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European Journal of Clinical Nutrition (2006), 1–10& 2006 Nature Publishing Group All rights reserved 0954-3007/06 $30.00
Consensus meeting: monosodium glutamate – anupdate
K Beyreuther1, HK Biesalski2, JD Fernstrom3, P Grimm4, WP Hammes5, U Heinemann6,O Kempski7, P Stehle8, H Steinhart9 and R Walker10
1ZMBH, University of Heidelberg, Germany; 2Department of Biological Chemistry and Nutrition (140a), University of Hohenheim,Germany; 3Departments of Psychiatry Pharmacology & Neuroscience and Center for Nutrition, University of Pittsburgh School ofMedicine, Pittsburg, USA; 4Nutrition Communication, Schurwaldstr. Schorndorf, Germany; 5Department of Food Technology andMicrobiology (150a), University of Hohenheim, Germany; 6Institute of Neurophysiology, Charite´ Berlin, Germany; 7Institute forNeurosurgical Pathophysiology, Johannes Gutenberg University Mainz, Germany; 8Department of Nutritional and Food Sciences –Nutrition Physiology, University of Bonn, Germany; 9Institute of Chemistry, Department of Food Chemistry, University of Hamburg,Germany and 10School of Biological Sciences, University of Surrey, UK
Objective: Update of the Hohenheim consensus on monosodium glutamate from 1997: Summary and evaluation of recentknowledge with respect to physiology and safety of monosodium glutamate.
Design: Experts from a range of relevant disciplines received and considered a series of questions related to aspects of the topic.
Setting: University of Hohenheim, Stuttgart, Germany.
Method: The experts met and discussed the questions and arrived at a consensus.
Conclusion: Total intake of glutamate from food in European countries is generally stable and ranged from 5 to 12 g/day (free:ca. 1 g, protein-bound: ca. 10 g, added as flavor: ca. 0.4 g). L-Glutamate (GLU) from all sources is mainly used as energy fuel inenterocytes. A maximum intake of 16.000 mg/kg body weight is regarded as safe. The general use of glutamate salts(monosodium-L-glutamate and others) as food additive can, thus, be regarded as harmless for the whole population. Even inunphysiologically high doses GLU will not trespass into fetal circulation. Further research work should, however, be doneconcerning the effects of high doses of a bolus supply at presence of an impaired blood brain barrier function. In situations withdecreased appetite (e.g., elderly persons) palatability can be improved by low dose use of monosodium-L-glutamate.
European Journal of Clinical Nutrition advance online publication, 6 September 2006; doi:10.1038/sj.ejcn.1602526
Keywords: monosodium glutamate; CNS; breast milk; food safety; toxicology; human nutrition
concensus conference considering the available new infor-mation with a special focus on safety aspects.
The 1997 Hohenheim consensus talk has dealt with aspectsof metabolic and safety aspects of monosodium glutamate(Biesalski et al., 1997). In the meantime, new data including
results of an ‘International Symposium on Glutamate’(Fernstrom and Garattini, 2000) were published. Conse-
quently, it was decided to update results of the 1997
To clarify that added monosodium-L-glutamate
(MSG) and all other glutamate salts dissociate in aqueoussolutions and therefore are identical with free glutamic acid,only the term L-glutamate (GLU) should be used in the
Correspondence: Professor P Stehle, Department of Nutritional and Food
Sciences – Nutrition Physiology, University of Bonn, Endenicher Allee 11-13,Bonn D-53115, Germany.
GLU) but it appears as well in its free form in certain foods
Guarantor: P Stehle.
Received 21 December 2005; revised 14 June 2006; accepted 6 July 2006
(free GLU). To this food derived GLU adds GLU salts (e.g.,
MSG) that are used as food enhancer in instant products
to 1 g/day. As the consumption of tomatoes/tomato products
such as soups, sauces or pizza. Presently, six additives are
and cheese consistently increased in Germany during the last
admitted in the European Union (EU): GLU (E620) and its
years (German Nutrition Society 2004), a further increase in
sodium (E621), potassium (E622), calcium (E623), ammo-
free GLU intake from food can be expected.
nium (E624) and magnesium (E625) salt. These food
Within the last couple of years, ‘low-carb diets’ were
enhancers are not allowed to be added to milk, emulsified
heavily promoted in western societies (Berkowitz, 2000).
fat and oil, pasta, cocoa/chocolate products and fruit juice.
Energy deficits due to low carbohydrate intake are generally
Following the compulsory EU-food labeling law the use of
compensated by a quantitatively higher protein, which may
‘enhancer’ has to be declared and the name or E-number of
the salt has to be given. GLU salts dissociate in the neutral
As food enhancer GLU is preferably used in form of
area so that independent from origin and salt species free
MSG. The concentration in convenience foods adds up to
0.1–0.8% of weight which is similar to the concentration ofnative free GLU in tomatoes or parmesan. Based onmeasured added GLU content of over 500 MSG-containing
Estimated intake of GLU from natural sources (European diet,
food items obtained from the grocery, Rhodes et al. (1991)
calculated daily added GLU intake in the United Kingdom
(UK). These are: whole population, 586 mg/day; households
(as protein constituent or in free form in foods) can be
buying foods in each category examined (likely to be
calculated to about 10 g/day (range: 4.6–12 g/day). The use of
maximum intake), 1560 mg/day; extreme users (97.5th
new technologies in food processing (e.g., microwave
percentile consumers), 2330 mg/day (likely to be maximum
technology) does not influence native GLU content.
intake); children, 10–11 and 14–15 year, 1300 mg/day (if
With respect to added GLU, only limited data are
40 kg body weight, 33 mg/kg/day; if 60 kg body weight,
available. In EU countries the mean intake ranges from 0.3
22 mg/kg/day). If extreme consumption group weighs 70 kg
to 0.5 g/day; in Asian countries people consume in average
(adults), daily dose is about 30 mg/kg/day; if whole popula-
1.2–1.7 g/day. It is, however, to mention that the individual
tion averages 50 kg (all ages), daily dose is about 12 mg/kg/
GLU intake from food additives shows broad variations; high
consumers in Europe may reach up to 1 g/day, in Asian
In Western societies, there is a general trend to an
countries 4 g/day. Average intake in EU countries might only
increased consumption of flavored convenience food. The-
oretically, this change in behavior might lead to an increased
The amount of GLU added to a specific product is limited
GLU intake, which is used in these products as flavor. On the
by the fact that increasing amounts of GLU will not increase
other hand, the food industry steadily increases the number
but decrease palatability. When specific nucleotides are
of MSG-free products due to an enhanced reservation of the
added as flavors to the products GLU content can be lowered
consumer against food additives (Dillon, 1993). Conse-
quently, overall intake of added GLU might not besignificantly altered.
