Use Of Immunonutrition Research Articles

Immunonutrition for patients undergoing elective surgery for gastrointestinal cancer: impact on hospital costs

BackgroundOral or enteral dietary supplementation with arginine, omega 3 fatty acids and nucleotides (known as immunonutrition) significantly improve outcomes in patients undergoing elective surgery. The objective of the study was to determine the impact on hospital costs of immunonutrition formulas used in patients undergoing elective surgery for gastrointestinal cancer.MethodsUS hospital costs of stay with and without surgical infectious complications, and average cost per day in the hospital for patients undergoing elective surgery for gastrointestinal cancer were estimated using data from the Healthcare Cost and Utilization Project’s 2008 Nationwide Inpatient Sample. These costs were then used to estimate the impact of perioperative immunonutrition on hospital costs using estimates of reduction in infectious complications or length of stay from a meta-analysis of clinical trials in patients undergoing elective surgery for gastrointestinal cancer. Sensitivity of the results to changes in baseline complication rates or length of stay was tested.ResultsFrom the meta-analysis estimates, use of immunonutrition resulted in savings per patient of $3,300 with costs based on reduction in infectious complication rates or $6,000 with costs based on length of hospital stay. Cost savings per patient were present for baseline complication rates above 3.5% or when baseline length of stay and infectious complication rates were reduced to reflect recent US data for those with upper and lower GI elective cancer surgery (range, $1,200 to $6,300).ConclusionsUse of immunonutrition for patients undergoing elective surgery for gastrointestinal cancer is an effective and cost-saving intervention.

Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a systematic review.

Significant malnutrition exists in a high percentage of patients with head and neck cancer. Malnutrition is associated with defects in immune function that may impair the host response to malignancy. Malnutrition and immunosupression make patients highly susceptible to postoperative infections and complications. Some studies of patients receiving immuno-nutrition in the perioperative period in head and neck cancer have shown beneficial effects on clinical outcome and inmune status. The authors carried out a systematic review of randomised control trials to determine whether perioperative immunonutrition has a role in the treatment of head and neck cancer. 14 trials of polymeric nutritional supplementation with immunonutrition were identified. Two studies compared two types of immunonutrition. A reduction in the length of postoperative hospital stay was seen in some trials, but the reason for this reduction is not clear. Some studides showed statistical differences with less complications in arginine-enhanced group and also showed a significant decrease of fistula complications in patients treated with a high arginine dose enhanced formula, if compared with a medium dose of arginine. [corrected] Those planning future studies face challenges. A suitable powered clinical trial is required before firm recommendations can be made on the use of immunonutrition in head and neck cancer patients postoperatively.

A Multi-Center International Survey Related to the Nutritional Support after Hematopoietic Stem Cell Transplantation Endorsed by the ASIA Pacific Blood and Marrow Transplantation (APBMT)

Background: The nutritional support after hematopoietic stem cell transplantation (HSCT) has not been well established due to the scarcity of clinical trials. To conduct international clinical trials in Asia, we performed the questionnaire survey to investigate the current standard of nutritional support after HSCT. Method: We sent the questionnaire to the physicians nominated by the Asia Pacific Blood and Marrow Transplantation (APBMT) members of each country/ region. Result: We received 15 responses from 7 different countries/regions. The target calorie amount is 1.0 - 1.3 × basal energy expenditure (BEE) in 11 institutes when partial parenteral nutrition is used. When total parenteral nutrition (TPN) is used, the target calorie amount is 1.0 - 1.3 × BEE in 9 institutes and 1.3 - 1.5 × BEE in 4 institutes. Lipid emulsion is routinely used in 12 institutes. Multivitamins and trace elements are routinely added to TPN used in most institutes. It is still uncommon to use the immunonutrition. Blood glucose levels are routinely monitored in all institutes, but the target range varies (<110 in 2 institutes, <150 in 4 institutes, and <200 in 8 institutes). Conclusions: Basic nutritional support is similar in participating institutes. However, the target glucose level varies and the use of immunonutrition is rather rare. These points can be the theme of future clinical trials.

