1
|
Gusdon AM, Savarraj JPJ, Feng D, Starkman A, Li G, Bodanapally U, Zimmerman W, Ryan AS, Choi HA, Badjatia N. Identification of metabolites associated with preserved muscle volume after aneurysmal subarachnoid hemorrhage due to high protein supplementation and neuromuscular electrical stimulation. Sci Rep 2024; 14:15071. [PMID: 38956192 PMCID: PMC11219968 DOI: 10.1038/s41598-024-64666-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
The INSPIRE randomized clinical trial demonstrated that a high protein diet (HPRO) combined with neuromuscular electrical stimulation (NMES) attenuates muscle atrophy and may improve outcomes after aneurysmal subarachnoid hemorrhage We sought to identify specific metabolites mediating these effects. Blood samples were collected from subjects on admission prior to randomization to either standard of care (SOC; N = 12) or HPRO + NMES (N = 12) and at 7 days. Untargeted metabolomics were performed for each plasma sample. Sparse partial least squared discriminant analysis identified metabolites differentiating each group. Correlation coefficients were calculated between each metabolite and total protein per day and muscle volume. Multivariable models determined associations between metabolites and muscle volume. Unique metabolites (18) were identified differentiating SOC from HPRO + NMES. Of these, 9 had significant positive correlations with protein intake. In multivariable models, N-acetylleucine was significantly associated with preserved temporalis [OR 1.08 (95% CI 1.01, 1.16)] and quadricep [OR 1.08 (95% CI 1.02, 1.15)] muscle volume. Quinolinate was also significantly associated with preserved temporalis [OR 1.05 (95% CI 1.01, 1.09)] and quadricep [OR 1.04 (95% CI 1.00, 1.07)] muscle volume. N-acetylserine and β-hydroxyisovaleroylcarnitine were associated with preserved temporalis or quadricep volume. Metabolites defining HPRO + NMES had strong correlations with protein intake and were associated with preserved muscle volume.
Collapse
Affiliation(s)
- Aaron M Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Jude P J Savarraj
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Diana Feng
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Adam Starkman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guoyan Li
- Division of Gerontology, Geriatric, and Palliative Medicine, Department of Medicine, Geriatric Research, Education, and Clinical Center (GRECC), University of Maryland School of Medicine, Baltimore, MD, USA
| | - Uttam Bodanapally
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William Zimmerman
- Program in Trauma, Shock Trauma Neurocritical Care and Department of Neurology, University of Maryland School of Medicine, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA
| | - Alice S Ryan
- Division of Gerontology, Geriatric, and Palliative Medicine, Department of Medicine, Geriatric Research, Education, and Clinical Center (GRECC), University of Maryland School of Medicine, Baltimore, MD, USA
| | - Huimahn A Choi
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Neeraj Badjatia
- Program in Trauma, Shock Trauma Neurocritical Care and Department of Neurology, University of Maryland School of Medicine, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA.
| |
Collapse
|
2
|
Sadaf A, Dong M, Pfeiffer A, Latham T, Kalfa T, Vinks AA, Ware RE, Quinn CT. A Population Pharmacokinetic Analysis of L-Glutamine Exposure in Patients with Sickle Cell Disease: Evaluation of Dose and Food Effects. Clin Pharmacokinet 2024; 63:357-365. [PMID: 38401036 PMCID: PMC10954986 DOI: 10.1007/s40262-024-01349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND OBJECTIVE L-Glutamine is a treatment for children and adults with sickle cell disease. A comprehensive evaluation of the pharmacokinetics of L-glutamine in sickle cell disease has not been conducted. We aimed to assess the effects of long-term dosing, multiple dose levels, and food intake on L-glutamine exposure in patients with sickle cell disease compared to normal participants. METHODS We conducted an open-label dose-ascending trial of L-glutamine in pediatric and adult participants with sickle cell disease (N = 8) and adult healthy volunteers (N = 4), providing a total of 400 plasma L-glutamine concentrations. Each participant received three ascending oral doses (0.1 and 0.3 g/kg twice daily and 0.6 g/kg once daily) over 3 weeks. Plasma L-glutamine concentrations were quantified using ion exchange chromatography. Both a non-compartmental pharmacokinetic analysis and a population pharmacokinetic analysis were performed. RESULTS L-glutamine had rapid absorption and elimination, and there was no significant change in the baseline (pre-dose) L-glutamine concentration throughout the study, indicating no drug accumulation. Pharmacokinetics was best described by a one-compartment model with first-order kinetics. The dose-normalized peak concentration decreased with dose escalation, indicating the capacity-limited non-linear pharmacokinetics of oral L-glutamine. A covariate analysis showed that baseline L-glutamine concentrations correlated negatively with glutamine clearance, whereas dose positively correlated with volume of distribution. Food intake did not significantly affect glutamine clearance, indicating that L-glutamine can be taken with or without food. CONCLUSIONS We report the first pharmacokinetic study of multiple-dose, long-term oral L-glutamine therapy and the first population pharmacokinetic analysis of L-glutamine for sickle cell disease. These findings may permit optimized dosing of L-glutamine for patients with sickle cell disease to maximize treatment benefits. CLINICAL TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (NCT04684381).
Collapse
Affiliation(s)
- Alina Sadaf
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Amanda Pfeiffer
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA
| | - Teresa Latham
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA
| | - Theodosia Kalfa
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Hematology ML, 3333 Burnet Ave., Cincinnati, OH, 701545229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
3
|
Peng F, Wang H, Li J, Ma M, Jiang X, Run H, Li Q, Leng J, Xiao L, Tang L. Best evidence summary for prevention and management of enteral feeding intolerance in critically ill patients. J Clin Nurs 2024; 33:781-796. [PMID: 37994227 DOI: 10.1111/jocn.16934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/17/2023] [Accepted: 10/18/2023] [Indexed: 11/24/2023]
Abstract
AIM To evaluate and summarize the evidence for prevention and management of enteral feeding intolerance in critically ill patients and provide reference for clinical practice. DESIGN This study was an evidence summary followed by the evidence summary reporting standard of Fudan University Center for Evidence-based Nursing. METHODS Current literatures were systematically searched for the best evidence for prevention and management of enteral feeding intolerance in critically ill patients. Literature types included clinical guidelines, best practice information sheets, expert consensuses, systematic reviews, evidence summaries and cohort studies. DATA SOURCES UpToDate, BMJ Best Practice, Joanna Briggs Institute, Guidelines International Network, National Institute for Health and Care Excellence, Registered Nurses Association of Ontario, Scottish Intercollegiate Guidelines Network, the Cochrane Library, Embase, PubMed, Sinomed, Web of Science, Yi Maitong Guidelines Network, DynaMed, MEDLINE, CNKI, WanFang database, Chinese Medical Journal Full-text Database, European Society for Clinical Nutrition and Metabolism website, the American Society for Parenteral and Enteral Nutrition website were searched from January 2012 to April 2023. RESULTS We finally identified 18 articles that had high-quality results. We summarized the 24 pieces of best evidence from these articles, covering five aspects: screening and assessment of the risk of enteral nutritional tolerance; formulation of enteral nutrition preparations; enteral nutritional feeding implementation; feeding intolerance symptom prevention and management; and multidisciplinary management. Of these pieces of evidence, 19 were 'strong' and 5 were 'weak', 7 pieces of evidence were recommended in level one and 4 pieces of evidence were recommended in level two. CONCLUSION The following 24 pieces of evidence for prevention and management of enteral feeding intolerance in critically ill patients were finally recommended. However, as these evidences came from different countries, relevant factors such as the clinical environment should be evaluated before application. Future studies should focus on more specific symptoms of feeding intolerance and more targeted prevention design applications. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE The clinical medical staffs are recommended to take evidence-based recommendations for the implementation of standardized enteral nutrition to improve patient outcomes and decrease gastrointestinal intolerance in critically ill patients. IMPACT The management of enteral nutrition feeding intolerance has always been a challenge and difficulty in critically ill patients. This study summarizes 24 pieces of the best evidence for prevention and management of enteral nutrition feeding intolerance in critically ill patients. Following and implementing these 24 pieces of evidence is beneficial to the prevention and management of feeding intolerance in clinical practice. The 24 pieces of evidence include five aspects, including screening and assessment of the risk of enteral nutritional tolerance, formulation of enteral nutrition preparations, enteral nutritional feeding implementation, feeding intolerance symptom prevention and management and multidisciplinary management. These five aspects constitute a good implementation process. Screening and assessment of enteral nutritional tolerance throughout intervention are important guarantees for developing a feasible nutrition program in critically ill patients. This study will be benefit to global medical workers in the nutritional management of critically ill patients. REPORTING METHOD This evidence summary followed the evidence summary reporting specifications of Fudan University Center for Evidence-based Nursing, which were based on the methodological process for the summary of the evidence produced by the Joanna Briggs Institute (JBI). The reporting specifications include problem establishment, literature retrieval, literature screening, literature evaluation, the summary and grading of evidence and the formation of practical suggestions. This study was based on the evidence summary reporting specifications of the Fudan University Center for the Evidence-based Nursing, the register name is 'Best evidence summary for prevention and management of enteral feeding intolerance in critically ill patients', the registration number is 'ES20231823'.