With respect to the amount of protein bound
In Asia, especially in Japan and Korea MSG and other
GLU in a mixed diet only limited data are available. This is
GLU salts are used more intensively than in Europe. In
due to the fact that the amino-acid composition of a food
these countries the intake of added GLU is estimated to
protein is commonly assessed after acid hydrolysis and that
1.2–1.7 g/day (for details see Biesalski et al. (1997)). In a
glutamine residues are decomposed to GLU during this
highly seasoned restaurant meal, however, intake as high as
process. In consequence, most of the amino-acid composi-
5000 mg or more may be possible (Yang et al., 1997).
tion data published only include the percentage of ‘GLX’ per100 g of protein/16 g of nitrogen reflecting the sum of GLUplus glutamine (Kuhn et al., 1996). With the assumption that
What is the role of GLU in biochemical and metabolic processes?
ca. 40% of GLX are native GLU residues, the amount of
Most of GLU (up to 95%) derived from food
protein bound GLU can be estimated to 4–12 g/100 g food
(bound and added) is used as energy source by the
protein (Anderson and Raiten, 1992). Considering an
enterocytes of the intestinal mucosa.
average protein intake of 90 g/day for young adults (GermanNutrition Society 2004), GLU intake from intact protein
In healthy adults, GLU can be endogenously
synthesized in adequate amounts and, thus, is qualified as a
In addition to bound GLU, some products like fresh fruits,
nonessential (dispensable) amino acid (Fu
vegetables and cheese contain various amounts of free
2004). The daily GLU turnover is calculated to about 48 g
GLU (unprocessed potatoes: 50–80 mg/100 g, tomatoes: 200–
(Garattini, 2000). GLU liberated from food protein is
300 mg/100 g, tomato products: up to 630 mg/100 g, long
quantitatively absorbed from the lumen. Absorption kinetics
matured cheese like Parmesan: up to 1200 mg/100 g). Based
is influenced by the retention time in the stomach and the
on a mixed diet, intake of free GLU can be presently estimated
Studies over the last two decades have demonstrated
0.15–0.22 g/kg bw increased the maternal plasma level from
extensive catabolism of nonessential amino acids in intest-
a baseline value (50 mmol/l) to about 500–1000 mmol/l; GLU
inal mucosa (Burrin and Reeds, 1997). In recent years, there
concentration in fetal plasma was thereby, however, not
has been growing recognition that catabolism also dom-
affected. Only at the highest exposure (0.40 g/kg bw)
inates the first-pass intestinal utilization of dietary essential
amino acids (Stoll et al., 1998). The major objective of
2800 mmol/l there was an increase of the fetal plasma level
current views of intestinal mucosal amino acid catabolism
up to 440 mmol/l. A plasma level between 2000 and
and its implications for protein and amino acid nutrition is
2500 mmol/l was identified as barrier for the GLU transfer
the role of nonessential (indispensable) amino acids like
to the fetus. It is therefore concluded that a transfer of GLU
GLU. Current studies of Reeds et al. (2000) demonstrated
from mother to fetus is highly unlikely even with the highest
that GLU is the most important oxidative substrate for the
intestinal mucosa. In addition, GLU (via glutamine) appearsto be a specific precursor for the amino acids arginine andproline as well as for the tripeptide glutathione by the small
Umami receptor and transduction mechanism: is it a selective
intestinal mucosa. Glutathione clearly plays an important
taste? Umami perception-recognition and palatability: nutritional
role in the protection of the mucosa from peroxide damage
and from dietary toxins. These results raise the intriguing
The Umami receptor is present in humans and
questions whether dietary GLU is an indispensable factor for
gives rise to a selective taste. The Umami receptor is specific
for GLU but might also detect other free amino acids.
Considerable behavioral and electrophysiolo-
Intestinal metabolism of GLU derived from natural sources or food
gical evidence already existed in the 1980s supporting the
additives and its function: are there differences?
notion that GLU (umami) represents a fifth basic taste,
Food-derived protein-bound and free GLU and
separate from sweet, sour, salty and bitter or combinations of
GLU derived from food additives are similarly metabolized in
these tastes. For example, in human taste testing studies,
subjects could differentiate umami tastes from those of theother basic tastes, in both simple and complex food matrices
It is well known that GLU penetrates carrier-
(Yamaguchi, 1987). In electrophysiological studies, record-
mediated but largely Na( þ )-independent through the cell
ing from afferent chorda tympani fibers in dogs, taste cells
membranes. There are no differences in luminal uptake
were found that responded to GLU application to the tongue
between GLU liberated from proteins, natural free GLU and
independent of sodium receptor stimulation (sodium recep-
additive GLU. All GLU taken up is used for the diverse
tors were blocked with amiloride) (Nakamura and Kurihara,
synthesis processes in intracellular compartments (Kovacevic
1991). In addition to these earlier results, glossopharyngeal
and McGivan, 1983; Hundal et al., 1986; Low et al., 1992).
afferent fibers were identified in mice that responded to GLU(and mononucleotide) applications to the tongue, but not tothe other basic tastants (Kurihara and Kashiwayanagi, 2000).
Fetal development: does the placenta barrier control GLU transfer?