Evidence-based immune-modulating nutritional therapy in critically ill and injured patients

BACKGROUND: Immunonutrition, both immune-enhancing (IE) and immune-modulating (IM), has become an important therapeutic option in the care of critically ill and injured patients. METHODS: Review of current literature and evidence on the use of immunonutrition, in particular use of immune enhancing and immune modulating nutrition support in critically ill and injured patients. RESULTS: We have gained much knowledge on the changes and on the mechanism of action of key nutrients and their substrates during critical illness and severe injuries, especially in acute respiratory distress syndrome (ARDS), sepsis, and septic shock; accordingly, the use of such nutrients and substrates has increased dramatically and has become Level I evidence (per the U.S. Preventive Services Task Force). CONCLUSIONS: There has been a significant paradigm shift with regard to selecting the appropriate nutritional strategy for critically ill and injured patients. Doing so for a particular patient and particular disease is no longer regarded as a supportive measure. Rather, it is regarded as direct nutritional therapy, based on molecular changes and on the biology of key nutrients induced by the disease process.

Immunonutrition in gastrointestinal surgery

Patients undergoing major gastrointestinal surgery are at increased risk of developing complications. The use of immunonutrition (IN) in such patients is not widespread because the available data are heterogeneous, and some show contradictory results with regard to complications, mortality and length of hospital stay. Randomized controlled trials (RCTs) published between January 1985 and September 2009 that assessed the clinical impact of perioperative enteral IN in major gastrointestinal elective surgery were included in a meta-analysis. Twenty-one RCTs enrolling a total of 2730 patients were included in the meta-analysis. Twelve were considered as high-quality studies. The included studies showed significant heterogeneity with respect to patients, control groups, timing and duration of IN, which limited group analysis. IN significantly reduced overall complications when used before surgery (odds ratio (OR) 0·48, 95 per cent confidence interval (c.i.) 0·34 to 0·69), both before and after operation (OR 0·39, 0·28 to 0·54) or after surgery (OR 0·46, 0·25 to 0·84). For these three timings of IN administration, ORs of postoperative infection were 0·36 (0·24 to 0·56), 0·41 (0·28 to 0·58) and 0·53 (0·40 to 0·71) respectively. Use of IN led to a shorter hospital stay: mean difference -2·12 (95 per cent c.i. -2·97 to -1·26) days. Beneficial effects of IN were confirmed when low-quality trials were excluded. Perioperative IN had no influence on mortality (OR 0·90, 0·46 to 1·76). Perioperative enteral IN decreases morbidity and hospital stay but not mortality after major gastrointestinal surgery; its routine use can be recommended.

Are we jumping the gun with pharmaconutrition (immunonutrition) in gastrointestinal onoclogical surgery?

Over the last 20 years there has been considerable research into the use of immunonutrition, also referred to as pharmaconutrition, in the management of patients undergoing and recovering from elective gastrointestinal surgery for malignancy. In this group of patients, the use of pharmaconutrition seems to confer superior outcomes to standard nutrition formulations with regards to postoperative infective complications and length of hospital stay. It is therefore frequently recommended for use in elective gastrointestinal oncological surgical populations. However, it remains unclear whether the data supporting these recommendation is robust. Studies reporting improved outcomes with pharmaconutrition frequently compare this intervention with non-equivalent control groups, do not report on the actual nutritional provision received by study participants, overlook the potential impact of industry funding on the conduct of research and do not adopt a multi-disciplinary approach to the research undertaken. For these reasons, an urgent critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is warranted to resolve some of the above mentioned issues.

Immunonutrition in patients undergoing esophageal cancer resection

Specialized nutritional support containing immunonutrients such as arginine, omega-3 fatty acids, and ribonucleic acid significantly reduces the incidence of postoperative infective complications and hospital length of stay in elective surgery patients. However, immunonutrition use is not standard practice in esophago-gastric units internationally. This review provides a clinical update regarding the use of immunonutrition in patients undergoing major gastrointestinal surgery and, in particular, esophageal cancer resection, and provides direction for future collaborative research. A review of MEDLINE and Cochrane Library databases was conducted for randomized controlled trials or meta-analyses. A recent meta-analysis demonstrated that preoperative immunonutrition use significantly reduces hospital length of stay and the incidence of postoperative complications in patients undergoing major elective surgery, particularly for gastrointestinal malignancies. Only three small randomized controlled trials have evaluated immunonutrition use in patients exclusively undergoing esophageal cancer surgery. These were unable to determine whether immune-enhancing formulae positively influence key clinical outcomes such as mortality, hospital and intensive care unit length of stay, and postoperative morbidity in this patient group. Currently, there is insufficient evidence to recommend routine use of immunonutrition in patients undergoing esophageal cancer surgery. Future collaborative research should evaluate whether: (i) immunonutrition use positively influences key clinical outcomes in this population; (ii) these patients benefit from preoperative supplementation with an immune-enhancing formula or whether they require postoperative continuation (perioperative approach) to combat their risk of complications after surgery; and (iii) these formulae can be used safely in those patients who develop sepsis.

