Immunonutrition Supplementation Research Articles

Nutrition in Surgery: An Orthopaedic Perspective.

➤ Malnutrition is common among subsets of patients undergoing orthopaedic surgery and is associated with an increased risk of postoperative complications.➤ Serum proteins, in particular, albumin, may be used in the evaluation of nutritional status.➤ Anthropometric measurements and surveys also play a role in the evaluation of nutritional status.➤ Increased energy and nutrient requirements due to surgical procedures necessitate increased caloric and protein intake in the perioperative period, which may be achieved through diet or supplementation.➤ Evidence supports the use of protein-calorie, amino acid, and immunonutrition supplements. Vitamin D supplementation is an area of further consideration.➤ Diet restriction, activity alterations, pharmacotherapy, and bariatric surgery are all safe, effective approaches to weight loss, although the optimal timing and magnitude of preoperative weight loss require further investigation.

Immunonutrition supplementation for resectable gastric cancer during standard perioperative chemotherapy (CT) FLOT: A pivotal study, I–SUPPLY.

57 Background: Gastric carcinomas (GC) can be divided into immunogenic and immune-resistant based on the infiltration of the tumour microenvironment (TME) from different immune cells (ICs) such as Natural Killer (NK), activated CD8+, CD3+ and CD4+ memory T cells. High ImmunoScore (IS) (positive cells/mm2 for each marker (CD8+, CD3+, Foxp3+) in the Core Tumour and Invasive Margins) is strongly related to better prognosis of GC patients in terms of Disease-Free Survival and Overall Survival. ICs activation and consequent immunogenic TME requires high nutrient absorption and synthesis accumulation of protein, lipid and nucleotides. However, tumour cells (TCs) promote their own proliferation by stealing the available micronutrients to ICs therefore leading to an immunosuppressive TME phenotype. Methods: This is a translational, prospective, non-randomized study. Primary endpoint is to assess if enteral immune nutrition (EIN) supplementation during the acme of the activity of cytotoxic of perioperative FLOT (docetaxel, oxaliplatin and 5-fluorouracil) in stage II-III GC can revert the TME in favour of ICs over TCs, witnessed by an increase of IS in surgical specimen over biopsy controls. A steady amount of EIN with Arginine, Omega-3-fatty acids, Glutamine and ribonucleic acid, will be added to patient’s diet from day 3 to 8 of each FLOT cycle, twice a day. We plan to use Image analysis software for automatic tumor detection and quantification of CD3+ and CD8+ stained cells whose densities will be converted into IS with pre-defined cutoffs. IS utilizes standardized percentile values (0 to 100%). We identify IS as Low, Intermediate (Int) and High with a mean percentile of 0-25%, >25-70%, >70-100% respectively. Two-group classifications are planned, corresponding to IS Low and Int-High. To better define the kind of tumor infiltrating cells (TILs) and assess the amount of immune suppressive cells, more IHC scoring will be evaluated: helper T-cells CD4+, CD8 T memory (CD 103+), T regulatory (both CD4+ and Foxp3+/CD105+), Macrophages M1 (CD 68+) and M2 (CD 163+). Results: Based on historical controls the rate of Int-High IS (>25-70%, >70% respectively) is about 64%, we expect to find a 20% increase of Int-High IS GC over biopsy control (internal validation cohort). To detect an increase in the percentage of high IS among patients treated with EIN (estimated around 85%) compared to biopsy controls (estimated around 64%) assuming a probability α and β of 0.2, the required sample size will be of 21 patients with resectable GC receiving EIN supplementation plus standard CT. To define the sample size a single proportion test was used. Conclusions: Our hypothesis is that EIN given during perioperative CT might prevent the establishment of an unfavourable TME for ICs in both auxotrophic and non-auxotrophic malignancies, thus leading to an increase of GC immunogenic pattern.

#3716 EFFECT OF IMMUNO-NUTRITION ON SYSTEMIC INFLAMMATION AND MUSCLE MASS IN A HAEMODIALYSIS POPULATION: A FEASIBILITY STUDY

