Compartmental approach for evaluation of plasma kinetics and (13)co(2)-exhalation after oral loading with L-[1-(13)c]leucine

Abstract A seven compartment model was applied for evaluation of oral L-[1-(13)C]leucine loading tests (38 μmol/kg body wt.) in healthy volunteers. The model comprises transport and absorption in stomach and gut into a central L-leucine-compartment which is connected to a protein compartment and to the compartment of the corresponding 2-oxo acid. CO(2) release from the latter occurs in a fast and a slow compartment into the central CO(2) compartment for exhalation. Using the fmins routine of MATLAB for parameter estimation, a good agreement was obtained between calculated and actually measured kinetics of (13)C-labelled metabolites and a mean in vivo L-leucine oxidation of 0.365 ± 0.071 μmol/kg per min (n = 5) was computed. Plausibility of the model was checked by predicting in vivo leucine oxidation rates from primed continuous infusion tests (priming: L-[1-(13)C]leucine, 5 μmol/kg; NaH(13)CO(2), 1.2 μmol/kg; infusion: L-[1-(13)C]leucine, 5 μmol/kg per h). In 5 tested volunteers, the experimental L-leucine oxidation rate amounted to 0.358 ± 0.105 μmol/kg per min versus predicted 0.324±0.099 μmol/kg per min. Possible causes for some observed intraindividual variations are discussed.     

Whole Body Branched-Chain L-Amino Acid Oxidation in Overnight Fasted Human Subjects

Abstract

Catabolism of the natural branched-chain L-amino acids in overnight fasted healthy volunteers was comparatively studied by performing oral loading tests with 1-¹³C-labelled L-leucine, L-valine, and L-isoleucine (38 μmol x kg (body weight)^?1), respectively. On the basis of the ¹³CO₂ exhalation and the ¹³C-isotope enrichment in the plasma branched-chain compounds, whole body branched-chain L-amino acid oxidation rates were estimated applying a seven compartment model and non-linear regression analysis. Mean computed in vivo oxidation rates were in the order L-leucine ? L-valine > L-isoleucine and amounted to 0.32 ± 0.06, 0.22 ± 0.04, and 0.17 ± 0.05 μmol x (kg body wt.)^?1 x min^?1 (n = 5), respectively. The data are discussed with respect to current estimates of human branched-chain L-amino acid requirements.     

Leucine Oxidation in vivo: Inter-and Intraindividual Variation in Healthy Subjects as Assessed by Oral L-[1-13C]Leucine Loads

Interindividual variability of leucine catabolism was studied in eight overnight fasted healthy volunteers by means of a controlled oral L-[1-¹³C]leucine loading test (5 mg/kg body weight). With the exception of total CO² expiration (CV = 5%),a considerable variation (CV generally < or ?10%)was observed with all other metabolic parameters: increase of leucine/2-oxoisocaproate in serum, ¹³C-enrichment in serum metabolites and ¹³CO² in expired air, and estimated oxidation rates. The degree of variation was only partially referable to individual differences. A comparable high degree of variability was found when two probands underwent multiple loading tests (n = 4). Possible reasons and implications are discussed.     

Exact profiles of 13CO2 recovery in breath air after per oral administration of [13C]methacetin in two groups of different ages

The aim of this study is to determine if age is a factor influencing the results of a [¹³C]methacetin breath test (¹³C-MBT). Two groups of healthy volunteers, each comprising six men and six women, but differing in average age (Y=young, 25.1±0.6 years, MA=middle-aged;, 46.0±2.1 years) orally took 75 mg [¹³C]methacetin. Samples of expiratory air for ¹³CO₂ measurement were collected up to 48 h after intake of the substrate. A maximum momentary ¹³CO₂ breath exhalation of 37.0±2.6%dose/h was observed at 18 min (median, range: 9–30 min) in the young subjects and of 38.4±2.5%dose/h at 18 min (median, range: 12–30 min) in the middle-age volunteers. The cumulative ¹³C elimination in expiratory air was statistically significantly higher in the MA compared with the Y group as from 75 min up to 180 min, indicating a greater microsomal metabolic efficiency of the liver in the middle-aged healthy subjects. Gender, use of hormonal contraception, cigarette smoking, or body mass index did not modify the age-related effect on the cumulative ¹³C elimination in breath air. The study results imply a necessity of composing control groups well matched with regard to the age structure for a proper interpretation of clinical ¹³C-MBT results.     

