Parenteral glutamine supplementation improves serum albumin values in surgical cancer patients

Current research and future prospects of immunonutrition in gastrointestinal malignancies

Immune nutrition, as an integral component of nutritional support therapy, has garnered significant attention and research in the treatment of gastrointestinal malignancies. Recent advancements in nutritional formulas containing components such as glutamine, omega-3 polyunsaturated fatty acids, and arginine have led to the development of what is now termed immune nutrition or pharmacological nutrition. These formulations go beyond traditional nutritional support, functioning more like nutritional supplements with pharmacological effects. Patients with gastrointestinal malignancies often experience malnutrition and metabolic disturbances, resulting in immune dysfunction, cytokine dysregulation, and endocrine abnormalities. These issues can compromise intestinal mucosal barrier function, affecting the efficacy and prognosis of anticancer therapies. Recent studies indicate that immune nutrition can modulate specific mechanisms involved in various immune and inflammatory pathways, thereby improving patients' immune status and treatment outcomes. While optimal patient selection, dosing, and timing of immune nutrition are still under investigation, its potential applications in oncology are promising. This article aims to analyze the existing evidence regarding the therapeutic benefits of immune nutrition in gastrointestinal malignancies, offering insights into its clinical standardization and application.

Glutamine-derived peptides: Current progress and future directions

Glutamine, the most abundant amino acid in the body, plays a critical role in preserving immune function, nitrogen balance, intestinal integrity, and resistance to infection. However, its limited solubility and instability present challenges for its use a functional nutrient. Consequently, there is a preference for utilizing glutamine-derived peptides as an alternative to achieve enhanced functionality. This article aims to review the applications of glutamine monomers in clinical, sports, and enteral nutrition. It compares the functional effectiveness of monomers and glutamine-derived peptides and provides a comprehensive assessment of glutamine-derived peptides in terms of their classification, preparation, mechanism of absorption, and biological activity. Furthermore, this study explores the potential integration of artificial intelligence (AI)-based peptidomics and synthetic biology in the de novo design and large-scale production of these peptides. The findings reveal that glutamine-derived peptides possess significant structure-related bioactivities, with the smaller molecular weight fraction serving as the primary active ingredient. These peptides possess the ability to promote intestinal homeostasis, exert hypotensive and hypoglycemic effects, and display antioxidant properties. However, our understanding of the structure-function relationships of glutamine-derived peptides remains largely exploratory at current stage. The combination of AI based peptidomics and synthetic biology presents an opportunity to explore the untapped resources of glutamine-derived peptides as functional food ingredients. Additionally, the utilization and bioavailability of these peptides can be enhanced through the use of delivery systems in vivo. This review serves as a valuable reference for future investigations of and developments in the discovery, functional validation, and biomanufacturing of glutamine-derived peptides in food science.

Pharmaconutrition: Which substrates?

With the term "pharmaconutrition" or "immunonutrition" is intended the use of specific nutritional substrates having the ability of modulating specific mechanisms involved in several immune and inflammatory pathways. To achieve these goals, these substrates have to be administered with over physiologic dose. Glutamine and omega-3 polyunsaturated fatty acids, used as single substrate, did not show clear clinical advantages on solid endpoints such as postoperative complications. Despite several multiple substrate enteral feeds are available on the market, very few of them have been tested in randomized clinical trial to prove efficacy. The most extensive investigated formulation is a combination of arginine, omega-3 fatty acids, ribonucleic acid with or without glutamine. Several meta-analyses of randomized clinical trials have been conducted to compare the effects of enteral immunonutrition with control diets on post-surgical morbidity. The results consistently showed that the use of enteral multiple substrate formulas significantly reduced infectious complications and duration of hospitalization. In a more contemporary view, pharmaconutrition should be tested more accurately in the contest of enhanced recovery programs, during neoadjuvant chemotherapy, and in the prehabilitation setting.

