The Dangers of Creatinine

Jeff Golini
 The Dangers of Creatinine
All Rights Reserved. Copyright 2006 Jeff Golini

The information presented in this book is based on information from sources believed
to be reliable, and every effort has been made to make this book as complete and
accurate as possible based on the information available as of the printing date. Despite
the best efforts of both the author and reviewers, the validity of the research, and
other previously printed information referenced, cannot be guaranteed. In addition, no
portion of this book is intended to be used as medical advice, nor is it to be
considered the ultimate source of information on the subject. No responsibility for any
adverse affects or consequences arising from the use of this information will be born
by the author or publisher. All matters pertaining to your physical health should be
supervised by a health care professional.

No part of this book may be reproduced or transmitted in any form or by any means,
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the publisher.

Booklocker.com, Inc., First Edition, 2006

KINDLE ISBN: 9781621414797

PRINT ISBN: 9781591139294

Published by Booklocker.com, Inc., Bradenton, FL.

 Dedication

This book is dedicated to those who are suffering from kidney failure
and to those who help them.
 In todays attempt to be a healthy society, we continue to destroy our
bodies with toxins that we do not have knowledge about. Dont assume
what you consume is always safe!
 Contents

Foreword
Preface
Acknowledgements

Chapter 1 - Keeping a Bio-mechanism in Perpetual Motion

Introduction The Body Human
Creatine - Bio-Fuel of Life
A Supplement is Born
An Ergo-Economic Bonanza
Summary

Chapter 2 -Creatinine The Other Side of the Coin

In Search of Ouroboros
No Free Lunch
Function of Creatinine in Man
Summary

Chapter 3 - On the Hoof vs. Off the Shelf

Survival Gene Genius
Food vs. Factory - Nutritional Sources of Creatine/Creatinine
Conversion of Meat Creatine to Creatinine
Of Meat and Man
Synthetic Creatine - Creatine Monohydrate
All Things Not Created Equal
In-Vitro Stability
Manufacturing Impurities
Summary
Chapter 4 - Creatinine Mutagenicity and Carcinogenicity
Do No Harm?
A Wolf in Sheeps Clothing?
By Any Other Name
In Harms Way?
Mutagenicity
Carcinogenicity
The Bacterial Connection
The Nutritional Connection
Summary

Chapter 5 - If a Little Does Good

Unethical Science
Physiologic Impact of Creatinine Excess
Metabolic Disruption and Cell Death
Inflammatory Promoter
Neurological and Hematological Impact
Insulin Resistance
Renal Stress and Renal Disease Progression
Supplement Induced:
Nutritionally Induced
Summary

Chapter 6 - A Smoking Spoon?

Whats the Beef?

Chapter 7 - An Experts Point of View

Interview with Sheri Colberg, PhD
Interview with Brian Andrews
Interview with Rehan Jalali
Interview with Dr. Kamen Stoychev, MD

Book Summary

Bibliography
 Foreword

Creatine, in and of itself, is a powerful and required source of bio-fuel, and we benefit from its
natural sources in our diet. In the natural progression of metabolism, what we take in as creatine is
used in the muscle and excreted as a group of byproducts, predominantly as creatinine. It is unclear
what impact excessive creatinine has on physiologic homeostasis. It is troubling however, how
increases in the metabolic waste products of creatine, both natural and supplemented, could place a
hefty burden on those with already faltering kidney function. In renal insufficiency, the reserve our
once healthy kidneys enjoyed for clearing toxins, becomes further tenuous when diet loads us with
spent creatine in the form of creatinine waste. Everything from cooking technique to the postprandial
handling of meals by our own natural bacterial flora can stack this proverbial card deck of creatine
versus creatinine against us.
As with any of todays mysteries, begging to be unveiled by convention of the scientific method,
there is bias driven by interest and profit margin. To this end, one group, which may have been over-
shadowed in all the hype of creatine monohydrate as a performance supplement, are those with renal
insufficiency. Albeit a relatively small faction of the population, the group is growing substantially,
and is now approximately sixty million worldwide. In this group, creatine monohydrate
supplementation has been under studied and its role unclear. Supplementation of any kind against a
backdrop of renal disease is a balancing act worthy of Cirque Du Soleil. Here, the wrong supplement
could spell disaster. Unfortunately, many of those with renal disease are unaware that with every
supplement they consume they may be positioning themselves that much closer to end stage renal
disease and the need for dialysis or transplant.
Creatinine and its renal clearance has long been a standard way of measuring the amount of
function ones kidneys have. And once on dialysis, serum creatinine levels can be used to evaluate to
what extent a persons blood is being cleansed of waste. What has yet to be well elucidated is the
role of lone creatinine on end-organ damage. Is creatinine toxic or is it the best available marker we
have for other, less identifiable, toxic metabolites? Amid the renal community answers to important
questions, like this one, will continue to be sought after. Until now however, what has not been
carefully considered is the deleterious impact that excessive creatine (nutritionally or nutraceutically
supplied) and especially its end product - creatinine, can have in one with declining renal function.
Of particular concern in this scenario is such supplementation in someone whom suffers undiagnosed
kidney disease.
- Shaun Kaiser, M.A., R.D., L.D.
 Preface

Creatine was discovered in 1832, followed shortly there after by the identification of creatinine in the
mid 1800's. Interest in these muscle associated molecules was initially esoterical, hence the
information generated from the very early creatine/creatinine investigations was relegated to the dusty
pages of scientific literary obscurity. Creatine went relatively unnoticed, outside of scientific circles,
for about the next 120 years. Only in the mid to latter half of the 1990's, did the athletic industry, in
their never-ending quest to uncover new untapped, non-doping performance enhancing substances, for
a hungry athletic market, take a closer look at the usefulness of this natural dietary constituent of meat.
At the time of its initial discovery, creatine was labor intense and expensive to isolate. But now
industry had learned to synthesize creatine monohydrate in virtually limitless quantities making it a
marketable product. Synthetically produced creatine monohydrate, in its various formulations, has
become one of the sports nutrition industry's top-selling supplements. Today, creatine monohydrate
sales are upwards of almost 3 million kilograms worldwide, yearly.
While creatine monohydrate has found its way into every level of the athletic and fitness industry,
its journey has not been without some controversy. The early part of this millennium has seen a tidal
wave of opponents and proponents, all arguing the safety, merits, and ethics of using this synthetic,
highly ergogenic, material.

While creatine can be thought of as essential bio-fuel, creatinine irrespective of its origin must
be considered bio-waste. While no one in the scientific arena questions the safety of normal
physiological-level creatine, the occasional controversy arises when the physiological creatine level
is artificially maintained at super-physiological levels (abnormal for the respective individual). In
such instances, the amount of this spent fuel generated can increase significantly, along with its
potential to cause physiological burden and unknown negative impact over time. It is this latent
potential, suggested in some of the animal studies, as well as occasional antidotal human reports, that
has caused the sounding of a cautionary note with regard to the perpetual, chronic use of large gram
quantities of creatine monohydrate.
While the author of this work acknowledges that it may be possible for a few individuals, who are
embracing a meat-saturated lifestyle, to ingest as much as 3 5 grams of meat-creatine daily, raising
and sustaining their potential creatinine burdened naturally, it is also likely that excessive creatinine
will be generated (on a long-term bases) from the regular ingestion of large amounts of commercially
available creatine monohydrate. Hence, a portion of the discussion in this book will refer to
creatinine generated from synthetic creatine monohydrate.
Also of interest, in the scope of this discussion, will be the creation of by-products or product
contaminants creatinine, as well as secondary products such as dicyandiamides and
dihydrotriazine, and their potential to cause long-term physiological impact. Such materials can
potentially be generated (in minute quantities) during various steps in the manufacturing process.
Of equal interest is the potential creatinine has shown (in some studies) to be able to be
transformed into one or more substances which either are, or may act in, a mutagenic and/or
carcinogenic capacity.

The purpose of this book is not to address the occasionally heated, and undeniably controversial,
issues surrounding the efficacy, immediate safety, or overall merits or ethics of creatine monohydrate
use by individuals (as young as 9 years old), who are involved in todays sports industry. Instead, this
work will take a close analytical look at the potential excess creatinine the end product of all
endogenous and exogenous creatine(s) has to cause dangerous physiological burden, against the
backdrop of pre-existing (and often undiagnosed) renal disease, which today exceeds 20 million
people in the U.S. and millions more worldwide.
 Acknowledgements

There are always special people who help you get a book published.

First, I would like to thank God for the many blessings he has given me and the wisdom to write this
book. Thank you to Wendy Jones of Royal Knight for your hard work on the research. My staff at All
American Pharmaceutical for the hard work that has led to the writing of this book. Thank you to all
the physicians and doctors for the research that you have done and will continue to do toward helping
people with kidney problems. My Dad, Dan Golini for all the wisdom he has given me over the years.
And last but not least, my wife Kim Golini for the support she continues to give me toward my
passion of helping people achieve health, the natural way. And no thanks would be complete without
mentioning my sister Nancy, my brothers Dave & James and kids Shanna, Shane & Andrea.

I am blessed for having each of you.

Literature research for the preparation of the manuscript, The (Potential) Dangers of
Creatinine, was accomplished by Wendy Lou Jones of Royal Knight, Inc. E-mail:
WLJ_1998@Yahoo.com
 Chapter 1

Keeping a Bio-mechanism in Perpetual Motion

Introduction The Body Human

How wondrous is the body and all its workings.
What poet and artist alike have unknowingly praised in sonnet and media is in fact infinitely more
complex than any physical rendering could have ever depicted the intricate inner workings of our
living machine the body.

The body is truly an amazing machine, without a man-made mechanical equal. Even in the 21st
century, we are just now beginning to unravel the mysteries of its most intricate processes which are
in a state of bio-mechanical perpetual motion. What regulates the creation and/or sequestering of
specific amino acids, the formation of a specialized protein, or an enzyme whose existence is
measured only in seconds, and most important how is it all kept in harmonious synchronized
motion?
For the most basic biological processes to continue uninterrupted, the body requires a means of
mobilizing energy throughout the system. To accomplish this, various eloquently designed
mechanisms, and facilitators, are created. These facilitators mobilize and direct high-energy raw
materials to intercellular sites for refinement and processing. The newly synthesized products are
then shuttled to sites of use, undergo further modification (in some instances), and finally spent
components, or fuels, are either transported via chaperone, or simply allowed to circulate back to an
appropriate waste recycler or, in many cases, the biological sewage disposal system.
Creatine - Bio-Fuel of Life
No discussion of creatinine could ever be complete without a close look at its starting material
creatine.

Creatine represents a form of bio-fuel, a physiologically essential nitrogenous compound.

Also known as methyl guanidine acetic acid, creatine is one such intermediate high-energy facilitator.
Creatine is absolutely indispensable. If the body were suddenly divested of all creatine, life would
cease.

Creatine is a non-protein, amino acid molecule. Its role in cellular energy regulation is intimately
interconnected with lifes processes, and based on the extremely complex biochemistry of metabolic
supply and cellular energy demands (Persky and Brazeau. 2001). All of the creatine which is
synthesized by the body (endogenously) is synthesis by direct involvement of three organs - the
kidneys, liver, and pancreas using arginine, glycine, and methionine (Burke. 1999) as the basic amino
acid building blocks (Fig. 1). The initial step in the molecular creation process is a basic coupling
reaction of arginine and glycine via an A-G transferase enzyme. Products of this rapid reaction are
ornithine and guanidinoacetate. The guanidinoacetate molecule itself then undergoes rapid
methylation, which occurs via S-adenosyl methionine (or SAM-e), an enzymatic cofactor involved in
methyl group transfer, originating primarily in the kidneys.

FIGURE 1 - Basic amino acid coupling reaction - a two step process in the creation of endogenous
creatine

Once syntheses are complete, creatine travels to the site of utilization (predominantly skeletal
muscles) (Fig. 2).

FIGURE 2 - The major paths of creatine (Cr) metabolism in the mammalian body. For the most part,
between 94-95% of all Cr is found in skeletal muscle tissues. Because muscle has almost no Cr-
synthesizing capacity, Cr has to be transported to the site of need. A muscle cells daily demand for Cr
must be met by intestinal absorption of dietary Cr or by Cr biosynthesis.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]

It has been estimated that approximately 94-95% of all creatine in the body is in close proximity to
the skeletal muscles. Most of the remainder of all inter-corporal creatine can be found in the brain,
kidney, and liver (Balsom et al. 1994; Casey and Greenhaff PL. 2000).

Creatine is rapidly transported across the cell membrane via a sodium dependent transport gating
mechanism (Ganguly et al. 2003). Because creatine is an essential constituent of all muscle fiber
bearing tissues, its role in the metabolic transfer of energy, and subsequent chain of events, is
absolutely critical. One of the most important features of creatine is the fact that it can, via its
chemical property, find the appropriate high-energy phosphate molecule and undergo reversible
binding (Fig. 3).

FIGURE 3 - The creatine kinase (CK) reaction. PCr, phosphorylcreatine; Cr, creatine.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]
This process begins with the creation of adenosine triphosphate (ATP) via aerobic respiration. Once
synthesized, it then reacts rapidly with free creatine in the cell. This reaction is facilitated using a
mitochondria associated creatine kinase. The enzymatic results are the formation of adenosine
diphosphate (ADP) a lower energy molecule, and phosphocreatine a high energy storage unit.
Synthesis continues rapidly until an intercellular equilibrium is reached (Fig. 4). In a depleted
muscleenergy state, the amount of time to repletion-equilibrium may vary. Once phosphocreatine is
formed, it remains trapped in the skeletal muscle cell because of its now polar nature which is
incompatible with the inner-cell membrane gating transport mechanism. The amount of
phosphocreatine that any one cell can contain is a reflection of its energy reservoir capacity.
Hence, when ATP is used during exercise (breathing, standing, walking, jogging, etc..)
phosphocreatine liberates its high-energy phosphate moiety back to low-energy ADP to replenish the
cells ATP supply. As such, the re-phosphorulation process is driven forward in a continual cycle
with newly synthesized creatine and, to a substantially lesser extent, recycled creatine. Despite
evidence that a small number of de-phosphorylated creatine molecules can be re-cycled, by in large,
the more common fate of used creatine is its conversion to creatinine. Transformation (degradation)
process is a continuous, non-enzymatic dehydration reaction. (Pline and Smith. 2005).

FIGURE 4 - A schematic overview representing the chemical reactions and enzymatic processes
involved in the creation and metabolism of creatine and creatinine.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]
In addition to acting as an energy shuttle, creatine can also act as buffer. This activity is seen when
creatine is in the same spatial association as nerve cells and striated tissue. In order to accomplish
this, phosphocreatine spatially moves within these cells. An interesting observation has been made
for nerve cell phosphocreatine. It has been shown to accumulate toward the synaptic head. In this
capacity, creatine can assist with the management of both high energy, and the more stable synaptic
potential energy (Brudnak. 2004).
A Supplement is Born
Whether naturally, or artificially produced, creatine and creatinine are locked in an endless union
the first required to aid in maintaining cellular existence, the second, the inevitable end product of
creatines existence.

Why has a relatively obscure scientific discovery, made over a century and a half ago, become so
important to so many today? And more importantly for this discussion, what are the potential
consequences of its overuse in those with kidney disease?
Shortly after its discovery in the flesh of freshly killed game, the term creatine was introduced
(Kepler. 1929; Bears. 1943). Given the crudeness of the isolation technique of 1835, this initial
muscle-tissue extract was most probably a mixture creatine, creatinine, and sarcosine (N-methyl
glycine an amino acid found in muscles and other tissues [Wikipedia, 2005]) as well as various
intermediates. Nevertheless, in 1835 the French scientist Michel Eugene Chevreuls finding was
initially considered controversial by the scientific community (Kepler. 1929). Isolation techniques
were perfected, and by 1847, Justus von Liebig was finally able to demonstrate that creatine could be
reliably isolated from various tissues of any freshly killed animals carcass. Liebig also noted that the
quantity of creatine was greater in wild animals as compared to captive domestic animals. This
discovery pointed, in some small way, to the role of creatine in an energy-demanding lifestyle
(Williams, Kreider, and Branch. 1999). In the same year, Liebig (followed by Gregory in 1848, and
Schlessberger in 1848) demonstrated that this molecule could be found in all mammals, birds and
fish.

Before 1910, creatine had been, for the most part, connected primarily with muscle-related tissue, but
there was still no clear consensus as to the richest site of creatine accumulation, or why. Liebigs
initial work in 1847, and those who followed, had produced evidence showing that a considerable
amount of creatine could be found in dark muscle tissue such as the cardiac muscle. Cardiac
muscles contractions are involuntary and smooth in motion, in some respects like the action of the
diaphragm muscle. A hearts muscle action is governed by the autonomic nervous system, and hence
moves in a predictable pattern and speed (for the most part). This muscle undergoes few rapid pace
changes, and no stops (except the final one!). Because of its physical behavior and its physiological
role, the cardiac muscles energy needs are significant but relatively constant. However, in 1910,
Pekelharing and Van Hoogenhuyze would provide the first real evidence for the richest site of
creatine accumulation, and a glimpse into creatines most important function as an energy delivery
system or sink. Pekelharing and Van Hoogenhuyze found that muscles which were involved in
physically demanding (strenuous explosive energy bursts, or prolonged aerobic) activity, harbored
by far, the most creatine. The richest site for creatine was actually discovered to be the rapidly
contracting pale muscles, instead of the more slowly contracting dark muscles, as it had been
believed (Pekelharing and van Hoogenhuyze. 1910).

