1
|
Elliott JE, Keil AT, Mithani S, Gill JM, O’Neil ME, Cohen AS, Lim MM. Dietary Supplementation With Branched Chain Amino Acids to Improve Sleep in Veterans With Traumatic Brain Injury: A Randomized Double-Blind Placebo-Controlled Pilot and Feasibility Trial. Front Syst Neurosci 2022; 16:854874. [PMID: 35602971 PMCID: PMC9114805 DOI: 10.3389/fnsys.2022.854874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Traumatic brain injury (TBI) is associated with chronic sleep disturbances and cognitive impairment. Our prior preclinical work demonstrated dietary supplementation with branched chain amino acids (BCAA: leucine, isoleucine, and valine), precursors to de novo glutamate production, restored impairments in glutamate, orexin/hypocretin neurons, sleep, and memory in rodent models of TBI. This pilot study assessed the feasibility and preliminary efficacy of dietary supplementation with BCAA on sleep and cognition in Veterans with TBI. Methods Thirty-two Veterans with TBI were prospectively enrolled in a randomized, double-blinded, placebo-controlled trial comparing BCAA (30 g, b.i.d. for 21-days) with one of two placebo arms (microcrystalline cellulose or rice protein, both 30 g, b.i.d. for 21-days). Pre- and post-intervention outcomes included sleep measures (questionnaires, daily sleep/study diaries, and wrist actigraphy), neuropsychological testing, and blood-based biomarkers related to BCAA consumption. Results Six subjects withdrew from the study (2/group), leaving 26 remaining subjects who were highly adherent to the protocol (BCAA, 93%; rice protein, 96%; microcrystalline, 95%; actigraphy 87%). BCAA were well-tolerated with few side effects and no adverse events. BCAA significantly improved subjective insomnia symptoms and objective sleep latency and wake after sleep onset on actigraphy. Conclusion Dietary supplementation with BCAA is a mechanism-based, promising intervention that shows feasibility, acceptability, and preliminary efficacy to treat insomnia and objective sleep disruption in Veterans with TBI. A larger scale randomized clinical trial is warranted to further evaluate the efficacy, dosing, and duration of BCAA effects on sleep and other related outcome measures in individuals with TBI. Clinical Trial Registration [http://clinicaltrials.gov/], identifier [NCT03990909].
Collapse
Affiliation(s)
- Jonathan E. Elliott
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | | | - Sara Mithani
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Jessica M. Gill
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Maya E. O’Neil
- VA Portland Health Care System, Portland, OR, United States,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States,Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
| | - Akiva S. Cohen
- Perelman School of Medicine, Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, United States,Anesthesiology, Children’s Hospital of Philadelphia, Joseph Stokes Research Institute, Philadelphia, PA, United States
| | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States,Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, United States,Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, United States,VA Portland Health Care System, National Center for Rehabilitation and Auditory Research, Portland, OR, United States,*Correspondence: Miranda M. Lim,
| |
Collapse
|
2
|
Hsu CC, Sun CY, Tsai CY, Chen MY, Wang SY, Hsu JT, Yeh CN, Yeh TS. Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice. J Multidiscip Healthc 2021; 14:1107-1117. [PMID: 34017176 PMCID: PMC8131070 DOI: 10.2147/jmdh.s306350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/23/2021] [Indexed: 12/29/2022] Open
Abstract
The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.
