Oral glutamine supplementation during preoperative radiochemotherapy in patients with rectal cancer: a randomised double blinded, placebo controlled pilot study

Effects of glutamine on plasma protein and inflammation in postoperative patients with colorectal cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effects of glutamine on the plasma protein and inflammatory responses in colorectal cancer (CRC) patients following radical surgery.

METHODS

We thoroughly retrieved online databases (EMBASE, MEDLINE, PubMed, and others) and selected the randomized controlled trials (RCTs) with glutamine vs. conventional nutrition or blank treatment up until March 2023. The plasma protein associated markers indicators (consisting of albumin (ALB), prealbumin (PA), nitrogen balance (NB), total protein (TP)), inflammatory indicators (including TNF-α, CRP, infectious complications (ICs)), and matching 95% confidence intervals (CIs) were evaluated utilizing the pooled analysis. Subsequently, meta-regression analysis, contour-enhanced funnel plot, Egger's test, and sensitivity analysis were carried out.

RESULTS

We discovered 26 RCTs, included an aggregate of 1678 patients, out of which 844 were classified into the glutamine group whereas 834 were classified into the control group. The findings recorded from pooled analysis illustrated that glutamine substantially enhanced the plasma protein markers (ALB [SMD[random-effect] = 0.79, 95% CI: 0.55 to 1.03, I2 = 79.4%], PA [SMD[random-effect] = 0.94, 95% CI: 0.69 to 1.20, I2 = 75.1%], NB [SMD[random-effect] = 1.11, 95% CI: 0.46 to 1.75, I2 = 86.9%). However, the content of TP was subjected to comparison across the 2 groups, and no statistical significance was found (SMD[random-effect] = - 0.02, 95% CI: - 0.60 to 0.57, P = 0.959, I2 = 89.7%). Meanwhile, the inflammatory indicators (including TNF-α [SMD[random-effect] = - 1.86, 95% CI: - 2.21 to - 1.59, I2 = 56.7%], CRP [SMD[random-effect] = - 1.94, 95% CI: - 2.41 to - 1.48, I2 = 79.9%], ICs [RR[fixed-effect] = 0.31, 95% CI: 0.21 to 0.46, I2 = 0.00%]) were decreased significantly followed by the treatment of glutamine.

CONCLUSIONS

The current study's findings illustrated that glutamine was an effective pharmaco-nutrient agent in treating CRC patients following a radical surgical operation. PROSPERO registration number: CRD42021243327.

Comparative Effects of Different Nutritional Supplements on Inflammation, Nutritional Status, and Clinical Outcomes in Colorectal Cancer Patients: A Systematic Review and Network Meta-Analysis

Nutritional supplements have been widely used in colorectal cancer (CRC) patients. The aim of this network meta-analysis (NMA) was to compare the effects of different nutritional supplements on inflammation, nutritional status, and clinical outcomes in CRC patients. Four electronic databases were searched until December 2022. Randomized controlled trials (RCTs) comparing nutritional supplements of omega-3 fatty acids (omega-3), arginine, vitamin D, glutamine, probiotics, or their combinations with placebo or standard treatment were selected. The outcomes were inflammatory indicators, nutritional indicators, and clinical outcomes. A random-effects Bayesian NMA was performed to rank the effect of each supplement. In total, 34 studies involving 2841 participants were included. Glutamine was superior in decreasing tumor necrosis factor-α (MD -25.2; 95% CrI [-32.62, -17.95]), whereas combined omega-3 and arginine supplementation was more effective in decreasing interleukin-6 (MD -61.41; 95% CrI [-97.85, -24.85]). No nutritional supplements significantly maintained nutritional indicators in CRC patients. Regarding clinical outcomes, glutamine ranked highest in reducing the length of hospital stay (MD -3.71; 95% CrI [-5.89, -1.72]) and the incidence of wound infections (RR 0.12; 95% CrI [0, 0.85]), and probiotics were rated as best in reducing the incidence of pneumonia (RR 0.38; 95% CrI [0.15, 0.81]). Future well-designed RCTs are needed to further confirm these findings.

The effect of nutritional interventions in acute radiation-induced diarrhoea in patients with primary pelvic cancer: A systematic review

Acute radiation-induced diarrhoea (RID) is a well-known side effect of external radiation therapy for pelvic cancer. Acute RID is an unresolved clinical problem in approximately 80% of patients. We investigated the effect of nutritional interventions on acute RID in patients with pelvic cancer treated with curative radiotherapy. A search was conducted using PubMed, Embase.com, CINAHL, and Cochrane Library, from 1 January 2005 until 10 October 2022. We included randomised controlled trials or prospective observational studies. Eleven of the 21 identified studies had low quality of evidence, mainly because of low patient numbers distributed among several cancer diagnoses, and non-systematic assessment of acute RID. Interventions included probiotics (n = 6), prebiotics (n = 6), glutamine (n = 4), and others (n = 5). Five studies, of which two provided high quality evidence, showed that probiotics improved acute RID. Future well-designed studies investigating the effects of probiotics on acute RID are warranted. PROSPERO ID: CRD42020209499).

