Aktuelle Ernährungsmedizin 2014; 39(05): 335-351
DOI: 10.1055/s-0034-1387199
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© Georg Thieme Verlag KG Stuttgart · New York

Immunonutrition

Immunonutrition
M. Plauth
Klinik für Innere Medizin, Städtisches Klinikum Dessau
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
06. Oktober 2014 (online)

Zusammenfassung

Mit dem Konzept der Immunonutrition wird die Erwartung verbunden, durch Ernährung mit Anreicherung spezifischer Wirkstoffe den Krankheitsverlauf vor allem bei kritisch Kranken oder chirurgischen Patienten, die oft der enteralen oder parenteralen Ernährung bedürfen, günstig beeinflussen zu können. In diesem Artikel wird eine Übersicht zu den jeweils zugrunde liegenden pathophysiologischen Vorstellungen und zu den mehr oder weniger gesicherten Indikationen für diese ernährungstherapeutische Strategie gegeben.

Abstract

The concept of immunonutrition has evolved from the idea of improving disease outcome in critically ill or surgical patients by nutritional intervention using enteral formulae or parenteral solutions enriched with specific nutrients. In this article the underlying pathophysiological concepts and the more or less agreed upon indications for such a nutritional strategy are reviewed.

 
  • Literatur

  • 1 Calder PC. Immunonutrition may have beneficial effects in surgical patients. BMJ 2003; 327: 117-118
  • 2 Mizock BA. Immunonutrition and critical illness: An update. Nutrition 2010; 26: 701-707
  • 3 Weimann A. Immunonutrition in der Intensivmedizin. Med Klin Intensivmed Notfmed 2013; 108: 85-95
  • 4 Heyland DK, Dhaliwal R. Immunonutrition in the critically ill: from old approaches to new paradigms. Intensive Care Med 2005; 31: 501-503
  • 5 Jones NE, Heyland DK. Pharmaconutrition: a new emerging paradigm. Curr Opin Gastroenterol 2008; 24: 215-222
  • 6 Dupertuis YM, Meguid MM, Pichard C. Advancing from immunonutrition to a pharmaconutrition: a gigantic challenge. Curr Opin Clin Nutr Metab Care 2009; 12: 398-403
  • 7 Fürst P, Stehle P. Glutaminzufuhr in der parenteralen Ernährungstherapie. Aktuel Ernahrungsmed 1995; 20: 89-97
  • 8 Windmueller HG, Spaeth AE. Uptake and metabolism of plasma glutamine by the small intestine. J Biol Chem 1974; 249: 5070-5079
  • 9 Newsholme EA, Crabtree B, Ardawi MSM. Glutamine metabolism in lymphocytes: Its biochemical physiological and clinical importance. Quart J Exp Physiol 1985; 70: 473-489
  • 10 Plauth M, Roske A-E, Romaniuk P et al. Post-Feeding Hyperammonemia in Patients with Transjugular Intrahepatic Portosystemic Shunt and Liver Cirrhosis: Role of Small Intestinal Ammonia Release and Route of Nutrient Administration. Gut 2000; 46: 849-855
  • 11 Windmueller HG, Spaeth AE. Source and fate of circulating citrulline. Am J Physiol 1981; 241: E473-E480
  • 12 Van de Poll MCG, Siroen MPC, van Leeuwen PAM et al. Interorgan amino acid exchange in humans: consequences for arginine and citrulline metabolism. Am J Clin Nutr 2007; 85: 167-172
  • 13 Van de Poll MCG, Ligthart-Melis GC, Boelens PG et al. Intestinal and hepatic metabolism of glutamine and citrulline in humans. J Physiol 2007; 581: 819-827
  • 14 Ligthart-Melis GC, van de Poll MCG, Boelens PG et al. Glutamine is an important precursor for de novo synthesis of arginine in humans. Am J Clin Nutr 2008; 87: 1282-1289
  • 15 Ligthart-Melis GC, van de Poll MC, Dejong CH et al. The route of administration (enteral or parenteral) affects the conversion of isotopically labeled L-[2-15N]glutamine into citrulline and arginine in humans. J Parenter Enteral Nutr 2007; 31: 343-348
  • 16 Ligthart-Melis GC, van de Poll MCG, Vermeulen MAR et al. Enteral administration of alanyl-[2-15N]glutamine contributes more to the de novo synthesis of arginine than does intravenous infusion of the dipeptide in humans. Am J Clin Nutr 2009; 90: 95-105