Effect of alcohol consumption on the liver detoxication capacity as measured by [13C]methacetin- and [methyl-13C]methionine-breath tests

The aim of this study was to investigate the hepatic microsomal and mitochondrial functions by using the ¹³CO₂-breath test in healthy subjects either before or after the consumption of red wine. Fourteen adults received [¹³C]methacetin and [methyl-¹³C]methionine together with a standardised dinner. Expired air samples were taken over 6 h. After a wash-out period, the subjects consumed 0.4 ml ethanol/kg/day together with dinner over a 10-day period. Thereafter, ¹³C-tracer administration was repeated under identical conditions. The ¹³CO₂-enrichments were measured by isotope ratio mass spectrometry. The mean cumulative percentage ¹³C-dose recovery (CPDR) after administration of [¹³C]methacetin and [methyl-¹³C]methionine either without or with red wine consumption amounted to 38.2±6.3 vs. 36.3±6.7% (p=0.363) and 9.5±3.3 vs. 8.8±2.5% (p=0.47), respectively. Moderate alcohol consumption does not induce significant short-term changes of the microsomal and the mitochondrial functions of the human liver in healthy subjects.     

Towards an Inhalative 13C Breath Test Method

Abstract

Customary ¹³CO₂ breath tests—and also ¹⁵N urine tests—always start with an oral administration of a test substrate. The test person swallows a stable isotope labelled diagnostic agent. This technique has been used to study several pathophysiological changes in gastrointestinal organs. However, to study pathophysiological changes of the bronchial and lung epithelium, the inhalative administration of a stable isotope labelled agent appeared more suitable to us. [1-¹³C]Hexadecanol and [1-¹³C]glucose were chosen. Inhaled [1-¹³C]hexadecanol did not yield ¹³CO₂ in the exhaled air, but [1-¹³C]glucose did. To study the practicability of the [1-¹³C]glucose method and the reproducibility of the results, 18 inhalation tests were performed with healthy subjects. In 6 self-tests, the optimum inhalative dose of [¹³C]glucose was determined to be 205 mg. Using the APS aerosol provocation system with the nebulizer ‘Medic Aid’ (Erich Jaeger Würzburg), a 25% aqueous solution was inhaled. Then, breath samples were collected at 15 min. intervals and analysed for ¹³CO₂. 75–120min after the end of inhalation a well-reproducible maximum δ¹³C value of 6‰ over baseline (DOB) was detected for 12 healthy probands.

Speculating that the pulmonary resorption of the [¹³C]glucose is the rate-limiting step of elimination, decompensations in the epithelium ought to be reflected in changed [1-¹³C]glucose resorption rates and changed ¹³CO₂ output.

Therefore, we speculate that the inhalation of suitable ¹³C-labelled substrates will pave the way for a new group of ¹³CO₂ breath tests aiding investigations of specific pathophysiological changes in the pulmonary tract, such as inflammations of certain sections and decompensations of cell functions.     

Comparison of two dosage regimens of the substrate for the [13C]methacetin breath test

The [¹³C]methacetin breath test ([¹³C]MBT) – a valuable non-invasive tool dedicated to the assessment of the liver metabolic capacity – still needs standardisation. The aim of this study was to check whether currently used dosage regimens of [¹³C]methacetin provide concordant [¹³C]MBT results in subjects with an atypical body constitution. Healthy volunteers: low body mass<55 kg (eight women), and high body mass>95 kg (eight large body frame men) were recruited. They underwent [¹³C]MBT on separate days, taking in random order [¹³C]methacetin: a fixed 75 mg dose (FX75), or a 1 mg kg^?1 body mass-adjusted dose (BMAD). Samples of expiratory air for ¹³CO₂ measurement were collected over 3 h. The maximum momentary ¹³C elimination in breath air occurred earlier and was higher following BMAD than with FX75 in the low body mass females (T _max 14.6±1.0 min vs. 22.1±2.4 min, p=0.019; D _max 41.9±2.9 % dose h^?1 vs. 36.6±3.6 % dose h^?1, p=0.071). In the high body mass men, T _max remained unchanged, whereas D _max was slightly higher with BMAD compared to FX75 (21.5±3.2 min vs. 23.0±3.0 min; 38.5±2.9 % dose h^?1 vs. 32.3±2.5 % dose h^?1). It is concluded that in subjects with a body constitution outside the general population average, the dosage of the substrate may affect some results of the [¹³C]MBT. The dosage-related differences appear, however, to be insignificant if the result of the [¹³C]MBT is reported as a cumulative ¹³C recovery in breath air.     

