Basic concepts of immunology and its application to clinical nutrition

Impact of Controlling Nutritional Status Score on Mortality in Elderly Patients with Idiopathic Pulmonary Fibrosis

Background: There are only a few reports on the nutritional status and mortality of patients with idiopathic pulmonary fibrosis (IPF). As such, this study aims to investigate the relationship between controlling nutritional status (CONUT) and the mortality of elderly patients with IPF. Methods: A total of 170 IPF patients aged ≥65 years old who visited the rehabilitation department of our hospital between July 2014 and July 2021 (mean age: 75.7 ± 6.3 years, sex (male/female): 138/32, %FVC: 78.3 ± 18.3%) were retrospectively analyzed. The Kaplan-Meier method and log-rank test were applied. Furthermore, using a Cox proportional hazards model with multivariate analysis, we analyzed the relationship between all-cause mortality and baseline characteristics including CONUT. Results: Based on the CONUT score, the normal group included 101 cases, the mild group included 58 cases, the moderate group included 11 cases, and the severe group had 0 cases. There were 49 cases of all-cause mortality events, suggesting that the mortality of the moderate group was significantly poorer than that of the normal and mild groups (p < 0.05). Furthermore, multivariate analysis identified GAP stage (HR: 5.972, 95%CI: 2.901~12.291, p < 0.0001), mMRC scale (HR: 0.615, 95%CI: 0.389~0.971, p = 0.009), and CONUT (HR: 2.012, 95%CI: 1.192~3.395, p = 0.037) as factors significantly influencing mortality. Conclusions: Severe malnutrition was not observed in elderly patients with IPF. Moderate malnutrition was associated with a significantly higher risk of all-cause mortality, suggesting that CONUT is an important indicator for predicting mortality.

Impact of malnutrition on prognosis in patients with pulmonary arterial hypertension

Pulmonary arterial hypertension is a life-threatening disease that coexists with right heart failure. We evaluated the relationship between malnutrition and prognosis in patients with pulmonary arterial hypertension, as malnutrition is known as a prognosis determinant in chronic heart failure. We retrospectively reviewed data of patients with pulmonary arterial hypertension before treatment. The Geriatric Nutritional Risk Index, Prognostic Nutritional Index, and Controlling Nutritional Status scores on the day of diagnosis were calculated to assess the nutritional status. Clinical endpoints were defined as composite outcomes of all-cause death or lung transplantation. Eighty patients were enrolled (mean age, 50 years; 23 men). The mean pulmonary arterial pressure was 47 ± 19 mmHg, Geriatric Nutritional Risk Index was 99.9 ± 12.0, and Prognostic Nutritional Index was 46.3 ± 10.0. The median Controlling Nutritional Status score was 2 (1-4). During the median 5.5-year follow-up period, 28 composite events occurred. Kaplan-Meier analysis demonstrated significant differences in the incidence of clinical endpoints between groups divided by each median Geriatric Nutritional Risk Index, Prognostic Nutritional Index, and Controlling Nutritional Status score (p = 0.007, 0.039, and 0.010, respectively). In multivariate Cox regression analysis, clinical endpoints were significantly associated with Geriatric Nutritional Risk Index (hazard ratio: 0.953, 95% confidence interval: 0.918-0.990), Prognostic Nutritional Index (hazard ratio: 0.942, 95% confidence interval: 0.892-0.996), and Controlling Nutritional Status score (hazard ratio: 1.230, 95% confidence interval: 1.056-1.433) after adjustment for factors associated in univariate Cox regression analysis. Malnutrition at diagnosis is a useful prognostic predictor for patients with pulmonary arterial hypertension.

