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Gholamalizadeh M, Tabrizi R, Rezaei S, Badeli M, Shadnoush M, Jarrahi AM, Doaei S. Effect of glutamine supplementation on inflammatory markers in critically ill patients supported with enteral or parenteral feeding. JPEN J Parenter Enteral Nutr 2021; 46:61-68. [PMID: 34213769 DOI: 10.1002/jpen.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Glutamine plays an important role in acute catabolic conditions in critically ill patients. This meta-analysis aimed to investigate the effect of glutamine supplementation on inflammatory markers in critically ill patients supported with enteral feeding (EN) or parenteral feeding (PN). METHODS PubMed, Web of Science, Scopus, and Embase were explored to identify the studies investigating the effect of glutamine on serum inflammatory markers in intensive care unit patients. All randomized clinical trials that assessed the effect of glutamine supplementation on "inflammatory markers" in EN or PN were included in the study. Because a small number of studies were included, SE was adjusted for overall effect size by using the Knapp-Hartung method. RESULTS In this study, 2728 eligible studies were initially included, and 10 eligible case-control studies were finally enrolled for further investigations. There was a statistical reduction between preintervention and postintervention CRP levels (standardized mean difference [SMD] = -0.38 mg/L; 95% CI, -0.72 to -0.03). No significant association was found between L-glutamine supplementation in the EN/PN and interleukin 6 (IL-6) (SMD = -0.58 pg/ml; 95% CI, -2.15 to 0.99) and tumor necrosis factor alpha (TNF-α) (SMD = 2.69 pg/ml; 95% CI, -9.66 to 15.03) compared with the control group. CONCLUSIONS This study identified that glutamine supplementation might have an important effect on CRP in acute conditions and no significant effect on IL-6 and TNF-α in acute conditions.
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Affiliation(s)
- Maryam Gholamalizadeh
- Student Research Committee, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Shahla Rezaei
- Department of Clinical Nutrition, Student Research Committee, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.,Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mostafa Badeli
- Department of Nutrition, Urmia University of Medical Science, Urmia, Iran
| | - Mahdi Shadnoush
- Department of Clinical Nutrition, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Saeid Doaei
- Reproductive Health Research Center, Department of Obstetrics & Gynecology, Al-zahra hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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Abe T, Hosoi T, Kawai R, Uemura N, Higaki E, An B, Kawakami J, Saito T, Shimizu Y. Perioperative enteral supplementation with glutamine, fiber, and oligosaccharide reduces early postoperative surgical stress following esophagectomy for esophageal cancer. Esophagus 2019; 16:63-70. [PMID: 30030739 DOI: 10.1007/s10388-018-0630-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND We clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress. METHODS Of 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes. RESULTS The duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2. CONCLUSIONS Perioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.
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Affiliation(s)
- Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan.
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Ryosuke Kawai
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Norihisa Uemura
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Eiji Higaki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Byonggu An
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Jiro Kawakami
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Takuya Saito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
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Probst P, Ohmann S, Klaiber U, Hüttner FJ, Billeter AT, Ulrich A, Büchler MW, Diener MK. Meta-analysis of immunonutrition in major abdominal surgery. Br J Surg 2017; 104:1594-1608. [DOI: 10.1002/bjs.10659] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 06/14/2017] [Accepted: 06/28/2017] [Indexed: 12/13/2022]
Abstract
Abstract
Background
The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias.
Methods
A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence.
Results
A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference –1·79 (95 per cent c.i. –2·39 to –1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01).
Conclusion
Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE: high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE: low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
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Affiliation(s)
- P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - S Ohmann
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - A T Billeter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - A Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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Influence of enteral glutamine on inflammatory and hormonal response in patients with rectal cancer during preoperative radiochemotherapy. Eur J Clin Nutr 2017; 71:671-673. [PMID: 28272402 DOI: 10.1038/ejcn.2017.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 12/30/2016] [Accepted: 01/09/2017] [Indexed: 01/31/2023]
Abstract
We conducted a randomized double-blind placebo-controlled study evaluating the influence of 5 weeks' duration of 30 g enteral glutamine supplementation on inflammatory and hormonal responses in 73 patients with rectal cancer undergoing preoperative radiochemotherapy. Plasma levels of inflammatory and hormonal parameters were controlled at the beginning and at the end of supplementation. Enteral glutamine resulted in modulation of inflammatory and hormonal responses as shown by a decreased plasma interleukin 6 and cortisol levels in glutamine compared with placebo group: 5.5±3.8 versus 11.1±19.9 ng/l (P=0.02) for IL-6 and 386±168.4 to 312.7±111.7 nmol/l (P=0.03) for cortisol. We conclude that enteral glutamine exhibits some anti-inflammatory activity and, consequently, leads to a lower hormonal stress response during radiochemotherapy in patients with rectal cancer.