During the early years, extraction of creatine from fresh muscle tissue was an expensive and labor-
intense activity. Nevertheless, by the dawn of the 20th century the first creatine supplement had been
produced in a laboratory and had been shown to increase muscle creatine content in experimental
animals.
The phosphorylated form of creatine phosphocreatine, was discovered in 1927 by Fisk and
Subbarow. Through their research they were able to show that this unstable compound, found in fresh
muscle tissue, disappears rapidly (in about 20 minutes) whether their tissue sample was let to stand
on the lab bench, or was stimulated. Inorganic phosphate and creatine replaced this labile compound.
However, when fresh muscle was collected after a rest from fatigue they found that the compound
had resynthesized itself. In the same year, an unstable ester of phosphoric acid, which was loosely
associated with creatine, was also discovered (Eggleton and Eggleton. 1927). These discoveries
helped bolster a hypothesis about creatines potential significance in relation to where it was
discovered, and why it was found in larger quantities. Prior to this work, creatine was believed to be
nothing more than a simple metabolite or a random by-product of muscle activity. However, the work
of Fisk, Subbarow, and Eggleton(s) provide the first tangible evidence that creatine wasnt simply a
metabolite, but a necessary component for normally functioning tissue.

Numerous additional milestones, during the early years of creatines discovery, which are beyond the
scope of this book, yet equally important, have been documented in a comprehensive review by
Hunter (1928).

Its important in this treatise to note that, as knowledge concerning the functional purpose for creatine
grew, the first potential uses for creatine proposed were not recreational (as a sports supplement), but
medicinal. As early as the later part of the 19th century and into the 20th century, investigators had
(and still do) looked at creatine for its potential to treat muscle wasting diseases. While creatines
use was confined to laboratory animal supplementation and experimentation, during the early part of
the 20th century, it was hypothesized that, if large muscle-creatine stores were an essential part of a
healthy muscle tissues profile, could various forms of muscle wasting diseases be reversed by the
reintroduction of extra synthesized creatine? Unfortunately, this is a question which has stubbornly
remained inconclusively answered to this day.
Initially, creatines use as a test substance had been restricted to relatively short experiments in
laboratory settings. Before a reliable, (reasonably) clean, and relatively inexpensive creatine
syntheses protocol was developed, creatine had been isolated from fresh muscle tissue and even
urine. This made it far too labor-intense and costly to be seriously considered for use in human test
subjects. Initial laboratory chemical reaction protocols, yielding high percentages of impurities were
also impractical. Serious research work in human subject could not begin until a method of large-
scale production was available. By 1903 papers began appearing in the American Chemistry Journal
which described simple straightforward chemical reactions yielding methyl guanidine acetic acid
(creatine). By 1930, a reliable method for preparing creatine had been described, which involved
reacting sarcosine hydrochloride with potassium hydroxide and methylisothiocarbamide
hydrochloride. Under controlled laboratory conditions, creatine could be made to crystallize out as
woolly needles (synthesis of creatine today occurs by reacting potassium or sodium sarcosine with
cyanamide).
Between the discovery of creatine kinase an enzyme that catalyzes phosphocreatine, in 1934 and
1940, a slow shift in what investigators were hypothesizing that this substance could be used for, had
already begun taking shape. In 1940, investigators had begun to theorize that creatine could possibly
be used as an ergogenic aid, based on preliminary data obtained from early gelatin supplementation
research. Because gelatin and creatine both contains the glycine building block (approximately 25%),
it was reasoned that supplementation with glycine or gelatin should be ergogenic in nature. Though
studies with both substances continued into the early 1960s, consistently conclusive evidence for their
ergogenic potential remained lacking (Williams. 1985).
By the early 1960s (sited in anecdotal reports), creatine use by competitive athletes had already
been quietly undertaken in Eastern European block countries (Plisk and Kreider. 1999). However it
wasnt until almost the beginning of the 1990s that creatine found its way into the world-wide sports
arena and on the nutritional store shelves as a mass-marketed product.
An Ergo-Economic Bonanza
Today, synthetic creatine (creatine monohydrate) in various forms and packaging is routinely mass
produced. With sales approaching almost 3 million kilograms annually, this synthetic energy-bearing
supplement is enjoying estimated sales revenue of $100 million per year (Strauss and Mihoces.
1998). As of this writing, hundreds of reports, both pro and con, have been generated on its
effectiveness as an ergogenic aid in all areas of sports fitness. Biologically produced creatine is both
a natural and very essential substance normally in metabolically high demand. It would be expected
that reports on the impact of creatine monohydrate, on the users health, would end with either a
unanimous cheer, or at least a neutral resign. Instead, a few Boos have now been heard.
Isolated reports have been trickling in, pointing to a potential dark side of this synthetic substance,
and casting a thin cloud of concern on the horizon.
Summary
Unraveling the intricate biochemical processes responsible for corporeal motion from the briefest
of cellular contraction to the dynamic perpetuation of life itself, has been one of the greatest sought
after secrets. With the discovery of creatine, a natural biochemically produced substance, more than
170 years ago, science has slowly added another chapter to this quest. Beginning with a basic
understanding of creatine synthesis from a few amino acid building blocks, creatine is now
acknowledged as vitally necessary for normally functioning tissues. With the finding of the richest site
of creatine accumulation in rapidly contracting pale muscle tissue in 1910 (Pekelharing and Van
Hoogenhuyze) and enzymatic transformation into a high-energy carrier, the elucidation of its true
function suddenly came to light. Creatine was a substance, which acted reversible as an energy
storage, transfer system and buffer to maintain a positive energy equilibrium, perpetuating dynamic
motion.
Lis and Bijan (1970) concluded that there was approximately 30 kilograms of muscle in an
average adult male (proportionally less in the female due to secondary-sex characteristics which are
hormonally related). An average of 5g/kg phosphocreatine exists in resting (male) skeletal muscle.
This gives a total potential energy reservoir of about 150 grams of phosphocreatine per (male) human
frame. So at any given time, phosphocreatine and creatine can total approximately 400 mg/gram of
muscle tissue.
Though creatine was initially framed as a potential medicinal substance, once a reliable method
for preparing creatine came into existence, creatine quickly found its way into the sports arena as a
potential ergogenic sports-nutrition. Today, a voluminous number of reports have described creatine
monohydrate use in all aspects of exercise science and in several corners of medical therapy as well.
While reports of its positive influence on human athletic performance have generally pointed to its
potential safety, a scattered and growing number of reports have revealed emerging health concerns.
Beneath the enormous shadow of preexisting (and often undiagnosed) kidney disease, professionals
question the wisdom of the unbridled use of supplements.
 Chapter 2

Creatinine The Other Side of the Coin

Ouroboros
At the beginning of everything, there was a dragon (or snake) called Ouroboros. Finding itself
alone, and without any means of obtaining sustenance in the vast timeless emptiness, Ouroboros
grasped its own tail, and forming a circle, began devouring itself. Continually nourishing,
consuming, and regenerating itself over and over again without waste, it perpetuates its life
eternally.

This icon of eternal bio-waste free recycling is more than 3 millenniums old (Wikipedia
-Ourborous. 2005). While many meanings have been ascribed to this cylindrical symbol
(occasionally depicted as an infinity sign), to the ancient Alchemists of Europes first millennium,
Ouroboros was more than a mere symbol. They sought to find, or create (among other things), a
substance that would be a perfect life-energy source. This mysterious energy source would be self-
renewing, bio-waste free, able to cure all disease, and extend life indefinitely (Wikipedia - Alchemy.
2005).
Interestingly enough, this seemingly ubiquitous life-sustaining creatine, found by the early 19th
century experimenters, may even have quietly been ascribed Ouroborious-like attributes. With the
discovery of creatinine less than 10 years later ([Pettenkefer 1844] quoted in Kepler 1929),
attempts to confirm the significance of these closely related molecules led to early feeding
experiments and later in vitro tests. Their preliminary findings may have given some cause to wonder
if they hadnt finally found the Alchemists Holy Grail.
Creatinine feeding experiments in animals, from 1913 to 1928 (Myers and Fine. 1913; Rose and
Dimmitt. 1916; Hunter. 1928), showed that, while most of the creatinine ingested or injected could be
accounted for unchanged in the urine, a portion of it could never be recovered. This led some to
hypothesize that the un-recovered portion may have been recycled back to creatine.
Speculation on this hypothesized creatine creatinine cycling receive further endorsement as later
in vitro experiments confirmed this potential. In a reaction chamber, equilibrium between creatine
creatinine can be achieved, depends upon the pH it is exposed to (Brazda et al. 1940). For instance,
in a slightly alkaline environment, the equilibrium would tend to shift favoring the creatinine to
creatine conversion. As much as a four-fold increase for creatinine transformation into creatine was
observed for this solution, which was incubated at 37C for approximately two weeks. The reverse
process was noted when the pH was shifted to an acetic environment.
Evidence for the in vitro reversibility and equilibrium of these non-enzymatically cycled
creatine-creatinine pair was again confirmed in 1958 by Ennor (et al.) and in 1959 by Lempert.
It was determined that three factors pH, temperature, and solute concentration are very
important in determining the direction of the creatine-creatinine equilibrium shift. Conversion
from creatinine to creatine is favored at high pH and low temperature (never found in the
human body). However under an acetic pH and 38C, this monomolecular reaction is pushed
decisively in a direction which favors the creation of creatinine (Morrison and Ennor. 1960).
In a surprising find, Boroujerdi and Mattocks (1983) were able to show that some radio-
labeled creatinine was converted into creatine, arginine, guanidinobutyrate, or guanidinopropionate,
in the in vivo rabbit model. It must be noted that the digestive system, nutritional needs, and
especially the handling of nitrogenous waste, in this member of the Lagomorph family, is
distinctly different than in man. The rabbit is a cecotropes eater (or night feces eater). This
behavior is normal and necessary for this species in order to maintain the proper physiological
balance of minerals. Because the rabbit regularly eats (recycles) these special feces (droppings)
pellets, one should expect that the physiological handling of waste products (nitrogenous and
bacterial) would differ significantly from man, or any other animal that does not. The rabbit,
like other herbivore, can synthesize bodily protein directly from plant cellulose, and (like other
recyclers) possess various enzymes which act to neutralize harmful internally produced
bacterially metabolites.
No Free Lunch
If research experience teaches nothing else, it will surely ingrain the following maxim in us all;
What works in a test tube does not always work in the body especially in mans. The second
maxim that many still occasionally overlook sometimes with tragic results (as in thalidomide) is
that; Every other species is not man. Many an experimenter has rejoiced over the most amazing
potential breakthrough in a test tube, only to learn that it achieves no more than mere mediocre
success or fails dismally when introduced into the human body.
The most basic of Newtonian physics teaches us that nothing is perpetually self-renewing. Both
energy and matter will process (slowly or quickly) from a state order to disorder. In any
energized system mechanical or biological, there is always loss (physical, bio-chemical, thermal,
photonic, sonic, radioactive, etc..), no matter how minute, that constantly diminishes the whole.
Though the cosmologists vision of a cyclic, and self-perpetuating grand cosmic infinity may one day
be proven correct, a bio-waste free creatine to creatinine to creatine system only functions in a test
tube environment, and in at least one non-primate species. Unfortunately for the millions with kidney
disease, this Ouroboros does not work in man.
Function of Creatinine in Man
If creatine is methyl guanidine acetic acid, then creatinine is its internal anhydride. Mentioned in
scientific literature first by Pettenkefer in 1844, creatinine has been examined by many investigators
trying to determine the reasons for its existence and any potential biological function(s) it might
fulfill. Other than the general consensus of it as being a product of energy metabolism, investigators
have tried exhaustively to determine whether or not another, perhaps unique, function for creatinine in
the human body exists (Lis and Bijan, 1970).
Creatinine can be readily derived by dehydrating creatine. Kepler (1929) noted in his review of
creatinines potential functions in the human body, it appeared that creatinine arose as the sole result
of creatine utilization. When creatinine was radio labeled with [ 15N], and fed to rats, most of the
labeled material was directly excreted into the urine as creatinine. Creatinine did not appear to
propagate additional creatine either, as no significant increase or exchange in the quantity of
corporeal creatine could be found. If creatinine had a role other than that of nitrogenous waste
removal (species independent) this remained to be deduced.

In man and in many other mammals, creatinine is an inert waste substance that is simply excreted from
the body. Creatine degradation occurs via a rapid non-enzymatic process to creatinine. Unlike the
results obtained in vitro and the in vivo rabbit model, when radioactive creatinine was fed to test
rats, none of the radio labeling was incorporated into the corporal creatine supply, even after 5
days. It is impossible to determine from any of the in vivo feeding data whether or not absolutely
100% of all creatinine exited the body without so much as a single molecule being converted
back into creatine (such as in the case of the rabbit model). However, for more than 99.9% of the
labeled creatinine, the experimenters were able to demonstrate that the conversion of creatine
into creatinine (in vivo) is a (virtually) irreversible process (Bloch and Schoenheimer. 1939).
Once generated, creatinine escapes the cell and enters the circulatory system by simple diffusion
without the need for an energy dependent chaperone molecule (Chanutin 1926; Walker 1979).
Another somewhat avant-garde view of the potential fate of the creatinine molecule was
presented by Lis and Bijan in 1970. In their theory, they postulated that while many imidazoles
(creatinine-X molecular constructs) were important biologically as components of amino acid
complexes, creatinine may have evolved a passive anti-ergogenic (responsible for suppressing
various muscle-energy utilizing activity) biological role albeit unintentionally.
For evidence of this effect, they administered creatinine to mice at concentrations of up to 300
mg/kg. Under these simulated uremic-like conditions, abnormal behavior, resembling that of a
psychotropic drug or tranquilizer induced states, were observed. Effects began 15 minutes after
administration and peaked at 75 90 minutes post drugs, lasting as long as 5 hours. Observation of
these unusual yet psycho-chemical similar properties, as well as clinical observations, led to the
postulation that creatinine had a potential of being involved in muscle-related regulatory mechanisms
of higher organisms. This regulatory mechanism (perhaps a simple evolutionary protective-
mechanism) could be inadvertently assisting in muscle cell recovery by forcing a reduction of
motion (due to sedation) in the organism as it built up*.
[*Authors note with regard to the above paragraph, a potential scenario in man (e.g. in an
athletic power lifter or distance runner) would be as follows: as blood levels of creatinine rose, the
competing individual would begin to feel a sense of tiredness or lethargy, experience less than
perfect muscle coordination, muscle aches and even cramps, and as such stop using those muscle
groups (and be out of the competition!). Not surprisingly, this kind of lethargy and muscle complaints
are routinely reported by people with a seriously compromised kidney function.]

For further evidence, Lis and Bijan cite observed properties of creatinine, responsible for torpor-
inducing light sleep in test animals, when administered in higher doses. They noted that the psycho-
active drug response became more apparent when abnormal derivatives of creatinine (i.e. amino-
creatinine, dioxy-creatinine) were administered. The existence of these derives was confirmed in the
urine of mentally retarded children and schizophrenic adults. Whether the existence of these abnormal
creatinine deamination products occurred naturally as the result of one or more defective gene/gene
sequences common to the medical condition, or whether the transformation took place as the result of
some type of atypically active bacterial involvement (again as a result of the alter physiology) was
not speculated upon.
A similar chronic intoxication effect was seen by Giovannetti (et al. 1969) in dogs. Though
Giovannetti observed a strikingly similar, yet deeper and more profound stupefaction effect in the
canine model then did Lis and Bijan in their mouse model, he drew an entirely different conclusion
about creatinine and its potential relation/function in the body. He observed that when the canine host
was subjected to abnormally high levels of creatinine mimicking those levels found in severely
uremic humans with kidney failure, the canine kidney exerted an extra effort to eliminate it.
Giovannetti concluded creatinine was interfering in the normal biological function of the organism,
and hence the organ stimulatory response to rid it from the body. Rather than being any passive
evolutionary mechanism, this waste product of creatine metabolism was nothing more than waste.
It is also interesting to note that Meltzer (1968) reported an increased activity of creatine kinase
in the serum is associated with acute psychotic patience. In his work Meltzer postulated that the
interrelation between phosphocreatine, creatine and creatinine may be the primary substance
responsible for these disturbances in the human central nervous system.

Overall, there appears to be no positive biochemical niche that this molecule fulfills on its way
out of the human body. In the healthy individual, creatinines only function is that of being a waste
product.
Summary
Like the ancient Alchemists of Europes first millennium, researchers have all sought to find a perfect,
biologically harmoniously self-renewing bio-waste free, energy for the perpetuation of life. The
initial discovery of the creatine-creatinine molecular-duo and early feeding experiments, especially
in the rabbit, may have initially fostered hope that the long sought after life-energy source had finally
been found. Later in vitro experiments appeared to confirm this potential. In a reaction chamber,
creatine creatinine appear readily interconvertible, the direction in which that conversion is
ultimately driven depending largely upon environmental pH and solute concentrations. Unfortunately,
this forward and reverse transformation is (for all practical purposes) limited to an in vitro
reaction chamber. Work by Kepler (1929) fixed the forward direction of creatine to creatinine
(almost exclusively) in the human body without a recycling potential. This was demonstrated with
labeled nitrogen [ 15N], in the rat model. The product of such labeling proceeded through the
animals system directly into the urine without the creation of a labeled fraction of creatine.
Indeed, since creatinine was first discovered, many investigators have searched for the existence
of an, as yet undiscovered, potential biological niche it might be fulfilling. Creatine degradation
occurs via a non-enzymatic process, and it does not appear to propagate additional creatine along
the way. Thus far, creatinine appears to be acting as a simple inert waste shuttle, which is excreted
from the body. Surprisingly, when presented in higher than physiologically normal concentrations,
creatinine appears capable of stimulating abnormal behavior. This behavior, resembling that of a
psychotropic drug or tranquilizer induced state, and varies depending upon the extent of exposure.
These clinical observations, have led at least two early investigators to the postulation that creatinine
was in someway involved in a muscle-related anti-ergogenic regulatory mechanism.
Creatinine can and does undergo modification in the human body (Fig. 5). Amino-creatinine, and
dioxy-creatinine derivatives are only two of numerous other combinations that can be created. The
existences of these, and numerous others, have been confirmed in urine of mentally retarded children,
schizophrenic adults, and thousands with extensive kidney failure.