Nutritional Status Predicts Fatty Acid Uptake from Fish and Soybean Oil Supplements for Treatment of Cancer-Related Fatigue: Results from a Phase II Nationwide Study

Cancer-related fatigue is a prevalent and debilitating condition that persists for years into survivorship. Studies evaluating both fish oil supplementation on fatigue and associations between fish oil consumption and fatigue have shown mixed effects; it is unknown what factors contribute to these differential effects. Herein, we investigate whether the nutritional status of cancer survivors was associated with serum omega-3 concentration or change in serum omega-3s throughout a fish oil supplementation study, and then if any of these factors were associated with fatigue. Breast cancer survivors 4-36 months post-treatment with moderate-severe fatigue were randomized to take 6 g fish oil, 6 g soybean oil, or 3 g of each daily for 6 weeks. Baseline nutritional status was calculated using the Controlling Nutritional Status tool (serum albumin, lymphocytes, cholesterol). At baseline and post-intervention, serum fatty acids were quantified and fatigue was assessed using the Multidimensional Fatigue Symptom Inventory. Participants (n = 85) were 61.2 ± 9.7 years old with a body mass index of 31.9 ± 6.7 kg/m²; 69% had a good nutritional score and 31% had light-moderate malnutrition. Those with good nutritional status had greater total serum omega-3s at baseline (p = 0.013) and a greater increase in serum omega-3s with supplementation (p = 0.003). Among those who were supplemented with fish oil, greater increases in serum omega-3s were associated with greater improvements in fatigue. In conclusion, good nutritional status may increase uptake of fatty acid supplements, increasing their ability to improve fatigue.

Relationship between Low Pretreatment Geriatric Nutritional Risk Index and Poor Tolerability of Azacitidine in Patients with Myelodysplastic Syndromes

BACKGROUND

Predicting tolerability and treatment-related risks associated with azacitidine (AZA) in patients with myelodysplastic syndromes (MDS) before the initiation of therapy is required for appropriate treatment. Thus, in this study, the nutritional status of patients with MDS prior to AZA treatment was evaluated using the geriatric nutritional risk index (GNRI). Tolerability and overall survival (OS) after AZA initiation were also investigated.

METHODS

This was a single-center retrospective observational study. A total of 59 patients with MDS treated with AZA were assessed using GNRI, and a comparison of undernourished (GNRI <92, n = 27) and non-undernourished (GNRI ≥92, n = 32) patients was performed.

RESULTS

The undernourished group had a significant reduction in the number of patients that successfully completed 4 cycles of AZA treatment compared with the non-undernourished group (undernourished group, 11/27 patients, 40.7% vs. non-undernourished group, 24/32 patients, 75.0%; p = 0.009). Factors associated with the difference included karyotype and GNRI. There was also a significant increase in the rate of infectious complications in the undernourished group compared with the non-undernourished group (undernourished group, 33/60 cycles, 55.0% vs. non-undernourished group, 31/92 cycles, 33.7%; p = 0.012). Lastly, a significant reduction in OS was observed in the undernourished group compared with the non-undernourished group (undernourished group, 11.5 months; 95% CI, 5.2-16.7 vs. non-undernourished group, 21.9 months; 95% CI, 13.8-24.0; p = 0.026). Factors associated with OS included both the revised International Prognostic Scoring System (IPSS-R) and GNRI.

CONCLUSIONS

These results indicate that predicting treatment completion and adverse events in patients with MDS prior to AZA treatment is important. This study suggests GNRI may be a valuable nutritional assessment tool for determining tolerability and OS of AZA treatment.

Association between the Prognostic Nutritional Index and Dietary Intake in Community-Dwelling Older Adults with Heart Failure: Findings from NHANES III

The objective of this study was to examine the association between nutritional status and dietary intake in community-dwelling older adults with heart failure (HF). A cross-sectional analysis of NHANES III data was conducted. The analytic sample was comprised of n = 445 individuals aged 50+ years with congestive HF (54.4% male, 22.9% non-Hispanic Black, 43.8% low-income). Nutritional status was measured using the Prognostic Nutritional Index (PNI). Participants were classified by PNI quintiles with lower PNI scores indicating lower nutritional status. Participants in quintile 5 showed significantly greater intakes of energy, protein, vegetables, magnesium, zinc, copper, potassium, red meat, saturated fat, and sodium. In multivariate analyses, increased intake of red meat (β = 0.253, p = 0.040) and vegetables (β = 0.255, p = 0.038) was associated with significantly better nutritional status. In the absence of comprehensive nutritional guidance for HF patients, it appears that small increases in energy, protein (red meat), and vegetable consumption are associated with improved nutritional status.

