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Effect of the route of nutrition and L-alanyl-L-glutamine supplementation in amino acids' concentration in trauma patients. Eur J Trauma Emerg Surg 2017; 44:869-876. [PMID: 28980034 DOI: 10.1007/s00068-017-0851-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/25/2017] [Indexed: 12/26/2022]
Abstract
PURPOSE Our purpose was to assess the amino acids' (AAs) profile in trauma patients and to assess the effect of the route of nutrition and the exogenous ALA-GLN dipeptide supplementation on plasma AAs' concentration. METHODS This is a secondary analysis of a previous randomized controlled trial. On day 1 and day 6 after trauma, plasma concentration of 25 AAs was measured using reverse phase high-performance liquid chromatography. Results were analyzed in relation to the route of nutrition and supplementation of ALA-GLN dipeptide. Differences between plasma AAs' concentrations at day 1 and day 6 were evaluated using the Student's t test or Mann-Whitney-Wilcoxon test. One-way ANOVA and the Kruskal-Wallis test were used to compare groups. A two-sided p value less than 0.05 was considered statistically significant. RESULTS Ninety-eight patients were analyzed. Mean plasma concentrations at day 1 were close to the lower normal level for most AAs. At day 6 we found an increase in the eight essential AAs' concentrations and in 9 out of 17 measured non-essential AAs. At day 6 we found no differences in plasma concentrations for the sum of all AAs (p = .72), glutamine (p = .31) and arginine (p = .23) distributed by the route of nutrition. Administration of ALA-GLN dipeptide increased the plasma concentration of alanine (p = .004), glutamine (p < .001) and citrulline (p = .006). CONCLUSIONS We found an early depletion of plasma AAs' concentration which partially recovered at day 6, which was unaffected by the route of nutrition. ALA-GLN dipeptide supplementation produced a small increase in plasma levels of glutamine and citrulline.
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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.
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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.
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Hébuterne X, Bensadoun RJ. Nutrition chez le patient adulte atteint de cancer : place de la pharmaconutrition en cancérologie. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Berg A, Rooyackers O, Wernerman J. Glutamine Supplementation in ICU Patients. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Luo M, Bazargan N, Griffith DP, Estívariz CF, Leader LM, Easley KA, Daignault NM, Hao L, Meddings JB, Galloway JR, Blumberg JB, Jones DP, Ziegler TR. Metabolic effects of enteral versus parenteral alanyl-glutamine dipeptide administration in critically ill patients receiving enteral feeding: a pilot study. Clin Nutr 2008; 27:297-306. [PMID: 18258342 DOI: 10.1016/j.clnu.2007.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 11/01/2007] [Accepted: 12/05/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Glutamine (Gln) may become conditionally indispensable during critical illness. The short-term metabolic effects of enteral versus parenteral Gln supplementation are unknown in this clinical setting. OBJECTIVES We studied metabolic effects of intravenous (i.v.) alanyl-Gln dipeptide (AG) supplementation and enteral (e.n.) AG supplementation on plasma Gln concentration, antioxidant status, plasma lymphocyte subset number, gut permeability and nitrogen balance in adult critically ill patients requiring tube feeding compared to a control group not receiving Gln supplementation. METHODS In a double-blind, pilot clinical trial, 44 medical and surgical ICU patients received identical Gln-free tube feedings 24 h/day and were randomized to either isonitrogenous control (n=15), e.n. AG (n=15) or i.v. AG (n=14) groups (AG). Twelve patients were discontinued from the study. The goal AG dose was 0.5 g/kg/day. Biochemical and metabolic endpoints were measured at baseline and on day 9 (plasma Gln, antioxidant indices, lymphocyte subsets; serum IGF-1 and IGF-binding protein-3; intestinal permeability). Nitrogen balance was determined between study days 6 and 8. RESULTS Illness severity indices, clinical demographics, enteral energy and nitrogen intake and major biochemical indices were similar between groups during study. Plasma Gln was higher in the i.v. AG (565+/-119 microM, mean+/-SEM) vs the e.n. AG (411+/-27 microM) group by day 9 (p=0.039); however, subjects in the i.v. AG group received a higher dose of AG (i.v. AG 0.50 versus e.n. AG 0.32+/-0.02 g/kg/day; p<0.001). E.n. AG subjects showed a significant increase in plasma alpha-tocopherol levels over time and maintained plasma gamma-tocopherol concentrations. There were no differences between groups for plasma concentrations of vitamin C, glutathione, malondialdehyde (MDA), T-lymphocyte subsets, intestinal permeability or nitrogen balance. CONCLUSIONS This study showed that alanyl-Gln administration by enteral or parenteral routes did not appear to affect antioxidant capacity or oxidative stress markers, T-lymphocyte subset (CD-3, CD-4, CD-8) number, gut barrier function or whole-body protein metabolism compared to unsupplemented ICU patients requiring enteral tube feeding. Enteral Gln appeared to maintain plasma tocopherol levels in this pilot metabolic study.