Collapse
Affiliation(s)
- Fang Peng
- School of Nursing, University of South China, Hunan, P.R. China
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Huaqin Wang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Jianzhi Li
- School of Nursing, University of South China, Hunan, P.R. China
| | - Mengqi Ma
- School of Nursing, University of South China, Hunan, P.R. China
| | - Xuemeng Jiang
- School of Nursing, University of South China, Hunan, P.R. China
| | - Han Run
- School of Nursing, University of South China, Hunan, P.R. China
| | - Qingting Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Juanjuan Leng
- School of Nursing, University of South China, Hunan, P.R. China
| | - Luwei Xiao
- School of Nursing, University of South China, Hunan, P.R. China
| | - Li Tang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| |
Collapse
|
4
|
Gusdon AM, Savarraj JP, Feng D, Starkman A, Li G, Bodanapally U, Zimmerman WD, Ryan AS, Choi HA, Badjatia N. High-Protein Supplementation and Neuromuscular Electric Stimulation after Aneurysmal Subarachnoid Hemorrhage Increases Systemic Amino Acid and Oxidative Metabolism: A Plasma Metabolomics Approach. RESEARCH SQUARE 2023:rs.3.rs-3600439. [PMID: 38014126 PMCID: PMC10680941 DOI: 10.21203/rs.3.rs-3600439/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Background The INSPIRE randomized clinical trial demonstrated that a high protein diet (HPRO) combined with neuromuscular electrical stimulation (NMES) attenuates muscle atrophy and may improve functional outcomes after aSAH. Using an untargeted metabolomics approach, we sought to identify specific metabolites mediating these effects. Methods Blood samples were collected from subjects on admission prior to randomization to either standard of care (SOC; N=12) or HPRO+NMES (N=12) and at 7 days as part of the INSPIRE protocol. Untargeted metabolomics were performed for each plasma sample. Paired fold changes were calculated for each metabolite among subjects in the HPRO+NMES group at baseline and 7 days after intervention. Changes in metabolites from baseline to 7 days were compared for the HPRO+NMES and SOC groups. Sparse partial least squared discriminant analysis (sPLS-DA) identified metabolites discriminating each group. Pearson's correlation coefficients were calculated between each metabolite and total protein per day, nitrogen balance, and muscle volume Multivariable models were developed to determine associations between each metabolite and muscle volume. Results A total of 18 unique metabolites were identified including pre and post treatment and differentiating SOC vs HPRO+NMES. Of these, 9 had significant positive correlations with protein intake: N-acetylserine (ρ=0.61, P =1.56x10 -3 ), N-acetylleucine (ρ=0.58, P =2.97x10 -3 ), β-hydroxyisovaleroylcarnitine (ρ=0.53, P =8.35x10 -3 ), tiglyl carnitine (ρ=0.48, P =0.0168), N-acetylisoleucine (ρ=0.48, P =0.0183), N-acetylthreonine (ρ=0.47, P =0.0218), N-acetylkynurenine (ρ=0.45, P =0.0263), N-acetylvaline (ρ=0.44, P =0.0306), and urea (ρ=0.43, P =0.0381). In multivariable regression models, N-acetylleucine was significantly associated with preserved temporalis [OR 1.08 (95%CI 1.01, 1.16)] and quadricep [OR 1.08 (95%CI 1.02, 1.15)] muscle volume. Quinolinate was also significantly associated with preserved temporalis [OR 1.05 (95%CI 1.01, 1.09)] and quadricep [OR 1.04 (95%CI 1.00, 1.07)] muscle volume. N-acetylserine, N-acetylcitrulline, and b-hydroxyisovaleroylcarnitine were also associated with preserved temporalis or quadricep volume. Conclusions Metabolites defining the HPRO+NMES intervention mainly consisted of amino acid derivatives. These metabolites had strong correlations with protein intake and were associated with preserved muscle volume.
Collapse
|
5
|
Wang Q, Yang Z, Guo L, Li Z, Liu Y, Feng S, Wang Y. Chemical composition, pharmacology and pharmacokinetic studies of GuHong injection in the treatment of ischemic stroke. Front Pharmacol 2023; 14:1261326. [PMID: 37745083 PMCID: PMC10512552 DOI: 10.3389/fphar.2023.1261326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
GuHong injection is composed of safflower and N-acetyl-L-glutamine. It is widely used in clinical for cerebrovascular diseases, such as ischemic stroke and related diseases. The objective of this review is to comprehensively summarize the most recent information related to GuHong in the treatment of stroke, including chemical composition, clinical studies, potential pharmacological mechanisms and pharmacokinetics. Additionally, it examines possible scientific gaps in current study and aims to provide a reliable reference for future GuHong studies. The systematic review reveals that the chemical composition of safflower in GuHong is more than 300 chemical components in five categories. GuHong injection is primarily used in clinical applications for acute ischemic stroke and related diseases. Pharmacological investigations have indicated that GuHong acts in the early and recovery stages of ischemic stroke by anti-inflammatory, anti-oxidative stress, anti-coagulation, neuroprotective and anti-apoptotic mechanisms simultaneously. Pharmacokinetic studies found that the main exposed substances in rat plasma after GuHong administration are hydroxysafflor yellow A and N-acetyl-L-glutamine, and N-acetyl-L-glutamine could exert its pharmacological effect across the blood-brain barrier. As a combination of Chinese herb and chemical drug, GuHong injection has great value in drug research and clinical treatment, especially for ischemic stroke disease. This article represents a comprehensive and systematic review of existing studies on GuHong injection, including chemical composition, pharmacological mechanism, and pharmacokinetics, which provides reference significance for the clinical treatment of ischemic stroke with GuHong, as well as provides guidance for further study.
Collapse
Affiliation(s)
- Qiuyue Wang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhihua Yang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Liuli Guo
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhenzhen Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangxi Liu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shaoling Feng
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yanxia Wang
- Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
| |
Collapse
|
6
|
Guerrero-Molina MP, Morales-Conejo M, Delmiro A, Morán M, Domínguez-González C, Arranz-Canales E, Ramos-González A, Arenas J, Martín MA, de la Aleja JG. High-dose oral glutamine supplementation reduces elevated glutamate levels in cerebrospinal fluid in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes syndrome. Eur J Neurol 2023; 30:538-547. [PMID: 36334048 DOI: 10.1111/ene.15626] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a genetically heterogeneous disorder caused by mitochondrial DNA mutations. There are no disease-modifying therapies, and treatment remains mainly supportive. It has been shown previously that patients with MELAS syndrome have significantly increased cerebrospinal fluid (CSF) glutamate and significantly decreased CSF glutamine levels compared to controls. Glutamine has many metabolic fates in neurons and astrocytes, and the glutamate-glutamine cycle couples with many metabolic pathways depending on cellular requirements. The aim was to compare CSF glutamate and glutamine levels before and after dietary glutamine supplementation. It is postulated that high-dose oral glutamine supplementation could reduce the increase in glutamate levels. METHOD This open-label, single-cohort study determined the safety and changes in glutamate and glutamine levels in CSF after 12 weeks of oral glutamine supplementation. RESULTS Nine adult patients with MELAS syndrome (66.7% females, mean age 35.8 ± 3.2 years) were included. After glutamine supplementation, CSF glutamate levels were significantly reduced (9.77 ± 1.21 vs. 18.48 ± 1.34 μmol/l, p < 0.001) and CSF glutamine levels were significantly increased (433.66 ± 15.31 vs. 336.31 ± 12.92 μmol/l, p = 0.002). A side effect observed in four of nine patients was a mild sensation of satiety. One patient developed mild and transient elevation of transaminases, and another patient was admitted for an epileptic status without stroke-like episode. DISCUSSION This study demonstrates that high-dose oral glutamine supplementation significantly reduces CSF glutamate and increases CSF glutamine levels in patients with MELAS syndrome. These findings may have potential therapeutic implications in these patients. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT04948138. Initial release 24 June 2021, first patient enrolled 1 July 2021. https://clinicaltrials.gov/ct2/show/NCT04948138.
