Curriculum Vitae

Nama Lengkap : dr. Juwita Soekarno, Sp.PD, FINASIM

Jabatan : Staf Pengajar
Bagian Ilmu Penyakit Dalam FK. UNSRAT
Tempat / Tgl. Lahir : Manado, 05 Juni 1979
Riwayat Pendidikan :
S1 : FK. UNSRAT
SP1 : Ilmu Penyakit Dalam FK. UNSRAT
SP2 : Pendidikan dokter Spesialis Konsultan Alergi Imunologi 

Organisasi : Anggota IDI Wilayah Sulawesi Utara

Anggota IDI Cabang Manado
Anggota PAPDI Cabang SULUT
Pengurus PERALMUNI Cabang Manado
IMMUNONUTRITION

Allergy and Clinical Immunology Division

Internal Department - Sam Ratulangi University, Manado
 IMMUNONUTRITION

Immunonutrition is an emergent science and interdisiplinary,

comprises several aspects related to:
Nutrition
Immunity
Infection known as Nutrition and 4 Is
Inflammation
Injury
Jurnal Zapatara B, Prados A, et all. Immunonutrition : Methodology and Application. Nutr Hosp. 2015; 31: 145-154.
Jurnal Zapatara B, Prados A, et all. Immunonutrition : Methodology and Application. Nutr Hosp. 2015; 31: 145-154.
Jurnal Zapatara B, Prados A, et all. Immunonutrition : Methodology and Application. Nutr Hosp. 2015; 31: 145-154.
IMMUNE SYSTEM
Schematic representation IMMUNE
of the human immune SYSTEM
system
Ann Nutr Metab 2007;51:301-323
INNATE ADAPTIVE
IMMUNITY IMMUNITY

Cell
Other non- Complement Humoral
Phagocytosis mediated
specific factors system immunity
immunity

Epithelial barrier
Neutrophilic T lymphocytes
and digestive
granulocyte
functions
Antigen-
NK cells, acute Eosinophilic presenting
phase proteins granulocyte

Monocyte/
Enzymes,
Macrophage,
transferrin, etc
Dendritic cells
 TNF-, IFN- Lymphokine mediated cytotoxicity
IFN-
TGF-
T IL-2 Complement
Helper 1 B cell IgG2a mediated
cell IFN- cytotoxicity
IFN- IFN-, TNF-

PC
FCR

A
Antibody dependent

n,
ge
Macrophage
Cell mediated cytotoxicity

nti
+a
Phagocytosis
Naïve
Intracellular killing
CD4+
T Cell IFN-, TNF-
DTH
+a

IL-4
ntig

IL-10 IL-4
en,

Eosinophil Mediator Release

IL-10 Eosinophil
A

progenitor
PC

IL-5
T IgE
B cell IgM, IgG1 Antibody
Helper 2
IL-4 cell IL-4

Stimulatory IgE
IL-3,IL-4
Mast Mast
Inhibitory IL-10 cell
Mediator Release
cell

Differentiation Cross regulation Effector Function

Immune Regulation of the Intestinal Barrier
NUTRITION
 NUTRITION

Macro Nutrient Micro Nutrient

carbohydrate, protein, fat Multivitamins and minerals

Glucose, amino acid, fatty acid

 Nutrition
NUTRIENT FUNCTION NUTRIENT

Carbohydrate Source of energy

Fat
Water
Tissue growth
and
maintenance
Protein
Mineral

Vitamin Regulator of
body process
IMMUNONUTRITION
Fat

Nutrient Amino acid

Nucleotide

Vitamin

Mineral

Prebiotic
Probiotic
MALNUTRITION
 Malnutrition

Nutrient deficiencies that adversely affect

immune functions include :

Protein deficiency
Vitamin deficiency, particularly those involved in
DNA & synthesis (eq. Vit A, B6, B12 & Folic Acid )
Mineral deficiencies, Particularly of zinc or iron, which
can cause decreases in T cell functions and
microbicides activity of phagocytes.
 Importance of Nutrition Therapy

Cancer

Surgery
Guidelines of nutrition for critical ill

Calories :
Initial/Critical phase  20-25 Kcal/kgWeight/day
Flow/Anabolic phase  25-30 Kcal/kgWeight/day

Protein :
Sepsis  1-1,5 g/kgWeight/day
Major surgery  1-2 g/kgWeight/day
Burns/Trauma  1,5-3 g/kgWeight/day

Carbohydrate  40-60% of total calories

Fat  25-40% of daily total calories

AMINO ACID
AMINO ACID
 the smallest part of the protein structure
 Protein : is a collection of amino acids
 a form of protein  absorbed by intestine

 Amino acid : - Essential

- Non essential
- Conditional
 GLUTAMINE

Glutamine is ‘conditionally’ essential amino

acid in severe illness, synthesized in skeletal
muscle.

