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102
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Słotwiński R, Słotwińska S, Kędziora S, Bałan BJ. Innate immunity signaling pathways: links between immunonutrition and responses to sepsis. Arch Immunol Ther Exp (Warsz) 2011; 59:139-50. [PMID: 21298487 DOI: 10.1007/s00005-011-0117-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 07/30/2010] [Indexed: 01/12/2023]
Abstract
Septic infections in patients treated in intensive care units show the highest mortality rates. Despite advances in treatment methods, there is still no therapy available to efficiently reduce the excessive inflammatory response, which can increase the risk of multiple organ failure. One of the ways to discover new, more efficient treatment methods involves regulating the mechanisms of inflammatory response to a massive infection. Toll-like receptors (TLRs) that recognize pathogen-associated molecular patterns play a significant role in innate antibacterial and inflammatory responses. The regulatory impact of immunonutrition on TLR expression in septic patients seems to be a promising research direction. This paper presents the main mechanisms for the innate immune response to lipopolysaccharide, based on the research results for both TLR-dependent and independent signaling pathways. Special emphasis was put on the research results for the TLR-dependent immune response and the anti-bacterial/anti-inflammatory response after applying immunonutrition with increased concentrations of glutamine and unsaturated fatty acids.
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Affiliation(s)
- Robert Słotwiński
- Department of Surgical Research and Transplantology, Polish Academy of Sciences Medical Research Center, Warsaw, Poland.
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103
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Cotogni P, Muzio G, Trombetta A, Ranieri VM, Canuto RA. Impact of the ω‐3 to ω‐6 Polyunsaturated Fatty Acid Ratio on Cytokine Release in Human Alveolar Cells. JPEN J Parenter Enteral Nutr 2011; 35:114-21. [DOI: 10.1177/0148607110372392] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Paolo Cotogni
- Department of Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Giuliana Muzio
- Department of Experimental Medicine and Oncology, University of Turin, Turin, Italy
| | - Antonella Trombetta
- Oncology and Hematology Laboratory, Department of Medicine, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - V. Marco Ranieri
- Department of Anesthesiology and Intensive Care, S. Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Rosa Angela Canuto
- Department of Experimental Medicine and Oncology, University of Turin, Turin, Italy
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104
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Stapleton RD, Martin JM, Mayer K. Fish oil in critical illness: mechanisms and clinical applications. Crit Care Clin 2010; 26:501-14, ix. [PMID: 20643303 DOI: 10.1016/j.ccc.2010.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fish oil is rich in omega-3 fatty acids, which have been shown to be beneficial in multiple disease states that involve an inflammatory process. It is now hypothesized that omega-3 fatty acids may decrease the inflammatory response and be beneficial in critical illness. After a review of the mechanisms of omega-3 fatty acids in inflammation, research using enteral nutrition formulas and parenteral nutrition lipid emulsions fortified with fish oil were examined. The results of this research to date are inconclusive for both enteral and parenteral omega-3 fatty acid administration. More research is required before definitive recommendations can be made on fish oil supplementation in critical illness.
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Affiliation(s)
- Renee D Stapleton
- Division of Pulmonary and Critical Care, Department of Medicine, University of Vermont College of Medicine, 149 Beaumont Avenue, HSRF 222, Burlington, VT 05405, USA.
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105
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Abstract
Supplementation of enteral nutritional formulas and parenteral nutrition lipid emulsions with omega-3 fatty acids is a recent area of research in patients with critical illness. It is hypothesized that omega-3 fatty acids may help reduce inflammation in critically ill patients, particularly those with sepsis and acute lung injury. The objective of this article is to review the data on supplementing omega-3 fatty acids during critical illness; enteral and parenteral supplemental nutrition are reviewed separately. The results of the research available to date are contradictory for both enteral and parenteral omega-3 fatty acid administration. Supplementation with omega-3 fatty acids may influence the acute inflammatory response in critically ill patients, but more research is needed before definitive recommendations about the routine use of omega-3 fatty acids in caring for critically ill patients can be made.
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Affiliation(s)
- Julie M Martin
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont 05405, USA
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106
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McCowen KC, Ling PR, Ollero M, Tawa N, Bistrian BR. Effect of a fish oil-containing beverage on changes in plasma lipid fatty acids in patients with malabsorption. Nutr Clin Pract 2010; 25:517-23. [PMID: 20962312 DOI: 10.1177/0884533610379815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this pilot study was to assess tolerance of a beverage containing ω-3 fatty acids (fish oil) in patients with malabsorption receiving chronic parenteral nutrition (PN). The authors wanted to determine whether fish oil could be absorbed and incorporated into plasma fatty acids and reduce markers of inflammation. METHODS This was a small intervention study in home-dwelling PN-dependent patients with chronic malabsorption. Ten patients were provided a drink containing 1.5 g of fish oil per day for 12 weeks. Baseline and post-supplement serum fatty acid profiles were compared. RESULTS Five of 10 patients withdrew from the study because of GI side effects, principally worsened diarrhea, associated with the supplement. Modest increases were found in 20:5ω-3, 22:5ω-3, and 22:6ω-3 levels in both phospholipids and triglycerides in plasma (all P < .05). In phospholipids, a reduced arachidonic acid level was seen (P = .02). These changes were not sufficient to effect improvements in serum tumor necrosis factor-alpha (TNFα), soluble TNF receptor, C-reactive protein, or interleukin-6. CONCLUSIONS Some patients with severe malabsorption can absorb oral ω-3 fatty acid supplements and incorporate these fatty acids into serum phospholipids and triglycerides. However, side effects are very common, and no anti-inflammatory effect was found, presumably related to the modest level of fatty acid change.
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107
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Goulet O, Antébi H, Wolf C, Talbotec C, Alcindor LG, Corriol O, Lamor M, Colomb-Jung V. A New Intravenous Fat Emulsion Containing Soybean Oil, Medium-Chain Triglycerides, Olive Oil, and Fish Oil. JPEN J Parenter Enteral Nutr 2010; 34:485-95. [DOI: 10.1177/0148607110363614] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition and National Reference Center for Rare Digestive Diseases, Hôpital des Enfants Malades, University of Paris 5, René Descartes
| | | | - Claude Wolf
- Service de Biochimie, Hôpital Saint Antoine, Paris
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition and National Reference Center for Rare Digestive Diseases, Hôpital des Enfants Malades, University of Paris 5, René Descartes
| | | | - Odile Corriol
- Hospital Pharmacy, Hôpital des Enfants Malades, University of Paris 5 René Descartes
| | - Michèle Lamor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition and National Reference Center for Rare Digestive Diseases, Hôpital des Enfants Malades, University of Paris 5, René Descartes
| | - Virginie Colomb-Jung
- Department of Pediatric Gastroenterology, Hepatology and Nutrition and National Reference Center for Rare Digestive Diseases, Hôpital des Enfants Malades, University of Paris 5, René Descartes
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108
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Jiang ZM, Wilmore DW, Wang XR, Wei JM, Zhang ZT, Gu ZY, Wang S, Han SM, Jiang H, Yu K. Randomized clinical trial of intravenous soybean oil alone versus soybean oil plus fish oil emulsion after gastrointestinal cancer surgery. Br J Surg 2010; 97:804-9. [PMID: 20473991 DOI: 10.1002/bjs.6999] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Specific immunonutrients may reduce the incidence of postoperative complications and shorten recovery time. This randomized trial evaluated the clinical efficacy of a fish oil emulsion on outcome and immune function after gastrointestinal cancer surgery. METHODS A total of 206 patients with gastrointestinal or colonic cancer were randomized to receive isocaloric and isonitrogenous intravenous infusions of either soybean oil alone (1.2 g per kg bodyweight per day; control group, 103 analysed) or soybean plus fish oil emulsion (1.0 and 0.2 g per kg per day respectively; treatment group, 100 analysed) over 20-24 h daily for 7 days after surgery. RESULTS Baseline data were comparable in the two groups. There were fewer infectious complications (four versus 12 on day 8; P = 0.066), systemic inflammatory response syndrome (SIRS) was significantly less common (four versus 13; P = 0.039) and hospital stay was significantly shorter (mean(s.d.) 15(5) versus 17(8) days; P = 0.041) in the treatment group. Total postoperative medical costs were comparable in the two groups (mean(s.d.) US $ 1269(254) and 1302(324) in treatment and control groups respectively; P = 0.424). The median (interquartile range) difference in CD4/CD8 between days 1 and 8 after surgery was + 0.30 (0.06 to 0.79) in patients receiving fish oil and + 0.20 (-0.19 to 0.55) in controls (P = 0.021). No severe adverse events occurred in either group. CONCLUSION Fish oil emulsion-supplemented parenteral nutrition significantly reduced SIRS and length of hospital stay. These clinical benefits may be related to normalization of cellular immune functions and modulation of the inflammatory response.
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Affiliation(s)
- Z M Jiang
- Department of Surgery and Parenteral and Enteral Nutrition, and Centre for Parenteral and Enteral Nutrition, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences.