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Konosu M, Iwaya T, Kimura Y, Akiyama Y, Shioi Y, Endo F, Nitta H, Otsuka K, Koeda K, Sasaki A. Peripheral vein infusions of amino acids facilitate recovery after esophagectomy for esophageal cancer: Retrospective cohort analysis. Ann Med Surg (Lond) 2017; 14:29-35. [PMID: 28138387 PMCID: PMC5256676 DOI: 10.1016/j.amsu.2017.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 01/12/2017] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
Background To investigate the efficacy of amino acid administration via peripheral veins in addition to conventional enteral feeding following esophagectomy. Materials and methods Retrospective analysis of data pertaining to 33 patients with esophageal cancer who underwent radical esophagectomy and satisfied the required nutrition control. Patients were divided into the amino acid group (n = 17) and control group (n = 16). Primary outcomes were albumin (Alb) and prealbumin (PreAlb) levels, urinary 3-methylhistidine/creatinine (3-MeHis/Cre) ratios, nitrogen balance, and weight; postoperative complications were noted as secondary outcomes. Results Alb levels were significantly higher in the amino acid group on postoperative day (POD)-14 (3.4 ± 0.3 vs. 3.1 ± 0.4 mg/dL in the control group, p = 0.018) and at 1 month after surgery (3.8 ± 0.4 vs. 3.5 ± 0.3 mg/dL, p = 0.045). No significant differences were observed in PreAlb and urinary 3-MeHis/Cre rates between the treatment groups. Body weights at 3 months postoperatively were decreased by 6% and 3% in the control and amino acid groups, respectively. Conclusion Peripheral venous administration of amino acids soon after surgical stress is an effective method for nutritional control. Radical resection for esophageal cancer is a highly invasive procedure. Enteral feeding has been used in postoperative period for esophagectomy. Peripheral vein infusion of amino acids is effective for post esophagectomy.
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Affiliation(s)
- Masafumi Konosu
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Yusuke Kimura
- Department of Palliative Care Medicine, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Yuji Akiyama
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Yoshihiro Shioi
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Keisuke Koeda
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, Morioka, Iwate 020-8505, Japan
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Effect of glutamine dipeptide supplementation on primary outcomes for elective major surgery: systematic review and meta-analysis. Nutrients 2015; 7:481-99. [PMID: 25584966 PMCID: PMC4303850 DOI: 10.3390/nu7010481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/04/2015] [Indexed: 12/15/2022] Open
Abstract
To evaluate if glutamine (GLN) supplementation may affect primary outcomes in patients undergoing major elective abdominal operations, we performed a systematic literature review of randomized clinical trials (RCTs) published from 1983 to 2013 and comparing intravenous glutamine dipeptide supplementation to no supplementation in elective surgical abdominal procedures. A meta-analysis for each outcome (overall and infectious morbidity and length of stay) of interest was carried out. The effect size was estimated by the risk ratio (RR) or by the weighted mean difference (WMD). Nineteen RCTs were identified with a total of 1243 patients (640 receiving GLN and 603 controls). In general, the studies were underpowered and of medium or low quality. GLN supplementation did not affect overall morbidity (RR = 0.84, 95% CI 0.51 to 1.36; p = 0.473) and infectious morbidity (RR = 0.64; 95% CI = 0.38 to 1.07; p = 0.087). Patients treated with glutamine had a significant reduction in length of hospital stay (WMD = −2.67; 95% CI = −3.83 to −1.50; p < 0.0001). In conclusion, GLN supplementation appears to reduce hospital stay without affecting the rate of complications. The positive effect of GLN on time of hospitalization is difficult to interpret due to the lack of significant effects on surgery-related morbidity.
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Arthur S, Sundaram U. Inducible nitric oxide regulates intestinal glutamine assimilation during chronic intestinal inflammation. Nitric Oxide 2014; 44:98-104. [PMID: 25524833 DOI: 10.1016/j.niox.2014.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/06/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
To facilitate assimilation of glutamine, different Na-dependent glutamine absorptive pathways are present in the rabbit small intestine, specifically B0AT1 in villus and SN2 in crypt cell brush border membrane. Further, both are uniquely regulated in the chronically inflamed intestine. B0AT1 is inhibited secondary to reduced number of brush border membrane (BBM) co-transporters while SN2 is stimulated secondary to an increased affinity for glutamine. These unique changes are reversible by treatment with a broad spectrum immune modulator such as glucocorticoids. However, whether inducible nitric oxide (iNO), known to be elevated in the mucosa of the chronically inflamed intestine, may be responsible for these co-transporter alterations is not known. In the present study, treatment of chronically inflamed rabbits with L-NIL, a selective inhibitor of iNO synthase, reversed the inhibition of B0AT1 in villus and the stimulation of SN2 in crypt cells. At the level of the co-transporter in the brush border membrane, inhibition of iNO production reversed the inhibition of villus B0AT1 by restoring the co-transporter numbers while the stimulation of crypt SN2 was reversed back to normal by restoring its affinity for glutamine. Western blot analyses of BBM proteins also confirmed the kinetic studies. Thus, L-NIL treatment restores the uniquely altered Na-glutamine co-transporters in the enterocytes of chronically inflamed intestine. All these data indicate that iNO functions as an upstream immune modulator directly regulating glutamine assimilation during chronic intestinal inflammation.
