Understanding the mechanisms of glutamine action in critically ill patients

Living on the edge: Crayfish as drivers to anoxification of their own shelter microenvironment

Burrowing is a common trait among crayfish thought to help species deal with adverse environmental challenges. However, little is known about the microhabitat ecology of crayfish taxa in relation to their burrows. To fill this knowledge gap, we assessed the availability of oxygen inside the crayfish shelter by series of in-vivo and in-silico modelling experiments. Under modeled condition, we found that, except for the entrance region of the 200 mm, a flooded burrow microenvironment became anoxic within 8 h, on average. Multiple 12-hour day-night cycles, with burrows occupied by crayfish for 12 h and empty for 12 h, were not sufficient for refreshing the burrow microenvironment. We then examined the degree to which crayfish species with different propensities for burrowing are tolerant of self-created anoxia. From these experiments, primary and secondary burrowers showed best and most consistent tolerance-exhibiting ≥ 64% survival to anoxia and 25-91% survival of ≥ 9 h at anoxia, respectively. Tertiary burrowers exhibited little to no tolerance of anoxia with 0-50% survival to anoxia and only one species exhibiting survival (2%) of ≥ 9 h at anoxia. Results suggest that moderate to strongly burrowing crayfish can quickly draw down the dissolved oxygen in burrow water but appear to have conserved a legacy of strong tolerance of anoxia from their monophyletic ancestors-the lobsters-whereas tertiary burrowers have lost (or never evolved) this ability.

Glutamine ameliorates hyperoxia-induced hippocampal damage by attenuating inflammation and apoptosis via the MKP-1/MAPK signaling pathway in neonatal rats

Glutamine (Gln) is an immunomodulatory protein that mediates oxidative stress, inflammation, and apoptosis, but has not been reported in the treatment of hyperoxia (Hyp)-induced brain injury. The aim of this study was to determine whether Gln could improve hyp-induced brain injury in neonatal rats to and later learning and memory dysfunction, and to explore its possible mechanisms. We prepared a model of neonatal rat brain injury caused by normobaric hyperoxia while administered with Gln for 7 days for evaluation. Learning memory function was assessed with the Morris water maze test. Histological analysis, protein expression analysis, oxidative stress and inflammation level analysis were performed using hippocampal tissue. Gln treatment significantly reduced brain tissue water content, oxidative stress levels, microglia activation and inflammatory factor expression, and attenuated tissue damage and apoptosis in the hippocampal region. Gln ameliorates hyp-induced learning, memory impairment in neonatal rats in water maze test. It also increased MKP-1 protein expression and decreased p-p38, p-ERK and p-JNK. Therefore, it is hypothesized that Gln may exert neuroprotective effects by increasing MKP-1 expression to negatively regulate MAPK signaling, with potential cognitive improvement in hyp-induced brain injury.

Effects of glutamine on the IKK/IκB/NF-кB system in the enterocytes of turbot Scophthalmus maximus L. stimulated with soya-saponins

Soya-saponins represent key anti-nutritional factors that contribute to soybean meal-induced enteritis, and glutamine is an effective fish intestine protectant that combats the negative effects of soya-saponins. Nuclear transcription factor-kappa B (NF-кB) systems are involved in the interactions between soya-saponins and glutamine, and the goal of the present work was to clarify the related molecular mechanisms used by the NF-кB kinase (IKK)/inhibitor of NF-κB (IκB)/NF-кB system. Primary cultured turbot (Scophthalmus maximus L.) intestinal epithelial cells were concurrently administrated with 1 mg/mL of soya-saponins and several levels of glutamine (0, 0.5, 1.0 and 2.0 mM) for 12 h and then subjected to real-time PCR and Western blot assays. Compared with cells treated with soya-saponins alone, glutamine significantly decreased the expression of interleukin-1 beta, interleukin 8 and tumor necrosis factor α genes, significantly reduced nuclear and cytosolic NF-κB p65 abundance levels in a dose-dependent manner, increased the IκBα protein level but decreased its phosphorylation, and down-regulated the IKKα/β and phosphorylated IKKα/β levels. In conclusion, this in vitro work confirmed that glutamine attenuated soya-saponin-induced inflammatory responses in turbot intestines. Moreover, it identified molecular pathways in which glutamine first decreased the p65 level and then prevented its nuclear translocation. In addition, glutamine reduced IκBα phosphorylation and maintained its level. Finally, glutamine decreased IKK expression and phosphorylation.