Collapse
Affiliation(s)
| | - Montserrat Morales-Conejo
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
| | - Aitor Delmiro
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - María Morán
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Cristina Domínguez-González
- Neurology Department, Neuromuscular Disorders Unit, University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Elena Arranz-Canales
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
| | | | - Joaquín Arenas
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Miguel A Martín
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Jesús González de la Aleja
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Neurology Department, Epilepsy Unit, University Hospital, Madrid, Spain
| |
Collapse
|
7
|
Safrhansova L, Hlozkova K, Starkova J. Targeting amino acid metabolism in cancer. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 373:37-79. [PMID: 36283767 DOI: 10.1016/bs.ircmb.2022.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Metabolic rewiring is a characteristic hallmark of cancer cells. This phenomenon sustains uncontrolled proliferation and resistance to apoptosis by increasing nutrients and energy supply. However, reprogramming comes together with vulnerabilities that can be used against tumor and can be applied in targeted therapy. In the last years, the genetic background of tumors has been identified thoroughly and new therapies targeting those mutations tested. Nevertheless, we propose that targeting the phenotype of cancer cells could be another way of treatment aiming to avoid drug resistance and non-responsiveness of cancer patients. Amino acid metabolism is part of the altered processes in cancer cells. Amino acids are building blocks and also sensors of signaling pathways regulating main biological processes. In this comprehensive review, we described four amino acids (asparagine, arginine, methionine, and cysteine) which have been actively investigated as potential targets for anti-tumor therapy. Asparagine depletion is successfully used for decades in the treatment of acute lymphoblastic leukemia and there is a strong implication to apply it to other types of tumors. Arginine auxotrophic tumors are great candidates for arginine-starvation therapy. Higher requirement for essential amino acids such as methionine and cysteine point out promising targetable weaknesses of cancer cells.
Collapse
Affiliation(s)
- Lucie Safrhansova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic; Dept. of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katerina Hlozkova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic; Dept. of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Julia Starkova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic; Dept. of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; University Hospital Motol, Prague, Czech Republic.
| |
Collapse
|
8
|
O'Brien NF, Fonseca Y, Johnson HC, Postels D, Birbeck GL, Chimalizeni Y, Seydel KB, Bernard Gushu M, Phiri T, June S, Chetcuti K, Vidal L, Goyal MS, Taylor TE. Mechanisms of Transcranial Doppler Ultrasound phenotypes in paediatric cerebral malaria remain elusive. Malar J 2022; 21:196. [PMID: 35729574 PMCID: PMC9210743 DOI: 10.1186/s12936-022-04163-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background Cerebral malaria (CM) results in significant paediatric death and neurodisability in sub-Saharan Africa. Several different alterations to typical Transcranial Doppler Ultrasound (TCD) flow velocities and waveforms in CM have been described, but mechanistic contributors to these abnormalities are unknown. If identified, targeted, TCD-guided adjunctive therapy in CM may improve outcomes. Methods This was a prospective, observational study of children 6 months to 12 years with CM in Blantyre, Malawi recruited between January 2018 and June 2021. Medical history, physical examination, laboratory analysis, electroencephalogram, and magnetic resonance imaging were undertaken on presentation. Admission TCD results determined phenotypic grouping following a priori definitions. Evaluation of the relationship between haemodynamic, metabolic, or intracranial perturbations that lead to these observed phenotypes in other diseases was undertaken. Neurological outcomes at hospital discharge were evaluated using the Paediatric Cerebral Performance Categorization (PCPC) score. Results One hundred seventy-four patients were enrolled. Seven (4%) had a normal TCD examination, 57 (33%) met criteria for hyperaemia, 50 (29%) for low flow, 14 (8%) for microvascular obstruction, 11 (6%) for vasospasm, and 35 (20%) for isolated posterior circulation high flow. A lower cardiac index (CI) and higher systemic vascular resistive index (SVRI) were present in those with low flow than other groups (p < 0.003), though these values are normal for age (CI 4.4 [3.7,5] l/min/m2, SVRI 1552 [1197,1961] dscm-5m2). Other parameters were largely not significantly different between phenotypes. Overall, 118 children (68%) had a good neurological outcome. Twenty-three (13%) died, and 33 (19%) had neurological deficits. Outcomes were best for participants with hyperaemia and isolated posterior high flow (PCPC 1–2 in 77 and 89% respectively). Participants with low flow had the least likelihood of a good outcome (PCPC 1–2 in 42%) (p < 0.001). Cerebral autoregulation was significantly better in children with good outcome (transient hyperemic response ratio (THRR) 1.12 [1.04,1.2]) compared to a poor outcome (THRR 1.05 [0.98,1.02], p = 0.05). Conclusions Common pathophysiological mechanisms leading to TCD phenotypes in non-malarial illness are not causative in children with CM. Alternative mechanistic contributors, including mechanical factors of the cerebrovasculature and biologically active regulators of vascular tone should be explored.
Collapse
Affiliation(s)
- Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA.
| | - Yudy Fonseca
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA
| | - Hunter C Johnson
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43502, USA
| | - Douglas Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, DC, USA
| | - Gretchen L Birbeck
- Department of Neurology, University of Rochester, Rochester, NY, USA.,University Teaching Hospitals Children's Hospital, Lusaka, Zambia
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Chichiri, Blantyre 3, Malawi
| | - Karl B Seydel
- Dept of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Montfort Bernard Gushu
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Karen Chetcuti
- Department of Pediatrics and Child Health, Kamuzu University of Health Sciences, Chichiri, Blantyre 3, Malawi
| | - Lorenna Vidal
- Department of Radiology, Division of Neuroradiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Manu S Goyal
- Washington University School of Medicine, St. Louis, MO, USA
| | - Terrie E Taylor
- Dept of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| |
Collapse
|
9
|
Zhao L, Liu Y, Zhang S, Wei L, Cheng H, Wang J, Wang J. Impacts and mechanisms of metabolic reprogramming of tumor microenvironment for immunotherapy in gastric cancer. Cell Death Dis 2022; 13:378. [PMID: 35444235 PMCID: PMC9021207 DOI: 10.1038/s41419-022-04821-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023]
Abstract
Metabolic disorders and abnormal immune function changes occur in tumor tissues and cells to varying degrees. There is increasing evidence that reprogrammed energy metabolism contributes to the development of tumor suppressive immune microenvironment and influences the course of gastric cancer (GC). Current studies have found that tumor microenvironment (TME) also has important clinicopathological significance in predicting prognosis and therapeutic efficacy. Novel approaches targeting TME therapy, such as immune checkpoint blockade (ICB), metabolic inhibitors and key enzymes of immune metabolism, have been involved in the treatment of GC. However, the interaction between GC cells metabolism and immune metabolism and how to make better use of these immunotherapy methods in the complex TME in GC are still being explored. Here, we discuss how metabolic reprogramming of GC cells and immune cells involved in GC immune responses modulate anti-tumor immune responses, as well as the effects of gastrointestinal flora in TME and GC. It is also proposed how to enhance anti-tumor immune response by understanding the targeted metabolism of these metabolic reprogramming to provide direction for the treatment and prognosis of GC.
Collapse
Affiliation(s)
- Lin Zhao
- The First Clinical College, Changzhi Medical College, Changzhi, Shanxi, 046000, China
| | - Yuanyuan Liu
- The First Clinical College, Changzhi Medical College, Changzhi, Shanxi, 046000, China
| | - Simiao Zhang
- The First Clinical College, Changzhi Medical College, Changzhi, Shanxi, 046000, China
| | - Lingyu Wei
- Collaborative Innovation Center for Aging Mechanism Research and Transformation, Center for Healthy Aging, Changzhi Medical College, Changzhi, Shanxi, 046000, China.,Key Laboratory of Esophageal Cancer Basic Research and Clinical Transformation, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, 046000, China
| | - Hongbing Cheng
- Collaborative Innovation Center for Aging Mechanism Research and Transformation, Center for Healthy Aging, Changzhi Medical College, Changzhi, Shanxi, 046000, China.,Department of Microbiology, Changzhi Medical College, Changzhi, Shanxi, 046000, China
| | - Jinsheng Wang
- Collaborative Innovation Center for Aging Mechanism Research and Transformation, Center for Healthy Aging, Changzhi Medical College, Changzhi, Shanxi, 046000, China. .,Key Laboratory of Esophageal Cancer Basic Research and Clinical Transformation, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, 046000, China.
| | - Jia Wang
- Collaborative Innovation Center for Aging Mechanism Research and Transformation, Center for Healthy Aging, Changzhi Medical College, Changzhi, Shanxi, 046000, China. .,Department of Immunology, Center for Healthy Aging, Changzhi Medical College, Changzhi, Shanxi, 046000, China.
| |
Collapse
|
10
|
Jennaro TS, Viglianti EM, Ingraham NE, Jones AE, Stringer KA, Puskarich MA. Serum Levels of Acylcarnitines and Amino Acids Are Associated with Liberation from Organ Support in Patients with Septic Shock. J Clin Med 2022; 11:jcm11030627. [PMID: 35160078 PMCID: PMC8836990 DOI: 10.3390/jcm11030627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Sepsis-induced metabolic dysfunction is associated with mortality, but the signatures that differentiate variable clinical outcomes among survivors are unknown. Our aim was to determine the relationship between host metabolism and chronic critical illness (CCI) in patients with septic shock. We analyzed metabolomics data from mechanically ventilated patients with vasopressor-dependent septic shock from the placebo arm of a recently completed clinical trial. Baseline serum metabolites were measured by liquid chromatography-mass spectrometry and 1H-nuclear magnetic resonance. We conducted a time-to-event analysis censored at 28 days. Specifically, we determined the relationship between metabolites and time to extubation and freedom from vasopressors using a competing risk survival model, with death as a competing risk. We also compared metabolite concentrations between CCI patients, defined as intensive care unit level of care ≥ 14 days, and those with rapid recovery. Elevations in two acylcarnitines and four amino acids were related to the freedom from organ support (subdistributional hazard ratio < 1 and false discovery rate < 0.05). Proline, glycine, glutamine, and methionine were also elevated in patients who developed CCI. Our work highlights the need for further testing of metabolomics to identify patients at risk of CCI and to elucidate potential mechanisms that contribute to its etiology.
