Lack of enteral feeding increases expression of E-selectin after LPS challenge

Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies

OBJECTIVE

To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by relevant literature.

CONCLUSIONS

Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.

Hibernation induces immune changes in the lung of 13-lined ground squirrels (Ictidomys tridecemlineatus)

During hibernation, significant changes occur in the systemic and intestinal immune populations. We found that the lungs of hibernating 13-lined ground squirrels (Ictidomys tridecemlineatus) also undergo shifts in immune phenotype. Within the population of mononuclear cells, the percentage of T cells increases and the percentage of CD11b/c(+) cells decreases in hibernators. E-selectin, which promotes endothelial attachment, increases during arousal from torpor. Levels of the anti-inflammatory cytokine interleukin (IL)-10 in the lung are lower during hibernation while levels of the pro-inflammatory cytokine, tumor necrosis factor (TNF)-α remain constant. Expression of suppressor of cytokine signaling (SOCS) proteins is also decreased in torpid hibernators. Our data point to a unique immune phenotype in the lung of hibernating ground squirrels in which certain immunosuppressive proteins are downregulated while some potentially inflammatory proteins are maintained or amplified. This indicates that the lung houses an immune population that can potentially respond to antigenic challenge during hibernation.

Parenteral nutrition maintains pulmonary IgA antibody transport capacity, but not active transport, following injury

BACKGROUND

Parenteral nutrition (PN) increases post-trauma pneumonia versus enteral feeding. PN impairs murine immunoglobulin A (IgA) airway defenses and abrogates a normal IgA increase following injury. This work investigates the effect of type/route of nutrition on lung IgA and its transport protein, polymeric immunoglobulin receptor (pIgR), after injury.

METHODS

Catheterized mice were randomized to Chow or PN for 5 days and sacrificed without injury (Chow: n = 12; PN n = 11), or 8 hours after laparotomy + neck incisions (Chow-injury: n = 11, PN-injury: n = 13). Bronchoalveolar lavage (BAL) and lung IgA levels were analyzed by enzyme-linked immunosorbent assay (ELISA) and lung pIgR by Western blot.

RESULTS

BAL IgA levels increased in Chow-injury versus PN-injury (P <.01) with no differences in pIgR. PN-injury tissue IgA levels decreased versus Chow (P <.01), Chow-injury (P <.01), and PN (P <.05).

CONCLUSIONS

PN impairs the airway IgA response to injury but not due to impaired IgA transport capacity/pIgR level.

Decreased enteral stimulation alters mucosal immune chemokines

BACKGROUND

Migration of lymphocytes into and through the mucosal immune system depends upon adhesion molecules to attract circulating cells and chemokines to stimulate diapedesis into tissues. Decreased enteral stimulation significantly reduces mucosal addressin cellular adhesion molecule-1 (MAdCAM-1) levels, an adhesion molecule critical for homing of T and B cells to Peyer's patches (PP), which reduces PP and intestinal T and B cells. We studied the effect of type and route of nutrition on tissue specific chemokines in PP (CXCL-12, -13 and CCL-19, -20 and -21), small intestine (SI; CCL-20, -25 and -28) and lung (CXCL-12, CCL-28).

METHODS

Intravenously cannulated male Institute of Cancer Research (ICR) mice were randomized to chow or parenteral nutrition (PN) for 5 days. PP, SI, and lung chemokine mRNA levels were measured using real-time qRT-polymerase chain reaction, and analyzed semiquantitatively by the DeltaDeltaCt method. Protein levels were quantified using enzyme-linked immunosorbent assay (ELISA) techniques, and groups compared using Student's t-test.

RESULTS

PP CXCL13 protein significantly decreased, whereas CCL21 protein increased significantly in the parenterally fed group. Parenteral feeding significantly decreased SI CCL20 and CCL 25 protein levels. CCL28 decreased significantly in the SI and lung of intravenously fed animals. mRNA levels changed in the opposite direction (compared with protein) for all chemokines except CCL28.

