Here is a selection of good Abstracts on Whey Protein and GSH.

ImmunePro Rx is the highest quality Cysteine donating whey protein available.

THE EFFECT OF SUPPLEMENTATION WITH A CYSTEINE DONOR ON MUSCULAR PERFORMANCE

L.C. Lands, MD, PhD*,Ý
V.L Grey, PhDÝ,ý
A.A Smountas, BSc*
*Division of Respiratory Medicine
ÝDapartment of Pediatrics
ýDepartment of Biochemistry, McGill University Medical Centre - Montreal Children's Hospital, Montreal, Quebec, Canada
This research was supported in part the Canadian CF Foundation and Immunotec Research, Inc.  
LC Lands is a clinical-investigator with the Fonds de la Recherche en Santé du Québec  
Address all correspondence to:
Dr. Larry C. Lands, M.D., Ph.D.
Respiratory Medicine
Montreal Children's Hospital
Room D-380
2300 Tupper St.
Montreal, Quebec, Canada
H3H 1P3
Phone: 514-934-4442
Fax: 514-934-4364
e-mail: llanpul@mch.mcgill.ca

Cysteine donor supplementation

ABSTRACT
Oxidative stress contributes to muscular fatigue. Glutathione (GSH) is the major intracellular antioxidant, whose biosynthesis is dependent upon cysteine availability. We hypothesized that supplementation with a whey-based cysteine donor (immunocal [HMS90]) designed to augment intracellular GSH, would enhance performance. Twenty healthy young adults (10 m) were studied pre- and 3 months post-supplementation with either immunocal (20 gm/day) or casein placebo. Muscular performance was assessed by whole leg isokenetic cycle testing, measuring Peak Power and 30-sec Work Capacity. Lymphocyte GSH was used as a marker of tissue GSH. There were no baseline differences (age, ht, wt, Peak Power, 30-sec Work Capacity). Follow-up data on 18 subjects (9 Immunocal, 9 placebo) were analyzed. Both Peak Power mean ±se: 13±3.5%, p<0.02) and 30-sec Work Capcity (13±3.7%, p<0.03) increased significantly in the Immunocal group, with no change (2±9.0 and 1±9.3%) in the placebo group. Lymphocyte GSH also increased significantly in the Immunocal group (35.5±11.04%, p<0.02) with no change in the placebo group (-0.9±9.6%). This is the first study to demonstrate that supplementation with a product designed to augment antioxidant defenses resulted in improved volitional performance. We speculate that supplementation with this product may have even more benefit in situations of ongoing oxidative stress, such as chronic obstructive lung disease and cystic fibrosis.

INTRODUCTION
Oxidative stress contributes to the development of muscular fatigue. Glutathione (glutamyl-L-cysteinylglycine, GSH) is a major intracellular antioxidant, whose biosynthesis depends upon the intracellular availability of cysteine. Previous work has shown that supplementation with N-acetylcysteine can slow the onset of muscular fatigue. However, there are significant adverse effects with such treatment, possibly related to elevations in extracellular cysteine. Cysteine, in the form of glutamlycystine moieties more readily enters into cells. Immunocal, a whey-based oral supplement with relative abundance of glutamycysteine, has been shown to augment intracellular GSH concentrations in vitro. We hypthesized that if this would occur in vivo, then supplementation with Immunocal would improve muscular performance.

Chest. 1999;116:201-205.)
© 1999 American College of Chest Physicians

Lymphocyte Glutathione Levels in Children With Cystic Fibrosis^*  
Larry C. Lands, MD, PhD; Vijaylaxmi Grey, PhD; Argyrios A. Smountas, BSc, RRT; Violeta G. Kramer, BSPharm and Danielle McKenna, DEC  
^{* From the Division of Respiratory Medicine (Dr. Lands and Mr. Smountas), the Department of Pediatrics (Drs. Lands and Grey), and the Department of Biochemistry (Dr. Grey, Mss. Kramer and McKenna), McGill University Medical Centre­Montreal Children's Hospital, Montreal, Quebec, Canada.  
Correspondence to: Larry C. Lands, MD, PhD, Assistant Director, Respiratory Medicine, Montreal Children's Hospital, Room D-380, 2300 Tupper St, Montreal, Quebec, Canada H3H 1P3; e-mail:} lanpul@mch.mcgill.ca

Objective: Lung disease in cystic fibrosis (CF) is characterized by a neutrophilic inflammatory response. This can lead to the production of oxidants, and to oxidative stress in the lungs. Glutathione (GSH) represents the primary intracellular antioxidant, and provides an important defense in the epithelial lining fluid. Evidence suggests that lymphocyte GSH reflects lung GSH concentrations, and so could potentially serve as a peripheral marker of lung inflammation.

