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Blesa-Malpica A, Martín-Luengo A, Robles-González A. Recommendations for specialized nutritional-metabolic management of the critical patient: Special situations, polytraumatisms and critical burn patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:73-76. [PMID: 32532416 DOI: 10.1016/j.medin.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 11/18/2022]
Affiliation(s)
- A Blesa-Malpica
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, España.
| | - A Martín-Luengo
- Servicio de Medicina Intensiva, Hospital Universitario de Burgos, Burgos, España
| | - A Robles-González
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España
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Clendenen N, Nunns GR, Moore EE, Reisz JA, Gonzalez E, Peltz E, Silliman CC, Fragoso M, Nemkov T, Wither MJ, Hansen K, Banerjee A, Moore HB, D’Alessandro A. Hemorrhagic shock and tissue injury drive distinct plasma metabolome derangements in swine. J Trauma Acute Care Surg 2017; 83:635-642. [PMID: 28463938 PMCID: PMC5608631 DOI: 10.1097/ta.0000000000001504] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tissue injury and hemorrhagic shock induce significant systemic metabolic reprogramming in animal models and critically injured patients. Recent expansions of the classic concepts of metabolomic aberrations in tissue injury and hemorrhage opened the way for novel resuscitative interventions based on the observed abnormal metabolic demands. We hypothesize that metabolic demands and resulting metabolic signatures in pig plasma will vary in response to isolated or combined tissue injury and hemorrhagic shock. METHODS A total of 20 pigs underwent either isolated tissue injury, hemorrhagic shock, or combined tissue injury and hemorrhagic shock referenced to a sham protocol (n = 5/group). Plasma samples were analyzed by UHPLC-MS. RESULTS Hemorrhagic shock promoted a hypermetabolic state. Tissue injury alone dampened metabolic responses in comparison to sham and hemorrhagic shock, and attenuated the hypermetabolic state triggered by shock with respect to energy metabolism (glycolysis, glutaminolysis, and Krebs cycle). Tissue injury and hemorrhagic shock had a more pronounced effect on nitrogen metabolism (arginine, polyamines, and purine metabolism) than hemorrhagic shock alone. CONCLUSION Isolated or combined tissue injury and hemorrhagic shock result in distinct plasma metabolic signatures. These findings indicate that optimized resuscitative interventions in critically ill patients are possible based on identifying the severity of tissue injury and hemorrhage.
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Affiliation(s)
- Nathan Clendenen
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA
| | - Geoffrey R Nunns
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | | | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | - Eduardo Gonzalez
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | - Erik Peltz
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | - Christopher C Silliman
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
- Bonfils Blood Center, Denver, CO, USA
- Department of Pediatrics, University of Colorado Denver, Aurora, CO, USA
| | - Miguel Fragoso
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | - Travis Nemkov
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | - Matthew J Wither
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | | | - Anirban Banerjee
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | - Hunter B Moore
- Department of Surgery - University of Colorado Denver, Aurora, CO, USA
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
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Red blood cells in hemorrhagic shock: a critical role for glutaminolysis in fueling alanine transamination in rats. Blood Adv 2017; 1:1296-1305. [PMID: 29296771 DOI: 10.1182/bloodadvances.2017007187] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/02/2017] [Indexed: 02/06/2023] Open
Abstract
Red blood cells (RBCs) are the most abundant host cell in the human body and play a critical role in oxygen transport and systemic metabolic homeostasis. Hypoxic metabolic reprogramming of RBCs in response to high-altitude hypoxia or anaerobic storage in the blood bank has been extensively described. However, little is known about the RBC metabolism following hemorrhagic shock (HS), the most common preventable cause of death in trauma, the global leading cause of total life-years lost. Metabolomics analyses were performed through ultra-high pressure liquid chromatography-mass spectrometry on RBCs from Sprague-Dawley rats undergoing HS (mean arterial pressure [MAP], <30 mm Hg) in comparison with sham rats (MAP, >80 mm Hg). Steady-state measurements were accompanied by metabolic flux analysis upon tracing of in vivo-injected 13C15N-glutamine or inhibition of glutaminolysis using the anticancer drug CB-839. RBC metabolic phenotypes recapitulated the systemic metabolic reprogramming observed in plasma from the same rodent model. Results indicate that shock RBCs rely on glutamine to fuel glutathione (GSH) synthesis and pyruvate transamination, whereas abrogation of glutaminolysis conferred early mortality and exacerbated lactic acidosis and systemic accumulation of succinate, a predictor of mortality in the military and civilian critically ill populations. Glutamine is here identified as an essential amine group donor in HS RBCs, plasma, liver, and lungs, providing additional rationale for the central role glutaminolysis plays in metabolic reprogramming and survival following severe hemorrhage.
