogenic activity and slow down or stop the
progression of fibrosis while allowing the reversal of fibrosis to
occur. This reversal of liver fibrosis is a primary and unexpected
advantageous result of the present invention. Reports of reversal
of fibrosis in ALD patients who have quit drinking vary and have
been inconsistent, while there has been a dearth of studies
regarding this topic. Therefore, clinical trials of the present
invention will determine if and/or when reversal of fibrosis is
possible in non-drinking, compliant patients with ALD. If the
initial clinical trial finds that reversal of fibrosis is possible
in ALD patients, future studies on non-drinking, compliant patients
with ALD may be necessary to determine whether reversal of fibrosis
may be induced or accelerated by fulfilling the distinct
nutritional requirements of patients with ALD and stabilizing their
altered metabolic pathways. Meanwhile, past studies have shown
reversal of fibrosis after the underlying etiology is eliminated in
HCV, HBV, NASH autoimmune hepatitis, and secondary biliary
fibrosis. The medical food clinical trials will investigate whether
the fibrogenic activity associated with CLD may be down-regulated
by fulfilling the distinctive nutritional requirements of CLD
patients, and furthermore, whether reversal of fibrosis may be
accomplished even in the presence of continuing CLD in the cases of
HCV, HBV and NAFLD/NASH patients or in the chronically altered
phenotype of non-drinking, compliant ALD patients.
[0120] The medical food clinical trials will monitor changes in
liver fibrosis staging in CLD patients over time. Any positive
improvement in fibrosis staging may be due to down-regulation of
the fibrogenic activation caused by fulfillment of the distinctive
nutritional requirements of the CLD patients. Conversely, any
additional progression of fibrosis may be associated with the
direct action of CLD rather than unfulfilled nutritional
requirements of the CLD patients.
Previous Studies
[0121] Over the last several decades Dr. C S Lieber published over
80 studies on ALD, cirrhosis, SAMe and PC. Dr. Leiber was
responsible for many important discoveries including the microsomal
ethanol oxidizing system (MEOS) involving cytochrome P4502E1. Dr.
Leiber performed many important animal studies involving PC and
SAMe administration in ALD. Early on, Dr. Leiber noted that PC
supplementation decreased oxidative stress, correctly observing
that supplying the biosynthetic end-product of the PC biosynthetic
pathway decreases draw on SAMe, which is then re-directed to GSH
biosynthesis. Dr. Lieber observed that the resulting up-regulation
in GSH production was responsible for the observed decrease in
oxidative stress.
[0122] Dr. Leiber went on to study PC and SAMe administration in
rats and baboons fed ethanol, noting that PC administration
attenuated CCl4 and ethanol-induced liver injury, while SAMe
restored hepatic GSH levels and had a positive effect on
mitochondrial lesions and leakage. In 2002, Dr. Leiber pointed to
promising animal studies and called for human studies involving
administration of SAMe to patients with ALD, noting that " . . .
therapeutic administration of SAMe should be the subject of a
comprehensive clinical trial to assess its capacity to attenuate
early stages of alcoholic liver injury in human beings."
[0123] Numerous other studies, for instance, a 1989 Scandinavian
human study reached the same conclusions, seeing a "significant
increase" in levels of hepatic glutathione, in patients with both
alcoholic and non-alcoholic liver diseases--"SAMe may therefore
exert an important role in reversing hepatic glutathione depletion
in patients with liver disease."
[0124] Dr. Leiber pointed out that the immediate metabolic
precursor of SAMe is methionine, but methionine must be
enzymatically activated to SAMe, and this enzyme is impaired in
ALD. Therefore, he warned against administering methionine instead
of SAMe due to this enzymatic inhibition, [0125] "The precursor of
SAMe is methionine, one of the essential amino acids, which is
activated by SAMe-synthetase (EC 2.5.1.6). Unfortunately, the
activity of this enzyme is significantly decreased as a consequence
of liver disease. Because of decreased utilization, methionine
accumulates and, simultaneously, there is a decrease in SAMe that
acquires the status of an essential nutrient and therefore must be
provided exogenously as a super nutrient to compensate for its
deficiency."
[0126] A 2011 review described various studies regarding the
efficacy of treating patients with ALD metabolic disorders with
SAMe. The authors conclude that because recent SAMe studies are
inconclusive or contradictory, the one-carbon methyl donors
associated with homocysteine/methionine conversion should be
included in future SAMe ALD studies, [0127] "The doors have now
been opened for potentially productive research into the
relationship of epigenetic changes in SAM-regulated gene
methylation to all pathways of liver injury in ALD. Furthermore,
the inconclusive results of trials in SAM treatment of ALD suggest
that provision of other nutritional factors involved in SAM
metabolism, such as vitamin B-6, should be included with SAM in
larger and more prolonged clinical trials."
[0128] A symposium titled, "Role of S-Adenosyl-L-Methionine (SAMe)
in the Treatment of Alcoholic Liver Disease" was sponsored by The
National Institute on Alcohol Abuse and Alcoholism and the Office
of Dietary Supplements, National Institutes of Health in Bethesda,
Md., September 2001, also discussed SAMe with a potential role in
ALD: [0129] "The presentations of this symposium support the
suggestion that SAMe may have potential to treat ALD by (1) acting
as a precursor of antioxidant glutathione, (2) repairing
mitochondrial glutathione transport system, (3) attenuating toxic
effects of proinflammatory cytokines, and (4) increasing DNA
methylation."
[0130] Dr. Leiber studied SAMe depletion in early ALD and noted
that decreased SAMe levels occur even before SAMe-synthetase is
inhibited. Dr. Leiber attributed SAMe depletion to extreme
oxidative stress associated with the metabolism of alcohol, which
rapidly consumes GSH. Because SAMe is one of the rate-limiting
steps in GSH biosynthesis, exogenous SAMe administration was an
object of many studies by Dr. Leiber on patients with ALD, and his
conclusions all favored human clinical trials involving SAMe and PC
administration in patients with CLD.