Methods: We assessed peripheral blood lymphocyte GSH concentrations in 20 children (13 boys) with CF who were in stable condition at the time of evaluation. Values were compared with nutritional status and lung function parameters.

Results: Patients were 11.7 ± 3.03 years old (mean ± SD). Their percentage of ideal body weight was 101.8 ± 17.92%; FEV₁, 79.5 ± 19.22% predicted; FEV₁/FVC, 75.0 ± 10.08%; and residual volume (RV)/total lung capacity (TLC), 31.3 ± 10.47%. For the group, the GSH concentration was 1.31 ± 0.52 µmol/10⁶ lymphocytes, which was not different from laboratory control values. GSH values were correlated with nutritional status (percentage of ideal body weight: r = 0.49, p < 0.03) and the degree of gas trapping (RV/TLC: r = 0.50, p < 0.03), and were correlated inversely with airflow limitation (FEV₁, percent predicted: r = -0.45, p < 0.05; FEV₁/FVC: r = -0.48, p < 0.04), but not with age, height, or weight (p > 0.1).

Conclusions: We interpret the inverse correlation between lymphocyte GSH concentration and lung function as a reflection of upregulation of GSH production by lung epithelial tissue in response to oxidative stress. We interpret the correlation between lymphocyte GSH concentration and nutritional status as a reflection of the role of cysteine in hepatic glutamine metabolism. Peripheral blood lymphocyte GSH concentration may potentially serve as a convenient marker of lung inflammation. Furthermore, the increased demand for GSH production in the face of ongoing inflammation suggests a potential role for supplementation with cysteine donors.

Key Words: antioxidants • inflammation • oxidative stress

This article has been cited by other articles: Lothian, B., Grey, V., Kimoff, R. J., Lands, L. C. (2000). Treatment of Obstructive Airway Disease With a Cysteine Donor Protein Supplement: A Case Report. Chest 117: 914-916
Chest-- Lothian et al. 117 (8):914
(Chest 2000 117:914-916)
© 2000 American College of Chest Physicians

Treatment of Obstructive Airway Disease With a Cysteine Donor Protein Supplement A Case Report *

Bryce Lothian, MD; Vijaylaxmi Grey, Ph.D.; R. John Kimoff, MD and Larry C. Lands, MD, Ph.D.  
From the Department of Pediatrics (Drs. Lothian and Grey), Department of Biochemistry (Dr. Grey), and Division of Respiratory Medicine (Dr. Lands), McGill University Health Centre Montreal Children's Hospital, Montreal, Quebec, Canada; and Division of Respiratory Medicine (Dr. Kimoff), McGill University Health Centre-Royal Victoria Hospital, Montreal, Quebec, Canada.
Correspondence to: Larry C. Lands, MD, Ph.D., Assistant Director, Respiratory Medicine, The Montreal Children’s Hospital, Room D-380, 2300 Tupper St, Montreal, Quebec, Canada H3H 1P3

Abstract
Oxidant/antioxidant imbalance can occur in obstructive airways disease as a result of ongoing inflammation - Glutathione (GSH) plays a major role in pulmonary antioxidant protection. As an alternative or complement to anti-inflammatory therapy, augmenting antioxidant protection could diminish the effects of inflammation. We describe a case of a patient who had obstructive lung disease responsive to corticosteroids, and low whole blood GSH levels. After 1 month of supplementation with a whey-based oral supplement designed to provide GSH precursors, whole blood GSH levels and pulmonary function increased significantly and dramatically. The potential for such supplementation in pulmonary inflammatory conditions deserves further study.

