1
|
Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Collapse
Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| |
Collapse
|
2
|
Wauters L, Joly F. Treatment of short bowel syndrome: Breaking the therapeutic ceiling? Nutr Clin Pract 2023; 38 Suppl 1:S76-S87. [PMID: 37115030 DOI: 10.1002/ncp.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.
Collapse
Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| |
Collapse
|
3
|
Cuerda C, Pironi L, Arends J, Bozzetti F, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Bischoff SC. ESPEN practical guideline: Clinical nutrition in chronic intestinal failure. Clin Nutr 2021; 40:5196-5220. [PMID: 34479179 DOI: 10.1016/j.clnu.2021.07.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
Collapse
Affiliation(s)
- Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Lyn Gillanders
- Emeritus of Auckland City Hospital, Auckland, New Zealand
| | - Palle Bekker Jeppesen
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Emeritus of Mayo Graduate School of Medicine, Rochester, Minnesota
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Stephan C Bischoff
- Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
| | | |
Collapse
|
4
|
Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Nutrients 2020; 12:nu12020520. [PMID: 32085587 PMCID: PMC7071274 DOI: 10.3390/nu12020520] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022] Open
Abstract
This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and <1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient.
Collapse
Affiliation(s)
- Jocelyn Ou
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Cathleen M. Courtney
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Allie E. Steinberger
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Maria E. Tecos
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
- Correspondence: ; Tel.: 314-454-6022
| |
Collapse
|
5
|
Effect of oral citrulline supplementation on whole body protein metabolism in adult patients with short bowel syndrome: A pilot, randomized, double-blind, cross-over study. Clin Nutr 2019; 38:2599-2606. [DOI: 10.1016/j.clnu.2018.12.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/27/2018] [Accepted: 12/26/2018] [Indexed: 11/19/2022]
|
6
|
Kim MH, Kim H. The Roles of Glutamine in the Intestine and Its Implication in Intestinal Diseases. Int J Mol Sci 2017; 18:ijms18051051. [PMID: 28498331 PMCID: PMC5454963 DOI: 10.3390/ijms18051051] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 12/16/2022] Open
Abstract
Glutamine, the most abundant free amino acid in the human body, is a major substrate utilized by intestinal cells. The roles of glutamine in intestinal physiology and management of multiple intestinal diseases have been reported. In gut physiology, glutamine promotes enterocyte proliferation, regulates tight junction proteins, suppresses pro-inflammatory signaling pathways, and protects cells against apoptosis and cellular stresses during normal and pathologic conditions. As glutamine stores are depleted during severe metabolic stress including trauma, sepsis, and inflammatory bowel diseases, glutamine supplementation has been examined in patients to improve their clinical outcomes. In this review, we discuss the physiological roles of glutamine for intestinal health and its underlying mechanisms. In addition, we discuss the current evidence for the efficacy of glutamine supplementation in intestinal diseases.
Collapse
Affiliation(s)
- Min-Hyun Kim
- Food Science and Human Nutrition Department, Center for Nutritional Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, FL 32611, USA.
| | - Hyeyoung Kim
- Department of Food and Nutrition, Brain Korea 21 PLUS Project, College of Human Ecology, Yonsei University, Seoul 03722, Korea.
| |
Collapse
|
7
|
Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K. Short Bowel Syndrome: Clinical Guidelines for Nutrition Management. Nutr Clin Pract 2017; 20:493-502. [PMID: 16207689 DOI: 10.1177/0115426505020005493] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.
Collapse
Affiliation(s)
- Laura E Matarese
- Intestinal Rehabilitation and Transplant Center, Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
| | | | | | | | | | | |
Collapse
|
8
|
Compher C, Rubesin S, Kinosian B, Madaras J, Metz D. Noninvasive Measurement of Transit Time in Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2017; 31:240-5. [PMID: 17463151 DOI: 10.1177/0148607107031003240] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with short bowel syndrome (SBS) have limited absorption of nutrients, in part because of the rapidity with which chyme passes through the bowel. We sought to evaluate noninvasive measurements of intestinal transit time to aid in research questions where transit is measured repeatedly. METHODS Three methods were compared in 8 patients with SBS: the time for blue food color to appear in ostomy effluent or stool, lactulose breath hydrogen testing, and the first radiopaque ring from a capsule in timed stool samples. RESULTS Median blue dye fasted transit was 96.3 minutes, with breakfast was 117.3 minutes, and with lactulose was 72 minutes. By breath hydrogen testing, transit time was 52.5 minutes but detectible in only 5 of 13 tests. Transit time by radiopaque marker was 967 minutes, but no markers passed in 7 of 14 tests. CONCLUSIONS Visualization of blue food color in ostomy effluent is a simple, inexpensive approach that can be applied to fasted subjects or after specific meals. Breath hydrogen testing should only be applied in the rare patient with SBS who has an intact ileocecal valve. Radiopaque markers are less useful, most likely because they become trapped due to anatomic changes.
Collapse
Affiliation(s)
- Charlene Compher
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania 19104-6096, USA.
| | | | | | | | | |
Collapse
|
9
|
Brown CR, DiBaise JK. Intestinal Rehabilitation: A Management Program for Short-Bowel Syndrome. Prog Transplant 2016; 14:290-6; quiz 297-8. [PMID: 15663014 DOI: 10.1177/152692480401400404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the last 3 decades, there has been significant improvement in the survival and quality of life of patients who require home parenteral nutrition; however, parenteral nutrition remains costly, is associated with multiple complications, and does not promote the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy and decreasing dependence on parenteral nutrition by utilizing dietary, pharmacological, and, occasionally, surgical interventions. A major focus of research has been to identify a trophic factor that will enhance adaptation of the remaining gastrointestinal tract following massive gut resection and allow enteral autonomy. Whether intestinal rehabilitation occurs as the result of increased intestinal adaptation or as the result of a comprehensive approach to care has yet to be determined. This article reviews intestinal failure as the result of short-bowel syndrome and the management strategy of an intestinal rehabilitation program in the care of these patients.
Collapse
Affiliation(s)
- Cindy R Brown
- Department of Surgery, University of Nebraska Medical Center, Omaha, Neb., USA
| | | |
Collapse
|
10
|
Promoting intestinal adaptation by nutrition and medication. Best Pract Res Clin Gastroenterol 2016; 30:249-61. [PMID: 27086889 DOI: 10.1016/j.bpg.2016.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
The ultimate goal in the treatment of short bowel syndrome is to wean patients off parenteral nutrition, by promoting intestinal adaptation. Intestinal adaptation is the natural compensatory process that occurs after small bowel resection. Stimulating the remaining bowel with enteral nutrition can enhance this process. Additionally, medication can be used to either reduce factors that complicate the adaptation process or to stimulate intestinal adaptation, such as antisecretory drugs and several growth factors. The aim of this review was to provide an overview of the best nutritional strategies and medication that best promote intestinal adaptation.