Combination L-Glutamine with Gemcitabine and Nab-Paclitaxel in Treatment-Naïve Advanced Pancreatic Cancer: The Phase I GlutaPanc Study Protocol

Advanced pancreatic cancer is underscored by progressive therapeutic resistance and a dismal 5-year survival rate of 3%. Preclinical data demonstrated glutamine supplementation, not deprivation, elicited antitumor effects against pancreatic ductal adenocarcinoma (PDAC) alone and in combination with gemcitabine in a dose-dependent manner. The GlutaPanc phase I trial is a single-arm, open-label clinical trial investigating the safety of combination L-glutamine, gemcitabine, and nab-paclitaxel in subjects (n = 16) with untreated, locally advanced unresectable or metastatic pancreatic cancer. Following a 7-day lead-in phase with L-glutamine, the dose-finding phase via Bayesian design begins with treatment cycles lasting 28 days until disease progression, intolerance, or withdrawal. The primary objective is to establish the recommended phase II dose (RP2D) of combination L-glutamine, gemcitabine, and nab-paclitaxel. Secondary objectives include safety of the combination across all dose levels and preliminary evidence of antitumor activity. Exploratory objectives include evaluating changes in plasma metabolites across multiple time points and changes in the stool microbiome pre and post L-glutamine supplementation. If this phase I clinical trial demonstrates the feasibility of L-glutamine in combination with nab-paclitaxel and gemcitabine, we would advance the development of this combination as a first-line systemic option in subjects with metastatic pancreatic cancer, a high-risk subgroup desperately in need of additional therapies.

Effect of Glutamine on Short-term Surgical Outcomes in Rectal Cancer Patients Receiving Neoadjuvant Therapy: A Propensity Score Matching Study

The effect of glutamine on postoperative complications and postoperative recovery in rectal cancer (RC) patients receiving neoadjuvant therapy (NT) is unclear. This study aimed to investigate the effects of intravenous glutamine supplementation on short-term postoperative outcomes in these patients. This retrospective study included patients with RC who received NT and underwent radical surgery between January 2013 and July 2022 and were either administered glutamine (glutamine group) or not administered glutamine (non-glutamine group). Propensity score matching method was used to analyze and compare postoperative complications and other outcome indicators. A total of 208 patients were reviewed, and 53 were included in each group post matching. While no significant difference in the time to first solid food intake between the two groups was observed, the glutamine group had a significantly reduced incidence of postoperative complications, shorter length of hospital stay, and shorter time to first defecation, first exhaust, and first fluid diet intake than those of the control group. Moreover, glutamine alleviated the reduction in albumin and prealbumin levels. Perioperative parenteral glutamine supplementation effectively reduces the incidence of postoperative complications, promotes postoperative recovery, and improves albumin levels in patients undergoing RC surgery and receiving NT.

Meta-analysis of Glutamine on Immune Function and Post-Operative Complications of Patients With Colorectal Cancer

The aim of this meta-analysis was to evaluate the clinical significance of glutamine in the management of patients with colorectal cancer (CRC) after radical operation. Electronic databases, including PubMed, EMBASE, MEDLINE, Cochrane Library, Chinese Biomedical Database (CBM), China National Knowledge Infrastructure (CNKI), VIP medicine information system (VIP), and Wanfang electronic databases were comprehensively searched from inception to 30, July 2021. Prospective randomized trials with glutamine vs. routine nutrition or blank therapy were selected. The immune function related indicators (including IgA, IgG, IgM, CD4+, CD8+, and the ratio of CD4+/CD8+), post-operative complications [including surgical site infection (SSI), anastomotic leakage, and length of hospital stay (LOS)], and corresponding 95% confidence intervals (CIs) were assessed in the pooled analysis. Subsequently, the heterogeneity between studies, sensitivity, publication bias, and meta-regression analysis were performed. Consequently, 31 studies which contained 2,201 patients (1,108 in the glutamine group and 1,093 in the control group) were included. Results of pooled analysis indicated that glutamine significantly improved the humoral immune function indicators [including IgA (SMD = 1.15, 95% CI: 0.72–1.58), IgM (SMD = 0.68, 95% CI: 0.48–0.89), and IgG (SMD = 1.10, 95% CI: 0.70–1.50)], and the T cell immune function indicators [including CD4+ (SMD = 0.76, 95% CI: 0.53–0.99) and the ratio of CD4+/CD8+ (SMD = 0.92, 95% CI: 0.57–1.28)]. Meanwhile, the content of CD8+ was decreased significantly (SMD = −0.50, 95% CI: −0.91 to −0.10) followed by glutamine intervention. Pooled analysis of SSI (RR = 0.48, 95% CI: 0.30–0.75), anastomotic leakage (RR = 0.23, 95% CI: 0.09–0.61), and LOS (SMD = −1.13, 95% CI: −1.68 to −0.58) were decreased significantly in glutamine group compared with control group. Metaregression analysis revealed that the covariate of small-sample effects influenced the robustness and reliability of IgG outcome potentially. Findings of the present work demonstrated that glutamine ought to be applied as an effective immunenutrition therapy in the treatment of patients with CRC after radical surgery. The present meta-analysis has been registered in PROSPERO (no. CRD42021243327).

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO, Identifier: CRD42021243327.

The role of dietary supplements, including biotics, glutamine, polyunsaturated fatty acids and polyphenols, in reducing gastrointestinal side effects in patients undergoing pelvic radiotherapy: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Pelvic radiotherapy (RT) often results in gastrointestinal toxicity and clinical trials have demonstrated a potential benefit of dietary supplements in alleviating acute effects. However, no prophylactic agents have been approved to date for relief of gastrointestinal side-effects caused by pelvic radiation. In this systematic review, we evaluated the efficacy of dietary supplements in preventing or alleviating symptoms of gastrointestinal toxicity in patients undergoing pelvic RT.