  • 17 Vermeulen MAR, van de Poll MCG, Ligthart-Melis GC et al. Specific amino acids in the critically ill patient – Exogenous glutamine/arginine: A common denominator?. Crit Care Med 2007; 35 (Suppl. 09) 568-576
  • 18 Oudemans-van Straaten HM, Bosman RJ, Treskes M et al. Plasma glutamine depletion and patient outcome in acute ICU admissions. Intensive Care Med 2001; 27: 84-90
  • 19 Rodas PC, Rooyackers O, Hebert C et al. Glutamine and glutathione at ICU admission in relation to outcome. Clin Sci 2012; 122: 591-597
  • 20 Parry-Billings M, Evans J, Calder PC et al. Does glutamine contribute to immunosuppression after major burns?. Lancet 1990; 336: 523-525
  • 21 Griffiths RD, Andrews F. Glutamine: a life-threatening deficiency in the critically ill?. Intensive Care Med 2001; 27: 12-15
  • 22 Schulman AS, Willcutts KF, Claridge JA et al. Does the addition of glutamine to enteral feeds affect patient mortality?. Crit Care Med 2005; 33: 2501-2506
  • 23 Andrews PJD, Avenell A, Noble DW et al. and the SIGNET Trials Group. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. BMJ 2011; 342: d1542
  • 24 Heyland D, Muscedere J, Wischmeyer PE et al. Canadian Critical Care Trials Group. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368: 1489-1497
  • 25 Van den Berghe G. Low glutamine levels during critical illness – adaptive or maladaptive?. N Engl J Med 2013; 368: 1549-1550
  • 26 Roth E. Immune and cell modulation by amino acids. Clin Nutr 2007; 26: 535-544
  • 27 McCowen KC, Bistrian BR. Immunonutrition: problematic or problem solving?. Am J Clin Nutr 2003; 77: 764-770
  • 28 Luiking YC, Ten Have GAM, Wolfe RR et al. Arginine de novo and nitric oxide production in disease states. Am J Physiol Endocrinol Metab 2012; 303: E1177-E1189
  • 29 Caparros T, Lopez J, Grau T. Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. J Parenter Enteral Nutr 2001; 25: 299-308
  • 30 Heyland DK, Novak F, Drover JW et al. Should Immunonutrition Become Routine in Critically Ill Patients? A Systematic Review of the Evidence. JAMA 2001; 286: 944-953
  • 31 Bai Y, Sun L, Yang T et al. Increase in fasting vascular endothelial function after short-term oral L-arginine is effective when baseline flow-mediated dilation is low: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2009; 89: 77-84
  • 32 Schwab JM, Chiang N, Arita M et al. Resolvin E1 and Protectin D1 Activate Inflammation-Resolution Programs. Nature 2007; 447: 869-874
  • 33 Russell CD, Schwarze J. The role of pro-resolution lipid mediators in infectious disease. Immunology 2014; 141: 166-173
  • 34 Moore FA, Moore EE, Kudsk KA et al. Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding. J Trauma 1994; 37: 607-615
  • 35 Mendez C, Jurkovich GJ, Garcia I et al. Effects of an immune-enhancing diet in critically injured patients. J Trauma 1997; 42: 933-940
  • 36 Kudsk KA, Minard G, Croce MA et al. A randomized trial of isoni-trogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996; 224: 531-540
  • 37 Weimann A, Bastian L, Bischoff WE et al. Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma. Nutrition 1998; 14: 165-172
  • 38 Plank LD, McCall JL, Gane EJ et al. Pre- and postoperative immunonutrition in patients undergoing liver transplantation: a pilot study of safety and efficacy. Clin Nutr 2005; 25: 288-296
  • 39 Plank LD, Mathur S, Gane EJ et al. Perioperative immunonutrition in liver transplantation: results of a double-blind randomized controlled trial. Clin Nutr 2010; 5 (Suppl. 02) 3
  • 40 Weimann A, Braga M, Harsanyi L et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006; 25: 224-244