More recently, attempts have been made to identify the
The placenta barrier controls GLU transfer even
specific type of receptor on the tongue that mediates umami
in situations of elevated maternal plasma levels. The
taste. One approach has been pharmacologic, and it was
limitation of transplacental transfer is due to placental
examined in rats and humans whether agonists at known
neuronal GLU receptors are perceived as having umamitaste. In rats, studies have focused on taste preference and
taste synergy studies, and evidence was found for an umami
Stegink et al. (1975) in pregnant females showed that even
taste receptor that shares pharmacologic similarities with the
very large, intravenously infused doses of GLU penetrate
metabotropic GLU receptor 4-subtype (mGLU-R4) (Delay
only to a minor extent into the fetal circulation. A
et al., 2000). In human studies, subjects reported the
biochemical explanation is offered by the recent studies in
presence and intensity of umami taste for a variety of GLU
sheep, in which the placenta was shown to extract GLU from
receptor agonists. The result was that the umami taste
both the maternal and fetal circulations for use as a principal
receptor is probably a metabotropic, but not an ionotropic
GLU receptor, perhaps somewhat similar to, but not
Up to which maternal plasma level this may be applicable
identical with the metabotropic GLU receptor subtype-4.
has been also tested in rhesus monkeys their placenta
Kurihara and Kashiwayanagi (2000) concluded from their
being morphologically and functionally the most similar to
human studies that the umami taste receptor may be a
human placenta (Stegink et al., 1975). Pregnant females
received during 1 h intravenous drip containing 0.15, 0.17–
A second approach has been to use molecular techniques
0.19, 0.22 or 0.40 g MSG/kg bw, respectively. Infusions with
to identify candidate umami taste receptors. One strategy,
based on earlier work suggesting that the mGLU-R4 might
Based on broad range of experimental data and human
function as an umami taste receptor, has been to search for
studies, MSG or calcium diglutamate can be used cautiously
the expression in taste tissue of the mGLU-R4. A gene
by the consumer in order to increase palatability and can
expressing an N-terminal truncated version of the mGLU-R4
also be used selectively by nutrition experts in order to
has been found in rat taste buds; this receptor elaborates
influence food selections towards a healthy diet composition
umami taste receptor-like properties (Chaudhari et al., 2000).
specifically in individuals with either a low food intake or
Another strategy has been to use novel screening strategies
to create a taste-bud enriched cDNA library from rats, anduse it to search for candidate taste receptors. This approachhas led to the identification of a set of G-protein-coupled
receptors, organized into two receptor families (taste recep-tor 1 (T1R) and taste receptor 2 (T2R)) that elaborate the
basic taste modalities, including umami (Hoon et al., 1999;
Food has to be safe. This statement is of paramount meaning
Nelson et al., 2002; Zhao et al., 2003). Umami taste receptors
in the legislation of virtually all countries and governs the
fall into the T1R family of receptors, and recent studies in
work of international bodies dealing with food and/or
knockout mice suggest that a particular member of the T1R
health. However, inappropriate eating habit, or individual
family (the T1R1 þ 3 variant) serves as an L-amino-acid
predisposition (e.g. idiosynkrasie, metabolic disorders) show
receptor in rat taste buds (Zhao et al., 2003), and an
that it is not possible to make food absolutely safe for
umami-specific taste receptor in humans (Li et al., 2002).
every person and under all circumstances. Therefore, the
Finally, a recent report has identified in humans a specific
definitions of food safety take these restrictions into
ageusia for GLU, suggesting that such individuals may lack
an umami taste receptor (Lugaz et al., 2002).
According to the general principles of Codex alimentarius
(1995) food safety is the assurance that food will not causeharm to the consumer when it is prepared and/or eaten
Does GLU improve palatability and does it have nutritional
according to its intended use. Several other definitions are
ISO 8402: Food safety means the state in which risk of
taste. Sodium or calcium salts of GLU increases acceptability
harm to persons or damage is limited to an acceptable
of new flavors. Liking of GLU-enriched foods may contribute
to maintain nutrient intake in subjects with reduced
ISI/CEI Guide 2: Food safety means freedom from
chemosensory sensitivity, for example institutionalized
OECD, 1993: ‘A food is safe if there is a reasonable
certainty that no harm will result from its consumption
Taste and smell losses can reduce appetite and
under the anticipated conditions of use’.
may lead to inadequate dietary intake, a situation frequently
Thus, one is aware that virtually no food can be described
occurring in elderly. Most of these chemosensory deficits are
to which a zero-risk may apply. This background leads to the
not reversible. Symptomatic treatment including intensifica-
question as to the ‘acceptable level of risk’ or ‘the reasonable
tion of taste and odor can compensate in part for perceptual
certainty’. It is commonly accepted that this limit rests on
losses. One method for treatment involves a sensory
enhancement of foods with flavors and MSG. Several studies
Whereas it is still a problem to assess the safety of a
showed that amplification of flavor and taste can improve
complex food, the assessment of a distinct compound that
food palatability, increase salivary flow and local immunity
may be employed as a food additive is a well established
and thereby at least acceptance of food (Schiffman, 2000;
procedure. The principles of which follow the recommenda-
tions of FAO/WHO Expert Committees and base on testing
In institutionalized elderly persons and in hospitalized
all toxicological endpoints as well as the definition of
diabetic patients, the addition of MSG to specific foods in a
acceptable daily intake amounts that take into account a
lunch meal induced an increased intake for those foods with
safety margin of a factor 100. This experimentally deter-
a subsequent decreased intake of foods presented later in the
mined amount is defined as the ‘no observed adverse effect
meal. In both populations only food selection was affected
by MSG but meal size remained the same (Bellisle, 1998).
With the idea to reduce sodium intake studies have been
performed to exchange sodium salts in foods with calcium
Can we define a safe level of intake regarding added GLU?
salts, for example calcium diglutamate. Addition of calcium
Based on dietary animal studies (metabolic
diglutamate raised liking of fried sausages (Bratwurst) similar
control), a NOAEL of 16 000 mg/kg body weight was
to the corresponding sodium salt-enriched products (Wood-
calculated in weaning animals, on parenteral supply 500–
There is an early literature showing that free
GLU sensitivity also showed no response to MSG; 80% of this
GLU can be administered chronically to humans in very
group demonstrated aspiring sensitivity. The investigators
large doses with no ill effect. An example of this is the study
concluded that MSG does not provoke bronchospasm
of Bazzano et al. (1970), in which doses up to 147 g/day GLU
were given for 30 days or more, with no adverse effects
In a survey of Stevenson (Stevenson, 2000) a total of 45
reported (147 g/day in a 70 kg male would be about 210 mg/
patients out of four studies cited are listed. The survey was on
kg bw/day). Other studies date even earlier that is from the
patients who reported asthma attacks after the consumption
1940s through the 1960s, for the most part. In animals, there
of meals in oriental restaurants. None of the patients showed
is the multigenerational study performed by Anantharaman
reactions on orally applied GLU per se. In contrast there are
in the 1970s (Anantharaman, 1979) using doses of 6000–
two former studies (Allen et al., 1987; Moneret-Vautrin,
7000 mg/kg bw/day into male and female mice and genera-
1987) reporting GLU provoking a reaction – under simple
tions of offspring with no ill effects whatsoever. But, no
blind conditions after discontinuing the antiasthma-medica-
LOAEL or NOAEL has been set for added GLU, at least by the
tion – in 16 out of 62 high-risk patients. Out of a total of 109
US Committee on Dietary Reference Intakes (Panel on
asthmatics tested none showed reactions on oriental food
An inquiry brought only one study up in which high-dose
GLU supplementation (up to 8% in the diet) improved
Do we have additional knowledge on the effect of added GLU on
significantly the immune status of rats recovering from
lung and immune system since 1997 until now?
chemotherapy. The immune-enhancing effect of dietary
GLU was dose-dependent and more pronounced after a
adverse effects on the lung. Other new data derived from
longer duration of dietary GLU intake (Lin et al., 1999).
in vitro studies show differing results but these cannotbe transferred to the situation of GLU derived from food.