The Use of Immunonutrition in Burn Injury Care: Where Are We?

The aim of this study is to review the current evidence for immunonutrition use in patients with burn injury. Nutrients of interest included glutamine, arginine, and omega-3 fatty acids (fish oil). A literature review was conducted to identify studies that evaluated the use of immunonutrients in pediatric and adult patients with burn injury. Search terms included burns, immunonutrition, pharmaconutrition, glutamine, arginine, omega-3, and fish oil. Glutamine: Nine randomized controlled trials (four represented in abstract only) investigating enteral supplementation and two trials investigating parenteral supplementation of glutamine were identified. Arginine: Five trials investigating the effect of arginine supplementation were identified (three represented in abstract only). Omega-3 fatty acids: Three studies investigating the effect of enteral fish oil supplementation were identified (one represented in abstract only). Combined immunonutrients: Six studies were identified that investigated immunonutrients as a combination of active dietary constituents (rather than as individual nutrients). Despite the semiessential nature of arginine after burn injury, there were surprisingly little data regarding nutritional supplementation. Literature around supplementation of omega-3 fatty acids is found to be lacking in the burn injury population. The combination of immunonutrients as a component of enteral formulae limits identification of the active nutrient and ideal dosage. Current evidence supports the use of enteral glutamine supplementation for patients with severe burn injuries. Questions remain regarding dosage, timing, and length of supplementation.

Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis

Although the benefits of enteral nutrition in acute pancreatitis are well established, the optimal composition of enteral feeding is largely unknown. The aim of the study was to compare the tolerance and safety of enteral nutrition formulations in patients with acute pancreatitis. Electronic databases (Scopus, MEDLINE, Cochrane Controlled Clinical Trials Register) and the proceedings of major pancreatology conferences were searched. Twenty randomized controlled trials, including 1070 patients, met the inclusion criteria. None of the following was associated with a significant difference in feeding intolerance: the use of (semi)elemental versus polymeric formulation (relative risk (RR) 0.62 (95 per cent confidence interval (c.i.) 0.10 to 3.97); P = 0.611); supplementation of enteral nutrition with probiotics (RR 0.69 (95 per cent c.i. 0.43 to 1.09); P = 0.110); or immunonutrition (RR 1.60 (95 per cent c.i. 0.31 to 8.29); P = 0.583). The risk of infectious complications and death did not differ significantly in any of the comparisons. The use of polymeric, compared with (semi)elemental, formulation does not lead to a significantly higher risk of feeding intolerance, infectious complications or death in patients with acute pancreatitis. Neither the supplementation of enteral nutrition with probiotics nor the use of immunonutrition significantly improves the clinical outcomes.

Nutrition Support in Burns—Is there Consistency in Practice?

Nutrition support is an integral part of the multidisciplinary management of a burn. However, the large body of research has lead to some confusion regarding optimal feeding practices. This review examines nutrition support practices in six United States (U.S.) and seven Australian burns units and compares practice to common themes and options in the literature. The review focuses on the consistency of practice in: managing the hormonal and metabolic changes resulting from a burn injury and their relationship to nutrition; techniques of estimating energy requirements; changes in macronutrient requirements; the use of specialized immune enhancing nutrition; methods of optimizing nutrition support; and methods of monitoring nutritional status and progress. In general, dietitians had a good understanding of the hypermetabolic response and increased nutritional requirements of burns patients. There were several areas where consistency was not seen, such as the fat and carbohydrate content of enteral formulas, the indications for use of total parenteral nutrition, the use of immunonutrition in enteral nutrition, and the most appropriate strategies for peri-operative feeding. This is a reflection of inconclusive research outcomes. There was more consistency in the techniques used for estimation of energy requirements, although more widespread use of indirect calorimetry would be beneficial. The need for high energy and high protein enteral feeds was also recognized across all units studied. The limitations of common nutritional markers was understood and managed by the use of multiple markers.