[0131] However, several recent SAMe studies on CLD have shown
inconclusive or inconsistent results. One recent study showed that
oral SAMe administration has low bioavailability, and the authors
recommend esterifying the molecule to form a "more lipid-soluble
prodrug". Therefore, low oral SAMe bioavailability may be a
significant contributing factor to the inconsistent results seen in
various recent SAMe studies. Further, SAMe is contraindicated for
patients with bipolar disorders and Parkinson's disease and it is
associated with serotonin metabolism, so use of serotonin-related
drugs are contraindicated for SAMe use as well.
[0132] For the reasons listed above, the present invention does not
include SAMe as a required metabolite in its formula. The medical
food compensates for this omission in three ways:
[0133] First, it has been proposed above that SAMe contributes four
major benefits in CLD; further, increased GSH production by SAMe is
generally regarded as the most significant benefit. Significantly,
there are two rate-limiting metabolites in the GSH biosynthetic
pathway: S-adenosylmethionine (SAMe) and N-acetylcysteine (NAC). In
other words, administration of either SAMe or NAC will promote GSH
production. The medical food of the present invention chooses to
fulfill the distinctive metabolic requirements of the
CMP-associated up-regulated GSH pathway by providing NAC as the
rate-limiting metabolite instead of SAMe to stabilize the GSH
pathway and to increase GSH synthesis. NAC safely and effectively
increases GSH production without affecting the SAM/SAH/methionine
pathway; thereby fulfilling CMP-increased metabolic demand for GSH
metabolites while simultaneously saving SAMe for other uses
including proper DNA methylation. Importantly, proper GSH
bioavailability will work to reduce CMP-associated oxidative stress
and CLD metabolic perturbations associated with extreme oxidative
stress.
[0134] Second, just as Dr. Leiber noted early on, providing PC
decreases oxidative stress by reducing the flux of SAMe into the
highly up-regulated PC pathways in CLD. Therefore, PC
administration resulted in more SAMe availability for GSH
production. In the same way, administration of NAC also increases
SAMe availability, because NAC administration reduces the draw of
SAMe into the GSH pathway. The result of fulfilling the increased
metabolic demand for metabolites in both of these up-regulated
CMP-associated pathways is that SAMe is less utilized, saving SAMe
for other metabolic functions, including DNA methylation.
[0135] Third, supplementing the one-carbon metabolite betaine
corrects SAMe-synthetase deficiency and effectively restores
methionine conversion to SAMe, as Dr. Leiber pointed out that
SAMe-synthetase is inhibited in ALD. In fact, administration of
one-carbon metabolites has been shown in many CLD studies to
restore proper SAM/SAH/methionine cycling, including homocysteine
to methionine cycling, and methionine to SAMe cycling. Many
researchers have concluded that future glutathione studies must
necessarily include one-carbon metabolites as well as metabolites
of the SAM/homocysteine cycle.
[0136] Most of the nutritional studies to date have focused on
single metabolites or single metabolic pathways in various
conditions of CLD. However, the interlinked nature of these
CMP-altered metabolic pathways beg for a comprehensive and
systematic approach to fulfill the distinctive nutritional
requirements of CLD patients. For instance, many researchers have
stated the need to add the one-carbon methyl donors to any future
CLD studies involving SAMe. As noted previously, many researchers
have advocated a multi-ingredient approach to future human CLD
clinical trials due to the interlinked nature of the CLD affected
metabolic pathways. The medical food supplies the one-carbon
metabolites, as well as the precursor metabolites and the
end-product metabolites to all CLD-affected biosynthetic pathways.
The medical food phase II human clinical trials will administer
CMP-associated metabolites in a comprehensive and systematic
approach to fulfill up-regulated CMP metabolic demand with proper
levels of required metabolites. The medical food clinical trials
will examine the effects of this regimen using FibroScan, a
non-invasive device, to assess liver stiffness, which correlates
well with fibrosis staging in patients with CLD.
[0137] The medical food does not treat CLD--it will not cure or
treat HCV, HBV, NASH or ALD; rather it satisfies the new
distinctive nutritional requirements of patients with CLD. Extreme
oxidative stress is created in CLD in part as a result of
unfulfilled nutritional requirements of patients. Fulfilling the
distinctive nutritional requirements of CLD patients may therefore
decrease oxidative stress. If long-term re-establishment of redox
homeostasis may be achieved, then improvement in fibrosis staging
may be possible. This is because fibrogenesis is not a direct
action of CLD. Fibrogenesis is a separate hepatic process that is
triggered by extreme oxidative stress associated with CLD, but
fibrosis is not caused by any direct action of CLD. In fact, GSH
depletion and oxidative stress have been implicated in triggering
fibrogenesis through hepatic stellate cell conversion to
myofibroblasts. Metabolomic studies have implicated CMP-associated
metabolic disruptions to the creation of CLD-associated extreme
oxidative stress. In other words, CLD-associated extreme oxidative
stress is at least in part the result of unfulfilled metabolic
requirements of patients with CLD, resulting in decreased
availability or depletion of necessary metabolites of the PC, GSH,
SAMe, and one-carbon metabolic pathways. Extreme oxidative stress
is associated with the trigger to fibrosis generation; therefore if
redox homeostasis is re-established, down-regulation of the
fibrogenic process may be achieved. The medical food of the present
invention's intended use is to re-establish redox homeostasis by
fulfilling the metabolic/nutritional demands of the CLD patients.
Studies have shown that once the fibrogenic activity is eliminated,
resorption of hepatic collagen may then occur thereby decreasing
fibrosis staging.