The existence of GLU-induced asthma, even in history-
Can groups sensitive to GLU (derived from either natural food or
positive patients, has not been established firmly.
food additives) be defined? Are there at present placebo controlled
The information on the effects of high GLU concentra-
studies available sufficiently to either exclude or promote side
tions on immunological parameters is scarce.
No, there is no clear description of a sensitive
In 1981, two experiments were described in
phenotype. One multicenter study with real placebo did not
which asthma attacks could be provoked by ingesting 2.5 g
find any effect of GLU when MSG was given with food.
GLU (Allen and Baker, 1981). Recently, GLU receptors of the
Another study did not show reproducible effects.
NMDA subtype have been identified in the lungs of rats,which might be responsible for the hypersensitivity of
Regarding GLU sensitivity, two articles are
asthmatics (Dickmann et al., 2004). A survey of Schwartz-
relevant since 1997 (Yang et al., 1997; Geha et al., 2000).
stein (Schwartzstein, 1992) documented 19 cases of asthma
Yang et al. conducted a double-blind study in self-identified,
attacks induced by GLU dosages (as MSG) in the gram range.
GLU-sensitive subjects. They received placebo or 5 g MSG in
Here, the design of the study has to be criticized: under
liquid in random order, and those showing a response to one
double-blind conditions only a single attack could be
of the treatments were retested with 1.25, 2.5 and 5 g MSG.
A response was defined as any two of a list of 10 symptoms
Concerning lungs in relation to asthma two studies have
listed in a recent expert panel-government report (Raiten
appeared since 1997. Woods (Woods et al., 1998) examined a
et al., 1995) Subjects reported any symptoms, and were
group of asthmatic subjects who believed that added GLU
unaware of the index symptoms being followed. In the first
was a cause of their asthma. They conducted a double-blind,
trial, 22 of 61 subjects responded to 5 g MSG, but not placebo
placebo-controlled, crossover study (n ¼ 12); subjects in-
(18 responded to neither treatment, six responded to both
gested placebo (lactose), 1 or 5 g MSG on separate test days,
and 15 responded to placebo). When analyzed for order
and lung function was followed for 12 h. They observed no
effects of treatment (an assessment of subject bias), positive
significant effect of MSG on lung function at either dose,
responses to placebo were greater when it was administered
relative to placebo. Woessner et al. recruited groups of
during the first, rather than the second challenge. Subjects
asthmatic patients who reported (a) sensitivity to added
showing a response to one treatment only (n ¼ 37:22
GLU (n ¼ 30) and (b) no GLU sensitivity (n ¼ 70). Subjects
MSG þ 15 placebo; the study was double-blind) were then
received, single-blind, on separate days either placebo or
retested. An analysis of total occurrences in all subjects of the
2.5 g MSG, and were followed for 12 h. All subjects were
10 index symptoms revealed that headache, muscle tight-
tested for aspirin sensitivity. Subjects who reported sensiti-
ness, numbness, weakness and flushing were increased when
vity to GLU showed no difference in response to placebo
MSG was ingested, and a dose-effect was evident.
and MSG. Twelve of these subjects demonstrated aspiring
The Yang study evaluated the total occurrence of all
sensitivity (a positive control). Subjects who reported no
index symptoms of GLU, and did not require that subjects
show reproducibility of symptoms with retesting, a key issue
addition, hard clinical criteria are requested when testing
of a recent US expert panel review (Raiten et al., 1995).
patients with food additives (Asero, 2004).
Another recent study addressed the issue of symptomreproducibility among subjects who identified themselves
The Geha study (Geha et al., 2000) had four sequential
tests, the first two being identical to those in the Yang study
In cases of an impaired blood/brain barrier (BBB) GLU from
(above). A total of 130 subjects entered the first phase of the
blood might cross the barrier and might cause toxic effects
study, in which they received, double-blind, placebo or 5 g
even at physiological plasma levels.
MSG in liquid in random order on separate days, and
As the gastrointestinal tract has a very high capacity for
symptoms were recorded for 2 h. Fifty subjects reported two
using GLU, dietary intake (free and bound GLU) has a minor
or more index symptoms following MSG ingestion, and 0
impact on plasma levels. Only high concentrations (as bolus)
or 1 following placebo, 19 reported two or more symptoms
(e.g. 550 mmol/l) may lead to a transient increase of plasma
with MSG and placebo, 17 two or more symptoms with
level. Consequently food-derived GLU (including added
placebo, and 0 or 1 with MSG, and 44 0–1 symptoms with
GLU as food additive in normal amounts of o1 g/day) does
either MSG or placebo. Phase two (the dose–response study
not further increase the risk for toxic effects in cases of an
using 0, 1.25, 2.5 and 5.0 g MSG) entered 86 subjects (they
impairment of BBB because plasma levels do not rise.
included all subjects who had two or more responses toeither or both treatments) and completed 69. In this phase,when total symptom occurrence was analyzed, the outcome
Does the BBB control the GLU transfer under normal conditions?
was similar to that observed by Yang et al. (1997): more
As long as BBB is intact there is no risk for GLU
subjects reported index responses as MSG dose increased.