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Hagi A, Nakayama M, Shinzaki W, Haji S, Ohyanagi H. Effects of the ω-6:ω-3 Fatty Acid Ratio of Fat Emulsions on the Fatty Acid Composition in Cell Membranes and the Anti-Inflammatory Action. JPEN J Parenter Enteral Nutr 2010; 34:263-70. [DOI: 10.1177/0148607109357625] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Akifumi Hagi
- R&D Center, Otsuka Pharmaceutical Factory, Inc, Tokushima, Japan
| | - Mitsuo Nakayama
- R&D Center, Otsuka Pharmaceutical Factory, Inc, Tokushima, Japan
| | - Wataru Shinzaki
- Department of Surgery, Kinki University School of Medicine, Osaka, Japan
| | - Seiji Haji
- Department of Surgery, Kinki University School of Medicine, Osaka, Japan
| | - Harumasa Ohyanagi
- Department of Surgery, Kinki University School of Medicine, Osaka, Japan
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110
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The 2008 ESPEN Sir David Cuthbertson Lecture: Fatty acids and inflammation--from the membrane to the nucleus and from the laboratory bench to the clinic. Clin Nutr 2010; 29:5-12. [PMID: 19931231 DOI: 10.1016/j.clnu.2009.11.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 09/02/2009] [Accepted: 11/04/2009] [Indexed: 11/21/2022]
Abstract
Many chronic conditions involve excessive inflammation that is damaging to host tissues. Excessive or inappropriate inflammation and immunosuppression are components of the response to surgery, trauma, injury and infection in some individuals and these can lead, progressively, to sepsis and septic shock. Hyperinflammation is characterised by the production of inflammatory cytokines, eicosanoids and other inflammatory mediators, while the immunosuppression is characterised by impairment of antigen presentation and of certain T cell responses. N-6 fatty acids may contribute to the hyperinflamed and immunosuppressed states. N-3 fatty acids from fish oil decrease the production of inflammatory cytokines and eicosanoids. They act both directly (by replacing arachidonic acid as an eicosanoid precursor) and indirectly (by altering the expression of inflammatory genes through effects on transcription factor activation). Thus, these fatty acids are potentially useful anti-inflammatory agents and may be of benefit in patients with chronic inflammatory diseases or at risk of hyperinflammation and sepsis. An emerging application of n-3 fatty acids is in surgical or critically ill patients where they may be added to parenteral or enteral formulas. Studies to date are suggestive of clinical benefits from these approaches, although more robust data are needed especially in critically ill patients.
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111
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Abstract
Lipids traditionally used in artificial nutrition are based on n-6 fatty acid-rich vegetable oils like soyabean oil. This may not be optimal because it may present an excessive supply of linoleic acid. One alternative to the use of soyabean oil is its partial replacement by fish oil, which contains n-3 fatty acids. These fatty acids influence inflammatory and immune responses and so may be useful in particular situations where those responses are not optimal. Fish oil-containing lipid emulsions have been used in parenteral nutrition in adult patients post-surgery (mainly gastrointestinal). This has been associated with alterations in patterns of inflammatory mediators and in immune function and, in some studies, a reduction in length of intensive care unit (ICU) and hospital stay. Perioperative administration of fish oil may be superior to post-operative. Parenteral fish oil has been used in critically ill adults. Here the influence on inflammatory processes, immune function and clinical endpoints is not clear, since there are too few studies and those that are available report contradictory findings. Fish oil is included in combination with other nutrients in various enteral formulas. In post-surgical patients and in those with mild sepsis or trauma, there is clinical benefit from a formula including fish oil and arginine. A formula including fish oil, borage oil and antioxidants has demonstrated marked benefits on gas exchange, ventilation requirement, new organ failures, ICU stay and mortality in patients with acute respiratory distress syndrome, acute lung injury or severe sepsis.
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112
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Mayer K, Seeger W. Fish oil-containing lipid emulsions in patients with sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:128. [PMID: 20236465 PMCID: PMC2887116 DOI: 10.1186/cc8882] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lipid emulsions based on soybean oil have been an integral part of parenteral nutrition supplying n-6 fatty acids, with possible negative effects in critically ill patients. Newer lipid emulsions supply less n-6 fatty acids. In addition, fish oil-based lipids may be included in the lipid component of parenteral nutrition. While clinical benefits of lipid emulsions with a reduced fraction in n-6 lipids and the addition of fish oil have been described in postoperative patients, data are less clear in critically ill or septic patients. Recent data suggest that beneficial effects may be achieved when used early but clearly more data are needed to come to a definitive conclusion. The present commentary will highlight current data in critically ill and septic patients and the use of fish oil as a part of parenteral nutrition.
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Affiliation(s)
- Konstantin Mayer
- University of Giessen Lung Center, Medical Clinic II, Justus-Liebig-University Giessen, Klinikstrasse 36, Giessen, Germany.
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113
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INDUCTION OF LYMPHOCYTE APOPTOSIS IN A MURINE MODEL OF ACUTE LUNG INJURY-MODULATION BY LIPID EMULSIONS. Shock 2010; 33:179-88. [DOI: 10.1097/shk.0b013e3181ac4b3b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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114
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Barbosa VM, Miles EA, Calhau C, Lafuente E, Calder PC. Effects of a fish oil containing lipid emulsion on plasma phospholipid fatty acids, inflammatory markers, and clinical outcomes in septic patients: a randomized, controlled clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R5. [PMID: 20085628 PMCID: PMC2875515 DOI: 10.1186/cc8844] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 11/06/2009] [Accepted: 01/19/2010] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The effect of parenteral fish oil in septic patients is not widely studied. This study investigated the effects of parenteral fish oil on plasma phospholipid fatty acids, inflammatory mediators, and clinical outcomes. METHODS Twenty-five patients with systemic inflammatory response syndrome or sepsis, and predicted to need parenteral nutrition were randomized to receive either a 50:50 mixture of medium-chain fatty acids and soybean oil or a 50:40:10 mixture of medium-chain fatty acids, soybean oil and fish oil. Parenteral nutrition was administrated continuously for five days from admission. Cytokines and eicosanoids were measured in plasma and in lipopolysaccharide-stimulated whole blood culture supernatants. Fatty acids were measured in plasma phosphatidylcholine. RESULTS Fish oil increased eicosapentaenoic acid in plasma phosphatidylcholine (P < 0.001). Plasma interleukin (IL)-6 concentration decreased significantly more, and IL-10 significantly less, in the fish oil group (both P < 0.001). At Day 6 the ratio PO2/FiO2 was significantly higher in the fish oil group (P = 0.047) and there were fewer patients with PO2/FiO2 <200 and <300 in the fish oil group (P = 0.001 and P = 0.015, respectively). Days of ventilation, length of intensive care unit (ICU) stay and mortality were not different between the two groups. The fish oil group tended to have a shorter length of hospital stay (22 +/- 7 vs. 55 +/- 16 days; P = 0.079) which became significant (28 +/- 9 vs. 82 +/- 19 days; P = 0.044) when only surviving patients were included. CONCLUSIONS Inclusion of fish oil in parenteral nutrition provided to septic ICU patients increases plasma eicosapentaenoic acid, modifies inflammatory cytokine concentrations and improves gas exchange. These changes are associated with a tendency towards shorter length of hospital stay. TRIALS REGISTRATION Clinical Trials Registration Number ISRCTN89432944.
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Affiliation(s)
- Vera M Barbosa
- Institute of Human Nutrition, School of Medicine, University of Southampton, IDS Building, MP887 Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
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115
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Calder PC, Jensen GL, Koletzko BV, Singer P, Wanten GJA. Lipid emulsions in parenteral nutrition of intensive care patients: current thinking and future directions. Intensive Care Med 2010; 36:735-49. [PMID: 20072779 PMCID: PMC2850535 DOI: 10.1007/s00134-009-1744-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 12/28/2009] [Indexed: 12/12/2022]
Abstract
Background Energy deficit is a common and serious problem in intensive care units and is associated with increased rates of complications, length of stay, and mortality. Parenteral nutrition (PN), either alone or in combination with enteral nutrition, can improve nutrient delivery to critically ill patients. Lipids provide a key source of calories within PN formulations, preventing or correcting energy deficits and improving outcomes. Discussion In this article, we review the role of parenteral lipid emulsions (LEs) in the management of critically ill patients and highlight important biologic activities associated with lipids. Soybean-oil-based LEs with high contents of polyunsaturated fatty acids (PUFA) were the first widely used formulations in the intensive care setting. However, they may be associated with increased rates of infection and lipid peroxidation, which can exacerbate oxidative stress. More recently developed parenteral LEs employ partial substitution of soybean oil with oils providing medium-chain triglycerides, ω-9 monounsaturated fatty acids or ω-3 PUFA. Many of these LEs have demonstrated reduced effects on oxidative stress, immune responses, and inflammation. However, the effects of these LEs on clinical outcomes have not been extensively evaluated. Conclusions Ongoing research using adequately designed and well-controlled studies that characterize the biologic properties of LEs should assist clinicians in selecting LEs within the critical care setting. Prescription of PN containing LEs should be based on available clinical data, while considering the individual patient’s physiologic profile and therapeutic requirements.
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Affiliation(s)
- Philip C Calder
- Institute of Human Nutrition, University of Southampton, Southampton, UK.