The Present Medical Food Invention Fulfills the New Distinctive
Nutritional Requirements of CLD Patients
Present Invention Supplies Metabolites Involved in Glutathione
(GSH) Biosynthesis
[0138] Glutathione (GSH) in the body is intrinsically involved with
cellular redox homeostasis, and therefore GSH homeostasis is
important in any disease that causes increased levels of oxidative
stress. As noted previously, extreme oxidative stress is a hallmark
of CLD and GSH is depleted due to decreased production and
overconsumption. Also, GSH experiences decreased production in CLD
due to CMP disruption of the SAMe cycle and one-carbon metabolism.
Therefore, researchers have called for studies that investigate the
administration of precursor metabolites of GSH synthesis to
patients with diseases associated with metabolic depletion of GSH,
describing it as a step that is important for research efforts into
a variety of chronic diseases.
[0139] GSH is essential for cellular redox homeostasis and GSH
synthesis is tightly regulated in the cytosol. After synthesis, GSH
is distributed to intracellular compartments such as the
mitochondrial membrane, endoplasmic reticulum and the nucleus. It
is also exported to extracellular spaces including the blood and
bile for utilization by other tissues. The half-life of GSH is only
2-3 hours. GSH is only catabolized in the extracellular space by
gamma-glutamyl transferase (GGT). The gamma glutamyl cycle involves
the rapid catabolism of extracellular GSH into constituent
peptides, which are then quickly taken back up by the cells for
rapid re-synthesis into GSH. This gamma glutamyl cycle of GSH
cellular export/catabolism/re-uptake/re-synthesis may be energy
inefficient, but it is a perfect design for a rapid-response
antioxidant system in response to extreme oxidative challenges.
Intracellular GSH status depends on precursor availability, the
rate of GSH oxidation to GSSG, and the capacity to recycle GSSG
back to GSH at the expense of NADPH. Under normal physiological
conditions, reduced GSH levels are 10 to 100 times greater than
oxidized GSH (GSSG) and mixed disulphide (GSSR). The ratio of
reduced and oxidized forms of GSH is important in cell signaling,
maintaining redox homeostasis and the promotion of cellular
mechanisms associated with cell proliferation, cell differentiation
or apoptosis, while small variations in GSH:GSSG ratio tightly
regulate redox signaling.
[0140] GSH depletion has been associated with inhibition of
cytochrome c oxidase (CcOX) activity, microtubule network
disassembly, and processes associated with NO toxicity.
[0141] In GSH biosynthesis, GSH is produced through the
transsulfuration pathway involving SAMe conversion (cycling) to
homocysteine, then to NAC. NAC and L-Glutamate are then combined
into gamma-glutamylcysteine by the enzyme gamma-glutamyl
synthetase--the rate-limiting step in the biosynthesis of GSH.
Glycine is then added to the C terminal of the
gamma-glutamylcysteine molecule by the action of the enzyme
glutathione synthetase.
[0142] CMP-associated oxidative stress induced by CLD increases GSH
activity and consumption, which in turn prompts changes in GSH
levels. CLD creates a distinctive nutritional requirement for
increased GSH production. As noted above, GSH is depleted in CLD,
causing demand for greater synthesis and flux of SAMe and other GSH
metabolites through the GSH pathway. GSH depletion has been shown
to be involved in hepatic stellate cell activation in
fibrogenesis.
[0143] GSH performs a variety of metabolic roles in the body,
including antioxidant functions as a radical scavenger and as a
redox signaling modulator. GSH scavenges free radical ROS and RNS
directly and indirectly through enzymatic reactions. GSH also
reacts enzymatically with hydroperoxides, being a co-substrate for
selenium-dependent Glutathione Peroxidase (GPX), which is the
body's most important mechanism for reducing H2O2 and lipid
hydroperoxides. GSH may also reduce and detoxify ROS-promoted
lipid-oxidation products such as malonyl dialdehyde and
4-hydroxy-2-nonenal, as well as many other species. GSH maintains
thiol homeostasis of cysteine residues on proteins. It also
conjugates and stores cysteine reserves. Glutathione is associated
with estrogen, leukotriene, and prostaglandin metabolism. GSH also
participates in the production of deoxyribonucleotides, in the
maturation of iron-sulfur cluster in proteins, and it participates
in signal transduction and cellular transcription.
[0144] As noted previously, the medical food has chosen to include
NAC to increase GSH production rather than SAMe. Administration of
NAC has also long been known to safely promote intracellular GSH
production, decrease oxidative stress and has had anti-fibrotic
actions in preliminary human studies. NAC has also been shown to
decrease inflammatory markers and decrease hepatic fatty acid
accumulation in ethanol-fed rats. The addition of NAC to
corticosteroids has also been shown to decrease hepatorenal
syndrome, infection, and short-term mortality in patients with
severe ALD.
[0145] The medical food supplies NAC for GSH synthesis, which
decreases demand for SAMe because SAMe is normally converted to NAC
for GSH synthesis. As stated previously, the present invention also
provides PC, which also decreases SAMe utilization in the PC PEMT
biosynthetic pathway in CLD. Administration of NAC and PC, both of
which are metabolic end-products of CMP-disrupted metabolic
pathways, conserve SAMe for other purposes, including DNA
methylation or some of the many other metabolic functions of
SAMe.
[0146] CLD is associated with DNA hypomethylation. DNA
hypomethylation results in phenotypic and epigenetic alterations.
ALD causes alcoholic steatosis and methionine metabolism disruption
associated with DNA hypomethylation and altered gene expression.
SAMe is one of the main one-carbon methyl donors that methylates
DNA. However, SAMe availability is limited by impaired enzyme
activity in the SAM/SAH/methionine cycle in ALD patients, and
decreased SAMe is one of the causes of DNA hypomethylation. The
medical food restores SAMe availability by administering all of the
one-carbon methyl donors associated with CMP pathways, as well as
by saving SAMe from overutilization in the GSH and PC pathways. In
this way, the medical food's one-carbon metabolites safely restore
enzymatic cycling of the homocysteine/SAH/methionine pathway to
produce more SAMe for proper DNA methylation.