However, the responses were then analyzed for reproduci-bility across both trials. As the MSG dose in the first trial was
The BBB restricts and regulates the flux of
5 g, the reproducibility of response to the 5 g dose was
substrates between the circulation and the central nervous
assessed over both trials. The criterion of symptom reprodu-
system. To cross the barrier substances must either cross the
cibility was met by only 14 of the subjects (a total of 19
lipoid cellular membranes or be transported by selected BBB
responded to MSG but not placebo, but only 14 had
carriers. GLU is a polar solute, thus the passive influx is
reproducible symptoms to MSG). Based on the expert panel
limited to o1% of that occurring at the blood vessels of
report (Raiten et al., 1995) the next phase of the study, which
included 12 of the 19 subjects who responded to MSG butnot placebo (only 12 agreed to participate further), involvedadministering MSG (5 g) or placebo in capsules (to prevent
Are there conditions where this barrier function regarding GLU
their tasting the test substance) twice, each on separate
occasions. Only two of the subjects reported two or more
Several common brain pathologies are known to
symptoms after MSG, but not placebo. However, neither
be associated with BBB disruption. There is no assured
subject reported the same symptoms following each MSG
research data available whether augmented plasma levels in
challenge. A final phase assessed symptom occurrence
this situation influence synaptic GLU concentrations.
following the ingestion of food containing MSG (or placebo)on three separate occasions. Even though no subjects
There is evidence that a doubling of plasma
remained that had proven MSG-sensitivity, the two that
GLU, for example after infusion of GLU containing par-
responded to MSG, but not placebo, were invited to
enteral nutrition augments brain edema in conditions with a
participate in this phase. Both subjects reported two or more
lesioned BBB (Stover and Kempski, 1999). Elevated plasma
symptoms in one of the three MSG trials, and the symptoms
GLU may also occur during anesthesia with isoflurane
were not the same as reported in previous MSG challenges.
(Stover et al., 2004; Stover and Kempski, 2005).
The study of Geha et al. demonstrates that when a group of
self-identified, GLU sensitive individuals is asked to showreproducibility in symptoms, none can do so.
Do we have data that might promote a relationship or role of
The conclusions of a subsequent review by the Federation
added GLU in the development of neurological degenerative
of American Societies for Experimental Biology (FASEB) and
the Federal Drug Administration (FDA) did not discount the
At present there is no scientific data available
existence of a sensitive subpopulation but otherwise con-
supporting the presumption of an involvement of added
curred with the safety evaluation of JECFA and the SCF
GLU in the development of human neurological disease.
The trend is going to exclude GLU from food additive
GLU functions in the CNS as excitatoric trans-
intolerance list because of uncertainty (Young, 1997). In
mitter. Therefore, high intracellular GLU concentrations
concurrently with low extracellular concentrations have to
animals that had received a continuous infusion of GLU
be maintained. This will be reached on the one hand by a
water content (edema) was significantly higher than in rats
fast elimination of the released GLU by surrounding
without GLU infusion. A doubling of plasma GLU concen-
astrocytes and on the other hand by an active transport
trations was sufficient to cause this effect, and brain edema
mechanism provided at the BBB which ensures that the
only worsened in those animals, which had elevated plasma
spinal fluid (CSF)-GLU level is kept lower than the concen-
GLU concentrations. GLU increases brain water content
most likely as a consequence of glial GLU uptake systems,
In the brain, GLU binds to the NMDA-receptor and
which eliminate extracellular GLU together with sodium
controls the intra- and extracellular (synaptic) calcium
ions and – osmotically obliged – water. The deterioration of
levels. In times of overactivation there is a reinforced
brain edema hence was a direct consequence of homeostatic
calcium influx into the cell leading finally to apoptosis.
mechanisms that prevent interaction of extracellular GLU
After ischemia in definite brain sections neurons will be
destroyed. Out of these damaged cells GLU will be released
However, several caveats should be noted: (1) The GLU
and the CSF GLU level will increase. Therefore, primarily not
transporters at the BBB appear to be on the abluminal
infarcted brain sections will probably also be affected.
membrane, and function to transport GLU out of the brain
Basal synaptic concentrations of GLU are estimated to be
(O’Kane et al., 1999). These transporters presumably would
in the 2–5 mmol/l range, and rise to 50–100 mmol/l following
still function in situations in which BBB permeability has
release (Daikhin and Yudkoff, 2000; Meldrum, 2000). Plasma
increased; (2) Glial and neuronal GLU transporters (Gold-
GLU concentrations are typically 50–100 mmol/l under
smith, 2000; Meldrum, 2000) would also presumably remain
normal conditions (Tsai and Huang, 1999; Fernstrom et al.,
functional under conditions of increased BBB permeability
1996) and do not rise significantly even in the presence of
(except if the brain is ischemic, and thus oxygen deprived,
sizable oral doses of MSG (Tsai and Huang, 1999). Plasma
such as during a stroke/vascular occlusion or under condi-
GLU concentrations appear to rise only when pharmacologic
tions of increased intracranial pressure), and help to keep
doses of MSG are administered. Hence, if the BBB were to
brain ECF and basal synaptic GLU concentrations low; and
become permeable (for review see Ballabh et al., 2004;
(3) Dietary GLU and MSG, even at a very high dose in the
Neuwelt, 2004), or BBB GLU transporters were to become
daily diet (Tsai and Huang, 1999), do not raise plasma GLU
compromised (they normally function to transport GLU out
concentrations (MSG intake is self-limiting, since it is not
of the brain (O’Kane et al., 1999), one might imagine that
palatable at high concentrations in foods (Yamaguchi,
synaptic GLU concentrations could rise, which would be
1987)); hence, dietary GLU or MSG should not influence
sufficient to stimulate GLU receptors.
synaptic GLU concentrations, per se, if BBB permeability were
Few studies to date have searched for changes in BBB GLU
transport in physiologic and pathophysiologic settings.
However, a growing body of evidence addresses alterationsin BBB permeability (typically to large molecules). For
Are toxicological data derived from animal experiments
example, increases in BBB permeability have been reported
(dose–effect-relations) directly transferable to humans?
to accompany aging (Shah and Mooradian, 1997), Alzhei-
Comparative functional and metabolic studies
mers dementia (Skoog et al., 1998; Ujiie et al., 2003), type II
in a variety of animals including primates and human
diabetes (Starr et al., 2003), and hypertension (Mooradian,
studies provide a rational safety evaluation for human
1988; Mayhan, 1990; Ueno et al., 2004). BBB permeability
also increases with increasing plasma osmolarity (Tamakiet al., 1984), and after the administration of certain drugs
Relevant literature has already been summar-
(Boertje et al., 1992). Presumably, increases in BBB perme-
ized and listed (Biesalski et al., 1997; Walker and Lupien,
ability would permit increased entry of all molecules from
2000). Briefly, the toxicologic database available for review
the plasma, including molecules such as GLU. However,
includes acute, subchronic and chronic toxicity studies as
most studies that have specifically examined GLU transport
well as studies on reproductive toxicity and teratology in
(penetration) into the brain, deal with aging, in which GLU
rats, mice and dogs. GLU has a very low acute toxicity under
transport appears to be not different in adult and aged
normal circumstances; the oral dose that is lethal to 50% of
animals (Shah and Mooradian, 1997), and with hyperten-
subjects (LD50) in rats and mice is 15000–18000 mg/kg bw,
sion, in which GLU uptake into brain may be increased (Tang
respectively. Subchronic and chronic toxicity studies of up to
et al., 1993; Al-Sarraf and Philip, 2003).