Correlation of Nutritional Indices on Admission to the Coronary Intensive Care Unit with the Development of Delirium

BACKGROUND

Delirium is a common occurrence in patients admitted to the intensive care unit and is related to mortality and morbidity. Malnutrition is a predisposing factor for the development of delirium. Nevertheless, whether the nutritional status on admission anticipates the development of delirium in patients with acute cardiovascular diseases remains unknown.

OBJECTIVE

This study aims to assess the correlation between the nutritional status on admission using the nutritional index and the development of delirium in the coronary intensive care unit.

DESIGN

We examined 653 consecutive patients (mean age: 70 ± 14 years) admitted to the coronary intensive care unit of Juntendo University Hospital between January 2015 and December 2016. We evaluated three nutritional indices frequently used to assess the nutritional status, i.e., Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI), and Controlling Nutritional Status (CONUT). We defined delirium as patients with a delirium score >4 using the Intensive Care Delirium Screening Checklist.

RESULTS

Delirium was present in 58 patients. All nutritional indices exhibited a tendency for malnutrition in the delirium group compared with the non-delirium group (GNRI, 86.5 ± 9.38 versus 91.6 ± 9.89; PNI, 36.4 ± 6.95 versus 41.6 ± 7.62; CONUT, 5.88 ± 3.00 versus 3.61 ± 2.56; for all, p < 0.001). Furthermore, the maximum delirium score increased progressively from the low- to the high-risk group, as evaluated by each nutritional index (GNRI, PNI, CONUT; for all, p < 0.001). A multivariate analysis revealed that the PNI and CONUT were independent risk factors for the occurrence of delirium.

CONCLUSIONS

A marked correlation exists between the nutritional index on admission, especially PNI and CONUT, and the development of delirium in patients with acute cardiovascular diseases, suggesting that malnutrition assessment upon admission could help identify patients at high risk of developing delirium.

Serum selenium levels in patients with respiratory diseases: a prospective observational study

BACKGROUND

Serum selenium levels are lower in critically ill patients as compared with healthy controls. However, there is no data about the difference in serum selenium levels depending on the severity of lung diseases. We aimed to identify the factors associated with low serum selenium levels in critically ill patients with respiratory diseases.

METHODS

A prospective study was performed in 83 patients with respiratory diseases who had admitted to the intensive care unit (ICU) and general wards. We obtained systemic inflammatory markers, nutritional indicators and prognostic factors as the explanatory variables for the outcome of low serum selenium levels.

RESULTS

Serum selenium levels on admission were lower by 28% in the ICU group as compared with the general ward group (70.0±26.4 and 97.9±20.8 ng/mL, respectively, P<0.001). Low serum selenium levels had a correlation with malnutrition represented by decreases in levels of lymphocyte (R(2)=0.107, P=0.005) and albumin (R(2)=0.174, P<0.001). In addition, low serum selenium levels were associated with an increase in baseline C-reactive protein (CRP) (R(2)=0.059, P=0.041) and APACHE II scores (R(2)=0.209, P<0.001). Lower albumin levels (P=0.032) and higher APACHE II scores (P=0.046) showed a significant correlation with lower serum selenium levels on multivariate analysis.

CONCLUSIONS

Low serum selenium levels in patients with respiratory diseases have a significant correlation with poor nutritional status and prognosis on admission.