CONCLUSIONS

Decreased enteral stimulation significantly alters key mucosal immune chemokine protein levels at multiple sites. In general, PN (and concomitant lack of enteral stimulation) results in decreased levels of chemokines that control lymphocyte migration within the mucosal immune system.

Nutrition support in severe acute pancreatitis

Nutritional support can improve the outcome from severe acute pancreatitis in two ways: first by providing the building blocks for tissue repair and recovery, and second, by modulating the inflammatory response and preventing organ failure, both of which are responsible for most of the morbidity and mortality associated with the disease. This review discusses the evidence on which these statements are based.

Gut ischemia-reperfusion affects gut mucosal immunity: A possible mechanism for infectious complications after severe surgical insults*

OBJECTIVE

To examine influences of gut ischemia/reperfusion (I/R) on gut-associated lymphoid tissue (GALT) mass and function.

DESIGN

Prospective, randomized controlled study.

SETTING

Research laboratory.

SUBJECTS

Male Institute of Cancer Research mice.

INTERVENTIONS

Ninety mice were randomized to three groups: I/R (60-min gut ischemia), sham (laparotomy only), and control (no operation). On days 1, 2, 4, 7, and 10, mice were killed to harvest lymphocytes from Peyer patches, the intraepithelial space, and the lamina propria (LP) of the small intestine. Respiratory tract and small intestinal washings were also obtained.

MEASUREMENTS AND MAIN RESULTS

Gut I/R significantly reduced lymphocyte numbers in Peyer patches, the intraepithelial space, and the LP. The reduction was prominent in GALT effector sites, that is, the intraepithelial space and LP, but numbers recovered quickly in LP. Changes in cell numbers in Peyer patches, GALT inductive sites, were subtle but persistent. Gut I/R reduced B cell numbers in Peyer patches; alphabeta T cell receptor (TCR)+, gammadeltaTCR+, CD8+, and B cell numbers in the intraepithelial space; and gammadeltaTCR+, CD8+, and B cell numbers in the LP, in comparison with the sham or control group. There were no significant differences in respiratory tract immunoglobulin A levels between the I/R and sham groups. Intestinal immunoglobulin A was elevated on day 1 in the I/R group, with no significant difference after day 2 in comparison with the sham group.

CONCLUSIONS

Despite the maintained mucosal immunoglobulin A level, gut I/R markedly reduces GALT cell numbers, with changes in lymphocyte phenotypes. These alterations may be associated with increased morbidity due to infectious complications after severe surgical insults.

Intermittent hepatic ischemia-reperfusion minimizes liver metastasis in rats

BACKGROUND

Surgical stresses, including hepatic ischemia-reperfusion (I/R), promote cancer growth and metastasis. We have reported that continuous hepatic I/R increases liver damage and promoted liver metastasis from colon cancer, whereas intermittent I/R causes less liver damage. We therefore examined whether intermittent I/R could reduce liver metastasis in a rat model.

MATERIALS AND METHODS

Adult male Fischer rats was divided between three groups: group A (control), which received laparotomy for 120 min with no liver ischemia; group B (continuous I/R), which received 60 min of 70% partial liver ischemia followed by 60 min of reperfusion; and group C (intermittent I/R), which received 15 min of 70% ischemia and 15 min of reperfusion, repeated four times. Just before closing the abdomen, all animals were inoculated intrasplenically with rat colon adenocarcinoma cells (RCN-H4). Tumor nodules on the liver surface were counted 3 weeks later. In addition, expression of E-selectin mRNA in liver was examined at 1, 3, and 6 h after completing I/R by a reverse transcription-polymerase chain reaction.

RESULTS

Continuous I/R (B) greatly promoted liver metastasis in both ischemic and nonischemic liver lobes, whereas intermittent I/R (C) showed significantly fewer metastasis than group B in both lobes. Significantly less E-selectin mRNA was expressed in group C than in group B.