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Affiliation(s)
- Menghua Luo
- Department of Medicine, Emory University, 1364 Clifton Road, Atlanta, GA 30322, United States
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Jo S, Choi SH, Heo JS, Kim EM, Min MS, Choi DW, Seo JM, Chung JC, Kim YI. Missing effect of glutamine supplementation on the surgical outcome after pancreaticoduodenectomy for periampullary tumors: a prospective, randomized, double-blind, controlled clinical trial. World J Surg 2007; 30:1974-82; discussion 1983-4. [PMID: 16927064 DOI: 10.1007/s00268-005-0678-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The effect of glutamine (Gln) supplementation in patients undergoing a major operation has not been conclusively established. This study was designed to elucidate the effect of Gln supplementation on the surgical outcome after a pancreaticoduodenectomy (PD) for periampullary tumors. METHODS A prospective, randomized, double-blind, and controlled clinical trial was undertaken for patients who underwent a classical PD or a pylorus-preserving PD for periampullary tumors. The Gln and control groups received isonitrogenous amino acid, with a 0.2 g/kg per day Gln regimen administered to the Gln group. The surgical outcome was compared in light of length of postoperative hospital stay, nutritional and chemical profiles, and complication rate between the Gln and control groups. RESULTS Sixty of the consecutive 143 patients who were admitted to undergo operation for periampullary tumors were enrolled in our study; 32 were in the Gln group and 28 in the control group. The two groups were comparable prior to and during the operation. The median length of the postoperative hospital stay and the postoperative nutritional and chemical profiles were not different between two groups. The overall and PD-related complication rates of the Gln group (37.5% and 25.0%) and the control group (28.6% and 14.3%) were not statistically different. CONCLUSIONS No significant beneficial effect of Gln supplementation with a low-dose parenteral regimen was demonstrated on the surgical outcome after a PD for periampullary tumors. Therefore, we should be prudent in using Gln as a routine pharmacologic supplement to the standard nutrition in patients who undergo major operations.
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Affiliation(s)
- Sungho Jo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-170, South Korea
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Sahin H, Mercanligil SM, Inanç N, Ok E. Effects of glutamine-enriched total parenteral nutrition on acute pancreatitis. Eur J Clin Nutr 2007; 61:1429-34. [PMID: 17311061 DOI: 10.1038/sj.ejcn.1602664] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM This study was performed to determine the effects of glutamine enriched total parenteral nutrition (TPN) on the patients with acute pancreatitis (AP). METHOD Forty patients with AP, who had Ranson's score between 2 and 4 received either standard TPN (control group) or TPN with glutamine (treatment group). The patients in the treatment group received TPN containing 0.3 g/kg/days glutamine. At the end of the study, patients were evaluated for nutritional and inflammatory parameters, length of TPN and length of hospital stay. RESULTS The length of TPN applications were 10.5+/-3.6 days and 11.6+/-2.5 days, and the length of hospital stays were 14.2+/-4.4 and 16.4+/-3.9 days for the treatment and control groups (NS), and the complication rates in the treatment and control groups were 10 and 40%, respectively (P<0.05). The transferrin level increased by 11.7% in the group that received glutamine-enriched TPN (P<0.05), whereas the transferrin level decreased by 12.1% in the control group (NS). At the end of the study, slight but not significant changes were determined in both groups in fasting blood sugar, albumin, blood urea nitrogen (BUN), creatinine, total cholesterol concentrations, aspartate aminotransferase (AST), alanine transaminase (ALT) and lactate dehydrogenase (LDH) activities, leukocytes, CD(4), CD(8), serum Zn, Ca and P levels compare to the baseline levels (NS). Significant decreases were determined in serum lipase, amylase activities and C-reactive protein (CRP) levels in both groups (P<0.05). CONCLUSIONS The results of this study have shown that glutamine supplementation to TPN have beneficial effects on the prevention of complications in patients with AP.