Key Words: glutathione, inflammation, oxidative stress, and supplementation

Introduction
Evidence of oxidant/antioxidant imbalance has been demonstrated in obstructive airway disease.^1-2 Continued lung inflammation with the mobilization and activation of neutrophils, macrophages, and eosinophils and their release of free oxygen radicals and other reactive oxygen species (ROS) is a source of oxidative stress. In addition to the direct effects of such ROS on Cell membranes, DNA, and proteins, breakdown products act as signals perpetuating the inflammatory cascade. Glutathione (GSH) and the GSH system play a key role in protecting against the effects of ROS.^3,4 Modulation of the oxidant/antioxidant status in obstructive airway disease primarily aimed at enhancement of the GSH system, has been limited by difficulties in delivery of an effective substrate.^2,3,5 We describe the response to an oral, whey-based supplement designed to supply GSH precursors.

Case Report
A 40-year-old woman of North African origin was followed by the pulmonology service at a tertiary care hospital in 1997. Her medical history was significant for Hodgkin's lymphoma, diagnosed 27 years earlier and treated with radiation and chemotherapy. She had a 25-pack-year smoking history and had quit smoking in 1994. In 1995, she received a diagnosis of mild valvular heart disease (aortic and mitral regurgitation). At that time (time 1), pulmonary function tests (PFTs) suggested mild airflow obstruction (Fig 1); bronchodilators were not prescribed. In 1997 (time 2), she was admitted to hospital with a virally induced exacerbation at obstructive lung disease as well as mild heart failure. She improved with diuretics, bronchodilators (salbutamol and ipratropium bromide), and oral prednisone, 20mg/d. She was discharged taking a tapering course of prednisone.

Figure 1. Tracking of the pulmonary function values over time.
TLC = total lung capacity;
RV = residual volume.

When seen in follow-up 1 week later (time 3), she had suffered an exacerbation of her respiratory symptoms (shortness of breath, wheeze, chest tightness, and excessive mucus production) coincident with cessation of prednisone. Prednisone was prescribed again.

She returned 2 weeks later (time 4) with significant symptomatic improvement while still taking systemic corticosteroids and regular bronchodilators (salbutamol metered-dose inhaler and ipratropium bromide metered-dose inhaler qid). An attempt was made to discontinue prednisone. When the patient was seen 1 month later(time 5), her symptoms had returned. At that time, review of her history revealed no environmental insult that could account for her deterioration. Additionally, serum IgE was 52 kU/L (laboratory control, 0 to 100 kU/L), and both allergen skin testing and Aspergillus precipitins testing were negative. A further course of oral prednisone was prescribed (40 mg/d initially; tapering over 1 month).

Four months later (time 6), the patient returned to clinic independently, having begun taking HMS90 (Immunocal; Immunotec Research Ltd.; Vaudreuil, Quebec, Canada) a whey-based protein supplement (10 g bid), 1 month before. She had heard that the product could be helpful in inflammatory conditions, and had started taking the product of her own accord. She reported a remarkable improvement in her respiratory status and had discontinued all inhalers and steroids, and was not taking any other supplements, medications, or over-the-counter therapies. She was asked to discontinue the Immunocal, and within 3 months her symptoms returned. PFTs were performed at this time (time 7). She then restarted Immunocal of her own accord and 1 month later (time 8), PFTs were again assessed. Additionally, whole blood GSH levels were measured before and 1 month after therapy was reinitiated, using a modification of the method previously described ^6,7 Again, a remarkable improvement in both symptoms and PFTS was noted (E)1.In addition1 the total lung capacity increased from 3.91 L at time 7 to 5.00 L at time 8, and the residual volume/total lung capacity ratio fell from 33 to 28%. Her whole blood GSH levels increased from 235 to 457 umol/L (laboratory control, 589.2 plus or minus 112.6 umol/L; n = 10). It should be further remarked that the last two PFTs performed showed reversibility of the obstructive airway disease (change in FEV₁, 48% at time 7 to 15% at time 8), whereas no prior PFT had shown reversibility. The patient continues to take HMS90 (Immunocal) and no other respiratory medications, without return of her symptoms.

Discussion
The patient suffered from a worsening of her previously diagnosed obstructive airway disease. The relative contributions of smoking, asthma, and cancer therapy to her baseline lung disease are unclear, as was the cause of her deterioration. She required multiple courses of systemic discussion steroids to maintain lung function. Symptomatic improvement correlating with pulmonary-function coincided with her initiation of HMS90. More significantly, pulmonary function worsened with withdrawal of HMS90 (Immunocal) and improved with re-introduction. Her final respiratory status is objectively and subjectively better than at any time in the previous 4 years.