Collapse
Affiliation(s)
- Theodore S. Jennaro
- Department of Clinical Pharmacy and the NMR Metabolomics Laboratory, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA; (T.S.J.); (K.A.S.)
| | - Elizabeth M. Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy and the NMR Metabolomics Laboratory, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA; (T.S.J.); (K.A.S.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN 55415, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA
- Correspondence:
| |
Collapse
|
11
|
Nabarrete JM, Pereira AZ, Garófolo A, Seber A, Venancio AM, Grecco CES, Bonfim CMS, Nakamura CH, Fernandes D, Campos DJ, Oliveira FLC, Cousseiro FK, Rossi FFP, Gurmini J, Viani KHC, Guterres LF, Mantovani LFAL, Darrigo LG, Albuquerque MIBPE, Brumatti M, Neves MA, Duran N, Villela NC, Zecchin VG, Fernandes JF. Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents. EINSTEIN-SAO PAULO 2021; 19:eAE5254. [PMID: 34909973 PMCID: PMC8664291 DOI: 10.31744/einstein_journal/2021ae5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/10/2020] [Indexed: 11/28/2022] Open
Abstract
The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.
Collapse
Affiliation(s)
- Juliana Moura Nabarrete
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Andrea Z Pereira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Adriana Garófolo
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Adriana Seber
- Universidade Federal de São PauloSão PauloSPBrazilUniversidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Angela Mandelli Venancio
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Carlos Eduardo Setanni Grecco
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Carmem Maria Sales Bonfim
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Claudia Harumi Nakamura
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Daieni Fernandes
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Denise Johnsson Campos
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Fernanda Luisa Ceragioli Oliveira
- Universidade Federal de São PauloEscola Paulista de MedicinaSão PauloSPBrazilEscola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Flávia Krüger Cousseiro
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Flávia Feijó Panico Rossi
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Jocemara Gurmini
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Karina Helena Canton Viani
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilInstituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Luciana Fernandes Guterres
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | | | - Luiz Guilherme Darrigo
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Maria Isabel Brandão Pires e Albuquerque
- Instituto Nacional de Câncer José Alencar Gomes da SilvaRio de JaneiroRJBrazilInstituto Nacional de Câncer José Alencar Gomes da Silva - INCA, Rio de Janeiro, RJ, Brazil.
| | - Melina Brumatti
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Mirella Aparecida Neves
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Natália Duran
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Neysimelia Costa Villela
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Victor Gottardello Zecchin
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Juliana Folloni Fernandes
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| |
Collapse
|
12
|
Chow H, Sun JK, Hart RP, Cheng KK, Hung CHL, Lau T, Kwan K. Low-Density Lipoprotein Receptor-Related Protein 6 Cell Surface Availability Regulates Fuel Metabolism in Astrocytes. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:e2004993. [PMID: 34180138 PMCID: PMC8373092 DOI: 10.1002/advs.202004993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 05/06/2021] [Indexed: 05/07/2023]
Abstract
Early changes in astrocyte energy metabolism are associated with late-onset Alzheimer's disease (LOAD), but the underlying mechanism remains elusive. A previous study suggested an association between a synonymous SNP (rs1012672, C→T) in LRP6 gene and LOAD; and that is indeed correlated with diminished LRP6 gene expression in the frontal cortex region. The authors show that LRP6 is a unique Wnt coreceptor on astrocytes, serving as a bimodal switch that modulates their metabolic landscapes. The Wnt-LRP6 mediated mTOR-AKT axis is essential for sustaining glucose metabolism. In its absence, Wnt switches to activate the LRP6-independent Ca2+ -PKC-NFAT axis, resulting in a transcription network that favors glutamine and branched chain amino acids (BCAAs) catabolism over glucose metabolism. Exhaustion of these raw materials essential for neurotransmitter biosynthesis and recycling results in compromised synaptic, cognitive, and memory functions; priming for early changes that are frequently found in LOAD. The authors also highlight that intranasal supplementation of glutamine and BCAAs is effective in preserving neuronal integrity and brain functions, proposing a nutrient-based method for delaying cognitive and memory decline when LRP6 cell surface levels and functions are suboptimal.
Collapse
Affiliation(s)
- Hei‐Man Chow
- School of Life Sciences, Faculty of ScienceThe Chinese University of Hong Kong999077Hong Kong
| | - Jacquelyne Ka‐Li Sun
- School of Life Sciences, Faculty of ScienceThe Chinese University of Hong Kong999077Hong Kong
| | - Ronald P. Hart
- Department of Cell Biology and NeuroscienceRutgers UniversityPiscatawayNJ08854USA
| | - Kenneth King‐Yip Cheng
- Department of Health Technology and InformaticsThe Hong Kong Polytechnic University999077Hong Kong
| | - Clara H. L. Hung
- The University Research Facility in Life SciencesThe Hong Kong Polytechnic University999077Hong Kong
| | - Tsun‐Ming Lau
- School of Life Sciences, Faculty of ScienceThe Chinese University of Hong Kong999077Hong Kong
| | - Kin‐Ming Kwan
- School of Life Sciences, Faculty of ScienceThe Chinese University of Hong Kong999077Hong Kong
| |
Collapse
|
13
|
Name JJ, Vasconcelos AR, Souza ACR, Fávaro WJ. Vitamin D, zinc and glutamine: Synergistic action with OncoTherad immunomodulator in interferon signaling and COVID‑19 (Review). Int J Mol Med 2021; 47:11. [PMID: 33448317 PMCID: PMC7834962 DOI: 10.3892/ijmm.2021.4844] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in December, 2019 in Wuhan, China. Since then, it has continued to spread rapidly in numerous countries, while the search for effective therapeutic options persists. Coronaviruses, including SARS-CoV-2, are known to suppress and evade the antiviral responses of the host organism mediated by interferon (IFN), a family of cytokines that plays an important role in antiviral defenses associated with innate immunity, and has been used therapeutically for chronic viral diseases and cancer. On the other hand, OncoTherad, a safe and effective immunotherapeutic agent in the treatment of non-muscle invasive bladder cancer (NMIBC), increases IFN signaling and has been shown to be a promising therapeutic approach for COVID-19 in a case report that described the rapid recovery of a 78-year-old patient with NMIBC with comorbidities. The present review discusses the possible synergistic action of OncoTherad with vitamin D, zinc and glutamine, nutrients that have been shown to facilitate immune responses mediated by IFN signaling, as well as the potential of this combination as a therapeutic option for COVID-19.
Collapse
Affiliation(s)
- José João Name
- Kilyos Assessoria, Cursos e Palestras (Kilyos Nutrition), São Paulo, SP 01311‑100, Brazil
| | - Andrea Rodrigues Vasconcelos
- Department of Pharmacology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, SP 05508‑000, Brazil
| | | | - Wagner José Fávaro
- Laboratory of Urogenital Carcinogenesis and Immunotherapy, University of Campinas, Campinas, SP 13083‑970, Brazil
| |
Collapse
|
14
|
Jabłońska B, Mrowiec S. The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy. Nutrients 2020; 12:E2547. [PMID: 32842475 PMCID: PMC7551458 DOI: 10.3390/nu12092547] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgical procedures in abdominal surgery. Malnutrition and immune dysfunction in patients with pancreatic cancer (PC) may lead to a higher risk of postoperative infectious complications. Although immunonutrition (IN) is recommended for enhanced recovery after surgery (ERAS) in patients undergoing PD for 5-7 days perioperatively, its role in patients undergoing pancreatectomy is still unclear and controversial. It is known that the proper surgical technique is very important in order to reduce a risk of postoperative complications, such as a pancreatic fistula, and to improve disease-free survival in patients following PD. However, it has been proven that IN decreases the risk of infectious complications, and shortens hospital stays in patients undergoing PD. This is a result of the impact on altered inflammatory responses in patients with cancer. Both enteral and parenteral, as well as preoperative and postoperative IN, using various nutrients, such as glutamine, arginine, omega-3 fatty acids and nucleotides, is administered. The most frequently used preoperative oral supplementation is recommended. The aim of this paper is to present the indications and benefits of IN in patients undergoing PD.