Collapse
|
11
|
Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 445] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
Collapse
Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | | |
Collapse
|
12
|
van Zanten ARH, Dhaliwal R, Garrel D, Heyland DK. Enteral glutamine supplementation in critically ill patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:294. [PMID: 26283217 PMCID: PMC4539709 DOI: 10.1186/s13054-015-1002-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/17/2015] [Indexed: 12/05/2022]
Abstract
Introduction Glutamine (GLN) has been suggested to have a beneficial influence on outcomes of critically ill patients. However, recent large-scale trials have suggested harm associated with GLN supplementation. Recently, systematic reviews on the use of parenteral GLN have been published; however, less information is available on the role of enteral GLN. Therefore, the aim of this systematic review was to study the effects of enteral GLN supplementation in patients with critical illness. Methods We identified randomized controlled trials conducted from 1980 to 2014 with enterally administered GLN in adult critically ill patients. Studies of parenteral GLN only or combined enteral-parenteral GLN were excluded. The methodological quality of studies was scored, and trial data were statistically combined. We examined a priori the treatment effects in subgroups of trials of burn and trauma patients. Results A total of 11 studies involving 1079 adult critically ill patients and enteral GLN supplementation were identified. Enteral GLN supplementation was not associated with a reduction of hospital mortality (risk ratio [RR] 0.94, 95 % confidence interval [CI] 0.65–1.36; p =0.74), infectious complications (RR 0.93, 95 % CI 0.79–1.10; p =0.39) or stay in the intensive care unit (weighted mean difference [WMD] −1.36 days, 95 % CI −5.51 to 2.78; p =0.52). However, there was a significant reduction in hospital stay (WMD 4.73 days, 95 % CI −8.53 to −0.90; p =0.02). In the subset of studies of patients with burns, enteral GLN supplementation was associated with significant reductions in hospital mortality (RR 0.19, 95 % 0.06–0.67; p =0.010) and hospital stay (WMD −9.16, 95 % CI −15.06 to −3.26; p =0.002). There was no effect in trauma patients. Conclusions Enteral GLN supplementation does not confer significant clinical benefit in critically ill patients, with the exception of reduced hospital stay. There may be a significant benefit in patients with burns, but data are sparse and larger randomized trials are warranted to confirm this effect.
Collapse
Affiliation(s)
- Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
| | - Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Dominique Garrel
- Department of Nutrition, University of Montreal, Pavillon Liliane de Stewart, 2405, Chemin de la Côte-Sainte-Catherine, Local 1204, Montreal, QC, H3T 1A8, Canada.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| |
Collapse
|
13
|
Seguy D, Darmaun D, Duhamel A, Thuillier F, Cynober L, Cortot A, Gottrand F, Messing B. Growth hormone enhances fat-free mass and glutamine availability in patients with short-bowel syndrome: an ancillary double-blind, randomized crossover study. Am J Clin Nutr 2014; 100:850-8. [PMID: 25080462 DOI: 10.3945/ajcn.113.071845] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Benefits of recombinant human growth hormone (rhGH) alone or combined with glutamine in patients with intestinal failure because of short-bowel syndrome remain controversial. OBJECTIVE We explored effects of rhGH on whole-body protein metabolism in patients with short-bowel syndrome with intestinal failure (SBS-IF) to gain insight into its mechanism of action. DESIGN Eight stable hyperphagic patients with severe SBS-IF received, in a double-blind, randomized crossover study, low-dose rhGH (0.05 mg · kg⁻¹ · d⁻¹) and a placebo for two 3-wk periods. Leucine and glutamine kinetics under fasting and fed conditions, fat-free mass (FFM), and serum insulin were determined on the final day of each treatment. RESULTS rhGH increased FFM and nonoxidative leucine disposal (NOLD; an index of protein synthesis) (P < 0.02), whereas FFM and NOLD were correlated in the fed state (r = 0.81, P = 0.015). With rhGH administration, leucine release from protein breakdown (an index of proteolysis) decreased in the fed compared with fasting states (P = 0.012), which was not observed with the placebo. However, the fast-to-fed difference in leucine release from protein breakdown was not significantly different between rhGH and placebo (P = 0.093). With rhGH, the intestinal absorption of leucine and glutamine increased (P = 0.036) and correlated with serum insulin (r = 0.91, P = 0.002). rhGH increased glutamine de novo synthesis (P < 0.02) and plasma concentrations (P < 0.03) in both fasting and fed states. CONCLUSIONS In SBS-IF patients, feeding fails to decrease proteolysis in contrast to what is physiologically observed in healthy subjects. rhGH enhances FFM through the stimulation of protein synthesis and might decrease proteolysis in response to feeding. Improvements in de novo synthesis and intestinal absorption increase glutamine availability over the physiologic range, suggesting that beneficial effects of rhGH in hyperphagic patients might be achieved without glutamine supplementation.
Collapse
Affiliation(s)
- David Seguy
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Dominique Darmaun
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Alain Duhamel
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - François Thuillier
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Luc Cynober
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Antoine Cortot
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Frédéric Gottrand
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| | - Bernard Messing
- From the Service de Nutrition Lille, France (DS); the Institut National de la Santé et de la Recherche Médicale, Lille, Unité U995, Université Lille Nord de France, Lille, France (DS and FG); the Département de Biostatistiques, Equipe d'Accueil EA2694, Lille, France (AD); the Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord de France, Lille, France (DS, AD, AC, and FG); the Institut National de la Recherche Agronomique Unité Mixte de Recherche 1280, Centre de Recherche en Nutrition Humaine, Université de Nantes, Nantes, France (DD); the Laboratoire de Biochimie, Centre Hospitalier, Meaux, France (FT); the Service Interhospitalier de Biochimie Cochin, Assistance Publique-Hôpitaux de Paris et Equipe d'Accueil EA4466, Faculté de Pharmacie, Université Paris Descartes, Paris, France (LC); and the Université Paris 7 Denis Diderot, Paris, France (BM)
| |
Collapse
|
14
|
|
15
|
Aydoğmuş MT, Tomak Y, Tekin M, Katı I, Hüseyinoğlu U. Glutamine supplemented parenteral nutrition to prevent ventilator-associated pneumonia in the intensive care unit. Balkan Med J 2012; 29:414-8. [PMID: 25207045 DOI: 10.5152/balkanmedj.2012.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 05/30/2012] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Ventilator-associated pneumonia (VAP) is a form of nosocomial pneumonia that increases patient morbidity and mortality, length of hospital stay, and healthcare costs. Glutamine preserves the intestinal mucosal structure, increases immune function, and reduces harmful changes in gut permeability in patients receiving total parenteral nutrition (TPN). We hypothesized that TPN supplemented by glutamine might prevent the development of VAP in patients on mechanical ventilator support in the intensive care unit (ICU). MATERIAL AND METHODS With the approval of the ethics committee and informed consent from relatives, 60 patients who were followed in the ICU with mechanical ventilator support were included in our study. Patients were divided into three groups. The first group received enteral nutrition (n=20), and the second was prescribed TPN (n=20) while the third group was given glutamine-supplemented TPN (n=20). C-reactive protein (CRP), sedimentation rate, body temperature, development of purulent secretions, increase in the amount of secretions, changes in the characteristics of secretions and an increase in requirement of deep tracheal aspiration were monitored for seven days by daily examination and radiographs. RESULTS No statistically significant difference was found among groups in terms of development of VAP (p=0.622). CONCLUSION Although VAP developed at a lower rate in the glutamine-supplemented TPN group, no statistically significant difference was found among any of the groups. Glutamine-supplemented TPN may have no superiority over unsupplemented enteral and TPN in preventing VAP.