Effects of glutamine supplementation on critically ill patients: Focus on efficacy and safety. An overview of systematic reviews

OBJECTIVES

The aim of this overview of systematic reviews was to synthesize, appraise, and present all systematic review (SR) evidence on the clinical efficacy of glutamine administration to severely ill patients.

METHODS

Medline, Scopus, the Cochrane Library, and Prospero were searched up to March 2020. Systematic reviews and meta-analyses of randomized controlled trials published in English, comparing immunomodulating diets-containing exclusively glutamine-with standard diets for critically ill adult patients were selected. Data were collected from each selected systematic review and all available primary studies. The primary outcome was overall mortality; secondary outcomes were rate of infectious complications, hospital and intensive care unit (ICU) length of stay (LOS).

RESULTS

Seventeen SRs were eligible for inclusion. Of the SRs, 16 included meta-analyses with moderate degree of overlap (corrected covered area = 10%). These included 117 randomized controlled trials with 9933 patients. Glutamine supplementation was not associated with overall mortality and ICU LOS. However, it may reduce the rate of infectious complications overall (N = 3666, risk ratio, 0.82; 95% confidence interval [CI], 0.73-0.92; I² = 33%: low quality of evidence). LOS was limited with the supplementation of glutamine (N = 4353 weighted mean difference, -2.90; 95% CI, -3.66 to -2.15; I² = 81%: very low quality of evidence), but this effect was diminished when only studies with low risk for bias were synthesized.

CONCLUSION

Glutamine could demonstrate a beneficial role in critical care patients of diminishing the rate of infectious complications and hospital and ICU LOS. However, future studies with better quality would confirm this finding.

The effect of glutamine on Dehydroepiandrosterone-induced polycystic ovary syndrome rats

Background

Previous studies have shown that chronic inflammation and oxidative stress may play an important role in the pathophysiology of polycystic ovary syndrome (PCOS), and glutamine (Gln) have showed the anti-inflammatory and antioxidant properties. So the aim of this study is to investigate the effect of glutamine supplementation on PCOS rats.

Methods

Female Sprague–Dawley rats were randomly assigned into four groups (n = 10 /group), control group, PCOS group, PCOS+ 0.5 g/kg Gln group and PCOS+ 1.0 g/kg Gln group. All the PCOS rats were administrated with 6 mg/100 g dehydroepiandrosterone (DHEA) for 20 consecutive days, all the PCOS+Gln groups were intraperitoneal injected glutamine twice in the next morning after the last DHEA injection. All the samples were collected 12 h after the last administration. Ovarian histological examinations were analyzed and the concentration of serum hormone, inflammatory and oxidative stress factors were measured.

Results

There was no obvious ovarian histological change among the PCOS group and PCOS+Gln groups. All the detected inflammation factors [C-reactive protein, interleukin (IL)-6, IL-18, tumor necrosis factor] showed significantly higher in all the PCOS groups compared to the control group (P < 0.01), and were significantly decreased with the supplementation of 0.5 g/kg glutamine (P < 0.01). Concentrations of superoxide dismutase were significantly lower in all the PCOS groups (P < 0.01) compared to the control group, and increased significantly with the supplementation of 0.5 g/kg glutamine (P < 0.01). Serum concentrations of malondialdehyde, nitric oxide synthase and nitric oxide were significantly higher in PCOS group (P < 0.01) compared with the control group, and significantly decreased to the comparative levels of control group with supplementation of 0.5 g/kg glutamine (P < 0.01).

Conclusion

There is low-grade inflammation and oxidative stress in DHEA-induced PCOS rats. The supplementation of 0.5 g/kg glutamine could effectively ameliorate the inflammation and oxidative stress conditions of PCOS.

l-theanine alleviates liver and kidney dysfunction in septic rats induced by cecal ligation and puncture

AIMS

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response against infection that triggers systemic inflammatory response syndrome. l-theanine (LT), a glutamate derivative, is a non-protein amino acid derived from tea (Camellia sinensis), and a valuable nutraceutical product used as an additive in the food industry. This study we aimed to investigate whether LT would exert any therapeutic effect on liver and kidney tissues in Sprague Dawley rats with sepsis induced with cecal ligation and puncture (CLP).