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Alpha-Ketoglutarate as a Molecule with Pleiotropic Activity: Well-Known and Novel Possibilities of Therapeutic Use. Arch Immunol Ther Exp (Warsz) 2016; 65:21-36. [PMID: 27326424 PMCID: PMC5274648 DOI: 10.1007/s00005-016-0406-x] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/22/2016] [Indexed: 12/17/2022]
Abstract
Alpha-ketoglutarate (AKG), an endogenous intermediary metabolite in the Krebs cycle, is a molecule involved in multiple metabolic and cellular pathways. It functions as an energy donor, a precursor in the amino acid biosynthesis, a signalling molecule, as well as a regulator of epigenetic processes and cellular signalling via protein binding. AKG is an obligatory co-substrate for 2-oxoglutarate-dependent dioxygenases, which catalyse hydroxylation reactions on various types of substrates. It regulates the activity of prolyl-4 hydroxylase, which controls the biosynthesis of collagen, a component of bone tissue. AKG also affects the functioning of prolyl hydroxylases, which, in turn, influences the function of the hypoxia-inducible factor, an important transcription factor in cancer development and progression. Additionally, it affects the functioning of enzymes that influence epigenetic modifications of chromatin: ten-eleven translocation hydroxylases involved in DNA demethylation and the Jumonji C domain containing lysine demethylases, which are the major histone demethylases. Thus, it regulates gene expression. The metabolic and extrametabolic function of AKG in cells and the organism open many different fields for therapeutic interventions for treatment of diseases. This review presents the results of studies conducted with the use of AKG in states of protein deficiency and oxidative stress conditions. It also discusses current knowledge about AKG as an immunomodulatory agent and a bone anabolic factor. Additionally, the regulatory role of AKG and its structural analogues in carcinogenesis as well as the results of studies of AKG as an anticancer agent are discussed.
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Lorenz KJ, Schallert R, Daniel V. Immunonutrition - the influence of early postoperative glutamine supplementation in enteral/parenteral nutrition on immune response, wound healing and length of hospital stay in multiple trauma patients and patients after extensive surgery. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2015; 4:Doc15. [PMID: 26734536 PMCID: PMC4686804 DOI: 10.3205/iprs000074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION In the postoperative phase, the prognosis of multiple trauma patients with severe brain injuries as well as of patients with extensive head and neck surgery mainly depends on protein metabolism and the prevention of septic complications. Wound healing problems can also result in markedly longer stays in the intensive care unit and general wards. As a result, the immunostimulation of patients in the postoperative phase is expected to improve their immunological and overall health. PATIENTS AND METHODS A study involving 15 patients with extensive ENT tumour surgery and 7 multiple-trauma patients investigated the effect of enteral glutamine supplementation on immune induction, wound healing and length of hospital stay. Half of the patients received a glutamine-supplemented diet. The control group received an isocaloric, isonitrogenous diet. RESULTS In summary, we found that total lymphocyte counts, the percentage of activated CD4+DR+ T helper lymphocytes, the in-vitro response of lymphocytes to mitogens, as well as IL-2 plasma levels normalised faster in patients who received glutamine-supplemented diets than in patients who received isocaloric, isonitrogenous diets and that these parameters were even above normal by the end of the second postoperative week. SUMMARY We believe that providing critically ill patients with a demand-oriented immunostimulating diet is fully justified as it reduces septic complications, accelerates wound healing, and shortens the length of ICU (intensive care unit) and general ward stays.