Collapse
Affiliation(s)
- Meltem Türkay Aydoğmuş
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Yakup Tomak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Rize University, Rize, Turkey
| | - Murat Tekin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Ismail Katı
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Urfettin Hüseyinoğlu
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| |
Collapse
|
16
|
Lund P, Sangild PT, Aunsholt L, Hartmann B, Holst JJ, Mortensen J, Mortensen PB, Jeppesen PB. Randomised controlled trial of colostrum to improve intestinal function in patients with short bowel syndrome. Eur J Clin Nutr 2012; 66:1059-65. [PMID: 22828734 DOI: 10.1038/ejcn.2012.93] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Colostrum is rich in immunoregulatory, antimicrobial and trophic components supporting intestinal development and function in newborns. We assessed whether bovine colostrum could enhance intestinal adaptation and function in adult short bowel syndrome (SBS) patients. SUBJECTS/METHODS Twelve SBS patients in this randomised cross-over study received 4 weeks oral supplement of bovine colostrum or an iso-energetic and iso-proteinaceous control (2.4 MJ/d, 500 ml/day) separated by a 4-week washout period. Patients were admitted four times for 72-h periods of fluid, electrolyte and nutrient balance studies. Meals, faeces and urine were weighed, and energy, macronutrient and electrolyte contents were analysed to calculate net nutrient uptake. Body composition was measured by dual-energy X-ray absorptiometry scans, and functional tests of handgrip strength and lung functions were performed. Eight patients completed the study and were included in the analysis. RESULTS Both supplements (colostrum and control) not only increased protein (0.96 ± 0.42 MJ/d, P=0.004 1.03 ± 0.44 MJ/d, P=0.003) and energy (1.46 ± 1.02 MJ/d, P=0.005, 1.76 ± 1.46 MJ/d, P=0.01) absorption but also absolute faecal wet weight excretions (231 ± 248 g/d, P=0.002, 319 ± 299 g/d, P=0.03), compared with baseline measurements. Both supplements improved handgrip strength (P=0.03) while only the control supplement increased lean body mass (1.12 ± 1.33 kg, P<0.049). Colostrum was not found to be superior to the control. CONCLUSION Intake of high-protein milk supplements increased net nutrient absorption for adult SBS patients, but at the expense of increased diarrhoea. Despite high contents of bioactive factors, colostrum did not significantly improve intestinal absorption, body composition or functional tests compared with the control.
Collapse
Affiliation(s)
- P Lund
- Department of Gastroenterology CA-2121, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Donnellan CF, Lal S. The future developments in nutrition. Frontline Gastroenterol 2012; 3:i28-i32. [PMID: 28839689 PMCID: PMC5551954 DOI: 10.1136/flgastro-2012-100137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 02/28/2012] [Indexed: 02/04/2023] Open
Abstract
Malnutrition is both a cause and consequence of disease. It is imperative that evidence-based approaches to detect and treat malnutrition are embedded into routine practice; these can range from routine malnutrition screening, the safe and appropriate use of enteral feeding and managing more complex patients with intestinal failure. This article outlines service developments over the next 5 years that may enable all hospitals to achieve optimal standards of care for a malnourished patient and examines the role of developments in clinical nutrition over the next 5-10 years.
Collapse
Affiliation(s)
- C F Donnellan
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - S Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
18
|
Tee CT, Wallis K, Gabe SM. Emerging treatment options for short bowel syndrome: potential role of teduglutide. Clin Exp Gastroenterol 2011; 4:189-96. [PMID: 22016579 PMCID: PMC3190286 DOI: 10.2147/ceg.s13906] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Current medical management of short bowel syndrome (SBS) involves the use of lifelong parenteral nutrition (PN). Glucagon-like peptide-2 (GLP-2), an important intestinotrophic growth factor has been shown to increase intestinal absorption in SBS through augmentation of post-resection intestinal adaptation. This may lead to the reduction of PN dependence in patients with SBS. AREAS COVERED IN REVIEW Advancing research of GLP-2 physiology has spurred the growing understanding of the diverse effects of GLP-2. The development of the degradation resistant GLP-2 analog, teduglutide (Gattex(TM), NPS Pharmaceuticals, Bedminster, NJ), has allowed its exploration as a therapeutic agent in a variety of clinical settings. Recent multicenter, placebo-controlled studies of GLP-2 in SBS patients demonstrate meaningful reductions in PN requirements with good safety profiles. The reparative and immunomodulatory effects of teduglutide may also be beneficial in patients with inflammatory bowel disease (IBD). Safety concerns about possible carcinogenic properties during long-term use require ongoing evaluation. SUMMARY GLP-2 appears to offer a novel adjuvant treatment modality for SBS. Promise for its use in other clinical settings like IBD has been shown in small pilot studies.
Collapse
Affiliation(s)
- Cheng T Tee
- Lennard-Jones Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Harrow, UK
| | | | | |
Collapse
|
19
|
Abstract
The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.