  • 41 Weimann A, Breitenstein S, Breuer JP et al. und das DGEM Steering Committee. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der GESKES, der AKE, der DGCH, der DGAI und der DGAV: Klinische Ernährung in der Chirurgie. Aktuel Ernahrungsmed 2013; 38: e155-e197
  • 42 Braga M, Gianotti L, Nespoli L et al. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 2002; 137: 174-180
  • 43 Braga M, Gianotti L, Radaelli G et al. Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Arch Surg 1999; 134: 428-433
  • 44 Senkal M, Zumtobel V, Bauer KH et al. Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study. Arch Surg 1999; 134: 1309-1316
  • 45 Tepaske R, Velthuis H, Oudemans-van Straaten HM et al. Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial. Lancet 2001; 358: 696-701
  • 46 Braga M, Gianotti L, Vignali A et al. Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 2002; 132: 805-814
  • 47 Gianotti L, Braga M, Nespoli L et al. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterol 2002; 122: 1763-1770
  • 48 Stableforth WD, Thomas S, Lewis SJ. A systematic review of the role of immunonutrition in patients undergoing surgery for head and neck cancer. Int J Oral Maxillofac Surg 2009; 38: 103-110
  • 49 Marik PE, Zaloga GP. Immunonutrition in high­risk surgical patients: a systematic review and analysis of the literature. J Parenter Enteral Nutr 2010; 34: 378-386
  • 50 Marimuthu K, Varadhan KK, Ljungqvist O et al. A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 2012; 255: 1060-1068
  • 51 Giger U, Büchler M, Farhadi J et al. Preoperative immunonutrition suppresses perioperative inflammatory response in patients with major abdominal surgery – a randomized controlled pilot study. Ann Surg Oncol 2007; 14: 2798-2806
  • 52 Bower RH, Cerra FB, Bershadsky B et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 1995; 23: 436-449
  • 53 Galban C, Montejo JC, Mesejo A et al. An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 2000; 28: 643-648
  • 54 Atkinson S, Sieffert E, Bihari D. A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Guy’s Hospital Intensive Care Group. Crit Care Med 1998; 26: 1164-1172
  • 55 Kreymann KG, Berger MM, Deutz NEP et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006; 25: 210-223
  • 56 Marik PE, Zaloga GP. Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive Care Med 2008; 34: 1980-1990
  • 57 Singer P, Shapiro H. Enteral omega-3 in acute respiratory distress syndrome. Curr Opin Clin Nutr Metab Care 2009; 12: 123-128
  • 58 Gadek JE, DeMichele SJ, Karlstad MD et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med 1999; 27: 1409-1420
  • 59 Singer P, Theilla M, Fisher H et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med 2006; 34: 1033-1038
  • 60 Pontes-Arruda A, Aragão AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 2006; 34: 2325-2333
  • 61 Grau-Carmona T, Morán-García V, García-de-Lorenzo A et al. Effect of an enteral diet enriched with eicosapentaenoic acid, gamma-linolenic acid and anti-oxidants on the outcome of mechanically ventilated, critically ill, septic patients. Clin Nutr 2011; 30: 578-584
  • 62 Rice TW, Wheeler AP, Thompson BT et al. NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA 2011; 306: 1574-1581
  • 63 Sultan J, Griffin SM, Di Franco F et al. Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery. Br J Surg 2012; 99: 346-355
  • 64 Heller AR, Rössler S, Litz RJ et al. Omega-3 fatty acids improve the diagnosis-related clinical outcome. Crit Care Med 2006; 34: 972-979
  • 65 Wohlmuth C, Dünser MW, Wurzinger B et al. Early fish oil supplementation and organ failure in patients with septic shock from abdominal infections: a propensity-matched cohort study. J Parenter Enteral Nutr 2010; 34: 431-437