Abstract Background and Aims Decreased skeletal muscle mass (SMM) and systemic inflammation are frequent complications associated with poor outcomes in people receiving haemodialysis. Although these problems are widely acknowledged, it has become clear that simply providing conventional oral nutritional supplements (ONS) is often not effective in increasing SMM. This is partly because systemic inflammation causes “anabolic resistance”, a condition that inhibits optimal rates of muscle protein synthesis being achieved despite adequate protein intake/availability. Immuno-nutrition supplements are high in energy and protein (similar to conventional ONS), but also contain a unique combination of nutrients that have shown to reduce inflammation in people with cancer. Therefore, the purpose of this feasibility study is to explore the potential effect of immuno-nutrition on systemic inflammation and SMM in a haemodialysis population. Method This was a single-centre, non-randomised, interventional feasibility study where 14 haemodialysis patients received 1 sachet per day (74 g dissolved in 125 ml of water) of a commercially available immuno-nutrition supplement (Oral Impact®, Nestlé) for 6 weeks. C reactive protein (CRP), skin autofluorescence (SAF, a marker of systemic inflammation), body composition assessment using bioelectrical impedance analysis (InBody 770), weight, body mass index (BMI), handgrip strength (HGS), routine biochemical variables (pre-dialysis), and energy, protein and fat intake were measured at baseline and after the 6-week intervention. Results Mean participant age was 69 ± 13 years and median dialysis vintage was 26 (interquartile range 9 to 94) months. Twelve participants (86%) were male and of white ethnicity. Diabetes and heart disease were present in 9 (64%) and 7 (50%) participants, respectively. Adherence to the intervention was high (98%). Participants reported that the taste of the supplement was nice and acceptable. No safety issues were observed in terms of development of hyperkalaemia or fluid overload. We observed a significant increase in HGS and urea. Fat-free body mass and SMM remained stable, while body weight, BMI and body fat mass tended to increase, though changes did not reach statistical significance. Markers of systemic inflammation and dietary intake did not show any significant change (Table 1). Conclusion In this interventional feasibility study, we observed that provision of an immuno-nutrition supplement was associated with an improvement in muscle strength, as well as maintenance of SMM. This suggests that immuno-nutrition may be effective in preventing SMM loss over time in people on haemodialysis. The findings of this feasibility study will help design a randomised controlled clinical trial investigating whether immuno-nutrition supplementation can improve SMM and other nutritional markers, and to evaluate the impact on long-term outcomes, including quality of life.

Immunonutrition of perioperative therapy for colorectal cancer

Abstract Immunonutrition, a modified nutritional formula that involves the addition of glutamine, arginine, omega-3 fatty acids, nucleotides, and other potential compounds to the diet, has proven its potential for use in immunomodulation and protein metabolism improvement. Its clinical benefits include shortening hospital stays and lowering surgical infectious complications in upper gastrointestinal surgery. However, the use of perioperative immunonutrition is rare among colorectal cancer patients undergoing surgical intervention. Colorectal cancer is one of the most common cancers around the world, but its malnutrition rate is not high in comparison with other cancers (eg, gastric cancer or esophageal cancer). Furthermore, the surgical modality for the majority of colorectal cancer patients involves minimal invasive surgery (MIS), which enhances recovery speed. It is an interesting clinical question whether or not perioperative immunonutrition supplementation for colorectal cancer patients undergoing MIS causes extraclinical impacts. The immunomodulation effect of CD4+ T cells has been proven in colorectal patients undergoing elective surgery. In recent years, there have been several prospective randomized studies elucidating the clinical effects of immunonutrition on colorectal cancer patients undergoing surgery in Western countries. These studies have generally found that perioperative immunonutrition was associated with a lower rate of surgical infectious complications even in normo-nourished patients undergoing MIS. The use of perioperative immunonutrition provides clinical benefits according to high-quality studies. However, most results come from Western countries, and its effect needs to be validated in Asian countries.

Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review.

Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer. A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team. A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation. Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.

Optimizing Nutritional Status in Patients Undergoing Radical Cystectomy: A Systematic Scoping Review.

BACKGROUND:Nutrition is a modifiable risk factor for patients undergoing multimodal oncologic interventions and plays a major supportive role in the setting of bladder cancer. For patients undergoing radical cystectomy (RC), malnutrition is associated with increased postoperative complications and mortality.OBJECTIVES:The purpose of this scoping review is to characterize the role of nutritional interventions for patients undergoing RC for bladder cancer.METHODS:A multi-database systematic scoping review based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) guidelines was performed. Search terms were developed a priori to identify clinical trials that focused on nutritional interventions for patients with bladder cancer undergoing RC. Eligible articles were original research articles or abstracts from clinical trials evaluating nutritional interventions in adult patients undergoing RC. Articles were excluded if they did not focus on a nutritional intervention, if patients did not carry a diagnosis of bladder cancer, or if RC was not performed. Articles were reviewed independently by the authors, and inclusion/exclusion were based on consensus agreement.RESULTS:A total of 83 articles were identified, of which 17 were included in the final analysis. A total of 49 articles were excluded during abstract screening. An additional 17 articles were excluded based on the review of full-text articles. Results of the scoping review suggest that data on the use of nutritional screening, assessment, and intervention for patients undergoing RC are scarce. Although parenteral nutrition (PN) appears to be associated with greater complications after RC, early introduction of food postoperatively or feeding enterally offers benefit and immunonutrition supplements with a focus on a high protein diet have the potential to better optimize surgical outcomes.CONCLUSIONS:Although the prevalence and consequences of malnutrition among patients undergoing RC are well-established, there are limited data evaluating the use of nutritional screening, assessment, and interventions for this population. The pursuit of future clinical trials in this space is critical.