L-[1-13C]phenylalanine breath test in patients with chronic liver disease of different etiologies

The aim of this study was to compare the oxidation of l-[1-¹³C]phenylalanine (¹³C-PheOx) in patients with chronic liver failure due to different etiologies using l-[1-¹³C]phenylalanine breath test. Breath samples were collected before the administration of 100 mg l-[1-¹³C]phenylalanine, and every 10 min thereafter until completion of 1 h. Control subjects (n=9) presented a larger cumulative percentage of ¹³C dose recovery (CPDR) than patients (n=124) with chronic liver disease, regardless of the etiology (7.5±0.7 vs. 4.2±0.2, p=0.001). No differences in CPDR were found considering the Child-Pugh (CP) class or etiology: alcoholic (CP A=7.7±0.7, CP B=4.1±0.5, CP C=2.0±0.3), hepatitis C virus (CP A=5.4±0.5, CP B=4.0±0.2, CP C=2.2±0.3), hepatocellular carcinoma (CP A=5.5±1.6, CP B=3.6±1.8, CP C=2.2±1.0); or cryptogenic cirrhotic patients (CP A=7.4±1.5, CP B=4.4±0.4, CP C=2.1±0.7). Results confirm that ¹³C-PheOx decreases in patients with cirrhosis with respect to controls, notwithstanding the etiology.     

The 13C bicarbonate method: an inverse end product method for measuring CO2 production and energy expenditure

We reconsider the principle of the ¹³C bicarbonate (NaH¹³CO₃) method (¹³C-BM) for the determination of the CO₂ production to obtain an estimate of energy expenditure (EE). Its mathematical concept based on a three-compartmental model is related to the [¹⁵N]glycine end product method. The CO₂ production calculated by the ¹³C-BM, R_aCO₂(¹³C) is compared to the result from the indirect calorimetry, RCO₂(IC). In an interspecies comparison (dog, goat, horse, cattle, children, adult human; body mass ranging from 15 to 350?kg, resting and fasting conditions) we found an excellent correlation between the results of ¹³C-BM and IC with RCO₂(IC)?=?0.703?×?R_aCO₂(¹³C), (R²?=?0.99). The slope of this correlation corresponds to the fractional ¹³C recovery (RF(¹³C)) of ¹³C in breath CO₂ after administration of NaH¹³CO₃. Significant increase in RF(¹³C) was found in physically active dogs (0.95?±?0.14; n?=?5) vs. resting dogs (0.71?±?0.10, n?=?17; p?=?.015). The ¹³C recovery in young bulls was greater in blood CO₂ (0.81?±?0.05) vs. breath CO₂ (0.73?±?0.05, n?=?12, p?<?.001) and in ponies with oral (0.76?±?0.03, n?=?8) vs. intravenous administration of NaH¹³CO₃ (0.69?±?0.07; n?=?8; p?=?.026). We suggest considering the ¹³C-BM as a ‘stand-alone’ method to provide information on the total CO₂ production as an index of EE.     

Macroscopic Isotope Separation of 13C by a CO2 Laser

By photochemical dissociation of the rare carbon isotope component of CHClF₂ by means of a CO₂ laser with an average power of 150 W, Q-switched at 10 kHz, we have demonstrated the separation of more than 1 mol of ¹³C, enriched to 50% (2 mol of total carbon). It is contained in about 1 mol (101 g) of the product C₂F₄. The total throughput of the starting material was 29 kg. The experiment was run day and night for 2 weeks, almost only controlled by a computer. We obtained production rates of 5 mmol/h, corresponding to about 0.5 kg ¹³C per year.     

Biomedical Application of an Isotope Selective Nondispersive Infrared Spectrometer for 13CO2 and 12CO2 Concentration Measurements in Breath Samples

A newly developed isotope selective nondispersive infrared (NDIR) spectrometer for the measurement of ¹³CO₂ and ¹²CO₂ concentrations in breath samples was applied as a low cost and very simple to operate alternative to isotope ratio mass spectrometry (IRMS). We used this device for several biomedical applications ([¹³C]urea breath test, [¹³C]leucine metabolism, [¹³C]methacetin catabolism of rats) and found that the results agree very well with IRMS.     