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Affiliation(s)
- Kai J Lorenz
- Bundeswehr Hospital of Ulm, Department of Otolaryngology, Head and Neck Surgery, Ulm, Germany
| | - Reiner Schallert
- Bundeswehr Hospital of Ulm, Surgical Centre, Department of Accident Surgery and Orthopaedics, Ulm, Germany
| | - Volker Daniel
- University of Heidelberg, Institute of Transplantation Immunology, Heidelberg, Germany
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Kang K, Shu XL, Zhang YS, Liu XL, Zhao J. Effect of glutamine enriched nutrition support on surgical patients with gastrointestinal tumor: a meta-analysis of randomized controlled trials. Chin Med J (Engl) 2015; 128:245-51. [PMID: 25591570 PMCID: PMC4837846 DOI: 10.4103/0366-6999.149219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Associations between glutamine (Gln) enriched nutrition support and surgical patients with gastrointestinal (GI) tumor remain controversy. The purpose of this meta-analysis was to assess the effect of Gln enriched nutrition support on surgical patients with GI tumor in term of relevant biochemical indices, immune indices, and clinical outcomes. Methods: Six databases were systematically searched to find eligible randomized controlled trials (RCTs) from 1966 to May 2014. When estimated the analysis indexes, the relative risk (RR) was used as the effect size of the categorical variable, while the weighted mean difference (MD) was used as the effect size of a continuous variable. Meta-analysis was conducted with Rev Man 5.2. Results: Thirteen RCTs, involving 1034 patients, were included in the meta-analysis. The analysis showed that Gln enriched nutrition support was more effective in increasing serum albumin (MD: 0.10; 95% confidence interval [CI]: 0.02–0.18; P < 0.05), serum prealbumin (MD: 1.98; 95% CI: 1.40–2.55; P < 0.05) and serum transferring (MD: 0.35; 95% CI: 0.12–0.57; P < 0.05), concentration of IgG (MD: 1.26; 95% CI: 0.90–1.63; P < 0.05), IgM (MD: 0.18; 95% CI: 0.11–0.25; P < 0.05), IgA (MD: 0.22; 95% CI: 0.10–0.33; P < 0.05), CD3+ (MD: 3.71; 95% CI: 2.57–4.85; P < 0.05) and CD4/CD8 ratio (MD: 0.27; 95% CI: 0.12–0.42; P < 0.05). Meanwhile, it was more significant in decreasing the incidence of infectious complications (RR: 0.67; 95% CI: 0.50–0.90; P < 0.05) and shortening the length of hospital stay (MD: −1.72; 95% CI: −3.31–−0.13; P < 0.05). Conclusions: Glutamine enriched nutrition support was superior in improving immune function, reducing the incidence of infectious complications and shortening the length of hospital stay, playing an important role in the rehabilitation of surgical GI cancer patients.
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Affiliation(s)
| | - Xiao-Liang Shu
- Department of Nutrition, East Hospital, Tong Ji University School of Medicine, Shanghai 200120, China
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Rosenthal MD, Vanzant EL, Martindale RG, Moore FA. Evolving paradigms in the nutritional support of critically ill surgical patients. Curr Probl Surg 2015; 52:147-82. [PMID: 25946621 DOI: 10.1067/j.cpsurg.2015.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/29/2015] [Accepted: 02/11/2015] [Indexed: 12/12/2022]
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Brianez LR, Caporossi C, de Moura YW, Dias LA, Leal RV, de Aguilar-Nascimento JE. Gastric residual volume by magnetic ressonance after intake of maltodextrin and glutamine: a randomized double-blind, crossover study. ARQUIVOS DE GASTROENTEROLOGIA 2015; 51:123-7. [PMID: 25003264 DOI: 10.1590/s0004-28032014000200010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/20/2014] [Indexed: 11/22/2022]
Abstract
CONTEXT The addition of glutamine in preoperative drinks may enhance the benefits of carbohydrate alone. OBJECTIVES To evaluate the gastric residual volume after the intake of a beverage containing carbohydrate plus glutamine. METHODS Eleven healthy volunteers (24-30 years-old) were randomized in a crossover fashion to intake 400 mL (4h before) and 200 mL (2h before) of a beverage containing either 12.5% maltodextrin (carbohydrate group) or 12.5% maltodextrin plus 15 g of glutamine (glutamine group) in two different moments 7 days apart. Magnetic ressonance was performed to measure the gastric residual volume (mL) 120 and 180 minutes after the last ingestion. RESULTS Gastric residual volume similar to basal condition was found after 2h and 3h of the intake of beverages. There was no difference in the mean ±SD GRV (mL) found at 120 minutes (carbohydrate group: 22.9±16.6 and glutamine group: 19.7±10.7) and at 180 minutes (carbohydrate group: 21.5±24.1 and glutamine group: 15.1±10.1) between the two drinks. CONCLUSIONS Gastric emptying is efficient, and occurs in up to two hours after the intake of a beverage containing either carbohydrate alone or carbohydrate associated with glutamine. The addition of glutamine to carbohydrate-enriched drink seems to be safe for the use up to 2h before an operation.