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116
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Felekis D, Eleftheriadou A, Papadakos G, Bosinakou I, Ferekidou E, Kandiloros D, Katsaragakis S, Charalabopoulos K, Manolopoulos L. Effect of perioperative immuno-enhanced enteral nutrition on inflammatory response, nutritional status, and outcomes in head and neck cancer patients undergoing major surgery. Nutr Cancer 2010; 62:1105-12. [PMID: 21058198 DOI: 10.1080/01635581.2010.494336] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Administration of immuno-enhanced nutritional support may decrease postoperative morbidity, mortality, and infectious complications in cancer patients. The aim of this study was to verify that perioperative enteral diet, enriched with the nutrients arginine, ribonucleic acid (RNA), and ω-3 fatty acids improves outcomes of head and neck cancer patients undergoing major surgery. Forty patients with squamous cell carcinoma of the head and neck were studied. Group 1 received no preoperative nutritional support, whereas Group 2 received an oral formula with nutrients arginine, RNA, and ω-3 fatty acids. After surgery, Group 1 received a standard enteral formula, whereas Group 2 received an enriched enteral formula. Albumin (g/dl), prealbumin, fibrinogen, CRP, Il-6, and TNFa were measured 5 days before and 8 days after surgery. No statistically significant difference was observed for all the evaluated markers between postoperative and preoperative levels for both groups. The rate of complications was significantly reduced in the total number of patients receiving immunonutrition and in the particular subgroup of well-nourished patients receiving an immuno-enhanced diet. Perioperative enteral immuno-enhanced feeding in head and neck cancer patients undergoing major surgery may influence the postoperative outcomes by reducing the frequency rate of infections and wound complications.
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Affiliation(s)
- Dimitrios Felekis
- Medical School, University of Athens, Hippokration Hospital, Athens, Greece
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117
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Diamond IR, Pencharz PB, Wales PW. Omega-3 lipids for intestinal failure associated liver disease. Semin Pediatr Surg 2009; 18:239-45. [PMID: 19782305 DOI: 10.1053/j.sempedsurg.2009.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intestinal failure associated liver disease (IFALD) is one of the most common and devastating complications in infants with intestinal failure. Although multifactorial, its pathophysiology is clearly related to the administration of parenteral nutrition (PN), with a recent focus on the role of PN lipid emulsions. This paper will review the evidence for the use of omega-3 fatty acid PN lipid emulsions, which are proposed to have efficacy in the treatment of IFALD. Mechanisms explaining their effects will be considered as will future research directions.
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Affiliation(s)
- Ivan R Diamond
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
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118
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Szklarek-Kubicka M, Fijałkowska-Morawska J, Zaremba-Drobnik D, Uciński A, Czekalski S, Nowicki M. Effect of Intradialytic Intravenous Administration of ω-3 Fatty Acids on Nutritional Status and Inflammatory Response in Hemodialysis Patients: A Pilot Study. J Ren Nutr 2009; 19:487-93. [DOI: 10.1053/j.jrn.2009.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Indexed: 01/12/2023] Open
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119
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Fetterman JW, Zdanowicz MM. Therapeutic potential of n-3 polyunsaturated fatty acids in disease. Am J Health Syst Pharm 2009; 66:1169-79. [PMID: 19535655 DOI: 10.2146/ajhp080411] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The potential therapeutic benefits of supplementation with n-3 polyunsaturated fatty acids (PUFAs) in various diseases are reviewed, and the antiinflammatory actions, activity, and potential drug interactions and adverse effects of n-3 PUFAs are discussed. SUMMARY Fish oils are an excellent source of long-chain n-3 PUFAs, such as eicosapentaenoic acid and docosahexaenoic acid. After consumption, n-3 PUFAs can be incorporated into cell membranes and reduce the amount of arachidonic acid available for the synthesis of proinflammatory eicosanoids (e.g., prostaglandins, leukotrienes). Likewise, n-3 PUFAs can also reduce the production of inflammatory cytokines, such as tumor necrosis factor alpha, interleukin-1, and interleukin-6. Considerable research has been conducted to evaluate the potential therapeutic effects of fish oils in numerous conditions, including arthritis, coronary artery disease, inflammatory bowel disease, asthma, and sepsis, all of which have inflammation as a key component of their pathology. Additional investigations into the use of supplementation with fish oils in patients with neural injury, cancer, ocular diseases, and critical illness have recently been conducted. The most commonly reported adverse effects of fish oil supplements are a fishy aftertaste and gastrointestinal upset. When recommending an n-3 PUFA, clinicians should be aware of any possible adverse effect or drug interaction that, although not necessarily clinically significant, may occur, especially for patients who may be susceptible to increased bleeding (e.g., patients taking warfarin). CONCLUSION The n-3 PUFAs have been shown to be efficacious in treating and preventing various diseases. The wide variation in dosages and formulations used in studies makes it difficult to recommend dosages for specific treatment goals.
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Affiliation(s)
- James W Fetterman
- Department of Pharmaceutical Sciences, School of Pharmacy, South University, Savannah, GA 31406, USA.
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120
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Waitzberg DL, Torrinhas RS. Fish Oil Lipid Emulsions and Immune Response: What Clinicians Need to Know. Nutr Clin Pract 2009; 24:487-99. [PMID: 19605803 DOI: 10.1177/0884533609339071] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Dan Linetzky Waitzberg
- From the Laboratory of Nutrition and Metabolic Surgery of the Digestive System, Gastroenterology Department, University of São Paulo Medical School, Brazil
| | - Raquel Susana Torrinhas
- From the Laboratory of Nutrition and Metabolic Surgery of the Digestive System, Gastroenterology Department, University of São Paulo Medical School, Brazil
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Abstract
PURPOSE OF REVIEW Chronic heart failure (CHF) is increasingly recognized as a multisystem disease with important comorbidities such as anemia, insulin resistance, autonomic dysbalance, or cardiac cachexia. RECENT FINDINGS Apart from these perturbations, increasing evidence points to alterations in intestinal morphology, permeability, and absorption function in patients with CHF. This review provides an overview of the sonographic, histological, and functional abnormalities of different gastrointestinal regions. This intestinal dysfunction and disturbed intestinal barrier may lead to both the chronic inflammatory state and catabolic/anabolic imbalance as seen in cardiac cachexia, as a terminal stage of CHF, which carries a particularly poor prognosis. This review highlights the current knowledge of nutritional abnormalities that may occur in CHF, including fat, carbohydrates, proteins, water, and micronutrients. The regulation of feeding is discussed, as are nutritional strategies with potentially anti-inflammatory effects in the treatment of CHF. SUMMARY The gut and its role for inflammation and dietary interventions in heart failure patients are a crucial target of further heart failure research.
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Affiliation(s)
- Anja Sandek
- Applied Cachexia Research, Department of Cardiology, Charité Medical School, Berlin, Germany.
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122
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ESPEN Guidelines on Parenteral Nutrition: hepatology. Clin Nutr 2009; 28:436-44. [PMID: 19520466 DOI: 10.1016/j.clnu.2009.04.019] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/27/2009] [Indexed: 12/13/2022]
Abstract
Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors' criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.
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Rationale for using new lipid emulsions in parenteral nutrition and a review of the trials performed in adults. Proc Nutr Soc 2009; 68:252-60. [DOI: 10.1017/s0029665109001268] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lipids traditionally used in parenteral nutrition are based on n-6 fatty acid-rich vegetable oils such as soyabean oil. This practice may not be optimal because it may present an excessive supply of linoleic acid. Alternatives to the use of soyabean oil include its partial replacement by so-called medium-chain TAG (MCT), olive oil or fish oil, either alone or in combination. Lipid emulsions containing MCT are well established, but those containing olive oil and fish oil, although commercially available, are still undergoing trials in different patient groups. Emulsions containing olive oil or fish oil are well tolerated and without adverse effects in a wide range of adult patients. An olive oil–soyabean oil emulsion has been used in quite small studies in critically-ill patients and in patients with trauma or burns with little real evidence of advantage over soyabean oil or MCT–soyabean oil. Fish oil-containing lipid emulsions have been used in adult patients post surgery (mainly gastrointestinal). This approach has been associated with alterations in patterns of inflammatory mediators and in immune function and, in some studies, a reduction in the length of stay in the intensive care unit and in hospital. One study indicates that peri-operative administration of fish oil may be superior to post-operative administration. Fish oil has been used in critically-ill adults. Here, the influence on inflammatory processes, immune function and clinical end points is not clear, since there are too few studies and those that are available report contradictory findings. One important factor is the dose of fish oil required to influence clinical outcomes. Further studies that are properly designed and adequately powered are required in order to strengthen the evidence base relating to the use of lipid emulsions that include olive oil and fish oil in critically-ill patients and in patients post surgery.
