Aktuelle Ernährungsmedizin 2002; 27(4): 205-215
DOI: 10.1055/s-2002-33352
Originalarbeit
© Georg Thieme Verlag Stuttgart · New York

Enterale Immunonutrition: wann, für wen, welche Zukunftsperspektiven gibt es?

Enteral Immunonutrition: When to Administer, who May Benefit, what are the Future Perspectives?U.  Suchner1
  • 1Fresenius Kabi Deutschland GmbH
Manuskript nach einem Vortrag auf dem Kongress „Ernährung und Immunsystem” 15./16. 2. 2002 in Berlin
Further Information

Publication History

Publication Date:
14 August 2002 (online)

Zusammenfassung

Eine zunehmende Anzahl aktueller klinischer Studien zur Evaluierung immunmodulierender enteraler Nährlösungen weisen auf eine günstige Beeinflussung definierter klinischer Endpunkte hin. Diese enteralen Nährlösungen werden mit einer Verringerung des Infektionsrisikos, einer Verkürzung der Beatmungszeit am Respirator sowie mit einer Reduktion des Aufenthalts auf der Intensivstation oder in der Klinik in Zusammenhang gebracht. Methodische Schwächen mancher dieser Untersuchungen sowie die Befunde aktueller Studien mahnen jedoch zur Vorsicht, was verallgemeinernde Empfehlungen zur klinischen Anwendung der enteralen Immunonutrition angeht. Zwar wurden an einem vorwiegend operativen Krankengut positive Resultate aufgezeigt, wobei jedoch nur bei denjenigen Patienten günstige Verläufe zu beobachten waren, bei denen eine kritische Mindestmenge der angebotenen enteralen Nährlösungen toleriert wurde. Zudem sind diese positiven Befunde nicht uneingeschränkt auf alle Patientenpopulationen übertragbar. Einige der Studien weisen darauf hin, dass kritisch Kranke mit schwersten Verlaufsformen von systemischer Inflammation (SIRS), Sepsis und konsekutivem Organversagen nicht von den derzeit verfügbaren enteralen Diäten zur Immunmodulation profitieren und unter Umständen sogar Schaden von deren Anwendung nehmen können. Mögliche Unzulänglichkeiten gegenwärtig verfügbarer Konzepte zur Immunonutrition bei kritisch kranken Patienten können wie folgt zusammengefasst werden: 1. inadäquate Bilanzierung von „Schlüsselsubstraten” bei eingeschränkter Toleranz der enteralen Ernährung; 2. mangelnde Prävention und Therapie gastrointestinaler Motilitätsstörungen; 3. mangelnde Prävention mukosaler Schädigungen durch den Einfluss freier Radikale; 4. Zufuhr immunmodulierender Substrate mit proinflammatorischen und radikalgenerierenden Wirkungen während schwerster hyperinflammatorischer Zustandsbilder. Während der Einsatz derzeit verfügbarer immunmodulierender Nährlösungen zur perioperativen Gabe bei mangelernährten Patienten sowie nach schweren Traumen empfohlen werden kann, sollte zukünftig die gezielte experimentelle und klinische Evaluierung neuer Konzepte zur enteralen Immunonutrition während schwerer Verlaufsformen von SIRS, Sepsis und Organversagen unter Berücksichtigung der genannten Kritikpunkte erfolgen.

Abstract

Numerous trials evaluating immune-enhancing diets suggest several beneficial clinical effects. These diets were shown to be associated with a reduction in infectious complications, ventilator days, ICU and hospital stay. However, methodological weaknesses of some of these studies as well as the results of recent publications give rise for concerns and may limit the inferences we can derive from these data. In particular, improvements in outcome were largely seen in surgical patients and in patients who tolerated critical amounts of formula. We posit that the beneficial findings cannot easily be extrapolated to other patient populations since there is suggestion from clinical trials that the sickest patients, especially those with severest appearances of sepsis, shock and organ failure, may not benefit or may even be harmed. We therefore hypothesise that currently available immune enhancing diets may not be suitable for this particular patient population. Potential limitations of currently available concepts for enteral immunonutrition in critically ill patients are to be summarized as follows: 1) inadequate provision of „key nutrients” via the enteral route while enteral feeding tolerance becomes significantly impaired; 2) inadequate prevention of intestinal motility disorders; 3) insufficient measures to fight free radical induced damage of the intestinal mucosal barrier; 4) administration of pro-inflammatory and radical generating substrates in patients presenting with severe appearances of a systemic inflammatory response syndrome (SIRS). In conclusion, the use of immune enhancing diets can be recommended in the perioperative period, in particular if patients are subjected to both malnutrition and operative stress as well as in the post trauma period not complicated by severe SIRS or sepsis. In patients with severe appearances of SIRS or sepsis, however, new concepts in enteral immunonutrition should be evaluated in the experimental and clinical setting whereas the potential limitations of currently available diets should be considered adequately.