[0147] CLD is also characterized by increased mitochondrial
permeability transition, and this is associated with ROS
penetration into the cytosol. NAC has been shown to inhibit
alterations of mitochondrial permeability transition. Therefore,
metabolic precursors of the GSH biosynthetic pathway including NAC,
glycine, and glutamate are the distinctive required nutrients for
patients with CLD.
The Present Invention Supplies Metabolites Involved in Other
GSH-Interlinked Antioxidant Systems
[0148] New distinctive nutritional requirements created by CLD
necessitate systematic and comprehensive dietary management. A 1997
review regarding viral diseases and their induction of oxidative
stress remarked how complex and deleterious the pathogenic
induction of oxidative stress is, noting that supplying specific
antioxidants may solve both short-term and long-term issues seen in
patients with HCV.
[0149] GSH biosynthesis is intrinsically involved in the regulation
and redox cycling of various antioxidant systems. In particular,
CMP up-regulated thiol-containing antioxidant systems need dietary
management to fulfill their functions and remain in homeostasis,
and the medical food supplies NAC, ALA and PC to fulfill the
distinctive nutritional requirement of CLD patients for these
up-regulated thiols.
[0150] The body has two basic antioxidant systems, classified as
the enzymatic antioxidant system and the non-enzymatic antioxidant
system: [0151] Enzymatic antioxidants include superoxide dismutase
(SOD), catalase, glutathione peroxidase, thioredoxin and
glutaredoxin. [0152] Small molecule non-enzymatic antioxidants
include lipid-soluble vitamins A, D and E. Vitamins B, C and GSH
are water-soluble antioxidants. GSH is the master controller for
proper cooperative reduction of these linked-chain small molecule
non-enzymatic cellular antioxidants.
[0153] Intracellular small molecule antioxidants like vitamins B's,
C, D and E are consumed at an increased rate due to CLD-associated
extreme oxidative stress. In addition, trace elements like zinc,
selenium, and manganese are metabolic antioxidant cofactors that
also experience greater utilization in patients with CLD. Selenium
is a cofactor of glutathione peroxidase, and zinc, manganese and
copper are cofactors for SOD.
[0154] These small molecule antioxidants require reduction after
oxidation in order to re-establish antioxidant function. This is
accomplished through reducing systems such as
glutathione/glutathione disulfide, dihydrolipoate/lipoate, or
NADPH/NADP+ and NADH/NAD+. These small molecule antioxidants also
reduce each other in a linked-chain re-charging redox system. For
instance, CoQ10 has been shown to enhance enzymatic NADH- and
NADPH-recycling of tocopherols in mitochondria without being
consumed itself. Vitamin C, ALA and GSH all reduce vitamin E.
Vitamin E reduces vitamin A and the carotenoids, while it
stabilizes membranes and protects against lipid peroxidation. ALA
and selenium reduce GSH. GSH reduces cystine, vitamin C and
polyphenols. Decreased levels of GSH and increased oxidative stress
associated with CLD have an impact on the reduction capacity of the
small-molecule non-enzymatic antioxidant system, while chronic
extreme oxidative stress may impair the ability of the redox system
to maintain cellular redox homeostasis. Due to the interlinked
nature of their redox duties, depletion of any individual members
of this cellular non-enzymatic small-molecule antioxidant
recharging system may result in decreased levels of all members of
this linked antioxidant system. For these reasons, proper
combinations of linked antioxidants are required for full-system
stabilization. GSH also contributes to the redox homeostasis of
mitochondrial antioxidant metabolites, including the B vitamin
family, CoQ10 and ALA.
[0155] Antioxidant minerals such as zinc, selenium and magnesium
are consumed at a higher rate in CLD related to increased oxidative
stress. ALD has also been shown to impair zinc uptake. Therefore,
CLD creates a distinct nutritional requirement for increased intake
of these antioxidant mineral metabolites. Zinc, selenium and
magnesium are part of the required nutrients contained in the
medical food to meet increased demand from CLD-associated elevation
of oxidative stress.
[0156] The medical food contemplated herein provides the full
complement of interlinked small-molecule non-enzymatic
antioxidants, including the antioxidant minerals zinc, selenium,
magnesium, CoQ10, vitamins A, B, C, D, E, and the thiol-based
cellular antioxidant ALA in moderate, balanced quantities. The
medical food's three times-daily administration schedule is
intended to maximize periods of nutrient delivery in response to
the constant up-regulated metabolic and nutritional demands of
patients with CLD.
[0157] The medical food nutrients also fulfill a distinctive
nutritional requirement for B vitamins, which are necessary for
proper mitochondrial metabolism, and which are altered in CLD.
Vitamin B deficiencies cause mitochondrial dysfunction, and
administration of B vitamins may ameliorate symptoms associated
with B vitamins deficiencies and prevent mitochondrial
toxicity.
[0158] The medical food fulfills a distinctive nutritional
requirement for all the B vitamins in patients with CLD. This
distinctive nutritional requirement is due to increased consumption
due to CLD-associated extreme oxidative stress. Niacin (vitamin B3)
is a necessary mitochondrial B vitamin and is the precursor of NAD
and NADPH. Niacin supplementation has a positive effect on fatty
liver. A study by Li et al found "Chronic EtOH feeding induced
significant lipid accumulation in the liver, which was . . .
ameliorated by dietary NA supplementation. Liver total NAD, NAD(+),
and NADH levels were remarkably higher in the NA supplemented group
than the NA deficient or EtOH alone groups". NADH reduces oxidized
GSH. The medical food supplies thiamine (vitamin B1), another
mitochondrial antioxidant B vitamin found decreased in CLD.
Thiamine administration reversed many of the detrimental effects of
ethanol administration in rats.