Collapse
Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Medyków 14 St., 40-752 Katowice, Poland;
| | | |
Collapse
|
15
|
Apostolopoulou A, Haidich AB, Kofina K, Manzanares W, Bouras E, Tsaousi G, Stoppe C, Dardavessis TI, Chourdakis M. Effects of glutamine supplementation on critically ill patients: Focus on efficacy and safety. An overview of systematic reviews. Nutrition 2020; 78:110960. [PMID: 32877810 DOI: 10.1016/j.nut.2020.110960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this overview of systematic reviews was to synthesize, appraise, and present all systematic review (SR) evidence on the clinical efficacy of glutamine administration to severely ill patients. METHODS Medline, Scopus, the Cochrane Library, and Prospero were searched up to March 2020. Systematic reviews and meta-analyses of randomized controlled trials published in English, comparing immunomodulating diets-containing exclusively glutamine-with standard diets for critically ill adult patients were selected. Data were collected from each selected systematic review and all available primary studies. The primary outcome was overall mortality; secondary outcomes were rate of infectious complications, hospital and intensive care unit (ICU) length of stay (LOS). RESULTS Seventeen SRs were eligible for inclusion. Of the SRs, 16 included meta-analyses with moderate degree of overlap (corrected covered area = 10%). These included 117 randomized controlled trials with 9933 patients. Glutamine supplementation was not associated with overall mortality and ICU LOS. However, it may reduce the rate of infectious complications overall (N = 3666, risk ratio, 0.82; 95% confidence interval [CI], 0.73-0.92; I2 = 33%: low quality of evidence). LOS was limited with the supplementation of glutamine (N = 4353 weighted mean difference, -2.90; 95% CI, -3.66 to -2.15; I2 = 81%: very low quality of evidence), but this effect was diminished when only studies with low risk for bias were synthesized. CONCLUSION Glutamine could demonstrate a beneficial role in critical care patients of diminishing the rate of infectious complications and hospital and ICU LOS. However, future studies with better quality would confirm this finding.
Collapse
Affiliation(s)
- Aikaterini Apostolopoulou
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Konstantinia Kofina
- First University Surgical Department, Faculty of Medicine, Democritus University of Thrace, University Campus, Alexandroupolis, Greece
| | - William Manzanares
- Department of Critical Care, University Hospital. Faculty of Medicine, Universidad de la República, Montevideo, Uruguay
| | - Emmanouil Bouras
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Anesthesiology and ICU, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Christian Stoppe
- Department of Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Theodoros I Dardavessis
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Michail Chourdakis
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece.
| |
Collapse
|
16
|
Chang JC. Acute Respiratory Distress Syndrome as an Organ Phenotype of Vascular Microthrombotic Disease: Based on Hemostatic Theory and Endothelial Molecular Pathogenesis. Clin Appl Thromb Hemost 2020; 25:1076029619887437. [PMID: 31775524 PMCID: PMC7019416 DOI: 10.1177/1076029619887437] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening noncardiogenic circulatory disorder of the lungs associated with critical illnesses such as sepsis, trauma, and immune and collagen vascular disease. Its mortality rate is marginally improved with the best supportive care. The demise occurs due to progressive pulmonary hypoxia and multi-organ dysfunction syndrome (MODS) with severe inflammation. Complement activation is a part of immune response against pathogen or insult in which membrane attack complex (MAC) is formed and eliminates microbes. If complement regulatory protein such as endothelial CD59 is underexpressed, MAC may also cause pulmonary vascular injury to the innocent bystander endothelial cell of host and provokes endotheliopathy that causes inflammation and pulmonary vascular microthrombosis, leading to ARDS. Its pathogenesis is based on a novel "two-path unifying theory" of hemostasis and "two-activation theory of the endothelium" promoting molecular pathogenesis. Endotheliopathy activates two independent molecular pathways: inflammatory and microthrombotic. The former triggers the release inflammatory cytokines and the latter promotes exocytosis of unusually large von Willebrand factor multimers (ULVWF) and platelet activation. Inflammatory pathway initiates inflammation, but microthrombotic pathway more seriously produces "microthrombi strings" composed of platelet-ULVWF complexes, which become anchored on the injured endothelial cells, and causes disseminated intravascular microthrombosis (DIT). DIT is a hemostatic disease due to lone activation of ULVWF path without activated tissue factor path. It leads to endotheliopathy-associated vascular microthrombotic disease (EA-VMTD), which orchestrates consumptive thrombocytopenia, microangiopathic hemolytic anemia, and MODS. Thrombotic thrombocytopenic purpura (TTP)-like syndrome is the hematologic phenotype of EA-VMTD. ARDS is one of organ phenotypes among MODS associated with TTP-like syndrome. The most effective treatment of ARDS can be achieved by counteracting the activated microthrombotic pathway based on two novel hemostatic theories.
Collapse
Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| |
Collapse
|
17
|
Abstract
Oxidative stress is an important contributor to the pathophysiology of sickle cell disease. The pathways involved are complex and interlinked. L-glutamine is an amino acid with myriad roles in the body, including the synthesis of antioxidants, such as reduced glutathione and the cofactors NAD(H) and NADP(H), as well as nitric oxide—so it has therapeutic potential as an antioxidant. However, the relative impact of L-glutamine on the redox environment in red blood cells in sickle cell disease is not fully understood, and there are few therapeutic trials in sickle cell disease. Following the FDA approval of L-glutamine for sickle cell disease, more research is still needed to understand its clinical effects and role in therapy.
Collapse
Affiliation(s)
- Alina Sadaf
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Charles T Quinn
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| |
Collapse
|
18
|
Early-Onset Neonatal Sepsis. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Despite the great progress made in neonatal and perinatal medicine over the last couple of decades, sepsis remains one of the main causes of morbidity and mortality. Sepsis in pediatric population was defined at the Pediatric Sepsis Consensus Conference in 2005. There is still no consensus on the definition of neonatal sepsis. Neonatal sepsis is a sepsis that occurs in the neonatal period. According to the time of occurrence, neonatal sepsis can be of early onset, when it occurs within the first 72 hours of birth and results from vertical transmission, and of late onset, in which the source of infection is found most often in the environment and occurs after the third day of life. The most common causes of early-onset sepsis are Group B Streptococcus (GBS) and E. coli. Risk factors can be mother-related and newborn-related. Clinical symptoms and signs of sepsis are quite unspecific. The dysfunction of different organs may imitate sepsis. On the other hand, infectious and non-infectious factors may exist simultaneously. The start of the antimicrobial therapy in any newborn with suspected sepsis should not be delayed. Pentoxifylline may have potential benefits in preterm newborns with sepsis. The only proven intervention that has been shown to reduce the risk of early-onset neonatal sepsis is intrapartum intravenous antibiotic administration to prevent GBS infection. It is still a great challenge to discontinue antibiotic treatment in non-infected newborns as soon as possible, because any extended antibiotic use may later be associated with other pathological conditions.
Collapse
|
19
|
Pillinger NL, Robson JL, Kam P. Nutritional prehabilitation: physiological basis and clinical evidence. Anaesth Intensive Care 2018; 46:453-462. [PMID: 30189818 DOI: 10.1177/0310057x1804600505] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In this narrative review, we describe the physiological basis for nutritional prehabilitation and evaluate the clinical evidence for its current roles in the perioperative period. Surgical stress and fasting induce insulin resistance as a result of altered mitochondrial function. Insulin resistance in the perioperative period leads to increased morbidity in a dose-dependent fashion, while preoperative carbohydrate loading attenuates insulin resistance, minimises protein loss and improves postoperative muscle function. Carbohydrate loading is an established practice in many countries and a key component of enhanced recovery after surgery (ERAS) programs, yet its independent effects on clinical outcomes remain unclear. Amino acid supplements may confer additional positive effects on a number of markers of clinical outcomes in the perioperative period, but their current role is also poorly defined. Clinical studies evaluating nutritional interventions have been marred by conflicting data, which may be due to small sample sizes, as well as heterogeneity of patients and surgical procedures. At present, it is known that carbohydrate loading is safe and improves patients' wellbeing, but does not appear to influence length of hospital stay or rate of postoperative complications. This should be appreciated before its routine inclusion in ERAS programs.