Glutamine Supplementation as an Anticancer Strategy: A Potential Therapeutic Alternative to the Convention

Glutamine, a multifaceted nonessential/conditionally essential amino acid integral to cellular metabolism and immune function, holds pivotal importance in the landscape of cancer therapy. This review delves into the intricate dynamics surrounding both glutamine antagonism strategies and glutamine supplementation within the context of cancer treatment, emphasizing the critical role of glutamine metabolism in cancer progression and therapy. Glutamine antagonism, aiming to disrupt tumor growth by targeting critical metabolic pathways, is challenged by the adaptive nature of cancer cells and the complex metabolic microenvironment, potentially compromising its therapeutic efficacy. In contrast, glutamine supplementation supports immune function, improves gut integrity, alleviates treatment-related toxicities, and improves patient well-being. Moreover, recent studies highlighted its contributions to epigenetic regulation within cancer cells and its potential to bolster anti-cancer immune functions. However, glutamine implementation necessitates careful consideration of potential interactions with ongoing treatment regimens and the delicate equilibrium between supporting normal cellular function and promoting tumorigenesis. By critically assessing the implications of both glutamine antagonism strategies and glutamine supplementation, this review aims to offer comprehensive insights into potential therapeutic strategies targeting glutamine metabolism for effective cancer management.

Energy metabolism: a new target for gastric cancer treatment

Gastric cancer is the fifth most common malignancy worldwide having the fourth highest mortality rate. Energy metabolism is key and closely linked to tumour development. Most important in the reprogramming of cancer metabolism is the Warburg effect, which suggests that tumour cells will utilise glycolysis even with normal oxygen levels. Various molecules exert their effects by acting on enzymes in the glycolytic pathway, integral to glycolysis. Second, mitochondrial abnormalities in the reprogramming of energy metabolism, with consequences for glutamine metabolism, the tricarboxylic acid cycle and oxidative phosphorylation, abnormal fatty acid oxidation and plasma lipoprotein metabolism are important components of tumour metabolism. Third, inflammation-induced oxidative stress is a danger signal for cancer. Fourth, patterns of signalling pathways involve all aspects of metabolic transduction, and many clinical drugs exert their anticancer effects through energy metabolic signalling. This review summarises research on energy metabolism genes, enzymes and proteins and transduction pathways associated with gastric cancer, and discusses the mechanisms affecting their effects on postoperative treatment resistance and prognoses of gastric cancer. We believe that an in-depth understanding of energy metabolism reprogramming will aid the diagnosis and subsequent treatment of gastric cancer.

Quantitative 1H NMR with global spectral deconvolution approach for quality assessment of natural and cultured Cordyceps sinensis

Cordyceps sinensis is a precious medicinal food which has been successfully cultivated indoors. It remains to be investigated for a simultaneous comparison on aqueous components of natural and cultivated samples. Herein, an approach of quantitative nuclear magnetic resonance (qNMR) analysis combined with global spectral deconvolution (GSD) was established for simultaneous quantification of 26 aqueous components in C. sinensis. Processed by GSD, the distorted baselines of 1H NMR spectra were greatly improved, and overlapped signals were also well separated so as to achieve accurate identification and quantitation of components in C. sinensis. Method validation by UHPLC-QTOF-MS and TOF-SIMS analysis revealed that qNMR combined with GSD is a reliable approach for simultaneous quantification of multiple components including characteristic markers of glutamine, GABA and trehalose in authentic and fake C. sinensis. The well-established qNMR approach can be used for quality assessment of natural and cultivated C. sinensis as well as differentiation from fake ones.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Prognostic Value and Potential Mechanism of Tumor-Nutrition-Inflammation Index and Genes in Patients with Advanced Lung Cancer

Background

Lung cancer (LC) has the highest mortality rate all over the world. It is necessary to search for novel potential biomarkers that are easily accessible and inexpensive in identifying patients with LC at early stage.