Collapse
Affiliation(s)
- Chih-Chieh Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Ci-Yuan Sun
- Division of Colon & Rectal Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| |
Collapse
|
3
|
Sharma B, Lawrence DW, Hutchison MG. Branched Chain Amino Acids (BCAAs) and Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil 2018; 33:33-45. [DOI: 10.1097/htr.0000000000000280] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
4
|
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
|
5
|
Nutrition therapy in the optimisation of health outcomes in adult patients with moderate to severe traumatic brain injury: findings from a scoping review. Injury 2014; 45:1834-41. [PMID: 24996574 DOI: 10.1016/j.injury.2014.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients who have sustained traumatic brain injury (TBI) have increased nutritional requirements yet are often unable to eat normally, and adequate nutritional therapy is needed to optimise recovery. The aim of the current scoping review was to describe the existing evidence for improved outcomes with optimal nutrition therapy in adult patients with moderate to severe TBI, and to identify gaps in the literature to inform future research. METHODS Using an exploratory scoping study approach, Medline, Cinahl, Embase, CENTRAL, the Neurotrauma reviews in the Global Evidence Mapping (GEM) Initiative, and Evidence Reviews in Acquired Brain Injury (ERABI) were searched from 2003 to 14 November 2013 using variations of the search terms 'traumatic brain injury' and 'nutrition'. Articles were included if they reported mortality, morbidity, or length of stay outcomes, and were classified according to the nature of nutrition intervention and study design. RESULTS Twenty relevant articles were identified of which: 12 were original research articles; two were systematic reviews; one a meta-analysis; and five were narrative reviews. Of these, eleven explored timing of feed provision, eight explored route of administration of feeding, nine examined the provision of specific nutrients, and none examined feeding environment. Some explored more than one intervention. Three sets of guidelines which contain feeding recommendations were also identified. DISCUSSION Inconsistency within nutrition intervention methods and outcome measures means that the present evidence base is inadequate for the construction of best practice guidelines for nutrition and TBI. Further research is necessary to elucidate the optimal nutrition therapy for adults with TBI with respect to the timing, route of administration, nutrient provision and feeding environment. A consensus on the ideal outcome measure and the most appropriate method and timing of its measurement is required as a foundation for this evidence base.
Collapse
|
6
|
Abstract
BACKGROUND Glutamine is a non-essential amino acid which is abundant in the healthy human body. There are studies reporting that plasma glutamine levels are reduced in patients with critical illness or following major surgery, suggesting that glutamine may be a conditionally essential amino acid in situations of extreme stress. In the past decade, several clinical trials examining the effects of glutamine supplementation in patients with critical illness or receiving surgery have been done, and the systematic review of this clinical evidence has suggested that glutamine supplementation may reduce infection and mortality rates in patients with critical illness. However, two recent large-scale randomized clinical trials did not find any beneficial effects of glutamine supplementation in patients with critical illness. OBJECTIVES The objective of this review was to:1. assess the effects of glutamine supplementation in critically ill adults and in adults after major surgery on infection rate, mortality and other clinically relevant outcomes;2. investigate potential heterogeneity across different patient groups and different routes for providing nutrition. SEARCH METHODS We searched the Cochrane Anaesthesia Review Group (CARG) Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 5); MEDLINE (1950 to May 2013); EMBASE (1980 to May 2013) and Web of Science (1945 to May 2013). SELECTION CRITERIA We included controlled clinical trials with random or quasi-random allocation that examined glutamine supplementation versus no supplementation or placebo in adults with a critical illness or undergoing elective major surgery. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two authors independently extracted the relevant information from each included study using a standardized data extraction form. For infectious complications and mortality and morbidity outcomes we used risk ratio (RR) as the summary measure with the 95% confidence interval (CI). We calculated, where appropriate, the number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH). We presented continuous data as the difference between means (MD) with the 95% CI. MAIN RESULTS Our search identified 1999 titles, of which 53 trials (57 articles) fulfilled our inclusion criteria. The 53 included studies enrolled a total of 4671 participants with critical illness or undergoing elective major surgery. We analysed seven domains of potential risk of bias. In 10 studies the risk of bias was evaluated as low in all of the domains. Thirty-three trials (2303 patients) provided data on nosocomial infectious complications; pooling of these data suggested that glutamine supplementation reduced the infectious complications rate in adults with critical illness or undergoing elective major surgery (RR 0.79, 95% CI 0.71 to 0.87, P < 0.00001, I² = 8%, moderate quality evidence). Thirty-six studies reported short-term (hospital or