MAIN METHODS

Rats were divided into four groups; sham, CLP, CLP+LT1 (2x250 mg/kg) and CLP+LT2 (2 × 750 mg/kg). Liver and kidney tissues were subjected to histopathological examination. Apoptotic index percentages (AI%) were examined using the TUNEL method. The oxidized glutathione to total glutathione (GSSG/TGSH) ratio (as a marker of oxidative stress, levels of caspase-3 (a marker of apoptosis), glutathione peroxidase (GPx) and glutathione S-transferase (GST) (as antioxidant enzymes), inducible nitric oxide synthase (iNOS) and the tumor necrosis factor-α to Interleukin-10 ratio (TNF-α/IL-10) (as markers of inflammation) were investigated using commercial kits. Levels of malondialdehyde (MDA) (a marker of oxidative stress) were determined spectrophotometrically.

KEY FINDINGS

A high dose of LT exhibited more significant effects in reducing oxidative stress, inflammation and apoptosis than a low dose of LT in liver and kidney tissues with CLP-induced sepsis (p < 0.05).

SIGNIFICANCE

Our results indicated that LT significantly and dose-dependently inhibited sepsis induced liver and kidney injury. This effect may be attributed to the antioxidant, anti-inflammatory, and anti-apoptotic activities of LT.

EFFECTS OF INTRAPERITONEAL GLUTAMINE IN THE TREATMENT OF EXPERIMENTAL SEPSIS

Background:

Sepsis is an important public health issue and is associated with high treatment costs and high mortality rates. Glutamine supplementation has proven to be beneficial to the functions of the immune system, acting beneficially in the evolution of patients in severe catabolic states.

Aim:

To evaluate the effect of glutamine supplementation via intraperitoneal in rats, induced sepsis, considering the following organs: intestines, liver, kidneys and lungs.

Methods:

Male Wistar rats subjected to sepsis by ligature and cecal puncture were divided into two groups: control C (n=6) and glutamine G (n=11), in which were administered dipeptiven 20% at a dose of 2 ml/kg/day (equivalent to 0.4g N(2)-L-alanyl-L-glutamine/kg) intraperitoneally 48 h prior to sepsis induction. After 48 h they were euthanized and intestine, liver, lung and kidney were removed for histological analysis.

Results:

Intestinal epithelial desquamation of the control group was more intense compared to the glutamine group (p=0.008). In the kidneys, degenerative tubular epithelial changes were less severe in the animals that received glutamine (p=0.029). Regarding to the liver, glutamine group showed lower levels of cell swelling than the control group (p=0.034). In the lung there were no results with statistical significance.

Conclusion:

Prior intraperitoneal supplementation with glutamine in experimental animals is able to reduce the damage to the intestinal mucosa, to the kidneys and liver’s histoarchitecture.

Role of intestinal trefoil factor in protecting intestinal epithelial cells from burn-induced injury

Although intestinal trefoil factor (ITF) can alleviate the burn-induced intestinal mucosa injury, the underlying mechanisms remains elusive. In this study, we investigated if ITF alters glutamine transport on the brush border membrane vesicles (BBMVs) of the intestines in Sprague-Dawley rats inflicted with 30% TBSA and the underlying mechanisms. We found that ITF significantly stimulated intestinal glutamine transport in burned rats. Mechanistically, ITF enhanced autophagy, reduces endoplasmic reticulum stress (ERS), and alleviates the impaired PDI, ASCT2, and B0AT1 in IECs and BBMVs after burn injury likely through AMPK activation. Therefore, ITF may protect intestinal epithelial cells from burn-induced injury through improving glutamine transport by alleviating ERS.

TCA cycle rewiring fosters metabolic adaptation to oxygen restriction in skeletal muscle from rodents and humans

In mammals, hypoxic stress management is under the control of the Hypoxia Inducible Factors, whose activity depends on the stabilization of their labile α subunit. In particular, the skeletal muscle appears to be able to react to changes in substrates and O₂ delivery by tuning its metabolism. The present study provides a comprehensive overview of skeletal muscle metabolic adaptation to hypoxia in mice and in human subjects exposed for 7/9 and 19 days to high altitude levels. The investigation was carried out combining proteomics, qRT-PCR mRNA transcripts analysis, and enzyme activities assessment in rodents, and protein detection by antigen antibody reactions in humans and rodents. Results indicate that the skeletal muscle react to a decreased O₂ delivery by rewiring the TCA cycle. The first TCA rewiring occurs in mice in 2-day hypoxia and is mediated by cytosolic malate whereas in 10-day hypoxia the rewiring is mediated by Idh1 and Fasn, supported by glutamine and HIF-2α increments. The combination of these specific anaplerotic steps can support energy demand despite HIFs degradation. These results were confirmed in human subjects, demonstrating that the TCA double rewiring represents an essential factor for the maintenance of muscle homeostasis during adaptation to hypoxia.