MATERIALS AND METHODS

CENTRAL, MEDLINE, EMBASE, and ClinicalTrials.gov were searched up to June 2020 for randomised controlled trials. Interventions included four supplement categories: biotics, glutamine, poly-unsaturated fatty acids and polyphenols. Efficacy was determined with reference to outcomes based on symptoms of acute gastrointestinal toxicity, including diarrhoea, nausea, vomiting, flatulence/bloating, bowel movement frequency, tenesmus and rectal bleeding.

RESULTS

Twenty-three randomised controlled trials (1919 patients) were identified in this review. Compared with placebo, probiotics (RR = 0.71; 95% CI: 0.52 to 0.99), synbiotics (RR = 0.45; 95% CI: 0.28 to 0.73) and polyphenols (RR = 0.30; 95% CI: 0.13 to 0.70) were significantly associated with a lower risk of diarrhoea. Biotic supplements also reduced the risk of moderate to severe diarrhoea (RR = 0.49; 95% CI: 0.36 to 0.67) and the need for anti-diarrhoeal medication (RR = 0.64; 95%CI: 0.44 to 0.92). In contrast, glutamine had no effect on acute symptoms (RR = 1.05; 95% CI: 0.86 to 1.29). There was a non-significant trend for reduction in nausea and mean bowel movements per day using dietary supplements.

CONCLUSIONS

Biotic supplements, especially probiotics and synbiotics, reduce acute symptoms of gastrointestinal toxicity in patients undergoing pelvic radiotherapy.

Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection

BACKGROUND

Malnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m², weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes.

RESULTS

Of the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models.

CONCLUSIONS

Malnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.

Immunometabolism: new insights and lessons from antigen-directed cellular immune responses

Modulation of immune responses by nutrients is an important area of study in cellular biology and clinical sciences in the context of cancer therapies and anti-pathogen-directed immune responses in health and disease. We review metabolic pathways that influence immune cell function and cellular persistence in chronic infections. We also highlight the role of nutrients in altering the tissue microenvironment with lessons from the tumor microenvironment that shapes the quality and quantity of cellular immune responses. Multiple layers of biological networks, including the nature of nutritional supplements, the genetic background, previous exposures, and gut microbiota status have impact on cellular performance and immune competence against molecularly defined targets. We discuss how immune metabolism determines the differentiation pathway of antigen-specific immune cells and how these insights can be explored to devise better strategies to strengthen anti-pathogen-directed immune responses, while curbing unwanted, non-productive inflammation.

Effects of Immunonutrition on Chemoradiotherapy Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We conducted a systematic review to assess the effects of immunonutrition on chemoradiotherapy patients.

METHODS

We searched the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science. We assessed the risk of bias using the Cochrane Risk of Bias tool. Our primary outcomes were the incidence of oral mucositis and diarrhea. The secondary outcomes were the incidence of esophagitis, grade ≥3 oral mucositis, grade ≥3 diarrhea, grade ≥3 esophagitis, and body weight loss.

RESULTS

A total of 1478 patients and 27 studies were included. There were no significant differences in the incidence of oral mucositis (relative risk [RR] = 0.91; 95% confidence interval [CI], 0.79-1.05), diarrhea (RR = 0.89; 95% CI, 0.76-1.05), or esophagitis (RR = 0.55; 95% CI, 0.11-2.86) between the immunonutrition group and standard nutrition/placebo group. Nevertheless, immunonutrition significantly reduced the incidence of grade ≥3 oral mucositis (RR = 0.45; 95% CI, 0.22-0.92), grade ≥3 diarrhea (RR = 0.56; 95% CI, 0.35-0.88), grade ≥3 esophagitis (RR = 0.15; 95% CI, 0.04-0.54), and losing >5% body weight (RR = 0.34; 95% CI, 0.18-0.64).

CONCLUSIONS

In this study, immunonutrition failed to reduce the incidence rates of oral mucositis, diarrhea, or esophagitis but was conducive to significantly improving the severity of oral mucositis and diarrhea esophagitis and reducing the rate of body weight loss.

Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers

BACKGROUND

An increasing number of people survive cancer but a significant proportion have gastrointestinal side effects as a result of radiotherapy (RT), which impairs their quality of life (QoL).

OBJECTIVES

To determine which prophylactic interventions reduce the incidence, severity or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers.

SEARCH METHODS

We conducted searches of CENTRAL, MEDLINE, and Embase in September 2016 and updated them on 2 November 2017. We also searched clinical trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions to prevent adverse gastrointestinal effects of pelvic radiotherapy among adults receiving radiotherapy to treat primary pelvic cancers, including radiotherapy techniques, other aspects of radiotherapy delivery, pharmacological interventions and non-pharmacological interventions. Studies needed a sample size of 20 or more participants and needed to evaluate gastrointestinal toxicity outcomes. We excluded studies that evaluated dosimetric parameters only. We also excluded trials of interventions to treat acute gastrointestinal symptoms, trials of altered fractionation and dose escalation schedules, and trials of pre- versus postoperative radiotherapy regimens, to restrict the vast scope of the review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. We used the random-effects statistical model for all meta-analyses, and the GRADE system to rate the certainty of the evidence.