Collapse
Affiliation(s)
- Claire L Donohoe
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, St James' Hospital, Dublin 8, Ireland
| | | |
Collapse
|
20
|
Wales PW, Nasr A, de Silva N, Yamada J. Human growth hormone and glutamine for patients with short bowel syndrome. Cochrane Database Syst Rev 2010:CD006321. [PMID: 20556765 DOI: 10.1002/14651858.cd006321.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND There has been clinical enthusiasm for treating short bowel patients with human recombinant growth hormone and/or glutamine in hopes of reducing parenteral nutrition dependency. It has been more than a decade since Byrne and colleagues reported enhanced absorption of nutrients, improved weight gain, and reduction in parenteral nutrition requirements with the administration of a combination of human growth hormone (HGH) and glutamine in patients with short bowel syndrome. Other studies have reported inconsistent results. OBJECTIVES The purpose of this systematic review was to evaluate the efficacy of growth hormone with or without glutamine supplementation for adult patients with short bowel syndrome. SEARCH STRATEGY Electronic searches were performed to identify all publications describing randomised controlled trials of the use of human growth hormone with or without glutamine for the treatment of patients with short bowel syndrome. SELECTION CRITERIA Randomised controlled trials of human growth hormone with or without glutamine for patients with short bowel syndrome were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from the published studies. The statistical analyses were performed using RevMan 5 software. Follmann's method was used for cross-over studies. MAIN RESULTS Five studies were included in the review. Human growth hormone with or without glutamine appears to provide benefit in terms of increased weight (MD 1.66 Kg; 95% CI 0.69 to 2.63;P = 0.0008), lean body mass (MD 1.93 Kg; 95% CI 0.97 to 2.90; P = 0.0001) energy absorption (MD 4.42 Kcal; 95% CI 0.26 to 8.58; P = 0.04) and nitrogen absorption (MD 44.85 g; 95%CI 0.20 to 9.49; P = 0.04) for patients with short bowel syndrome. The single RCT that focused on parenteral nutrition (PN) requirements demonstrated decreased PN volume and calories and number of infusions in patients who received HGH with or without glutamine supplementation. Only patients who received HGH with glutamine maintained statistically significant PN reductions at 3 month follow-up. AUTHORS' CONCLUSIONS The results suggest a positive effect of human growth hormone on weight gain and energy absorption. However, in the majority of trials, the effects are short-lived returning to baseline shortly after cessation of therapy. The temporary benefit calls into question the clinical utility of this treatment. To date, the evidence is inconclusive to recommend this therapy. Consideration should be made to studying patients during the active phase of intestinal adaptation rather than in the setting of chronic intestinal failure. The role of HGH in paediatric short bowel syndrome remains unknown.
Collapse
Affiliation(s)
- Paul W Wales
- Division of General Surgery and Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Rm 1526, 555 University Ave, Toronto, Ontario, Canada, M5G 1X8
| | | | | | | |
Collapse
|
21
|
Estívariz CF, Luo M, Umeakunne K, Bazargan N, Galloway JR, Leader LM, Ziegler TR. Nutrient intake from habitual oral diet in patients with severe short bowel syndrome living in the southeastern United States. Nutrition 2008; 24:330-9. [PMID: 18328409 DOI: 10.1016/j.nut.2007.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Revised: 11/05/2007] [Accepted: 12/20/2007] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Little data are published on the habitual home oral diet of patients with short bowel syndrome (SBS). METHODS We assessed nutrient intake from oral food and beverages in 19 stable patients with severe SBS who live in the southeastern United States. Intestinal absorption of energy, fat, nitrogen (N), and carbohydrate (CHO) was determined in a metabolic ward. RESULTS We studied 12 women and 7 men, age 48 +/- 3 y of age (mean +/- SE) receiving parenteral nutrition for 31 +/- 8 mo following massive small bowel resection (118 +/- 25 cm residual small bowel). The patients demonstrated severe malabsorption of energy (59 +/- 3% of oral intake), fat (41 +/- 5%), N (42 +/- 5%) and CHO (76 +/- 3%). Oral energy intake was 2656 +/- 242 kcal/d (39 +/- 3 kcal/kg/d) and oral protein intake was 1.4 +/- 0.1 g/kg/d. Food/beverage intake constituted 49 +/- 4% of total (enteral plus parenteral) daily fluid intake, 66 +/- 4% of total daily kcal and 58 +/- 5% of total daily N intake. Oral fat intake averaged 92 +/- 11 g/day ( approximately 35% of total oral energy). Oral fluid intake averaged 2712 +/- 240 ml/d, primarily from water, soft drinks, sweet tea and coffee. Simple sugars comprised 42 +/- 3% of oral CHO intake. Usual dietary intake of multiple micronutrients were below the Recommended Dietary Allowances (RDA) in a large percentage of patients: vitamin A (47%), vitamin D (79%), vitamin E (79%), vitamin K (63%), thiamine (42%), vitamin B6 (68%), vitamin B12 (11%), vitamin C (58%), folate (37%), iron (37%), calcium (63%), magnesium (79%) and zinc (68%). Only seven patients (37%) were taking oral multivitamin-mineral supplements and only six subjects (32%) were taking oral iron and calcium supplements, respectively. CONCLUSION In these SBS patients, an oral diet provided a significant proportion of daily nutrient intake. The types of foods and fluids consumed are likely to worsen malabsorption and thus increase PN requirements. Oral intake of essential micronutrients was very low in a significant proportion of these individuals.
Collapse
|
22
|
Horbach T. [Short bowel syndrome]. Chirurg 2006; 77:1169-81; quiz 1182. [PMID: 17131099 DOI: 10.1007/s00104-006-1261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Short bowel syndrome (SBS) is defined in adults as a malabsorption disorder as a result of shortening the bowel to <200 cm. The severity of symptoms is less dependent on the amount of residual intestine than on the anatomical position of the resected bowel, the type of operative reconstruction, and the type and quality of nutritional, medical, and surgical treatment. Numerous complications and deficiency symptoms are associated with SBS. The extent of deficient nutrition should be determined. The need to create accesses for enteral and parenteral delivery, to supply supplementation as needed, perform pharmacological therapy, and in individual cases surgical treatment all necessitate a broad knowledge of nutritional medicine. The goals of therapy are correction and prevention of malnourishment, restoration of a normal nutritional status, and the normal thriving of children. Complications should be avoided, particularly those problems associated with parenteral nutrition. The frequency of diarrhea should be reduced. Overall, the aim is to achieve an optimized quality of life.
Collapse
Affiliation(s)
- T Horbach
- Chirurgische Klinik, Universitätsklinikum Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Deutschland.
| |
Collapse
|
23
|
Zhou JN, Tan L, Wang XH, Ju HX. Effect of Enteral Nutrition Formula on Fat Absorption and Serum Free Fatty Acid Profiles in Rat with Short-Bowel Syndrome. CHINESE J CHEM 2006. [DOI: 10.1002/cjoc.200690255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
24
|
Messing B, Blethen S, Dibaise JK, Matarese LE, Steiger E. Treatment of adult short bowel syndrome with recombinant human growth hormone: a review of clinical studies. J Clin Gastroenterol 2006; 40 Suppl 2:S75-84. [PMID: 16770166 DOI: 10.1097/01.mcg.0000212677.06549.80] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Extensive resection of the intestinal tract frequently results in inadequate digestion and/or absorption of nutrients, a condition known as short bowel syndrome (SBS). Several therapies, including parenteral nutrition (PN), bowel rehabilitation, and surgical procedures to reconstruct the bowel, have been used for patients with SBS. However, these treatments only partially correct the underlying problem of reduced bowel function in some patients. This review investigates the results of studies of recombinant human growth hormone (r-hGH) in patients with SBS. In one randomized, controlled and five open-label studies, treatment with r-hGH significantly increased absorption of energy, protein and/or carbohydrates. Four studies also demonstrated significantly increased body weight, lean body mass, total body potassium and/or total body water in response to r-hGH. However, in two other randomized controlled trials, r-hGH had no significant effect on energy or fluid absorption. In one randomized, controlled study and six open-label trials, treatment with r-hGH also allowed a majority of patients, including those with no colon and significant bowel resection, to eliminate or substantially reduce PN. Optimal clinical benefits appear to be achieved when r-hGH is administered in combination with a specialized oral diet and perhaps with glutamine. Although the use of r-hGH to treat SBS patients remains controversial, results from these studies suggest that short-term r-hGH treatment in combination with optimized medical and dietetic treatments can enhance bowel absorption and function and, with the continuation of optimized medical and dietetic treatments, may reduce PN requirements for a wide range of patients with SBS.