CONCLUSIONS

Intermittent I/R limits expression of E-selectin mRNA and liver metastasis. Intermittent hepatic I/R is less stressful than continuous I/R, minimizing liver metastasis by colon cancer cells through avoidance of E-selectin up-regulation.

Increased ICAM-1 and beta2 integrin expression in parenterally fed mice after a gut ischemic insult

Lack of enteral feeding increases P- and E-selectin and ICAM-1 expression on endothelial cells in organs, such as the small intestine and lung, and increases neutrophils in the intestine. These changes are associated with increased mortality after gut ischemia. We hypothesize that nutritional regimen affects endothelial ICAM-1 levels and leukocyte beta2 integrins after gut ischemia. Mice received chow, intravenous (IV) TPN, or intragastric (IG) TPN. In experiment 1, after 5 days of diet, 28 mice underwent 15 min of superior mesenteric artery (SMA) occlusion (I/R) for quantification of ICAM-1 expression in organs 3 h later. In experiment 2, after the same nutrient pretreatments of 38 mice, peripheral blood was obtained with or without gut I/R to measure CD11a and CD11b expression on myeloid cells. CD18 immunofluorescence staining was studied in the lung. Expression of ICAM-1 in the liver, kidney, and small intestine was significantly higher after IV-TPN than chow. IG-TPN reduced liver and kidney ICAM-1 levels midway between the chow and IV-TPN groups, but not intestinal expression. Expression of CD11b on the myeloid cell population in each group was similar before I/R, but CD11b levels increased after IV-TPN on circulating cells after I/R compared with all uninjured animals or injured chow or IG-TPN mice. Only IV-TPN mice had lung CD18-positive leukocytes after I/R. After I/R, lack of enteral feeding increases organ expression of ICAM-1, CD11b levels on myeloid cells, and lung of CD18 positive leukocytes. Through these changes, lack of enteral feeding may increase organ damage after gut ischemia.

Immune-enhancing enteral diet selectively augments ileal blood flow in the rat

BACKGROUND

Clinical studies show that immune-enhancing enteral diets (IED; with L-arginine, fish oil, and RNA fragments) decrease the rate of sepsis and shorten the length of hospital stay after the start of enteral feeding. These beneficial effects are dependent on the route of administration (enteral vs parenteral) and on the nutrient composition (IED vs standard diets). Gut exposure to an IED seems to preserve and/or augment intestinal mucosal immunity. However, nutrient absorption stimulates gut blood flow in a nutrient-specific manner (i.e., postprandial hyperemia). We hypothesized that an IED would initiate a different pattern of whole organ blood flow compared to a standard diet. This suggests that a mechanism for the protective effect of IED might be the preferential augmentation of gut blood flow to gut-associated lymphoid tissue (GALT) or mucosa-associated lymphoid tissue (MALT).

METHODS

Male Sprague-Dawley rats (200-225 g) were anesthetized and cannulated for colorimetric microsphere determination of blood flow distribution (with the phantom organ technique). Animals received gastric gavage (2 ml) of an IED (Impact; Novartis) or an isocaloric, isonitrogenous control diet (Boost; Mead-Johnson). Blood flow to the antrum, duodenum, jejunum, ileum, colon, liver, kidneys, and spleen was determined at baseline and 30, 60, 90, and 120 min after gavage.

RESULTS

Baseline blood flows to the left and right kidneys were within 10%, indicating the technical integrity of the microsphere technique and assay. Control diet augmented blood flow compared to IED in the antrum, duodenum, jejunum, and spleen. Conversely, IED gavage stimulated a delayed and sustained hyperemic response in the ileum. IED also increased hepatic blood flow early (30 min). IED increased blood glucose levels compared to control diet at 30, 60, and 90 min, suggesting enhanced nutrient absorption.