  • 66 Chen B, Zhou Y, Yang P et al. Safety and efficacy of fish oil-enriched parenteral nutrition regimen on postoperative patients undergoing major abdominal surgery: a meta-analysis of randomized controlled trials. J Parenter Enteral Nutr 2010; 34: 387-394
  • 67 Pradelli L, Mayer K, Muscaritoli M et al. n-3 fatty acid-enriched parenteral nutrition regimens in elective surgical and ICU patients: a meta-analysis. Crit Care 2012; 16: R184
  • 68 Wirtitsch M, Wessner B, Spittler A et al. Effect of different lipid emulsions on the immunological function in humans: A systematic review with meta-analysis. Clin Nutr 2007; 26: 302-313
  • 69 Singer P, Berger MM, van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clin Nutr 2009; 28: 387-400
  • 70 Arends J. Ernährung von Tumorpatienten. Aktuel Ernahrungsmed 2012; 37: 91-106
  • 71 Turner D, Zlotkin SH, Shah PS et al. Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev 2007; (02) CD006320
  • 72 Turner D, Steinhart AH, Griffiths AM. Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev 2007; (03) CD006443
  • 73 Feagan BG, Sandborn WJ, Mittmann U et al. Omega-3 free fatty acids for the maintenance of remission in Crohn disease: the EPIC Randomized Controlled Trials. JAMA 2008; 299: 1690-1697
  • 74 Meier R. Ernährung bei chronisch entzündlichen Darmerkrankungen (CED). Aktuel Ernahrungsmed 2012; 37: 349-362
  • 75 Marchioli R, Barzi F, Bomba E et al. and on behalf of the GISSI-Prevenzione Investigators. Early Protection Against Sudden Death by n-3 Polyunsaturated Fatty Acids After Myocardial Infarction: Time-Course Analysis of the Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI)-Prevenzione. Circulation 2002; 105: 1897-1903
  • 76 GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet 2008; 372: 1223-1230
  • 77 Einvik G, Klemsdal TO, Sandvik L et al. A randomized clinical trial on n-3 polyunsaturated fatty acids supplementation and all-cause mortality in elderly men at high cardiovascular risk. Eur J Cardiovasc Prev Rehabil 2010; 17: 588-592
  • 78 The Risk and Prevention Study Collaborative Group. n-3 Fatty Acids in Patients with Multiple Cardiovascular Risk Factors. N Engl J Med 2013; 368: 1800-1808
  • 79 Heidt MC, Vician M, Stracke SK et al. Beneficial effects of intravenously administered N-3 fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a prospective randomized study. Thorac Cardiovasc Surg 2009; 57: 276-280
  • 80 Berry JD, Prineas RJ, van Horn L et al. Dietary fish intake and incident atrial fibrillation (from the Women's Health Initiative). Am J Cardiol 2010; 105: 844-848
  • 81 Stehle P, Zander J, Mertes N et al. Effect of parenteral glutamine peptide supplements on muscle glutamine loss and nitrogen balance after major surgery. Lancet II 1989; 231-233
  • 82 Hammarqvist F, Wernerman J, Ali R et al. Addition of glutamine to total parenteral nutrition after elective abdominal surgery spares free glutamine in muscle, counteracts the fall in muscle protein synthesis, and improves nitrogen balance. Ann Surg 1989; 209: 455-461
  • 83 van der Hulst RRW, van Kreel BK, von Meyenfeldt MF et al. Glutamine and the preservation of gut integrity. Lancet 1993; 341: 1363-1365
  • 84 Tremel H, Kienle B, Weilemann LS et al. Glutamine dipeptide-supplemented parenteral nutrition maintains intestinal function in the critically ill. Gastroenterol 1994; 107: 1595-1601
  • 85 Bakalar B, Duska F, Pachl J et al. Parenterally administered dipeptide alanyl-glutamine prevents worsening of insulin sensitivity in multiple-trauma patients. Crit Care Med 2006; 34: 381-386
  • 86 Ziegler TR, Young LA, Benfell K et al. Clinical and metabolic efficacy of glutamine-supplemented parenteral nutrition after bone marrow transplantation. Ann Intern Med 1992; 116: 821-828
