Download Role of Advanced Clinical Immuno-nutrition in Hospitalized Patients

Advanced Clinical Immuno
Nutrition & Its Application
Soly James
Chief Dietician
S.L.Raheja hospital-A Fortis Associate
Mahim, Mumbai
A high proportion of patients in hospital are
malnourished and that malnourishment
impairs immune function.
 The capacity for nutrients to modulate the
actions of the immune system and, to affect
clinical outcome has thus become an
important issue in clinical practice.

(McWhirter & Pennington, 1994)
Immunonutrition
Immunonutrition is defined as modulation of the
activities of the immune activation by nutrients or
specific food items fed in amounts above those normally
encountered in the diet
Immunomodulatory substance interfere with 3 basic area
of the immune responses directly or indirectly;
(i)
the mucosal barrier function
(ii)
the cellular defence function and
(iii) the local or systemic inflammatory response
Conditions associated with low
immunity
Trauma
(Accidents & Burns)
Illness
& Stress
Post Operative complication
 Surgery
 Cancer
 Critically ill

Trauma , surgery & critically ill
Stress response
Glycolysis,
Lipolysis
Proteolysis
Auto-catabolism
Pro-inflammatory
cascades
Immuno-suppression
Induce
hormonal,
metabolic &
inflammatory
changes
Peripheral Blood
Mononuclear Cell
Key Processes
Initiated by secretion of the pro-inflammatory cytokines
interleukin (IL) 1, IL-6 and Tumour Necrosis Factor
(TNF) α.
(1) creation of a hostile environment (for pathogens);
(2) provision of nutrients for the immune system from
endogenous sources;
(3) strengthening of the protective and control systems
against damage to healthy tissue by the immune
response
(Grimble, 1998a)
Trauma and infection and
burn
Immunonutrition
Immune system
activation
Pro-inflammatory
cytokines (IL1&6, TNF)
T& B Cells
glucose
Immunonutrients
(glutamine)
Nutrient release
from host tissue
S amino
acid
Acute phase
protein synthesis
Glutathione
synthesis
Antioxidant
defense
strengthened
How can we enhance the Immunity?
Omega-3 fatty acids (PUFA-3)
“Conditionally Essential” amino acids
◦ Arginine
◦ Glutamine
Nucleotides
S. D. Heys et al Nutr. Hosp. (2004) XIX (6) 325-332
(Grimble,1998a; O.Flaherty & Bouchier Hayes, 1999)
IMF in the Critical Care…

Review of 26 studies (surgical, trauma, burn, mixed population)
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Decreased infection rate:
Intra-abdominal abscess (74% reduction)
Nosocomial pneumonia (46% reduction)
Wound infections (54% reduction)
2.25 less vent days
1.6 less ICU days
3.4 less hospital days
reduces significantly the rate of severe mucosal toxicity during
concomitant chemoradiotherapy for advanced local-regional squamous
cell carcinomas of the head and neck.
Journal of Clinical Oncology, 2008 ASCO Annual Meeting Proceedings
Montejo, Clinical Nutrition, 2003, Kenneth A. Kudsk Annu. Rev. Nutr. 2006
Omega 3 Fatty Acids
Clinical data
Biochemical data
• Inflammatory response
Cardiac arrhythmias
Tissue microperfusion
Graft function
Cancer in cell lines
Limits omega-6 immune
suppression
• Maturation of CNS
• Clearance
•
•
•
•
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• Biological regulators
• Cell membrane structure and
function
• Influences membrane fluidity
• Alters receptors activity
• Eicosanoid metabolism
• Cytokine production
• Gene expression
Intensive Care Med. 2008 Nov;34(11):1980-90. Crit Care. 2009;13(3):305.
L-Arginine

L-arginine is converted in the body into a chemical
called nitric oxide.
◦ Vasodilator
◦ Stimulates the release of growth hormone & insulin

Improves recovery after surgery
◦ L-arginine with RNA and EPA
 reduce the recovery time
 reduce infections
 improve wound healing
Improves immune system in people with head and
neck cancer
 Improves helper T-cell numbers (lymphocyte proliferation)