Glutamine is a precursor for nucleotide synthesis,

glutathione a product of glutamine metabolism has
an important role as an antioxidant.

Pravin Amin. Immunonutrition : current status, Crit Care & Shock (2004) 7: 77 – 86.
 GLUTAMINE
Glutamine is used in big amount for :
Cell immune system
Lymphocyte proliferation
Cytokine production by lymphocytes and macrophages
Protecting lymphocytes and macrophages’ function
Glutathione precursor (antioxidant)
Integrity of intestines’ mucosa
Lowering insulin resistance
Expression of heat shock protein

Dose of glutamine :
Single oral: 0,3 g/kgWeight/day  intestines’ integrity
Enteral nutrition  30,5 g/100 g protein

Calder PC, et al. Glutamine and the immune system. Amino Acids. 1999;17(3):227-41.
Hyeyoung Kim. Glutamine as an immunonutrient. Yonsei Med J. 2011;52(6): 892-97.
 GLUTAMINE

BioMed Research International. Volume 2015, Article ID 545467, 7 pages. http://dx.doi.org/10.1155/2015/545467

 Overview on studies included in the
two meta-analyses presented in detail

© Copyright Fresenius Kabi AG 23

 Summary & Conclusions
Meta-analysis by Bollhalder et al. (2013) has demonstrated…
…overall, glutamine-supplemented parenteral nutrition significantly reduces infection rates
and length of hospital stay:
 Relative risk of infections reduced by 17%
 Hospital LOS reduced by 2.35 days

…when given in adequate, recommended doses (>0.2g/kg/day) glutamine-supplemented

parenteral nutrition significantly reduces mortality, infection rates, and length of hospital
stay:
 Relative risk of mortality reduced by 31%
 Relative risk of infections reduced by 21%

 Hospital LOS reduced by 2.29 days

© Copyright Fresenius Kabi AG 24

 Clinical study Glutamine
In Surgery
Significantly
Significantlyreduced
reducedinfections
infections

For surgical and critically ill

patients, GLUTAMINE
(Dipeptiven ®) is associated
with significant relative risk
reduction of infectious
complications
(p = 0.009)

Meta-analysis with 40 studies in

3109 mixed patients

Bollhalder L. et al. Clin Nutr 2013; 32: 213-223
 New Recommendation from
ESPEN Guideline Surgery 2017
 ARGININE
Arginine is a semi-essential amino acid
becoming essential in catabolic states.

Arginine stimulates: growth hormone,

prolactin, insulin like growth factors.

Pravin Amin. Immunonutrition : current status, Crit Care & Shock (2004) 7 : 77 – 86.
• Stimulates T-lymphocyte’s function ARGININE
• Forms nitrite oxide to increase
macrophage’s effect and bactericidal
activity

• Strengthens macrophage and NK cell’s

function

• Fastens wound healing by stimulating

collagen synthesis

• Stimulates insulin secretion, growth

hormone, prolactin, glucagon,
somatostatin, and norepinephrine
 BCAA
Amino acid essential:
Valine
Leucine
Isoleucine

Increases protein synthesis

From research, giving BCAA 45% in 7 days post-

operative  increases amount of lymphocytes.

Giving BCAA to sepsis and metabolic stress 

decreases mortality.

Phillip C. Calder. Branched-Chain Amino Acids and Immunity. J. Nutr. 2006;136:288S–293S.

LIPID - OMEGA 3
 IMMUNONUTRIENT

Eikosapentaenoic Acid (EPA)

• As an essential fatty • Unsaturated fatty acid • Is omega 3 fatty acid
acid • Decosahexaenoic acid
• Play an important role (DHA) can lower pro-
in growth and immune inflammation mediator
system
Diet and nutritional aspects in systemic lupus erythematosus
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32
Diet and nutritional aspects in systemic lupus erythematosus
Rev. Bras. Reumatol. vol.52 no.3 São Paulo May/June 2012
33
VITAMINS AND MINERALS
The Role of Some Vitamins and Minerals in the
Body and Sources of Nutrients1

Nutrient Its Role

Required for maintenance of epithelial cells, mucous
membranes and skin. Needed for immune system
Vitamin A function and resistance to infections. Ensures good
vision. Needed for bone growth.

Used in energy metabolism supports appetite and central

Vitamin B1/Thiamine nervous system functions.

Vitamin Used in energy metabolism supports normal vision,

B2/Riboflavin health and integrity of skin

Essential for energy metabolism; supports health and

Vitamin B3/Niacin integrity of skin, nervous and digestive system.

