Oral administration of alanyl-glutamine and glutamine improve random pattern dorsal skin flap survival in rats

Document Type : Original Article


1 Department of Anatomy, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran

2 Neurophysiology Research Center, Department of Anatomy, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran


Objective(s): Skin flap necrosis is the most common postoperative side effect in reconstructive surgeries. Glutamine (GLN) has been shown to accelerate wound healing process. The purpose of this study was to evaluate the effects of GLN either in free form or in the dipeptide form along with L- alanyl (Ala-GLN) on random skin flaps survival in rats.
Materials and Methods: Dorsal skin flaps with caudal bases (8 ×2 cm) were established in 24 adult male Wistar rats. Then, the animals were randomly assigned into 3 groups (n=8). Control, GLN (0.75 g/kg) and Ala-GLN (0.75 g/kg). All groups administrated orally 24 and 6 hr before flap elevation and continued repeatedly daily until 7 days postoperation. The flap survival rate and vascular density using histological analysis were evaluated. Vascular endothelial growth factor (VEGF) by immunohistochemical method was determined.
Results: Seven days after surgery, the mean surviving area in the GLN and Ala-GLN groups were significantly greater than in the untreated control group (P<0.001). Furthermore, in comparison with the control group, the number of blood vessels and VEGF-positive cells in treated groups with GLN and Ala-GLN were significantly higher. However, no significant differences were observed between treated groups with GLN and Ala-GLN.
Conclusion: The findings from this study indicate that oral administration of GLN in free form or in the dipeptide (Ala-GLN) could promote neovascularization and improve skin flap survival in rats.