[0159] Studies showed HCV creates a distinctive nutritional
requirement for increased CoQ10 due to HCV-induced depletion of
mitochondrial GSH, increase in ROS production and disruption of the
mitochondrial electron transport chain. CoQ10 is a mitochondrial
antioxidant and involved in electron transport in the mitochondria.
Intracellular CoQ10 levels reflect the functional status of the
electron transport complex in the mitochondria. CoQ10 reduces GSH
without being consumed itself due to its promotion of enzymatic
process.
[0160] The medical food formula fulfills the distinctive
nutritional requirements for vitamin E, selenium, magnesium and
zinc, which are depleted in CLD, in particular HCV infection.
Studies demonstrated administration of these antioxidants
alleviated symptoms of oxidative stress in patients with HCV.
[0161] The medical food also fulfills a distinctive nutritional
requirement for magnesium. Magnesium deficiency is associated with
cirrhosis and it plays a significant role in increasing oxidative
stress and apoptosis, as well as accelerating the aging process.
Zinc has long been known to have antioxidant functions. As noted
above, various studies found selenium and zinc at low levels in CLD
and HCV-infected patients. Zinc and selenium were also found to be
decreased in liver cirrhosis patients, and administration of zinc
and selenium had positive metabolic effects on cirrhotic and cancer
patients. Vitamin E and selenium were found to promote hepatic
stellate cell apoptosis in rats. Selenium has long been known for
its antioxidant effects, and studies show that selenium appears to
cause up-regulation of manganese superoxide dismutase (MnSOD).
Selenium is also involved in the thioredoxin and glutaredoxin
thiol-based enzymatic antioxidant systems. Vitamin E and selenium
supplied together have been found to decrease hepatic stellate cell
activation and hepatic fibrosis.
[0162] Vitamin D is a metabolic antioxidant, and it is known to be
deficient in all CLD, in particular NAFLD and HCV. The medical food
nutrients fulfill a distinctive nutritional requirement for Vitamin
D in CLD patients.
[0163] The medical food nutrients fulfill a distinctive nutritional
requirement for alpha lipoic acid (ALA), which is a cellular
thiol-containing antioxidant. ALA can lower oxidative stress and it
plays an essential role in mitochondrial antioxidant reactions,
quenching ROS such as superoxide radicals, hydroxyl radicals,
hypochlorous acid, peroxyl radicals, and singlet oxygen. ALA also
reduces vitamin C and GSH, which in turn recycles vitamin E. ALA
fulfills a requisite distinctive nutritional need because of the
role that ALA plays in CMP-altered metabolic systems, especially in
CMP-altered cellular redox homeostasis. ALA directly scavenges ROS,
but it also recycles other antioxidants like GSH and vitamin C and
prevents toxicities associated with their depletion. ALA promotes
GSH synthesis and vitamin C levels, and modulates transcription
factors like NFkappaB. Studies show ALA has dramatic effects in
oxidative stress conditions. L-carnitine and ALA reversed
mitochondrial oxidative damage and serum liver enzymes in NASH
model mice. Further, ALA chelates metal ions like iron and
copper.
[0164] ALA is an important constituent of the linked-chain
intracellular antioxidant system and it is known to have potent
redox properties, but evidence shows that besides being a direct
scavenger of oxidants, ALA has been shown to stimulate GSH
synthesis through an up-regulation of a transcription factor, Nrf2.
Nrf2 determines the expression of antioxidant and detoxification
genes regulated by the antioxidant response element (ARE).
Significantly, ALA has also been shown to modulate NF-kappaB
transcription factor activity, which is involved in hepatic
stellate cell activation.
[0165] CLD-induced oxidative stress establishes the distinctive
nutritional requirement for thiol-containing antioxidants as well
as non-enzymatic small molecule cellular antioxidants, of which ALA
is both. The medical food protocol provides moderate amounts of ALA
to fulfill the distinctive nutritional requirements of CLD
patients.
The Medical Food of the Present Invention Supplies Botanical
Polyphenols--Integral Components of the Body's Physiological
Antioxidant Response
[0166] The medical food provides polyphenols from GRAS botanicals
due to the new distinctive nutritional requirements of CLD patients
and their CMP-associated disruption of redox system homeostasis and
inducement of extreme oxidative stress. Polyphenols from GRAS
botanicals are important integral components of the body's normal
metabolic response to oxidative stress. Studies have shown that
botanical polyphenols prevent Nrf2 translocation and modulate
NF-kappaB pathways, thereby protect DNA from oxidative
stress-mediated damage. Dietary botanical polyphenols are integral
components of our bodies' physiological antioxidant response.
Administration of botanical polyphenols and other antioxidant
metabolites have been shown to be helpful in liver disease due to
their metabolic antioxidant effects.
[0167] The medical food provides the following GRAS botanicals
whose administration in animal and human studies on CMP-associated
oxidative stress have been demonstrated:
[0168] Artimisia absinthia (wormwood) has been shown to prevent
chemically induced liver damage in animal models. Artimisia has
also been shown to be hepatoprotective in ethanol-induced
hepatotoxicity in animal models and antifibrotic in CCl4 induced
fibrosis in animal models. Artimisia inhibited the inflammatory
response induced by lipopolysaccharides by preventing NF-kappaB
activation in human hepatoma cells and rat livers.
[0169] Piper cubeba (cubeb berries) has been used in folk medicine
for centuries. It contains monoterpenes and sesquiterpenes among
its phenolic components while also providing micronutrients. Piper
also contains piperine, which has been associated with antioxidant
efficacy, inhibition of liver fibrosis and hypolipidic effects in
high-fat diet rats. Piperine has also been shown to inhibit the
macrophage inflammatory response.