MAIN RESULTS

We included 92 RCTs involving more than 10,000 men and women undergoing pelvic radiotherapy. Trials involved 44 different interventions, including radiotherapy techniques (11 trials, 4 interventions/comparisons), other aspects of radiotherapy delivery (14 trials, 10 interventions), pharmacological interventions (38 trials, 16 interventions), and non-pharmacological interventions (29 trials, 13 interventions). Most studies (79/92) had design limitations. Thirteen studies had a low risk of bias, 50 studies had an unclear risk of bias and 29 studies had a high risk of bias. Main findings include the following:Radiotherapy techniques: Intensity-modulated radiotherapy (IMRT) versus 3D conformal RT (3DCRT) may reduce acute (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.26 to 0.88; participants = 444; studies = 4; I2 = 77%; low-certainty evidence) and late gastrointestinal (GI) toxicity grade 2+ (RR 0.37, 95% CI 0.21 to 0.65; participants = 332; studies = 2; I2 = 0%; low-certainty evidence). Conformal RT (3DCRT or IMRT) versus conventional RT reduces acute GI toxicity grade 2+ (RR 0.57, 95% CI 0.40 to 0.82; participants = 307; studies = 2; I2 = 0%; high-certainty evidence) and probably leads to less late GI toxicity grade 2+ (RR 0.49, 95% CI 0.22 to 1.09; participants = 517; studies = 3; I2 = 44%; moderate-certainty evidence). When brachytherapy (BT) is used instead of external beam radiotherapy (EBRT) in early endometrial cancer, evidence indicates that it reduces acute GI toxicity (grade 2+) (RR 0.02, 95% CI 0.00 to 0.18; participants = 423; studies = 1; high-certainty evidence).Other aspects of radiotherapy delivery: There is probably little or no difference in acute GI toxicity grade 2+ with reduced radiation dose volume (RR 1.21, 95% CI 0.81 to 1.81; participants = 211; studies = 1; moderate-certainty evidence) and maybe no difference in late GI toxicity grade 2+ (RR 1.02, 95% CI 0.15 to 6.97; participants = 107; studies = 1; low-certainty evidence). Evening delivery of RT may reduce acute GI toxicity (diarrhoea) grade 2+ during RT compared with morning delivery of RT (RR 0.51, 95% CI 0.34 to 0.76; participants = 294; studies = 2; I2 = 0%; low-certainty evidence). There may be no difference in acute (RR 2.22, 95% CI 0.62 to 7.93, participants = 110; studies = 1) and late GI toxicity grade 2+ (RR 0.44, 95% CI 0.12 to 1.65; participants = 81; studies = 1) between a bladder volume preparation of 1080 mls and that of 540 mls (low-certainty evidence). Low-certainty evidence on balloon and hydrogel spacers suggests that these interventions for prostate cancer RT may make little or no difference to GI outcomes.Pharmacological interventions: Evidence for any beneficial effects of aminosalicylates, sucralfate, amifostine, corticosteroid enemas, bile acid sequestrants, famotidine and selenium is of a low or very low certainty. However, evidence on certain aminosalicylates (mesalazine, olsalazine), misoprostol suppositories, oral magnesium oxide and octreotide injections suggests that these agents may worsen GI symptoms, such as diarrhoea or rectal bleeding.Non-pharmacological interventions: Low-certainty evidence suggests that protein supplements (RR 0.23, 95% CI 0.07 to 0.74; participants = 74; studies = 1), dietary counselling (RR 0.04, 95% CI 0.00 to 0.60; participants = 74; studies = 1) and probiotics (RR 0.43, 95% CI 0.22 to 0.82; participants = 923; studies = 5; I2 = 91%) may reduce acute RT-related diarrhoea (grade 2+). Dietary counselling may also reduce diarrhoeal symptoms in the long term (at five years, RR 0.05, 95% CI 0.00 to 0.78; participants = 61; studies = 1). Low-certainty evidence from one study (108 participants) suggests that a high-fibre diet may have a beneficial effect on GI symptoms (mean difference (MD) 6.10, 95% CI 1.71 to 10.49) and quality of life (MD 20.50, 95% CI 9.97 to 31.03) at one year. High-certainty evidence indicates that glutamine supplements do not prevent RT-induced diarrhoea. Evidence on various other non-pharmacological interventions, such as green tea tablets, is lacking.Quality of life was rarely and inconsistently reported across included studies, and the available data were seldom adequate for meta-analysis.

AUTHORS' CONCLUSIONS

Conformal radiotherapy techniques are an improvement on older radiotherapy techniques. IMRT may be better than 3DCRT in terms of GI toxicity, but the evidence to support this is uncertain. There is no high-quality evidence to support the use of any other prophylactic intervention evaluated. However, evidence on some potential interventions shows that they probably have no role to play in reducing RT-related GI toxicity. More RCTs are needed for interventions with limited evidence suggesting potential benefits.

Diagnosis and management of gastrointestinal complications in adult cancer patients: 2017 updated evidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently suffer from gastrointestinal complications. In this manuscript, we update our 2013 guideline on the diagnosis and management of gastrointestinal complications in adult cancer patients by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). An expert group was put together by the AGIHO to update the existing guideline. For each sub-topic, a literature search was performed in PubMed, Medline, and Cochrane databases, and strengths of recommendation and the quality of the published evidence for major therapeutic strategies were categorized using the 2015 European Society for Clinical Microbiology and Infectious Diseases (ESCMID) criteria. Final recommendations were approved by the AGIHO plenary conference. Recommendations were made with respect to non-infectious and infectious gastrointestinal complications. Strengths of recommendation and levels of evidence are presented. A multidisciplinary approach to the diagnosis and management of gastrointestinal complications in cancer patients is mandatory. Evidence-based recommendations are provided in this updated guideline.

