Amino acid control of muscle protein turnover in renal disease

This review discusses the concept that skeletal muscle intracellular amino acids (ICAAs), in particular the essential amino acids, are regulated throughout a wide range of physiologic circumstances. Whether in critical illness, severe injury, or healthy states, ICAAs are closely regulated by a coordinated response in 1 or more of the processes of synthesis, breakdown, and tissue transport. For a given metabolic signal (hormonal, change in plasma amino acid concentrations), the regulation of ICAAs entails appropriate and corresponding changes in amino acid kinetics. These changes vary according to the strength of the metabolic signal and the existing requirement to maintain the ICAA pool. For the patient with end-stage renal disease (ESRD), frequent dialysis induces an abrupt removal of half of the circulating amino acids, which in turn results in a substantial efflux of amino acids from skeletal muscle. ICAAs are maintained through the increase in protein breakdown, and similar to other stress states, there is a concomitant increase in protein synthesis. Thus, the regulation of ICAAs often pushes subsequent adaptations in amino acid kinetics to maintain the existing homeostasis. This regulatory mechanism is evident in circumstances ranging from increased amino acid availability in healthy volunteers to a change in anabolic signal in severe injury. Despite the substantial evidence of ICAA regulation, its physiologic significance is not evident. However, the regulation of ICAAs represents a method by which skeletal muscle ensures its capacity for anabolism.