[0170] Cynara scolymus (artichoke) has been shown to reduce hepatic
oxidative stress and restore lipoprotein homeostasis in rats fed a
high cholesterol diet. Polyphenols from artichoke have been shown
to markedly reduce hepatic oxidative stress in rats and to prevent
the loss of GSH in rat hepatocytes. Further, artichoke was found to
inhibit cholesterol biosynthesis in rat hepatocytes. As seen in
Part A, cholesterol levels increase in patients with CLD due to
CMP-associated metabolic changes.
[0171] Nigella sativa (black cumin) administration to HCV patients
in Egypt was found to be " . . . tolerable, safe, decreased viral
load, and improved oxidative stress, clinical condition and
glycemic control in diabetic patients". Black cumin seeds and oils
have been found to be hepatoprotective against hepatotoxicity
induced by either disease or chemicals. The beneficial effects are
likely related to their cytoprotective and metabolic antioxidant
actions. In lipopolysaccharide-induced inflammation, black cumin
has an antioxidant effect. Black cumin has also been shown to have
beneficial immunomodulatory properties related to its metabolic
antioxidant properties.
[0172] Curcuma longa (Turmeric) has been found to have significant
hepatic antioxidant properties in ethanol-induced oxidative stress,
in rabbits fed an atherogenic diet, and in liver oxidative damage
induced by lead acetate in mice. Turmeric extract (curcumin) has
been found to inhibit the progression of liver cirrhosis in
thiocetamide induced liver cirrhosis in rats. Turmeric extract was
also found to regulate plasma cholesterol and fatty liver in rats
fed a high-cholesterol diet. Turmeric exerts an antioxidative
effect on phospholipid peroxidation and hepatic lipid metabolism in
mice fed a high cholesterol or atherogenic diet. Curcumin has long
been shown to be an effective antioxidant nutrient in liver
diseases. Further, Curcumin inhibits several factors like nuclear
factor NF-kappaB, a prototypical proinflammatory signaling pathway.
Curcumin attenuates liver injury induced by ethanol, thioacetamide,
iron overdose, cholestasis and acute, subchronic and chronic carbon
tetrachloride (CCl(4)) intoxication. Moreover, curcumin reverses
CCl(4) induced cirrhosis. Curcumin has been shown to be
hepatoprotective against ethanol-induced hepatic fibrosis by
inhibiting hepatic stellate cell proliferation and by suppressing
TGF-Beta signaling.
[0173] Grape Seed extract has been shown to reduce oxidative stress
in experimental animal biliary obstruction studies, in methotrexate
induced oxidative stress in rat liver, in radiation induced
oxidative stress in rat liver, and in a rat model of diabetes
mellitus, which is a condition that aggravates CLD. Grape Seed
extract has also been shown to improve liver function in patients
with NAFLD.
The Medical Food of the Present Invention Supplies
Phosphatidylcholine (PC), which Fulfills a Distinctive Nutritional
Requirement for Increased PC in Chronic Liver Disease Patients
[0174] A recent review summarized current and historical in-vitro
and clinical studies on PC. The animal studies and in-vitro studies
reviewed in the analysis found that, " . . . EPL influenced
membrane-dependent cellular functions and showed anti-oxidant,
anti-inflammatory, anti-fibrotic, apoptosis-modulating,
regenerative, membrane-repairing and -protective, cell-signaling
and receptor influencing, as well as lipid-regulating effects in
intoxication models with chemicals or drugs." The review also
analyzed clinical studies, where patients with CLD of all
etiologies, " . . . have shown improvement in subjective symptoms;
clinical, biochemical and imaging findings; and histology in liver
indications such as fatty liver of different origin, drug
hepatotoxicity, and adjuvant in chronic viral hepatitis and hepatic
coma."
[0175] PC is a main cellular membrane phosphoplipid, and it is
associated with proper cell membrane and mitochondrial membrane
form and function. PC is synthesized in two different biosynthetic
pathways in the body. These include the SAMe dependent PEMT pathway
and CDP-choline pathway. In the PEMT pathway, SAMe is involved in
three successive methylations of phosphatidylethanolamine (PE) to
form PC. The PEMT pathway occurs in the liver only. The other main
PC biosynthetic pathway is called the CDP-choline pathway (or the
Kennedy pathway) and it occurs in the rest of the cells of the
body. In this pathway, PC is created through conversion of dietary
choline into CDP-choline and then to PC.
[0176] CLD causes decreased availability of PC, and oxidation of PC
in membranes can occur in CLD due to extreme oxidative stress. It
has been shown that CLD creates increased demand for PC and
choline. The medical food supplies PC, the biosynthetic end-product
of both PC pathways. PC administration spares SAMe from increased
flux into the PEMT PC pathway. PC administration also produces
choline, which is produced from the catabolism of PC. Both dietary
choline and PC-derived choline are either cycled back to the
CDP-choline pathway for PC production or cycled to the production
of betaine, a necessary one-carbon donor involved in the
SAM/SAH/methionine metabolism, or also to acetylcholine.
[0177] Choline regulates cholesterol metabolism, which is another
up-regulated CMP-associated pathway. Choline supplementation
improved liver function and prevented NASH in a study on PEMT
knockout mice. As reported by Al Rajabi et al, hepatic cholesterol
but not triglyceride was normalized with a significant improvement
in liver function when supplemented with choline. They concluded
that their findings suggested choline can maintain cholesterol
homeostasis and thereby promote liver health.
[0178] Dr. Lieber found that oral supplementation of PC caused
increased GSH synthesis due to increased SAMe availability. This
increase in SAMe stores was due to decreased metabolic demand for
SAMe into the PEMT pathway due to PC end-product supplementation.
Dr. Leiber surmised, " . . . it is likely that . . . providing PCs,
decreases the utilization of SAMe and thereby contributes to its
restoration, with replenishment of GSH and correction of the
alcohol-induced oxidative stress".