Effect of alpha-lipoic acid on radiation-induced small intestine injury in mice

Purpose

Radiation therapy is a highly effective treatment for patients with solid tumors. However, it can cause damage and inflammation in normal tissues. Here, we investigated the effects of alpha-lipoic acid (ALA) as radioprotection agent for the small intestine in a mouse model.

Materials and Methods

Whole abdomen was evenly irradiated with total a dose of 15 Gy. Mice were treated with either ALA (100 mg/kg, intraperitoneal injection [i.p.]) or saline (equal volume, i.p.) the prior to radiation as 100 mg/kg/day for 3 days. Body weight, food intake, histopathology, and biochemical parameters were evaluated.

Results

Significant differences in body weight and food intake were observed between the radiation (RT) and ALA + RT groups. Moreover, the number of crypt cells was higher in the ALA + RT group. Inflammation was decreased and recovery time was shortened in the ALA + RT group compared with the RT group. The levels of inflammation-related factors (i.e., phosphorylated nuclear factor kappa B and matrix metalloproteinase-9) and mitogen-activated protein kinases were significantly decreased in the ALA + RT group compared with those in the RT group.

Conclusions

ALA treatment prior to radiation decreases the severity and duration of radiation-induced enteritis by reducing inflammation, oxidative stress, and cell death.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Application of Glutamine-enriched nutrition therapy in childhood acute lymphoblastic leukemia

BACKGROUND

We investigated the effects of glutamine (Gln)-enriched nutritional therapy during chemotherapy on the nutritional status and immune function of children with acute lymphoblastic leukemia (ALL).

METHODS

We enrolled 48 children who were newly diagnosed with ALL in our department during the period of 2013.1-2014.12. The patients (follow random number table) were randomly divided into the control group (peptamen) and the treatment group (peptamen + glutamine), 24 cases in each group. The remission induction regimens were all based on VDLP (D) chemotherapy (VCR (Vincrisstine), DNR (Daunomycin), L-ASP (L-Asparagiase), Prednisolone and Dexamethasone). The treatment group received Gln-enriched nutritional therapy every day during the full course of chemotherapy,and the control group is as same as the treatment group except without glutamine. The indicators of general nutritional status, such as weight, height, and triceps skinfold thickness, and the indicators of biochemical tests, such as serum albumin, prealbumin, creatinine-height index, retinol binding protein, and urinary hydroxyproline index, were compared between the two groups at the end of the first, second, third and the fourth week when the chemotherapy was completed. And in the fourth week, flow cytometry was applied to detect the levels of T cell subsets and the activities of natural killer (NK) cells in peripheral blood of the two groups.

RESULTS

1. after 4 weeks nutritional therapy, there is no significant difference (p > 0.05) between the two groups of children in weight, height and other indicators. 2. At the end of 2 weeks treatment, the level of prealbumin (PA) and retinol-binding protein (RBP) is higher in treatment group than that in the control group (P <0.05), at the end of 3 weeks treatment, the thickness of triceps skinfold is higher (P <0.05) than that in the control group; 3. At the end of 3 and 4 weeks, the concentrations serum ALB, PA, RBP and UHI were higher than in the control group (P <0.05); 4. There is statistically significant (p < 0.05) between the two groups in edema incidence; 5. At the end of treatment (4 weeks), the percentages of CD3 +, CD4 +, CD4 +/CD8 +, NK cell are significantly decreased in the two groups (P <0.05).

CONCLUSION

Gln-enriched nutritional therapy can effectively improve the systemic nutritional status of children with leukemia, improve immune function.

The effect of glutamine intake on complications of colorectal and colon cancer treatment: A systematic review

Background:

Improvement in complications of antitumor agents and surgery is important to enhance life quality and survival among patients with colon and colorectal cancer. It has been reported that some dietary components such as glutamine (Gln) have beneficial effects on these complications of cancer therapies. However, the results of studies are inconsistent in this area. We performed a review on randomized controlled trials (RCTs) evaluating the effects of Gln intake on complications related to therapeutic strategies of the colon and colorectal cancer.

Materials and Methods:

A systematic search was conducted in PubMed, Google Scholar, Cochrane Library, and SID databases to find the relevant literature, published before July 2015.

Results:

Nine RCTs of 217 screened articles were included in this systematic review. The results of the present review suggested that Gln intake among colon and colorectal cancer patients could reduce some complications induced by chemotherapy such as gut mucositis and diarrhea and improve nitrogen balance, immune system and wound healing after surgery, whereas benefits role of Gln on radiochemotherapy side effects were not provided.

Conclusion:

The role of Gln intake on some improvement of complications induced by cancer therapeutic methods and shorten the length of hospital stay may be promising and one that is worthy of further exploration.

Effect of nutritional diet improvement on the digestive system of intensive care unit patients

AIM: To investigate the effect of improvement of nutritional diet on the digestive system of intensive care unit (ICU) patients.

METHODS: One hundred and twenty-six ICU patients treated from January and December 2014 at our hospital were randomly divided into an observation group and a control group, with 63 cases in each group. All cases received early enteral nutrition through a nasogastric tube. Nutrition was used in the control group, while an improved nutritional diet, which mixed Sanku compound nutrition and protein nutrition at 2:1, was used in the observation group. The incidences of gastrointestinal complications such as diarrhea, constipation, and gastric retention, score of gastrointestinal function and patient's

satisfaction were compared between the two groups.