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Affiliation(s)
- Subha Arthur
- Department of Clinical and Translational Sciences, Joan C Edwards School of Medicine, Marshall University, 1600 Medical Centre Drive, Huntington, WV 25701, United States
| | - Uma Sundaram
- Department of Clinical and Translational Sciences, Joan C Edwards School of Medicine, Marshall University, 1600 Medical Centre Drive, Huntington, WV 25701, United States.
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Abstract
Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high. Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: ‘esophagectomy’, ‘esophagus’, ‘neoplasm’ and ‘cancer’ to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care. Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients. Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons’ practice.
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Affiliation(s)
- Thomas J Lee
- Division of Surgical Oncology, University of Louisville School of Medicine, Department of Surgery, 315 East Broadway, Suite 313, Louisville, KY 40202, USA
| | - Robert CG Martin
- Division of Surgical Oncology, University of Louisville School of Medicine, Department of Surgery, 315 East Broadway, Suite 313, Louisville, KY 40202, USA.
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Bollhalder L, Pfeil AM, Tomonaga Y, Schwenkglenks M. A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation. Clin Nutr 2012. [PMID: 23196117 DOI: 10.1016/j.clnu.2012.11.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Glutamine supplementation has been associated with reduced mortality, infections and hospital length of stay in critically ill patients and patients undergoing major surgery. We carried out a meta-analysis to examine randomized clinical trial (RCT)-based evidence of these effects. METHODS Based on a systematic database search, RCTs published since 1990 were included if they evaluated the effect of parenteral glutamine supplementation against a background of parenteral nutrition. Enteral (tube) feeding in a proportion of patients was allowable. Information on RCT methodology, quality and outcomes was extracted. Random effects meta-analysis followed the DerSimonian-Laird approach. RESULTS Forty RCTs were eligible for meta-analysis. Parenteral glutamine supplementation was associated with a non-significant 11% reduction in short-term mortality (RR = 0.89; 95% CI, 0.77-1.04). Infections were significantly reduced (RR = 0.83; 95% CI, 0.72-0.95) and length of stay was 2.35 days shorter (95% CI, -3.68 to -1.02) in the glutamine arms. Meta-analysis results were strongly influenced by one recent trial. An element of publication bias could not be excluded. CONCLUSION Parenteral glutamine supplementation in severely ill patients may reduce infections, length of stay and mortality, but substantial uncertainty remains. Unlike previous meta-analyses, we could not demonstrate a significant reduction in mortality.
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Affiliation(s)
- Lea Bollhalder
- Institute of Social and Preventive Medicine, Medical Economics Unit, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland.
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Arthur S, Saha P, Sundaram S, Kekuda R, Sundaram U. Regulation of sodium-glutamine cotransport in villus and crypt cells by glucocorticoids during chronic enteritis. Inflamm Bowel Dis 2012; 18:2149-57. [PMID: 22508450 DOI: 10.1002/ibd.22924] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/30/2012] [Indexed: 12/09/2022]
Abstract
BACKGROUND Assimilation of the preferred nutrient of enterocytes is mediated primarily by sodium (Na)-dependent cotransport (NGct) in the intestine. The predominant NGcT in villus cells, B0AT1, is inhibited secondary to a decrease in cotransporter numbers during chronic intestinal inflammation. In contrast, NGcT mediated by SN2 in crypt cells is stimulated secondary to increased affinity of the cotransporter for glutamine during chronic ileitis. Glucocorticoid is a mainstay of treatment for inflammatory bowel disease. However, its effect on NGcT is not known. METHODS The inhibition of B0AT1 in villus cells during chronic intestinal inflammation was reversed back to normal by methylprednisolone (MP). This was secondary to the restoration of the cotransporter numbers in the brush border membrane rather than an alteration in the affinity. The stimulation of NGcT in crypt cells during chronic ileitis was also restored back to its normal levels by MP treatment. This reversal was secondary to the restoration of the altered affinity of the cotransporter SN2 for glutamine. RESULTS Kinetic studies and western blot analysis were consistent with functional studies for both cotransporters. Thus, glucocorticoids restore two uniquely altered Na-glutamine cotransporters, B0AT1 in villus and SN2 in crypt cells during chronic enteritis. CONCLUSIONS These data indicate that glucocorticoids function as an upstream broad spectrum immune modulator in the chronically inflamed intestine.
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Affiliation(s)
- Subha Arthur
- Section of Digestive Diseases and Clinical and Translational Science Institute West Virginia University Health Sciences Center, Morgantown, West Virginia 26506, USA
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