Sometimes The Experts Aren’t Experts

Gasparin palkkalistoilla majaileva Deserusan oli postannut blogiinsa hyvän kommentin tuoreeseen heraproteiini-kreatiini -tapausselostukseen liittyen. Aivan käsittämättömiä juttuja ilmestyy silloin tällöin myös tieteellisissä aikakauslehdissä. Jutun alussa on suora copypastaus tapausselostuksesta (kursivoituna) ja sen jälkeen Deserusanin kommentit.

Sometimes The Experts Aren’t Experts

Whitt KN, Ward SC, Deniz K, Liu L, Odin JA, Qin L Seminars in Liver Disease. 2008 May;28(2):226-31. Cholestatic liver injury associated with whey protein and creatine supplements. Semin Liver Dis. 2008 May;28(2):226-31

We present a case of acute cholestatic liver injury associated with the combination of whey protein and creatine supplements. The difficulty of diagnosing drug-induced liver injury is emphasized. The patient is a healthy, 27-year-old man who presented with painless jaundice. He had no occupational exposures to solvents, was not taking prescription medications, and did not use recreational drugs or alcohol. He was an enthusiastic weight-lifter and had been taking creatine for 8 to 9 months and whey protein supplements for 4 weeks prior to the development of symptoms. Laboratory tests revealed elevated total bilirubin (54.7 mg/dL) and alkaline phosphatase (436 U/L), minimally elevated transaminases, and a creatinine of 3.1 mg/dL. Serologic work-up was negative for viral hepatitis and autoimmune liver disease, and Wilson’s disease was ruled out. Magnetic resonance cholangiopancreatogram was unremarkable, but a liver biopsy showed marked cholestasis with ductular proliferation. He had dramatic clinical improvement with intravenous fluids and discontinuation of the nutritional supplements. In patients with acute liver injury, clinicians should inquire about dietary supplement usage and consider immediate discontinuation of all unnecessary products. We describe a case of profound jaundice related to a commonly used and reportedly safe combination of such supplements.

As many of you may or may not know, there are relatively new adverse reaction reporting protocols in place for dietary supplements which began December 2006. Essentially, this serves as a collection house for healthcare professionals and consumers to report negative experiences with dietary supplements. Politics aside, this has been put in place to protect consumers and to hopefully root out dangerous or mislabeled dietary supplements.

Now if you read the abstract above, you are probably wondering how could creatine or whey protein cause cholestatic liver injury? The fact of the matter is, supplemental creatine would only raise creatinine to a significant degree and not the other clinical markers (1,2). So should we point the finger at whey protein for elevating the questionable clinical markers since creatine most likely did not?

In reality, whey protein has actually proven to have a positive impact on the liver in many clinical studies (3-5) often lowering the same parameters including bile duct proliferation (3). The same can be said for casein protein and whey hydrolysates (3,5) but that is a moot point. Regardless, we are still left with the question of what could have potentially caused this man’s cholestatic liver injury?

One use of terminology that I found rather intriguing in this citation was the term “enthusiastic weight lifter” and also the time frame in which he began using “whey supplements.” Now I may be going out on a limb here, but perhaps instead of starting whey protein four weeks prior to his ailment, could there be a possibility he was taking some form of oral steroid? It’s not like anyone hasn’t done a four week cycle of oral steroids before and had elevated liver values right? Either way, it is a definite possibility that an “enthusiastic weightlifter” might turn to steroids to increase their strength and muscle mass. There is no doubt about that.