Literatur

  • 1 Suchner U, Kuhn K S, Fürst P. The scientific basis of immunonutrition.  Proceedings of the Nutrition Society. 2000;  59 1-11
  • 2 v Ruecker A, Schmidt-Wolf I GH. Strategies to evaluate metabolic stress and catabolism by means of immunological variables.  Clinical Nutrition. 2000;  19 147-156
  • 3 Daly J M, Liebermann M D, Goldfine J, Shou J, Weintraub F, Rosato E F, Lavin P. Enteral nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after operation: Immunologic, metabolic, and clinical outcome.  Surgery. 1992;  112 56-67
  • 4 Moore F A, Moore E E, Kudsk K A, Brown R O, Bower R H, Koruda M J, Baker C C, Barbul A. Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding.  The Journal of Trauma. 1994;  37 607-614
  • 5 Kemen M, Senkal M, Homann H H. Early postoperative enteral nutrition with arginine, n-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact.  Crit Care Med. 1995;  23 652-659
  • 6 Cerra F B. Nutrient modulation of inflammatory and immune function.  Am J Surgery. 1991;  161 230-234
  • 7 Heyland D K, Cook D J, Guyatt G H. Does the formulation of enteral feeding products influence infectious morbidity and mortality rates in the critically ill patient? A critical review of the evidence.  Crit Care Med. 1994;  22 1192-1202
  • 8 Zaloga G P. Immune-enhancing enteral diets: Where's the beef?.  Crit Care Med. 1998;  25 1143-1146
  • 9 Beale J R, Bryg D J, Bihari D J. Immunonutrition in the critically ill: A systematic review of clinical outcome.  Crit Care Med. 1999;  27 2799-2805
  • 10 Heys S D, Walker L G, Smith I, Eremin O. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials.  Annals of Surgery. 1999;  229 467-477
  • 11 Heyland D K, Novak F, Drover J W, Jain M, Su X, Suchner U. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence.  JAMA. 1999;  286 944-953
  • 12 Atkinson S, Sieffert E, Bihari D J. A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill.  Crit Care Med. 1998;  26 1164-1172
  • 13 Nelson L D. Death knell for parenteral nutrition?.  Crit Care Med. 1998;  26 24-30
  • 14 Galban C, Montejo J C, Mesejo A, Marco P, Celaya S, Sanchez-Segura J M, Farre M, Bryg D J. 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
  • 15 Senkal M, Mumme A, Eickhoff U, Geier B, Späth G, Wulfert D, Joosten U, Frei A, Kemen M. Early postoperative enteral immunonutrition: Clinical outcome and cost-comparison analysis in surgical patients.  Crit Care Med. 1999;  25 1489-1495
  • 16 Saffle J R, Wiebke G, Jennings K, Morris S E, Barton R G. Randomized trial of immune-enhancing enteral nutrition in burn patients.  The Journal of Trauma. 1997;  42 793-802
  • 17 Mendez C, Jurkovich G J, Garcia I, Davis D, Parker A, Maier R V. Effects of an immune-enhancing diet in critically injured patients.  The Journal of Trauma. 1997;  42 933-941
  • 18 Mendez C, Jurkovich G J, Wener M H, Garcia I, Mays M, Maier R V. Effects of supplemental dietary arginine, canola oil, and trace elements on cellular immune function in critically injured patients.  Shock. 1996;  6 7-12
  • 19 Bower R H, Cerra F B, Bershadsky B, Licari J J, Hoyt D B, Jensen G L, Van Buren C T, Rothkopf M M, Daly J M, Adelsberg B R. 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
  • 20 Consensus Recommendations From the U.S. Summit on Immune-Enhancing Enteral Therapy. JPEN 2001 25: 61-63
  • 21 Kudsk K A, Minard G, Guyatt G H. A randomized trial of isonitrogenous enteral diets after severe trauma: An immune-enhancing diet in critically injured patients.  Ann Surg. 1996;  224 531-543
  • 22 Braga M, Gianotti L, Radaelli G, Vignali A, Mari G, Gentilini O, Di Carlo V. Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial.  Arch Surg. 1999;  134 428-433
  • 23 Gadek J E, DeMichele S J, Karlstad M D. Effect of enteral feeding with eicosapentaenoic acid, -y-linoleic acid, and antioxidants in patients with acute respiratory distress syndrome.  Crit Care Med. 1999;  27 1409-1420
  • 24 Senkal M, Zumtobel V, Bauer K H, Marpe B, Wolfram G, Frei A, Eickhoff U, Kemen M. 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