Fish oil in the critically ill: from experimental to clinical data

The aim of this paper is to describe recent relevant literature concerning the role of n-3 lipids derived from fish oil in clinical nutrition in an intensive care setting. N-3 fatty acids compete with arachidonic acid for metabolism to lipid mediators and exert profound effects on second mediator generation and dependent cellular functions. In experimental models, dietary and parenteral use of fish oil was shown to protect the gut by increasing its perfusion. In contrast, use of immunonutrition including fish oil in critical ill patients or patients with severe sepsis may exert an excess mortality. Using parenteral fish oil in surgical patients promising data became available. In septic patients, immunologic effects of fish oil-based lipid emulsions have been found and intravenous supplementation with fish oil may have a beneficial impact on mortality and length of stay. For both patient groups, however, prospective data from randomized trials are lacking. N-3 lipids exhibit strong immunologic properties. They offer the possibility to counterbalance the negative effects of conventional n-6 fatty acids. Recent studies exhibit positive effects of intravenous use of fish oil on immunologic functions and clinical parameters in surgical and septic patients.

Management of blast injuries and shock lung

Blast injuries have always occurred both in civilian life and as acts of war or terrorism. Nowadays, the risk of being involved in an explosion has increased even for those living in countries with no previous experience of such events. It is our intention that this review is of assistance to those providing emergency/critical care to patients who have sustained blast injuries. Exposure to blast may indirectly produce physiological insults such as bradycardia, hypotension, tissue hypoxia and oxidative stress. The use of early goal-directed therapy might be important in minimizing such insults. Explosions in an enclosed environment are associated with increased risk of pulmonary blast injury and also air and fat embolism. Mechanical ventilation after pulmonary blast injury is associated with barotrauma and the use of lung protective strategies previously recommended in acute lung injury may be beneficial. The potential for blast to cause injury depends on the nature of the explosive and environment in which the blast occurs. Soft tissue injury with environmental contamination is frequent. Optimal antimicrobial cover and strategies such as selective digestive decontamination may be advantageous. Early surgery should follow the principles of 'damage control'. Blast injury often leads to severe sepsis/systemic inflammatory response, multiple organ dysfunction and prolonged critical illness. In this clinical scenario, recent studies have shown improved outcome with the use of activated protein C, steroid replacement and aggressive control of blood glucose but have been less convincing regarding the use of immuno-nutrition.

Arginine Immunonutrition in Critically Ill Patients: A Clinical Dilemma

Commercial enteral nutritional formulas for enhancement of the immune system are widely used in critical care. Immunonutrition with arginine can enhance inflammatory and immunologic responses in animal models and in humans. Although clinical improvements in surgical patients have been reported, benefits in critically ill patients with systemic inflammatory response syndrome, sepsis, or organ failure are less clear. Recent meta-analyses on the use of immunonutrition with arginine in critically ill and surgical patients revealed methodological weaknesses in most published studies. Specifically, a meta-analysis indicated that critically ill patients with preexisting severe sepsis may have an increased mortality rate when fed an immunonutritional enteral formula that contains arginine. These findings brought about confusion and controversy over the use of immunonutritional formulas in subsets of critically ill patients. A review of the literature on the function of arginine, its effect on the immune system, its roles in immunonutrition and in the clinical outcomes of critically ill patients, and the implications for nursing practice indicated that the benefits of immunonutrition with arginine in critically ill patients are unproven and warrant further study. Until more information is available, nutritional support should focus primarily on preventing nutritional deficiencies rather than on immunomodulation.