Collapse
Affiliation(s)
- N L Pillinger
- Department of Anaesthetics, Royal Prince Alfred Hospital; Clinical Lecturer, University of Sydney; Sydney, New South Wales
| | | | - Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney; Department of Anaesthetics, Royal Prince Alfred Hospital; Sydney, New South Wales
| |
Collapse
|
20
|
Schüller SS, Kramer BW, Villamor E, Spittler A, Berger A, Levy O. Immunomodulation to Prevent or Treat Neonatal Sepsis: Past, Present, and Future. Front Pediatr 2018; 6:199. [PMID: 30073156 PMCID: PMC6060673 DOI: 10.3389/fped.2018.00199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/25/2018] [Indexed: 12/12/2022] Open
Abstract
Despite continued advances in neonatal medicine, sepsis remains a leading cause of death worldwide in neonatal intensive care units. The clinical presentation of sepsis in neonates varies markedly from that in older children and adults, and distinct acute inflammatory responses results in age-specific inflammatory and protective immune response to infection. This review first provides an overview of the neonatal immune system, then covers current mainstream, and experimental preventive and adjuvant therapies in neonatal sepsis. We also discuss how the distinct physiology of the perinatal period shapes early life immune responses and review strategies to reduce neonatal sepsis-related morbidity and mortality. A summary of studies that characterize immune ontogeny and neonatal sepsis is presented, followed by discussion of clinical trials assessing interventions such as breast milk, lactoferrin, probiotics, and pentoxifylline. Finally, we critically appraise future treatment options such as stem cell therapy, other antimicrobial protein and peptides, and targeting of pattern recognition receptors in an effort to prevent and/or treat sepsis in this highly vulnerable neonatal population.
Collapse
Affiliation(s)
- Simone S. Schüller
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Andreas Spittler
- Department of Surgery, Research Labs & Core Facility Flow Cytometry, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ofer Levy
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Broad Institute of MIT and Harvard, Boston, MA, United States
| |
Collapse
|
21
|
Lewis SR, Schofield‐Robinson OJ, Alderson P, Smith AF. Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit. Cochrane Database Syst Rev 2018; 6:CD012276. [PMID: 29883514 PMCID: PMC6353207 DOI: 10.1002/14651858.cd012276.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition. OBJECTIVES To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting. AUTHORS' CONCLUSIONS We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.
Collapse
Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
| | | |
Collapse
|
22
|
Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
Collapse
Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
| | | |
Collapse
|
23
|
Stability and assessment of amino acids in parenteral nutrition solutions. J Pharm Biomed Anal 2018; 147:125-139. [DOI: 10.1016/j.jpba.2017.07.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 10/19/2022]
|
24
|
Functional and Transcriptomic Characterization of Peritoneal Immune-Modulation by Addition of Alanyl-Glutamine to Dialysis Fluid. Sci Rep 2017; 7:6229. [PMID: 28740213 PMCID: PMC5524796 DOI: 10.1038/s41598-017-05872-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/05/2017] [Indexed: 01/01/2023] Open
Abstract
Peritonitis remains a major cause of morbidity and mortality during chronic peritoneal dialysis (PD). Glucose-based PD fluids reduce immunological defenses in the peritoneal cavity. Low concentrations of peritoneal extracellular glutamine during PD may contribute to this immune deficit. For these reasons we have developed a clinical assay to measure the function of the immune-competent cells in PD effluent from PD patients. We then applied this assay to test the impact on peritoneal immune-competence of PD fluid supplementation with alanyl-glutamine (AlaGln) in 6 patients in an open-label, randomized, crossover pilot trial (EudraCT 2012-004004-36), and related the functional results to transcriptome changes in PD effluent cells. Ex-vivo stimulation of PD effluent peritoneal cells increased release of interleukin (IL) 6 and tumor necrosis factor (TNF) α. Both IL-6 and TNF-α were lower at 1 h than at 4 h of the peritoneal equilibration test but the reductions in cytokine release were attenuated in AlaGln-supplemented samples. AlaGln-supplemented samples exhibited priming of IL-6-related pathways and downregulation of TNF-α upstream elements. Results from measurement of cytokine release and transcriptome analysis in this pilot clinical study support the conclusion that suppression of PD effluent cell immune function in human subjects by standard PD fluid is attenuated by AlaGln supplementation.
Collapse
|
25
|
McRae MP. Therapeutic benefits of glutamine: An umbrella review of meta-analyses. Biomed Rep 2017; 6:576-584. [PMID: 28529738 DOI: 10.3892/br.2017.885] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/09/2017] [Indexed: 02/07/2023] Open
Abstract
Glutamine may be an essential amino acid in patients with catabolic disease, as it has been demonstrated that circulating glutamine levels drop during critical illness and following major surgery; this may result in an increase in secondary infection risk, recovery time and mortality rates. However, there is much discrepancy in the literature with regards to randomized controlled studies, and therefore, the present study is an umbrella review of published meta-analyses, conducted to examine the effectiveness of glutamine's role as a therapeutic agent. A search using PubMed, Cochrane Library and CINAHL from January 1st, 1980 to December 31st, 2016 was conducted using the following strategy: 'Glutamine AND (meta-analysis OR systematic review)' and publications were retrieved, which provided quantitative statistical analysis of pooled treatment effects on the relative risks of infectious complications, mortality and length of stay in hospital. A total of 22 meta-analyses were entered into the current umbrella review. As displayed in Tables I, II and III, these analyses are split into three groups, based on different parameters. Of the 19 meta-analyses investigating the effects of infectious complications, 15 identified statistically significant reductions in complications, with relative risks ranging between 0.42 and 0.93. In addition, 12 of the 18 meta-analyses analyzing the length of hospital stays presented statistically significant reductions in the length of stay, with reductions ranging between 0.19 to 4.73 days. Only 4 of the 15 meta-analyses studying mortality effects identified statistically significant reductions in mortality with relative risks ranging between 0.64 and 1.28. Statistically significant heterogeneity was observed in 16 of 22 meta-analyses, and publication bias was observed in five of 11 meta-analyses. Glutamine supplementation for critically ill or surgical patients through parenteral or enteral routes appears to reduce the rate of hospital acquired infectious complications and shortening of the length of stay in hospital. Furthermore, glutamine supplementation appeared to reduce the rate of in-patient mortality, but the majority of meta-analyses did not reach statistical significance. However, researchers must appreciate the positive results with caution in light of the fact that there exists statistically significant heterogeneity for the majority of meta-analyses, and statistically significant publication bias in almost half.
Collapse
Affiliation(s)
- Marc P McRae
- Department of Basic Science, National University of Health Sciences, Lombard, IL 60148, USA
| |
Collapse
|
26
|
Both high and low plasma glutamine levels predict mortality in critically ill patients. Surg Today 2017; 47:1331-1338. [PMID: 28374265 DOI: 10.1007/s00595-017-1511-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 02/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Plasma amino acids are important indicators for understanding human kinetics and amino acid dynamics. We aimed to investigate the association between the plasma glutamine levels and the mortality rates and determine whether plasma glutamine can predict the prognosis of critically ill patients. METHODS The clinical records of adult patients who were admitted to an ICU were retrospectively evaluated to investigate the plasma levels of amino acids, including glutamine. RESULTS Two hundred fourteen patients were included in this study (male, 62%; median age, 64 years; range 20-97 years). The patients' diagnoses included sepsis (45%), trauma (14%), cardiovascular disease (9%), fulminant hepatitis (9%), burns (4%), and others (19%). The mortality rates in patients with plasma glutamine <400 nmol/mL (group L; 39%, 28/71) or ≥700 nmol/mL (group H; 50%, 15/30) were significantly higher (p < 0.05 and p < 0.01, respectively) than those in patients with plasma glutamine levels of 400-700 nmol/mL (group M; 21%, 24/113). Among patients with sepsis, the mortality rates of group L (46%) and group H (67%) were significantly higher (p < 0.05 or p < 0.01, respectively) in comparison with group M (26%). CONCLUSION Both lower and higher plasma glutamine levels were risk factors for mortality in critically ill patients.
Collapse
|
27
|
Martins P. Glutamine in critically ill patients: is it a fundamental nutritional supplement? Rev Bras Ter Intensiva 2017; 28:100-3. [PMID: 27410403 PMCID: PMC4943045 DOI: 10.5935/0103-507x.20160022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/28/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Paulo Martins
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| |
Collapse
|
28
|
Sandoval CP. Glutamine Supplementation for Critically Ill Adults: A summary of findings from the Cochrane Library with implications for critical care nursing. Crit Care Nurse 2017; 35:71-2. [PMID: 26628549 DOI: 10.4037/ccn2015220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cass Piper Sandoval
- Cass Piper Sandoval is a clinical nurse specialist in adult critical care at the Institute for Nursing Excellence, University of California San Francisco (UCSF) Medical Center and a certified Joanna Briggs Institute (JBI) Comprehensive Systematic Review trainer at the UCSF JBI Centre for Evidence-Based Patient and Family Care, San Francisco, California
| |
Collapse
|
29
|
Morris CR, Hamilton-Reeves J, Martindale RG, Sarav M, Ochoa Gautier JB. Acquired Amino Acid Deficiencies: A Focus on Arginine and Glutamine. Nutr Clin Pract 2017; 32:30S-47S. [PMID: 28388380 DOI: 10.1177/0884533617691250] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Nonessential amino acids are synthesized de novo and therefore not diet dependent. In contrast, essential amino acids must be obtained through nutrition since they cannot be synthesized internally. Several nonessential amino acids may become essential under conditions of stress and catabolic states when the capacity of endogenous amino acid synthesis is exceeded. Arginine and glutamine are 2 such conditionally essential amino acids and are the focus of this review. Low arginine bioavailability plays a pivotal role in the pathogenesis of a growing number of varied diseases, including sickle cell disease, thalassemia, malaria, acute asthma, cystic fibrosis, pulmonary hypertension, cardiovascular disease, certain cancers, and trauma, among others. Catabolism of arginine by arginase enzymes is the most common cause of an acquired arginine deficiency syndrome, frequently contributing to endothelial dysfunction and/or T-cell dysfunction, depending on the clinical scenario and disease state. Glutamine, an arginine precursor, is one of the most abundant amino acids in the body and, like arginine, becomes deficient in several conditions of stress, including critical illness, trauma, infection, cancer, and gastrointestinal disorders. At-risk populations are discussed together with therapeutic options that target these specific acquired amino acid deficiencies.
