The hepatic catabolic stress response. Hormonal regulation of urea synthesis after surgery.

Following non complicated surgical trauma in man a hepatic condition has been identified that is characterized by lower than normal plasma alpha-amino nitrogen concentration and increased plasma clearance of gluconeogenic and ureagenic amino acids. Amino acids are removed from the blood by the liver, by way of a doubling of the hepatic efficacy fo urea synthesis. At any plasma amino acid concentration twice as much amino-nitrogen is excreted as urea-nitrogen, and thus lost for protein synthesis. This hepatic stress response lasts for one week postoperatively. In rats, hysterectomy elicits a similar response, but the time of the maximum increase in urea synthesis occurs earlier. Combined neuro-hormonal blockade totally prevents the response in cholecystectomized patients. In rats, it is preventable by selective blockades of glucocorticoid action and of prostaglandins synthesis. In isolated livers catecholamines, corticosterone, and glucagon together bring about 40% of the increase in urea synthesis in vivo, but only in livers "conditioned" by hysterectomy three hours earlier. Prostaglandin E2 in itself has no effect on urea synthesis, but accelerates the effect of the hormones. The regulatory system is incompletely elucidated, although several mediators are identified. A hierarchical system is suggested and discussed, and further possible regulators indicated. The role of liver for whole body nitrogen homeostasis during stress is estimated. The increase in hepatic efficacy for urea synthesis in itself accounts for about 50% of the postoperative nitrogen loss. Identification of the pathophysiological changes following surgical trauma is probably decisive for endeavours to improve postoperative morbidity and mortality. Modification of the hepatic contribution to postoperative loss of nitrogen may be necessary.