[0179] The Lieber study above showed that PC supplementation
decreases flux of SAMe from the PC biosynthetic pathway to the GSH
biosynthetic pathway. It is also true that the flux of SAMe may be
decreased into the CMP up-regulated GSH biosynthetic pathway if
that pathway is supplied with additional amounts of NAC. NAC and
SAMe are the two rate-limiting metabolites in GSH biosynthesis, and
either will promote the production of GSH. NAC has been shown to
decrease oxidative stress in alcoholic hepatitis and in cirrhosis
animal studies.
[0180] Interestingly, PC administration by itself has shown an
anti-fibrogenic effect in studies performed on patients with CLD. A
European PC clinical study found reduced levels of
procollagen-III-peptide in HBV patients, while a study on HCV
patients found decreased levels of albumin-bound hydroxyproline.
Remarkably, anti-fibrotic improvement in histology was shown in
pharmacological and clinical studies performed on patients and
animals administered PC.
The Medical Food of the Present Invention Supplies Metabolites of
the SAM/SAH/Methionine Cycles, which Experience Greater Utilization
by Chronic Liver Disease Patients
[0181] Studies showed SAMe has positive effects on oxidative stress
in CLD, increasing GSH levels, which are depleted in CLD. It is
known that SAMe may play an important role in reversing hepatic
glutathione depletion in patients with CLD. While the medical food
does not supply SAMe, it supplies the other rate limiting
metabolite of GSH synthesis, NAC, for GSH synthesis instead.
Supplying NAC decreases demand for SAMe in the GSH biosynthetic
loop because SAMe is converted to NAC for GSH synthesis. The
medical food also supplies PC to the CMP up-regulated PC pathway;
thus, decreasing flux of SAMe into the PC pathway. Both of these
actions free up potential SAMe stores for DNA methylation or the
many other biosynthetic functions of SAMe.
[0182] A 1989 study showed that SAMe increases hepatic GSH in
patients with liver disease. In an ethanol-induced fibrotic mouse
model, SAMe administration was shown to attenuate oxidative stress
and hepatic stellate cell activation. SAM/SAH/methionine cycling
has been shown to be impaired in CLD and administration of
one-carbon metabolites has been shown to restore proper cycling.
Thus, the medical food contemplated herein fulfills the distinctive
nutritional requirements for increased SAMe and one-carbon
metabolites for proper Sam/SAH/methionine cycling.
[0183] Methionine/homocysteine metabolism and choline metabolism
are interdependent. Choline is recycled from catabolized PC and is
converted mainly back to PC, but also to acetylcholine and betaine.
Feeding a diet deficient in choline and methionine has been used as
a mechanism to create steatosis in the lab for studies. As noted
previously, all of these CLD-affected pathways are linked to
SAM/SAH/methionine and GSH metabolism, and therefore nutritional
deficiencies in any of these pathways may contribute to oxidative
stress.
The Medical Food of the Present Invention Supplies Metabolites of
One-Carbon Methyl Metabolism
[0184] The medical food formula also includes one-carbon methyl
donors such as folate, vitamin B12, vitamin B6 and betaine.
Increased SAM/SAH/methionine cycling creates greater demand for
one-carbon methylation factors. These one-carbon metabolites are
distinctive required nutrients provided in the medical food
protocol for their one-carbon methyl donating properties and their
interlinked duties with the SAM/SAH/methionine cycle and the
homocysteine/NAC/GSH cycle, both of which experience greater
utilization in patients with CLD.
[0185] One-carbon methyl donors like folate, vitamin B12 and
betaine convert homocysteine to methionine, and vitamin B6 directs
homocysteine to NAC, which is then ultimately converted to GSH.
Proper methylation by these one-carbon methyl donors is important
to avoid accumulation of homocysteine in the body. Therefore, any
up-regulation of the SAM/SAH/methionine cycle must necessarily be
accompanied by increased utilization of these critical one-carbon
methyl donors.
[0186] A study showed that ALD patients experience decreased
folate, vitamin B6 and thiamine levels, suggesting that these
deficiencies were due to the patients' inability to absorb those
vitamins from food. Interestingly, these patients were able to
absorb synthesized supplemental forms of these vitamins, in spite
of their inability to absorb the nutrients from food. Another study
showed Thiamine supplementation reversed ethanol-induced
hepatotoxicity in rats.
[0187] Betaine, one of a necessary medical food metabolites, aids
in the conversion of homocysteine to methionine. Betaine is also a
thiol-enhancing cofactor.
[0188] One-carbon methyl donors have positive nutritional effects
on redox homeostasis and oxidative stress due to their intrinsic
role in SAM/SAH/methionine metabolism. As noted previously, the
medical food does not provide SAMe or methionine to satisfy the
distinctive nutritional requirement of CLD patients for increased
SAMe. Rather, the medical food concentrates on saving SAMe by
decreasing the draw of SAMe into the other highly up-regulated CMP
pathways, the PC and GSH pathways. Further,
SAMe-homocysteine-methionine cycling is impaired due to decreased
enzymatic activity, which the medical food restores by
administering one-carbon metabolic methyl donors like betaine,
which protects against ethanol-induce fatty liver infiltration in
ALD. Betaine's restorative power to disrupted ALD metabolic
pathways is generally attributed to its role in restoring SAMe
supplies and thereby decreasing oxidative stress. A study conducted
by Yung et al documented that betaine's hepatoprotective activity
is associated with its effects on sulfur amino acid metabolism.
The Medical Food of the Present Invention Supplies Metabolites of
CLD Depleted Amino Acid Metabolism
[0189] CLD increases utilization and decreases availability of
L-Carnitine. L-Carnitine levels are diminished in all CLD, in
particular HCV, and this makes it a required metabolite in the
medical food formula. Depletion of L-Carnitine may have negative
effects on CLD-associated steatosis because L-Carnitine transports
cytosolic fatty acids to the mitochondria for .beta.-oxidation.
.beta.-oxidation of fatty acids is another CMP up-regulated
activity. The medical food supplies L-lysine, which combines with
methionine to form the CMP-depleted amino acid, L-Carnitine. The
medical food also supplies L-Carnitine to meet increased demands
for increased .beta.-oxidation of fatty acids in patients with CLD.