Collapse
Affiliation(s)
- Claudia R Morris
- 1 Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jill Hamilton-Reeves
- 2 Department of Dietetics and Nutrition, University of Kansas, Kansas City, Kansas, USA
| | - Robert G Martindale
- 3 Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Menaka Sarav
- 4 Department of Medicine, Division of Nephrology, Northshore University Health System, University of Chicago, Chicago, Illinois, USA
| | | |
Collapse
|
30
|
Is there such a thing as biocompatible peritoneal dialysis fluid? Pediatr Nephrol 2017; 32:1835-1843. [PMID: 27722783 PMCID: PMC5579143 DOI: 10.1007/s00467-016-3461-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/01/2016] [Accepted: 07/01/2016] [Indexed: 10/31/2022]
Abstract
Introduction of the so-called biocompatible peritoneal dialysis (PD) fluids was based on a large body of experimental evidence and various clinical trials suggesting important clinical benefits. Of these, until now, only preservation of residual renal function-likely due to lower glucose degradation product load and, in case of icodextrin, improved fluid and blood pressure control-have consistently been proven, whereas the impact on important clinical endpoints such as infectious complications, preservation of PD membrane transport function, and patient outcome, are still debated. In view of the high morbidity and mortality rates of PD patients, novel approaches are warranted and comprise the search for alternative osmotic agents and enrichment of PD fluids with specific pharmacologic agents, such as alanyl-glutamine, potentially counteracting local but also systemic sequelae of uremia and PD.
Collapse
|
31
|
Is the glutamine story over? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:361. [PMID: 27829456 PMCID: PMC5103504 DOI: 10.1186/s13054-016-1531-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/14/2016] [Indexed: 12/29/2022]
Abstract
Glutamine has been launched as a conditionally indispensible amino acid for the critically ill. Supplementation has been recommended in guidelines from international societies. Although data have been presented pointing out that glutamine supplementation may not be for everybody, recommendations for treatments and design of study protocols have included all critically ill patients. Results from more recent studies and meta-analyses indicate that indiscriminate use of glutamine supplementation in critically ill patients may actually cause harm rather than beneficial effects. This viewpoint sorts out arguments of controversy in the glutamine story.
Collapse
|
32
|
Stehle P, Ellger B, Kojic D, Feuersenger A, Schneid C, Stover J, Scheiner D, Westphal M. Glutamine dipeptide-supplemented parenteral nutrition improves the clinical outcomes of critically ill patients: A systematic evaluation of randomised controlled trials. Clin Nutr ESPEN 2016; 17:75-85. [PMID: 28361751 DOI: 10.1016/j.clnesp.2016.09.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/01/2016] [Accepted: 09/26/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND & AIMS Early randomised controlled trials (RCTs) testing whether parenteral nutrition regimens that include glutamine dipeptides improves the outcomes of critically ill patients demonstrated convincingly that this regimen associates with reduced mortality, infections, and hospital stays. However, several new RCTs on the same question challenged this. To resolve this controversy, the present meta-analysis was performed. Stringent eligibility criteria were used to select only those RCTs that tested the outcomes of critically ill adult patients without hepatic and/or renal failure who were haemodynamically and metabolically stabilised and who were administered glutamine dipeptide strictly according to current clinical guidelines (via the parenteral route at 0.3-0.5 g/kg/day; max. 30% of the prescribed nitrogen supply) in combination with adequate nutrition. METHODS The literature research (PubMed, Embase, Cochrane Central Register of Controlled Trials) searched for English and German articles that had been published in peer-review journals (last entry March 31, 2015) and reported the results of RCTs in critically ill adult patients (major surgery, trauma, infection, or organ failure) who received parenteral glutamine dipeptide as part of an isoenergetic and isonitrogenous nutrition therapy. The following data were extracted: infectious complications, lengths of stay (LOS) in the hospital and intensive care unit (ICU), duration of mechanical ventilation, days on inotropic support, and ICU and hospital mortality rates. The selection of and data extraction from studies were performed by two independent reviewers. RESULTS Fifteen RCTs (16 publications) fulfilled all selection criteria. They involved 842 critically ill patients. None had renal and/or hepatic failure. The average study quality (Jadad score: 3.8 points) was well above the predefined cut-off of 3.0. Common effect estimates indicated that parenteral glutamine dipeptide supplementation significantly reduced infectious complications (relative risk [RR] = 0.70, 95% CI 0.60, 0.83, p < 0.0001), ICU LOS (common mean difference [MD] -1.61 days, 95% CI -3.17, -0.05, p = 0.04), hospital LOS (MD -2.30 days, 95% CI -4.14, -0.45, p = 0.01), and mechanical ventilation duration (MD -1.56 days, 95% CI -2.88, -0.24, p = 0.02). It also lowered the hospital mortality rate by 45% (RR = 0.55, 95% CI 0.32, 0.94, p = 0.03) but had no effect on ICU mortality. Visual inspection of funnel plots did not reveal any potential selective reporting of studies. CONCLUSIONS This meta-analysis clearly confirms that when critically ill patients are supplemented with parenteral glutamine dipeptide according to clinical guidelines as part of a balanced nutrition regimen, it significantly reduces hospital mortality, infectious complication rates, and hospital LOS. The latter two effects indicate that glutamine dipeptide supplementation also confers economic benefits in this setting. The present analysis indicates the importance of delivering glutamine dipeptides together with adequate parenteral energy and nitrogen so that the administered glutamine serves as precursor in various biosynthetic pathways rather than simply as a fuel.
Collapse
Affiliation(s)
- Peter Stehle
- Department of Nutrition and Food Sciences, University of Bonn, Bonn, Germany.
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany.
| | - Dubravka Kojic
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany.
| | | | | | - John Stover
- Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany.
| | | | | |
Collapse
|
33
|
Kratochwill K, Boehm M, Herzog R, Gruber K, Lichtenauer AM, Kuster L, Csaicsich D, Gleiss A, Alper SL, Aufricht C, Vychytil A. Addition of Alanyl-Glutamine to Dialysis Fluid Restores Peritoneal Cellular Stress Responses - A First-In-Man Trial. PLoS One 2016; 11:e0165045. [PMID: 27768727 PMCID: PMC5074513 DOI: 10.1371/journal.pone.0165045] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/01/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Peritonitis and ultrafiltration failure remain serious complications of chronic peritoneal dialysis (PD). Dysfunctional cellular stress responses aggravate peritoneal injury associated with PD fluid exposure, potentially due to peritoneal glutamine depletion. In this randomized cross-over phase I/II trial we investigated cytoprotective effects of alanyl-glutamine (AlaGln) addition to glucose-based PDF. METHODS In a prospective randomized cross-over design, 20 stable PD outpatients underwent paired peritoneal equilibration tests 4 weeks apart, using conventional acidic, single chamber 3.86% glucose PD fluid, with and without 8 mM supplemental AlaGln. Heat-shock protein 72 expression was assessed in peritoneal effluent cells as surrogate parameter of cellular stress responses, complemented by metabolomics and functional immunocompetence assays. RESULTS AlaGln restored peritoneal glutamine levels and increased the primary outcome heat-shock protein expression (effect 1.51-fold, CI 1.07-2.14; p = 0.022), without changes in peritoneal ultrafiltration, small solute transport, or biomarkers reflecting cell mass and inflammation. Further effects were glutamine-like metabolomic changes and increased ex-vivo LPS-stimulated cytokine release from healthy donor peripheral blood monocytes. In patients with a history of peritonitis (5 of 20), AlaGln supplementation decreased dialysate interleukin-8 levels. Supplemented PD fluid also attenuated inflammation and enhanced stimulated cytokine release in a mouse model of PD-associated peritonitis. CONCLUSION We conclude that AlaGln-supplemented, glucose-based PD fluid can restore peritoneal cellular stress responses with attenuation of sterile inflammation, and may improve peritoneal host-defense in the setting of PD.