less than one month) mortality. The combined rate of mortality from these studies was not statistically different between the groups receiving glutamine supplement and those receiving no supplement (RR 0.89, 95% CI 0.78 to 1.02, P = 0.10, I² = 22%, low quality evidence). Eleven studies reported long-term (more than six months) mortality; meta-analysis of these studies (2277 participants) yielded a RR of 1.00 (95% CI 0.89 to 1.12, P = 0.94, I² = 30%, moderate quality evidence). Subgroup analysis of infectious complications and mortality outcomes did not find any statistically significant differences between the predefined groups. Hospital length of stay was reported in 36 studies. We found that the length of hospital stay was shorter in the intervention group than in the control group (MD -3.46 days, 95% CI -4.61 to -2.32, P < 0.0001, I² = 63%, low quality evidence). Slightly prolonged intensive care unit (ICU) stay was found in the glutamine supplemented group from 22 studies (2285 participants) (MD 0.18 days, 95% CI 0.07 to 0.29, P = 0.002, I² = 11%, moderate quality evidence). Days on mechanical ventilation (14 studies, 1297 participants) was found to be slightly shorter in the intervention group than in the control group (MD - 0.69 days, 95% CI -1.37 to -0.02, P = 0.04, I² = 18%, moderate quality evidence). There was no clear evidence of a difference between the groups for side effects and quality of life, however results were imprecise for serious adverse events and few studies reported on quality of life. Sensitivity analysis including only low risk of bias studies found that glutamine supplementation had beneficial effects in reducing the length of hospital stay (MD -2.9 days, 95% CI -5.3 to -0.5, P = 0.02, I² = 58%, eight studies) while there was no statistically significant difference between the groups for all of the other outcomes. AUTHORS' CONCLUSIONS This review found moderate evidence that glutamine supplementation reduced the infection rate and days on mechanical ventilation, and low quality evidence that glutamine supplementation reduced length of hospital stay in critically ill or surgical patients. It seems to have little or no effect on the risk of mortality and length of ICU stay, however. The effects on the risk of serious side effects were imprecise. The strength of evidence in this review was impaired by a high risk of overall bias, suspected publication bias, and moderate to substantial heterogeneity within the included studies.
Collapse
Affiliation(s)
- Kun‐Ming Tao
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Xiao‐Qian Li
- Changhai Hospital, Second Military Medical UniversityDepartment of Traditional Chinese MedicineRoom 2201, School of TCM, No.800 Xiangyin RoadShanghaiShanghaiChina200433
| | - Li‐Qun Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Wei‐Feng Yu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Zhi‐Jie Lu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Yu‐Ming Sun
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | - Fei‐Xiang Wu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical UniversityDepartment of AnesthesiologyRoom 404, Building 3, Eastern Hepatobiliary Surgery Hospital, 225 Changhai RoadShanghaiShanghaiChina200438
| | | |
Collapse
|
7
|
Wischmeyer PE, Dhaliwal R, McCall M, Ziegler TR, Heyland DK. Parenteral glutamine supplementation in critical illness: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R76. [PMID: 24745648 PMCID: PMC4056606 DOI: 10.1186/cc13836] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/14/2014] [Indexed: 02/07/2023]
Abstract
Introduction The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data. Methods All randomized controlled trials of parenterally administered GLN in critically ill patients conducted from 1997 to 2013 were identified. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded. Methodological quality of studies was scored and data was abstracted by independent reviewers. Results A total of 26 studies involving 2,484 patients examining only parenteral GLN supplementation of nutrition support were identified in ICU patients. Parenteral GLN supplementation was associated with a trend towards a reduction of overall mortality (relative risk (RR) 0.88, 95% confidence interval (CI) 0.75, 1.03, P = 0.10) and a significant reduction in hospital mortality (RR 0.68, 95% CI 0.51, 0.90, P = 0.008). In addition, parenteral GLN was associated with a strong trend towards a reduction in infectious complications (RR 0.86, 95% CI 0.73, 1.02, P = 0.09) and ICU length of stay (LOS) (WMD –1.91, (95% CI -4.10, 0.28, P = 0.09) and significant reduction in hospital LOS (WMD -2.56, 95% CI -4.71, -0.42, P = 0.02). In the subset of studies examining patients receiving parenteral nutrition (PN), parenteral GLN supplementation was associated with a trend towards reduced overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07). Conclusions Parenteral GLN supplementation given in conjunction with nutrition support continues to be associated with a significant reduction in hospital mortality and hospital LOS. Parenteral GLN supplementation as a component of nutrition support should continue to be considered to improve outcomes in critically ill patients.
Collapse
|
8
|
Dhaliwal R, Cahill N, Lemieux M, Heyland DK. The Canadian Critical Care Nutrition Guidelines in 2013. Nutr Clin Pract 2013; 29:29-43. [DOI: 10.1177/0884533613510948] [Citation(s) in RCA: 198] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Naomi Cahill
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Margot Lemieux
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Daren K. Heyland
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| |
Collapse
|