At present, the consensus is that creatinine is a simple waste product, without a secondary useful
biochemical niche to fulfill on its way out of the human body. The bodys first defense mechanism,
when creatinine is sensed in higher than normal physiological levels, is to ramp-up mechanisms of
elimination (i.e. thirst, renin-angiotensin, etc.) to flush it from the system. Creatinine can be utilized
by some gut bacteria creating polycyclic amines, aliphatic amines, and various conjugations there of.
These creatinine-derivatives, created by bacterial activity, are known to be toxic in man. Not
normally found in any appreciable concentration other than in urine, polycyclic amines, and aliphatic
amines are commonly found in internal bodily fluids of those with steadily failing kidneys. The
negative physiological potential of these creatinine mutants will be covered in Chapter 4.

FIGURE 5 - A schematic overview representing the reactions and enzymes involved in microbial
Creatine and Creatinine degradation pathways. Enzymes are as follows: 1) creatinine iminohydrolase
(creatinine deaminase); 2) cytosine aminohydrolase (cytosine deaminase); 3) 1-methylhydantoin
amidohydrolase [ATP dependent or non-ATP dependent]; 4) N-carbamoylsarcosine amidohydrolase;
5) creatinine amidohydrolase (creatininase); 6) creatine amidinohydrolase (creatinase); 7) sarcosine
reductase; 8) un characterized; 9) methylguanidine amidinohydrolase); 10) sarcosine oxidase); 11)
sarcosine dehydrogenase or dimethylglycine dehydrogenase
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]
 Chapter 3

On the Hoof vs. Off the Shelf

Survival Gene Genius

Man, both primitive and present, is the perfect example of a true omnivore an organism adapted for
a dietary mixture of both plant and meat matter. Possessing all genetically relevant anatomical traits -
the omnivore dentition (teeth), intestinal absorbing surface area with an intermediate number of
crypts, lack of fermenting vats or rumens, sacculated colon, etc., humans are actually a perfect fit in
this classification.
Another, somewhat less scientific, definition of an omnivore is an opportunistic eater. This
creature has genetically and biologically for whatever reason, been forced to adapt to wringing a
meal out of whatever it was able to find. When it came to the ability to adapt and survive, early man
was one of the elite few survivor champs (along with pigeons, prairie dogs, and coyotes!). Fossil
records give solemn testament to those species that could not embrace flexibility.

To the skilled but primitive pre-Neolithic hunter/gatherers who lived before about 10,000 years ago,
simple weapons, very fast or powerful (and dangerous) prey, meant that meat was not always on the
menu. Early mans diet was primarily a blend of meat, high fibrous plant matter, starchy seeds and
tubers (all eaten both raw and cooked). Human physiology was (and is) accustomed to relying on its
own ability to manufacture its needed creatine energy supply amino acid building blocks. A meal of
meat was always a welcome source of extra nutrients and energy, but our human opportunist certainly
wouldnt have starved without it. With the advent of domestication and cultivation, a reliable supply
of meat and more nutritious plant matter entered mans diet. Archeological findings give evidence to
support this continued duo-dietary life style from our present day, back as far as mans existence can
be traced (Molleson. 1989; Molleson and Jones. 1991; Molleson. 1994).
Since time immemorial, all omnivores both large and small, have primarily derived their
creatine (and produced creatinine) through endogenous production, and to a modest or moderate
degree, exogenous dietary creatine/creatinine sources. As discussed earlier in this book, todays man
is capable of deriving all his bodys creatine needs from amino acids in his diet (Delanghe et al.
1989). However mans opportunistic survival genetics* afford him the ability to intersperse his
vegetable-matter based diet with meat and thus utilize this rich, preexisting creatine source as an extra
pre-made energy supply. Today (as then), an average adult (male/female) can reasonably consume
between 1 2 grams of creatine by eating approximately a pound, to a pound-and-a-half of a varied
meat diet each day.
[*Authors note - Those survival genes, which have served man so well throughout his
existence in the absence of preprocessed convenience foods and food enhancing additives, are the
same genetics which are now being implicated as partly responsible for todays ramped obesity,
leading to Type II diabetes in more than 18 million Americans many of whom will eventually be
afflicted with kidney disease.]
Food vs. Factory - Nutritional Sources of Creatine/Creatinine
With meat regularly on the menu today, it is now estimated that more than 10 - 30% of all creatinine
generation in the human body is being derived from ingestion of creatine and creatinine found in
various meats (Levey et al. 1988). While meat is considered the primary source of dietary
creatine/creatinine, it is interesting to note that meat is not the only natural source. Creatine can be
found in dairy products such as milk (100 mg/kg) as well as cheeses derived from every lactating
mammal. This substance is also found in a measurable quantity in the cranberry (approximately 20
mg/kg) (Balsom, Sderlund and Ekblom. 1994). Though creatine has been reported to exist in
miniscule quantities throughout plant kingdom, it is impossible for a human to consume enough
creatine-bearing plant matter for plant-based creatine to be considered a serious creatine-creatinine
source (e.g., in order to ingest 3 grams of plant and milk based creatine, one would have to consume
more than 100 kg [220 lbs] of cranberries while washing it down with 22 lbs of milk, per day!).

Creatine/creatinine (creatine[s]) concentration in meat varies between different species and tissue
types within the same species. Uniformly, those tissues containing the highest amounts of creatine(s)
are muscle and neural (brain) tissue, while the lowest contents may be found in kidney and liver. In an
extensive study of 16 different meat animals, Vikse and Jones (1993) were able to demonstrate that
samples of raw muscle meat, taken from different commonly consumed animals, each produced
different concentration ranges of creatine(s). Of all the animal flesh tested, the domestic rabbit,
followed by seal, deer, beef, pork, sheep, horse, and reindeer consistently gave the highest level of
total creatine(s). Table 1 lists a summation of the average creatine(s) concentrations found in
numerous meat sources by various authors. It is important to note that the level of the creatinine
fraction in raw meat is always substantially less than creatine (until the meat is cooked). And, as with
creatine, creatinine varies greatly from species to species, and does not appear to correlate well with
the amount of muscle activity expected for that species. For example the lowest concentrations of
creatinine in raw flesh was found in grouse (undetected), domestic pig, pheasant, domestic sheep,
wild hare, elk, and ground beef (15mg/100g for beef [Felton et al. 1994]). The highest amounts were
found in domestic rabbit (>90 mg/100g [8.3mM]), goat, roe-deer, and reindeer (Vikse and Jones.
1993). One should have reasonably expected to find the highest amounts of creatine(s) in animals that
must run, swim, or fly extensively for their survival. Instead it appear that our master recycler the
domestic rabbit (from Chapter 2) maintains a relatively high tissue level of both creatine and its
waste product creatinine, possibly (in part) due to this animals physiology and recycling habit.
Table 1. Average amount of creatine(s) in commonly consumed meats (measurements of total
creatine(s) [creatine/creatinine] were taken in 100 gram samples of raw meat).

Species Creatine(s) (g/kg)

Fish
Shrimp Trace1
Cod 3.01
Herring 6.5-101
Plaice 2.01
Salmon 4.51
Tuna 4.01
Meats
Beef 4.51 - 4.42
Beef Kidney & Liver 0.3 0.42
Pork 4.92 - 5.01
Ham (cured) 2.92
(pork) Wieners 0.92
Mutton At least 5.0 - 5.53
Deer At least 4.5 - 5.03
Elk At least 4.0 - 4.53
Goat At least 4.5 - 5.03
Hare At least 3.0 - 4.03
Horse At least 4.0 - 5.03
Domestic Rabbit At least 9.0 - 10.03
Reindeer At least 4.0 - 5.03
Roe-deer At least 4.5 - 5.03
Seal At least 5.5 - 6.53
Poultry
 Pheasant At least 3.5 4.03
Grouse At least 3.5 4.03
Chicken At least 5.03 - 5.32
Turkey 4.02
1. Balsom, Soderlund and Ekblom (1994); 2. Jones (2001); 3. Vikse and Jones (1993)
Conversion of Meat Creatine to Creatinine
Meat creatine is heat labile (temperature sensitive). As the cooking temperature nears and rises above
the boiling point (212F or 100C), creatine in the surface cells of the meat, followed by inner-tissue,
begin converting to creatinine. This is not to say that creatine converts to creatinine only in boiling
water! It makes no difference to the molecule whether the heat source is a dry frying pan, a grease-
saturated frying pan, a deep-fat fryer, a pot of water, or an open flame the speed and extent to which
creatine is converted to creatinine in your favorite meal of meat depends primarily upon two factors
temperature and time (Jacobsen et al. 1979; Jgerstad and Skog. 1991).
Creatine concentration of minced beef was observed to decrease during boiling, as creatinine
concentration increased in the supernatant. This conversion creatine to creatinine, once initiated,
proceeds rather quickly until heating is discontinued and the temperature falls.
In an experiment designed to examine the rate and degree of conversion of creatine to creatinine,
as well as the levels of mutagenicity caused by the formation of creatinine-imidazol-X compounds,
during normal meat cooking (mutagenicity and carcinogenicity of creatinine-X are covered in
Chapter 4), Jagerstad and Skog (1991) subjected three muscle-associated beef-flesh samples (general
beef [hamburger quality], heart, tongue), and two organ-flesh samples (liver and kidney) to three
cooking temperatures. Meat samples were tested raw, and after cooking for three minutes at: 150C,
175C, or 200C (Fig. 6). In raw beef, creatine content was approximately 94% of all meat
creatine(s), dropping dramatically to 66% after cooking at 150C, to 52% of all creatine(s) after
cooking at 175C, and to only 38% of the total creatine(s) after cooking at 200C. Concomitantly,
creatinine concentration in these beef samples rose sharply from approximately 6% - 62%. Similar
patterns were also observed for the other meat types (heart, tongue, liver, and kidney).

FIGURE 6 - Conversion of Meat Creatine to Creatinine

Meat juice extracts, bouillon, gravies, and dark pan-browning have been shown to posses a
significantly higher total creatinine. However, no matter the total content, neither the final creatine nor
creatinine concentration in meat was found to be a good indicator of the overall flavor of the meat
cooked by any method (Korschgen et al. 1976).
Meat flavor depends upon many factors, but creatine and creatinine content arent really involved.
Browning however is another matter. Though extensive browning was observed in these samples,
browning in and of itself is not an indication of the amount of creatine or creatinine in a sample of
meat, either. Though browning can influence taste dramatically, development of a brown color during
cooking results from a process called the Maillard reaction. This non-enzymatic color change,
resulting from a special interaction between carbohydrates and amino acids, involves the carbonyl
groups of simple sugars in meat (meat as an example) and the free amino groups of likewise available
meat amino acids. This reaction can proceed through several transformations, involving the loss of
water molecules, the production of a deep caramelized appearance all the way through to a brown
nitrogenous polymer and copolymers substance called melanoidins, and can range in flavors and
odors from bitter, burnt, rancid, sweaty all the way to a delicious fresh roasted coffee aroma and
taste (Jagerstad et al. 1983).

Creatinine content of three different beef meat extracts (pastes) ranged from 45% - 79%. In beef
bouillon stock, creatinine content varied from 16% - 58%. The creatinine content of round steak crust,
baked in a traditional oven at temperatures from 115C 245C was generally lower in final
creatinine content than pan fried or boiled meats. This lower content was observed only when
cooking temperatures were kept low. As the temperature rose to 245C, the total amount of creatine
in round steak crust plunged from 138 68 micro-mole/grams of dry weight representing a total
reduction in creatine by more than half. When gravy was baked at 245C, the creatine content
dropped 88% (to 67 micro-moles/grams of dry weight) and creatinine rose approximately 73% (to
375 micro-moles/grams of dry weight) (with a corresponding increase in mutagenicity - see Chapter
4 [Laser Reuterswrd. 1987]). Interestingly, a creatine/creatinine content was identified for a
concentrated vegetable bouillon powder as well. The assay revealed 90% of the total creatine(s)
were in the creatine form, and only 10% existed as creatinine. The total amount of creatinine was
miniscule (1.8 micro-moles/grams of dry matter) but measurable (Jgerstad and Skog. 1991).

Overall, the work by the aforementioned authors provided evidence that, while initial creatine content
was high in their respective test samples of beef flesh, creatine was transformed into creatinine, under
temperatures one could reasonably be expected to expose meat to during the cooking process (to
achieve moderate or well-doneness).

After considering the heat labileness of this molecule, one might reasonably ask why all of meats
creatine isnt transformed into creatinine each time meat is cooked to doneness? Again, the reason
is time and temperature now add to that equation, heat conductivity. Molecular conversion depends
upon the degree to which heat is transferred from cell to cell. Baking, for instance, involves heat
transfer by air convection. This is a less efficient means of heat distribution around and through flesh
than direct contact with a hot metal surface (Jagerstad and Skog. 1991). Heat (like sound) is
conducted best through a medium. Air is a poor conductor, water and (some) solids are better. The
center of a solid piece of steak will take the longest to heat up because layers of its cellular
neighbors are insulating it. The thicker the meat is, the less likely the center will reach a specific
temperature, unless cooking time is extended in some cases, to the point of charring the outside. If
cooking time is short, it is conceivable that the internal temperature will never exceed the threshold
needed for conversion. The dilemma of uneven thermal conductive is at the heart of all cooking meat
safely warnings, which especially apply to the cooking of whole turkeys and other large/thick pieces
of meat.

Though not mentioned directly by any author, it is logical to assume that pickled meats, or meats
which have been exposed to enzymatic pre-treatment for extended periods of time, can be expected to
contain more creatinine per 100 grams of flesh than raw untreated meat. This assumption was
extrapolated from the findings of Brazda (et al. 1940), King (1930), as well as Edgar and
Hinegardner (1925) and others, who have provided evidence of creatine-creatinines instability in a
low pH environment.
Of Meat and Man
The work by Jacobsen (et al. 1979) provides an enlightening look into the contribution made by
cooked meats toward the nutritionally supplied, blood serum creatinine burden.