Methods

A total of 195 patients with advanced LC who have received first-line chemotherapy were involved in this study. The optimized cut-off values of AGR and SIRI (AGR = albumin/globulin; SIRI = neutrophil ∗ monocyte/lymphocyte) were determined by survival function analysis based on R software. COX regression analysis was performed to obtain the independent factors for establishing the nomogram model. A nomogram model comprising these independent prognostic parameters was built for the TNI (tumor-nutrition-inflammation index) score calculation. The predictive accuracy was demonstrated through ROC curve and calibration curves after index concordance.

Results

The optimized cut-off values of AGR and SIRI were 1.22 and 1.60, respectively. It was revealed that liver metastasis, SCC, AGR, and SIRI were independent prognostic factors in advanced lung cancer by Cox analysis. Afterwards, the nomogram model comprised of these independent prognostic parameters was built for TNI scores calculation. Based on the TNI quartile values, patients were divided into four groups. And it was indicated that higher TNI had worse OS (P < 0.05) via Kaplan-Meier analysis and log-rank test. Moreover, the C-index and 1-year AUC area were 0.756 (0.723-0.788) and 75.62, respectively. There was high consistency shown in the calibration curves between predicted and actual survival proportions in the TNI model. In addition, tumor-nutrition-inflammation index and genes play an important role in LC development that might affect some pathways related to tumor development including cell cycle, homologous recombination, and P53 signaling pathway from a molecular level.

Conclusion

TNI might be an analytical tool which was practical and precise for survival prediction of patients with advanced LC. Tumor-nutrition-inflammation index and genes play an important role in LC development. A preprint has previously been published [1].

Postoperative parenteral glutamine supplementation improves the short-term outcomes in patients undergoing colorectal cancer surgery: A propensity score matching study

Introduction

The clinical utility of glutamine in patients undergoing colorectal cancer (CRC) surgery remains unclear. Therefore, we aimed to investigate the impact of postoperative treatment with glutamine on postoperative outcomes in patients undergoing CRC surgery.

Methods

We included patients with CRC undergoing elective surgery between January 2014 and January 2021. Patients were divided into the glutamine and control groups. We retrospectively analyzed postoperative infections complications within 30 days and other outcomes using propensity score matching and performed between-group comparisons.

Results

We included 1,004 patients who underwent CRC surgeries; among them, 660 received parenteral glutamine supplementation. After matching, there were 342 patients in each group. The overall incidence of postoperative complications was 14.9 and 36.8% in the glutamine and control groups, respectively, indicating that glutamine significantly reduced the incidence of postoperative complications [p &lt; 0.001; risk ratio (RR) 0.41 [95% CI 0.30–0.54]]. Compared with the control group, the glutamine group had a significantly lower postoperative infection complications rate (10.5 vs. 28.9%; p &lt; 0.001; RR 0.36 [95% CI 0.26–0.52]). Although there was no significant between-group difference in the time to first fluid diet (p = 0.052), the time to first defecation (p &lt; 0.001), first exhaust (p &lt; 0.001), and first solid diet (p &lt; 0.001), as well as hospital stay (p &lt; 0.001) were significantly shorter in the glutamine group than in the control group. Furthermore, glutamine supplementation significantly reduced the incidence of postoperative intestinal obstruction (p = 0.046). Moreover, glutamine supplementation alleviated the decrease in albumin (p &lt; 0.001), total protein (p &lt; 0.001), and prealbumin levels (p &lt; 0.001).

Conclusions

Taken together, postoperative parenteral glutamine supplementation can effectively reduce the incidence of postoperative complications, promote the recovery of intestinal function, and improve albumin levels in patients undergoing CRC surgery.