HMS90 (Immunocal) is a bovine whey-protein concentrate purified by ultrafiltration and low-temperature pasteurization of milk. The undenatured whey protein is rich in cystine (the oxidized form of cysteine) and glutamylcystine which are precursors of GSH synthesis. The tripeptide GSH (glutamylcysteineglycine) is synthesized in the cell in two steps. The first step, the synthesis of glutamylcystiene, is limited by the availability of intracellular cysteine⁴. As well, glutamylcystiene, as a glutamyl amino acid, can easily be transported into the cell where it combines with glycine in the second step of GSH synthesis⁸

^{Cells cannot take up extracellular GSH3. In the patient described, whole blood GSH levels were significantly increased (94%) following regular intake of HMS90 (Immunocal). This is much higher than the reported intraindividual variation in whole blood GSH values (7.8 to 15.8%) 9. In order to avoid any possible influence of the timing of sampling on GSH levels and pulmonary function, the patient was tested between 10:00AM and 11:00AM on each visit. Animal studies of GSH metabolism have demonstrated that whole blood GSH is reflective, temporally and quantitatively, of lymphocyte and tissue GSH levels. Although no direct markers of oxidant /antioxidant status or inflammation were measured in the patient described, the observed clinical effect is coincident with augmented GSH levels.}

^{Several specific abnormalities, or inadequacies, of the GSH antioxidant system have been identified in reversible obstructive airway disease. GSH itself is present in high concentrations in the lung epithelial lining fluid (ELF), where it may act to directly reduce ROS10,11. Clinically stable asthmatics have higher ELF GSH than symptomatic asthmatics5, while experimental models of oxidative stress show an increase in ELF GSH with oxidative stress10. Upregulation of antioxidant defenses, although not in proportion to oxidative stress1 is hypothesized to account for the increased BAL fluid GSH levels observed in both these studies and other pulmonary conditions the) are attributed, in part, to excessive oxidative stress10, GSH is also a substrate for the decomposition of a large number of ROSs (including hydrogen and other peroxidases)4. Studies have shown decreased peripheral blood GSH-Px activity in asthmatic patients1. Finally, it has been recently demonstrated in a murine model that GSH levels in the antigen presenting cell affect the differentiation of the T-helper cell Th1/Th2 cytokine response12.}

Improvement in GSH status could result in augmented lung function through several mechanisms. Within lung epithelial cells, augmented GSH may block the

C  activation of nuclear factor ?B by tumor necrosis factor-?, 13,14,15 and so limit the production and release of pro-inflammatory cytokines. Augmented intracellular GSH may reduce the need to recycle GSH from the lung lining fluid, and thus maintain extracellular levels16. Alternatively, increased intracellular GSH levels may lead to extracellular transport to buttress lung lining levels. In the lung lining fluid, augmented GSH may prevent oxidative damage to antiproteases17,18. Improvement in skeletal muscle function due to augmented GSH stores7 may also partially account for our results, as the baseline FEV1/FVC ratio did not change between times 7 and 8 (66% and 62%, respectively).

^{The ELF GSH pool has been the target of direct administration of nebulized GSH, although success has been limited by GSH-induced brnnchospasm5. Trials of systemic N-acetyl cysteine, acting as both a cysteine donor and an ROS scavenger, for the treatment of chronic obstructive airway disease have met with limited success, because of N-acetyl cysteine toxicity and limited clinical effect2,19.}

^{The relationship between whole blood GSH, lung epithelial cell GSH levels, ELF GSH, and peripheral blood GSH-Px activity is poorly defined. There are several possible mechanisms by which GSH could improve obstructive airway disease, either via immunologic modulation or by improving antioxidant defenses. More work needs to be done to further define the specific abnormalities of antioxidant function, as welt as the relative contribution of such abnormalities to the pathophysiology observed in obstructive airway disease. Nevertheless, the modulation of GSH and antioxidant defenses in obstructive airway disease (and many other diseases) represents an intriguing potential modality for anti-inflammatory therapy.}

Footnotes
Abbreviations: ELF = epithelial lining fluid, GSH = glutathione, GSH-PX = glutathione peroxidase, PFT = pulmonary function test, ROS = reactive oxygen species, L.C. Lands and H.J. Kimoff are clinical investigators with the Fonds de la Recherché en Santé du Québec.
Received for publication June 21,1999-Accepted for publication September14, 1999.

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