On two separate occasions, when six young men with confirmed normal renal clearance, were given
non-meat (yet not strict vegetarian) meals consisting of eggs, bread, butter, cheese, marmalade and
coffee, a small and statistically insignificant spike in blood serum creatinine was observed
approximately 1 hour after the meal. Serum creatinine then drifted slowly downward toward the
preprandial level over approximately the next 7 - 8 hours. Though Jacobsen (et al. 1979) did not
comment, cheese consumption could have been responsible for the small 4 micro-molar/L spike
observed in serum creatinine, not otherwise seen in a strict vegetable meal (Delanghe et al. 1989).
Milk contains creatine(s) at a level of approximately 100 mg/kg. Jones (2001) noted that 100
grams of American processed cheese contained as much as 26mg of creatine, though the total
creatinine content was not mentioned.
When 300 grams (about lb) of minced raw beef was given to the subjects, no measurable
postprandial increase in serum creatinine was observed. This finding was initially somewhat
surprising. Raw beef contains a moderately high level of creatine between 440 450 mg/100 grams
(4.4 - 4.5 grams/kg). A possible explanation for the absence of a serum creatinine rise (not addressed
directly by the investigator), is the near absence of pre-existing meat creatinine. Raw beef contains
very little creatinine approximately 7.9 micro-moles/gram of dry weight. This creatinine is
contained within intact meat cells and not necessarily immediately available for metabolic
assimilation. In order to release meat creatine(s), chunks of meat must be mechanically broken into
bits, then each cells membrane must be enzymatically digested. Man is not able to digest and process
raw meat as efficiently as a carnivore (i.e. a lion). For man, the digestion and assimilation of raw
meat (and its inner cellular materials) proceed at a slower rate than it would for thoroughly cooked
meat. After mastication (chewing), minimally torn cellular matter is subjected to salivary gland
enzymes and swallowed. Passing into the stomach, it may remain there for as little as 30 minutes to
approximately 1 hour, depending upon the amount of additional free fatty contents consumed with it.
As the stomach fills, the pH may rise to as high as 4 as its acid content is temporarily diluted.
During the time it would take man to consume a pound of raw meat, some of the stomach contents
would already be exiting the stomach, passing into the duodenum and into a less acetic environment
(approximate pH 5). Cellular creatine/creatinine is released slowly as the combined acid/enzymatic
digestion process breaks down the cells. Raw meats minimal amount of cellular creatinine would
enter the blood stream as it was released during the digestion and passage through the gastrointestinal
tract (G.I.) (average 24 36 hour transit time). Meats creatine(s) of which approximately 90% -
94% is in the creatine form, enters the blood stream rapidly, as soon as they are made available. This
creatine is utilized by the body to replenish the creatine pool and not immediately converted and
dumped as creatinine.
Cooking meat, on the other hand, converts modest to substantial amounts of meat creatine to
creatinine (and can also create carcinogenic compounds), damages/destroys cellular integrity, and
allows the cellular contents to be accessed quickly for digestion. Free creatinine (and creatine) are
then exposed to stomach acid (average pH 2.0 4.0). Passing into the duodenum and the upper
portion of the small intestine, they are quickly absorbed. In other words, after cooking meat, as much
as 16% 79% of all meat creatine(s) now in the creatinine configuration, are automatically
dumped directly into the blood stream as waste and slated for disposal without contributing to the
bodys creatine needs. It was the rapid release of as much as 1,000 1,400 mg of (beef) creatinine
into the blood stream of Jacobsens (et al. 1979) volunteers that was seen as a large blood serum
creatinine spike on postprandial blood tests. When samples of meat-water and meat alone were
analyzed, meat creatine content had dropped, across the board, to an average of approximately 1/3 its
original content, while creatinine content (in the supernatant) had more than tripled. Jacobsen stated
that his volunteers were, healthy young medical students [estimated age <35 years], with
normal renal clearance (glomerular filtration rate [GFR] greater than 90 ml/min/1.73m2 or, a
creatinine clearance >81 ml/min/1.72m2 for a adult <40 years of age**). Even with normal renal
function, this amount of additional creatinine caused an apparent temporary overload of the kidneys
filtration system. From a pre-ingestion value of 86 micro-mole/L 10.2 (SD), creatinine spiked
sharply to approximately double the pre-blood serum creatinine value, reaching a mean peak value of
l75 micro-mole/L 11.9 (SD) (p <0.001) 3 hours later. The creatinine spike was even more
pronounced when the meat was boiled to doneness and the water was consumed with the meat. Ten
hours after the start of the cooked-meat meals, blood serum creatinine in these men (each with normal
kidney function) was still markedly elevated. Mayersohn (et al. 1983), using normal volunteers,
reported a similar pattern of increase as much as 52% in serum creatinine within three hours after
ingesting a single 225-gram meal of cooked (well-done) meat.
This dietary observation necessitates a somewhat novae acknowledgement serum creatinine
was not elevated as the result of meat ingestion-digestion-assimilation-creatine-conversion, and
finally cellular excretion. Instead, results suggest that it is the preexisting meat creatinine which is
being quickly absorbed and dumped directly into the bloodstream. The absence of an increase of
serum creatinine after the consumption of raw minced beef, would tend to support this.
All in all, the observations made by Jacobsen (et al.) in 1979 point to a potentially significant dietary
implication for the 20 million Americans with chronic kidney disease (CKD) today. A single
creatinine-laden cooked meat meal can (temporarily) surpass a healthy kidneys ability to return the
physiological creatinine level rapidly to normal. For those with diminished function, this re-
normalization stretches out longer and longer, in some cases more than 24 hours. For those with
moderately to severely diminished function (<30 ml/min/1.72m2), a regular diet of creatinine-laden
cooked meat may mean that from meal to meal, serum creatinine may continue to rise slowly over
time, never returning to normal. And, in individuals with kidney failure (<15 ml/minute/1.72m2)
[cooked] meat creatinine is (partly) responsible for a dramatic and unrelenting rise in serum
creatinine. This rise, and the potential overall burden it places on those with pre-existing CKD, will
be discussed in Chapter 5.
Meat can be creatine/creatinine reduced prior to cooking, as well as cooked in such a way as not
to contribute significantly to its transformation. Studies (Jones, 2001) have shown that when meat is
ground, thinly sliced, or minced into small cubes, and then extensively rinsed or soaked for a brief
specified period, most of the free cellular creatine (and creatinine) can be removed. When persons
with kidney failure eat a conservative meat diet of meats that have been treated in such a manner,
serum creatinine rise has been observed to be retarded (unpublished observation Jones, 2001).
[**The National Kidney Foundation Kidney Disease Quality Initiative (K/DOQI) has
established general guidelines for the stratification of Chronic Kidney Disease (CKD) Stage 1-5.
Glomerular filtration rate (GFR), >90ml/min/1.73m2 defined as normal renal function for the
young adult (m16 years of age) to middle age (40 - 45 years). The GFR normally declines slowly
as we age. At present, there is no absolute norm number for persons approximately 50 year of age
and older. Depending upon gender, body size, age, and other numerous factors, it is possible to have a
normal renal function with a GFR of 60-89. Still more uncertainty exists for what the norm is for
persons over 90 or 100 years of age. There is a specific GFR threshold that is considered minimal
for renal clearance below that threshold the definition of kidney disease and kidney failure
applies, irrespective of age. For more detailed and general information, check out the National
Kidney Foundations Web site at: www.kidney.org].
Synthetic Creatine - Creatine Monohydrate
Isolating a sufficient quantity of biologically made (natural) creatine from meat, to meet an ever
growing commercial demand, is impossible. Fortunately for todays burgeoning sports industry, early
in the 1900s, science discovered a reliable way to synthesize it. Though today, many firms zealously
guard their special creatine monohydrate home brewed recipes, basic creatine monohydrate is still
made the same way it always has been (albeit cleaner in some shops).
All Things Not Created Equal
Though the final product is creatine (monohydrate), the way in which it is artificially synthesized for
your consumption bares no resemblance to the way this molecule is synthesized in the body. With only
a few simple amino acids, the body through eloquently exchange and building reactions, which are
carried out at physiological temperature and near neutral pH, weaves a molecularly simple bio-
energy shuttle of immense importance.

The commercial starting material for creatine monohydrate is sodium or potassium sarcosine - also
called methyl-glycoccoll, a material which (in the body) is naturally created during the metabolism of
choline to glycine. Synthetic sarcosine results from a reaction between methylamine and
monochloracetic acid.
The second ingredient is cyanamide. A highly reactive molecule (first made in 1838 through a
reaction between ammonia and cyanogen chloride), the synthesis process was refined in the later half
of the 20th century to increase its stability and commercial usability.
In the creation of creatine monohydrate, sarcosinate and cyanamide are reacted together in a vat of
solvent-water mix at various temperatures which range from room temperature, to above the boiling
point of water, and a pH range equally broad. A final purification processes is included to remove (or
greatly reduce) residual un-reacted compounds and impurities (Williams, et al. 1999).

The body is capable of using this synthetic creatine in the same manner as natural endogenous and
exogenous meat-creatine to replenish its creatine pool. Countless articles both in scientific and lay
publications, as well as books and treatises have been written, discussing the merits (pro and con) of
this supplement and its impact on various aspects of athletic performance. A targeted search of Pub-
Med revealed 168 scientific papers directly addressing creatine monohydrate, while Amazon.com (in
2005) listed more than 4000 books mentioning or discussing its use. It is outside the scope of this
work to rehash what has already been written, however one point is worth noting.
It has been estimated that an average 70kg adult male (omnivorous and vegetarian) has a creatine
stores (on average) of 120 grams (Clark. 1996 ; Greenhaff. 1995, 1997) or approximately 120 155
millimoles per kilogram of dry mass (Harris et al. 1992), with an upper limit that is only slightly
higher. Between 1.5 2% of this pool is normally degraded daily to creatinine during energy
utilization. Females, by virtue of their genetically-dictated reduction in muscle mass, store (on
average) slightly less creatine. The body (male/female) possesses a finite storage limit for creatine.
This limit (which may be modestly expandable to the degree one can develop additional muscle
cells) is dictated by individual genetics, body type, and gender. When more creatine is consumed then
can be stored in the body, it is treated as metabolic excess endogenous creatine synthesis is
suppressed, and excess creatine is eliminated. Creatine (like creatinine) is a low molecular weight
compound and its removal occurs in the same manner via non-energy utilizing diffusion. Harris (et
al. 1992) reported that excretion of creatine excess was as high as 40% on day one, 61% on day two,
and 68% on day three of supplementation. Studies by Maganaris and Maughan (1998) and Poortmans
(et al. 1997) generally agree with Harris (et al. 1992) findings. While there are no references in
medical literature indicating that an artificially induced creatine metabolic excess (induced via
creatine monohydrate supplementation) is toxic, it is still wise to remember that when the
concentration of a physiological necessary substance is raised to super-physiological levels, the body
will view this as a bio-excess and possibly a bio-burden. The concept of a super-physiological
creatine bio-burden can be inferred from the bodys reported feed-back responses the
suppression, or shut-down, of a natural metabolic process creatine biosynthesis. This would suggest
that in the face of a gross creatine excess, the body throws up a physiological red flag indicating no
further creatine is needed and removal of this much excess is now warranted. Unlike the situation for
vitamin-D, there is no physiological storage sink (some natural sponge) built into man, which was
ever intended to hold a gross excess of creatine for use in the distant future in other words, you
cant bank it for posterity. Poortmans (et al. 1997) observations that excess creatine resulted in
an almost immediate increase in creatine clearance of more than 26 fold, would tend to support this
view.
One final note it is also possible that the body may view a sudden large excess of creatine in
the blood stream as the result of a disease state, or an abrupt metabolic alteration. Creatine is
routinely found in the urine of pre-pubescent children, pregnant women, and castrated animals.
However, it is rarely found (beyond trace amounts) in the urine of an adult. When it is as in
creatinuria, the reasons are usually associated with primary or secondary muscle-wasting, or
neuromuscular-wasting diseases such as Duchenne muscular dystrophy (DMD) and Becker
muscular dystrophy (BMD), facioscapulohumeral dystrophy, limb-girdle muscular dystrophy,
myotonic dystrophy, spinal muscle atrophy, amyotrophic lateral sclerosis (ALS), myasthenia
gravis, poliomyelitis anterior, and others; or as the result of starvation (bulimia/anorexia), severe
deprivation of carbohydrates, diabetes, febrile states, certain goiters, and hyperthyroidism (Kepler,
1929; Beard, 1943; Wyss and Kaddurah-Daouk, 2000).
In-Vitro Stability
As previously mentioned, early in-vitro studies have shown that creatine is labile at certain pHs, and
temperatures, as well as in an aqueous (water) environment. US Patent 6,399,661 gives us substantial
scientific research to now report a minute-by-minute degradation curve for commercial creatine
monohydrate (to creatinine). This scientific break though (called Kre-Alklayn) has eliminated the
amount of creatinine ingested, due to its stabilization process.

The solid-state properties of commercially available creatine monohydrate were investigated by

Dask (et al. 2002). While these conditions only occur in a laboratory, the study gave important insight
into the physical change which occurs between the instant of dehydration and cyclization to form
creatinine. Under laboratory conditions, creatine monohydrate dehydrates at about 97-125C (normal
body temperature is approximately 37C) at which point a phase transition occurs. A further loss of
structural water occurred as the temperature increased above 230C triggering an intermolecular
cyclization, forming creatinine. Mass spectrophotometry indicated possible dimerization potential of
creatinine molecule during the solid-state transformation.
Conversion of creatine to creatinine has been confirmed to proceed naturally once any of the
appropriate conditions for its conversion are met. For more than a century, creatinine has been
created out of creatine by subjecting creatine to strong acid (hydrochloric acid) and ammonia, at room
temperature, or more rapidly at the boiling point (Edgar and Hinegardner. 1925).
Experiments have given evidence that creatine creatinine can shift back and forth (from
cyclization to de-cyclization) in an in-vitro environment. At a higher pH and a lower
temperature, the creation and maintenance of this molecule in the creatine state is favored. At
an elevated temperature and acetic pH the opposite (creatinine) is the case (Lempert. 1959).
When a pure solution of creatine was incubated at pH 7.07.2 and 38C, creatine was converted
to creatinine at a rate of approximately 1.01.3% per day (Ennor and Morrison. 1958; Morrison
and Ennor. 1960; Davidwk et al. 1976).
Ganguly (et al. 2003) reported that liquefied creatine effervescent powders (containing di-
creatine citrate) became unstable and degraded irrespective of their storage temperature (4C -
25C). At a storage temperature of 25C, ninety percent of the creatine in the mix was confirmed to
have degraded within 45 days. When the same solution was stored at 4C over the same period of
time, approximately 80% degradation was observed. The author noted that the pH of the room
temperature samples (only) increased from 3.6 to 4.5 during storage.
Dash and Sawhney (2002), using a UV detection system, noted that substantial conversion of
creatine to creatinine occurred in liquid creatine formulations. In addition, a number of over-the-
counter (OTC) supplements claiming to contain pure creatine, actually contained very low levels of
existing intact creatine. The authors did not comment on the moisture content of the non-aqueous
formulas.
Manufacturing Impurities
There is no such thing as a 100% pure synthetic creatine preparation. Unlike the body, the industrial
production of creatine monohydrate from sarcosine (sodium or potassium) and cyanamide doesnt
come without contaminants and unwanted byproducts.
Industry cant create creatine without creating a little creatinine, nor can it eliminate all of the
intermediates, or contaminates. In each batch produced, a certain quantity of contaminants like
dicyandiamide, dihydrotriazines, creatinine, ions, and heavy metals (mercury, arsenic, lead) may be
present in very limited parts per million (ppm) concentrations. In addition the starting material itself
sarcosine, which can be sourced from bovine tissue, is not free from suspicion either. This material
carries a certain (small) risk of contamination by bovine spongiform encephalitis (BSE), or mad-
cow disease. Though small, the risk of contamination can never be excluded (Benzi and Ceci. 2001).

From the second ingredient, cyanamide which is a strongly irritating compound in its pure form,
several unwanted molecular variations can be generated during manufacturing. This molecule is
capable of dimerizing to form dicyandiamide (Sittig, 1985) as well as trimerizing to form
dihydrotriazine, an organic base. Cyanamide compounds are routinely used in fertilizers, defoliant,
herbicide, fungicide, and pesticide, etc. (The Merck Index, 1989). Dicyandiamide is also used to
produce nitrogen fertilizers, as well as flame-retardants, adhesives, explosives and pharmaceuticals
(to name a few) (Dicyandiamide 2005). When exposed to a strong acid (stomach acid is
approximately pH 2-4), dicyandiamide can liberate hydrogen cyanide gas (IPCS 2001).
Dihydrotriazine metabolites are currently used in medical research. These metabolites tend to exhibit
potent anti-malarial activity in-vitro (Shearer et al. 2005).

With todays technology, a company that exercises exceptionally good quality control over their final
product can reduce the level of any contaminant to extremely minute quantities. The concentrations of
creatine and creatinine in various liquid supplement preparations (Harris et al. 2004), is less
predictable.
Summary
Mans omnivorous, dietary opportunistic nature, has given him a clear survival advantage over
creatures who could not adapt to rapid changes in their food supply and environment. In stark contrast
to early mans diet which was rich in minimally processed plant matter, and lacking in extensive
exogenous creatine supplementation, 21st century mans diet liberally indulges his system in meat and
synthesized creatine/creatinine along with a large dose of refined sugar. From a nutritional
perspective, modern man has seemingly taken a 90 turn from omnivore toward carnivore with a
sweet tooth.
Meat plays an important part in creatinine generation in the human body. The concentration of
creatine(s) in meat varies widely between different species (from a trace to 10.0 g/kg) and tissue type
within the same species. Unanimously, those tissues containing the highest amount of creatine(s) are
muscle and neural (brain) tissue, and the lowest contents are kidney and liver. The existence of
creatine(s) has also been reported in milk and cheese, as well as in miniscule quantities throughout
the plant kingdom.

Considering the human kidneys inability to rapidly clear modest doses of nutritional or sports-
supplement generated creatinine, one might question whether mans system was truly designed to
process more than a small amount of meat or more precisely, cooked meat (as well as meat gravies,
drippings and flesh charrings). If an average 70kg adult male has a relatively modest creatine store of
only 120 grams of creatine (modestly less for females) and only 1.5 2% of this pool is degraded on
a daily bases to creatinine, it would appear that human physiology was designed to store its creatine
zealously and utilize it very prudently.
Interestingly enough, artificially supplemented creatine (creatine monohydrate) given in excessive
amounts, receives no better treatment than creatinine, and is flushed from the body in increasing
amounts beginning on the day of supplementation (Harris R, et al. 1992). While not reported (in
medical literature) to be toxic in super-physiological concentrations, the bodys response to
excessive creatine could be inferred as a bio-excess and possibly bio-burden feed back response.

Creatine monohydrate is commercially synthesized by combining sarcosine and cyanamide in a

process that generates additional and undesirable compounds (predominantly dicyandiamide and
dihydrotriazine, and creatinine). Medical literature has not identified a positive use for these
materials in the human body. Additionally, the starting material may itself be contaminated with heavy
metals such as lead and mercury (proven to be nephro and neuro toxic) and even biologics. Though
the risk is small when exceptionally good manufacturing vigilance is exercised, the potential for
contamination can never be completely excluded (Benzi and Ceci. 2001).
Creatine monohydrate (like natural meat creatine) is also labile under certain conditions.
Conversion of creatine to creatinine has been confirmed to proceed automatically once any of the
appropriate conditions (temperature, pH, and moisture) for conversion are met. Few independent
scientific studies have reported creatines stability after formulation however, several notable
exceptions described the extensive degradation of liquefied creatine (Dash and Sawhney [2002];
Harris et al. 2004), and liquid effervescent powders when held at refrigerated and room temperature
(Ganguly et al. 2003). BioCeuticals Research & Development Analytical Laboratory has proven
though that at a pH of 12, creatine is completely stable in liquid.

Under laboratory conditions, creatine creatinine can be induced to shift back and forth (from
cyclization to de-cyclization) as the pH and temperature of the solution is varied. Unfortunately,
creatinine does not (normally) return to creatine in the body (in useful quantities). It creates an ever
increasing bio-burden for those with moderate to severely diminished kidney function. In these
individuals, serum creatinine may continue to rise, creating conditions ripe for the disruption of
normal cellular processes (Chapter 5) and the potential for the initiation of mutagenic/carcinogenic
events, as we shall see next, in Chapter 4.
 Chapter 4

Creatinine Mutagenicity and Carcinogenicity

Do No Harm?
Is my supplement safe? you ask.
A simple question or is it?
While the question may seem simple, the problem isnt black and white nor is the answer. What you
should be asking is Are both the (a) supplements individual molecular constituents, as well as (b)
any secondary metabolic byproduct produced from it, without toxic potential? At the very least, if a
supplement is ineffective, it should do no harm (Primum non nocere. 2005).