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Early inhibition of prostaglandin synthesis by n-3 fatty acids determinates histologic severity of necrotizing pancreatitis. Pancreas 2009; 38:436-41. [PMID: 19295455 DOI: 10.1097/mpa.0b013e318198283b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previously, we observed decreased histopathological severity of acute necrotizing pancreatitis (ANP) by parenteral nutrition with n-3 fatty acids. Thus, we now sequentially analyzed the impact of n-3 fatty acids on prostaglandin and leukotriene synthesis in ANP. METHODS One hundred ninety-eight Sprague-Dawley rats (11 groups, n = 18) underwent intraductal glycodesoxycholat instillation and 6-hour cerulein infusion. Afterward, saline was infused in groups 2, 4, 6, 8, and 10, whereas groups 3, 5, 7, 9, and 11 received infusion rich in n-3 fatty acids (Omegaven, Fresenius Kabi, Bad Homburg, Germany). Animals were killed after 6 (group 1), 10 (groups 2 and 3), 14 (groups 4 and 5), 18 (groups 6 and 7), 22 (groups 8 and 9), and 26 hours (groups 10 and 11). The pancreas was histopathologically examined, and the pancreatic eicosanoid metabolism (prostaglandin E2, prostaglandin F1alpha [PGF1alpha], and leukotrienes) and lipid peroxidation (thiobarbituric acid-reactive substance, superoxide dismutase, and glutathione peroxidase) were analyzed. RESULTS Between the 14th and 26th hours, histopathologic scores (edema, inflammation, bleeding, and necrosis) were reduced in the n-3 fatty acid group compared with the corresponding saline group. Pancreatic prostaglandin E2 and PGF1alpha were decreased between the 10th and 18th hour by n-3 fatty acids; PGF1alpha was reduced after 26 hours compared with the corresponding saline group. Lipid peroxidation was decreased by n-3 fatty acids after 14 hours (thiobarbituric acid-reactive substance); however, there was no difference concerning lipid peroxidation protective enzymes (glutathione peroxidase and superoxide dismutase). CONCLUSIONS Parenteral therapy with n-3 fatty acids decreased histopathologic severity in ANP by early inhibition of prostaglandin (E2 and F1alpha) synthesis and reduction of lipid peroxidation.
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Mayer K, Kiessling A, Ott J, Schaefer MB, Hecker M, Henneke I, Schulz R, Günther A, Wang J, Wu L, Roth J, Seeger W, Kang JX. Acute lung injury is reduced in fat-1 mice endogenously synthesizing n-3 fatty acids. Am J Respir Crit Care Med 2009; 179:474-83. [PMID: 19136374 DOI: 10.1164/rccm.200807-1064oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Acute lung injury (ALI) remains an important cause of mortality in intensive care units. Inflammation is controlled by cytokines and eicosanoids derived from the n-6 fatty acid (FA) arachidonic acid (AA). The n-3 FA eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and mediators derived from EPA and DHA possess reduced inflammatory potency. OBJECTIVES To determine whether the ability of fat-1 mice to endogenously convert n-6 to n-3 FA, and thus generate an increased ratio of n-3 to n-6 FA, impacts experimental ALI. METHODS We investigated ALI induced by intratracheal instillation of endotoxin in fat-1 and wild-type (WT) mice, assessing leukocyte numbers, protein concentration, and prostaglandin and cytokine levels in bronchoalveolar lavage fluid, as well as free FA in plasma, and lung ventilator compliance. Body temperature and motor activity of mice--markers of sickness behavior--were also recorded. MEASUREMENTS AND MAIN RESULTS In ALI, fat-1 mice exhibited significantly reduced leukocyte invasion, protein leakage, and macrophage inflammatory protein-2 and thromboxane B(2) levels in lavage fluid compared with WT mice. Free AA levels were increased in the plasma of WT mice in response to endotoxin, whereas EPA and DHA were increased in the fat-1 group. Ventilator compliance was significantly improved in fat-1 mice. Body temperature and motor activity were decreased in ALI. fat-1 Mice recovered body temperature and motor activity faster. CONCLUSIONS fat-1 Mice exhibited reduced features of ALI and sickness behavior. Increasing the availability of n-3 FA may thus be beneficial in critically ill patients with ALI.
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Affiliation(s)
- Konstantin Mayer
- University of Giessen Lung Center (UGLC), Medical Clinic II, Justus-Liebig-University Giessen, Klinikstr. 36, D-35392 Giessen, Germany.
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Gottrand F. Long-chain polyunsaturated fatty acids influence the immune system of infants. J Nutr 2008; 138:1807S-1812S. [PMID: 18716191 DOI: 10.1093/jn/138.9.1807s] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Several events occur during the first months of life that allow the immune system to become competent and functional. The aim of this article is to review the rationale and evidence of an influence of (n-3) long-chain PUFA (LCPUFA) on the immune system of infants. The (n-3) LCPUFA exert their immunomodulatory activities at different levels. The (n-3) LCPUFA metabolites induce eicosanoid production, alter gene expression, and modify lipid raft composition, altering T-cell signaling; all contribute to immunological functional changes. However, the roles of these mechanisms and the types of T or other immunological cells involved remain unclear at present. Moreover, the effect of (n-3) LCPUFA on the immune system of infants may vary according to dose, time of exposure, and profile of the immune system (T-helper, Th1/Th2). Most of the interventional studies in infancy have been performed for the prevention of allergy. They all confirmed influence on T-cell function and cytokine profiles, but clinically beneficial effects are more conflicting. Supplementation of the maternal diet in pregnancy or early childhood with (n-3) LCPUFA is potentially a noninvasive intervention strategy to prevent the development of allergy, infection, and possibly other immune-mediated diseases. However, any long-term in vivo effects on (n-3) LCPUFA early in life for immunomodulatory defense in infants and later on immune status and health remain to be assessed.
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Affiliation(s)
- Frédéric Gottrand
- EA 3925, IFR 114, Faculty of Medicine and University of Lille 2, Lille, France.
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Friesecke S, Lotze C, Köhler J, Heinrich A, Felix SB, Abel P. Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomised controlled trial. Intensive Care Med 2008; 34:1411-20. [PMID: 18357434 DOI: 10.1007/s00134-008-1072-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Accepted: 02/21/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To test whether supplementation of parenteral nutrition with fish oil - aimed at increasing the n-3:n-6 ratio of polyunsaturated fatty acids (PUFA) to 1:2 - affects systemic inflammation and clinical outcome compared to standard parenteral nutrition with an n-3/n-6 ratio of 1:7 in medical intensive care unit (ICU) patients. DESIGN Single-centre, placebo-controlled, double-blind, randomised clinical trial. SETTING Twelve-bed medical ICU of a university hospital. PATIENTS A total of 166 consecutive patients anticipated to need parenteral nutrition for more than 6 days. Patients were stratified for the presence of systemic inflammatory response syndrome (SIRS) at baseline (115 SIRS, 51 non-SIRS). INTERVENTION Patients were randomly assigned to receive either a 1:1-mixture of medium-chain triglycerides (MCT) and long-chain triglycerides (LCT) with an n-3/n-6 PUFA ratio of 1:7, or the same MCT/LCT emulsion supplemented with fish oil (resulting in an n-3/n-6 ratio of 1:2). MEASUREMENTS AND RESULTS Primary endpoints were changes in interleukin 6 (IL-6) and monocyte HLA-DR expression relative to baseline. Secondary endpoints were incidence of nosocomial infections, duration of mechanical ventilation, length of ICU stay, and 28-day mortality. Bleeding complications were recorded as a possible side effect of fish oil. Between standard and intervention groups, overall as well as stratified for SIRS or non-SIRS, no significant difference was detected in any of the endpoints or frequency and severity of bleeding events. CONCLUSIONS In unselected critically ill medical patients, fish oil supplementation that increased the n-3/n-6 PUFA ratio to 1:2 did not affect inflammation or clinical outcome, compared to parenteral lipid nutrition with an MCT/LCT emulsion.
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Affiliation(s)
- Sigrun Friesecke
- Department of Internal Medicine, Ernst Moritz Arndt University of Greifswald, 17475, Greifswald, Germany.