Collapse
Affiliation(s)
- Bernard Messing
- Gastroenterology and Nutrition Support Department, Hôpital Beaujon, clichy, France.
| | | | | | | | | |
Collapse
|
25
|
Lochs H, Dejong C, Hammarqvist F, Hebuterne X, Leon-Sanz M, Schütz T, van Gemert W, van Gossum A, Valentini L, Lübke H, Bischoff S, Engelmann N, Thul P. ESPEN Guidelines on Enteral Nutrition: Gastroenterology. Clin Nutr 2006; 25:260-74. [PMID: 16698129 DOI: 10.1016/j.clnu.2006.01.007] [Citation(s) in RCA: 233] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 01/13/2006] [Indexed: 12/18/2022]
Abstract
Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.
Collapse
Affiliation(s)
- H Lochs
- Department of Gastroenterology, Charité-Universitätsmedizin, CCM, Berlin, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Sax HC. Specific nutrients in intestinal failure: one size fits no one. Gastroenterology 2006; 130:S91-2. [PMID: 16473078 DOI: 10.1053/j.gastro.2005.11.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Accepted: 11/14/2005] [Indexed: 12/02/2022]
|
27
|
Alpers DH. Glutamine: do the data support the cause for glutamine supplementation in humans? Gastroenterology 2006; 130:S106-16. [PMID: 16473057 DOI: 10.1053/j.gastro.2005.11.049] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 11/14/2005] [Indexed: 12/17/2022]
Abstract
This review examines the preclinical rationale for using glutamine supplements and reviews the prospective randomized trials using glutamine to improve outcomes in patients. A special role for glutamine in gut physiology and in management of a variety of serious illnesses has been suggested, because it is the most abundant extracellular amino acid, and is used at high rates by the gut, liver, central nervous system, and immune cells. A state of relative Gln deficiency has been postulated in humans based on the decrease in plasma Gln in acute critical illness, but the decrease in plasma Gln is not specific for that amino acid, predicts only poorer outcome, and has not been validated to identify a deficiency state. Current evidence does not necessarily predict a special need or role for Gln in critical illness. Clinical efficacy of supplemental Gln has been difficult to demonstrate, possibly related to the lack of a Gln deficiency state, the wide range of end points used that reflect the lack of certainty of the predicted effect of supplementation, the heterogeneous patient populations studied, the lack of stable clinical course during the study, the lack of adequate power, and the relatively short follow-up period. Prospective randomized clinical trials of Gln supplementation were reviewed in patients with short-bowel syndrome, during cancer chemotherapy and in bone marrow transplantation, and in surgical, burn, and intensive care unit patients. No firm recommendation can be made at this time. Future studies should seek to develop a more standard and stable design for intervention in sufficiently powered studies.
Collapse
Affiliation(s)
- David H Alpers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri 63110, USA.
| |
Collapse
|
28
|
Scolapio JS. Short bowel syndrome: recent clinical outcomes with growth hormone. Gastroenterology 2006; 130:S122-6. [PMID: 16473059 DOI: 10.1053/j.gastro.2005.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 08/24/2005] [Indexed: 12/02/2022]
Abstract
There has been recent clinical enthusiasm for treating short bowel patients with either human recombinant growth hormone alone or in combination with glutamine and diet in hopes of reducing their parenteral nutrition requirements. Part of this interest has been the result of studies done in short bowel animal models showing increased bowel growth and function following such treatment. Since 1995, 5 key clinical studies have been published in peer-reviewed literature reporting the effects of growth hormone alone or in combination with glutamine and diet in patients with short bowel syndrome. Three of these controlled studies have reported negative results, and 1 controlled and 1 uncontrolled study reported positive results. This review discusses each of these articles and provides some explanation on how these studies and results may have differed.
Collapse
Affiliation(s)
- James S Scolapio
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA.
| |
Collapse
|
29
|
|
30
|
Duran B. The effects of long-term total parenteral nutrition on gut mucosal immunity in children with short bowel syndrome: a systematic review. BMC Nurs 2005; 4:2. [PMID: 15686591 PMCID: PMC549542 DOI: 10.1186/1472-6955-4-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2004] [Accepted: 02/01/2005] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND: Short bowel syndrome (SBS) is defined as the malabsorptive state that often follows massive resection of the small intestine. Most cases originate in the newborn period and result from congenital anomalies. It is associated with a high morbidity, is potentially lethal and often requires months, sometimes years, in the hospital and home on total parenteral nutrition (TPN). Long-term survival without parenteral nutrition depends upon establishing enteral nutrition and the process of intestinal adaptation through which the remaining small bowel gradually increases its absorptive capacity. The purpose of this article is to perform a descriptive systematic review of the published articles on the effects of TPN on the intestinal immune system investigating whether long-term TPN induces bacterial translocation, decreases secretory immunoglobulin A (S-IgA), impairs intestinal immunity, and changes mucosal architecture in children with SBS. METHODS: The databases of OVID, such as MEDLINE and CINAHL, Cochran Library, and Evidence-Based Medicine were searched for articles published from 1990 to 2001. Search terms were total parenteral nutrition, children, bacterial translocation, small bowel syndrome, short gut syndrome, intestinal immunity, gut permeability, sepsis, hyperglycemia, immunonutrition, glutamine, enteral tube feeding, and systematic reviews. The goal was to include all clinical studies conducted in children directly addressing the effects of TPN on gut immunity. RESULTS: A total of 13 studies were identified. These 13 studies included a total of 414 infants and children between the ages approximately 4 months to 17 years old, and 16 healthy adults as controls; and they varied in design and were conducted in several disciplines. The results were integrated into common themes. Five themes were identified: 1) sepsis, 2) impaired immune functions: In vitro studies, 3) mortality, 4) villous atrophy, 5) duration of dependency on TPN after bowel resection. CONCLUSION: Based on this exhaustive literature review, there is no direct evidence suggesting that TPN promotes bacterial overgrowth, impairs neutrophil functions, inhibits blood's bactericidal effect, causes villous atrophy, or causes to death in human model.The hypothesis relating negative effects of TPN on gut immunity remains attractive, but unproven. Enteral nutrition is cheaper, but no safer than TPN. Based on the current evidence, TPN seems to be safe and a life saving solution.