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Affiliation(s)
- H Sahin
- Department of Nutrition and Dietetics, Ataturk School of Health, University of Erciyes, Kayseri, Turkey.
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De-Souza DA, Greene LJ. Intestinal permeability and systemic infections in critically ill patients: effect of glutamine. Crit Care Med 2005; 33:1125-35. [PMID: 15891348 DOI: 10.1097/01.ccm.0000162680.52397.97] [Citation(s) in RCA: 220] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This article provides a critical review of the evidence indicating that an increase in intestinal permeability is associated with the installation of bacteremia, sepsis, and the multiple organ failure syndrome and that glutamine in pharmacologic doses reduces the acute increase of intestinal permeability and the infection frequency in critically ill patients. DATA SOURCE All studies published until December 2004 about intestinal permeability, bacterial translocation, and glutamine were located by search of PubMed and Web of Science. The reference lists of review articles and primary publications were also examined to identify references not detected in the computer search. STUDY SELECTION Clinical and experimental studies investigating the correlation between intestinal permeability, bacterial translocation, and frequency of infections, associated or not with the effect of glutamine administration. DATA EXTRACTION Information regarding patient population, experimental design, glutamine doses and routes of administration, nutritional therapy prescribed, methods used to assess intestinal permeability, metabolic variables, and the frequency of infections were obtained from the primary literature. DATA SYNTHESIS Intestinal permeability is increased in critically ill patients. The results have not always been consistent, but the studies whose results support the association between intestinal permeability and systemic infections have had better design and more appropriate controls. The administration of glutamine by the intravenous or oral route and at the doses recommended before or immediately after surgery, burns, or the administration of parenteral nutrition has a protective effect that prevents or reduces the intensity of the increase in intestinal permeability. Glutamine reduces the frequency of systemic infections and may also reduce the translocation of intestinal bacteria and toxins, but this has not been demonstrated. CONCLUSIONS Glutamine administration improves the prognosis of critically ill patients presumably by maintaining the physiologic intestinal barrier and by reducing the frequency of infections.
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Affiliation(s)
- Daurea A De-Souza
- Department of Internal Medicine, Faculty of Medicine, Federal University of Uberlândia (DADS), Uberlândia, MG, Brazil
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Gupta R, Patel K, Calder PC, Yaqoob P, Primrose JN, Johnson CD. A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE II > or =6). Pancreatology 2003; 3:406-13. [PMID: 14526151 DOI: 10.1159/000073657] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2002] [Indexed: 12/11/2022]
Abstract
BACKGROUND Total enteral nutrition (TEN) within 48 h of admission has recently been shown to be safe and efficacious as part of the management of severe acute pancreatitis. Our aim was to ascertain the safety of immediate TEN in these patients and the effect of TEN on systemic inflammation, psychological state, oxidative stress, plasma glutamine levels and endotoxaemia. METHODS Patients admitted with predicted severe acute pancreatitis(APACHE II score >5) were randomised to total enteral (TEN; n = 8) or total parenteral nutrition (TPN; n = 9). Measurements of systemic inflammation (C-reactive protein), fatigue (visual analogue scale), oxidative stress (plasma thiobarbituric acid-reactive substances), plasma glutamine and anti-endotoxin IgG and IgM antibody concentrations were made on admission and repeated on days 3 and 7 thereafter. Clinical progress was monitored using APACHE II score. Organ failure and complications were recorded. RESULTS All patients tolerated the feeding regime well with few nutrition-related complications. Fatigue improved in both groups but more rapidly in the TEN group. Oxidative stress was high on admission and rose by similar amounts in both groups. Plasma glutamine concentrations did not change significantly in either group. In the TPN group, 3 patients developed respiratory failure and 3 developed non-respiratory single organ failure. There were no such complications in the TEN group. Hospital stay was shorter in the TEN group [7(4-14) vs. 10 (7-26) days; p = 0.05] as was time to passing flatus and time to opening bowels [1 (0-2) vs. 2 (1-5)days; p = 0.01]. The cost of TEN was considerably less than of TPN. CONCLUSION Immediate institution of nutritional support in the form of TEN is safe in predicted severe acute pancreatitis. It is as safe and as efficacious as TPN and may be beneficial in the clinical course of this disease.