Let’s think about this for second. Have oral steroids over cause cholestatic liver injury? Have oral steroids ever been attributed to elevated bilirubin that can cause Jaundice? Have they been attributed to raising liver enzymes such as the ones noted in the case study? The answer quite succinctly is yes (7-13). For detailed description of how this occurs please read A Closer Look at Steroid Liver Toxicity by M. Fischer. Now what is absolutely disturbing regarding our case study is that they did not even think or have the wherewithal to investigate this possibility. Instead, they based their conclusions on the patient’s testimonial regarding creatine and whey protein instead checking for an elevated T/E ratio or serum testosterone levels.
Now what is more alarming? The fact that these hepatologists do not even know how some of the most widely consumed dietary sport supplements effect the organ which they specialize in? On the flipside, is it even worse the board of reviewers who accepted this case study for publication didn’t think to question their results either? Perhaps the stark possibility this case study might be presented one day as justification to remove access to proven ergogenic aides? We could speculate all day what a travesty this is, but the fact remains this misinformation is still out there. Even the safest of supplements are sure to be scrutinized under false pretenses.

The reason why I brought your attention to this particular case study is that it really illustrates just how ill-informed and prejudiced the established medical community can be against dietary supplements like creatine and whey protein. It is my hope that many of the myths regarding supplementation are dispelled so the tide of ignorance that is quite prevalent among some medical researchers doesn’t catch the watchful eye of Uncle Sam anymore then they already have. It’s up to every one of you to help secure your rights to freedom of choice before those choices are taken away from you.

1. Robinson TM, Sewell DA, Casey A, Steenge G, Greenhaff PL. Dietary creatine supplementation does not affect some haematological indices, or indices of muscle damage and hepatic and renal function. Br J Sports Med. 2000 Aug;34(4):284-8.

2. Bizzarini E, De Angelis L.Is the use of oral creatine supplementation safe? J Sports Med Phys Fitness. 2004 Dec;44(4):411-6.

3. Morifuji M, Sakai K, Sugiura K.Dietary whey protein modulates liver glycogen level and glycoregulatory enzyme activities in exercise-trained rats. Exp Biol Med (Maywood). 2005 Jan;230(1):23-30.

4. Belobrajdic D, McIntosh G, Owens J.The effects of dietary protein on rat growth, body composition and insulin sensitivity. Asia Pac J Clin Nutr. 2003;12 Suppl:S42.

5. Pacheco MT, Sgarbieri VC.Effect of different hydrolysates of whey protein on hepatic glutathione content in mice. J Med Food. 2005 Fall;8(3):337-42.

6. Kume H, Okazaki K, Sasaki H. Hepatoprotective effects of whey protein on D-galactosamine-induced hepatitis and liver fibrosis in rats. Biosci Biotechnol Biochem. 2006 May;70(5):1281-5.
7. Giannattasio A, D’Ambrosi M, Volpicelli M, Iorio R. Steroid therapy for a case of severe drug-induced cholestasis. Ann Pharmacother. 2006 Jun;40(6):1196-9.

8. Habscheid W, Abele U, Dahm HH.Severe cholestasis with kidney failure from anabolic steroids in a body builder Dtsch Med Wochenschr. 1999 Sep 10;124(36):1029-32

9. Stang-Voss C, Appell HJ.Structural alterations of liver parenchyma induced by anabolic steroids. Int J Sports Med. 1981 May;2(2):101-5.

10. Hartleb M, Nowak A.Severe jaundice with destructive cholangitis after administration of methyltestosterone. Am J Gastroenterol. 1990 Jun;85(6):766-7.

11. Lucey MR, Moseley RH.Severe cholestasis associated with methyltestosterone: a case report. Am J Gastroenterol. 1987 May;82(5):461-2.

12. Shah NL, Zacharias I, Khettry U, Afdhal N, Gordon FD. Methasteron-associated cholestatic liver injury: clinicopathologic findings in 5 cases. Clin Gastroenterol Hepatol. 2008 Feb;6(2):255-8.

13. Jasiurkowski B, Raj J, Wisinger D, Carlson R, Zou L, Nadir A. Cholestatic jaundice and IgA nephropathy induced by OTC muscle building agent superdrol. Am J Gastroenterol. 2006 Nov;101(11):2659-62.