A small amount of a supplement, used for a relatively short period of time, in and of itself, may not
present any bio-burden or in any way be toxic. But, what about the under-evaluated long-term
physiological impact of excessive supplementation, or secondary products formed as a result of
bacterial or enzymatic interaction with it? And most important for the scope of this book what
impact could all of this have on someone with poor kidney function?
A Wolf in Sheeps Clothing?
More than 70% of all Americans have used some form of a nutritional supplement (Herbal Roulette -
1995) with the hope of enhancing, improving, or restoring something in their lives especially in
situations when patent medicine has failed them (Yang and Wang. 1993). These supplements have
taken many forms from powdered bits of plant matter, lactation fractions, earths (clays), metals
(silver and gold), vitamins, minerals, and glandulars, to synthesized mimics or substitutes of an active
chemical constituent. While some people consume supplements in mass quantity and with little
thought of potential unknown health risks (Betz. 1998; Ernst. 1998; Koff. 1995), few of these
supplements have any real scientific proof of their efficacy, and fewer still have any toxicology data
(Saxe. 1987; Anderson et al. 1996). In 1994, the Dietary Supplement Health and Education Act
(DSHEA) was established, in part, to provide a guidepost in defining a supplements
nature/classification, as well as general safety standards, and allowed claims. But the mere
establishment of this act had very little, if any, significant impact on defining safe-limits for any
supplement. In fact, the burden of proof with regard to a substances toxicity rests squarely on the
Food and Drug Administration (FDA) shoulders, especially in cases where such a supplement has
already had a history of human use (See et al. 1999).
Unfortunately, just because a supplement has had a history of human use, doesnt guarantee that it
is, or ever has been, safe. A glaring example of this can be found in the ancient Roman culinary art.
Highly flavored foods (syrups and meats) were prized among the Roman aristocracy. In order to
achieve that le got de perfection, the most savvy chefs would always rely on their special
cookware to infuse that secret ingredient lead leached from their lead-lined cook pots now
known to be highly neural and nephro-toxic! Historians have estimated that much of Roman
aristocracy, throughout Roman history, was afflicted with lead poisoning (Woodman. 1983).

Surprising as it may seem even today, a few of the seemingly innocent and extensively used
supplements have proven (in vitro) to be potentially toxic as well. In an extensive study by See, et al
(1999), 196 widely used single and combination supplements were tested for toxicity, in order to
determine their potential for inducing damage at the cellular level. Parameters tested were potential
hepatic (liver) and peripheral blood mononuclear cell (PBMC) toxicity, as well as any influence on
Natural Killer (NK) cells and intracellular glutathione (GSH) production and levels, respectively.
Cytochrome p450 is an important liver enzyme, responsible for processing (detoxifying/metabolizing)
many drugs as well as alcohol. Suppressing or increasing p450 function could impact the level of a
substance/drug that is normally influenced by it. Likewise, diminished intracellular GSH levels have
the potential to promote disease, oxidative stress, and premature aging. NK cells are (in part)
responsible for keeping the initiation of cancer, viral infections, and certain strains of bacteria
overgrowth at bay. Of the 196 supplements tested, only 35 were rated Positive on at least one of
three points (NK/GSH/antiviral), the remaining 161 were rated neutral (kelp, myrrh, wild yam,
etc.), toxic (sage, catnip, ginger, etc.), or potentially very toxic (horseradish, turmeric, licorice,
etc.) on all three points.
By Any Other Name
Creatinine is creatinine, irrespective of its origin.
Whether it is a simple metabolic conversion product from ingested meat creatine or creatine
monohydrate or, an ingested contaminant of a commercially prepared creatine supplement, or
creatinine from your well-cooked piece of meat the source is completely irrelevant. It is all still the
same molecule creatinine.
It must be noted here that the mutagenic information, presented in this chapter, originates solely
from a review of the data generated from food-based creatine creatinine. However, it must also be
acknowledged that it is equally likely that a creatine monohydrate supplement could also supply the
same physiological excess of creatine creatinine, potentially providing fuel for the same
carcinogenic events discussed in the later half of this chapter.
In Harms Way?
Why has the seemingly harmless creatinine (and excessive creatine) been reported, in numerous
studies, as having the potential to become mutagenic and even carcinogenic? The answer lies along
two distinctly different paths: a) this molecules affinity and potential for combining with other
molecules (by hydrogen bonding as well as other means of association [Lis and Bijan. 1970]) more
specifically, bonding with purines (guanidines and xanthines [Nagase et al. 1985]), various amino
acids, and sugars (especially glucose and glycine) to form mutagenic heterocyclic aromatic amines,
under elevated temperatures (Skog. 2002); and, b) the affinity certain strains of bacterium
(lactobacilli, streptococci, Corynebacterium ureofaciens, and others) have for utilizing creatinine in
the generation of methylamines (monomethylamine, dimethylamine, and trimethylamine) (Guest and
Varma. 1991), and other toxic molecular species (in the body) especially in those with poor kidney
function.
Mutagenicity
How does creatinine convert into mutagenic and potentially carcinogenic heterocyclic (aromatic)
amines [usually abbreviated HCA] (Wyss, Kaddurah-Daouk R. 2000)? The process begins when the
temperature of raw meat is raised to the degree needed to begin the conversion of creatine to
creatinine (approximately around the boiling point [>212-220F]).
Creatine (and creatinine) have been demonstrated to be indispensable (Simenhoff et al. 1978;
Kikugawa et al. 2000) in the formation of creatinine to creatinine-X mutagenic molecules. The
mutagenicity of various fried bovine tissues and meat extracts has been reliably reported by
Reuterswrd (et al. 1987), Robbana-Barnat (et al. 1996) and others in a variety of beef and beef
associated products. Jgerstad (et al. 1983) and Vervik (et al. 1989) reported that the addition of
creatine (or phosphocreatine) to meat, or meat extracts, before cooking dramatically increased
mutagenicity (as measured with the Ames test, using primarily the Salmonella typhimurium strains
TA98, TA1538, and TA100, in-vitro) more than 40-fold. When creatinine was reduced through the use
of a creatinase, before frying, mutagenicity fell dramatically (Vikse and Jones. 1993).
A post cooking dietary origin for these creatinine-amino-imidazo-mutagens was also confirmed
by Ushiyama (et al. 1991) with their discovery in the urine of healthy volunteers eating a normal diet.
Thus cooking was deemed an indispensable first step for the transformation to initiate, as none of
these mutagenic chemicals are present in raw meats * (Wyss and Kaddurah-Daouk. 2000; Skog.
2002; Kinae et al. 2000).
Some authors argue that significant formation of creatinine-X mutants does not truly get
underway until the temperature is raised to 392F and the meat is approaching well-done, instead
of merely rare or medium-done. Nevertheless, research does support the initiation of a low
level rate of conversion initiating at a much lower cooking temperature than 392F (Adamson and
Thorgeirsson. 1995; Bjeldanes et al. 1982, 1983; Dolara et al. 1979; Felton et al. 1984, 1986; Pariza
et al. 1979). Nevertheless, as the temperature threshold is passed, creatine (in predominantly muscle
meats, from various animal species) is converted to creatinine through dehydration, condensation, and
cyclization. Sugars and free amino acids (also found in meats) begin to associate with creatinine,
resulting in a type of polymerization of these components, finally forming heterocyclic compounds
(Fig. 7) (Wyss and Kaddurah-Daouk. 2000; Nader, Spencer, and Weller. 1981). Interestingly, the
mutagenicity depends largely upon the activity at the 2-amino group of the molecule, as well as
any methyl group and its attachment position. Positions 1- or 3- on the aminoimidazo ring give
the chemical the greatest mutagenicity (De Meeater. 1989; Hatch et al. 1996). It has also been
noted that all amino-imidazo food mutagens share a 2-aminoimidazo moiety, which resembles the
structure of creatinine. Interestingly, the type of sugar in which creatinine binds with will increase or
decrease the overall mutagenicity. Laser-Reuterswrd (et al. 1987) reported that mixing fructose (as
opposed to glucose, sucrose, or lactose), with creatine(s) created a more mutagenic outcome. Not
unexpectedly, the degree of mutagenicity also varies from tissue type within the same species, with
fried muscle meats (i.e. hamburger, heart, and tongue) normally possessing higher levels
creatine/creatinine and displaying higher mutagenicity, to liver and kidney which have the lowest
levels of creatine(s) and display almost no mutagenicity. Cooked plant matter has been reported by
Spingarn (et al. 1980) to be virtually non-mutagenic, due to the near absence of creatine(s) in the
plant kingdom.

FIGURE 7 - Food mutagens derived probably from Creatine or Creatinine.

(1) Imidazoquinolines; (2) & (3) imidazoquinoxalines; (4-6) imidazopyridines;
(7) 2-amino-(1 or 3),6-dimethylfuro[2,3-e]imidazo-[4,5-b]pyridine;
(8) naphthyridine mutagen. Mutagen
(9) 2,6-diamino-3,4-dimethyl-7-oxo-pyrano[4,3-g] benzimidazole, was only detected in a artificial
system.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]
In addition, the following citations while not intended to be an all-inclusive review of the past 25
years that these cooked meat mutagenic compounds have been known to exist, point to the widespread
acknowledgment of their creation under various cooking conditions.
Felton (et al. 1994) and Knize (et al. 1994; 1995) examined the potential creatinine had to induce
mutagenicity when meat (beef) was cooked under various cooking conditions. Microwaving meat, as
a pretreatment step, was reported by Felton (et al. 1994) to reduce the creatine(s) content of meat and
hence lower mutagenicity.
Arvidsson (et al. 1997) reported on the kinetics of the formation of polar heterocyclic-amines in
meat during cooking.
Yaylayan (et al. 2004) reported that creatine labeling studies gave evidence that creatine
(ultimately creatinine) was a very good source of methylamine and indeed was responsible for the
formation of a new toxin in cooked beef meat samples N-methylacrylamide.
Hashimoto (et al. 1981) examined the neurotoxic impact of creatinine-acrylamide, and related
compounds, on male mouse gonads.
Overvik (et al. 1989) demonstrated that the addition of only 5% (w/w) creatine (pre-cooking) to
meat increased the total mutagenicity of pan-fried meat 4-fold. Adjusting the moisture produced no
change in mutagenicity.
A number of controllable factors were determined to influence mutagen yield including the
concentration of antioxidants in the mix (Skog. 1993).
Laser-Reuterswrd (et al. 1987) reported that the in-vitro maximal mutagen yield was achieved
when either creatine or creatinine was mixed with an amino acid and a sugar in a molar ratio of
1:1:0.5 which is approximately the same ratio as has been reported for bovine muscle flesh.
Carcinogenicity
As we read in the previous section, heterocyclic aromatic amines have been shown capable of
inducing mutations in a bacterial system (in-vitro). Before cancer initiates, there must be an insult to
the DNA of a cell that changes the way it behaves. That insult can take many forms. Anything which
is capable of inducing a mutation at the cellular level could be viewed as a potential carcinogen. In
other words, the first step toward carcinogenicity (in most cases) is the initiation of aberrant DNA
activity through a mutation.

In this section we will examine how a seemingly innocuous waste product (creatinine) can initiate a
mutagenic event (both in vitro and in vivo) that could potentially lead to carcinogenicity in a human
host. Fortunately, circulating antioxidants and enzymes all in combination with an ever vigilant and
robust immune system, usually detects such damaged cells and obliterates most of them before they
can establish themselves. When the immune system falters a condition that is frequently observed
when an organ is compromised (such as in chronic kidney disease, or kidney failure), or fails (as in
AIDS), opportunistic infections and cancers many times very rare cancer types, are observed and
frequently undergo explosive growth.

At this point you are no doubt thinking, Wait a minute! What does all this talk of carcinogenicity
have to do with my creatine monohydrate supplement?

Read on.
As shown in the previous nutritional section, when the temperature passes the threshold of
conversion, creatine converts to creatinine creating a molecule that has an affinity for other
molecules. Combining with additional single methyl-moieties as well as pentose (5-sided) and
hexose (6-sided) ring molecules, creatinine forms heterocyclic aromatic amines which have been
shown to be mutagenic (in-vitro). Obviously, in this [meat creatine(s) + heat = creatinine]
transformational setting, creatine monohydrate usage would play no part in the creation of mutagenic,
and potentially carcinogenic molecules unless of course, you were in the habit of garnishing your
favorite meal of meat with this supplement before cooking (then it would be very significant!).
Unfortunately, heat isnt the only way the creatinine molecule can become armed and
dangerous, as it were. In a state of perpetual physiological creatinine and creatine excess as
potentially exists when a large gram quantity of creatine monohydrate is chronically consumed by an
individual with (unknowingly) compromised kidney function, opportunistic intestinal bacteria can
take advantage of this bio-burden to make a bad situation even worse. The evidence for this very
plausible scenario comes from both in vitro, and in vivo data.
The Bacterial Connection
Several strains of bacteria (pathogenic and non-pathogenic), have been shown, or implicated, as
having the ability to utilize creatinine (especially excessive creatinine and creatine) in the generation
of various molecular machinations with varying degrees of toxicity (Wyss and Kaddurah-Daouk.
2000; Van Eyk et al. 1968). Several strains of strictly anaerobic spore forming Gram-positive
Clostridium bacteria, isolated ex-vivo (sewage sludge) have a demonstrated capacity to totally
degraded both creatinine and N-methylhydantoin into other toxic molecules (Hermann et al. 1992).
Both in-vitro and in-vivo studies provide evidence that a number of different creatinine
derivatives can and do arise as a result of oxidative degradation. Many of these intermediates are not
in and of themselves end products but may be utilized or degraded further into more or less toxic
compounds, though the final concentration of each is by no means certain (Fig. 8). As serum
concentration of creatinine chronically increases, a favorable environment is created which
encourages the formation of amino-imidazo creatinine molecules such as 2-amino-3,8-
dimethylimidazo[4,5-f]quinoxaline a molecule that has been detected in the dialysis fluid of all
uremic patients (Yanagisawa, et al. 1986), as well as methylamines methylurea,
methylguanidine, 1-methylhydantoin and others (Ienaga et al. 1991).

Many such methylamines have been shown to arise from de-novo synthesis, at temperatures around
37C and do not originate from cooked meat consumption (Manabe, 1992, 1993). While this type of
creatinine utilization and molecular transformation has also been observed to occur under general
conditions, and in healthy individuals, it has primarily been observed and studied in individuals with
failing kidneys (Perez and Faluotico, 1973; Yokozawa et al. 1989).
Because innumerable people are taking creatine supplements today (year - 2006) and millions
around the globe have chronic (and usually undiagnosed) kidney disease (USRDS, 2003), this section
is of special significance.
FIGURE 8 - Oxidative creatinine degradation pathways favored in uremia and/or inflamed skin
tissue: 1) creatinine; 2) creatol; 3) creatone A; 4) creatone B; 5) 1-methylguanidine; 6) tautomer of
creatinine; 7) 1-methylhydanton; 8) 5-hydroxy-1-methylhydanton; 9) methylparabanic acid; 10) N(5)-
methyloxaluric acid; 11) methylurea.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]

It has been estimated that between 6 8 liters of gut fluid passes across the adult intestinal barrier
each 24 hour period (Jambhekar, 2002). This fluid carries both nutrients and waste products. As
kidney function is compromised, an ever-increasing concentration of creatine and creatinine (as well
as other waste products) build up in the system and is carried back across this barrier, repeatedly.
This creates a fertile field, especially in the duodenum and small intestinal region for bacteria, which
are capable of acting on creatinine. To date, there is no solid evidence to support the hypothesis that
the bacterial conversion of minute amounts of residual creatinine, found in the gut fluid of individuals
with normal kidney function, will result in carcinogenicity. In those with compromised kidney
function, present research tells an entirely different story.
Individuals with chronically compromised kidney function especially those with kidney failure,
have been reported to be at an increased risk for cancer (Wyss and Kaddurah-Daouk, 2000). One of
the models postulated for the higher frequency of cancer in those with renal insufficiency and
especially among uremic (kidney failure) patients is a failing or greatly depressed DNA repair
mechanism. In an experiment by Malachi (et al. 1993) the ability of the body to carry out correctly
timed and executed DNA repair synthesis, in peripheral lymphocytes, was measured after damage had
been inflicted. In those individuals with normal function and in individuals who had recently
undergone hemodialysis, repairs proceeded in a normal and near normal manner, respectively.
However, in individuals with chronically compromised kidney function having a higher than normal
physiological creatinine, and other toxin levels, DNA repair abilities were depressed to about 60%
of controls. When damaged peripheral lymphocytes from those with renal insufficiency were isolated
and incubated in normal plasma, in-vitro, the DNA repair process improved to a nearly normal level.
Reversing the process (i.e. transferring damaged cells from normal plasma into chronic renal failure
plasma) depressed their repair capacity to 70% of the initial level. These results suggest that a
plasmatic toxic substance (such as a carcinogenic heterocyclic amine) may be involved in the
impairment of DNA repair in those with chronic renal failure.
A number of alternative pathways for the bacterial and/or enzymatic creation of in vivo
carcinogens from excess creatine/creatinine have been postulated. The primary ones are believed to
be nitrosation of creatine and creatinine or methylguanidine (Hartman 1983). However, chronic gut
fluid creatinine excess may also proceed further to 1-Methylhydantoin, or be reprocessed and
recycled abnormally to creatine, as well as sarcosine, methylamine, and glycolate (Jones and
Burnett, 1974). In the case of recycling creatinine creatine, the rationale for this bacterial
degradation activity has been postulated as a mechanism for controlling physiological toxicity of
creatinine and its degradation products. Evidence of this bacterial utilization pathway for
creatinine in vivo (man) was supported by the work of Jones and Burnett (1972, 1974). They
discovered that as much as 1666% of the creatinine in the system of those with severe chronic
kidney failure could not be accounted for by excretion alone. When duodenal intubation was
carried out, bacterial overgrowth associated with high concentrations of toxic methylamines in
both the duodenal and small bowel regions was confirmed. Stool samples drawn from the same
region of individuals previously treated with antibiotics, revealed a greatly depressed concentration
of the same toxic molecular compounds (Dunn et al. 1997). Bergstrm and Frst (1978) reported on
the impact bacterial flora had on the development of toxicity symptoms experienced in both animal
studies, and humans with failing kidneys. These symptoms were greatly reduced when bacterial
numbers were reduced. This in vivo finding lends further support in unraveling the nature of
bacterial utilization of creatinine.
Another area of concern is the potential for direct toxicity such bacterially generated molecules
may possess, especially in the cases of methylguanidine, guanidinosuccinic acid, and creatinine.
When rats were given methylguanidine, guanidinosuccinic acid, and creatinine (three of the molecules
which accumulate in increasing concentrations with progressive renal insufficiency) intraperitoneally,
methylguanidine proved to be the most toxic followed by guanidinosuccinic acid, and creatinine,
respectively. In addition, each substance had a dramatic impact on the length and quality of the test
animals life (Yokozawa, et al. 1989).
Another molecular creation occurs via creatinine nitrosation (Fig. 9).