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Affiliation(s)
- R Gupta
- University Department of Surgery, Southampton General Hospital, UK
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11
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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).
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The effects of perioperative oral enteral support with glutamine-added elemental formulas in patients with gastrointestinal cancers. A prospective, randomized, clinical study. Nutr Res 2002. [DOI: 10.1016/s0271-5317(02)00407-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Numerous studies demonstrate that free glutamine can be added to commercially available crystalline amino acid-based preparations before their administration. Instability during heat sterilization and prolonged storage and limited solubility (35 g/L at 20 degrees C) hamper the use of free glutamine in the routine clinical setting. Indeed, there are many well-controlled and valuable trials with free glutamine, yet its use is restricted to clinical research. The obvious limitations of using free glutamine initiated an intensive search for alternative substrates. Synthetic glutamine dipeptides are stable under heat sterilization and highly soluble; these properties qualify the dipeptides as suitable constituents of nutritional preparations. Industrial production of these dipeptides at a reasonable price is an essential prerequisite for implications of dipeptide-containing solutions in clinical practice. Recent development of novel synthesis procedures allows increased capacity in industrial-scale production. Basic studies with synthetic glutamine-containing short-chain peptides provide convincing evidence that these new substrates are cleared rapidly from plasma after parenteral administration, without being accumulated in tissues and with negligible loss in urine. The presence of membrane-bound as well as tissue-free extracellular hydrolase activity facilitates a prompt and quantitative peptide hydrolysis, the liberated amino acids being available for protein synthesis and/or generation of energy. In the clinical setting, glutamine dipeptide nutrition beneficially influences outcome (nitrogen balance, immunity, gut integrity, hospital stay, morbidity and mortality). The provision of conditionally indispensable glutamine should be considered a necessary replacement of a deficiency rather than a supplementation. The beneficial effects observed with glutamine dipeptide nutrition should be seen simply as a correction of disadvantages produced by the inadequacy of conventional clinical nutrition. The availability of stable dipeptide preparations certainly facilitates, for the first time, adequate amino acid nutrition of critically ill, malnourished or stressed patients in the routine clinical setting and, thus, represents a new dimension in artificial nutrition.
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Affiliation(s)
- P Fürst
- University of Hohenheim, Institute for Biological Chemistry and Nutrition, Stuttgart, Germany.
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Wilmore DW. The effect of glutamine supplementation in patients following elective surgery and accidental injury. J Nutr 2001; 131:2543S-9S; discussion 2550S-1S. [PMID: 11533310 DOI: 10.1093/jn/131.9.2543s] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The metabolic response to injury, whether a controlled elective surgical procedure or an accidental injury, is characterized by the breakdown of skeletal muscle protein and the translocation of the amino acids to visceral organs and the wound. At these sites, the substrate serves to enhance host defenses, and support vital organ function and wound repair. Glutamine (GLN) plays a major role in these processes, accounting for approximately one third of the translocated nitrogen. From available data, GLN-supplemented intravenous nutrition in patients undergoing elective surgery improves nitrogen balance, helps correct the decreased GLN concentration found in the free intracellular skeletal muscle amino acid pool and enhances net protein synthesis (particularly in skeletal muscle). Six randomized blind trials (two multicentered investigations) reported a decreased length in hospital stay in postoperative patients receiving GLN supplementation. After blunt trauma, GLN supplementation increased plasma concentrations, attenuated the immunosuppression commonly observed and decreased the rate of infection. Patients with burn injury have low GLN plasma and intramuscular concentrations; turnover and synthesis rate are accelerated, yet apparently inadequate to support normal concentrations. These data suggest that GLN supplementation has important effects in catabolic surgical patients, but the exact mechanisms to explain these events remain unknown, and more research is required to explain the apparent benefits of dietary GLN.