Effect of Immunonutrition supplementation on Post-operative outcome after major Gastrointestinal surgery for Malignancy

This prospective, pilot study evaluated the effect of immunonutrition supplementation using Pentasure Immunomax® on recovery after major gastrointestinal (GI) surgery for malignancy. It included two groups of patients (n = 25 each) who underwent major GI surgery for malignancy in two units, one of which routinely gave Pentasure Immunomax® (L – arginine, omega 3 fatty acids and ribonucleic acids) for two weeks following surgery (Group 1) while the other did not (Group 2). The pre-operative nutritional status of the patients were assessed using Subjective Global Assessment (SGA) scale. Post-operatively the following parameters were compared between the two groups: complications (using Clavien Dindo scale), calorie intake, length of intensive care unit (ICU) and hospital stay using SPSS software, version 20.0. Based on the SGA score, 66% of the entire study population was moderately malnourished, while 6% were severely malnourished. On assessing the body mass index, 26 (52%) patients were found to be overweight or obese, out of which 16 patients were found to be moderately malnourished. The mean caloric intake in Group 1 was significantly more than in Group 2 (1112.7± 51.6 versus 874.8±56.7; p = 0.0032). There was, however, no significant difference between the two groups in complications, ICU or hospital stay. The incidence of malnutrition in patients undergoing major GI surgery for malignancy is high even amongst those who are overweight/obese. Use of immunonutrition may help in better attainment of adequate calorie in post-operative period.

Beneficial effects of an 8-week enteral immunonutrition supplementation on adult Arab patients with pressure ulcers

Beneficial effects of an 8-week enteral immunonutrition supplementation on adult Arab patients with pressure ulcers

Dietary Amino Acids and Immunonutrition Supplementation in Cancer-Induced Skeletal Muscle Mass Depletion: A Mini-Review.

Cancer patients display systemic inflammation, which leads to an increase in protein catabolism, thus promoting the release of free amino acids to further support metabolism and remodelling of muscle proteins. Inflammation associated with tumor growth leads to malnutrition, a factor that increases the risk of developing cachexia. With cancer-induced cachexia, nutritional interventions have gained traction as a preventative method to manage this condition. Currently, cancer consensus recommendations suggest a protein intake above 1.0 g/kg.day-1 up to 2.0 g/k.day-1 for cancer patients, although an ideal amount for some amino acids in isolation has yet to be determined. Due to controversy in the literature regarding the benefits of the biochemical mechanisms of various muscle mass supplements, such as L-leucine (including whey protein and BCAA), β-hydroxy-beta-methyl butyrate (HMβ), arginine, glutamine and creatine, several studies have carefully examined their effects. L-leucine and its derivatives appear to regulate protein synthesis by direct or indirect activation of the mTORC1 pool of kinases, further promoting muscle protein balance. Arginine and glutamine may act by reducing inflammation and infection progression, thus promoting improvements in food intake. Creatine exerts anabolic activity, acting as an immediate energy substrate to support muscle contraction further increasing lean mass, mainly due to greater water uptake by the muscle. In this narrative review, we highlighted the main findings regarding protein consumption and amino acids to mitigate cancer-induced skeletal muscle depletion.

Effects of nutritional support on the clinical outcomes of well-nourished patients with cancer: a meta-analysis.

The effects of nutritional support on well-nourished patients have been investigated, but the results were inconsistent among different articles. We performed the meta-analysis to examine the existing evidence. We systematically retrieved articles from PubMed, Web of Science and the Cochrane Library to identify the evidence of nutritional support for well-nourished patients. Methodological quality assessment was assessed based on the Cochrane Handbook and GRADE. Nine randomized controlled trials (RCTs) and one non-RCT with 1400 participants were included in this meta-analysis. Nutritional support, particularly immunonutrition, was associated with a significant reduction in postoperative infectious complications (OR = 0.74, 95% CI: 0.57-0.96), and a decreasing trends in morbidity and the length of the hospital stay (LOS) were observed. However, the mortality rates were comparable between two groups. The quality of evidence was moderate to high. Nutritional support, particularly immunonutrition supplementation, is likely to reduce infectious complications, morbidity and LOS without influencing mortality and may be a safe and preferred choice for well-nourished patients undergoing surgery for cancer. However, additional RCTs are warranted to determine the effects of nutritional support on well-nourished patients.