American Journal of Critical Care. 2004
Heyland DK al (2001) JAMA 286,
Glutamine
One of the 20 amino acids
 Glutamine is a nonessential amino acid, which
becomes “conditionally essential” during
periods of catabolic stress
 When the body is stressed, it releases high
levels of hormone cortisol into the
bloodstream which can lower the body's stores
of glutamine

Buchman AL, Am J Clin Nutr, 2001
Why Glutamine?
• During stress- drastic reduction in the glutamine level
(more than 50%)
• Requirement increases in critical illness
• Synthesis rate is very less
• Demand increases but rate of synthesis does not
increase
• Only BCAA – is not sufficient because synthesis of
glutamine from BCAA is limited
• Normal Diet might provide 3-5 gms glutamine/day
GLN Therapy
GI Tract

Major source of energy for enterocytes
 Supports nucleotide biosynthesis
 May protect epithelial cells against endotoxin
 Enhances HSP expression post stress
Immune Cell
function

Kidney
 Acid
Muscle

Lungs

Major source of energy for proliferating cells
 Supports neutrophil killing & macrophage function
 Enhances HSP expression post stress
 Vital for appropriate cytokine secretion
base regulation
 NH3 metabolism
Increase protein synthesis
Major source of energy for endothelial cells
 May protect epithelial cells against endotoxin
 Enhances HSP expression post stress
Glutamine & Cancer
Chemotherapy
Mucositis, Stomatitis, Enterocolitis, Bacterial translocation,
Endotoximia
Radiotherapy
Abdominal pain, bloody diarrhea, malabsorption and bacterial
translocation because of…
- Destruction of crypt cells
- Decreased villous height
- Ulceration
- Necrosis of GI epithelium
Glutamine and cancer. J Nutr. 2001;131
Clin J Oncol Nurs, 2002
Glutamine Dosage
Clinical Condition
Dosage
Critical condition
0.57 g / kg bw /day
Before chemotherapy/radiation
treatment
During chemotherapy/radiation
treatment
BMT
5-10 g / day
Paediatric oncology
0.65 gm /kg bw/day
20-30 g /day
20-30 g /day
Contraindications
• End stage liver diseases
• End stage kidney diseases
• Elderly people who have decreased kidney function
Dietary Nucleotides
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Building blocks for DNA and RNA.
Conditionally essential in stressed states
Improves T-cell function
Required for almost all cell activity and growth
Essential for rapidly replicating cells to help support immune
function
Benefits of supplementation:
Protein synthesis
 Liver recovery
 Digestion
 Intestinal repair

When to feed an IMF?

Immune Modulating Formulations
(supplemented with agents such as arginine,
glutamine, nucleic acid, omega-3 fatty acids, and
antioxidants) should be used for the
appropriate patient population (major elective
surgery, trauma, burns, head and neck cancer,
and critically ill patients on mechanical
ventilation), being cautious in patients with
severe sepsis (Grade A).
SCCM/ASEPN Critical Care Nutrition Guidelines, 2009
(Cowley et al. 1996; Arnalich et al. 2000).
Pharmaconutrients can positively or negatively effect
clinical outcome just as any other pharmacologic
agent would
Administer the right nutrients, in the right amounts,
at the right time
Thank You…
ZINC:3mg (as Zinc Sulphate
monohydrate)
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A critical element
Small deficiency is a disaster.
Role in tissue repair.
Helps the body use carbohydrate, protein, and
fat.
Helps to maintain proper immune function,
including promoting wound healing.
Maintaining a sense of taste and smell.
Maintaining normal vitamin A levels and usage.
SELENIUM: 15mcg (as L-Selenomethionine)
• Essential trace mineral required for normal human
health and reproduction.
• Needed by certain enzymes that help with normal
body functions.
• Aids in protein synthesis, and enhances fertility and
growth and development.
• An anti-oxidant-thus helps protect the body from
damaging effects of free radicals.
• May also prevent or slow tumor growth.