2 years duration in mice and rats, including a reproductive
However, there is evidence that a doubling of plasma GLU,
phase, did not reveal any specific adverse effects at dietary
e.g. after infusion of GLU-containing parenteral nutrition
levels of up to 4%. Reproduction and teratology studies using
augments brain edema in conditions with a lesioned blood
the oral route of administration have been uneventful
brain barrier (Kempski et al., 1990). In those experiments the
indicating that the fetus and suckling neonate was not
BBB of rats was focally destroyed by a freezing lesion, and
exposed to toxic GLU levels from the maternal diet through
water content of the brain was measured a day later. In
transplacental transfer. Based on these results from mammals
authoritative organizations have affirmed the safety of added
amino acids accounting for around 50% of total free amino
GLU at levels normally consumed by the general population.
acids (Agostoni et al., 2000; Ramirez et al., 2001). Actualanalyses of free GLU in milk samples of mothers delivered ontime revealed 8277342 mmol/l for transitional milk and
Large doses of dietary GLU: do they have an impact on endocrine
8687462 mmol/l for mature milk (Meinardus et al., 2004;
Jochum et al., 2006). Considering a daily feeding of 600 ml, a
Very high doses of GLU influence the insulin
4-kg-infant would ingest around 130 mmol/kg (19 mg/kg) free
reaction induced by an unphysiologically high glucose load.
GLU. Moreover, the intake of bound GLU would reach ca.
1.3–1.5 g/day depending of the protein content of the milk.
Recently, Chevassus et al. (2002) gave 10 g MSG
The role of free amino acids in breast milk is still under
or placebo in capsules orally to fasted human subjects at the
debate. It is, however, speculated that especially free GLU
time they received a 75 g glucose load, and followed the
and glutamine might have a double role of protecting the
plasma insulin changes over time. There was a significant
intestinal growth while supplying functional substrates to
positive correlation between plasma insulin area-under-the-
the nervous tissue (Agostoni et al., 2000; Jochum et al.,
curve and peak plasma GLU concentrations, suggesting to
2006). Consequently, the intake of free GLU in suckling
the authors that GLU enhanced glucose-induced insulin
babies is seen as a useful physiological support of growth and
secretion, consistent with the existence of stimulatory GLU
metabolic development. In addition, GLU is seen as a rapidly
receptors on pancreatic beta cells (Hinoi et al., 2004). In this
available nitrogen donor in growing mammals due to its
study, peak plasma GLU concentrations were about doubled
central role in transamination processes.
over baseline and placebo values. Studies of similar designhave also been conducted by Graham and associates, butadministering MSG (or a placebo) by itself to fasting subjects;
with this design, significant increases in plasma insulinconcentrations are clearly evident (Graham et al., 2000;
Agostoni C, Carratu` B, Boniglia C, Riva E, Sanzini E (2000). Free
amino acid content in standard infant formulas: comparison withhuman milk. J Am Coll Nutr 19, 434–438.
Allen DH, Baker GJ (1981). Chinese-restaurant asthma. N Engl J Med
Are there any effects of GLU on neonatal development?
Allen DH, Delohery MB, Baker G (1987). Monosodium L-glutamate-
Even in unphysiologically high doses GLU will
induced asthma. J Allergy Clin Immunol 80, 530–537.
not trespass in fetal circulation. Therefore, orally applied
Al-Sarraf H, Philip L (2003). Increased brain uptake and CSF clearance
of 14C-glutamate in spontaneously hypertensive rats. Brain Res
GLU is not expected to influence neonatal development.
Anantharaman K (1979). In utero and dietary administration of
monosodium L-glutamate to mice: Reproductive performance and
Anantharaman (1979), who conducted a multi-generation
development in a multigeneration study. In: Filer LJ et al. (eds).
Glutamic Acid: Advances in Biochemistry and Physiology. Raven Press:
study in male and female mice exposed to MSG in a standard
diet (at 1 or 4%). The average daily MSG intake at the higher
Anderson SA, Raiten DJ (1992). Safety of amino acids used as dietary
dose was calculated to be 6000 mg/kg/day in males and
supplements. Special Publications Office, Federation of American
7200 mg/kg/day in females, extremely high doses. Animals
Societies for Experimental Biology: Bethesda, MD.
Asero R (2004). Food additives intolerance: does it present as perennial
were exposed to MSG at all ages and at all stages of
rhinitis?. Head of the Allergy Unit, San Carlo Clinic, Paderno
development. No developmental or reproductive effects
Dugnano (MI): Italy, United States. pp 25–29.
were noted. No histological incidences of brain lesions or
Ballabh P, Braun A, Nedergaard M (2004). The blood-brain barrier: an
overview: structure, regulation, and clinical implications. Neuro-biol Dis 16, 1–13.
Battaglia FC (2000). Glutamine and glutamate exchange between the
fetal liver and the placenta. J Nutr 130, 974S–977S.
Do babies fed with breast milk consume free GLU?
Bazzano G, D’Elia JA, Olson RE (1970). Monosodium glutamate:
Breast milk contains measurable amounts of free
feeding of large amounts in man and gerbils. Science 169,1208–1209.
GLU with great individual variations. Babies, thus, consume
Bellisle F (1998). Effects of monosodium glutamate on human food
higher amount of free GLU per kg body weight than during
palatability. Ann NY Acad Sci 855, 438–441.