FIGURE 9 - Potential nitrosation products of Creatine (Cr), Creatinine (Crn), and methylguanidine
(MG). MNU, methylnitrosourea; MU, methylurea. Nitrosation products that were shown to be
carcinogenic in animal experiments are boxed.
[Used with permission Wyss M. and Kaddurah-Daouk R., 2000]

While the process of creatinine(s) nitrosation has been observed and studied primarily in the in vitro
systems, the conversion of creatinine to N-methyl-N-nitrosourea can be demonstrated to occur in four
successive steps (in vitro and in vivo) and may also include the formation of additional secondary,
potentially carcinogenic, molecules (Mirvish et al. 1993) such as methylnitrosoguanidine and
methylnitrosocyanamide as intermediates. Favorable conditions for nitrosation exist in oral and
stomach, bacteria/enzymes and juices, respectively.
Though creatine supplement intake was never mentioned, there is a strong correlation between
dietary nitrate (and nitrite) and gastric cancer incidence and mortality (Mirvish. 1983).
 Other creatinine-nitrate/nitrite oxidatively generated products are N-methyl-N-nitrosourea,
methylnitrosoguanidine, methylnitrosocyanamide, N-nitrosodimethylamine, and creatinine-5-
oxime. N-methyl-N-nitrosourea. These molecules have a proven history of carcinogenicity, with
tumor target organs such as the stomach, central nervous system, intestine, kidney, and skin
(Watanabe et al. 1994; Tatematsu et al. 1992; Leaver et al. 1969). Initial mutations resulting
from exposure occur primarily as a result of base-pair substitutions in the DNA (Zhang and
Jenssen D. 1991). However, in the case of creatinine-5-oxime, this molecule has not been
conclusively shown to be carcinogenic by any author (Xue et al. 1988).
The Nutritional Connection
The association between a diet that is very rich in red muscle meats, and an increased risk of
gastrointestinal tract, breast, pancreatic, and liver cancers has been brought to the consumers
attention for more then two decades. As we previously read, what has actually been discovered is
that cooking meat and not the meat itself causes the formation of heterocyclic amines from the
basic amino acids, sugars, and creatinine in the tissue. Research has provided ample evidence that
cooking at high temperatures creates these chemicals that were not originally present in raw meats.
Many of those newly created heterocyclic amines have been shown to be mutagenic in a bacterial
test system, and carcinogenic in test animals. Present day research has identified at least 17 different
heterocyclic amines that have experimentally proven to be carcinogenic. Consuming these chemicals
in any significant quantity may also pose a human cancer risk.
A direct association has been made between cooking habits, frequency of beef eating, and stomach
cancer. When the diets and cooking habits of 176 people diagnosed with stomach cancer and 503
people without cancer were compared, it was discovered that those who ate their beef medium-well
or well-done had more than three times the risk of stomach cancer than those who ate their beef rare
or medium-rare. An increased risk of developing colorectal, pancreatic, and breast cancer has been
associated with high intakes of well-done, fried, or barbecued meats. The exception is organ meat
(liver and kidney) which is very low in creatine-creatinine. (Adamson and Thorgeirsson. 1995;
Adamson et al. 1990; Bogen, 1994; Knekt et al. 1994; Muscat and Wynder; 1994).
The amount of mutagenic/carcinogenic compounds formed during meat cooking can also be varied
depends on additional factors such as microwave pretreatment (Felton et al. 1994) addition of soy
protein, chlorophyll or antioxidants before cooking.
The potential these heterocyclic amines have to induce carcinogenic events in man was examined
in a joint research project between Brigham and Womens Hospital, and Harvard Medical School.
Data obtained from the questioners provided information that could potentially be used to estimate the
degree of exposure to these chemicals, and correlate it with the probability of such exposure resulting
in a disease association (Byrne et al. 1998).
The mutagenicity of many of these compounds was examined using the following microbial, insect
(Drosophila), and several mammalian cell lines (Eisenbrand and Tang. 1993; Chen et al. 1990;
Ramsey et al. 1998; Schut et al. 1999; Schweiger et al. 1988). These compounds demonstrated
the ability to evoke unscheduled DNA activity, and induce preneoplastic lesion formation
(Okonogi et al. 1997; Hasegawa, et al. 1994; Kristiansen. 1996). Tumors were induced in both
adult and neonatal mice, adult rats, and in non-human primates (monkeys) in various organs.
Though the authors of these works offered no conclusive explanation for the favored differences
in target tissue between species, one suggestion put forth focused upon potential tissue-specific
genetic/enzymatic differences and the affinity the specific mutagen may have for them. Some of
the mutagens tested displayed carcinogenicity only at concentrations above those one would
normally encounter in cooked meat (Kushida, 1994; Thorgeirsson et al. 1996a-b; Weisburger et al.
1994). It was interesting to note that carcinogenicity was many times higher in newborn or young
mice than in adult mice. Data from these studies seemed to suggest that a much greater health risk
exists for the very young because they lack a fully developed detoxification or DNA repair
mechanisms at this stage of life (Dooley et al. 1992). This finding, if directly applicable to
humans, would suggest that there is a far greater risk to the very young (and possibly the very
old) due to a less than robust immunological defense system and repair mechanism.
Summary
The answer to the question of whether or not a supplement is absolutely safe, is rarely known. While
a new supplement inducing gross and acute toxicity symptoms is the easiest to spot and eliminate,
older supplements, with a history of human use, may produce few if any overtly recognizable bio-
stress symptoms. The potential a supplements individual molecular constituents, and metabolic
byproducts or breakdown products, have to create bio-burden and damage when consumed in large
quantities and/or over a long period of time by persons with compromised kidney function, are often
not considered by the user or simply unknown.

Creatinine, irrespective of its origin, has been shown to undergo transformation when heated during
cooking, or by bacterial action. During the cooking of muscle meats at temperatures which exceed
212F, or when creatine/creatinine are utilized by certain strains of upper G.I. tract bacteria,
creatinine X chemicals are created which vary in their degrees of toxicity, mutagenicity, and
carcinogenicity. Compared to muscle meats, organ meats specifically liver and kidney, as well as
plant matter, have the lowest levels of creatine(s) and display almost no mutagenicity after cooking.
This chemical formation can be controlled somewhat by the concomitant concentrations of
antioxidants in the mix.
While none of the mutagenic or carcinogenic information, presented in this chapter, was linked by
any author to creatine monohydrate usage, it must be acknowledged that a creatine supplement could
potentially supply the same physiological excess of creatine creatinine, fuelling the same
bacterially initiated mutagenic/carcinogenic molecular creations in those with poor kidney function.

The impact excessive creatinine and creatinine- X toxins have on human physiology will be
explored in Chapter 5.

[*Authors note: Although the data shows that cooking meat creates creatinine- X mutagenic and
carcinogenic chemicals, the author of this book does not support the practice of eating raw meat
because of the potential raw meat has to transmit harmful pathogenic bacteria. Meat can be creatine
reduced, prior to cooking, by using simple procedures reported by Jones (2001).]
 Chapter 5

If a Little Does Good

Youve heard the old adage If a little does good, then a lot must be better. But is it really true?
Possibly if that anonymous author had a diet rich in fresh fruits and vegetables in mind when he
uttered that immortalized advice. But would the advice be the same for many of the supplements on
our shelves today? If your answer is, Yes in many cases, you would be wrong in some,
(literally) dead wrong! The candidates for the, You Cant Live Without It or With It category may
surprise you.

Vitamin A
Retinol is a fat-soluble vitamin. It is made from provitamin carotenoids via conversion first to retinal
in the mucosal cells of the small intestine, reduced to retinol, and finally esterified and stored in the
liver. It is absolutely essential for the functioning of photoreceptor cells in the retina, maintaining
epithelial tissue (skin), and functions as a gene regulator by binding to the DNA.
A deficiency of Vitamin A (retinol) causes blindness, impairs immune response and raises the
risk of disease and death from infections. Children who are vitamin A deficient die within 12 months
of losing their sight. Pregnant women who are vitamin A deficient are at a much greater risk of
maternal mortality.
But when taken in excessive amounts, Vitamin A is toxic! Toxicity is dose related and can
manifest rapidly, culminating in death. Sub-lethal toxicity depending upon the dose and duration of
ingestion (i.e. chronic vs. acute, hours vs. days vs. months or years), can manifest as any one of
several symptoms including vomiting, severe intracranial pressure and headaches, drowsiness,
muscular weakness, and peeling of the skin. Birth defects have been reported under certain
conditions.

Vitamin D
Vitamin D is a fat-soluble vitamin, and prohormone, which exists in two forms: ergocalciferol and
cholecalciferol. Ultimately the provitamin is transformed (via help from the liver and kidneys) into
the highly active 1,25-dihydroxycholecalciferol. Its function is to increase calcium absorption from
the intestine, promote normal bone mineralization, and act as a regulator for the parathyroid
hormone (PTH).
 Vitamin D deficiency is responsible for rickets and osteomalacia (demineralization of primarily
the spine, pelvis, and lower extremities). In severely D deficient pregnant women, fetal skeletal
formation is abnormal. Prepubescent deficient children are at an increased risk for stunted growth,
fractures and osteoporosis. It has been suggested that chronic Vitamin D deficiency may be linked to
some cancers, as well as diabetes and hypertension.
But when taken in excessive amounts, vitamin D is toxic. Toxicity can manifest over the course of
1 to 4 months as nausea, vomiting, polyuria, polydipsia, weakness, nervousness, and pruritus. Vitamin
D toxicity exerts its greatest impact on the heart, blood vessels and kidneys as calcium is absorbed in
abnormally high amounts and deposited (along with phosphorus) in soft tissues throughout the body.
Once kidneys are calcified, the damage is irreversible.\atal cardiac calcification has been
documented under certain situations where the active form of the vitamin is being ingested (The
Merck Manual of Diagnosis and Therapy. 2005).

Iron
Iron is an essential mineral. It is needed to form myoglobin (muscle cell protein), and hemoglobin.
Iron is also used by certain critical enzymes.
Iron deficiency results in anemia, fatigue, breathlessness, rapid or irregular heartbeat, angina, and
even heart failure (OMeara. 2004). Other symptoms reported are: pale skin, a decreased ability to
exercise, troubles in swallowing, sore mouth or tongue, susceptible to infections, as well as unusually
brittle fingernails and/or an abnormal curling and softness of the nails called spooning.
But when taken in excessive amounts, iron can be extremely toxic! Iron poisoning is considered a
leading cause of poisoning-related death in young children (Morris. 2000). Severe hepatocellular
damage progressing to acute liver failure, shock, extreme intestinal distress, and impaired
consciousness have all been reported following therapeutic intravenous iron sucrose infusion or iron-
tablet ingestion. Sub-lethal doses result in a rapid onset of vomiting, diarrhea, malena and
hemetemesis have been observed (Wood et al. 2005; Daram and Hayashi. 2005; Singhi and
Baranwal. 2003).

So what about creatine monohydrate?

Data to date overwhelmingly suggests that a little an average of between 1- 2.5 grams daily,
taken by those with healthy kidneys really, does good (i.e. provides skeletal muscular, and
occasionally even other numerous health benefits) without adverse effect. But does that also imply
that a lot 10g, 20g, and higher gram amounts, taken daily over the long-haul, would be better or as
safe? While authors such as Harris, Racette, Soderlund, Fry, Starks, Hultman, Farquhar, Kearney,
Johnson, Zambraski, Kreider, Melton, Benzi, Rasmussen, Greenwood, Lancaster, Cantler, Milnor,
Almada, Ceci, Schilling, Stone, Utter, Coglianese, Smith, O'Bryant, Keith, Stone, Williams and
Branch, as well as others, have repeatedly affirmed the safety of low doses of this supplement (taken
over extended periods), or higher doses (i.e. 10-20 grams) taken for one or several days, by persons
with healthy kidneys, professional opinion becomes mixed and even guarded when higher doses, for
longer periods are used.
Consumerreport.org quoted Dr. Bernard Griesemer, M.D., director of a pediatric sports-
medicines, cautionary note. In his professional opinion, most creatine monohydrate studies were
actually short-duration studies (i.e. days) using confirmed healthy adults. Long-term use implications,
in a large study population (especially in cases of higher doses), have not been done and, as such, any
potential dangers were not truly known.
Benzi and Ceci (2001) commented that the maximal amount of oral creatine monohydrate
supplementation should be no higher than 5-6 grams, which already represents two times the daily
turnover (in a 70 kg man), for less than two weeks. The authors deemed, administration of more
that 6 g per day as therapeutic intervention, which should be prescribed and monitored by
physicians, out of safety concerns.
Bizzarini and De Angelis (2004) reported a lack of well-controlled study data, linking defined
causal relationship of creatine supplementation by healthy individuals to organ deterioration. Because
of potential unexpected events, resulting from industrial contaminants, which have been inadequately
studied, they cautioned that serious use of this supplement should be under medical supervision.

Now what about the safety of this supplement in individuals with kidney disease or kidney failure?
Against such a backdrop, professional opinion about the safety of this (and most) supplements
usually takes a rapid about-face turn for the worse and for good reason. Healthy kidneys are the
bodys only safety net where excess creatinine (and creatine) is concerned. With the long term
potential dangers of creatinine excess and in this instance supplement induced creatinine (and
creatine) excess, not adequately studied in large populations of individuals with healthy kidneys to
indorse creatine supplements safety in persons with kidney disease (or failure) would be taking a
potentially dangerous step into the unknown.

What are the potential physiological dangers of long-term creatinine excess?

The information concerning the physiological impact of long-term creatinine excess comes
primarily from sporadically reported human and animal studies, and indirectly from patients with
kidney failure. To date, there have been no large-scale studies in animal or in man.
Why?
Simply put, there is no real financial gain to be realized from such a research program. A large
scale long duration study in animals would be an expensive endeavor. There is no potential
financial gain to be had from the data generated, and as such, no pharmaceutical, health based
organization, or agency has an urgent incentive to fund it.
Another potential point of contention is the argument which could be made for species specificity
with regard to a creatinine physiological response. While dose-response correlations can be
calculated for many mice-to-man drug studies, equally numerous studies have shown species specific
response for such substances as: creatine monohydrate (Tarnopolsky et al. 2003), xenobiotics (Dai
and Wan. 2005), thalidomide (Lu et al. 2004), alcohol (Saito et al. 2004) estrogen (Hossaini et al.
2003), etc.. Ultimately, if we wish to know how something affects man, we must turn to man as the
only truly definitive experimental animal and here in lies the problem.

With regard to question of the potential dangers of long-term creatinine excess the following never-
to-be-performed horrific human experiment would most certainly answer our creatinine
physiological impact question. However, if it (hypothetically) were performed, our definitive
experiment would probably look something like this:

***
Unethical Science
Objectives:
Determine the organ specific and overall physiological impact of a long-term, gross excess of creatinine in man.

Experimental Design:
100 healthy large, male athletes (age 21 29; weight >80 kg) will be recruited. No informed consent will be sought.
Perspective participants, once identified, will be secured by any means possible for the duration of the study. Subjects will be
divided into two groups of 50 participants labeled A and B. Both groups will be forced to consume a diet which, in addition
to a vitamin supplement, will contain at least 95% animal protein (2.5 kg/day) and associated fats, with minimal (<5%)
amounts of vegetable matter, and non-meat related carbohydrates. Both groups will be forced to exercise to exhaustion
repeatedly each day. In addition to diet, Group B will have their blood levels of creatinine artificially maintained at 10 mg/dl
(simulating a highly uremic state often observed in End Stage Renal Disease [ESRD] patients) through creatinine
supplementation (oral or intravenously administered) throughout the test period. Test period will run nine consecutive
months. The experimental End Point will be death, or 270 days. At the conclusion of the test period (or at death),
hematological investigation as well as biopsies will be performed on all major organs including sampling of bone marrow and
intestine. Surviving members displaying gross physiological impairment will be euthanized.

Experimental Design Rationally:

Male Men have a greater percent of muscle mass than females of the same weight. Men (on average) generate more
creatinine than women of the same stature and weight.

Athletes Greatest percent of muscle mass per frame as compared to non-athletic or sedentary adults.

Age selection High probability of normal kidney function. Age related organ degeneration is expected to be non-existent or
minimal in this age group.

Diet Consuming 2.5 kg (average 5 lbs) of extremely well done and charred steak is expected to deliver >11 grams of
dietary creatine of which as much as 55 - 75% (or 6.0 - 8.25g) is expected to be in the creatinine form directly to the
blood stream.

Exercise Program Strenuous physical activity requires muscles to convert greater amounts of muscle creatine to
creatinine as compared to general physical activity.