Protective nutrients

Recognition that specific nutrients can be beneficial when consumed in amounts above the accepted daily requirements has provided a major impetus for the critical examination of dietary approaches with single or multiple nutrient supplements chosen to modulate the inflammatory response, enhance immune function, or improve the blood-gut barrier. Patients suffering the effects of hypercatabolism caused by surgery, cancer, or extensive burns are prime candidates for immunonutrition, as the intervention has come to be known, as are immunosuppressed patients with the human immunodeficiency virus or other overwhelming infections. This review focuses on key nutrients used in clinical trials for which a body of information on the mode of action and metabolic pathways is available. The topics covered include the amino acids, glutamine and arginine; omega-3 fatty acids, eicosapentaenoic acid and docosahexanoic acid; vitamin A; and zinc. Lastly, we address the area of pre- and probiotics and how "friendly" microorganisms are being incorporated into therapeutic regimens aimed at sustaining health. The use of immunonutrition requires judicious consideration of the potential undesirable effects of certain additives in clinical settings where enhanced immune responsiveness can translate into tissue damage and altered mucosal defenses.

Immunonutrition in Critical Illness

Immunonutrition is an emerging therapy that has been the focus of a number of clinical trials. Manipulation of the immune system has the substantial potential to modify disease outcome, particularly in regard to infectious complications. Many studies have examined the effects of nutritional formulas supplemented with arginine, n-3 fatty acids, structured lipids, and nucleotides compared with standard enteral feeding. Unfortunately, because of marked heterogeneity between studies, only limited consensus has been reached. Some randomized studies have shown that immune-enhanced nutritional formulas can reduce postoperative infectious complications in surgical patients with gastrointestinal or head and neck cancer and may be effective when provided preoperatively as well. A few studies show no benefit, but none demonstrated higher infection rates in this population, which is reinforced by the finding from three separate meta-analyses of overall benefit. 1‐3 Therefore, for surgical patients with gastrointestinal/head and neck cancer, the evidence is reasonably strong in favor of the use of immunonutrition, particularly in malnourished patients. In trauma and critically ill patients, the data are less clear, and no overall recommendation in favor of immunonutrition was made recently by Dr Heyland 4 in a review of the evidence (this issue of NCP). There are three large published studies in intensive care unit (ICU) patients, all using the same immune-enhancing diet, which differ in many ways, with only one showing a significant improvement in morbidity and mortality overall. 5‐7 There was a clear trend toward increased mortality with the immune-enhancing diet in the earliest study. 5 Dr

Should immunonutrition become routine in critically ill patients? A systematic review of the evidence.

Several nutrients have been shown to influence immunologic and inflammatory responses in humans. Whether these effects translate into an improvement in clinical outcomes in critically ill patients remains unclear. To examine the relationship between enteral nutrition supplemented with immune-enhancing nutrients and infectious complications and mortality rates in critically ill patients. The databases of MEDLINE, EMBASE, Biosis, and CINAHL were searched for articles published from 1990 to 2000. Additional data sources included the Cochrane Controlled Trials Register from 1990 to 2000, personal files, abstract proceedings, and relevant reference lists of articles identified by database review. A total of 326 titles, abstracts, and articles were reviewed. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of enteral nutrition supplemented with some combination of arginine, glutamine, nucleotides, and omega-3 fatty acids on infectious complication and mortality rates compared with standard enteral nutrition, and included clinically important outcomes, such as mortality. Methodological quality of individual studies was scored and necessary data were abstracted in duplicate and independently. Twenty-two randomized trials with a total of 2419 patients compared the use of immunonutrition with standard enteral nutrition in surgical and critically ill patients. With respect to mortality, immunonutrition was associated with a pooled risk ratio (RR) of 1.10 (95% confidence interval [CI], 0.93-1.31). Immunonutrition was associated with lower infectious complications (RR, 0.66; 95% CI, 0.54-0.80). Since there was significant heterogeneity across studies, we examined several a priori subgroup analyses. We found that studies using commercial formulas with high arginine content were associated with a significant reduction in infectious complications and a trend toward a lower mortality rate compared with other immune-enhancing diets. Studies of surgical patients were associated with a significant reduction in infectious complication rates compared with studies of critically ill patients. In studies of critically ill patients, studies with a high-quality score were associated with increased mortality and a significant reduction in infectious complication rates compared with studies with a low-quality score. Immunonutrition may decrease infectious complication rates but it is not associated with an overall mortality advantage. However, the treatment effect varies depending on the intervention, the patient population, and the methodological quality of the study.