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Affiliation(s)
- D W Wilmore
- Laboratories for Surgical Metabolism and Nutrition, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Research into the metabolic role of glutamine in trauma and sepsis brings evidence to suggest a conditional deficiency occurs because increased and altered tissue demands exceed endogenous production. Such a deficiency has functional implications, and the restorative provision of parenteral glutamine has been shown to offer improved clinical outcomes in a variety of conditions. In the critically-ill it is associated with improvements in immune function, and improved survival from infection leading to an overall improved outcome.
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Affiliation(s)
- R D Griffiths
- Intensive Care Research Group, Department of Medicine, University of Liverpool, UK.
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Affiliation(s)
- E Roth
- Surgical Research Laboratory, University of Vienna/AKH, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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Mertes N, Schulzki C, Goeters C, Winde G, Benzing S, Kuhn KS, Van Aken H, Stehle P, Fürst P. Cost containment through L-alanyl-L-glutamine supplemented total parenteral nutrition after major abdominal surgery: a prospective randomized double-blind controlled study. Clin Nutr 2000; 19:395-401. [PMID: 11104589 DOI: 10.1054/clnu.2000.0142] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS Glutamine is recognized as a conditionally essential amino acid. Recent studies indicate that glutamine-containing total parenteral nutrition improves nitrogen economy, enhances gastrointestinal and immune functions and shortens hospital stay. METHODS Thirty-seven patients (19 w and 18 m; age 61. 4+/-10.4 years; BMI 23.7+/-2.8 kg/m(2)) following major abdominal surgery receiving an isonitrogenous isoenergetic TPN with or without alanyl-glutamine supplementation (0.5 g/kg BW/day), were evaluated in a double-blind, randomized, controlled trial over a five-day period by measuring nitrogen balance, selected biochemical parameters and length of hospital stay. RESULTS Supplemental alanyl-glutamine improved the overall mean (-3.5+/-1.6 vs. -5.5+/-1. 4 g N;P<0.05) and cumulative nitrogen balance (-14.1+/-9.1 vs. -21.7+/-11.4 g N;P<0.05) compared with the isonitrogenous, isoenergetic standard regimen. Alanyl-glutamine normalized plasma glutamine concentration and reduced the length of hospital stay (12.8+/-2.6 vs. 17.5+/-6.4 days;P<0.05). CONCLUSIONS The results of the study confirm that supplementation with synthetic alanyl-glutamine dipeptide is associated with cost containment due to shortened hospitalization and improved nitrogen economy.
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Affiliation(s)
- N Mertes
- Department of Anaesthesiology and Intensive Care Medicine, University of Münster, Germany
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Fürst P, Kuhn KS. Amino-acid substrates in new bottles: implications for clinical nutrition in the 21st century. Nutrition 2000; 16:603-6. [PMID: 10906569 DOI: 10.1016/s0899-9007(00)00321-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- P Fürst
- Institute for Biological Chemistry and Nutrition, University of Hohneheim, Stuttgart, Germany.
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Abstract
There is considerable literature demonstrating that specific nutrients can influence immune function in health and disease. This review will examine the literature and the rational for classifying two amino acids, glutamine (gln) and arginine (arg), as "immunonutrients" during infections. An understanding of immune defenses during infections (virus, parasite, bacteria, protozoa) and metabolism of gln and arg by immune cells is necessary to understand how these nutrients can influence specific functions of the immune system. This review focuses on several key clinical studies in immunosuppressed individuals (burn patients, individuals with cancer and HIV infection, and those undergoing surgery or who have experienced major traumas) that have tested the hypothesis that the provision of gln and/or arg is beneficial to immune function and clinical outcome. These clinical studies support the dietary "essentiality" of these two nutrients for improving immune responses in most immunosuppressive states associated with high rates of infection. However, the role of these nutrients in modulating the immune changes that occur with exercise in healthy athletes demands additional experiments.
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Affiliation(s)
- C J Field
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Canada.