Therapeutic benefits of glutamine: An umbrella review of meta-analyses

Glutamine may be an essential amino acid in patients with catabolic disease, as it has been demonstrated that circulating glutamine levels drop during critical illness and following major surgery; this may result in an increase in secondary infection risk, recovery time and mortality rates. However, there is much discrepancy in the literature with regards to randomized controlled studies, and therefore, the present study is an umbrella review of published meta-analyses, conducted to examine the effectiveness of glutamine's role as a therapeutic agent. A search using PubMed, Cochrane Library and CINAHL from January 1st, 1980 to December 31st, 2016 was conducted using the following strategy: 'Glutamine AND (meta-analysis OR systematic review)' and publications were retrieved, which provided quantitative statistical analysis of pooled treatment effects on the relative risks of infectious complications, mortality and length of stay in hospital. A total of 22 meta-analyses were entered into the current umbrella review. As displayed in Tables I, II and III, these analyses are split into three groups, based on different parameters. Of the 19 meta-analyses investigating the effects of infectious complications, 15 identified statistically significant reductions in complications, with relative risks ranging between 0.42 and 0.93. In addition, 12 of the 18 meta-analyses analyzing the length of hospital stays presented statistically significant reductions in the length of stay, with reductions ranging between 0.19 to 4.73 days. Only 4 of the 15 meta-analyses studying mortality effects identified statistically significant reductions in mortality with relative risks ranging between 0.64 and 1.28. Statistically significant heterogeneity was observed in 16 of 22 meta-analyses, and publication bias was observed in five of 11 meta-analyses. Glutamine supplementation for critically ill or surgical patients through parenteral or enteral routes appears to reduce the rate of hospital acquired infectious complications and shortening of the length of stay in hospital. Furthermore, glutamine supplementation appeared to reduce the rate of in-patient mortality, but the majority of meta-analyses did not reach statistical significance. However, researchers must appreciate the positive results with caution in light of the fact that there exists statistically significant heterogeneity for the majority of meta-analyses, and statistically significant publication bias in almost half.

Potential Nutrients for Preventing or Treating Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a frequent complication occurring in extremely preterm infants. Despite recent advances in newborn medicine, the incidence of BPD does not appear to have changed markedly, and specific treatments and prevention strategies are still lacking. Nutrition plays an important role in normal lung development and maturation. Malnutrition may delay somatic growth and new alveoli development, thus aggravating pulmonary injury involved in the pathogenesis of BPD. However, few nutrients have been investigated for their potential to mitigate the pathogenesis of BPD. In this article, we reviewed the recent progress in research on potential nutrients useful for the prevention or treatment of BPD, including glutamine, cysteine and N-acetylcysteine, L-arginine and L-citrulline, long chain polyunsaturated fatty acids (LCPUFAs), inositol, selenium, and some antioxidant vitamins including vitamin A. Current evidence shows that vitamin A and LCPUFA can prevent BPD, and that L-citrulline might provide a new method to treat chronic pulmonary hypertension associated with BPD in premature infants. The effects of other nutrients on BPD prevention need to be further studied.

Plasma glutamine levels before cardiac surgery are related to post-surgery infections; an observational study

Background

A low plasma glutamine level was found in 34% of patients after elective cardiothoracic surgery. This could be a result of the inflammation caused by surgical stress or the use of extracorporeal circulation (ECC). But it is also possible that plasma glutamine levels were already lowered before surgery and reflect an impaired metabolic state and a higher likelihood to develop complications.

In the present study plasma glutamine levels were measured before and after cardiac surgery and we questioned whether there is a relation between plasma glutamine levels and duration of ECC and the occurrence of postoperative infections.

Methods

We performed a single-centre prospective, observational study in a closed-format, 20-bed, mixed ICU in a tertiary teaching hospital. We included consecutive patients after elective cardiac surgery with use of extracorporeal circulation. Blood samples were collected on the day prior to surgery and at admission on the ICU.

The study was approved by the local Medical Ethics Committee (Regional Review Committee Patient-related Research, Medical Centre Leeuwarden, nWMO 115, April 28th 2015).

Results

Ninety patients were included. Pre-operative plasma glutamine level was 0.42 ± 0.10 mmol/l and post-operative 0.38 ± 0.09 mmol/l (p < 0.001). There was no relation between duration of extracorporeal circulation or aortic occlusion time and changes in plasma glutamine levels. A logistic regression analysis showed a significant correlation between the presence of a positive culture during the post-operative course and pre-operative plasma glutamine levels (p = 0.04).