CONCLUSIONS

These data show that blood flow distribution depends on nutrient composition and that IED preferentially augments blood flow to the ileum. Since the terminal jejunum and ileum contain much of the GALT, our data suggest that a mechanism for enterally stimulated mucosal immunity involves selective perfusion of the terminal ileum during IED nutrient absorption.

Current aspects of mucosal immunology and its influence by nutrition

BACKGROUND

A significant body of clinical literature demonstrates that enteral feeding significantly reduces the incidence of pneumonia compared to patients fed parenterally. An immunologic link between the gastrointestinal tract and respiratory tract is postulated via the common mucosal immune hypothesis. This hypothesis states that cells are sensitized within the Peyer's patches of the small intestine and are subsequently distributed to submucosal locations in both intestinal and extra intestinal sites. This system is exquisitely sensitive to route and type of nutrition.

DATA SOURCE

This review examines the laboratory data regarding cell numbers, cell phenotypes, cytokine profile, and immunologic function in both intestinal and extra intestinal sites in animals that have been administered either parenteral feeding or various types of enteral feeding. It also establishes links between a specific nutrient, glutamine, the enteric nervous system, by way of neuropeptides, and mucosal immunity.

CONCLUSION

Progress in understanding relationships between nutrient availability, enteric nervous system stimulation, and nutrient delivery on mucosal immunity offers opportunities to explore immune systems previously not appreciated by clinicians and basic scientists. These opportunities offer new challenges to the physician scientist, basic scientist, and clinician to understand, manipulate, and apply these concepts to the critically ill patient population by favorably influencing immunologic barriers and the inflammatory response.

The neuropeptide bombesin improves IgA-mediated mucosal immunity with preservation of gut interleukin-4 in total parenteral nutrition-fed mice

BACKGROUND

The Th2 cytokines, interleukin-4 (IL-4) and interleukin-10 (IL-10), stimulate IgA production. Total parenteral nutrition (TPN) reduces IL-4 and IL-10 messenger RNA in gut lamina propria lymphocytes, total IL-4 and IL-10 in gut homogenates, and IgA-mediated mucosal immunity. Bombesin (BBS) can maintain mucosal immunity in TPN-fed mice, but the effects of BBS on gut IL-4 and IL-10 levels and their mRNA expression in the lamina propria are unknown.

METHODS

In experiment 1, mice that were fed chow, TPN, or TPN + BBS (15 microg/kg intravenously-three times a day) for 5 days were killed, and respiratory tract IgA and intestinal IgA, IL-4, and IL-10 levels were measured. In experiment 2, IL-4 and IL-10 mRNA were measured in isolated lamina propria lymphocytes from chow-, TPN-, and TPN+BBS-fed mice by reverse transcriptase-polymerase chain reaction. Intestines were harvested 1 hour after injection of 100 7 microg of lipopolysaccharide intraperitoneally. Samples were standardized to beta-actin.

RESULTS

TPN-fed mice had significantly lower respiratory tract IgA levels than chow- or TPN + BBS-fed mice. TPN+BBS did not increase intestinal IL-10 or IL-10 lamina propria mRNA levels but maintained intestinal IL-4 levels and lamina propria IL-4 mRNA expression equal to those of chow-fed mice.

CONCLUSIONS

BBS reverses the effects of TPN on intestinal and respiratory tract IgA levels and most effects on gut cytokines. Lamina propria cytokine mRNA levels reflect total gut cytokine concentration.

The gastrointestinal tract in critical illness

The gut has often been suggested to be one of the essential factors in the pathogenesis of many nosocomial infections and possibly multi-organ failure. In the light of several recent studies, the importance of normal gut bacterial flora and the role of the gastrointestinal tract in human immune function are now better understood. It now seems clear that stimulation of gut-associated lymphoid tissue through enteral feeding is the key to the preservation of mucosal-derived immunity; however, the role of this native gastrointestinal immune function in the subsequent development of sepsis and multi-organ dysfunction syndrome remains the subject of ongoing study.