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Abstract
Although the small intestinal mucosa is designed to transport large quantities of all nutrients to the blood, the primary nutrients utilized by the enterocyte for growth and/or maintenance are quite restricted. The major fuels for the small intestinal mucosa are amino acids (glutamine, glutamate, aspartate), whereas glucose and fatty acids are of much less importance. Many of the experiments have been performed during growth or maintenance of mucosa in small rodents, especially the rat, a model in which the adaptation of the intestinal mucosa, at least to fasting, is quite different than in humans. A special role has been suggested for glutamine as a small intestinal fuel, compared with glutamate and aspartate, but the available data do not support this view. Clinical trials of glutamine supplementation suggest that, if glutamine has a role, it may be related to functions other than those relating to small intestinal function.
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Abstract
Immunonutrition generally refers to the effect of the provision of specific nutrients on the immune system. These nutrients typically have immunoenhancing properties, and recent advances in nutrition support involve studies designed to exploit the desirable biological properties of these nutrients. The term immunonutrition strictly implies that we are focusing on the effect of certain nutrients on aspects of the immune system. However, in reality immunonutrition also refers to studies that not only examine the function of lymphocytes and leucocytes, but which also study the influence of key nutrients on the acute-phase response, the inflammatory response and on gastrointestinal structure and function. The interest, therefore, is on the impact of immunonutrition on all aspects of host defence mechanisms in response to a catabolic stress. Major surgery evokes an acute-phase response, a transient immunosuppression and alterations in gastrointestinal function. Normal function is usually restored after a few days; however, in a subgroup of patients homeostasis may be lost and development of the systemic inflammatory response syndrome (SIRS) ensues. Results of recent clinical trials suggest that provision of immunomodulatory nutrients, including glutamine, arginine, n-3 polyunsaturated fatty acids and dietary nucleotides, may promote restoration of normal tissue function post-operatively and prevent the occurrence of SIRS.
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Affiliation(s)
- L O'Flaherty
- Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Republic of Ireland.
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Schloerb PR, Skikne BS. Oral and parenteral glutamine in bone marrow transplantation: a randomized, double-blind study. JPEN J Parenter Enteral Nutr 1999; 23:117-22. [PMID: 10338217 DOI: 10.1177/0148607199023003117] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Total parenteral nutrition (TPN) supplemented with glutamine (GLN) has been reported to be effective for patients with bone marrow transplantation (BMT). Our aim was to evaluate enteral and parenteral glutamine in patients undergoing BMT. METHODS For evaluation of GLN in BMT, 66 patients with 43 hematologic and 23 solid malignancies (21 breast carcinomas), were randomized, double-blinded, to either oral GLN (n = 35) or glycine-control (GLY) (n = 31), 10 g three times daily. When TPN became necessary, patients who received GLN orally were given TPN with GLN (0.57 g/kg). Those who received GLY received standard TPN, isocaloric and isonitrogenous. Patients with hematologic malignancies received high-dose chemotherapy, total body irradiation, and either allogeneic (ALLO) BMT (n = 18) or autologous (AUTO) stem cell transplantation (n = 25). Patients with solid malignancies (n = 23) received AUTO. RESULTS There were 14 in-hospital deaths without relationship to GLN administration. For respective comparisons of ALLO and AUTO transplants in the GLN and GLY hematologic groups and AUTO in the solid tumor groups, there were no significant differences in hospital stay, duration of stay after BMT, TPN days, neutrophil recovery >500/mm3, incidence of positive blood cultures, sepsis, mucositis, and diarrhea. Acute graft us host disease occurred in 1 of 10 hematologic patients receiving GLN and in 3 of 8 patients receiving GLY placebo (p > .05). Possible reduction in need for TPN and a suggestion of improved long-term survival were associated with GLN. CONCLUSIONS Oral and parenteral GLN seemed to be of limited benefit for patients having AUTO or ALLO BMT for hematologic or solid malignancies. Further study of long-term effects of GLN in BMT seems warranted.
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Affiliation(s)
- P R Schloerb
- Department of Surgery, University of Kansas Medical Center, Kansas City 66160, USA
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Abstract
Glutamine, a non-essential amino acid, is abundant in the human body and in the food we eat; it is mainly produced in skeletal muscle and acts as a major inter-organ nitrogen and carbon transporter. Its importance to the metabolism is evident during stress, when it becomes a conditionally essential amino acid when endogenous supply fails to meet increased demands. During the past 2 years, an increased understanding has been gained into the role of glutamine in metabolism. A number of new clinical studies of glutamine supplementation have shown interesting outcomes that should be influencing clinical decision-making.