Conclusion

Plasma glutamine levels are significantly lower just after cardiac surgery compared to pre-operative levels. We did not find a relation between the decrease in plasma glutamine levels and the duration of extracorporeal circulation or aortic clamp time. There was a correlation between pre-operative plasma glutamine levels and the presence of a positive culture after cardiac surgery.

Trial registration

ClinicalTrials.gov, number NCT02444780.

Dietary supplementation of L-glutamine and L-glutamate in broiler chicks subjected to delayed placement

This study was conducted to investigate the effect of dietary glutamine (Gln) + glutamic acid (Glu) supplementation on growth performance and physiological stress response in broiler chickens subjected to 24 h delay in placement. Equal number of day-old broiler chicks were assigned to either immediate placement or with 24 h delay in placement with no access to feed and water. Chicks from each placement group were fed either standard starter diet (control) or standard starter diet +1% AminoGut (AG; mixture of 10% Gln and 10% Glu) from 1 to 21 d. Blood and duodenal samples were collected at 21 d for analysis of serum levels of ceruloplasmin (CER), ovotransferin (OVT) and α-1 acid glycoprotein (AGP), duodenal heat shock protein (HSP) 70 expression, and villi length and crypt depth. Results showed that delayed placement for 24 h was detrimental to weight gain during the starter phase (1 to 21 d) but not thereafter. AG supplementation was not able to eliminate that reduction in weight gain and feed intake during the starter stage. However, the observed enhancement in villi length and crypt depth at d 21 resulted in improvement of FCR and weight gain during the finisher stage (22 to 42 d) and consequently the overall period (1 to 42 d). Broiler chickens supplemented with AG also showed lower mortality rate, and higher AGP, OVT, CER, and HSP 70 expression compared to their control counterparts. Based on AGP, OVT, CER, and HSP 70 expression, there is no indication that delayed placement was physiologically stressful to the broiler chickens at 21 d of age.

Plasma glutamine levels in patients after non-elective or elective ICU admission: an observational study

BACKGROUND

A low plasma glutamine level at the time of acute admission to the intensive care unit (ICU) is an independent predictor of an unfavourable outcome in critically ill patients. The primary objective of this study was to determine whether there are differences in plasma glutamine levels upon non-elective or elective ICU admission. The secondary objective was to compare glutamine levels over time, and to determine correlations between glutamine levels and the severity of illness and presence of infection in ICU patients.

METHODS

We performed a single-centre observational study in a closed-format, 22-bed, mixed ICU. Plasma glutamine levels were measured at admission and every morning at 6.00 a.m. during the ICU stay. We aimed to include at least 80 patients per group. The study was approved by the local Medical Ethics Committee.

RESULTS

In 88 patients after elective surgery, the median plasma glutamine level at admission was significantly higher compared with that in 90 non-elective patients (0.43 mmol/l [0.33-0.55 mmol/l] versus 0.25 mmol/l [0.09-0.37 mmol/l], P = 0.001). During the ICU stay, plasma glutamine levels remained significantly higher in elective patients than in non-elective patients. There was a significant correlation between the APACHE IV score and glutamine levels (R = 0.52, P < 0.001). Moreover, backward linear regression analysis showed that this correlation was independently associated with the APACHE IV score and the presence of infection, but not with the type of admission.

CONCLUSIONS

Plasma glutamine levels are significantly lower after non-elective admission compared with elective admission to the ICU. A considerable amount of elective and non-elective patients have decreased plasma glutamine levels, but this is not independently associated with the type of admission. In contrast to previous studies, we found that plasma glutamine levels were determined by the severity of illness and the presence of an infection.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02310035.

Walker 256 tumor-bearing rats demonstrate altered interstitial cells of Cajal. Effects on ICC in the Walker 256 tumor model

BACKGROUND

Cachexia is a significant problem in patients with cancer. The effect of cancer on interstitial cells of Cajal (ICC) and neurons of the gastrointestinal tract have not been studied previously. Although supplementation with L-glutamine 2% may have beneficial effects in cancer-related cachexia, and be protective of ICC in models of oxidative stress such as diabetes, its effects on ICC in cancer have also not been studied.

METHODS

Twenty-eight male Wistar rats were divided into four groups: control (C), control supplemented with L-glutamine (CG), Walker 256 tumor (WT), and Walker 256 tumor supplemented with L-glutamine (WTG). Rats were implanted with tumor cells or injected with saline in the right flank. After 14 days, the jejunal tissues were collected and processed for immunohistochemical techniques including whole mounts and cryosections and Western blot analysis.