Main Subjects

1. Wang F, Peled AW, Garwood E, Fiscalini AS, Sbitany H, Foster RD, et al. Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes. Ann Surg Oncol 2014; 21: 3223-3230.
2. Wang WZ, Baynosa RC, Zamboni WA. Update on ischemia-reperfusion injury for the plastic surgeon: 2011. Plast Reconstr Surg 2011; 128: 685e-692e.
3. Dölen UC, Sungur N, Koca G, Ertunç O, Bağcı Bosi AT, Koçer U, et al. The vasodilator effect of a cream containing 10% menthol and 15% methyl salicylate on random-pattern skin flaps in rats. Arch Plast Surg 2015; 42: 695-703.
4. Dingsheng L, Zengbing L, Dong H. Favorable effects of progesterone on skin random flap survival in rats. Iran J Basic Med Sci 2016; 19: 1116-1170.
5. Chehelcheraghi F, Eimani H, Sadraie SH, Torkaman G, Amini A, Shemshadi H, et al. Improved viability of random pattern skin flaps with the use of bone marrow mesenchymal-derived stem cells and chicken embryo extract. Iran J Basic Med Sci 2015; 18: 764-772.
6. Baldan CS, Marques AP, Schiavinato AM, Casarotto RA. The effects of different doses of 670 nm diode laser on skin flap survival in rats. Acta Cir Bras 2012; 27: 155-161.
7. Karimipour M, Amanzade V, Jabbari N, Farjah GH. Effects of gamma-low dose irradiation on skin flap survival in rats. Phys Med 2017; 40:104-109.
8. Shih Y-M, Shih J-M, Pai M-H, Hou Y-C, Yeh C-L, Yeh S-L. Glutamine administration after sublethal lower limb ischemia reduces inflammatory reaction and offers organ protection in ischemia/reperfusion injury. J Parenter Enteral Nutr 2016; 40: 1122-1130.
9. Kovacevic Z, McGivan J. Mitochondrial metabolism of glutamine and glutamate and its physiolgical significance. Physiol Rev 1983; 63: 547-605.
10. Boza JJ, Maire J-C, Bovetto L, Ballèvre O. Plasma glutamine response to enteral administration of glutamine in human volunteers (free glutamine versus protein-bound glutamine). Nutrition 2000; 16: 1037-1042.
11. Rogero MM, Tirapegui J, Pedrosa RG, de Oliveira Pires IS, de Castro IA. Plasma and tissue glutamine response to acute and chronic supplementation with L-glutamine and L-alanyl-L-glutamine in rats. Nutr Res 2004; 24: 261-270.
12. Chamney C, Godar M, Garrigan E, Huey KA. Effects of glutamine supplementation on muscle function and stress responses in a mouse model of spinal cord injury. Exp Physiol 2013; 98: 796-806.
13. Prem JT, Eppinger M, Lemmon G, Miller S, Nolan D, Peoples J. The role of glutamine in skeletal muscle ischemia/reperfusion injury in the rat hind limb model. Am J Surg 1999; 178: 147-150.
14. Wischmeyer PE, Jayakar D, Williams U, Singleton KD, Riehm J, Bacha EA, et al. Single dose of glutamine enhances myocardial tissue metabolism, glutathione content, and improves myocardial function after ischemia-reperfusion injury. J Parenter Enteral Nutr 2003; 27: 396-403.
15.    Kim KS, Suh GJ, Kwon WY, Lee HJ, Jeong KY, Jung SK, et al. The effect of glutamine on cerebral ischemic injury after cardiac arrest. Resuscitation 2013; 84: 1285-1290.
16. Goswami S, Kandhare A, Zanwar AA, Hegde MV, Bodhankar SL, Shinde S, et al. Oral l‐glutamine administration attenuated cutaneous wound healing in Wistar rats. Int wound J 2016; 13: 116-124.
17. de Oliveira Mora L, Antunes LMG, Bianchi MdLP. The effects of oral glutamine on cisplatin-induced nephrotoxicity in rats. Pharmacol Res 2003; 47: 517-522.
18. Jalilimanesh M, Mozaffari-Khosravi H, Azhdari M.  The effect of oral L-glutamine on the healing of second-degree burns in mice. Wounds 2011; 23: 53-58.
19. Rogero MM, Tirapegui J, Pedrosa RG, de Castro IA, de Oliveira Pires IS. Effect of alanyl-glutamine supplementation on plasma and tissue glutamine concentrations in rats submitted to exhaustive exercise. Nutrition 2006; 22: 564-671.
20. Bollhalder L, Pfeil AM, Tomonaga Y, Schwenkglenks M. A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation. Clin Nutr 2013; 32: 213-223.
21. Cruzat VF, Bittencourt A, Scomazzon SP, Leite JSM, de Bittencourt PIH, Tirapegui J. Oral free and dipeptide forms of glutamine supplementation attenuate oxidative stress and inflammation induced by endotoxemia. Nutrition 2014; 30 :602-611.