Collapse
Affiliation(s)
- Beyhan Duran
- School of Nursing, University of Connecticut, Storrs, Connecticut, USA.
| |
Collapse
|
31
|
Ribeiro SR, Pinto PE, de Miranda AC, Bromberg SH, Lopasso FP, Irya K. Weight loss and morphometric study of intestinal mucosa in rats after massive intestinal resection: influence of a glutamine-enriched diet. ACTA ACUST UNITED AC 2005; 59:349-56. [PMID: 15654488 DOI: 10.1590/s0041-87812004000600007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
UNLABELLED Short-bowel syndrome is responsible for significant metabolic alterations that compromise nutritional status. Glutamine is considered an essential nutrient for enterocytes, so beneficial effects from supplementation of the diet with glutamine are hypothesized. PURPOSE In this study, the effect of a diet enriched with glutamine was evaluated in rats undergoing extensive small bowel resection, with analysis of postoperative weight loss and intestinal morphometrics of villi height, crypt depth, and thickness of the duodenal and remnant jejunal mucosa. METHODS Three groups of male Wistar rats were established receiving the following diets: with glutamine, without glutamine, and the standard diet of laboratory ration. All animals underwent an extensive small bowel resection, including the ileocecal valve, leaving a remnant jejunum of only 25 cm from the pylorus that was anastomosed lateral-laterally to the ascendant colon. The animals were weighed at the beginning and end of the experiment (20th postoperative day). Then they were killed and the remnant intestine was removed. Fragments of duodenal and jejunal mucosa were collected from the remnant intestine and submitted to histopathologic exam. The morphometric study of the intestinal mucosa was accomplished using a digital system (KS 300) connected to an optic microscope. Morphometrics included villi height, crypt depth, and the total thickness of intestinal mucosa. RESULTS The weight loss comparison among the 3 groups showed no significant loss difference. The morphometric studies showed significantly taller duodenal villi in the glutamine group in comparison to the without glutamine group, but not different from the standard diet group. The measurements obtained comparing the 3 groups for villi height, crypt depth, and thickness of the remnant jejunum mucosa were greater in the glutamine-enriched diet group than for the without-glutamine diet group, though not significantly different from with standard-diet group. CONCLUSIONS In rats with experimentally produced short-bowel syndrome, glutamine-enrichment of an isonitrogenous test diet was associated with an improved adaptation response by the intestinal mucosa but not reduced weight loss. However, the adaptation response in the group receiving the glutamine-enriched diet was not improved over that for the group fed regular chow.
Collapse
Affiliation(s)
- Sidney Resende Ribeiro
- Instituto de Assistência ao Servidor Público Estadual (IAMSPE) and Clinical Investigation Laboratory, Faculty of Medicine, University of São Paulo--São Paulo/SP, Brazil
| | | | | | | | | | | |
Collapse
|
32
|
|
33
|
|
34
|
Abstract
The management of patients with intestinal failure due to short bowel syndrome is complex, requiring a comprehensive approach that frequently necessitates long-term, if not life-long, use of parenteral nutrition. Despite tremendous advances in the provision of parenteral nutrition over the past three decades, which have allowed significant improvements in the survival and quality of life of these patients, this mode of nutritional support carries with it significant risks to the patient, is very costly, and ultimately, does not attempt to improve the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy, and thus, allowing freedom from parenteral nutrition, usually by means of dietary, medical, and occasionally, surgical strategies. While recent investigations have focused on the use of trophic substances to increase the absorptive function of the remaining gut, whether intestinal rehabilitation occurs as a consequence of enhanced bowel adaptation or is simply a result of an optimized, comprehensive approach to the care of these patients remains unclear. In Part 1 of this review, we provided an overview of short bowel syndrome and pathophysiological considerations related to the remaining bowel anatomy in these patients. We also reviewed intestinal adaptation and factors that may enhance the adaptive process, focusing on evidence derived from animal studies. In Part 2, relevant data on the development of intestinal adaptation in humans are reviewed as is the general management of short bowel syndrome. Lastly, the potential benefits of a multidisciplinary intestinal rehabilitation program in the care of these patients are also discussed.
Collapse
Affiliation(s)
- John K DiBaise
- Department of Internal Medicine, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, USA
| | | | | |
Collapse
|
35
|
Matarese LE, Seidner DL, Steiger E. Growth hormone, glutamine, and modified diet for intestinal adaptation. ACTA ACUST UNITED AC 2004; 104:1265-72. [PMID: 15281045 DOI: 10.1016/j.jada.2004.05.202] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Many patients who undergo extensive resection of the gastrointestinal tract develop intestinal failure from short-bowel syndrome that results in significant malabsorption of fluid, electrolytes, and other nutrients. This may result in dependence on long-term parenteral nutrition. It has been almost a decade since Byrne and colleagues published their research demonstrating enhanced absorption of nutrients, improved weight gain, and reduction in parenteral nutrition requirements with the administration of a combination of growth hormone, glutamine, and a modified diet. Other researchers have conducted similar studies with inconsistent results. A systematic search on electronic databases and the Internet for the purpose of identifying the evidence published to date on this subject was performed. The analysis suggests administering recombinant human growth hormone alone or together with glutamine with or without a modified diet may be of benefit when the appropriate patients are selected for treatment.
Collapse
Affiliation(s)
- Laura E Matarese
- Nutrition Intestinal Rehabilitation, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | | | | |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the current data on trophic factors in adult patients with short-bowel syndrome. The present article reviews the clinical role of glutamine, growth hormone, and GLP-2 in the treatment of short-bowel syndrome. RECENT FINDINGS This review is clinically relevant, given the recent publications in this area. The summary of the current literature does not support that the currently available trophic factors are clinically beneficial for patients with short-bowel syndrome. SUMMARY Systemic side effects from growth hormone factors have been reported. Current trophic should be considered investigational and not standard of practice in the author's opinion.
