TOP Nutrition Newsletter

Vol: 8 No: 3 March 2005

Immunonutrition.
PURPOSE OF REVIEW: To outline recent findings on the efficacy of immunonutrients in patients undergoing inflammatory stress due to surgery infection and cancer! RE"E#T FI#$I#%S: Enteral nutrition is more efficacious and poses lo&er ris's than parenteral nutrition! It reduces infection rates and shortens I"U and hospital length of stay of critically ill patients! (eneficial effects of immunonutrition are most apparent in malnourished patients! Perioperati)e enteral nutrition is more effecti)e than postoperati)e nutrition! In "rohn disease similar remission rates are achie)ed &ith enteral nutrition as &ith steroids! %lutamine omega*+ fatty acids and antio,idants e,ert -eneficial influences in di)erse patient populations! .*arginine is an important immunonutrient ha)ing -oth -eneficial and ad)erse effects! The former effect occurs in necroti/ing enterocolitis0 the latter influence is seen in septic patients! The gut plays a ma1or role in &hole -ody amino acid meta-olism particularly arginine homeostasis! 2rginase and nitric o,ide synthetase compete for arginine &ithin immune cells and play a pi)otal role in clinical outcome during infection! In cancer a range of antio,idants are a-le to ameliorate immunosuppression! Intra)enous lipids may -e deleterious due to the pro*inflammatory effects of omega* 3 fatty acids! Omega*+ fatty acids are anti*inflammatory and com-ined &ith medium chain triglyceride 45"T6 and oli)e oil may pro)ide a more efficacious form of intra)enous lipid! SU552R7: Immunonutrition is effecti)e in impro)ing outcome in a &ide range of patients &hen applied enterally particularly in malnourished indi)iduals! Parenteral immunonutrition carries a higher ris' -ut can -e efficacious in selected patient groups for &hom enteral nutrition is pro-lematic! Curr Opin Gastroenterol. 2005 Mar;21(2):216-22.

Reducin costs and !atient mor"idit# in the enterall# $ed intensi%e care unit

!atient.
(2"8%ROU#$: "ritically ill patients are at high ris' for nosocomial infections and resultant organ dysfunction and death! These patients typically ha)e protracted intensi)e care unit 4I"U6 courses and consume increasingly limited resources! Enteral nutrition &ith specific immune*modulating components has -een pre)iously sho&n to impro)e outcomes in select populations of patients -ut results ha)e -een mi,ed in critically ill patients! Impact 9!: 4#o)artis #utrition 5inneapolis 5#6 is a commercially a)aila-le enteral formula containing ingredients 'no&n to impro)e se)eral parameters of immune function! We hypothesi/ed that administration of Impact 9!: tu-e feedings &ould reduce the incidence of nosocomial infection and I"U resources in critically ill patients admitted to the I"U for se)ere trauma -urns or sepsis insults! 5ET;O$S: The Impact 9!: group 4n < 9=6 &as compared &ith a historical cohort of I"U patients 4n < >96 of similar illness se)erity that recei)ed a standard high*energy enteral formula! The incidence of nosocomial infections and mortality and the consumption of multiple I"U resources &ere e,amined! 2 cost analysis -ased on these results &as then performed to determine the cost effecti)eness of this proprietary immunonutrition enteral formula! RESU.TS: 2 pronounced reduction in nosocomial pneumonia 49>? )s :>? p @ !A96 &as identified &ith conseBuent trends to&ard a reduction in duration of mechanical )entilation and I"U length of stay! Urinary tract infections that may ha)e less influence on I"U resources &ere increased in the Impact 9!: group! #o difference in mortality &as identified despite the inclusion of patients &ith se)ere sepsis in the study group! 2ccording to the a)erage num-er of I"U days reBuired for each study cohort the Impact 9!: group led to a cost sa)ings of at least C9D+ +:A!AA! "O#".USIO#S: I"U patients &ith significant illness se)erity e,perienced a decrease in the incidence of an important nosocomial infection that is commonly associated &ith increased use of I"U resources and length of stay! This decrease in patient mor-idity led to su-stantial cost sa)ings despite the small si/e of our study trial! JPEN 2005 Jan- e!;2"(1 #uppl):#62-".

Preo!erati%e immunonutrition: cost"ene$it anal#sis.