Study Considerations:
In addition to the final aforementioned anatomical and hematological tests, participants serum and urine creatine/creatinine,
uric acid (potential gout indicator), and protein (indicator of kidney damage) as well as blood pressure will be monitored
weekly; signs of edema, nausea, unrelenting itching, and hypertension will be noted.
Given the general medical consensus and comments concerning exclusively meat based diets, Group A is expected to
display signs of gout and general renal distress, manifesting both hematologically as well as visibly before the end of the
study period.

From historical data and observations of those with ESRD, Group B (and possibly Group A to some minor extent) is
expected to experience daily bouts of nausea, severe itching, muscle weakness, mild confusion and sedation effect. Minor
bleeding episodes (externally and internally) as well as repeated spontaneous sub-dermal bruising is anticipated in Group
B.
Secondary Test Hypothesis:
In addition to the question of physiological impact, the question of whether or not the same prolonged gross artificial excess
of physiological creatinine, in and of itself, can induce renal failure, will be addressed.

IRB* Approval:
*(Institutional Review Board [reviews, approves and oversees the legal and ethical use of humans as test subjects in any
proposed protocol])
No approval was sought.
****
Physiologic Impact of Creatinine Excess
So, if we dont have the final answer, what do we really know about the impact excessive creatinine
can have on the body? Even without the data from the above heinous experiment, we can assemble a
pretty reasonable picture from antidotal reports, animal studies, and from the data gleaned from those
with kidney disease.

Metabolic Disruption and Cell Death

A gross excess of physiological creatinine (at least 7mg/dl or more) is capable of disrupting cell
adhesion and killing seeded cells, in vitro. This ability was demonstrated in an experiment by Humes
(et al. 1999) in which cells, seeded into a bioartificial kidney, experienced a rapid kill rate (surface
detachment and death) when exposed to artificially induced uremic conditions in a dog model. Plasma
values for various electrolytes in this artificially induced uremic state were not grossly elevated and,
in many instances, were within the normal range. Two values were distinctly elevated Blood Urea
Nitrogen (BUN) and creatinine. Urea can be considered, and utilized as, a nitrogen source by both
cells and animals (notably, the cow) under certain conditions. Urea is formed by the body to bind up
and remove free ammonia, which is very toxic. Urea is also toxic at high physiological
concentrations, but in a mildly uremic state, it is a relatively non-toxic. While an elevated BUN may
have contributed to the cell detachment and death observed, the authors credited this reaction to
grossly elevated creatinine, rather than BUN or any other abnormality.
Creatinine and its degradation products were shown (in vivo) to cause deteriorate of renal
function when administered to either normal rats or to rats with chronic renal failure.
(Yokozawa et al. 1993).
One of the breakdown products of creatinine methylguanidine (MG) has been shown to be
potentially very toxic, in vitro. Excess MG exerts a direct inhibitory impact on the mitochondrial
metabolic process, oxidative phosphorylation, growth of cultured cells, and various chemical
reactions in the brain (De Deyn et al. 1990).

Inflammatory Promoter
It is also possible that a large physiological excess of creatinine (and in some instances creatine)
may be acting as a general inflammatory promoter, or as a vascular-irritant systemically and at the
site of the kidney. One such marker of inflammation is C-reactive protein (CRP). CRP is an acute
phase protein, produced in response to an inflammatory event. Such inflammatory factors are credited
with the initiation of numerous inflammatory related diseases (atherosclerotic plaques, diabetes, and
an increase in cardiovascular disease). An elevation of inflammatory factors is almost universally
observed in persons with moderate to severe kidney disease, whether or not they are dialyzing (Jones
and Kaiser. 2002). This suggests that the known inflammatory promoters (i.e. certain I.V. drugs,
extracorporeal circulation of bodily fluids, etc..) are clearly not the only things acting as stimuli, and
provides support for the notion that excess physiological waste is an inflammatory promoter.
When transgenic mice ingested creatine, at doses slightly above those habitually consumed by
humans, for approximately one-half their life span, mice (but not rats) exhibited dose-related
increases in the level of oxidative stress, as well as evidence of hepatocyte (liver cell) inflammation.
For these observations, the author posed two theoretical explanations: a) Hepatocyte swelling (and
the subsequently observed gross inflammatory response) may have resulted from the osmotic effect
of a chronic increase in total physiological creatine, similar to the osmotic muscle plumping effect
seen by athletic-creatine users; b) the histopathological findings may be a feature of toxic stress
(chronically elevated creatinine). Similar (though not identical) types of structural damage can be
observed when mice are exposed to toxic levels of ethanol (Tarnopolsky et al. 2003).
Bohle (et al. 1990) reported that in various types of kidney- and kidney-related disease conditions
(i.e. glomerulonephritis, diabetic glomerulosclerosis, and other), a significant correlation existed
between the severity of fibrosis of the renal cortical interstitium (and tubular atrophy), and elevated
creatinine. In these kidney conditions, chronic interstitial inflammation led to a progressive
worsening of kidney function. It was interesting to note that serum creatinine concentration was mildly
to grossly elevated in most, but not in 100%, of all cases. Though the data inferred it, the author could
not conclude that the primary inflammatory trigger was excessive creatinine.

Neurological and Hematological Impact

Creatinine, and the breakdown products of creatinine, have been shown to have negative
physiological impact in the dog model.
When MG was administered to dogs, at concentrations approximating a uremic state similar to
that found in severe renal disease, the impact was initially one of chronic intoxication. As this state
was prolonged, an increase in protein catabolism with signs of muscle wasting (as opposed to
anabolism muscle building) became apparent. Additional observations included anemia, decrease
in the circulating platelet count (creating a potential tendency to bleed), neuropathy, pruritus,
arrhythmias and myocardial degeneration and congestion. In later stages of MG excess
exposure, intoxication intensified, anorexia, vomiting, increased salivation, and diarrhea
were commonly observed (Barsotti et al. 1975).
An excess of one or more of the breakdown products of creatinine (and possibly creatine itself)
has been shown to be capable of inhibiting an isoenzyme responsible for certain aspects of blood
pressure regulation. This raises the possibility that creatinine excess may contribute (somewhat)
to the hypertension seen in many patients with chronic kidney failure (Sorrentino and Pinto.
1997).
Excessive creatinine has been shown to induce spontaneous human red-cell hemolysis in vitro
(Giovannetti et al. 1969).

Insulin Resistance
In those with severe chronic kidney disease, insulin resistance is a common finding.
Creatine/creatinine receptor influence was examined by observing insulin-receptors binding potential
before and after hemodialysis. The binding of insulin to its receptor is negatively influenced by
excessive levels of creatine, creatinine, and guanidinoacetate. Receptor sensitivity has been
shown to be quickly restored after hemodialysis has been completed. In vitro tests revealed that
the addition of creatine/creatinine and guanidinoacetate depressed binding to a similar degree as
that observed in vivo (Rocic et al. 1991).

Renal Stress and Renal Disease Progression

The kidney is a sensitive barometer of the bodys health. While it may not immediately become
apparent, many organic compounds, heavy metals, antibiotics, some dietary supplements, and even
analgesics have been shown to negatively impact the functional cells of these organs. When damage is
minimal, the kidney can compensate for a modest loss of nephrons (filtering unit) by hyperfiltrating,
thereby making it appear as if function is essentially still normal (normal renal clearance is 120
ml/min). When damage is sudden, significant or severe, clinical abnormalities are seen very quickly.
Of all the clinical abnormalities which can occur as kidney function fails, one consistent finding is
noted early an unrelenting increase in the serum concentration of creatinine. Creatinine is
considered a middle molecule, and used as a reliable marker for renal failure.

Supplement Induced:
Within 6 hours after creatine monohydrate is consumed, a rise in serum levels followed by the
initiation of urinary excretion of creatine (and creatinine according to some authors) was observed.
Though not universally observed, this pattern has been observed by numerous authors, including
Cutter (1999) in athletes using 2.5 grams to 20 grams, Harris (et al. 1992) in volunteers receiving 30
grams, Poortman (et al. 1997) in healthy men using 20 grams, by Schedel (et al. 1999) in volunteers
receiving doses from 2.5 grams to 30 grams, by Engelhardt (et al. 1998) in volunteers using 6 grams
of creatine monohydrate. A modest to moderate rise in serum creatine (>50%) and creatinine (>13% -
16%) was overshadowed by the rise in excreted creatine (40% - >1,400%) and creatinine (>66%) in
their healthy volunteers. Time to the initiation of excretion as well as percent (creatine/creatinine)
excreted is dose dependent, as is the rise in plasma creatine/creatinine. Though not universally
reported, similar elevated findings have been reported by other authors. It appears that (on average)
when a body is presented with more than 2 grams of creatine supplementation per day, the excess
creatine is simply dumped into the urine. This is followed by a statistically significant amount of
excess serum creatinine approximately 24 (in some cases 48 and 72) hours post-ingestion,
depending upon the dose. Vandenberghe (et al. 1997) noted that when 5 grams of supplementation was
continued for 10 weeks, urinary levels (and we presume serum levels as well) of creatine and
creatinine remained modestly elevated after supplementation was finally discontinued.
In a setting of significant kidney disease, elevations in serum creatine and creatinine would be
expected to remain much longer as much as 2X and 6X longer. While the authors generally
concluded that creatine-supplement induced serum elevations in creatine/creatinine caused no
immediately discernable kidney stress or damage in normal volunteers, no such similar conclusion
was put forth when discussing use by persons with pre-existing kidney disease. Investigators
Yoshizumi and Tsourounis (2004) contend that such elevations, in persons with pre-existing renal
conditions, actually represent further renal stress. In people with a history of kidney disease, it is
potentially possible that creatine supplement use may be associated with an increased risk of renal
dysfunction.
Several anecdotal reports of adverse events, including worsening of pre-existing kidney disease
appear to bear this sentiment out. In one of the few documented and reported cases, Koshy (et al.
1999) described a situation in which a previously healthy 20-yr-old man presented with rapidly
deteriorating renal function, beginning approximately four weeks after he started taking 20 grams of
creatine monohydrate orally, per day. The rapid progression of renal failure in this young man was
traced to this supplements use. Once discontinued, renal function improved, however it was not
mentioned whether or not the Glomerular Filtration Rate (GFR) returned to normal.
In a second report of worsening renal condition, Pritchard and Kalra described the case of a 25-
yr-old man with pre-existing focal segmental glomerulosclerosis. Creatine monohydrate use was
linked to a rapid deterioration of renal function.
A similar situation was reported by Edmunds (et al. 2001) in an experiment using Han:Sprague-
Dawley (SPRD)-cy rats which had cystic kidney disease. Rats were given a creatine supplement at a
dose which mimicked that normally consumed by man. Exacerbation of existing kidney disease was
confirmed. However his finding was by no means universal. Taes (et al. 2003) reported that creatine
supplementation for 4 weeks (at low dose) did not affect kidney function in Male Wistar rats that had
been two-thirds nephrectomized. Though each of these rat experiments looked at creatines impact on
pre-existing renal insufficiency, the way in which the organs were compromised for this experiment
more than likely played a significant role in the experimental outcome. Polycystic kidney disease, and
ischemic induced renal insufficiency are two entirely different pathologies, and could potentially
have influenced the ultimate outcomes of the experiments.

In addition, the Food and Drug Administration has also included unspecified rashes, dyspnea,
vomiting, diarrhea, nervousness, anxiety, fatigue, migraine, myopathy, polymyositis, seizures
(Wyss and Kaddurah-Daouk, 2000), and atrial fibrillation (Kammer. 2005), as documented adverse
events involving creatine supplementation in man. Whether or not creatine, creatinine or one of the
myriad break down products thereof was actually responsible for the reported events, remains
unknown.

Nutritionally Induced
Animal based protein has been shown to be capable of contributing to further renal deterioration in
those with already impaired kidney function. In an article, entitled: For those with Impaired Kidney
Function, Beef is NOT for Dinner (May 2003 issue of Nephrology News and Issues), meat
especially nondairy meats, were found to negatively impact renal function. The collaborative
study between Harvard Medical School and Brigham Womens Hospital, examined the dietary
habits of 1,600 women ages 42 to 68 over an 11-year period. Women with pre-existing impaired
kidney function were found to be 3.5 times more likely to further damage their kidneys if they
maintain a high animal protein diet. While gross meat protein was cited as the culprit in the March
18th issue of the Annals of Internal Medicine, it is also possible that meat myoglobin, purines,
creatinine (and creatinines breakdown products) and similar small molecular constituents of meat
are actually responsible.
Summary
Data from in vitro and in vivo (animal) studies, as well as from those with ESRD patients, provide us
with a sobering picture of the physiological impact that a protracted excess of creatinine (and its
break down products) can potentially have. From general cell-receptor-hormone or receptor-isozyme
interference, and potential inflammatory promoter, to gross metabolic/neurological disruption and
cell death, this seemingly harmless waste product of creatine can (potentially) become very toxic
depending upon the degree to which it is elevated.

With regard to the reported worsening of pre-existing kidney function in man and animal, it is unclear
whether said excess (creatine or creatinine) is capable of acting as the primary cellular insult
responsible for causing renal disease or failure. Given the organs response when presented with a
temporary creatine/creatinine excess (in the case of man), it seems more likely that the excessive
creatine/creatinine is being treated by the kidneys as direct bio-burden, one that the organs could
recover from.

If however, it is ultimately proven that this molecular-duo (in-and-of-itself) has the ability to
stimulate the production of inflammatory proteins, or is itself inflammatory in man, it could ultimately
be considered a potential health hazard.
 Chapter 6

A Smoking Spoon?

In a darkened hallway, the sound of hurried footsteps is heard. Slowly, the silhouette of a trench coat
clad figure emerges from the shadowy recesses of a doorway and follows. A moment later, a blood-
chilling scream pierces the darkness followed by a shot. Suddenly a light is switched on revealing the
guilty smoking gun in his hand!

This classic piece of open-and-shut detective work, immortalized on the Silver Screen, is rarely
played out in real life. More often than not, clues abound, yet a clean cause and effect is rarely
established. Such is the case with the question of the ultimate physiological impact of creatinine. Data
is sketchy forming a twisted Agatha Christie-like mystery, ensuring that any would-be-detective
relies as much on a crystal ball as a magnifying glass for the ultimate answer. Our clues in this
creatinine puzzle are a patchwork of experiments done on varied species, as well as in-vitro systems
all of which have occasionally produced conflicting results. In other words, while we (may) have
heard the shot we have yet to truly identify the gun from which the bullet was fired (Fig. 10).

There is little question of the impact that a heavy meat laden life-style will have on someone with
failing kidneys. But is it actually the meat creatine/creatinine which is responsible, or one of the
numerous other small molecular compounds? And what about creatine monohydrate? Why has this
substance occasionally produced serious negative physiological effects, reported in some animal
studies, and in sporadic reports in man?
With all of the pros, and (few) cons reported, how close are we to finding a smoking spoon?
While the knife and fork may be on the verge of smoldering, the spoons status is, in fact, still
largely unknown.

FIGURE 10 - WHATDUNIT?
Beef?
We have been looking perpetually at the far left the potential consequences of too much
creatinine. What about the potential direct consequences of too little of the starting material
creatine? This non-protein, amino acid molecule is absolutely indispensable in the mechanical
scheme of muscular motion. Without an adequate supply of this energy shuttle, could the physiological
consequences be as (potentially) serious as has been suggested for too much of its waste product
creatinine?
With the exception of starvation, a significant physiological creatine deficit would most likely be
a secondary result of an abnormal medical condition. However in the following three very rare
genetic conditions, creatine metabolism, synthesis, and shuttle defects are the primary disease
conditions.
Creatine Deficiency Syndromes are characterized by a depletion of creatine/phosphocreatine in
the brain. These diseases manifest as varying degrees of mental retardation and severe neurological
disorders. While most cases are usually diagnosed in early infancy, a few adult cases have recently
been discovered. Two of the deficiency syndromes glycine amidinotransferase, and
guanidinoacetate methyltransferase, are reported to be treatable with oral creatine, while the third, a
creatine transporter defect is not (Sykut-Cegielska et al. 2004; Cheillan et al. 2005).
In the autosomal recessive condition, known as Gyrate atrophy of the choroid and retina, type II
skeletal muscle fibers become atrophied. While not the primary cause, a decisive deficiency in
creatine/creatine phosphate synthesis has been implicated as a measurable part of the pathogenesis of
this disease. Vannas-Sulonen (et al. 1985) noted that when an oral creatine supplementation was
consumed by 13 Gyrate atrophy patients, skeletal muscle abnormalities either decreased or
disappeared. When supplementation was terminated, abnormalities reappeared.
Skeletal muscle wasting and dysfunction are conditions frequently seen in chronic obstructive
pulmonary disease. The appearance of such wasting is an independent predictor of mortality. Oral
creatine supplementation was reported by Fuld (et al. 2005) to improve peripheral muscle
performance, but not exercise capacity, in 38 such patients.
Low dose oral creatine supplementation gave a modest but statistically significant benefit to a
limited number of volunteers suffering from the rare McArdle's disease (Glycogen Storage Disease
type V). Symptoms of this disease include exercise-induced pain, cramps, fatigue, pronounced
myoglobinuria, and acute renal failure (Quinlivan and Beynon. 2004).
While not a cure, in each of these rare medical conditions reported, oral creatine monohydrate use
was followed by a measurable and perceived symptomatic improvement. Creatine was well
tolerated, with an absence of untoward reactions.
 Because of creatines intimate relationship with both muscle and brain cells, it has been
hypothesized that creatine might prove beneficial in other neural-muscular disorders, such as
Amyotrophic Lateral Sclerosis (ALS), a condition which results in a progressive degeneration of
motor neurons, resulting in skeletal muscle atrophy. However, two clinical trials using oral creatine
monohydrate have failed to demonstrate any significant sustained improvements or overall long-term
increase in survival for this disease condition (Ellis and Rosenfeld. 2004).