The Influence of Feeding Frequency on Nitrogen Turnover and Whole Body Protein Synthesis in Adult Rats (Estimation using [14C]- and [15N]- Labelled Leucine)

Abstract

Male Wistar rats (17 wks. old, body weight ～400 g), fitted with an intra gastric cannula and with a catheter in the vena jugularis were divided into 3 groups and given a marginal ration of the feeding solution Nutrison Standard (1g protein and 350 kJ ME per day). Group 1 had ad lib. access to the drinking bottle, the groups 2 and 3 were pair fed by gastric infusion, splitted up into 2 greater meals for group 2 respectively into 6 smaller meals for group 3. After adaptation all animals get an i.p. injection of doubly labelled tracer solution (200μl) containing 2.5mg L-[¹⁵N]leucine (72 atom% ¹⁵N) combined with either [1-¹⁴C]- or [U-¹⁴C] leucine (37 kBq).

The course of ¹⁴CO₂ expiration was estimated by breath test over 4h in intervals of 15 min and the course of urinary ¹⁵N excretion over 24h in intervals of 45 resp. 90 min. An infusion of saline (0.9% 5ml/h) into the vena jugularis was used to provoke sustained urine production of the animals during the experiment.

From the parameters of the excretion curves of breath ¹⁴CO₂ resp. urine ¹⁵N (cumulative end value) and from the N balance the portions of leucine-C and leucine-N used for protein synthesis, transamination decarboxylation and total oxidation as well as the kinetic parameters for whole body protein metabolism were computed.

The following conclusions were drawn:

6 x feeding regime produces a small but measurable amino acid economy effect in comparison to 2 x feeding regime.

Protein gain for 2 x feeding group was significant smaller than for 6 x feeding group, though protein synthesis rate was higher, but was overcompensated by a greater increase of protein breakdown rate for the 2 x feeding group. Energy storage in form of fat and glycogen built from decarboxylation was unaffected by feeding frequency. The amount of leucine oxidized for heat production was 4% higher for the 6 x feeding group. Transamination rate for leucine was estimated to 8–15%. Absolute values for protein flux, protein synthesis and protein breakdown may be overestimated or underestimated because the metabolism of [¹⁵N] leucine does not exactly agree with that of total N; but the proportions of them and therefore also the conclusions will be true. Better results for absolute values will be obtained using a mixture of ¹⁵N labelled AA, ¹⁵N labelled protein or hydrolysate of ¹⁵N labelled protein (yeast) as the tracer source.     

13C-Leucin-Atemtest zur Beurteilung der anabolen Verwertung von diätetischen Aminosäurengemischen bei Phenylketonurie

It is essential to establish whether and how environmental factors affect the reliability of [¹³C]methacetin breath test (¹³C-MBT). In 12 healthy volunteers (smokers), a standard ¹³C-MBT with 75 mg [¹³C]methacetin was performed twice in random order: on a control day without smoking and on another day with smoking two cigarettes antecedently. A considerable flattening of the curve of the momentary ¹³C recovery within the expiratory air was observed when the ¹³C-MBT was performed after smoking. The maximum of the momentary ¹³C recovery, D _max, decreased from 37.20±2.58 to 25.39±2.29% dose/h (p=0.00052). Moreover, the time to reach D _max was prolonged after cigarette smoking (26.5±3.1 vs. 16.5±1.9 min, p=0.0199). The curve of the cumulative ¹³C recovery on the cigarette smoking day appeared to be shifted downwards, and statistically significant differences relative to the control situation were found between the 24th and 75th minute following [¹³C]methacetin administration. Smoking cigarettes immediately prior to the ¹³C-MBT diminishes the ability of the liver to handle methacetin, and hence a possibility of such an interaction should be excluded in order to interpret the results of the test correctly.     