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Gawecka A, Michalkiewicz J, Kornacka MK, Luckiewicz B, Kubiszewska I. Immunologic Properties Differ in Preterm Infants Fed Olive Oil vs Soy-Based Lipid Emulsions During Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2008; 32:448-53. [DOI: 10.1177/0148607108319802] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Agnieszka Gawecka
- From the Department of Neonatology, Medical Academy, Warsaw, Poland; the Pediatric Intensive Care Unit, Medical Academy Children's Hospital, Warsaw, Poland; the Immunology and Microbiology Department, The Children's Memorial Health Institute, Warsaw, Poland; the Hospital Pharmacy of Princess Anna Mazowiecka Hospital, Warsaw, Poland; and the Immunology Department, Rydygiers's Medical Academy, Bydgoszcz, Poland
| | - Jacek Michalkiewicz
- From the Department of Neonatology, Medical Academy, Warsaw, Poland; the Pediatric Intensive Care Unit, Medical Academy Children's Hospital, Warsaw, Poland; the Immunology and Microbiology Department, The Children's Memorial Health Institute, Warsaw, Poland; the Hospital Pharmacy of Princess Anna Mazowiecka Hospital, Warsaw, Poland; and the Immunology Department, Rydygiers's Medical Academy, Bydgoszcz, Poland
| | - Maria Katarzyna Kornacka
- From the Department of Neonatology, Medical Academy, Warsaw, Poland; the Pediatric Intensive Care Unit, Medical Academy Children's Hospital, Warsaw, Poland; the Immunology and Microbiology Department, The Children's Memorial Health Institute, Warsaw, Poland; the Hospital Pharmacy of Princess Anna Mazowiecka Hospital, Warsaw, Poland; and the Immunology Department, Rydygiers's Medical Academy, Bydgoszcz, Poland
| | - Barbara Luckiewicz
- From the Department of Neonatology, Medical Academy, Warsaw, Poland; the Pediatric Intensive Care Unit, Medical Academy Children's Hospital, Warsaw, Poland; the Immunology and Microbiology Department, The Children's Memorial Health Institute, Warsaw, Poland; the Hospital Pharmacy of Princess Anna Mazowiecka Hospital, Warsaw, Poland; and the Immunology Department, Rydygiers's Medical Academy, Bydgoszcz, Poland
| | - Iza Kubiszewska
- From the Department of Neonatology, Medical Academy, Warsaw, Poland; the Pediatric Intensive Care Unit, Medical Academy Children's Hospital, Warsaw, Poland; the Immunology and Microbiology Department, The Children's Memorial Health Institute, Warsaw, Poland; the Hospital Pharmacy of Princess Anna Mazowiecka Hospital, Warsaw, Poland; and the Immunology Department, Rydygiers's Medical Academy, Bydgoszcz, Poland
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Singer P, Shapiro H, Theilla M, Anbar R, Singer J, Cohen J. Anti-inflammatory properties of omega-3 fatty acids in critical illness: novel mechanisms and an integrative perspective. Intensive Care Med 2008; 34:1580-92. [PMID: 18461305 DOI: 10.1007/s00134-008-1142-4] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Accepted: 04/19/2008] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Fish oil-based nutrition is protective in severe critical care conditions. Regulation of the activity of transcription factor NF-kappaB is an important therapeutic effect of the major omega-3 fatty acids in fish oil, eicosapentaenoic and docosahexaenoic acid (EPA and DHA). METHODS AND RESULTS Using the articles obtained by a Pubmed research, this article reviews three aspects of NF-kappaB/inflammatory inhibition by fish oil. (1) Inhibition of the NF-kappaB pathway at several subsequent steps: extracellular, free omega-3 inhibits the activation of the Toll-like receptor 4 by endotoxin and free saturated fatty acids. In addition, EPA/DHA blocks the signaling cascade between Toll-like/cytokine receptors and the activator of NF-kappaB, IKK. Oxidized omega-3 also interferes with the initiation of transcription by NF-kappaB. (2) The altered profile of lipid mediators generated during inflammation, with production of the newly identified, DHA-derived inflammation-resolving mediator classes (in addition to the formation of less pro-inflammatory eicosanoids from EPA). Resolvin D1 and Protectin D1 are potent, endogenous, DHA-derived lipid mediators that attenuate neutrophil migration and tissue injury in peritonitis and ischemia-reperfusion injury. Their production is increased in the later stages of an inflammatory response, at which time they enhance the removal of neutrophils. (3) Modulation of vagal tone with potential anti-inflammatory effects: vagal fibers innervating the viscera down-regulate inflammation by activating nicotinic receptors upon infiltrating and resident macrophages. Stimulation of the efferent vagus is therapeutic in experimental septic shock. Fish oil supplementation increases vagal tone following myocardial infarction and in experimental human endotoxinemia. CONCLUSION It remains to be shown whether these pleiotropic actions of EPA/DHA contribute to fish oil's therapeutic effect in sepsis.
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Affiliation(s)
- Pierre Singer
- Department of General Intensive Care, Institute for Nutrition Research, Petach Tikva, Israel.
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McCarthy MS, Fabling J, Martindale R, Meyer SA. Nutrition support of the traumatically injured warfighter. Crit Care Nurs Clin North Am 2008; 20:59-65, vi-vii. [PMID: 18206585 DOI: 10.1016/j.ccell.2007.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Major trauma induces metabolic alterations that contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. Nutrition modulation of cellular processes has evolved into a high-priority therapy, backed by substantial scientific evidence. The appropriate selection, timing, and dose of nutrients required for metabolic resuscitation must be individualized and goal directed. Ideally, the nutritional interventions for warfighters will be developed strategically based on the extent of injuries and underlying deficiencies and will be designed to provide the nutrients necessary to balance hypermetabolic processes, heal wounds, and promote optimal recovery.
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Affiliation(s)
- Mary S McCarthy
- Madigan Army Medical Center, ATTN: MCHJ-CON-NR, Tacoma, WA 98431, USA.
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Abstract
PURPOSE OF REVIEW The aim of this review is to discuss recent advances in the role of n-3 lipids derived from fish oil in clinical nutrition in an intensive care setting. RECENT FINDINGS Fish oil supplies n-3 fatty acids which compete with arachidonic acid (n-6) for the conversion to lipid mediators, influence lipid-bound second messenger generation and dependent cellular functions, and are a source for resolvins necessary for the resolution of inflammation. Enteral nutrition with n-3 fatty acids improved ventilation time in patients with acute lung injury and in one study reduced mortality in septic patients. Using a high-dose short-term infusion of fish oil-based lipid emulsion, rapid immunologic changes and effects on the endotoxin-induced stress response may be achieved. Inclusion of n-3 fatty acids in parenteral nutrition improved immunologic parameters and length of stay in surgical patients. SUMMARY Inclusion of fish oil in nutrition may influence the immune response and clinical outcomes by balancing the negative effects of n-6 fatty acids. Application as a part of enteral immunonutrition in surgical or acute respiratory distress syndrome patients and in lipid emulsions in surgical patients has beneficial effects. In septic patients, data on enteral use are highly controversial. Prospective data from randomized trials, however, are lacking.
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Affiliation(s)
- Konstantin Mayer
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, Justus Liebig University Giessen, Germany.
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133
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Abstract
Surgery, trauma, burns and injury induce an inflammatory response that can become excessive and damaging in some patients. This hyperinflammation can be followed by an immunosuppressed state which increases susceptibility to infection. The resulting septic syndromes are associated with significant morbidity and mortality. A range of nutrients are able to modulate inflammation (and the associated oxidative stress) and to maintain or improve immune function. These include several amino acids, antioxidant vitamins and minerals, long-chain n-3 fatty acids and nucleotides. Experimental studies support a role for each of these nutrients in surgical, injured or critically ill patients. There is good evidence that glutamine influences immune function in such patients and that this is associated with clinical improvement. Evidence is also mounting for the use of long-chain n-3 fatty acids in surgical and septic patients, but more evidence of clinical efficacy is required. Mixtures of antioxidant vitamins and minerals are also clinically effective, especially if they include selenium. Their action appears not to involve improved immune function, although an anti-inflammatory mode of action has not been ruled out. Enteral immunonutrient mixtures, usually including arginine, nucleotides and long-chain n-3 fatty acids, have been used widely in surgical and critically ill patients. Evidence of efficacy is good in surgical patients. However whether these same mixtures are beneficial, or should even be used, in critically ill patients remains controversial, since some studies show increased mortality with such mixtures. There is a view that this is due to a high arginine content driving nitric oxide production.
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Montero D, Grasso V, Izquierdo MS, Ganga R, Real F, Tort L, Caballero MJ, Acosta F. Total substitution of fish oil by vegetable oils in gilthead sea bream (Sparus aurata) diets: effects on hepatic Mx expression and some immune parameters. FISH & SHELLFISH IMMUNOLOGY 2008; 24:147-155. [PMID: 18158252 DOI: 10.1016/j.fsi.2007.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 08/01/2007] [Accepted: 08/03/2007] [Indexed: 05/25/2023]
Abstract
The use of vegetable oils in fish nutrition has been extensively studied; and recent work has focused attention on replacing fish oil with alternative fatty acid sources and their effect on the immune system. However, little is known about the effect of these oils on immune parameters such as the fish interferon system. In this study we evaluate the effect of two vegetable oils (linseed and soybean) on gilthead sea bream Mx expression and other innate immune parameters. Experimental diets were formulated where fish oil was totally replaced by vegetable oils or for a mixture of them (50% linseed and 50% soybean). Another diet prepared with pure fish oil was used as a control. Two experiments were carried out in order to evaluate growth, feed utilization, serum alternative complement pathway activity, serum lysozyme and phagocytic activity of head kidney leucocytes as well as Mx expression in the liver. In the first experiment fish were fed with experimental diets for 6 months and then, growth and feed utilization as well as immune parameters were analyzed. In the second experiment, fish from the previous feeding trial were injected with either a sub-lethal dose of Photobacterium damselae subsp. piscicida (94/99) or a synthetic dsRNA (Poly I:C) in order to stimulate an Mx response. The results show that total substitution of fish oil by vegetable oils decreased the growth of gilthead sea bream juveniles. Furthermore, both phagocytic activity and serum alternative complement pathway activity were significantly reduced by the inclusion of either vegetable oil individually in the sea bream diets, but the diet with mixed vegetable oils had no significant effect. There was no effect on serum lysozyme levels but the basal constitutive levels of Mx transcript expression in the liver were elevated in the fish fed the vegetable oil diets. The time-course of the Mx response to injection of Poly I:C was shorter in the fish fed the fish oil diet and the fish fed the diet based on a mixture of both vegetable oils showed a faster Mx response to bacterial injection. Following stimulation with Poly I:C or PDP the fish fed the vegetable oil based diets still maintained higher basal levels of hepatic Mx expression than the fish fed the fish oil diet which returned to undetectable levels.
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Affiliation(s)
- D Montero
- Grupo de Investigación en Acuicultura, ICCM-IUSA, Telde, Las Palmas, Canary Islands, Spain.