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

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

Dietary supplementation with L-glutamine enhances immunity and reduces heat stress in Hanwoo steers under heat stress conditions

This study investigated the effects of L-glutamine (Gln) supplementation on growth performance, physiological traits, heat shock proteins (HSPs), and gene expression related to muscle and adipose tissue development in Hanwoo steers under heat stress (HS) conditions. Eight Hanwoo steers (initial body weight [BW] 570.7 ± 43.6 kg, months of age 22.3 ± 0.88) were randomly separated into two groups, control and treatment, and supplied with the concentration (1.5% of BW kg/day/head) and rice straw (1.5 kg/day/head). The treatment group were fed the Gln supplementation (0.5% of concentration, as-fed basis) once a day at 08:00 h. Blood samples for the assessment of haematological and biochemical parameters and the separation of peripheral blood mononuclear cells (PBMCs) were collected four times, at 0, 3, 6, and 10 weeks of the experiment. Feed intake was measured daily. BW to analyze growth performance and hair follicle collection to analyze the expression of HSPs were executed four times at 0, 3, 6, and 10 weeks. To analyze gene expression, longissimus dorsi muscle samples were collected by biopsy at the end of the study. As a result, growing performance, including final BW, average daily gain, and gain-to-feed ratio, were not different between the two groups. Leukocytes including lymphocytes and granulocytes, tended to increase in the Gln supplementation group (p = 0.058). There were also no differences in biochemical parameters shown between the two groups, except total protein and albumin, both of which were lower in the Gln supplementation group (p < 0.05). Gene expressions related to muscle and adipose tissue development were not different between the two groups. As temperature-humidity index (THI) increased, HSP70 and HSP90 expression in the hair follicle showed a high correlation. HSP90 in the hair follicle was decreased in the treatment group compared with the control group at 10 weeks (p < 0.05). Collectively, dietary Gln supplementation (0.5% of concentration, as-fed basis) may not be influential enough to affect growth performance and gene expression related to muscle and adipose tissue development in steers. However, Gln supplementation increased the number of immune cells and decreased HSP90 in the hair follicle implying HS reduction in the corresponding group.

Associations between omega-3 polyunsaturated fatty acids supplementation and surgical prognosis in patients with gastrointestinal cancer: A systematic review and meta-analysis

Background

Surgical resection remains the primary treatment for gastrointestinal (GI) cancer, omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been reported to improve the prognosis of patients undergoing gastrointestinal tumor surgery. This meta-analysis aims to explore the efficacy of n-3 PUFAs on GI cancer patients undergoing surgery.

Methods

A systematic search of PubMed, Cochrane Library databases, EMBASE (until December 2021) was conducted. PRISMA checklist was followed. The data were analyzed by RevMan v5.3.0.

Results

A total of ten RCTs articles including 663 patients were studied. The analysis demonstrated that the n-3 PUFAs group significantly reduced levels of interleukin-6 (IL-6) (P = 0.001), C-reactive protein (CRP) (P < 0.00001), tumor necrosis factor-ɑ (TNF-α) (P = 0.0003) compared with the control group. and higher levels of CD4⁺T cells (P = 0.03), CD8⁺T cells (P = 0.02) and CD4⁺/CD8⁺ratio (P = 0.03) compared with the control group. but there was no significant difference in infection complications rate (P = 0.50) and the level of prealbumin (P = 0.80), albumin (P = 0.21), retinol-binding protein(P = 0.80) between the two groups. In addition, the n-3 PUFAs group significantly reduced the length of hospital stay (P = 0.007).

Conclusion

Our meta-analysis shows that n-3 PUFAs can effectively improve the immune function of patients undergoing gastrointestinal cancer surgery, reduce inflammatory response and reduce the length of hospital stay, But it has no significant impact on the incidence of infectious-related complications and the level of nutrient protein.

The effects of preoperative supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine on inflammatory and hematological markers of patients with heart surgery: a randomized controlled trial

Background

Cardiac surgery is associated with a widespread inflammatory response, by an additional release of free radicals. Due to the importance of these patient’s nutritional status, the present study was designed to evaluate the effectiveness of supplementation with a combination of glutamine, β-hydroxy-β-methylbutyrate (HMB) and arginine in patients undergoing to the heart surgery.