  • 87 Schloerb P, Ammare M. Total parenteral nutrition with glutamine in bone marrow transplantation and other clinical applications (a randomized, double-blind study). J Parenter Enteral Nutr 1993; 17: 407-413
  • 88 Powell-Tuck J, Jamieson CP, Bettany GE et al. A double blind, randomised, controlled trial of glutamine supplementation in parenteral nutrition. Gut 1999; 45: 82-88
  • 89 Wischmeyer PE, Lynch J, Liedel J et al. Glutamine administration reduces Gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control. Crit Care Med 2001; 29: 2075-2080
  • 90 Fuentes-Orozco C, Anaya-Prado R, González-Ojeda A et al. L-Alanyl-L-glutamine-supplemented parenteral nutrition improves infectious morbidity in secondary peritonitis. Clin Nutr 2004; 23: 13-21
  • 91 Déchelotte P, Hasselmann M, Cynober L et al. L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study. Crit Care Med 2006; 34: 598-604
  • 92 Fuentes-Orozco C, Cervantes-Guevara G, Muciño-Hernández I et al. L-Alanyl-L-Glutamine-supplemented parenteral nutrition decreases infectious morbidity rate in patients with severe acute pancreatitis. J Parenter Enteral Nutr 2008; 32: 403-411
  • 93 Grau T, Bonet A, Minambres E et al. The effect of L-alanyl-L-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients. Crit Care Med 2011; 39: 1263-1268
  • 94 Griffiths RD, Jones C, Palmer TEA. Six-month outcome of critically ill patients given glutamine-supplemented parenteral nutrition. Nutrition 1997; 13: 295-302
  • 95 Goeters C, Wenn A, Mertes N et al. Parenteral L-alanyl-L-glutamine improves 6-month outcome in critically ill patients. Crit Care Med 2002; 30: 2032-2037
  • 96 Wernerman J, Kirketeig T, Andersson B et al. and Scandinavian Critical Care Trials Group. Scandinavian glutamine trial: a pragmatic multi-centre randomised clinical trial of intensive care unit patients. Acta Anaesthesiol Scand 2011; 55: 812-818
  • 97 Novak F, Heyland DK, Avenell A et al. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med 2002; 30: 2022-2029
  • 98 Canadian Critical Care Clinical Practice Guidelines Committee. Nutritional support in mechanically ventilated critically ill adult patients. (2009 Update). Im Internet: http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Stand: 04.09)
  • 99 Kreymann G, Adolph M, Druml W et al. Leitlinie Parenterale Ernährung der DGEM. Intensivmedizin. Aktuel Ernahrungsmed 2007; 32: 89-92
  • 100 Peterson B, Waller S-O, Vinnars E et al. Long-term effect od glycylglutamine after elective surgery on free amino acids in muscle. J Parenter Enteral Nutr 1994; 18: 320-325
  • 101 van Zaanen HCT, van der Lelie H, Timmer JG et al. Parenteral glutamine dipeptide supplementation does not ameliorate chemotherapy-induced toxicity. Cancer 1994; 74: 2879-2884
  • 102 Heyland DK, Dhaliwal R, Drover JW et al. and the Canadian Critical Care Clinical Practice Guidelines Committee. Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parent Enteral Nutr 2003; 27: 355-373
  • 103 Houdijk AP, Rijnsburger ER, Jansen J et al. Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma. Lancet 1998; 352: 772-776
  • 104 Wang Y, Jiang ZM, Nolan MT et al. The impact of glutamine dipeptide-supplemented parenteral nutrition on outcomes of surgical patients: a meta-analysis of randomized clinical trials. J Parenter Enteral Nutr 2010; 34: 521-529
  • 105 van Gossum A, Cabrè E, Hébuterne X et al. ESPEN Guidelines on Parenteral Nutrition: Gastroenterology. Clin Nutr 2009; 28: 415-427
  • 106 Beale RJ, Sherry T, Lei K et al. Early enteral supplementation with key pharmaconutrients improves Sequential Organ Failure Assessment score in critically ill patients with sepsis: outcome of a randomized, controlled, double-blind trial. Crit Care Med 2008; 36: 131-144