KEY RESULTS

Tumor-bearing rats demonstrate reduced numbers of Myenteric ICC and deep muscular plexus ICC and yet increased Ano1 protein expression and enhanced ICC networks. In addition, there is more nNOS protein expressed in tumor-bearing rats compared to controls. L-glutamine treatment had a variety of effects on ICC that may be related to the disease state and the interaction of ICC and nNOS neurons. Regardless, L-glutamine reduced the size of tumors and also tumor-induced cachexia that was not due to altered food intake.

CONCLUSIONS & INFERENCES

There are significant effects on ICC in the Walker 256 tumor model. Although supplementation with L-glutamine has differential and complex effects of ICC, it reduces tumor size and tumor-associated cachexia, which supports its beneficial therapeutic role in cancer.

Glutamine: an obligatory parenteral nutrition substrate in critical care therapy

Critical illness is characterized by glutamine depletion owing to increased metabolic demand. Glutamine is essential to maintain intestinal integrity and function, sustain immunologic response, and maintain antioxidative balance. Insufficient endogenous availability of glutamine may impair outcome in critically ill patients. Consequently, glutamine has been considered to be a conditionally essential amino acid and a necessary component to complete any parenteral nutrition regimen. Recently, this scientifically sound recommendation has been questioned, primarily based on controversial findings from a large multicentre study published in 2013 that evoked considerable uncertainty among clinicians. The present review was conceived to clarify the most important questions surrounding glutamine supplementation in critical care. This was achieved by addressing the role of glutamine in the pathophysiology of critical illness, summarizing recent clinical studies in patients receiving parenteral nutrition with intravenous glutamine, and describing practical concepts for providing parenteral glutamine in critical care.

Effect of glutamine enriched nutrition support on surgical patients with gastrointestinal tumor: a meta-analysis of randomized controlled trials

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.

Perioperative Alanyl-Glutamine-Supplemented Parenteral Nutrition in Chronic Radiation Enteritis Patients With Surgical Intestinal Obstruction: A Prospective, Randomized, Controlled Study

BACKGROUND

A prospective, randomized, controlled study was performed to evaluate the effects of perioperative alanyl-glutamine-supplemented parenteral nutrition (PN) support on the immunologic function, intestinal permeability, and nutrition status of surgical patients with chronic radiation enteritis (CRE)-induced intestinal obstruction.

METHODS

Patients who received 0.4 g/kg/d alanyl-glutamine and isonitrogenous PN were assigned to an alanyl-glutamine-supplemented PN (Gln-PN) group and a control group, respectively. Serum levels of alanine aminotransferase and glutamine, body fat mass (FM), immunologic function, and intestinal permeability were measured before and after surgery.

RESULTS

Serum glutamine levels of the Gln-PN group significantly exceeded that of the control group (P < .001; Gln-PN, baseline 460.7 ± 42.5 vs 523.3 ± 48.6 µmol/L on postoperative day 14 [POD14], P < .001; control, baseline 451.9 ± 44.0 vs 453.8 ± 42.3 µmol/L on POD14, P = .708). Lactulose/mannitol ratios of both groups decreased over time (Gln-PN, baseline 0.129 ± 0.0403 vs 0.024 ± 0.0107 on POD1 4; control, baseline 0.125 ± 0.0378 vs 0.044 ± 0.0126 on POD14, P < .001 in both groups). CD4/CD8-positive T-lymphocyte ratios significantly rose in both groups, with significant intergroup difference (P < .001; Gln-PN, baseline 1.36 ± 0.32 vs 1.82 ± 0.30 on POD14, P < .001; control, baseline 1.37 ± 0.25 vs 1.63 ± 0.31 on POD14, P < .001). In the Gln-PN group, FM increased from 3.68 ± 1.68 kg at baseline to 5.22 ± 1.42 kg on POD14 (P < .001). FM of control group increased from 3.84 ± 1.57 kg at baseline to 5.40 ± 1.54 kg on POD14 (P < .001). However, there were no significant intergroup differences (P = .614).

CONCLUSION

Gln-PN significantly boosted the immune state and decreased the intestinal permeability of CRE patients. However, Gln-PN was not superior to standard PN in improving the nutrition state and intestinal motility of surgical patients with CRE-induced intestinal obstruction.

Antioxidants as a treatment for acute pancreatitis: A meta-analysis

OBJECTIVE

To assess the efficacy of antioxidants in acute (AP) pancreatitis.