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Affiliation(s)
- R D Griffiths
- Department of Medicine, University of Liverpool, UK.
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25
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Jones C, Palmer TE, Griffiths RD. Randomized clinical outcome study of critically ill patients given glutamine-supplemented enteral nutrition. Nutrition 1999; 15:108-15. [PMID: 9990574 DOI: 10.1016/s0899-9007(98)00172-5] [Citation(s) in RCA: 176] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Glutamine is normally an abundant amino acid in the body. It has many important metabolic roles, which may protect or promote tissue integrity and enhance the immune system. Low plasma and tissue levels of glutamine in the critically ill suggest that demand may exceed endogenous supply. A relative deficiency of glutamine could compromise recovery, resulting in prolonged illness and an increase in late mortality, morbidity, and consequently hospital costs. Using a prospective block-randomized, double-blind treatment study design, we tested whether a glutamine-containing enteral feed compared with an isonitrogenous, isoenergetic control feed would influence outcome. The study endpoints were morbidity, mortality, and hospital cost at 6 mo postintervention. In one general intensive care unit (ICU), to ensure consistency of management policies, 78 critically ill adult patients with Acute Physiological and Chronic Health Evaluation (APACHE) II score of 11 and greater and who were considered able to tolerate introduction of enteral nutrition were studied. Fifty patients successfully received enteral nutrition (26 glutamine, 24 control). There was no mortality difference between those patients receiving glutamine-containing enteral feed and the controls. However, there was a significant reduction in the median postintervention ICU and hospital patient costs in the glutamine recipients $23,000 versus $30,900 in the control patients (P = 0.036). For patients given glutamine there was a reduced cost per survivor of 30%. We conclude that in critically ill ICU patients enteral feeds containing glutamine have significant hospital cost benefits.
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Affiliation(s)
- C Jones
- Department of Medicine, University of Liverpool, UK
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26
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Lipman TO. Grains or veins: is enteral nutrition really better than parenteral nutrition? A look at the evidence. JPEN J Parenter Enteral Nutr 1998; 22:167-82. [PMID: 9586795 DOI: 10.1177/0148607198022003167] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Enteral nutrition is said to be better than parenteral nutrition for providing nutrition support to humans. PURPOSE To assess the literature documenting the assertions that enteral nutrition is superior to parenteral nutrition with respect to cost, safety, physiology, intestinal structure and function, bacterial translocation, and outcome. DATA IDENTIFICATION Sources included MEDLINE search, personal files, and references from human comparative studies of enteral vs parenteral nutrition. STUDY SELECTION The goal was to include all human studies directly addressing questions of comparative efficacy of enteral and parenteral nutrition. Emphasis was given to prospective randomized controlled studies where available. Retrospective comparisons were not included. DATA EXTRACTION An attempt was made to briefly summarize methodology and findings of relevant studies. No general attempt was made to assess quality of individual studies. RESULTS OF DATA SYNTHESIS Enteral nutrition appears to be less expensive than parenteral nutrition, but new economic analyses are needed given the newer aggressive access techniques for enteral nutrition. Enteral nutrition is associated with meaningful morbidity and mortality. The little comparative data existent suggest no differences in safety. Comparative studies of physiology and metabolism as well as comparative and noncomparative studies of intestinal function and structure do not support putative advantages of enteral nutrition. There is no evidence that enteral nutrition prevents bacterial translocation in humans. Enteral nutrition probably reduces septic morbidity compared with parenteral nutrition in abdominal trauma. Otherwise, there is no evidence that enteral nutrition consistently improves patient outcome compared with parenteral nutrition. CONCLUSIONS With the exception of decreased cost and probable reduced septic morbidity in acute abdominal trauma, the available literature does not support the thesis that enteral nutrition is better than parenteral nutrition in humans.
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Affiliation(s)
- T O Lipman
- Gastroenterology-Hepatology-Nutrition Section, Department of Veterans Affairs Medical Center, Georgetown University School of Medicine, Washington, DC 20422, USA
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