Collapse
Affiliation(s)
- James S Scolapio
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida 32224, USA.
| |
Collapse
|
37
|
Neves JDS, Nascimento JEDA, Silva MHGGD, Bicudo AS, Nascimento M, Nochi Junior R. Influência da glutamina na mucosa do instestino de ratos submetidos à enterectomia extensa. Rev Col Bras Cir 2003. [DOI: 10.1590/s0100-69912003000600002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar a influência de uma dieta suplementada com glutamina sobre as alterações adaptativas no intestino delgado de ratos com enterectomia extensa. MÉTODO: Vinte ratos Wistar, divididos aleatoriamente em dois grupos de dez animais, foram enterectomizados e alimentados com dois tipos diferentes de dieta nos 14 dias de pós-operatório: grupo controle (GC)-dieta padrão; grupo glutamina (GG)-dietapadrão acrescida de 3,05% de glutamina. Avaliou-se evolução ponderal, peso da mucosa intestinal (PM), profundidade das criptas (PC), altura das vilosidades (AV), espessura da parede (EP) e o conteúdo de ácido desoxirribonucléico (DNA) na mucosa intestinal, no início e no final do experimento. RESULTADOS: Com exceção da PC ileal do Grupo GG, todas as variáveis estudadas tiveram um aumento significativo em seus valores finais tanto no jejuno quanto no íleo (p<0,05).Entre os grupos, a comparação do PM, AV, DNA da mucosa, no jejuno e no íleo, tanto inicialmente quanto no final do estudo, bem como da EP inicial no jejuno e íleo eda PC no jejuno final e no íleo inicial e final não mostraram diferenças significativas (p>0,05). No jejuno inicial, a PC no grupo GC foi maior (p=0,005). A EP do jejuno e íleo final foi maior no grupo GC. CONCLUSÃO: A suplementação dietética com a glutamina não melhorou as alterações adaptativas que ocorrem no remanescente intestinal.
Collapse
|
38
|
Vanderhoof JA, Young RJ. Enteral and parenteral nutrition in the care of patients with short-bowel syndrome. Best Pract Res Clin Gastroenterol 2003; 17:997-1015. [PMID: 14642862 DOI: 10.1016/s1521-6918(03)00082-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Short-bowel syndrome is a challenging entity for the gastroenterologist, requiring integration of medical, nutritional, surgical and psychological therapies. Treatment must be based on the patient's age, remaining gastrointestinal anatomy, baseline nutritional status and underlying general health as well as the numerous complications which may arise. This chapter reviews physiological alterations that occur with short-bowel syndrome and how therapies can be tailored to most adequately meet the needs of these patients. Emphasis on early stages of therapy to enhance intestinal adaptation is focused on as management during this time has a significant impact on the long-term outcome of these patients.
Collapse
Affiliation(s)
- Jon A Vanderhoof
- Chief Section of Pediatric Gastroenterology and Nutrition, University of Nebraska Medical Center, 985160 Nebraska Medical Center, Omaha, NE 68198-5160, USA.
| | | |
Collapse
|
39
|
Wu GH, Wu ZH, Wu ZG. Effects of bowel rehabilitation and combined trophic therapy on intestinal adaptation in short bowel patients. World J Gastroenterol 2003; 9:2601-4. [PMID: 14606106 PMCID: PMC4656550 DOI: 10.3748/wjg.v9.i11.2601] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effects of bowel rehabilitation and combined trophic therapy on intestinal adaptation in short bowel patients.
METHODS: Thirty-eight patients with severe short-bowel syndrome (SBS) were employed in the present study, whose average length of jejunum-ileum was 35.8 ± 21.2 cm. The TPN treatment was initiated early to attain positive nitrogen balance and prevent severe weight loss. The TPN composition was designated to be individualized and altered when necessary. Enteral feeding was given as soon as possible after resection and increased gradually. Meals were distributed throughout the day. Eight patients received treatment of growth hormone (0.14 mg/kg•d) and glutamine (0.3 g/kg•d) for 3 wk. D-xylose test, 15N-Gly trace test and 13C-palmitic acid breath test were done to determine the patients' absorption capability.
RESULTS: Thirty-three patients maintained well body weight and serum albumin concentration. The average time of follow-up for 33 survival patients was 5.9 ± 4.3 years. Twenty-two patients weaned from TPN with an average TPN time of 9.5 ± 6.6 mo. Two patients, whose whole small bowel, ascending and transverse colon were resected received home TPN. An other 9 patients received parenteral or enteral nutritional support partly as well as oral diet. Three week rhGH + GLN therapy increased nutrients absorption but the effects were transient.
CONCLUSION: By rehabilitation therapy, most short bowel patients could wean from parenteral nutrition. Dietary manipulation is an integral part of the treatment of SBS. Treatment with growth hormone and glutamine may increase nutrients absorption but the effects are not sustained beyond the treatment period.
Collapse
Affiliation(s)
- Guo-Hao Wu
- Department of General Surgery, Zhongshan Hospital, Fu Dan University, Shanghai 200032, China.
| | | | | |
Collapse
|
40
|
Ziegler TR, Evans ME, Fernández-Estívariz C, Jones DP. Trophic and cytoprotective nutrition for intestinal adaptation, mucosal repair, and barrier function. Annu Rev Nutr 2003; 23:229-61. [PMID: 12626687 DOI: 10.1146/annurev.nutr.23.011702.073036] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Intestinal epithelial cell turnover (proliferation, migration, differentiation, and apoptosis) and gut barrier functions are dynamic processes that are markedly affected by nutritional status, the route of feeding, and the adequacy of specific nutrients in the diet. Emerging studies are defining potential therapeutic roles for specific nutrients and diet-derived compounds (including arginine, glutamate, glutamine, glutathione, glycine, vitamin A, zinc, and specific lipids) in gut mucosal turnover, repair, adaptation after massive bowel resection, and barrier function. The role and regulation of endogenous bowel flora in generating short-chain fatty acids from diet-derived fiber and other diet-derived compounds and the effects of these agents on gut function are increasingly being elucidated. Results of these investigations should define new nutritional methods for trophic and cytoprotective effects on the intestine in conditions such as inflammatory bowel disease, malnutrition, and short bowel syndrome.
Collapse
Affiliation(s)
- Thomas R Ziegler
- Department of Medicine, Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
| | | | | | | |
Collapse
|
41
|
Abstract
In situations of stress, such as clinical trauma, starvation or prolonged, strenuous exercise, the concentration of glutamine in the blood is decreased, often substantially. In endurance athletes this decrease occurs concomitantly with relatively transient immunodepression. Glutamine is used as a fuel by some cells of the immune system. Provision of glutamine or a glutamine precursor, such as branched chain amino acids, has been seen to have a beneficial effect on gut function, on morbidity and mortality, and on some aspects of immune cell function in clinical studies. It has also been seen to decrease the self-reported incidence of illness in endurance athletes. So far, there is no firm evidence as to precisely which aspect of the immune system is affected by glutamine feeding during the transient immunodepression that occurs after prolonged, strenuous exercise. However, there is increasing evidence that neutrophils may be implicated. Other aspects of glutamine and glutamine supplementation are also addressed.