Evaluation of CONUT for Clinical Malnutrition Detection and Short-Term Prognostic Assessment in Hospitalized Elderly People

OBJECTIVES

To assess agreement between the CONUT and Mini Nutritional Assessment (MNA) instruments in detecting malnutrition in hospitalized elderly patients and to determine their prognostic value compared to that of serum albumin alone in relation to in-hospital and 1-month and 6-month post-discharge mortality rates.

DESIGN

Prospective observational study.

SETTING

A Catalan regional hospital.

PARTICIPANTS

2155 patients admitted to an acute geriatric unit were assessed using MNA and CONUT and were followed up for 6 months after discharge.

MEASUREMENTS

On admission, data were collected on age, sex, referral, geriatric syndromes, cognitive status, functional status and nutritional status according to MNA (as the gold standard). Plasma albumin, total cholesterol and lymphocyte levels were recorded to implement CONUT. Mortality was recorded until 6 months after discharge.

RESULTS

Sample characteristics: 61.3% females, mean age 84.9 years, mean Charlson index 2.2. CONUT sensitivity and specificity for malnutrition were 43% and 71.6%, respectively, with positive and negative predictive values of 88.9% and 19.2%. MNA, CONUT and albumin alone were good predictors of mortality but showed similar sensitivity and specificity results.

CONCLUSION

CONUT agreement with MNA in nutritional risk assessments for elderly people is poor. Although CONUT is a good predictor of short-and medium-term mortality, it adds little to information provided by albumin alone.

Nutrition and Immune Function

The complexity of the immune system allows for a multitude of potential avenues for nutrient modulation, but this also increase the challenge of producing a predictable in vivo response. Because the immune response is a cascade of biologic events, development of nutritional support paradigms cannot and should not be made in a vacuum or with the expectation of a singular response. It is absolutely imperative that the clinician/nutritionist understand the differences in metabolIc and physiologic responses to disease states (ie, shock, trauma, organ-specific dysfunction) so as to maximize immunocompetence through specialized feeding practices. This level of understanding is invaluable, especially when considering the possible benefit of nutrient combinations for immunomodualtion.

Nutritional support of the critically ill and injured patient

The understanding of the importance of nutrition, particularly in the critically ill patient, is based on the known physiologic consequences of malnutrition. It includes respiratory muscle function, cardiac function, the coagulation cascade balance, electrolyte and hormonal balance, and renal function. Nutrition affects emotional and behavioral responses, functional recovery, and the overall cost of health care. The need to identify and treat the malnourished or potentially malnourished patient is a critical aspect of patient management. Much is known of catabolic and hypermetabolic state caused by trauma and burns. The response to injury needs to be mediated. There is much to learn about the intervention of that response through adjuvant nutritional therapy.

Immunomodulatory activity of Chilean Cyttaria species in mice with L5178Y lymphoma

The immunomodulatory effect of hydrosoluble extracts of four Chilean Cyttaria species (Discomycetes, Fungi) was assessed in mice with L5178Y lymphoma. Oral administration of 100 mg extract per day for 7 days enhanced the percentual phagocytosis and phagocytosis index in animals receiving Cyttaria berteroi, Cyttaria darwinii, Cyttaria espinosae and Cyttaria harioti extracts. Differences in the digestion index were observed in mice treated with C. darwinii and C. berteroi. In the delayed-type hypersensitivity model, only C. harioti was able to modify the immune response. The results suggest that intake of Cyttaria can improve the immune system of consumers.

The immunocompromised host and risk for cardiovascular infection

The risk factors for cardiovascular (CV) infections are related to the immunocompetence of the host, preexisting cardiac conditions, and exposure to infectious organisms. Immunocompromised states are related to defective physical and chemical barriers and/or alterations of immune organs, cells, and substances. There are many conditions, diseases, drugs, and therapies that are associated with immunocompromised states. In-dwelling central venous catheters, prosthetic valves/devices, cardiac lesions, and conditions that create turbulent blood flow increase risk for CV infections. An understanding of the immune response, risk factors for immunocompromise, and risk factors for CV infections helps guide the CV nurse's plan of care related to assessment and interventions for prevention, identification, and treatment of CV infections. Diagnosis, monitoring, and management challenges of the immunocompromised patient with infective endocarditis and myocarditis are presented.