RESULTS: The incidences of diarrhea, constipation, and gastric retention after nasal feeding in the observation group were significantly lower than those in the control group (P < 0.05). The scores of gastrointestinal function on 3 and 7 d after nasal feeding in the observation group were significantly lower than those in the control group (P < 0.05). The patients' satisfaction and total satisfaction rate in the observation group were significantly better than those in the control group (P < 0.05).

CONCLUSION: Nutritional diet improvement in ICU patients could significantly reduce the risk of gastrointestinal dysfunction, promote the recovery of digestive system function, and improve the patients' satisfaction.

Effects of glutamine and valsartan on the brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide of patients with chronic heart failure

OBJECTIVE

To analyze the effects of glutamine and valsartan on the brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) of patients with chronic heart failure (CHF).

METHODS

A total of 140 CHF patients were divided into a treatment group and a control group by random drawing, and were subjected to standard anti-heart failure treatment and administered with valsartan. Besides, the treatment group was also intravenously transfused glutamine. The treatment lasted eight weeks.

RESULTS

The overall efficacy of treatment group and control group were 98.6% and 90.0% respectively, with a statistically significant difference (P<0.05). The two groups had significantly increased left ventricular ejection fractions as well as significantly decreased left ventricular end-diastolic volumes and left ventricular end-diastolic dimensions after treatments (P<0.05) compared with those before. There were also inter-group differences between these values (P<0.05). After treatment, the levels of BNP, NT-proBNP and CD8(+) in both groups significantly decreased (P<0.05), whereas those of CD4(+) significantly increased (P<0.05). The two groups also had significantly different values (P<0.05).

CONCLUSION

Glutamine in combination with valsartan enhanced the therapeutic effects by improving cardiac function, which may be associated with decreased expressions of BNP and NT-proBNP and beneficial effects of glutamine on immune function.

Glutamine effects on heat shock protein 70 and interleukines 6 and 10: Randomized trial of glutamine supplementation versus standard parenteral nutrition in critically ill children

BACKGROUND & AIMS

To determine whether glutamine (Gln) supplementation would have a role modifying both the oxidative stress and the inflammatory response of critically ill children.

METHODS

Prospective, randomized, double-blind, interventional clinical trial. Selection criteria were children requiring parenteral nutrition for at least 5 days diagnosed with severe sepsis or post major surgery. Patients were randomly assigned to standard parenteral nutrition (SPN, 49 subjects) or standard parenteral nutrition with glutamine supplementation (SPN + Gln, 49 subjects).

RESULTS

Glutamine levels failed to show statistical differences between groups. At day 5, patients in the SPN + Gln group had significantly higher levels of HSP-70 (heat shock protein 70) as compared with the SPN group (68.6 vs 5.4, p = 0.014). In both groups, IL-6 (interleukine 6) levels showed a remarkable descent from baseline and day 2 (SPN: 42.24 vs 9.39, p < 0.001; SPN + Gln: 35.20 vs 13.80, p < 0.001) but only the treatment group showed a statistically significant decrease between day 2 and day 5 (13.80 vs 10.55, p = 0.013). Levels of IL-10 (interleukine 10) did not vary among visits except in the SPN between baseline and day 2 (9.55 vs 5.356, p < 0.001). At the end of the study, no significant differences between groups for PICU and hospital stay were observed. No adverse events were detected in any group.

CONCLUSIONS

Glutamine supplementation in critically-ill children contributed to maintain high HSP-70 levels for longer. Glutamine supplementation had no influence on IL-10 and failed to show a significant reduction of IL-6 levels.

Effects of oral glutamine during abdominal radiotherapy on chronic radiation enteritis: a randomized controlled trial

OBJECTIVE

Glutamine has been proposed as a preventive treatment for toxicity related to cancer therapies. The aim of this study was to test the efficacy of glutamine in the prevention of radiation enteritis.

METHODS

A randomized, double-blind, controlled trial was performed including 69 patients who were assigned to receive either glutamine (Gln, 30 g/d) or placebo while they were receiving abdominal radiotherapy. Patients were re-evaluated 1 y after completion of treatment. The presence of chronic enteritis was assessed using the Radiation Therapy Oncology Group scale. Nutritional status was evaluated using subjective global assessment, weight, and bioimpedance. Relative risk (RR) and its confidence interval (CI) were also calculated.

RESULTS

The trial initially included 69 patients (34 Gln, 35 placebo), but 11 patients were lost during follow-up (4 Gln, 7 placebo; P = 0.296). Chronic enteritis was developed by 14 % of patients: Gln 16.7 % versus placebo 11.1% (RR = 1.33; 95% CI, 0.35-5.03; P = 0.540). Most cases of enteritis were grade I (75%), with no differences between groups. The stool frequency increased after radiotherapy in patients who received Gln (from 1 ± 1 to 2 ± 2 stools per day, P = 0.012), but remained unchanged with placebo (1 ± 1 stools per day, P = 0.858; difference between groups P = 0.004). There were no differences between the two groups in terms of weight, fat mass, or fat-free mass index, or between patients with enteritis and those without intestinal toxicity.

CONCLUSIONS

Chronic enteritis is a relatively infrequent phenomenon, and Gln administration during radiotherapy does not exert a protective effect.

