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Rapid Responses: Rapid Responses published:
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Increased mortality associated with immunonutrition in sepsis.
- David JW Knight (22 July 2003)
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Vitamin C
- Philip Stowell (23 July 2003)
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Re: Vitamin C
- Jorge Luis Vázquez cedeño (3 October 2003)
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Immunodietetics
- Rajendra P Deolankar (7 August 2004)
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David JW Knight, Research Fellow Academic Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham, NG7 2UH
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Editor- The review by Calder 1 highlights a number of meta-analysis that suggest a benefit of immunonutrition in the critically ill, however more recent literature does not support this. A number of recent publications looking specifically at the critically ill have shown an increase in mortality in the subgroups of patients suffering from sepsis when they receive immunonutrition 2,3. This point was recently highlighted by interim analysis of a large, ongoing, multicentre Italian immunonutrition trial 3. The data revealed an increased mortality in the severe sepsis and septic shock subgroups and as a result, recruitment of patients with severe sepsis has been stopped. The increase in mortality was even more alarming when we consider that the control group was fed parenterally (associated with an increase in mortality in the critically ill) and had more unfavourable baseline characteristics (age greater than 60 and combined cardiopulmonary failure). Unfortunately most studies use immunutrition mixtures containing multiple ingredients. The Italian study highlighted above, for example, uses a mixture containing L-arginine, omega-3 fatty acids, vitamin E, beta -carotene, zinc and selenium. It is becoming increasingly clear that not all these ingredients are beneficial to all patients. Animal studies would suggest that it is the L-arginine component of this mixture that is primarily responsible for the unfavourable response. The mechanism of this effect is probably secondary to enhanced nitric oxide production 4. Probiotics are also immunonutrients (according to the definition provided by Calder 1) and it is disappointing that no recognition is given to their immune-enhancing properties in the critically ill. Probiotics are live microbial food ingredients that are beneficial to health. ICU research in this area is still in its early stages but preliminary studies have shown mortality benefit in diverse groups of critically ill patients5. The potential mechanisms of these benefits are reduced gut permeability and enhancement of lymphocyte activity. The benefits of immunonutrition in the critically ill have yet to be realised. It may transpire that different individuals require very different immunontrients during critical illness and these requirements may also change within the individual as the disease progresses. In this complex process I hope probiotics are not going to be the forgotten relative of the more commercial immunonutrient cocktails. 1.Calder PC. Immunonutrition. BMJ 2003; 327: 117-118. 2 Bower RH, Cerra FB, Bershadsky B, Licari JJ, Hoyt DB, Jenson GL, et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicentre, prospective, randomised, clinical trial. Crit Care Med 1995; 23(3): 436-49. 3 Bertolini G, Iapichino G, Radrizzani D, Facchini R, Simini B. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomised multicentre clinical trial. Intensive Care Med 2003; 29(5): 834-40. 4. Bruins MJ, Soeters PB, Lamers WH, Meijer AJ, Deutz ME. L-arginine supplementation in hyperdynamic endotoxemic pigs: effect on nitric oxide synthesis by the different organs. Crit Care Med 2002; 30(3): 508-17. 5 Olah A, Belagyi T, Issekutz A, Gammel ME, Bengmark S. Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis. Brit. J. Surgery 2002; 89, 1103-7. Competing interests: None declared |
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Philip Stowell, GP Brisbane
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I was disappointed to see no mention of Vitamin C, Zinc, or probiotics in this article / review that presumably is motivated by a desire to see severely ill patients recover or recover faster. It is my clinical experience along with many other nutritionally trained doctors that IV infusions of Vitamin C significantly improve well being and shorten recovery times in patients that we see in general practice. I accept that this is different from the ICU situation but so often this essential nutrient is forgotten by those trying to help patients fight off infections. It is cheap and non toxic and has no side effects. Competing interests: None declared |