Nutrition Practices in Hematopoietic Stem Cell Transplantation (HSCT): A Comparison between Guidelines and Clinical Practice

Background Several professional societies have established nutrition guidelines for patients undergoing HSCT. We surveyed HSCT programs to understand how these compare with clinical practice. Methods Qualitative surveys were emailed to HSCT dietitians. Surveys addressed malnutrition screening; dietary recommendations including nutrition support, graft-versus-host disease (GVHD), immune enhancing nutrients, and prebiotics/probiotics; and nutrition-related preventive care screening. Results Twenty adult programs (19 United States (US), 1 Australia) and 3 pediatric programs (3 US) responded. Annual volume across the 22 US programs was 5405 patients, representing 25% of all transplants in the US. Nineteen programs (83%) follow guidelines for nutrition screening and fourteen for nutrition therapy in the inpatient setting (Table 1); six (26%) follow guidelines for screening and therapy in the outpatient setting. All programs adhere to food safety recommendations and 5 (22%) have additional institutional precautions. However, only 2 programs (9%) report frequent adherence to guidelines for use of enteral nutrition. While there are no guidelines for GVHD diet and uncertainty over alternative nutrition practices, 8 programs (35%) follow a stepwise GVHD diet; 4 (17%) allow immunonutrition supplements; 2 (9%) allow prebiotics, and 7 (30%) allow probiotics after the resolution of neutropenia. With regard to adherence to preventive screening recommendations, only 4 programs (17%) screen for diabetes, 6 (26%) screen for hyperlipidemia, and none screen for abdominal obesity. There are no guidelines for vitamin D deficiency screening, but 10 programs (43%) screen for this. Discussion Wide variations in nutrition practices exist across HSCT programs. Similarly, with the exception of food safety recommendations, there are also wide variations in adherence to established nutrition guidelines. The use of enteral nutrition and preventive screening is particularly varied. Efforts are needed to understand barriers to guideline implementation and their correlation to patient outcomes. Further research is needed regarding new interventions such as immunonutrition, prebiotics, and probiotics.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program.

The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

A Double-blind, Paired Comparison Taste Test of Two Oral Immunonutrition Supplements

To state the preference of an oral immunonutrition supplement.

Efficacy of preoperative immunonutrition in locally advanced pancreatic cancer undergoing irreversible electroporation (IRE)

BackgroundImproved preoperative immunonutrition has been shown to decrease the length of stay (LOS) and complications among patients undergoing elective gastrointestinal cancer surgeries. The purpose of this study was to determine whether preoperative immunonutrition supplementation decreases postoperative LOS, infectious complications, and morbidity in patients undergoing irreversible electroporation (IRE) surgery for locally advanced pancreatic cancer (LAPC). MethodsAt a regional hepatopancreatobiliary referral center within an academic medical center 71 patients receiving IRE treatment of LAPC were included in the study. The participants were divided into those receiving preoperative immunonutrition (n = 44) and those receiving no supplemental preoperative immunonutrition (n = 27). Main outcomes and measures were LOS, postoperative complications, nutritional risk index (NRI), and albumin levels. ResultsPatients in both groups were similar for preoperative nutrition parameters and operative therapy. Patients in the immunonutrition group experienced a statistically significant decrease in postoperative complications (p = 0.05) and LOS (10.7 vs. 17.4, p = 0.01), and less of a decrease in nutritional risk index (−12.6 vs. −16.2, p = 0.03) and albumin levels (−1.1 vs. −1.5, p < 0.01). ConclusionPreoperative immunonutrition was clinically significant in decreasing postoperative complications, LOS, and improving post-surgery NRI and albumin levels in patients receiving elective IRE treatment of non-resectable pancreatic cancer. These results indicate that preoperative immunonutrition is effective and feasible in this subset of cancer patients.

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients. Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost. A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37). Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Immunonutrition support for athletes

Multiple components of the immune systems in athletes exhibit transient dysfunction after prolonged, heavy exertion. During this "open window" of impaired immunity, pathogens may gain a foothold, increasing infection risk. Nutritional supplements have been studied as countermeasures to exercise-induced immune changes and infection risk. This review focuses on findings from recent exercise-based studies with macro- and micronutrient supplements, and "advanced" immunonutrition supplements including beta-glucan, curcumin, and quercetin. Results from these studies indicate that immunonutrition supplements have the potential to lessen the magnitude of exercise-induced perturbations in immune function and to reduce the risk of upper respiratory tract infections.

Immunonutrition and Upper Gastrointestinal Surgery: What Really Matters

Patients with upper gastrointestinal cancer or other surgical diseases are at high risk for both mechanical and infectious complications. The disease process itself places these patients at increased risk for malnutrition, with subsequent postoperative complications. Because these surgeries are semielective, a period of time is available to optimize the patient's condition. There are several trials that suggest preoperative immunonutrition supplementation improves outcomes and is cost-effective by reducing complications. However, the most important choice a patient or clinician can make may well be by whom and where the surgery is performed.