(2"8%ROU#$: To e)aluate &hether preoperati)e immunonutrition might lead to a sa)ings in patient care! $ata on resources consumed to treat postoperati)e complications are scanty -ut mor-idity costs continue to -e a ma1or -urden for any health care system! 2 recent randomi/ed clinical trial carried out in &ell*nourished patients &ith gastrointestinal cancer sho&ed that a :*day preoperati)e oral immunonutrition reduced postoperati)e mor-idity compared &ith con)entional treatment 4no supplementation6! 5ET;O$S: The a-o)ementioned trial &as the -asis for the economic e)aluation! In*hospital related costs of routine surgical care and costs of nutrition &ere calculated! Estimates of complication costs &ere -ased on -oth resources used for treatment and additional length of hospital stay! "ost comparison and cost*effecti)eness analysis &ere then carried out! RESU.TS: Total cost of nutrition &as +EA= euro in the con)entional group and 9E =>D euro in the preoperati)e group! In patients &ithout complication the cost of inhospital routine care &as similar in -oth groups! The mean cost of complication &as 39=F euro in the con)entional group and E3+D euro in the preoperati)e group 4p < !A:6! Total cost of patients &ith complications &as :+: >+3 euro in the con)entional group and ++E 9EF euro in the preoperati)e group! Total costs consumed D+? of the diagnosis*related*group 4$R%6 reim-ursement rate in the con)entional group and =F? in the preoperati)e group! "ost*effecti)eness &as 3>E: euro for the con)entional group and >DF: euro for the preoperati)e group! "O#".USIO#S: The costs of postoperati)e mor-idity consumed a large amount of the $R% reim-ursement rate! Preoperati)e immunonutrition &as cost*effecti)e in our series! JPEN 2005 Jan- e!;2"(1 #uppl):#5$-61

T l#m!hoc#te num"ers in human ut associated l#m!hoid tissue are reduced without enteral nutrition.
(2"8%ROU#$: "linically in the a-sence of enteral nutrition the mor-idity of infectious complication is high! 2lthough e,periments using mice ha)e sho&n alterations in gut*associated lymphoid tissue 4%2.T6 to -e an important mechanism underlying impaired host defense

there are no clinical studies on the effects of nutritional routes on %2.T! 5ET;O$S: 2 total of >= colon cancer cases &ho under&ent right colectomy or hemicolectomy &ere re)ie&ed! Si, patients did not recei)e enteral nutrition for E to >F days -efore surgery -ecause of -o&el o-struction 4parenteral nutrition GP#I group6! T&enty*one patients &ere enterally fed -efore surgery 4enteral nutrition GE#H group6! The terminal ileum from resected specimens &as e,amined microscopically! T*cell num-ers in intraepithelial spaces 4IE6 and the lamina propria 4.P6 &ere determined immunohistochemically in -linded fashion! RESU.TS: There &ere no significant differences in -aseline characteristics -et&een the > groups! T*cell num-er in the .P &as significantly lo&er in the P# group than in the E# group &ith no difference in IE cell num-ers! "O#".USIO#S: .ac' of enteral deli)ery of nutrients reduces %2.T cell num-er in patients &ith colon cancer as is the case in mice! JPEN 2005 Jan- e!;2"(1):56

&ssociation "etween dietar# ar inine and '(reacti%e !rotein.

"O#".USIO#S: The results of this study sho& a relation -et&een arginine inta'e and "RP le)el that persisted after controlling for factors associated &ith "RP! Indi)iduals may -e a-le to lo&er their ris' for cardio)ascular disease -y consuming more arginine*rich foods such as nuts and fish! Nutrition. 2005 e!;21(2):125-%0.

)l#cemic and li!id control in hos!itali*ed t#!e 2 dia"etic !atients: e%aluation o$ 2 enteral nutrition $ormulas +low car"oh#drate(hi h monounsaturated $at %s hi h car"oh#drate,.
2n enteral formula &ith lo&er car-ohydrate and higher monounsaturated fat 4%lucerna6 has a neutral effect on glycemic control and lipid meta-olism in type > dia-etic patients compared &ith a high*car-ohydrate and a lo&erfat formula 4Precitene $ia-et6! JPEN 2005 Jan- e!;2"(1):21
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