Berkowitz VJ (2000). A view on high-protein, low-carb diets. J Am
Biesalski HK, Ba¨ssler KH, Diehl JF, Erbersdobler HF, Fu
Free amino acids are constituents of the so-
W et al. (1997). Na-Glutamat. Akt Erna¨hr-Med 22, 169–178.
called nonprotein nitrogen fraction of human milk (Rudloff
Boertje SB, Ward S, Robinson A (1992). H2-receptors mediate
and Kunz, 1997; Agostoni et al., 2000). The total amount of
free amino acids is around 3 mmol/l plasma with great
blood-brain barrier of rats. Res Commun Chem Pathol Pharmacol76, 143–154.
variations (association with the nutritional behavior of the
Burrin DG, Reeds PJ (1997). Alternative fuels in the gastrointestinal
mother). GLU, glutamine and taurine are the prevalent
tract. Curr Opin Gastroenterol 13, 165–170.
Chaudhari N, Landin AM, Roper SD (2000). A metabotropic
Low SY, Taylor PM, Hundal HS, Pogson CI, Rennie MJ (1992).
glutamate receptor variant functions as a taste receptor. Nature
Transport of L-glutamine and L-glutamate across sinusoidal
membranes of rat liver. Effects of starvation, diabetes and
Chevassus H, Renard E, Bertrand G, Mourand I, Puech R, Molinier N
corticosteroid treatment. Biochem J 284, 333–340.
et al. (2002). Effects of oral monosodium (L)-glutamate on insulin
Lugaz O, Pillias AM, Faurion A (2002). A new specific ageusia: some
secretion and glucose tolerance in healthy volunteers. Br J Clin
humans cannot taste L-glutamate. Chem Senses 27, 105–115.
Mayhan WG (1990). Disruption of blood–brain barrier during
Daikhin Y, Yudkoff M (2000). Compartmentation of brain glutamate
acute hypertension in adult and aged rats. Am J Physiol 258,
metabolism in neurons and glia. J Nutr 130, 1026S–1031S.
Delay ER, Beaver AJ, Wagner KA, Stapleton JR, Harbaugh JO, Catron
Meinardus P, Alteheld B, Colling S, Fusch C, Jochum F, Stehle P
KD et al. (2000). Taste preference synergy between glutamate
(2004). Glutamine content in breast milk after term and preterm
receptor agonists and inosine monophosphate in rats. Chem Senses
Dickmann LJ, Locuson CW, Jones JP, Rettie AE (2004). Differential
the brain: review of physiology and pathology. J Nutr 130,
roles of Arg97, Asp293, and Arg108 in enzyme stability and
substrate specificity of CYP2C9. Mol Pharmacol 65, 842–850.
Mojet J, Heidema J, Christ-Hazelhof E (2003). Taste perception with
Dillon PM (1993). Invasion of the MSG-free ingredients. Food Eng 64,
age: generic or specific losses in supra-threshold intensities of five
taste qualities? Chem Senses 28, 397–413.
Fernstrom JD, Cameron JL, Fernstrom MH, McConaha C, Weltzin TE,
Moneret-Vautrin DA (1987). Monosodium glutamate – induced
Kaye WH (1996). Short-term neuroendocrine effects of a large oral
asthma: study of the potential risk in 30 asthmatics and review
dose of monosodium glutamate in fasting male subjects. J Clin
of the literature. Allergic Immunol 19, 29–35.
Mooradian AD (1988). Effect of aging on the blood–brain barrier.
Fernstrom JD, Garattini S (2000). International symposium on
glutamate. J Nutr 130 (Suppl 4), 891S–1079S.
Mourtzakis M, Graham TE (2002). Glutamate ingestion and its
¨rst P, Stehle P (2004). What are the essential elements needed for
effects at rest and during exercise in humans. J Appl Physiol 93,
the determination of amino acid requirements in humans? J Nutr
Nakamura M, Kurihara K (1991). Canine taste nerve responses to
Garattini S (2000). Glutamic acid, twenty years later. J Nutr 130,
monosodium glutamate and disodium guanylate: differentiation
between umami and salt components with amiloride. Brain Res
Geha RS, Beiser A, Ren C, Patterson R, Greenberger PA, Grammer LC
et al. (2000). Multicenter, double-blind, placebo-controlled, multi-
Nelson G, Chandrashekar J, Hoon MA, Feng L, Zhao G, Ryba NJ et al.
ple-challenge evaluation of reported reactions to monosodium
(2002). An amino-acid taste receptor. Nature 416, 199–202.
glutamate. J Allergy Clin Immunol 106, 973–980.
Neuwelt EA (2004). Mechanisms of disease: the blood–brain barrier.
German Nutrition Society (2004). The Nutrition Report 2004. Bonn,
O’Kane RL, Martinez-Lopez I, DeJoseph MR, Vina JR, Hawkins RA
Goldsmith PC (2000). Neuroglial responses to elevated glutamate in
(1999). Na þ -dependent glutamate transporters (EAAT1, EAAT2,
the medial basal hypothalamus of the infant mouse. J Nutr 130,
and EAAT3) of the blood–brain barrier. A mechanism for
glutamate removal. J Biol Chem 274, 31891–31895.
Graham TE, Sgro V, Friars D, Gibala MJ (2000). Glutamate ingestion:
Panel on Macronutrients: Protein and Amino Acids (2002) In: Dietary
the plasma and muscle free amino acid pools of resting humans.
Reference Intakes for Energy, Carbohydrate, Fibre, Fat, Fatty Acids,
Am J Physiol Endocinol Metab 278, E83–E89.
Cholesterol, Protein and Amino Acids (Macronutrients). Institute
Hinoi E, Takarada T, Ueshima T, Tsuchihashi Y, Yoneda Y (2004).
of Medicine (Ed.) National Academies Press:Washington, D.C,
Glutamate signaling in peripheral tissues. Eur J Biochem 271,
Raiten DJ, Talbot JM, Fisher KD (1995). Analysis of adverse reactions to
Hoon MA, Adler E, Lindemeier J, Battey JF, Ryba NJ, Zuker CS (1999).
monosodium glutamate (MSG). FASEB Life Sciences Research Office:
Putative mammalian taste receptors: a class of taste-specific GPCRs
with distinct topographic selectivity. Cell 96, 541–551.
Ramirez I, DeSantiago S, Tovar AR, Ortiz N, Torres N (2001). Amino
Hundal HS, Watt PW, Rennie MJ (1986). Amino acid transport
acid intake during lactation and amino acids of plasma and
in perfused rat skeletal muscle. Biochem Soc Transactions 14,
human milk. Adv Exp Med Biol 501, 415–421.