Facilitates metabolism and absorption of fats and

proteins; converts tryptophan to niacin; helps make red
Vitamin B6 blood cells. Some TB drugs cause B6 deficiency.
The Role of Some Vitamins and Minerals in the Body and
Sources of Nutrients2
Nutrient Its Role
Required for synthesis of new cells, especially red blood
Folate (folic acid) cells and gastrointestinal cells.
Required for synthesis of new cells, helps to maintain
Vitamin B12 nerve cells. Works together with folate.
Helps the body to use calcium and other nutrients to build
bones and blood vessel walls. Increases non-heme iron
Vitamin C absorption. Increases resistance to infection and acts as
an antioxidant. Important for protein metabolism

Vitamin D Required for mineralization of bones teeth

Acts as an antioxidant. Protects cell membranes and

metabolism, especially red and white blood cells. Protects
Vitamin E vitamin A and other fats from oxidation. Facilitates
resistance against diseases, particularly in lungs.
Diet and nutritional aspects in systemic lupus erythematosus
Rev. Bras. Reumatol. vol.52 no.3 São Paulo May/June 2012 37
Effects of vitamins and minerals on immunity

 Vitamin T-Cell B-Cell Macrophage Neutrophil

   
A  +++ +++  
Thiamin/B1   ++    
Riboflavin/B2   ++    
B6 +++ +++    
B12 ++ +   ++
Biotin   +++   +
Pantothenic acid   +++    
Folic acid ++ +++    
C     ++  
D   ++   ++
E ++ ++ ++ ++
Niacin and tryptophan   ++    
The Role of Some Vitamins and Minerals in the Body
and Sources of Nutrients3

Nutrient Its Role

Calcium Required for building strong bones and teeth. Important

for normal heart and muscle functions, blood clothing and
pressure, and immune defenses
Zinc Important for function of many enzymes. Act as an
antioxidant. Involved with making genetic material and
proteins, immune reactions, transport of vitamin A, taste
perception, wound healing and sperm production

Selenium Acts as an antioxidant together with vitamin E. Prevents

the impairing of heart muscles.

Magnesium Important for building strong bones ant teeth, protein

synthesis, muscle contraction and transmission of nerve
impulses.
Iodine Ensures the development and proper functioning of the
brain and the nervous system. Important for growth,
development and metabolism
Diet and nutritional aspects in systemic lupus erythematosus
Rev. Bras. Reumatol. vol.52 no.3 São Paulo May/June 2012 40
 
 Effects of giving excessive
nutrition on immunity

Nutrition status Immunity

Obesity
Hypercholesterolemia
Increase of unsaturated fatty acid
 
Hypolipoproteinemia
Hyperglycemia
Decreases ability of cell immunity
Decreases lymphocyte’s function
Decreases ability to reject graph
Lowers slow-type hypersensitivity
Decreases blast transformation response of
T-cell
Decreases ability to do phagocytosis
TAKE HOME MESSAGE
Immuno Nutrition
Sizer F and Whitney E. Nutrition: concepts and controversies, 10 th ed, 2006
 DIPEPTIVEN
( dipeptide alanyl-glutamine )
Diet and nutritional aspects in systemic lupus erythematosus
Rev. Bras. Reumatol. vol.52 no.3 São Paulo May/June 2012
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Diet and nutritional aspects in systemic lupus erythematosus
Rev. Bras. Reumatol. vol.52 no.3 São Paulo May/June 2012
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 Basic Adult Daily Requirements for Total Parenteral Nutrition1
Nutrient Amount
Water / (kg body wt/day) 30-40 ml
Energy*
Medical patient 30 kcal
Postoperative patient 30-45 kcal
Hypercatabolic patient 45-60 Kcal
Amino acids (/kg body wt/day)
Medical patient 1.0 g
Postoperative patient 2.0 g
Hypercatabolic patient 3.0 g
Minerals
Acetate/gluconate 90 mEq
Calcium 15 mEq

* Requirements for energy increase by 12% per 1 C of fever

 Basic Adult Daily Requirements for Total Parenteral
Nutrition2

Nutrient Amount
Chloride 130 mEq
Chromium 15 mg
Copper 1.5 mg
Iodine 120 µg
Magnesium 20 mEq
Manganese 2 mg
Phosphorus 300 mg
Potassium 100 mEq
Selenium 100 µg
Sodium 100 mEq
Zinc 5 mg
Basic Adult Daily Requirements for Total Parenteral
Nutrition3
Nutrient Amount
Vitamins
Ascorbic acid 100 Mg
Biotin 60 µg
Cobalamin 5 µg
Folic acid 400 µg
Niacin 40 mg
Pantothenic acid 15 mg
Pyridoxine 4 mg
Riboflavin 3.6 mg
Thiamin 3 mg
Vitamin A 4000 IU
Vitamin D 400 IU
Vitamin E 15 mg
Vitamin K 200 µg