Complementary strategies for the management of radiation therapy side effects

Patients with cancer utilize complementary and alternative medicine (CAM) for a variety of purposes, one of which is the reduction of side effects of conventional treatment. With a large number of their patients using CAM, it is important for advanced practitioners in oncology to have an understanding of these therapies to better guide their patients. Side effects of radiation therapy that may have dose-limiting poten-tial include diarrhea, mucositis, skin toxicity, and xerostomia. A com-mon side effect that is not necessarily dose-limiting but considerably troublesome to patients is cancer- and treatment-related fatigue. The CAM therapies that may alleviate some of the side effects of radiation therapy include probiotics, psyllium, exercise, melatonin, honey, acu-puncture, and calendula. Therapies that require more research or have been shown to be ineffective include aloe vera, glutamine, and deglyc-yrrhizinated licorice. This article provides an overview of these thera-pies as well as related research and analysis.

Clinical effects of glutamine and dietary fiber enhanced enteral nutrition in critically ill trauma patients

AIM: To explore the clinical effects of glutamine and dietary fiber enhanced enteral nutrition (EN) in critically ill trauma patients.

METHODS: Eighty-six patients with critically ill trauma were randomly divided into either an experiment group or a control group. Patients in both groups were treated by conventional EN. On the basis of conventional EN, the experiment group was additionally given glutamine (Gln) and soluble dietary fiber. The levels of heamoglobin (HGB), total serum protein (TP), albumin (ALB), CD4⁺, CD8⁺, CD4⁺/CD8⁺, IgA, IgG, IgM, fasting blood glucose (FBG), C-reactive protein (CRP) and the gastrointestinal adverse effects were compared between the two groups and between before and after treatment.

RESULTS: In both groups, the levels of HGB, TP, ALB, CD4⁺, CD4⁺/CD8⁺, IgA, IgG, and IgM were significantly higher (130.77 g/L ± 10.21 g/L vs 94.55 g/L ± 7.24 g/L, 67.87 g/L ± 2.21 g/L vs 50.95 g/L ± 10.23 g/L, 36.87 g/L ± 2.41 g/L vs 21.55 g/L ± 4.24 g/L, 50.02% ± 8.62% vs 42.19%± 9.52%, 2.37 ± 0.06 vs 1.61 ± 0.08, 3.32 g/L ± 0.67 g/L vs 2.20 g/L ± 0.69 g/L, 15.11 g/L ± 3.85 g/L vs 10.40 g/L ± 2.59 g/L, 1.79 g/L ± 0.45 g/L vs 1.39 g/L ± 0.49 g/L, 110.39 g/L ± 9.88 g/L vs 97.72 g/L ± 8.36 g/L, 59.39 g/L ± 3.00 g/L vs 40.77 g/L ± 3.06 g/L, 30.79 g/L ± 2.33 g/L vs 20.59 g/L ± 5.54 g/L, 46.22% ± 6.58% vs 41.44% ± 7.87%, 2.53 ± 0.06 vs 1.67 ± 0.07, 2.45 g/L ± 0.51 g/L vs 2.19 g/L ± 0.65 g/L, 12.24 g/L ± 3.82 g/L vs 10.48 g/L ± 3.03 g/L, 1.69 g/L ± 0.53 g/L vs 1.24 g/L ± 0.44 g/L; P < 0.05 or P < 0.01), and the levels of CD8⁺, FBG, and CRP were significantly lower (19.94% ± 2.66% vs 25.20% ± 5.27%, 8.11 mmol/L ± 2.06 mmol/L vs 14.57 mmol/L ± 2.12 mmol/L, 1.49 mg/L ± 0.39 mg/L vs 6.53 mg/L L ± 1.33 mg/L, 19.13% ± 2.15% vs 25.17% ± 3.32%, 10.79 mmol/L ± 1.33 mmol/L vs 14.64 mmol/L ± 2.31 mmol/L, 5.19 mg/L ± 2.11 mg/L vs 6.51 mg/L ± 1.44 mg/L; P < 0.05 or P < 0.01) after EN than before EN. After EN, the levels of HGB, TP, ALB, CD4⁺, IgA, and IgG in the experiment group were significantly higher than those in the control group (130.77 g/L ± 10.21 g/L vs 110.39 g/L ± 9.88 g/L, 67.87 g/L ± 2.21 g/L vs 59.39 g/L ± 3.00 g/L, 36.87 g/L ± 2.41 g/L vs 30.79 g/L ± 2.33 g/L, 50.02% ± 8.62% vs 46.22% ± 6.58%, 3.32 g/L ± 0.67 g/L vs 2.45 g/L ± 0.51 g/L, 15.11 g/L ± 3.85 g/L vs 12.24 g/L ± 3.82 g/L; P < 0.05 or P < 0.01), while the levels of FBG, CRP and the rate of constipation were significantly lower in the experiment group than in the control group (8.11 mmol/L ± 2.06 mmol/L vs 10.79 mmol/L ± 1.33 mmol/L, 1.49 mg/L ± 0.39 mg/L vs 5.19 mg/L ± 2.11 mg/L, 13.95% vs 30.23%; P < 0.05 or P < 0.01).

CONCLUSION: Glutamine and dietary fiber enhanced enteral nutrition can improve the nutritional status and immune function, promote the gastrointestinal vermicular motion, and thereby improve the gastrointestinal function.

Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy

BACKGROUND

Across the developed world, an estimated 150,000 to 300,000 people are treated annually with pelvic radiotherapy and 80% will develop gastrointestinal (GI) symptoms during treatment. Acute GI symptoms are associated with a greater risk of chronic, often debilitating, GI symptoms. Up to one-third of patients are malnourished before pelvic radiotherapy and up to four-fifths of patients lose weight during treatment. Malnutrition is linked to a higher risk of GI toxicity, which can lead to breaks in radiotherapy and early cessation of chemotherapy, thus compromising the efficacy of the primary cancer treatment.