In a NASH mouse model, "L-Carnitine prevents progression of NASH in
a mouse model by up-regulating the mitochondrial .beta.-oxidation
and redox system". L-Carnitine and ALA reversed mitochondrial
oxidative damage and serum liver enzymes in NASH mouse model.
[0190] The medical food also supplies arginine as a required amino
acid metabolite in CLD patients. Arginine is oxidized to form
nitric oxide (NO). NO is involved in the modulation of hepatic
microcirculatory perfusion and oxygenation in cholesterol-induced
hepatic steatosis. Arginine administration selectively increases NO
levels, which improves hepatic microcirculation and tissue
oxygenation in patients with cirrhosis. A study conducted by Nanji
et al reported that " . . . our results show that arginine
administration, probably through the generation of nitric oxide,
leads to improvement in pathological changes such as fatty liver,
necrosis, inflammation, and fibrosis. These improvements were
accompanied by down-regulation of nuclear factor NF-.kappa.B,
pro-inflammatory cytokines cyclooxygenase-2, and inducible nitric
oxide synthase". GSH depletion leads to NO toxicity, so the medical
food contemplated herein supplies the GSH metabolites, NAC,
L-glutamate and L-lysine for GSH production.
[0191] The medical food supplies arginine as a necessary amino acid
metabolite for patients with CLD. Decreased arginine levels may be
associated with hepatic encephalopathy and hyperammonemia due to
urea cycle disruption. Studies have found that the CMP-associated
metabolic disruption of the of the ammonia detoxification pathway "
. . . precede the histological manifestation of irreversible liver
damage". Arginine administration must be balanced with lysine
administration, which is also present in the medical food formula.
Lysine is also a metabolic precursor of L-carnitine, as mentioned
above.
Exemplary Composition Embodiments
[0192] In a particular embodiment, a daily dose of the medical food
contemplated herein may comprise the following ingredients in the
following mass ranges:
L-Lysine in a range of 400-5,000 mg N-Acetyl Cysteine in a range of
500-5,000 mg L-Arginine in a range of 1,000-9,000 mg
Polyenylphosphatidylcholine in a range of 500-10,000 mg Alpha
Lipoic Acid in a range of 200-2,500 mg Vitamin C (as ascorbic acid
& calcium ascorbate) in a range of 500-10,000 mg N-Acetyl
L-Carnitine in a range of 250-3,000 mg Betaine HCl in a range of
300-20,000 mg L-Glutamate in a range of 200-2,000 mg Turmeric
(Curcuma longa) in a range of 200-1,500 mg Grape seed extract (95%
Proanthocyanidins) in a range of 100-1,000 mg Black cumin seed
(Nigella sativa) in a range of 50-400 mg Pantothenic acid (as
calcium pantothenate) in a range of 20-10,000 mg Benfotiamine in a
range of 50-400 mg Magnesium (as magnesium citrate) in a range of
50-800 mg Vitamin E (as mixed tocopherols) in a range of 50-1,000
.mu.l Artichoke (leaf) extract (Cynara scolymus) in a range of
25-300 mg L-Glycine in a range of 50-3000 mg Vitamin B1 in a range
of 10-200 mg Vitamin B2 in a range of 10-200 mg CoQ10 (as
ubiquinol) in a range of 30-1,000 mg Cubeb berries (Piper cubeba)
in a range of 10-100 mg Wormwood (Artemisia absinthium) in a range
of 10-100 mg Vitamin B3 in a range of 45-3,000 mg Vitamin B6 (as
pyridoxine HCl) in a range of 10-200 mg Zinc (as zinc citrate) in a
range of 5-50 mg Vitamin D3 in a range of 400-10,000 IU Folate (as
folic acid) in a range of 200-3,000 mcg Vitamin B12 (as
methylcobalamin in a range of 200-3,000 mcg Selenium (as selenate
aspartate) in a range of 100-600 mcg Biotin in a range of 50-2,000
mcg
[0193] It should be understood that in varying embodiments, the
present medical food may not have all of the above listed
components. Indeed many may be omitted. In a particular embodiment,
any combination of N-Acetyl Cysteine, Alpha Lipoic Acid,
Polyenylphosphatidylcholine, and one or more of the above listed
components may constitute the medical food of the present
invention. In another embodiment, the medical food the composition
may comprise Acetyl Cysteine, Alpha Lipoic Acid,
Polyenylphosphatidylcholine.
[0194] In still another embodiment a daily dose of the medical food
contemplated herein may comprise the following ingredients in the
following mass ranges:
N-Acetyl Cysteine in a range of 500-5,000 mg L-Arginine in a range
of 1,000-9,000 mg Polyenylphosphatidylcholine in a range of
500-10,000 mg Alpha Lipoic Acid in a range of 200-2,500 mg
[0195] Turning now to FIG. 1, a flow chart of an embodiment of use
of the medical food of the present invention is provided. In this
view, initially a patient having chronic liver disease is
identified. This patient is then provided with a three times daily
regimen of an embodiment of the medical food. The medical food may
be taken in any number of manners, as noted above. After a period
of time with taking the three times daily regimen of medical food,
the patient may be tested to track progress and efficacy. This
testing may involve periodic blood tests and liver stiffness
measurement using a non-invasive medical device called FibroScan.
Based on the changes measured and caused by the medical food
regimen, it may be adjusted, continued, or the like.
[0196] While several variations of the present invention have been
illustrated by way of example in preferred or particular
embodiments, it is apparent that further embodiments could be
developed within the spirit and scope of the present invention, or
the inventive concept thereof. However, it is to be expressly
understood that such modifications and adaptations are within the
spirit and scope of the present invention, and are inclusive, but
not limited to the following appended claims as set forth.
* * * * *