Reeds PJ, Burrin DG, Stoll B, Jahoor F (2000). Intestinal glutamate
Jochum F, Meinardus P, Alteheld B, Colling S, Fusch C, Stehle P
metabolism. J Nutr 130, 978S–982S.
(2006). Total glutamine content in preterm and term human
Rhodes J, Titherley AC, Norman JA, Wood R, Lord DW (1991). A
breast milk. Acta Paediatr 95, 985–990.
survey of the monosodium glutamate content of foods and an
estimation of the dietary intake of monosodium glutamate. Food
nous glutamate enhances edema formation after a freezing lesion.
Rudloff S, Kunz C (1997). Protein and nonprotein nitrogen
Kovacevic Z, McGivan JD (1983). Mitochondrial metabolism of
components in human milk, bovine milk, and infant formula:
glutamine and glutamate and its physiological significance.
quantitative and qualitative aspects in infant nutrition. J Pediatr
¨rst P (1996). Glutamine content of protein and
Schiffman SS (2000). Intensification of sensory properties of foods for
peptide-based enteral products. J Parenter Enteral Nutr 20, 292–295.
the elderly. J Nutr 130, 927S–930S.
Kurihara K, Kashiwayanagi M (2000). Physiological studies on
Schwartzstein RM (1992). Pulmonary reactions to monosodium
umami taste. J Nutr 130, 931S–934S.
glutamate. Pediatr Allergy Immunol 3, 228–232.
Li X, Staszewski L, Xu H, Durick K, Zoller M, Adler E (2002). Human
Shah GN, Mooradian AD (1997). Age-related changes in the blood–
receptors for sweet and umami taste. Proc Natl Acad Sci (USA) 99,
brain barrier. Exp Gerontol 32, 501–519.
Skoog I, Wallin A, Fredman P, Hesse C, Aevarsson O, Karlsson I et al.
Lin CM, Abcouwer SF, Souba WW (1999). Effect of dietary glutamate
(1998). A population study on blood–brain barrier function in 85-
on chemotherapy-induced immunosuppression. Nutrition 15,
year-olds: relation to Alzheimer’s disease and vascular dementia.
Smith QR (2000). Transport of glutamate and other amino acids at
in men on a diet without and with added monosodium glutamate.
the blood–brain barrier. J Nutr 130, 1016S–1022S.
Starr JM, Wardlaw J, Ferguson K, MacLullich A, Deary IJ, Marshall I
Ueno M, Sakamoto H, Tomimoto H, Akiguchi I, Onodera M, Huang
(2003). Increased blood-brain barrier permeability in type II
CL et al. (2004). Blood-brain barrier is impaired in the hippo-
diabetes demonstrated by gadolinium magnetic resonance ima-
campus of young adult spontaneously hypertensive rats. Acta
ging. J Neurol Neurosurg Psychiatry 74, 70–76.
Stegink LD, Pitkin RM, Reynolds WA, Filer Jr LJ, Boaz DP, Brummel
Ujiie M, Dickstein DL, Carlow DA, Jefferies WA (2003). Blood–brain
MC (1975). Placental transfer of glutamate and its metabolites in
barrier permeability precedes senile plaque formation in an
the primate. Am J Obstet Gynecol 122, 70–78.
Alzheimer disease model. Microcirculation 10, 463–470.
Stevenson DD (2000). Monosodium glutamate and asthma. J Nutr
Walker R, Lupien JR (2000). The safety evaluation of monosodium
glutamate. J Nutr 130, 1049S–1052S.
Stoll B, Henry J, Reeds PJ, Yu H, Jahoor F, Burrin DG (1998).
Woessner KM, Simon RA, Stevenson DD (1999). Monosodium
Catabolism dominates the first-pass intestinal metabolism of
glutamate sensitivity in asthma. J Allergy Clin Immunol 104,
dietary essential amino acids in milk protein-fed piglets. J Nutr
Woods RK, Weiner JM, Thien F, Abramson M, Walters EH (1998). The
Stover JF, Kempski OS (1999). Glutamate-containing parenteral nutri-
effects of monosodium glutamate in adults with asthma
tion doubles plasma glutamate: a risk factor in neurosurgical patients
who perceive themselves to be monosodium glutamate-intolerant.
with blood brain-barrier damage? Crit Care Med 27, 2252–2256.
J Allergy Clin Immunol 101, 762–771.
Stover JF, Kempski OS (2005). Anesthesia increases circulating
Woodward DR, Lewis PA, Ball PJ, Beard TC (2003). Calcium
glutamate in neurosurgical patients. Acta Neurochir 147, 847–853.
glutamate enhances acceptability of reduced-salt sausages. Asia
Stover JF, Sakowitz OW, Kroppenstedt SN, Thomale UW, Kempski OS,
Flugge G et al. (2004). Differential effects of prolonged isoflurane
Yamaguchi S (1987). Fundamental properties of umami in human
anesthesia on plasma, extracellular, and CSF glutamate, neuronal
taste sensation. In: Kawamura, Y and Kare MR (eds). Umami:
activity, 125I-Mk801 NMDA receptor binding, and brain edema in
A Basic Taste. Marcel Dekker: New York. pp 41–73.
traumatic brain-injured rats. Acta Neurochir 146, 819–830.
Yang WH, Drouin MA, Herbert M, Mao Y, Karsh J (1997). The
Tamaki K, Sadoshima S, Heistad DD (1984). Increased susceptibility
monosodium glutamate symptom complex: assessment in a
to osmotic disruption of the blood-brain barrier in chronic
double-blind, placebo-controlled, randomized study. J Allergy Clin
hypertension. Hypertension 6, 633–638.
Tang JP, Xu ZQ, Douglas FL, Rakhit A, Melethil S (1993). Increased
Young E (1997). Prevalence of intolerance to food additives. Environ
blood–brain barrier permeability of amino acids in chronic
hypertension. Life Sci 53, PL417–420.
Zhao GQ, Zhang Y, Hoon MA, Chandrashekar J, Erlenbach I, Ryba NJ
Tsai PJ, Huang PC (1999). Circadian variations in plasma and
et al. (2003). The receptors for mammalian sweet and umami taste.
erythrocyte concentrations of glutamate, glutamine, and alanine
Delayed Graft Function (DGF) Delayed graft function in the pediatric kidney transplant patient represents a significant adverse event for the graft with repercussions in both short-term and long-term graft survival and compromising the post-op management significantly. Every possible effort should be exerted to avoid DGF and to pursue constant surveil ance of the patient’s statu
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