METHODS

We searched PubMed, Embase and the Cochrane library for all randomized controlled trials (RCT) involving administration of antioxidants in the therapy of AP until February 2012. AP studies were pooled to analyze the effect of antioxidants on hospital stay, mortality, and complications. Subgroup analyses were performed on the use of the antioxidant glutamine.

RESULTS

In total, eleven RCTs were included. Among patients with AP, antioxidant therapy resulted in a borderline significant reduction in hospital stay (mean difference -1.74; 95%CI -3.56 to 0.08), a significant decrease in complications (RR 0.66; 95%CI 0.46-0.95) and a non-significant decrease in mortality rate (RR 0.66; 95%CI 0.30-1.46). Subgroup analyses showed that glutamine significantly reduced complications (RR 0.51; 95%CI 0.34-0.78) and mortality rate (RR 0.33; 95%CI 0.13-0.85).

CONCLUSION

The present meta-analysis shows a possible benefit of glutamine supplementation in patients with acute pancreatitis. However, large randomized trials are needed to confirm these observations.

The protective effects of glutamine in a rat model of ventilator-induced lung injury

BACKGROUND

The mortality rate of patients with acute respiratory distress syndrome (ARDS) is still high despite the use of protective ventilatory strategies. We sought to examine the pharmacological effects of glutamine (GLN) in a two-hit model of endotoxin-induced inflammation followed by ventilator-induced lung injury (VILI). We hypothesized that the administration of GLN ameliorates the VILI.

METHODS

Sprague-Dawley rats were anesthetized and given lipopolysaccharide (LPS) intratracheally as a first hit to induce lung inflammation, followed 24 h later by a second hit of mechanical ventilation (MV) with either low tidal volume (6 mL/kg) with 5 cmH2O of positive end-expiratory pressure (PEEP) or high tidal volume (22 mL/kg) with zero PEEP for 4 h. GLN or lactated Ringer's solution as the placebo was administered intravenously 15 min prior to MV.

RESULTS

In the LPS-challenged rats ventilated with high tidal volume, the treatment with GLN improved lung injury indices, lung mechanics and cytokine responses compared with the placebo group.

CONCLUSIONS

The administration of GLN given immediately prior to MV may be beneficial in the context of reducing VILI.

The importance and dosage of amino acids in nutritional support of various pathological conditions in ICU patients

BACKGROUND

Normal adults require twenty L-amino acids (AA) for protein synthesis. Functional AA regulate key metabolic pathways that are necessary for maintenance, growth, reproduction and immunity. Dietary supplementation with one or a mixture of these AA may be beneficial for ameliorating health problems at various stages of the life cycle and for optimizing of the efficiency of metabolic transformations. During disease, other amino acids also become essential. The principal goal of protein/amino acid administration in various pathological conditions in intensive care unit (ICU) patients is to provide the precursors of protein synthesis in tissues with high turnover and to protect skeletal muscle mass and function. Amino acid requirements in parenteral nutrition (PN) are higher when the patient is stressed/traumatized/infected than in the unstressed state. In severely ill ICU patients a higher provision of protein and amino acids has been associated with a lower mortality.

METHODS AND RESULTS

An overview of the effects and dosage of amino acids in nutritional support of various pathological conditions in ICU patients is presented.

CONCLUSION

It was demonstrated that 2.0-2.5 g protein substrate/kg normal body weight/day is safe and could be optimal for the most critically ill adults to decrease the risk of morbidity and mortality in some pathological conditions.

Correlation of the oxygen radical activity and antioxidants and severity in critically ill surgical patients - study protocol

Background

Surgical patients who require an emergent operation commonly have severe sepsis or septic shock, followed by high morbidity and mortality rates.

Despite advances in treatment however, no predictable markers are available. In severe sepsis, many pathophysiologic mechanisms are involved in progression to organ failure, and oxygen free radical and antioxidants are known to contribute to this process. Oxygen free radical and antioxidants contribute to progression of organ failure in severe sepsis. In fact, oxygen radical activity has been reported to be correlated with disease severity and prognosis in patients with severe sepsis or septic shock. Accordingly, we aim to assess the usefulness of oxygen free radical and antioxidant concentrations to predict the disease severity and mortality in a cohort of critically ill surgical patients.

Methods/Design

This is a prospective observation study including patient demographic characteristics, clinical information, blood sampling/serum oxygen radical activity, serum antioxidant activity, serum antioxidant concentrations (zinc, selenium and glutamate), disease severity scores, outcomes, lengths of stay in intensive care unit, hospital 30-day mortality.