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Takeuchi H, Ikeuchi S, Kawaguchi Y, Kitagawa Y, Isobe Y, Kubochi K, Kitajima M, Matsumoto S. Clinical Significance of Perioperative Immunonutrition for Patients with Esophageal Cancer. World J Surg 2007; 31:2160-7. [PMID: 17876664 DOI: 10.1007/s00268-007-9219-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We hypothesized that preoperative and/or postoperative enteral immune-enhanced formulas that are supplemented with arginine, omega-3 fatty acids, and RNA may reduce postoperative complications in patients undergoing esophagectomy for thoracic esophageal squamous cell carcinoma (ESCC). METHODS Forty patients who underwent esophagectomy were divided into three groups: group A (n = 20) received a control enteral diet (Erental) through the jejunostomy after surgery. group B (n = 6) received an enteral diet supplemented with immune-enhancing substrates (Impact) containing arginine, omega-3 fatty acids, and RNA after surgery. group C (n = 14) received the impact before and after surgery. RESULTS Lymphocyte counts in group C on postoperative day (POD) 7 were somewhat higher than that in group A (p = 0.07) and significantly higher than in group B (p = 0.03). Furthermore the incidence of incisional wound infection in group C was significantly lower than that in group A (p = 0.03). Moreover, the duration of postoperative systemic inflammatory response syndrome (SIRS) was significantly shorter in group C than in group A (p < 0.05). CONCLUSIONS This study reveals that the perioperative immune-enhanced formula may be superior to postoperative control enteral formulas in terms of reducing surgical wound infection and postoperative SIRS, which may result in serious postoperative complications for patients who have undergone esophagectomy.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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136
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Abstract
PURPOSE OF REVIEW Although enthusiasm of intensivists has been raised during the last 2-3 years due to several successful clinical trials, severe sepsis and septic shock still have an increasing incidence with more or less unchanged mortality. Within the last 12 months, the progress in sepsis research covering definitions, epidemiology, pathophysiology, diagnosis, standard and adjunctive therapy, as well as experimental approaches is encouraging. In this review, state-of-the-art publications of 2003 are presented to elucidate the possible impact on clinical routine. RECENT FINDINGS The rationale for using a new definition based on the PIRO system has been widely acknowledged, although it is not yet applicable in clinical practice. This includes genomic information for stratifying subgroups of patients, and a broader field of laboratory diagnostics due to clinical studies and basic research on the cellular mechanisms of inflammation and organ dysfunction. Early diagnosis is important for a fast implementation of specific therapies, and it has been confirmed that the time until the start of therapy has an impact on patient outcome. Thorough data analysis of successful trials with activated protein C has revealed encouraging details on long-term outcome and subgroup effects. Together with new findings on low-dose hydrocortisone, this stresses the relevance of adjunctive therapy in severe sepsis and septic shock. SUMMARY Scientific progress in areas of sepsis has been continuing throughout 2003, although the challenges are still enormous. The identification of more specific markers and new therapeutic approaches will hopefully improve the diagnosis, monitoring of therapy, and outcome in the septic patient.
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Affiliation(s)
- Herwig Gerlach
- Department of Anaesthesiology and Intensive Care, Vivantes--Neukoelln Clinic, Berlin, Germany.
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Glatzle J, Kasparek MS, Mueller MH, Binder F, Meile T, Kreis ME, Konigsrainer A, Steurer W. Enteral immunonutrition during sepsis prevents pulmonary dysfunction in a rat model. J Gastrointest Surg 2007; 11:719-24. [PMID: 17394047 DOI: 10.1007/s11605-007-0144-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sepsis often results in severe pulmonary dysfunction. Via the thoracic duct, the lung is the first organ exposed to gut-derived inflammatory mediators released into mesenteric lymph during sepsis. AIM To investigate whether an enteral immunonutrition during sepsis improves pulmonary function. METHODS Mesenteric lymph was obtained from lymph fistula donor rats after intra peritoneal (i.p.) saline (control lymph) or lipopolysaccharide (sepsis lymph) injection. Sepsis lymph was also collected during enteral immunonutrition with omega-3 enriched, long-chain fatty acids (SMOF lipid). Control, sepsis, or sepsis-SMOF lymph was reinfused into the jugular vein of separate recipient rats. The lungs were then harvested, stained with hematoxylin-eosin, and analyzed for: (1) perpendicular parenchyma thickness of the alveolar wall; (2) myeloperoxidase-positive cells; and (3) terminal deoxynucleotidyl transferase Biotin-dUTP nick end labeling (TUNEL)-positive cells. RESULTS Enteral immunonutrition during sepsis reduced the release of TNFalpha into mesenteric lymph by about 4.5-fold within the first 2 h. Infusion of sepsis lymph into recipient rats induced thickening of alveolar walls, inflammatory reaction, and apoptosis. Infusion of sepsis lymph obtained during enteral immunonutrition did not cause anatomical changes, induced only a mild inflammatory reaction, and prevented apoptosis in the lungs of recipient rats. CONCLUSIONS Mediators in sepsis lymph induce pulmonary dysfunction such as an increased distance for oxygen transport, inflammatory reaction, and apoptosis. The lung may be protected by an enteral immunonutrition containing long-chain fatty acids.
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Affiliation(s)
- Joerg Glatzle
- Department of General and Transplantation Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
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138
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Abstract
Total parenteral nutrition is the final option for nutritional support of patients with severe intestinal failure. Lipid emulsions constitute the main source of fuel calories and fatty acids (FAs) in parenteral nutrition formulations. However, adverse effects on patient outcomes have been attributed to the use of lipids, mostly in relation to impaired immune defenses and altered inflammatory responses. Over the years, this issue has remained in the limelight, also because technical advances have provided no safeguard against the most daunting problems, ie, infectious complications. Nevertheless, numerous investigations have failed to produce a clear picture of the immunologic characteristics of the most commonly used soybean oil-derived lipid emulsions, although their high content of n-6 polyunsaturated FAs (PUFAs) has been considered a drawback because of their proinflammatory potential. This concern initiated the development of emulsions in which part of the n-6 FA component is replaced by less bioactive FAs, such as coconut oil (rich in medium-chain saturated FAs) or olive oil (rich in the n-9 monounsaturated FA oleic acid). Another approach has been to use fish oil (rich in n-3 PUFA), the FAs of which have biological activities different from those of n-6 PUFAs. Recent studies on the modulation of host defenses and inflammation by fish-oil emulsions have yielded consistent data, which indicate that these emulsions may provide a tool to beneficially alter the course of immune-mediated conditions. Although most of these lipids have not yet become available on the US market, this review synthesizes available information on immunologic characteristics of the different lipids that currently can be applied via parenteral nutrition support.
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MESH Headings
- Coconut Oil
- Dietary Fats, Unsaturated/administration & dosage
- Dietary Fats, Unsaturated/immunology
- Fat Emulsions, Intravenous/adverse effects
- Fat Emulsions, Intravenous/chemistry
- Fat Emulsions, Intravenous/metabolism
- Fatty Acids, Omega-3/administration & dosage
- Fatty Acids, Omega-3/immunology
- Fatty Acids, Omega-6/administration & dosage
- Fatty Acids, Omega-6/immunology
- Fish Oils/administration & dosage
- Fish Oils/chemistry
- Fish Oils/immunology
- Humans
- Immune System/drug effects
- Lipid Metabolism/drug effects
- Lipid Metabolism/physiology
- Membrane Lipids/metabolism
- Olive Oil
- Parenteral Nutrition, Total/methods
- Plant Oils
- Soybean Oil/administration & dosage
- Soybean Oil/chemistry
- Soybean Oil/immunology
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Affiliation(s)
- Geert J A Wanten
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
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139
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Wirtitsch M, Wessner B, Spittler A, Roth E, Volk T, Bachmann L, Hiesmayr M. Effect of different lipid emulsions on the immunological function in humans: a systematic review with meta-analysis. Clin Nutr 2007; 26:302-13. [PMID: 17449147 DOI: 10.1016/j.clnu.2007.02.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 12/22/2006] [Accepted: 02/25/2007] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS Reports regarding the pro- or anti-inflammatory effects of lipid emulsion used in parenteral nutrition are conflicting. Aim was to assess the effect of different intravenous lipid emulsions on immunological function in humans. METHODS We performed a computerized bibliographic search, searched reference lists in trial reports, hand-searched journals and contacted experts in the field. Randomized clinical trials evaluating the immunological effects of different parenteral lipid emulsions were included. Three authors independently performed data extraction, statistical processes were performed by two experts. Immunological parameters were classified by two immunologists as marker of improved or worsened immune function. A meta-analysis with standardized effect size estimation was performed for the comparison between long-chain triglycerides vs. glucose or other fat emulsions. RESULTS Of 682 assessed studies, 120 compared the immunological effects of intravenously applied lipid emulsions. Of 30 randomized trials, 14 were included in the meta-analysis. None of the lipid regimens showed any clear effect on the evolution of the immunological status or mortality in humans. Length of hospital stay and stay in the intensive care unit could not be evaluated. CONCLUSION We found no evidence that lipid emulsions and in particular those containing long-chain triglycerides have an unfavorable effect on immune function.