OBJECTIVES

To assess the effects of nutritional interventions for reducing GI toxicity in adults undergoing radical pelvic radiotherapy.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 4, 2012, MEDLINE and EMBASE to May 2012. We handsearched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials.

SELECTION CRITERIA

We included studies if they were randomised controlled trials (RCTs) or non-randomised studies with concurrent comparison groups including quasi-randomised trials, cluster RCTs, non-randomised trials, prospective and retrospective cohort studies, and case series of 30 or more patients. We only included studies if they assessed the effect of a nutritional intervention in adults aged 18 years or over undergoing radical pelvic radiotherapy as part of anticancer treatment for a primary pelvic malignancy. We excluded patients with stomas and a previous history of inflammatory bowel disease. Nutritional support interventions could be provided at any stage before or during pelvic radiotherapy and included dietary counselling; dietary modification of fibre, lactose or fat; supplementary foods or drinks or fortified foods; standard oral nutrition supplements including polymeric-, peptide- or amino acid-based supplements and those where novel substrates have been added; enteral tube feeds; or parenteral nutrition (partial or total). We excluded probiotics, prebiotics and synbiotics.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors to obtain missing data. We assessed bias for each of the included studies using the bias assessment tables in the Cochrane software Review Manager5. We performed meta-analysis, when indicated, using the Mantel-Haenszel fixed-effect method or inverse variance fixed-effect method displayed with heterogeneity. We undertook meta-analyses on trials evaluating dietary modification against standard treatment for diarrhoea at the end of radiotherapy and for change in weight from baseline to end of radiotherapy.

MAIN RESULTS

The searches identified 7558 titles, and we excluded 7513 during title and abstract searches. We reviewed 45 papers in full, and excluded 39. We identified four studies on handsearching of the references, which, along with the six eligible papers from the database search, led to 10 studies being included. Four studies, three of which were RCTs and one prospective study, investigated the effect of elemental diet on GI symptoms; one RCT investigated the effect of dietary modification and elemental diet; and five RCTs investigated dietary modification. Studies were varied in terms of risk of bias. Data were dichotomised for presence and absence of diarrhoea at the end of radiotherapy for four trials evaluating dietary modification comprising modified fat, lactose, fibre or combinations of these dietary changes. A reduction in diarrhoea was demonstrated with nutritional intervention (risk ratio (RR) 0.66; 95% confidence interval (CI) 0.51 to 0.87, four studies, 413 participants, moderate quality of evidence) with low heterogeneity (Chi(2) = 3.50, I(2) = 14%). Two trials evaluating dietary modification on weight change (comparing baseline and end of radiotherapy) showed no difference between intervention or control (mean difference (MD) -0.57 kg; 95% CI -1.22 to 0.09) with low heterogeneity (Chi(2) = 1.41, I(2) = 29%). Generally adverse effects were poorly reported in included studies. Elemental diet in particular was poorly tolerated. GI symptoms or toxicity > 6 months after radiotherapy was not reported in included studies

AUTHORS' CONCLUSIONS

There have been benefits demonstrated with dietary modification during pelvic radiotherapy to reduce diarrhoea. Those diets included single interventions or combinations of modified fat, lactose-restriction, fat-restriction and fibre supplementation. We were unable to meta-analyse elemental diet, as data were not available. We considered some of the studies to be at high risk of bias. There have been recent advances in novel, more targeted radiotherapy techniques, such that the findings of older studies need to be interpreted with caution. In addition, there were problems with compliance and palatability with some of the interventions, particularly elemental diet, which limits its usefulness in clinical practice.

Efficacy of glutamine in the prevention of acute radiation enteritis: a randomized controlled trial

BACKGROUND

Acute radiation enteritis is a common adverse effect related to radiotherapy (RT). Glutamine is an immune modulator and antioxidant amino acid that can exert a protective role in patients receiving abdominal or pelvic radiation. The aim of this study was to test if glutamine prevents radiation enteritis during RT.

MATERIALS AND METHODS

Double-blind, randomized, controlled trial including 69 patients who needed RT because of pelvic or abdominal malignancies and received glutamine (30 g/d) or placebo (casein, 30 g/d). Enteritis was evaluated according to the Radiation Therapy Oncology Group scale, intestinal inflammation using fecal calprotectin, and gut integrity with citrulline. The incidence of enteritis was analyzed by Kaplan-Meier curves, and the hazard ratio (HR) was calculated using Cox regression.

RESULTS

Patients were predominantly male (65.2%), with an average (SD) age of 66.6 (9.9) years, with urologic (44.9%), rectal (24.6%), or gynecological cancer (23.1%). More patients developed enteritis with glutamine than with the placebo (55.9% vs 22.0%; P = .002), with an HR OF 1.59 (95% confidence interval, 0.624.05). There were no differences in final calprotectin levels (glutamine, 57.9 [85.8] mg/kg vs placebo, 54.0 [57.7] mg/kg; p = .182) or the number of patients with values 50 mg/kg (glutamine, 58.1% vs placebo, 54.6%; p = .777). Final citrulline levels were similar between groups (glutamine, 26.31 [10.29] mmol/l vs placebo, 27.69 [12.31] mmol/l; p = .639), without differences in the number of patients with 20 mmol/l (glutamine, 24.1% vs placebo, 25.0%; P = .938). Citrulline concentration was reduced during rt with placebo but remained unchanged with glutamine.

CONCLUSION

Glutamine does not prevent the development of enteritis during RT.

Nutrition therapy issues in esophageal cancer

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.