Glutamine and alanyl-glutamine increase RhoA expression and reduce Clostridium difficile toxin-a-induced intestinal epithelial cell damage

Clostridium difficile is a major cause of antibiotic-associated colitis and is associated with significant morbidity and mortality. Glutamine (Gln) is a major fuel for the intestinal cell population. Alanyl-glutamine (Ala-Gln) is a dipeptide that is highly soluble and well tolerated. IEC-6 cells were used in the in vitro experiments. Cell morphology was evaluated by atomic force microscopy (AFM) and scanning electron microscopy (SEM). Cell proliferation was assessed by WST-1 and Ki-67 and apoptosis was assessed by TUNEL. Cytoskeleton was evaluated by immunofluorescence for RhoA and F-actin. RhoA was quantified by immunoblotting. TcdA induced cell shrinkage as observed by AFM, SEM, and fluorescent microscopy. Additionally, collapse of the F-actin cytoskeleton was demonstrated by immunofluorescence. TcdA decreased cell volume and area and increased cell height by 79%, 66.2%, and 58.9%, respectively. Following TcdA treatment, Ala-Gln and Gln supplementation, significantly increased RhoA by 65.5% and 89.7%, respectively at 24 h. Ala-Gln supplementation increased cell proliferation by 137.5% at 24 h and decreased cell apoptosis by 61.4% at 24 h following TcdA treatment. In conclusion, TcdA altered intestinal cell morphology and cytoskeleton organization, decreased cell proliferation, and increased cell apoptosis. Ala-Gln and Gln supplementation reduced intestinal epithelial cell damage and increased RhoA expression.

Effects of glutamine supplementation on muscle function and stress responses in a mouse model of spinal cord injury

Spinal cord injury (SCI) results in loss of muscle function due to rapid breakdown of contractile proteins. Glutamine supplementation improves clinical outcomes, but its effects on muscle function after SCI are unknown. The benefits of glutamine in non-skeletal muscle tissues involve elevated heat shock protein (Hsp)70 and Hsp25, but the muscle response may differ because it is the largest contributor to plasma glutamine. We tested the hypothesis that glutamine preserves muscle function after SCI and that this is associated with increased heat shock protein and reduced inflammatory factors, interleukin-6 (IL-6) and tumour necrosis factor-α (TNFα). Changes in plantarflexor force, fatigability and total myofibrillar, Hsp70, Hsp25, IL-6 and TNFα muscle protein levels were measured 7 days after sham or spinal cord transection surgery in mice receiving daily placebo or glutamine. Compared with placebo, after SCI glutamine significantly attenuated the reductions in maximal isometric force (0.22 ± 0.01 versus 0.31 ± 0.03 N, respectively) and fatigue resistance (34 ± 4 versus 59 ± 4% of initial force, respectively). Glutamine significantly ameliorated the loss of myofibrillar protein with spinal cord transection. Spinal cord transection was associated with decreased Hsp70 and Hsp25 with glutamine only (45 ± 3 and 44 ± 5% of placebo, respectively). Glutamine significantly reduced spinal cord transection-associated increases in IL-6 and TNFα compared with placebo (38 ± 6 and 37 ± 8% of placebo, respectively). Functionally, early reductions in contractile protein, force and fatigue resistance after SCI were reversed with glutamine. Spinal cord transection-associated reductions in Hsp70, Hsp25, IL-6 and TNFα with glutamine versus placebo suggest lower stress in the muscle, possibly related to a reduced need to produce glutamine. These findings support glutamine as a therapeutic intervention to accelerate recovery of muscle function after SCI.

A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation

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.

Appropriate protein and specific amino acid delivery can improve patient outcome: fact or fantasy?

Protein utilization and requirements in critical illness are much researched and debated topics. The enhanced turnover and catabolism of protein in the setting of critical illness is well described and multifactorial in nature. The need to preserve lean body mass and enhance nitrogen retention in this state to improve immunologic function and reduce morbidity is well described. Debates as to the optimum amount of protein to provide in such states still exist, and a significant amount of research has contributed to our understanding of not only how much protein to supply to these patients, but how best to do so. Small peptide formulations, intact protein formulations, branched chain amino acids, and specialty formulas all exist, and their benefits, drawbacks, and potential uses have been investigated. Specific amino acid therapy has become part of the concept of immunonutrition, or the modification and enhancement of the immune response with specific nutrients. In this article, we describe the changes in outcomes demonstrated through the provision of protein, both as a macronutrient and as specific amino acids.