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Affiliation(s)
- Melanie Wirtitsch
- Surgical Research Laboratories, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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140
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Pluess TT, Hayoz D, Berger MM, Tappy L, Revelly JP, Michaeli B, Carpentier YA, Chioléro RL. Intravenous fish oil blunts the physiological response to endotoxin in healthy subjects. Intensive Care Med 2007; 33:789-797. [PMID: 17377770 DOI: 10.1007/s00134-007-0591-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 02/21/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the effects of intravenous fish oil fat emulsion on the metabolic alterations induced by lipopolysaccharide (LPS) challenge in healthy volunteers. DESIGN Two groups of eight healthy subjects were randomized to receive either two pharmacological doses of intravenous FO fat emulsion or no treatment. The FO group received twice 0.5 g/kg 10% emulsion (Omegaven) 48 and 24h before investigation. LPS (2 ng/kg) was injected as a bolus on the investigation day. Systemic parameters, indirect calorimetry, heart rate variability, and platelet membrane phospholipid composition were measured. RESULTS Basal EPA and DHA content in platelet phospholipids was low (0.28% and 2.54%, respectively) and increased significantly after FO to 1.68% and 3.32%. LPS induced reproducible effects in all subjects. Fever was higher in the control [corrected] group than in FO group [corrected] the difference was significant from t (120) until t (360). FO blunted the neuroendocrine response: the rise in plasma norepinephrine was sevenfold lower at t (120) while the ACTH peak was fourfold lower. Tumor necrosis factor alpha was significantly lower between t (360) and t (180) in the FO group. CONCLUSIONS Two doses of intravenous FO fat emulsion modified the phospholipid composition of platelets in healthy subjects. FO blunted fever and increased the neuroendocrine and the inflammatory responses to LPS.
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Affiliation(s)
- Thomas-Thi Pluess
- Department of Intensive Care Medicine, CHUV, 1011, Lausanne, Switzerland
| | - Daniel Hayoz
- Division of Hypertension and Vascular Medicine, CHUV, 1011, Lausanne, Switzerland
| | - Mette M Berger
- Department of Intensive Care Medicine, CHUV, 1011, Lausanne, Switzerland
| | - Luc Tappy
- Institute of Human Physiology, University of Lausanne, 1011, Lausanne, Switzerland
| | | | - Burkhard Michaeli
- Department of Intensive Care Medicine, CHUV, 1011, Lausanne, Switzerland
| | - Yvon A Carpentier
- Laboratory of Experimental Surgery, Université Libre de Bruxelles, Brussels, Belgium
| | - René L Chioléro
- Department of Intensive Care Medicine, CHUV, 1011, Lausanne, Switzerland.
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141
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Schaefer MB, Ott J, Mohr A, Bi MH, Grosz A, Weissmann N, Ishii S, Grimminger F, Seeger W, Mayer K. Immunomodulation by n-3- versus n-6-rich lipid emulsions in murine acute lung injury--role of platelet-activating factor receptor. Crit Care Med 2007; 35:544-54. [PMID: 17205023 DOI: 10.1097/01.ccm.0000253811.74112.b6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Cytokines, platelet-activating factor (PAF), and eicosanoids control local and systemic inflammation. Conventional soybean oil-based lipid emulsions used for parenteral nutrition may aggravate the leukocyte inflammatory response or adhesion to the vessel wall. Fish oil-based lipid emulsions, in contrast, may exert an anti-inflammatory effect. DESIGN We investigated the impact of lipid emulsions on leukocyte invasion, protein leakage, and cytokines in two murine models of acute inflammation. SETTING Research laboratory of a university hospital. SUBJECTS Wild-type mice and PAF-receptor knockout mice. INTERVENTIONS Mice received an infusion of normal saline, fish oil- or soybean oil-based lipid emulsions before lipopolysaccharide challenge. MEASUREMENTS AND MAIN RESULTS Preinfusion with soybean oil resulted in increased leukocyte invasion, myeloperoxidase activity, and protein leakage and exaggerated release of tumor necrosis factor (TNF)-alpha as well as macrophage inflammatory protein (MIP)-2 into the alveolar space after intratracheal lipopolysaccharide challenge. In contrast, preinfusion with fish oil reduced leukocyte invasion, myeloperoxidase activity, protein leakage, and TNF-alpha as well as MIP-2 generation. Corresponding profiles were found in plasma following intraperitoneal lipopolysaccharide application: Soybean oil increased but fish oil decreased the TNF-alpha and MIP-2 formation. When PAF-receptor-deficient mice were challenged with lipopolysaccharide, leukocyte invasion, lung tissue myeloperoxidase, cytokine generation, and alveolar protein leakage corresponded to those observed in wild-type animals. Fish oil and soybean oil lost their diverging effects on leukocyte transmigration, myeloperoxidase activity, leakage response, and cytokine generation in these knockout mice. Similarly, the differential impact of both lipid emulsions on these lipopolysaccharide-provoked changes was suppressed after pretreating animals with a PAF-receptor antagonist. CONCLUSIONS Fish oil- vs. soybean oil-based lipid infusions exert anti- vs. proinflammatory effects in murine models of acute inflammation. The PAF/PAF-receptor-linked signaling appears to be a prerequisite for this differential profile.
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142
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Kohl M, Wedel T, Entenmann A, Stuttmann J, Bendiks M, Loff S, Köster S, Ortfeld S, Bos I. Influence of different intravenous lipid emulsions on hepatobiliary dysfunction in a rabbit model. J Pediatr Gastroenterol Nutr 2007; 44:237-44. [PMID: 17255838 DOI: 10.1097/01.mpg.0000252193.99331.03] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Long-term total parenteral nutrition (TPN) in children is often complicated by the development of cholestasis, liver fibrosis, and liver failure. High doses of intravenous lipids may be involved in the pathogenesis of hepatobiliary dysfunction. The purpose of this study was to determine whether the use of 2 newly developed lipid emulsions could reduce liver damage. MATERIALS AND METHODS Three groups of prepubescent rabbits received TPN including a lipid emulsion either based on soybean oil, olive oil, or soybean oil with n-3 fatty acids added. Enterally fed animals served as controls. After 21 d the animals were killed. Serum samples were obtained at the beginning and end of the study period. Specimens were processed for histological evaluation using a specific score to assess the severity of liver damage. RESULTS Biochemical parameters did not predict the extent of liver damage. Hydropic degeneration as an indicator of toxic liver injury was the predominant histological alteration regardless of the type of lipids infused. The extent of fibrosis did not significantly differ among treatment groups except for animals infused with n-3 fatty acids exhibiting increased fibrotic transformation as compared with controls. CONCLUSION In our animal model, the use of a lipid emulsion with a reduced amount of polyunsaturated fatty acids was not superior to a lipid emulsion based on soybean oil. Long-term application of n-3 fatty acids was associated with more extensive fibrosis. Therefore, intravenous n-3 fatty acids containing lipid preparations (fish oil) should not be used in patients for long-term TPN.
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Affiliation(s)
- Martina Kohl
- Department of Pediatrics, University Hospital, Luebeck, Germany
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143
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Abstract
Excessive or inappropriate inflammation and immunosuppression are components of the response to surgery, trauma, injury and infection in some individuals and can lead, progressively, to sepsis and septic shock. The hyperinflammation is characterised by the production of inflammatory cytokines, arachidonic acid-derived eicosanoids and other inflammatory mediators, while the immunosuppression is characterised by impairment of antigen presentation and of T-helper lymphocyte type-1 responses. Long-chain n-3 fatty acids from fish oil decrease the production of inflammatory cytokines and eicosanoids. They act both directly (by replacing arachidonic acid as an eicosanoid substrate and by inhibiting arachidonic acid metabolism) and indirectly (by altering the expression of inflammatory genes through effects on transcription factor activation). Thus, long-chain n-3 fatty acids are potentially useful anti-inflammatory agents and may be of benefit in patients at risk of hyperinflammation and sepsis. As a consequence, an emerging application for n-3 fatty acids, in which they may be added to parenteral (or enteral) formulas, is in surgical or critically-ill patients. Parenteral nutrition that includes n-3 fatty acids appears to preserve immune function better than standard formulas and appears to diminish the extent of the inflammatory response. Studies to date are suggestive of clinical benefits from these approaches, especially in patients post surgery, although evidence of clinical benefit in patients with sepsis is emerging.
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Affiliation(s)
- Philip C Calder
- Institute of Human Nutrition, School of Medicine, University of Southampton, Bassett Crescent East, Southampton SO16 7PX, UK.
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144
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Jensen GL. Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine. JPEN J Parenter Enteral Nutr 2006; 30:453-63. [PMID: 16931617 DOI: 10.1177/0148607106030005453] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There has been tremendous interest in inflammation by researchers, the medical community, and the lay public. Modulation of injury response is felt to represent a tenuous balance of pro- and anti-inflammatory cytokines. Adverse outcomes may result from severe, sustained, or repeated bouts of inflammation. A critical observation is that nutrition support alone is inadequate to prevent muscle loss during active inflammation. It is necessary to take inflammation into consideration in conducting appropriate nutrition assessment, intervention, and monitoring. A host of medical conditions are actually inflammatory states that have important implications for nutrition care. Multifaceted interventions that may include anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti-inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions. Nutrition practitioners can seize this opportunity to be a part of the future medical team that brings highly individualized patient care to the bedside.