The First in Vivo Observation of C–N Coupling in Mammalian Brain

[5-¹³C,¹⁵N]Glutamine, with ¹J(¹³C–¹⁵N) of 16 Hz, was observed in vivo in the brain of spontaneously breathing rats by ¹³C MRS at 4.7 T. The brain [5-¹³C]glutamine peak consisted of the doublet from [5-¹³C,¹⁵N]glutamine and the center [5-¹³C,¹⁴N]glutamine peak, resulting in an apparent triplet with a separation of 8 Hz. The time course of formation of brain [5-¹³C,¹⁵N]glutamine was monitored in vivo with a time resolution of 20–35 min. This [5-¹³C,¹⁵N]glutamine was formed by glial uptake of released neurotransmitter [5-¹³C]glutamate and its reaction with ¹⁵NH₃ catalyzed by the glia-specific glutamine synthetase. The neurotransmitter glutamate C5 was selectively¹³C-enriched by intravenous [2,5-¹³C]glucose infusion to ¹³C-label whole-brain glutamate C5, followed by [¹²C]glucose infusion to chase ¹³C from the small and rapidly turning-over glial glutamate pool, leaving ¹³C mainly in the neurotransmitter [5-¹³C]glutamate pool, which is sequestered in vesicles until release. Hence, the observed [5-¹³C,¹⁵N]glutamine arises from a coupling between ¹³C of neuronal origin and ¹⁵N of glial origin. Measurement of the rate of brain [5-¹³C,¹⁵N]glutamine formation provides a novel noninvasive method of studying the kinetics of neurotransmitter uptake into glia in vivo, a process that is crucial for protecting the brain from glutamate excitotoxicity.     

Effect of oxalate test dose size on absolute and percent oxalate absorption

The purpose of this pilot study was to establish the dependence or independence of oxalate absorption on the quantity of the test dose of sodium oxalate over a range of test doses corresponding to physiological dietary oxalate intake values. Gastrointestinal oxalate absorption was measured with the [¹³C₂]oxalate absorption test. Six healthy volunteers were always tested under standardized dietary conditions with 63 mg dietary oxalate and 800 mg dietary calcium per day. The volunteers were tested thrice each with sodium oxalate test doses of 25, 50, 200, and 600 mg. Additionally, 1000 mg sodium oxalate was applied once to three of these volunteers. The oxalate absorption of the six volunteers tested under the standardized conditions with 50 mg sodium [¹³C₂]oxalate was 7.2 ± 2.62 % (mean ± SD), similar to the 120 volunteers tested previously: 8.0 ± 4.4 % (mean ± SD). The tests with sodium [¹³C₂]oxalate doses in the range 25–1000 mg revealed similar percent oxalate absorption values. In conclusion, in healthy volunteers, the amount of oxalate absorbed in the gastrointestinal tract increased proportionally with the higher test doses of oxalate. However, percent oxalate absorption remained unchanged with test doses in the dose range of physiological dietary oxalate intakes.     

Development of high resolution 3D hyperpolarized carbon-13 MR molecular imaging techniques

The goal of this project was to develop and apply techniques for T₂ mapping and 3D high resolution (1.5 mm isotropic; 0.003 cm³) ¹³C imaging of hyperpolarized (HP) probes [1-¹³C]lactate, [1-¹³C]pyruvate, [2-¹³C]pyruvate, and [¹³C,¹⁵N₂]urea in vivo. A specialized 2D bSSFP sequence was implemented on a clinical 3T scanner and used to obtain the first high resolution T₂ maps of these different hyperpolarized compounds in both rats and tumor-bearing mice. These maps were first used to optimize timings for highest SNR for single time-point 3D bSSFP acquisitions with a 1.5 mm isotropic spatial resolution of normal rats. This 3D acquisition approach was extended to serial dynamic imaging with 2-fold compressed sensing acceleration without changing spatial resolution. The T₂ mapping experiments yielded measurements of T₂ values of > 1 s for all compounds within rat kidneys/vasculature and TRAMP tumors, except for [2-¹³C]pyruvate which was ~ 730 ms and ~ 320 ms, respectively. The high resolution 3D imaging enabled visualization the biodistribution of [1-¹³C]lactate, [1-¹³C]pyruvate, and [2-¹³C]pyruvate within different kidney compartments as well as in the vasculature. While the mouse anatomy is smaller, the resolution was also sufficient to image the distribution of all compounds within kidney, vasculature, and tumor. The development of the specialized 3D sequence with compressed sensing provided improved structural and functional assessments at a high (0.003 cm³) spatial and 2 s temporal resolution in vivo utilizing HP ¹³C substrates by exploiting their long T₂ values. This 1.5 mm isotropic resolution is comparable to ¹H imaging and application of this approach could be extended to future studies of uptake, metabolism, and perfusion in cancer and other disease models and may ultimately be of value for clinical imaging.     