Nutrition and the immune system of the gut

Studies suggest that the development and expression of the regional immune system in the gastrointestinal (GI) tract is relatively independent of systemic immunity. This is reflected in significant differences in functional response of T cells and B cells and affects cytokine patterns and activation pathways when regional immunity is compared to systemic immunity. Nutrients have fundamental and regulatory influences on the immune response of the GI tract and, therefore, on host defense. In addition to the effect of nutrition during development, the local impact of different dietary and antigenic elements on the regional immune system contributes to potential diversion of the two systems throughout life. The route of exposure during antigenic contact is known to affect host immune response, whether it be a normal process, happening in the context of normal environmental encounter with nonpathogenic microbes or planned immunization, or occurring as a result of resolution of a potentially pathologic process i.e., an infectious encounter. Interactions at the local level profoundly influence systemic immune response, in part because of intrinsic differences in these systems, and also because of different requirements for optimal function. Although inflammatory processes are central to host defense in the periphery, the protective blocking action of the secretory immunoglobulin A immune response is crucial to local host defense, and, therefore, to the integrity of GI tract immune function. For these reasons, interaction with normal bacteria of the GI tract may be seen as the model of how the system has evolved and provide clues to the restoration of balance in the immunocompromised host. Reduction of normal commensal bacteria in the context of infection or after antibiotic treatment may interfere with nutrient availability and impair beneficial stimulation of GI immune response. This impairment may be associated with continued colonization with opportunistic microbes and inflammatory immune response that could lead to malabsorption and malnutrition. Study of the impact of nutrient imbalance on the function of the GI tract has profound implications for clinical medicine and may in the future lead to the rational design of preventive approaches to support immune response and host defense.

Common nutritional issues in pediatric and adult critical care medicine

This article discusses many of the nutritional topics important to the intensivist. Nutritional assessment, substrate immunonutrition, and disease specific issues are presented. Early introduction of enteral feeds and the use of nutritional modulation are emphasized.

Effects of an immune-enhancing diet in critically injured patients

OBJECTIVE

To determine the effects of an immune-enhancing experimental diet (XD = supplemental arginine, trace elements, and increased omega-3 fatty acids) versus standard diet (SD), on immune cell function and clinical outcome of critically injured patients.

DESIGN

Prospective randomized clinical trial of patients admitted to the surgical intensive care unit after trauma (Injury Severity Score > 13).

MATERIALS AND METHODS

Patients received early enteral nutrition with either XD or SD for a minimum of 5 days.

MEASUREMENTS

Mortality, intensive care unit, ventilator, and hospital days, as well as incidence of adult respiratory distress syndrome (ARDS) and infectious complications were recorded. Nutritional parameters were also studied. Peripheral blood leukocytes were isolated from normal volunteers and from patients on days 1, 6, and 10 of feeding.

MAIN RESULTS

Demographics and injury severity were similar in both groups. Both SD (n = 21) and XD (n = 22) groups revealed depressed monocyte function (tumor necrosis factor, prostaglandin E2, and procoagulant activity) on day 1 compared with a reference group (p < 0.05). However, monocytes from XD patients began to "normalize" their response (tumor necrosis factor, prostaglandin E2, and procoagulant activity) by day 6. Although ARDS occurred more frequently in the XD group (45 vs. 19%), the majority of ARDS in both groups occurred very early, with only three patients in the XD (13.6%) and one patient in the SD (4.7%) groups developing ARDS after study entry. XD patients remained on the ventilator longer (16.4 vs. 9.7 days) and in the hospital longer (32.9 vs. 22 days) compared with the SD group, but overall mortality was nearly identical (4.5 vs. 5%).

CONCLUSION

The exact role and timing for diets with immune-enhancing effects has yet to be defined.