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Jorge Luis Vázquez cedeño, Calle 18 No. 5726 Apart. 10 Entre 57y 59 Nueva Gerona. Isla de la Juventud. Cuba Hospital ¨Héroes del Baire¨ Nueva Gerona PC 25300
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In fact we think the same as Philip Stowell about no mention of Vitamin C in the article; it is very useful and without significant deleterious effects. We work in a unit of critical care and use it in all our sick persons with increase in metabolism and also in all those illnesses in which its oxidant effect on metabolism represents an advantage for the patient. Thank you Dr. Jorge Luis Vázquez Cedeño
Competing interests: None declared |
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Rajendra P Deolankar, Assistant Director National Institute of Virology, 20A Dr. Ambekar Road, Pune 411 001, INDIA
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Immunodietetics The desired immune response can possibly be triggered by certain nutrients. The nutrients contributing to such functionality in an aggregate action of a nutrition support solution have been termed as immunonutrients. The functionality of immunonutrients depends upon disease state or nutritional state. This implies that certain nutrients act as immunonutrients, only in a certain disease state and even could be harmful in other disease states [1]. Diseases could be associated with an impairment of protective antioxidant pathways and under such circumstances e.g. avirulent virus could become virulent because of changes in the viral genome [2]. Modulation of immune response for the benefit of a patient is being termed as immunonutrition. Immunonutrition is provided as a preventive measure to the surgical patients to reduce complications due to infection. Immunonutrition is yet to be evolved to treat the diseases of patients particularly the ones who are immunocompromized and critically ill. The imuunonutrition given parenterally usually encompasses glutamine, w-3 fatty acids, arginine and/or nucleic acids as immunonutrients while enteral preparations in addition to these may contain Prebiotics or Synbiotics. The cost of immunonutrition to non-ICU patients is exorbitant and hence strategy to use some functional foods at this end would be useful. These foods could be rich in immunonutrients or aggregate action of such food might modulate the immune response for the benefit of a patient. The term Immunodietetics is the most appropriate to characterize the diet management using this group of functional foods. The native microbiota of the man is considered as an eco-organ of the body [3]. Prebiotics nourish the eco-organ and hence are nutrients. The approach to use the prebiotics as nutrients in diet formulation and preparation of their composition tables is already described [4]. In fact, raw-fresh vegetables and fruits as a source of immunonutrients are being known long back. This has initiated five a day (five servings of fruits/ vegetables) or five plus a day program in some countries. These foods are source of vitamins and amino acids. These sources have yet to be looked upon as sources of prebiotics. Probiotic bacteria are both factory of immunonutrients and the functional foods. Hyperimmune eggs [5], hyperimmune milk [6], fermented foods [7] and certain herbs could also be instruments to treat dysbiosis, strengthen mucosal barriers, promote cellular defense and reduce local or systemic inflammation. Thus immunodietetics could be useful to treat the patients and also to set the dietary goals to reduce incidence or prevalence of diseases. References: [1] Heyland DK, Novak F. Immunonutrition in the critically ill patient: more harm than good? JPEN J Parenter Enteral Nutr. 2001 Mar-Apr;25(2 Suppl):S51-5; discussion S55-6. (Medline) [2] Beck MA. Nutritionally induced oxidative stress: effect on viral disease. Am J Clin Nutr. 2000 Jun;71(6 Suppl):1676S-81S. (Full Text) [3] Deolankar RP, Weaning/Post-weaning dysbiosis: standardization of assay of dysbiosis is required (21 April 2004), Gut online, e-Letter. (Full Text) [4] Deolankar RP, Prebiotics scores of foods for the formulation of some functional foods (15 March 2004), BMJ Rapid Rapid Response. (Full Text) [5] Sarker SA, Casswall TH, Juneja LR, Hoq E, Hossain I, Fuchs GJ, HammarstromL. Randomized, placebo-controlled, clinical trial of hyperimmunized chicken egg yolk immunoglobulin in children with rotavirus diarrhea. J Pediatr Gastroenterol Nutr. 2001 Jan;32(1):19-25. (Medline) [6] Lilius EM, Marnila P. The role of colostral antibodies in prevention of microbial infections. Curr Opin Infect Dis. 2001 Jun;14(3):295-300. (Medline) [7] Lorri W and Svanberg U. Lower prevalence of diarrhoea in young children fed lactic acid-fermented cereal gruels. Food Nutr Bull, 1994; 15: 57-63. (Full Text)Competing interests: None declared |
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