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Affiliation(s)
- Luigi R Brianez
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - Cervantes Caporossi
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - Yure W de Moura
- Instituto de Diagnósticos em Medicina, Hospital Santa Rosa, Cuiabá, MT, Brasil
| | - Lorena A Dias
- Instituto de Diagnósticos em Medicina, Hospital Santa Rosa, Cuiabá, MT, Brasil
| | - Regis V Leal
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
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Fan J, Li G, Wu L, Tao S, Wang W, Sheng Z, Meng Q. Parenteral glutamine supplementation in combination with enteral nutrition improves intestinal immunity in septic rats. Nutrition 2014; 31:766-74. [PMID: 25837225 DOI: 10.1016/j.nut.2014.11.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 11/15/2014] [Accepted: 11/29/2014] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The gut-associated lymphoid tissue is continuously exposed to antigens in the gut lumen and becomes the first line of defense against enteric bacteria and associated toxin. The aim of this study was to investigate the effects of parenteral glutamine (GLN) supplementation in combination with enteral nutrition (EN) on intestinal mucosal immunity in septic rats by cecal ligation and puncture (CLP). METHODS Male Sprague-Dawley rats were randomly assigned into four groups: A sham CLP + EN + saline group (n = 10), a sham CLP + EN + GLN group (n = 10), a CLP + EN + saline group (n = 10), and a CLP + EN + GLN group (n = 10). At 2 h after CLP or sham CLP, all rats in each of the four groups received an identical enteral nutrition solution as their base formula. Then, the rats in the sham CLP + EN + GLN group and CLP + EN + GLN group were given 0.35 g GLN/kg body weight daily for 7 d, all at the same time, via a tail vein injection; whereas those in the sham CLP + EN + saline group and CLP + EN + saline group were daily administered isovolumic sterile 0.9% saline for comparison. All rats in each of the four groups were given 290 kcal/kg body wt/d for 7 d. At the end of the seventh day after the nutritional program was finished, all rats were euthanized and the entire intestine was collected. Total Peyer's patches (PP) cell yield was counted by a hemocytometer. The percentage of PP lymphocyte subsets was analyzed by flow cytometry. The number of intestinal lamina propria IgA plasma cells was determined by the immunohistochemistry technique. The intestinal immunoglobulin A (IgA) levels were assessed by ELISA. PP apoptosis was evaluated by terminal deoxyuridine nick-end labeling. RESULTS The results revealed total PP cell yield, the numbers of PP lymphocyte subsets, intestinal lamina propria IgA plasma cells, and intestinal IgA levels in the CLP + EN + GLN group were significantly increased when compared with the CLP + EN + saline group (P < 0.05). On the other hand, the number of TUNEL-stained cells within PPs in the CLP + EN + GLN group was markedly decreased as compared with the CLP + EN + saline group (P < 0.05). CONCLUSION The results of this study show that parenteral glutamine supplementation in combination with enteral nutrition may attenuate PP apoptosis, increase PP cell yield and intestinal lamina propria IgA plasma cells, and subsequently improve intestinal mucosal immunity. Clinically, these results suggest therapeutic efforts at improving intestinal immunity may contribute to the prevention and treatment of sepsis.
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Affiliation(s)
- Jun Fan
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China.
| | - Guoping Li
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China
| | - Lidong Wu
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China
| | - Shaoyu Tao
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China
| | - Wei Wang
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China
| | - Zhiyong Sheng
- Department of Emergency and Critical Care Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, P.R. China
| | - Qingyan Meng
- Department of Burns, The Northern Hospital, Liaoning, P.R. China
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Abstract
One of the most important factors affecting outcome and recovery from surgical trauma is preoperative nutritional status. Research in perioperative nutritional support has suffered from a lack of consensus as to the definition of malnutrition, no recognition of which nutrients are important to surgical healing, and a paucity of well-designed studies. In the past decade, there has been some activity to address this situation, recognizing the importance of nutrition as a therapy before surgery, after surgery, and possibly even during surgery.
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Affiliation(s)
- T Miko Enomoto
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, UHS-2, Portland, OR 97239, USA
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