22. Fuller TF, Rose F, Singleton KD, Linde Y, Hoff U, Freise CE, et al. Glutamine donor pretreatment in rat kidney transplants with severe preservation reperfusion injury. J Surg Res 2007; 140: 77-83.
23. McFarlane R, DeYoung G, Henry R, McFarlane R. The design of a pedicle flap in the rat to study necrosis and its prevention. Plast Reconstr Surg 1965; 35: 177-182.
24. Lin B, Lin Y, Lin D, Cao B. Effects of Bezafibrate on the Survival of Random Skin Flaps in Rats. J Reconstr Microsurg 2016; 32: 395-401.
25. Bagdas D, Etoz BC, Ozturkoglu SI, Cinkilic N, Ozyigit MO, Gul Z, et al. Effects of systemic chlorogenic acid on random-pattern dorsal skin flap survival in diabetic rats. Biol Pharm Bull 2014; 37: 361-370.
26. Kailiang Z, Yihui Z, Dingsheng L, Xianyao T. Effects of muscone on random skin flap survival in rats. J Reconstr Microsurg 2016; 32: 200-207.
27. Lin Y, Lin B, Lin D, Huang G, Cao B. Effect of thymosin β4 on the survival of random skin flaps in rats. J Reconstr Microsurg 2015; 31: 464-470.
28. Ashtiyani SC, Zohrabi M, Hassanpoor A, Hosseini N, Hajihashemi S. Oral administration of the aqueous extract of Rosmarinus officinalis in rats before renal reperfusion injury. Iran J Kidney Dis 2013; 7: 367-375.
29. Lu F, Mizuno H, Uysal CA, Cai X, Ogawa R, Hyakusoku H. Improved viability of random pattern skin flaps through the use of adipose-derived stem cells. Plast Reconstr Surg 2008; 121: 50-58.
30. Fläring U, Rooyackers O, Wernerman J, Hammarqvist F. Glutamine attenuates post-traumatic glutathione depletion in human muscle. Clin Sci 2003; 104: 275-282.
31. Kao C, Hsu J, Bandi V, Jahoor F. Alterations in glutamine metabolism and its conversion to citrulline in sepsis. Am J Physiol Endocrinol Metab 2013; 304:E1359-1364.
32. Rutten EP, Engelen MP, Schols AM, Deutz NE. Skeletal muscle glutamate metabolism in health and disease: state of the art. Curr Opin Clin Nutr Metab Care 2005; 8: 41-51.
33. Cruzat VF, Pantaleão LC, Donato J, de Bittencourt PIH, Tirapegui J. Oral supplementations with free and dipeptide forms of L-glutamine in endotoxemic mice: effects on muscle glutamine-glutathione axis and heat shock proteins. J Nutr Biochem 2014; 25: 345-352.
34. Li P, Yin Y-L, Li D, Kim SW, Wu G. Amino acids and immune function. Br J Nutr 2007; 98: 237-252.
35. Adibi SA. Regulation of expression of the intestinal oligopeptide transporter (Pept-1) in health and disease. Am J Physiol Gastrointest Liver Physiol 2003; 285: G779-788.
36. da Silva Krause M, de Bittencourt PIH. Type 1 diabetes: can exercise impair the autoimmune event? The L‐arginine/glutamine coupling hypothesis. Cell Biochem Funct 2008; 26: 406-433.
37. Bahri S, Zerrouk N, Aussel C, Moinard C, Crenn P, Curis E, et al. Citrulline: from metabolism to therapeutic use. Nutrition 2013; 29: 479-484.
38. Taleb S, Moghaddas P, Balaei MR, Taleb S, Rahimpour S, Abbasi A, et al. Metformin improves skin flap survival through nitric oxide system. J Surg Res 2014; 192: 686-691.
39. Wernerman J. Clinical use of glutamine supplementation. J Nutr 2008; 138: 2040S-2044S.
40. Zhang Y, Zou Z, LI YK, YUAN HB, SHI XY. Glutamine‐induced heat shock protein protects against renal ischaemia‐reperfusion injury in rats. Nephrology 2009; 14: 573-580.
41. Brown LF, Yeo K, Berse B, Yeo T-K, Senger DR, Dvorak HF, et al. Expression of vascular permeability factor (vascular endothelial growth factor) by epidermal keratinocytes during wound healing. J Exp Med 1992; 176: 1375-1379.
42. Shiota N, Nishikori Y, Kakizoe E, Shimoura K, Niibayashi T, Shimbori C, et al. Pathophysiological role of skin mast cells in wound healing after scald injury: study with mast cell-deficient W/Wv mice. Int Arch Allergy  Immunol 2010; 151:80-88.
43. Leung DW, Cachianes G, Kuang W-J, Goeddel DV, Ferrara N. Vascular endothelial growth factor is a secreted angiogenic mitogen. Science 1989; 246:1306-1309.
44.    Keck PJ, Hauser SD, Krivi G, Sanzo K, Warren T, Feder J, et al. Vascular permeability factor, an endothelial cell mitogen related to PDGF. Science 1989; 246: 1309-1312.