Methods

The experiment was performed in 1 month (30 days) before cardiac surgery. patients were asked to take 2 sachets of Heallagen® (a combination of 7 g l-arginine, 7 g l-glutamine, and 1.5 g daily HMB) or placebo with identical appearance and taste (maltodextrin) with 120 cc of water. Clinical and biochemical factors were evaluated in the baseline and end of the study.

Results

Totally, 60 preoperative patients (30 interventions and 30 placeboes) with a mean age of 53.13 ± 14.35 years participated in the study. Subjects in Heallagen® group had a lower serum levels of interleukin-6 (P = 0.023), erythrocyte sedimentation rate (P < 0.01), high sensitivity C-reactive protein (P < 0.01), and lymphocyte number (P = 0.007) compared to the placebo, at end of the study.

Conclusion

In the patients undergoing heart surgery, Heallagen® significantly improved some of the inflammatory factors and hematological parameters. These results need to be confirmed in a larger trial.

Trial registration: The protocol of the study was registered in the IRCT.ir with registration no. IRCT20120913010826N31 at 13/10/2020.

Metabolic Reprogramming of Thyroid Cancer Cells and Crosstalk in Their Microenvironment

Metabolism differs significantly between tumor and normal cells. Metabolic reprogramming in cancer cells and metabolic interplay in the tumor microenvironment (TME) are important for tumor formation and progression. Tumor cells show changes in both catabolism and anabolism. Altered aerobic glycolysis, known as the Warburg effect, is a well-recognized characteristic of tumor cell energy metabolism. Compared with normal cells, tumor cells consume more glucose and glutamine. The enhanced anabolism in tumor cells includes de novo lipid synthesis as well as protein and nucleic acid synthesis. Although these forms of energy supply are uneconomical, they are required for the functioning of cancer cells, including those in thyroid cancer (TC). Increasing attention has recently focused on alterations of the TME. Understanding the metabolic changes governing the intricate relationship between TC cells and the TME may provide novel ideas for the treatment of TC.

Intravenous Glutamine Administration Improves Glucose Tolerance and Attenuates the Inflammatory Response in Diet-Induced Obese Mice after Sleeve Gastrectomy

Obesity is a health problem associated with many metabolic disorders. Weight reduction can effectively alleviate obesity-associated complications. Sleeve gastrectomy is a commonly used bariatric surgery and is considered safe and effective for improving outcomes. Glutamine (GLN) is an amino acid with anti-oxidative and anti-inflammatory properties. This study used a mouse model of sleeve gastrectomy to investigate the impacts of intravenous GLN administration on glucose tolerance and adipocyte inflammation short-term after surgery. C57BL6 male mice were divided into normal control (NC) and high-fat diet groups. The high-fat diet provided 60% of energy from fat for 10 weeks to induce obesity. Mice fed the high-fat diet were then assigned to a sham (SH) or sleeve gastrectomy with saline (S) or GLN (G) groups. The S group was intravenously injected with saline, while the G group was administered GLN (0.75 g/kg body weight) via a tail vein postoperatively. Mice in the experimental groups were sacrificed on day 1 or 3 after the surgery. Results showed that obesity resulted in fat accumulation, elevated glucose levels, and adipokines production. Sleeve gastrectomy aggravated expressions of inflammatory cytokine and macrophage infiltration markers, cluster of differentiation 68 (CD68), epidermal growth factor-like module-containing mucin-like hormone receptor-like 1 (EMR-1), and macrophage chemoattractant protein-1, in adipose tissues. Treatment of obese mice with GLN downregulated hepatic proteomic profiles associated with the gluconeogenesis pathway and improved glucose tolerance. Moreover, macrophage infiltration and adipose tissue inflammation were attenuated after the sleeve gastrectomy. These findings imply that postoperative intravenous GLN administration may improve glucose tolerance and attenuate inflammation shortly after the bariatric surgery in subjects with obesity.

The Role of Immunonutrition in Patients Undergoing Pancreaticoduodenectomy

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.