Creatine and cyclocreatine have both been shown to be anti-neoplastic (inhibit tumor growth) against
a variety of murine (mice) and human tumors.
When creatine analogs (cyclocreatine, beta-guanidinopropionic acid) or creatine-phosphate were
administered intravenously to rats with implanted mammary carcinomas, tumor growth delay was
observed. A distinct decrease in plasma insulin coupled with increases in plasma glucagon, and
plasma somatostatin were also seen. The author concluded that an alteration in the pancreatic
hormone balance was likely responsible for the anti-neoplastic activity observed for creatine and the
analogs (Ara et al. 1998)
In a study by Kristesen et al. (1999) nude mice carrying a human colon adenocarcinoma were fed
either creatine, at varying concentrations from 2.5 5%, or cyclocreatine at concentrations of 0.025
0.5%, for 2 weeks. Results indicated that both test substances were equally effective in inhibiting
tumor growth in vivo. In addition, neither of the test substances were reported to induce a state of
excessive water accumulation (bloating) or other physiologically deleterious effects.
In one neoplastic cell line the Ehrlich ascites tumor, which grows as free cells in the abdominal
space of mice, creatine has been observed to stimulate its growth. When creatine availability was
restricted (in vitro), a significant decrease in cell viability was observed. When creatine was added
back, viability improved significantly (Ohira and Inoue. 1995).
 Chapter 7

An Experts Point of View

Over the years, researchers and nutrition/sports writers alike seem to have had a love hate, and
even an indifferent relationship with regard to this waste product of creatine. Unlike in the 19th and
early part of the 20th century, where much of all scientific findings were destined to occupy a dusty,
seldom referenced obscure journal, today research information is eagerly awaited by nutrition
conscious supplement users, striving to be informed consumer. With millions becoming much more
health conscious taking an active role in their health maintenance, and willing to make significant
lifestyle changes, informing oneself of the latest nutrition and supplement research is taken very
seriously indeed. Unfortunately, available data is sketchy concerning the impact that this simple waste
product of creatine may impose in persons with kidney disease. With regard to creatine monohydrate
usage in such a setting numerous unanswered questions remain:
When does enough become too much?
Does the creatine source (food vs. supplement) make any difference?
Does creatinine become a detriment at super physiological concentrations?
Or, is this all just a lot of hype?
So, what do other professionals have to say regarding creatinine?
Interview with Sheri Colberg, PhD
Associate Professor and Director, Human Performance Laboratory

Author of:
The Diabetic Athletic: Prescriptions for Exercise and Sports
Diabetes-Free Kids:A Take-Charge Plan for Preventing and Treating Type-2 Diabetes in
Children
The Diabetic Athlete

Question: Because diabetes is the leading cause of kidney failure, and the subsequent need for
dialysis (>45% to 60% in some dialysis centers), what potential impact might extra creatinine
(generated from creatine supplementation) have on a compromised renal organ?

Reply: What would be the renal effect of supplementing with creatine monohydrate by a diabetic
athlete in an attempt to improve athletic power and performance? Creatine supplementation appears
safe when used by healthy adults at the recommended loading (20 gm/day for five days) and
maintenance doses ( 3 gm/day) for as long as five years (Poortmans JR, et al., 1999). However,
while few trials have investigated the long-term use of creatine supplementation in doses exceeding
10 gm/day, at least one report of a 20-year-old non-diabetic man taking 20 gm of creatine daily for a
period of four weeks who experienced acute renal failure has been published. Physical activity is not
inherently bad for people with compromised renal function; in fact, they are able to undertake mild to
moderate aerobic exercise during dialysis treatments. Moreover, a prior study (Matsuoka K, et al.,
1991) on patients with progressing diabetic neuropathy demonstrated that restricting physical activity
was of little benefit in slowing the progression of the disease, and postural hypotension was actually
less pronounced in patients who maintained normal levels of activity. A more recent study (De
Moraes R, et al., 2005) demonstrated that, at least in non-diabetic rabbit kidneys, exercise training
protects against endothelial dysfunction elicited by acute exposure to moderately elevated glucose
levels, such as would be experienced during postprandial hyperglycemia in people with diabetes.
In people with a history of renal disease, it is not known whether creatine supplementation causes
an increased risk of renal dysfunction. One might hypothesize that the extra creatinine created by the
breakdown of excess creatine would likely create an additional stressor on existing renal function,
but at least one study conducted on Wistar rats demonstrated that a creatine-supplemented diet for 4
weeks does not impair kidney function in animals with pre-existing renal failure (Taes YE, et al.,
2003). However, since creatine supplementation may increase creatinine levels, taking it may make
existing dysfunction appear worse when monitored by serum creatinine and creatinine clearance. Its
use in such cases may be discouraged for that reason alone, unless more evidence of a deleterious
effect on renal function in compromised kidneys is discovered.

Contact Information:
Sheri Colberg, PhD
ESPER Department
Old Dominion University
Norfolk, VA 23529
E-mail: scolberg@odu.edu
Interview with Brian Andrews
President, All American EFX

Author of:
Creatine: Industry Insider Secrets Revealed. 12 Facts Every Consumer Should Know

Question: As the owner of a Sport Nutrition Company who markets creatine products, what is your
position in the ongoing debate surrounding creatine monohydrate and the possibility that it may play a
role in negatively impacting the body on a long-term basis?

Reply: Actually, the very fact that we work inside the sports nutrition industry provides us with quite
a unique vantage point. You see, this is an issue we take very seriously.
Now, the key term in your question is long-term. We need to define exactly what that means.
First of all, there are numerous studies showing that using traditional creatine supplements in
moderation are safe short-term (less than 10 years). However, what we dont have is enough
information to show what the long-term effects may be, if any, of using creatine.
With that said, the real issue here is actually not the usage of creatine supplements, but rather their
instability in fluids. As creatine is activated by aqueous solutions, its molecules begin to fall apart
and degrade into creatinine. Therefore, creatinine, especially elevated levels of it within the body
over a long-term period, is the bigger issue we all need to consider.
Many do not realize that creatine has this inherent flaw. Some experts even deny it altogether.
However, the prestigious Merck Index clearly points out this problem with traditional creatine and its
conversion to creatinine in fluids and acids.
Thats why we only offer a patented creatine technology called Kre-Alkalyn EFX to the
marketplace. In fact, this particular compound is the only known 100% stable form of creatine
monohydrate to date. Furthermore, we believe it stands to solve many of the above-mentioned issues.
Of course, this would only hold true if it, too, is used in moderation.
By avoiding the issue upfront of overloading the bodily systems with excess creatinine, it is only
logical to conclude that any possible problems surrounding the impact creatinine may play on the
body, are concurrently reduced.

Question: Based on how you answered above, what role then do you believe creatine monohydrate
may play in the progression of pre-existing CKD or renal failure? Furthermore, what, if any, "bio-
burden" do you believe is being imposed on the body by such protracted creatinine elevation?

Reply: My direct experience so far with creatinine is that it is a very interesting and often hotly
contested subject...one that causes much debate in the medical world. And interestingly, even more so
in the sports supplement world.
The reason for this is that it has become, and still remains, the number one selling legal compound
for enhancing muscular size and performance. Simply put, the market for it is enormous, to the tune of
$200-400 million in sales a year. Obviously, there are many companies, including mine, who have a
vested interested in keeping it on the market.
Once again, the big issue at stake is creatines stability and conversion to creatinine on the front
side. That is, what you actually ingest after activating it with a fluid and causing its chemical
reaction to creatinine.
As I stated previously, we simply do not know what possible problems excessive creatinine
levels may cause after years and years of deliberate ingestion. But only time will tell, as emerging
research is beginning to hint at a possible link between creatinine and various maladies.
Once more, this is precisely why we only promote Kre-Alkalyn EFX creatine. We want to
circumvent any potential problems as much as possiblethe clear point here being why take chances
when you dont have to?
Of course, some of our detractors have already stated that creatinine isnt really a big dealthat
were just using scare tactics to sell our creatine technology. However, what they dont know is that
we work very closely with some of the worlds leading researchers in the medical industry (notice I
didnt say supplement industry) on creatinine and renal analysis. And what we are learning is
nothing less than eye-opening, to say the least.
Unfortunately, most people arent aware of this fact: 20 million Americans suffer from some level
of Chronic Kidney Disease (CKD). Thats 1 out of every 9 adults. Even worse there are also
another 20 million estimated individuals out there who are at risk for kidney problems. Keep this
point in mind: these people do NOT know it...yet. (By the way, these figures are taken directly from
the National Kidney Foundation and are freely available for all to see at www.kidney.org).
So the real problem, as I see it, is telling the masses at large that ingesting unstable creatine
products is totally harmless...when we do not know who all these people are to begin with. And it is
only logical that increasing the load on ones kidneys with excess creatinine (a waste product)
certainly isnt going to help their situation either. Rather, it will likely only serve to exacerbate it,
especially within the nephrons (the functional units of the kidney).
Contact Information:
Brian Andrews
President, All American EFX
www.aaefx.com
Interview with Rehan Jalali
President, Supplement Research Foundation

Author of:
The Six-Pack Diet Plan: The Secrets to Getting Lean Abs and a Rock-Hard Body Permanently

Background Information:
According the National Kidney Foundation and Urology databases of 2003- 2004, Chronic Kidney
Disease (CKD) afflicts 20 million in the U.S. and an estimated additional 10-15 million persons
globally. In the U.S., there is presently approximately 1.7M classified as pre-dialysis (stage 4), and
>380,000 currently dialyzing (stage 5).
Research strongly suggests that a heavy meat diet hastens the decline of renal function in those
with confirmed CKD. Reasons for such decline are multi-factorial. In individuals with normal kidney
function, serum values for meat-generated creatinine have been shown to remain mildly elevated for
up to 10 hrs postprandial with no confirmed negative consequences.
The nutritional supplement creatine monohydrate supplies a generous helping of (primarily)
creatine. Research has shown that excess creatine (beyond what the bodys physiology can utilize or
store) is dumped, unconverted, into the urine. Concomitantly, serum creatinine rises only modestly,
while urinary creatine and creatinine are elevated. Serum creatinine (and creatine) excesses, arising
from chronic ingestion of large gram doses of the supplement (10-30 g), may remain mildly elevated
(after discontinuation) for several days. In those with normal kidney function, these excesses are
eventually cleared via the kidneys-urine route. However, in individuals with moderately diminished
renal function, these excesses of creatinine (and creatine in the case of the supplement), can take much
longer to clear.

Question: Considering the number of persons with CKD today, could you comment on the safety of
meat and supplement creatine consumption in individuals with pre-existing kidney disease as it
relates to the generation of excess creatinine?
Reply: Individuals with pre-existing kidney disease may have a harder time handling excess
creatinine production as a result of creatine supplementation. There have been over 500 published
studies on creatine supplementation and none show any clinically significant side effects in training
individuals. But since these are generally healthy people, the effects of creatine supplementation on
training individuals with compromised renal function has not been investigated in depth over the long
term. It can however, be theorized that they may have a harder time handling the excess creatinine that
may be produced. Again, more research needs to be done to conclusively prove this notion.

Question: Could you elaborate on anything you feel is relevant (e.g. creatines mechanism of action,
and potential impact) in persons with confirmed kidney disease?
Reply: The mechanism of action of creatine once it enters the muscle cell, is it's conversion into
creatine phosphate by the enzyme creatine kinase. Once used, the creatine molecule is converted into
creatinine and excreted as a waste product. This can tax the kidneys of individuals with confirmed
kidney disease. Plus, creatine seems to cause increased water retention inside muscle cells. This is
great for normal (renal function) training individuals, but may be a problem for people with kidney
disease.

Question: What, if any, "bio-burden" do you believe is being imposed on the body by such protracted
creatinine elevation?
Reply: In normal individuals, several safety studies on creatine supplementation have shown no
adverse effects to the kidney or liver.

Question: Do you believe that a protracted creatinine excess could potentially lead to the Domino
Effect (i.e. One problem compounding, or initiating, another)?
Reply: In people with kidney disease, this Domino Effect could theoretically occur due to the
abnormal excretion of excess creatinine. Since creatinine is a waste product, its excess accumulation
could lead to toxicity in the body including pH imbalance.

Question: Do you believe the nutritional supplement, creatine monohydrate, could negatively impact
the kidney?
Reply: In normal healthy training individuals, I believe that, based on the research, it is very safe and
effective. In non-training people with kidney disease, it may be a problem because it causes the
kidneys to work slightly harder to handle the creatinine byproduct load.

Question: What role do you believe creatine monohydrate may play in the progression of pre-
existing CKD or renal failure?
Reply: I'm not sure there is clear clinical evidence to suggest that creatine monohydrate
supplementation causes a progression of pre-existing CKD or renal failure. There is research
evidence to suggest otherwise, i.e. that it is safe. But theoretically, I can say I don't believe creatine
supplementation will make this disorder better.

Question: In CKD, where do you believe excess creatinine (and excess creatine) may exert its
potential negative influence?
Reply: Based on mechanism of action, I would think it would most likely effect the nephron.

Question: Do you believe that this supplement can or can not be used safely by someone with CKD
or ESRD?
Reply: I would not recommend it because there is just not enough research on this group safely using
it. It also depends if this group is training or not, since training allows creatine to be used much more
effectively.

Contact Information:
Rehan Jalali, President
Supplement Research Foundation
www.Tsrf.com
Interview with Dr. Kamen Stoychev, MD
Assistant Director -- Dr. I.S. Greenberg Medical Center

Questions: Could a chronic physiological excess of creatinine (generated from continual creatine
monohydrate use), pose a potential metabolic or renal burden to those with pre-existing renal
disease? AND:
Could a chronic physiological excess of said creatinine be involved in a worsening of pre-existing
kidney disease?

Reply: In order to understand the risks associated with high levels of creatinine in the blood, one
must first understand the role of creatinine, as an indicator of renal function, and its place in our
metabolism as a waste product. Its concentration in the blood is indicative of the kidneys health
(given that the individual is not ingesting excessive amounts of meat or creatine monohydrate for
months). Our creatinine level is maintained within physiologically normal limits due to the process of
filtration through the basal glomerular membrane. The glomeruls are the kidneys waste purification
plants. Filtration is a process, which does not require energy, and its speed is proportional to the
concentration of the waste product in the blood. However, its speed is limited by the permeability of
the basal membrane. In other words, if the level of creatinine in the blood exceeds certain values, the
basal membrane becomes inadequate as the only mechanism for eliminating creatinine from the body.
If this happens, a second mechanism is activated, which aids the kidney in its endeavor to eliminate
creatinine from the body. This mechanism is a type of active transport, since it requires energy, and it
is performed by another piece of equipment inside the kidney the so called proximal tubule. This
second mechanism activates as soon as the creatinine levels rise above certain values. The intake of
large amounts of proteins, or creatine monohydrate, for prolonged periods of time (three weeks or
more), can be the reason for a rise of creatinine levels in the blood. Another reason for such a rise
could be any one of a number of kidney diseases, any of which would cause a decrease in the ability
of the kidney to eliminate toxic waste products from the body. An especially dangerous combination
could be the intake of large quantities of creatine such as occurs in the consumption of an Atkins
diet (a heavy meat-rich diet), or excessive supplementation with creatine monohydrate, by someone
with an underlying kidney disease state involving the basal glomerular membrane (such as
collagenosis, IgA nephritis or nephritis). Often such conditions are silent for many years. Creatinine
overload due to diet, can act as the ultimate stress, trigger a decline which can lead to rapid renal
deterioration, proceeding all the way to renal failure and need for dialysis or kidney transplantation.
Another very common condition, especially among women, is the inflammation of the kidneys due to
microbial infections the so called nephritis. This nephritis often involves the tubules and can
cause tubular insufficiency. This, in combination with large dietary intakes of excessive creatine, can
also lead to renal failure. Just like with any other substance (including the very air we breath), the
intake of excessive amounts of creatine are toxic, and can cause harm, while the intake of
physiological amounts of creatine can be beneficial.

Contact Information:
Dr. Kamen Stoychev, MD, Assistant Director
Dr. I.S. Greenberg Medical Center
Sofia, Bulgaria
kamenst@techno-link.com
 Book Summary

Research is a never-ending process. If it teaches anything, its that any investigation into a substances
ultimate physiological impact is never simply open-and-shut. Any number of variables can influence
an outcome none or all of which may, or may not, be observed in man.

The generation of creatinine from creatine, and its elimination via the renal organ, is a normal
metabolic process not associated with any disease promoting conditions. As long as kidney function
is not compromised, this organ acts as a forgiving, dynamic regulator of many ingested,
manufactured, and/or internally modified substance the body requires to sustain its life. When kidney
function is seriously compromised (or fails), dynamic regulatory metabolic control is lost, allowing
abnormal manufacturing and build up of these same essential molecules effectively turning friend
into foe. Such is the case with creatine and creatinine.

Some of the short term effects of grossly elevated creatinine have been demonstrated in laboratory
animals and observed in humans with kidney failure, but the long-term impact of greatly elevated
creatinine remains largely unknown, and awaits further investigation.
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 Jeff Golini

Athlete, scientist, and entrepreneur, Jeff Golini founded the All American
Pharmaceutical & Natural Foods Corporation in 1984. Considered the founding
father of Near InfraRed (NIR) analysis in the nutraceutical world, Jeff also serves as
the Executive Research Scientist for a cutting-edge food and chemical analysis
laboratory. Among Jeffs achievements are, the discovery of the nitric oxide
amplifying agent AAKG (arginine alpha-ketoglutarate), and the development of Kre-
Alkalyn - the worlds first 100% stable creatine. All American Pharmaceutical is a
leading manufacturer of sports nutrition products and dietary supplements. Jeff is
regularly asked to consult within the pharmaceutical industry. He resides in the
beautiful state of Montana with his wife Kim, and their three children.