Collapse
Affiliation(s)
- Linda Castell
- Nuffield Department of Anaesthetics, University of Oxford, England.
| |
Collapse
|
42
|
García-de-Lorenzo A, Zarazaga A, García-Luna PP, Gonzalez-Huix F, López-Martínez J, Miján A, Quecedo L, Casimiro C, Usán L, del Llano J. Clinical evidence for enteral nutritional support with glutamine: a systematic review. Nutrition 2003; 19:805-11. [PMID: 12921894 DOI: 10.1016/s0899-9007(03)00103-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this systematic review was to locate and assess the quality of scientific evidence to establish a graded recommendation based on the effectiveness of glutamine-enriched enteral nutrition in different medical and surgical conditions. We were concerned with the following topics: 1) benefits of enteral administration of glutamine in different pathologic conditions, and 2) dose, duration, and time of initiation of glutamine-enriched diets. METHODS The sources consulted for the search were MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Healthstar and HSTAT. Ninety-one studies were assessed; after a methodologic review (primary review), only 16 studies met the inclusion criteria for analysis by a group of experts (secondary review). The coordinators supervised all data, and a final consensus was reached among the coordinators, experts, and methodologists. RESULTS AND CONCLUSIONS Glutamine-enriched diets showed good overall tolerance, improvement of immunologic aspects in multiple trauma patients, cost reduction in critically ill patients, and improvement of mucositis in post-chemotherapy patients (grade B recommendations). The doses given and the duration of therapy varied widely depending on the pathologic condition. Intake of 20 to 30 g/d, early initiation of diet, and maintenance for 5 d or longer are recommended (grade C recommendations).
Collapse
|
43
|
Abstract
This is a literature review over a time period of the past 2 years concerning glutamine in clinical nutrition. Emphasis is put upon studies of glutamine in clinical settings, but a brief overview of the large range of literature over the role of glutamine in various experimental settings is also included. The most interesting concept for the past 2 years is the suggestion to use plasma glutamine concentration at admission to the intensive care unit as a prognostic marker and as a possible indicator for indication of glutamine supplementation.
Collapse
Affiliation(s)
- Jan Wernerman
- Department of Anesthesiology and Intensive Care, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
44
|
Gades MD, Stern JS. Chitosan supplementation and fecal fat excretion in men. OBESITY RESEARCH 2003; 11:683-8. [PMID: 12740459 DOI: 10.1038/oby.2003.97] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Few weight loss supplements are clinically tested for efficacy, yet their proliferation continues. Chitosan-based supplements are sold as fat trappers and fat magnets. They purportedly block fat absorption and cause weight loss without food restriction. We quantified the in vivo effect of a chitosan product on fat absorption. RESEARCH METHODS AND PROCEDURES Participants (n = 15) consumed five meals per day for 12 days. Energy intake was not restricted. Participants consumed no supplements during a 4-day control period and two capsules five times per day (4.5 g chitosan/d), 30 minutes before each meal, during a 4-day supplement period. All feces were collected from days 2 to 12. Oral charcoal markers permitted division of the feces into two periods. The two fecal pools were analyzed for fat content. RESULTS Participants were male, 26.3 +/- 5.9 years old, BMI of 25.6 +/- 2.3 kg/m(2). Subjects consumed 133 +/- 23 g of fat/d and 12.91 +/- 1.79 MJ/d (3084 +/- 427 kcal/d). Individual meals averaged 26.3 +/- 9.3 g of fat. With chitosan supplementation at 10 capsules/day, fecal fat excretion increased by 1.1 +/- 1.8 g/d (p = 0.02), from 6.1 +/- 1.2 to 7.2 +/- 1.8 g/d. DISCUSSION The effect of chitosan on fat absorption is clinically negligible. Far from being a fat trapper, at 0.11 +/- 0.18 g of fat trapped per 0.45-g capsule or 1.1 g (9.9 kcal) fat trapped per day, this product would have no significant effect on energy balance. The fat trapping claims associated with chitosan are unsubstantiated.
Collapse
Affiliation(s)
- Matthew D Gades
- Department of Nutrition and. Department of Internal Medicine, University of California Davis, Davis, California 95616, USA
| | | |
Collapse
|
45
|
|
46
|
Abstract
Malabsorption of both nonessential and essential nutrients, fluid, and electrolytes will, if not compensated for by increased intake, lead to diminished body stores and to subclinical and eventually clinical deficiencies. By definition, intestinal failure prevails when parenteral support is necessary to maintain nutritional equilibrium. After intestinal resection, adaptation, a progressive recovery from the malabsorptive disorder, may be seen. Research has focused on optimizing remnant intestinal function through dietary or pharmacologic interventions. In this review, factors responsible for the morphologic and functional changes in the adaptive processes are described. Results of clinical trials employing either growth hormone and glutamine or glucagon-like peptide-2 in short bowel patients are presented.
Collapse
Affiliation(s)
- Palle Bekker Jeppesen
- Department of Medicine CA-2121, Section of Gastroenterology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
| | | |
Collapse
|
47
|
Candusso M, Faraguna D, Sperlì D, Dodaro N. Outcome and quality of life in paediatric home parenteral nutrition. Curr Opin Clin Nutr Metab Care 2002; 5:309-14. [PMID: 11953657 DOI: 10.1097/00075197-200205000-00011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this review the current status of home parenteral nutrition is analysed, with respect to the predictability of weaning from nutritional support and the risk of developing major complications associated with the technique, the loss of vascular access and liver disease. These two complications were evaluated because they represent the more important indication for intestinal transplantation, the availability of which has changed the perspectives of patients and of physicians. Analysis of outcomes from the largest series allows the identification of patients who could be weaned from parenteral nutrition. Important prognostic factors in patients affected by short bowel syndrome are the length and type of the remnant and the time to tolerate enteral feeding. The main complications of therapy are sepsis, thrombosis, nutrient imbalances and liver disease. Sepsis and thrombosis could lead to line replacement and the loss of vascular access. Sepsis no longer represents a major cause of death, but it is a frequent complication. In some patients, it is difficult to assess the risk factors for sepsis, which is possibly related to a poorer outcome. The care of gut failure appears to be the best preventative measure for the occurrence of cholestatic liver disease, but further studies are needed to define the eventual role of lipid emulsion and of specific nutrient deficiency. The quality of life still remains to be studied: because home parenteral nutrition in children has a longer duration, its analysis is mandatory.
Collapse
Affiliation(s)
- Manila Candusso
- Department of Paediatrics, Azienda Ospedaliera di Cosenza, Cosenza, Italy.
| | | | | | | |
Collapse
|
48
|
Abstract
The present article reviews the current literature on the role of diet and other trophic factors in the treatment of short-bowel syndrome. Results using glutamine, growth hormone and glucagon-like peptide 2 are reviewed. Although experimental animal data would suggest that various growth factors are of benefit in the treatment of short-bowel syndrome, only a few clinical studies have made the same claim.
Collapse
Affiliation(s)
- J S Scolapio
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida 32224, USA.
| |
Collapse
|