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Affiliation(s)
- Gordon L Jensen
- Vanderbilt Center for Human Nutrition, Nashville, Tennessee 37215, USA
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145
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Gorjão R, Verlengia R, Lima TMD, Soriano FG, Boaventura MFC, Kanunfre CC, Peres CM, Sampaio SC, Otton R, Folador A, Martins EF, Curi TCP, Portiolli EP, Newsholme P, Curi R. Effect of docosahexaenoic acid-rich fish oil supplementation on human leukocyte function. Clin Nutr 2006; 25:923-38. [PMID: 16697494 DOI: 10.1016/j.clnu.2006.03.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 03/10/2006] [Accepted: 03/17/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND The effect of a docosahexaenoic acid (DHA)-rich fish oil (FO) supplementation on human leukocyte function was investigated. METHODS Ten male volunteers were supplemented with 3g/day FO containing 26% eicosapentaenoic acid (EPA, 20:5, n-3) and 54% DHA (22:6, n-3) for 2 months. RESULTS FO supplementation changed the fatty acid (FA) composition of leukocytes resulting in an increase of n-3/n-6 ratio from 0.18 to 0.62 in lymphocytes and from 0.15 to 0.70 in neutrophils. DHA-rich FO stimulated an increase in phagocytic activity by 62% and 145% in neutrophils and monocytes, respectively. Neutrophil chemotactic response was increased by 128%. The rate of production of reactive oxygen species by neutrophils was also increased, as it was with lymphocyte proliferation. These changes were partially reversed after a 2-month wash out period. With respect to cytokine production by lymphocytes, interleukin (IL)-4 release was not altered, whereas secretions of IL-10, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha were raised. These results are in contrast to those described by others using EPA-rich FO supplementation. Lymphocyte pleiotropic gene expression was analyzed by a macroarray technique. Of the analyzed genes (588 in total), 77 were modified by the supplementation. FO supplementation resulted in up-regulation of 6 genes (GATA binding protein 2, IL-6 signal transducer, transforming growth factor alpha, TNF, heat shock 90kDa protein 1-alpha and heat shock protein 70kDa 1A) and a down regulation of 71 genes (92.2% of total genes changed). The largest functional group of altered genes was that related to signaling pathways (22% of the total modified genes). CONCLUSIONS Therefore, although EPA and DHA are members of n-3 FA family, changes in the proportion of DHA and EPA exert different effects on neutrophil, monocyte and lymphocyte function, which may be a result of specific changes in gene expression.
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Affiliation(s)
- Renata Gorjão
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, Av. Prof. Lineu Prestes, 1524, 05508-900, Butantã, São Paulo, SP, Brazil.
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146
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Mayer K, Schaefer M, Walmrath H, Grimminger F, Seeger W. [Nutrition and immunonutrition in septic patients]. Internist (Berl) 2006; 47:374, 376-82. [PMID: 16538510 DOI: 10.1007/s00108-006-1592-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Nutrition in septic patients is more than just caloric support. Not all nutritional concepts in general intensive care may be applied to septic patients. A tight glycemic control successfully used in post-operative intensive care patients has to be modified for the septic patient. Enteral immunonutrition leading to reduced length of stay in post-operative patients may be associated with increased mortality in patients suffering from severe sepsis. Newly developed lipid emulsions for parenteral nutrition became available. Application of these emulsions may prove to be beneficial in septic patients. An intravenous supplementation with glutamine of long-term exclusively parenterally fed intensive care patients may reduce their mortality. A nutrition individually optimized and adapted to the severity of the disease is considered to be an adjunct therapeutic measure in the treatment concept in sepsis.
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Affiliation(s)
- K Mayer
- University of Giessen Lung Center, Medizinische Klinik II, Klinikstrasse 36, 35392, Giessen.
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147
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Hasselmann M. Nutrition du malade agressé : évolution au cours des vingt dernières années. NUTR CLIN METAB 2006. [DOI: 10.1016/s0985-0562(06)80020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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148
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Michaeli B, Berger MM, Revelly JP, Tappy L, Chioléro R. Effects of fish oil on the neuro-endocrine responses to an endotoxin challenge in healthy volunteers. Clin Nutr 2006; 26:70-7. [PMID: 17055120 DOI: 10.1016/j.clnu.2006.06.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Revised: 06/04/2006] [Accepted: 06/13/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND & AIMS Fish oil (FO) has been shown to modulate the acute and chronic inflammatory responses. Endotoxin (LPS) has been shown to mimic several aspects of sepsis. The study aimed at testing the effects of oral FO supplements in healthy subjects submitted to intravenous LPS on systemic and endocrine response. SUBJECTS AND METHODS Fifteen healthy men (aged 26.0+/-3.1 years, BMI 23.8+/-1.9 kg/m2), were enrolled. Subjects were randomised to 3-4 weeks of oral FO supplementation (7.2 g/day, providing 1.1 g/day of 20:5 (n-3) and 0.7 g/day of 22:6 (n-3) fatty acids) or no supplementation and then submitted to endotoxin challenge: 2 ng/kg of LPS. All subjects were studied twice (placebo and LPS). MEASUREMENTS vital signs, energy expenditure (EE), glucose and lipid metabolism ((2)H2-glucose), plasma cytokines and stress hormones for 6 h after LPS or placebo. RESULTS LPS caused cytokine release, fever, increases in heart rate, resting EE and substrate oxidation, plasma glucagon and glucose concentrations; the neuro-endocrine response was characterised by increased plasma stress hormones. FO significantly blunted fever, ACTH and cortisol plasma levels (no effect on cytokine release). FO blunted the peak norepinephrine after LPS. CONCLUSION FO supplements blunted the endocrine stress response and the increase in body temperature, but had no impact on cytokine production after LPS. These findings conflict with the postulated anti-inflammatory effects of FO on arachidonic acid metabolism and cytokine release. These results suggest that FO may exert beneficial effects in sepsis though non-inflammatory which require further investigations.
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Affiliation(s)
- Burkhard Michaeli
- Department of Intensive Care Medicine, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
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149
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Garófolo A, Petrilli AS. Balanço entre ácidos graxos ômega-3 e 6 na resposta inflamatória em pacientes com câncer e caquexia. REV NUTR 2006. [DOI: 10.1590/s1415-52732006000500009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
O emagrecimento, associado à perda de massa magra, é um fenômeno observado com freqüência em pacientes com câncer. Tal condição predispõe o paciente ao maior risco de infecções, pior resposta aos tratamentos implantados e, como conseqüência, desfavorece o prognóstico de cura. Além disso, a desnutrição também está associada à pior qualidade de vida. Dessa forma, algumas terapias têm sido propostas na tentativa de reverter o catabolismo, por meio da atenuação da resposta inflamatória, observado em grande porcentagem de pacientes com câncer e caquexia. Entre elas, a suplementação com ácidos graxos da família ômega-3 pode representar uma estratégia na redução da formação de citocinas pró-inflamatórias, favorecendo a tolerância metabólica dos substratos energéticos e atenuando o catabolismo protéico, com o intuito de melhorar o prognóstico de cura de pacientes com câncer. Entretanto, os estudos mostram alguns resultados conflitantes da suplementação com ômega-3 na resposta imunológica. Por outro lado, em pacientes com câncer, os ensaios clínicos mostraram atenuar a resposta inflamatória e melhorar o estado nutricional. O objetivo deste artigo é realizar uma revisão criteriosa do assunto.
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Affiliation(s)
- Adriana Garófolo
- Universidade Federal de São Paulo, Brasil; Universidade Federal de São Paulo, Brasil
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150
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Ali S, Roberts PR. Nutrients with immune-modulating effects: what role should they play in the intensive care unit? Curr Opin Anaesthesiol 2006; 19:132-9. [PMID: 16552219 DOI: 10.1097/01.aco.0000192800.95172.47] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review will summarize recent clinical and experimental data on the use of immune-modulating nutrients in critical illness. It will present the concept of these nutrients as pharmacologic agents or 'nutraceuticals' administered in addition to protein, calorie, vitamin, and trace element sources. RECENT FINDINGS Studies have defined the physiologic roles of arginine in critical illness, such as its role as a precursor for the production of nitric oxide. Investigations have determined that, in critical illness, glutamine levels decrease and severe glutamine deficiency is associated with increased mortality. Experimental studies have revealed that glutamine attenuates proinflammatory cytokine responses, improves gut barrier and immune cell functions, increases the ability to mount a stress response, and decreases mortality. Clinical trials and meta-analyses of studies testing immune-modulating nutritional formulations have reported numerous benefits but also some conflicting results. Dose and route of administration are key factors that influence the benefit, or lack thereof, of these nutraceuticals. SUMMARY Cumulative studies of enteral immune-modulating nutritional formulations report benefits in surgical critically ill patients such as burn, trauma, or gastrointestinal surgery populations. Conflicting data in patients with sepsis warrant concern and further evaluation; in particular, controversy seems to stem around the use of arginine. Glutamine is beneficial when given in high doses or via the parenteral route (>0.20-0.30 g/kg per day or >or=30 g/day). Providing both omega-3 and omega-6 polyunsaturated fatty acids is important in immune modulation. The best doses and combinations of immune-modulating components remain unclear.
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Affiliation(s)
- Suleiman Ali
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1009, USA
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