Collapse
Affiliation(s)
- Klaus Kratochwill
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Zytoprotec GmbH, Vienna, Austria
| | - Michael Boehm
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Rebecca Herzog
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Molecular Stress Research in Peritoneal Dialysis, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Zytoprotec GmbH, Vienna, Austria
| | - Katharina Gruber
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Anton Michael Lichtenauer
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Zytoprotec GmbH, Vienna, Austria
| | - Lilian Kuster
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Zytoprotec GmbH, Vienna, Austria
| | - Dagmar Csaicsich
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Seth L. Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christoph Aufricht
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Andreas Vychytil
- Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
34
|
Castro-Gutiérrez V, Rada G. Is there a role for glutamine supplementation in the management of acute pancreatitis? Medwave 2016; 16 Suppl 3:e6512. [PMID: 27580296 DOI: 10.5867/medwave.2016.6512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There is no consensus about the effects of glutamine supplementation for acute pancreatitis. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 15 systematic reviews including 31 randomized controlled trials addressing the question of this article. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded glutamine supplementation might decrease infectious complications in acute pancreatitis, but it is not clear if it affects mortality or length of hospital stay because the certainty of the evidence is very low.
Collapse
Affiliation(s)
- Victoria Castro-Gutiérrez
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro. Chile
| | - Gabriel Rada
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile; Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration
| |
Collapse
|
35
|
Efficacy and Safety of Glutamine-supplemented Parenteral Nutrition in Surgical ICU Patients: An American Multicenter Randomized Controlled Trial. Ann Surg 2016; 263:646-55. [PMID: 26501700 DOI: 10.1097/sla.0000000000001487] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine whether glutamine (GLN)-supplemented parenteral nutrition (PN) improves clinical outcomes in surgical intensive care unit (SICU) patients. SUMMARY BACKGROUND DATA GLN requirements may increase with critical illness. GLN-supplemented PN may improve clinical outcomes in SICU patients. METHODS A parallel-group, multicenter, double-blind, randomized, controlled clinical trial in 150 adults after gastrointestinal, vascular, or cardiac surgery requiring PN and SICU care. Patients were without significant renal or hepatic failure or shock at entry. All received isonitrogenous, isocaloric PN [1.5 g/kg/d amino acids (AAs) and energy at 1.3× estimated basal energy expenditure]. Controls (n = 75) received standard GLN-free PN (STD-PN); the GLN group (n = 75) received PN containing alanyl-GLN dipeptide (0.5 g/kg/d), proportionally replacing AA in PN (GLN-PN). Enteral nutrition (EN) was advanced and PN weaned as indicated. Hospital mortality and infections were primary endpoints. RESULTS Baseline characteristics, days on study PN and daily macronutrient intakes via PN and EN, were similar between groups. There were 11 hospital deaths (14.7%) in the GLN-PN group and 13 deaths in the STD-PN group (17.3%; difference, -2.6%; 95% confidence interval, -14.6% to 9.3%; P = 0.66). The 6-month cumulative mortality was 31.4% in the GLN-PN group and 29.7% in the STD-PN group (P = 0.88). Incident bloodstream infection rate was 9.6 and 8.4 per 1000 hospital days in the GLN-PN and STD-PN groups, respectively (P = 0.73). Other clinical outcomes and adverse events were similar. CONCLUSIONS PN supplemented with GLN dipeptide was safe, but did not alter clinical outcomes among SICU patients.
Collapse
|
36
|
Lee G, Khatib R. An unusual case of atrial fibrillation. Int Emerg Nurs 2016; 27:56-9. [PMID: 26872843 DOI: 10.1016/j.ienj.2016.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 01/17/2016] [Accepted: 01/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Geraldine Lee
- Department of Postgraduate Research, Florence Nightingale Faculty of Nursing & Midwifery, Kings College London, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Rani Khatib
- Medicines Management and Pharmacy Service, Leeds Teaching Hospitals NHS Trust, Great George St., Leeds LS1 3EX, United Kingdom
| |
Collapse
|
37
|
Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
Collapse
Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
| |
Collapse
|
38
|
Glutamine: an obligatory parenteral nutrition substrate in critical care therapy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:545467. [PMID: 26495301 PMCID: PMC4606408 DOI: 10.1155/2015/545467] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023]
Abstract
Critical illness is characterized by glutamine depletion owing to increased metabolic demand. Glutamine is essential to maintain intestinal integrity and function, sustain immunologic response, and maintain antioxidative balance. Insufficient endogenous availability of glutamine may impair outcome in critically ill patients. Consequently, glutamine has been considered to be a conditionally essential amino acid and a necessary component to complete any parenteral nutrition regimen. Recently, this scientifically sound recommendation has been questioned, primarily based on controversial findings from a large multicentre study published in 2013 that evoked considerable uncertainty among clinicians. The present review was conceived to clarify the most important questions surrounding glutamine supplementation in critical care. This was achieved by addressing the role of glutamine in the pathophysiology of critical illness, summarizing recent clinical studies in patients receiving parenteral nutrition with intravenous glutamine, and describing practical concepts for providing parenteral glutamine in critical care.
Collapse
|
39
|
Meta-analysis is not enough: The critical role of pathophysiology in determining optimal care in clinical nutrition. Clin Nutr 2015; 35:748-57. [PMID: 26615913 DOI: 10.1016/j.clnu.2015.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/24/2015] [Accepted: 08/27/2015] [Indexed: 12/20/2022]
Abstract
Evidence based medicine has preferably been based on prospective randomized controlled trials (PRCT's) and subsequent meta-analyses in many fields including nutrition and metabolism. These meta-analyses often yield convincing, contradictory or no proof of effectiveness. Consequently recommendations and guidelines of varying validity and quality have been published, often failing to convince the medical, insurance and government worlds to support nutritional care. Causes for lack of adequate proof of effectiveness are manifold. Many studies and meta-analyses lacked pathophysiological depth in design and interpretation. Study populations were not homogenous and endpoints not always clearly defined. Patients were included not at nutritional risk, unlikely to benefit from nutritional intervention. Others received nutrients in excess of requirements or tolerance due to organ failure. To include all available studies in a meta-analysis, study quality and homogeneity were only assessed on the basis of formal study design and outcome rather than on patient characteristics. Consequently, some studies showed benefit but included patients suffering harm, other studies were negative but contained patients that benefited. Recommendations did not always emphasize these shortcomings, confusing the medical and nutritional community and creating the impression that nutritional support is not beneficial. Strong reliance on meta-analyses and guidelines shifts the focus of education from studying clinical and nutritional physiology to memorizing guidelines. To prevent or improve malnutrition more physiological knowledge should be acquired to personalize nutritional practices and to more correctly value and evaluate the evidence. This also applies to the design and interpretation of PRCT's and meta-analyses.
Collapse
|
40
|
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
|
41
|
Oldani M, Sandini M, Nespoli L, Coppola S, Bernasconi DP, Gianotti L. Glutamine Supplementation in Intensive Care Patients: A Meta-Analysis of Randomized Clinical Trials. Medicine (Baltimore) 2015; 94:e1319. [PMID: 26252319 PMCID: PMC4616616 DOI: 10.1097/md.0000000000001319] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The role of glutamine (GLN) supplementation in critically ill patients is controversial. Our aim was to analyze its potential effect in patients admitted to intensive care unit (ICU).We performed a systematic literature review through Medline, Embase, Pubmed, Scopus, Ovid, ISI Web of Science, and the Cochrane-Controlled Trials Register searching for randomized clinical trials (RCTs) published from 1983 to 2014 and comparing GLN supplementation to no supplementation in patients admitted to ICU. A random-effect meta-analysis for each outcome (hospital and ICU mortality and rate of infections) of interest was carried out. The effect size was estimated by the risk ratio (RR).Thirty RCTs were analyzed with a total of 3696 patients, 1825 (49.4%) receiving GLN and 1859 (50.6%) no GLN (control groups). Hospital mortality rate was 27.6% in the GLN patients and 28.6% in controls with an RR of 0.93 (95% CI = 0.81-1.07; P = 0.325, I = 10.7%). ICU mortality was 18.0 % in the patients receiving GLN and 17.6% in controls with an RR of 1.01 (95% CI = 0.86-1.19; P = 0.932, I = 0%). The incidence of infections was 39.7% in GLN group versus 41.7% in controls. The effect of GLN was not significant (RR = 0.88; 95% CI = 0.76-1.03; P = 0.108, I = 56.1%).These results do not allow to recommend GLN supplementation in a generic population of critically ills. Further RCTs are needed to explore the effect of GLN in more specific cohort of patients.
Collapse
Affiliation(s)
- Massimo Oldani
- From the Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza (MO, MS, LN, LG); Department of Surgery, Humanitas Gavazzeni, Bergamo (SC); and Department of Health Sciences, Center of Biostatistics for Clinical Epidemiology, Milano-Bicocca University, Monza, Italy (DPB)
| | | | | | | | | | | |
Collapse
|