Dynamics of [n.3]paracyclophanes (n = 2 – 4) as studied by NMR. Obtaining separate Arrhenius parameters for two dynamic processes in [4.3]paracyclophane

Extending our earlier findings for [3.3]paracyclophane, NMR line shape studies of the conformational dynamics in [3.2] and [4.3]paracyclophanes are reported, of which the former is conformationally homogeneous and the latter occurs in two enantiomeric forms. For [3.2]paracyclophane, the Arrhenius activation energy E_a = 11.6 ± 0.1 kcal/mol and preexponential factor log (A/s^?1) = 12.92 ± 0.07 were found. In [4.3]paracyclophane, the conformational dynamics are quite complicated because, apart from interconversions of each enantiomer into itself proceeding via inversion of the propano bridge with rate constant k₁, the enantiomers mutually rearrange with rate constant k₂ due to inversion of the butano bridge. The determination of Arrhenius parameters from dynamic ¹H spectra of the aromatic protons for these two conformational processes (E_a = 11.2 ± 0.5 kcal/mol and log (A/s^?1) = 13.6 ± 0.5 for the former, and E_a = 9.7 ± 0.4 kcal/mol and log (A/s^?1) = 13.2 ± 0.4 for the latter) is the highlight of this work. In the investigated temperature range, in [4.3]paracyclophane, the occurrence of other conformational processes beyond those mentioned above can be excluded, because they would produce different line shape patterns than those actually observed. Copyright © 2013 John Wiley & Sons, Ltd.     

Determination of 13CO2/12CO2 Ratio by IRMS and NDIRS

Abstract

Breath tests using ¹³C-labelled substrates require the measurement of ¹³CO₂/¹²CO₂ ratio in breath gas samples. Next to isotope ratio mass spectrometry (IRMS), which is very sensitive but also complex and expensive, alternatively isotope selective nondispersive infrared spectrometry (NDIRS) can be used to determine the ¹³CO₂/¹²CO₂ ratio in expired breath. In this study we compared NDIRS- with IRMS-results to investigate whether the less expensive and very simply to operate NDIRS works as reliable as IRMS. For this purpose we applicated 1-¹³C-Phenylalanine to patients with advanced liver cirrhosis and healthy volunteers and took duplicated breath samples for IRMS and NDIRS at selected time points. Our data show a good correlation between these two methods for a small number of samples as required for simple breath tests. Longer series, where repeated measurements are required on the NDIRS instrument lead to a decreasing correlation. This indicates the superiority of IRMS concerning ¹³CO₂-kinetics over longer time periods.     

Simultaneous online detection of isoprene and isoprene-d2 using infrared photoacoustic spectroscopy

A photoacoustic spectrometer for the simultaneous detection of isoprene and the deuterated species [4,4-²H]-2-methyl-1,3-butadiene (isoprene-d₂) is presented. Using a sealed-off ¹³CO₂ laser a single-component detection limit of 400 ppt (isoprene) and 600 ppt (isoprene-d₂) was achieved. Simultaneous monitoring of both compounds allowed the detection of labelling levels down to 6% (isoprene-d₂ in total isoprene) with a time resolution of 3 min. In emission studies with Eucalyptus globulus, the deuterated precursor [4,4-²H]-1-deoxy-D-xylulose was fed to a leaf through the transpiration stream. Emission of isoprene-d₂ started as early as 10 min after application of the precursor. Received: 3 May 2002 / Revised version: 31 May 2002 / Published online: 21 August 2002 RID="*" ID="*"Corresponding author. Fax: +49-228/733474, E-mail: frank.kuehnemann@iap.uni-bonn.de     

A comparison of the reproducibility of the parameters of the 13C-aminopyrine breath test for the assessment of hepatic function

This study determined the within-subject and between-subject variability of different ways of expressing the results of the ¹³C-aminopyrine breath test (¹³C-ABT) and the effect of shortening the test duration. The ¹³C-ABT was conducted on three separate occasions in 10 healthy volunteers and on a single occasion in 22 patients with established liver cirrhosis. The within-subject variability of cumulative percentage dose recovered (cPDR), using measured CO₂ production rate (VCO₂), in the reference group over three trials was 15% over 120 min. Higher within-subject variability in cPDR would have been evident if the test was terminated at either 30 or 60 min. Substitution of predicted VCO₂ to calculate cPDR yielded comparable values at all time points. Significant differences between cirrhotics and reference group were evident after just 10 min using PDR/h, cPDR or enrichment (all P<0.05). The ABT demonstrates clinically acceptable reproducibility. Shortening of the duration may make the test more acceptable clinically, but it is associated with increasing imprecision.