  • 25 Snyderman C H, Kachman K, Molseed L, Wagner R, D'Amico F, Bumpous J, Rueger R. Reduced postoperative infections with an immune-enhancing nutritional supplement.  Laryngoscope. 1999;  109 915-921
  • 26 Tepaske R, Velthuis H, Oudemans-van Straaten H M, Heisterkamp S H, van Deventer S J, Ince C, Eysman L, Kesecioglu J. 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
  • 27 Suchner U, Felbinger T W. Enterale, minimal enterale, parenterale Ernährung - Vorteile einer enteralen Ernährungsstrategie. In: Löser C, Keymling M Praxis der enteralen Ernährung - Indikationen - Technik - Nachsorge. Stuttgart; Thieme Verlag 2001 4: 32-40
  • 28 Felbinger T W, Goetz A E, Suchner U. Enterale Ernährung: Wunsch und Wirklichkeit - Probleme bei der Durchführung der enteralen Ernährung und deren Therapie.  Intensiv- und Notfallbehandlung. 2000;  25 53-72
  • 29 Bone R C. Sir Isaac Newton, sepsis, SIRS, CARS.  Crit Care Med. 1996;  24 1125-1128
  • 30 Montejo J C. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units.  Crit Care Med. 1999;  27 1447-1453
  • 31 Adam S, Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK.  Intensive Care Med. 1997;  23 261-266
  • 32 McClave S A, Sexton L K, Spain D A, Adams J L, Owens N A, Sullins M B, Blandford B S, Snider H L. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.  Crit Care Med. 1999;  27 1252-1256
  • 33 Wächtershäuser A, Stein J. Rationale for the luminal provision of butyrate in intestinal diseases.  Eur J Nutr. 2000;  39 171
  • 34 Richardson A, Delbridge A T, Brown N J, Rumsey R D, Read N W. Short chain fatty acids in the terminal ileum accelerate stomach to caecum transit time in the rat.  Gut. 1991;  32 266-269
  • 35 Cherbut C, Aubé A C, Blottière H M, Galmiche J P. Effects of short-chain fatty acids on gastrointestinal motility.  Scand J Gastroenterol. 1997;  32 58-61
  • 36 Edwarts C A. Production and effects on gut motility. In: Kritchevsky, Bonfielde Dietary fibre in health and disease. New York; Plenum Press 1992: 155-167
  • 37 Curran F J, Sattar N, Talwar D, Baxter J N, Imrie C W. Relationship of carotenoid and vitamins A and E with the acute inflammatory response in acute pancreatitis.  Br J Surg. 2000;  87 301-305
  • 38 Metnitz P G, Bartens C, Fischer M, Fridrich P, Steltzer H, Druml W. Antioxidant status in patients with acute respiratory distress syndrome.  Intensive Care Med. 1999;  25 180-185
  • 39 Kharb S, Ghalaut V S, Ghalaut P S. Alpha tocopherol concentration in serum of critically ill patients.  J Assoc Physicians India. 1999;  47 400-402
  • 40 Berger M M, Cavadini C, Chiolero R, Dirren H. Copper, selenium, and zinc status and balances after major trauma.  J Trauma. 1996;  40 103-109
  • 41 Schorah C J, Downing C, Piripitsi A, Gallivan L, Al-Hazaa A H, Sanderson M J, Bodenham A. Total vitamin C, ascorbic acid, and dehydroascorbic acid concentrations in plasma of critically ill patients.  Am J Clin Nutr. 1996;  63 760-765
  • 42 Borrelli E, Roux-Lombard P, Grau G E, Girardin R, Ricou B, Dayer J, Suter P M. Plasma concentrations of cytokines, their soluble receptors, and antioxidant vitamins can predict the development of multiple organ failure in patients at risk.  Crit Care Med. 1996;  24 392-397
  • 43 Goode H F, Cowley H C, Walker B E, Walker B E, Howdle P D, Webster N R. Decreased antioxidant status and increased lipid peroxidation in patients with septic shock and secondary organ dysfunction.  Crit Care Med. 1995;  23 646-651
  • 44 Takeda K, Shimada Y, Amano M, Sakai T, Okada T, Yoshiya I. Plasma lipid peroxides and alpha-tocopherol in critically ill patients.  Crit Care Med. 1984;  12 957-959
  • 45 Galley H F, Howdle P D, Walker B E, Webster N R. The effects of intravenous antioxidants in patients with septic shock.  Free Radic Biol Med. 1997;  23 768-774
  • 46 Goode H F, Webster N R, Howdle P D, Leek J P, Lodge J P, Sadek S A, Walker B E. Reperfusion injury, antioxidants and hemodynamics during orthotopic liver transplantation.  Hepatology. 1994;  19 354-359
  • 47 Forceville X, Vitoux D, Gauzit R, Combes A, Lahilaire P, Chappuis P. Selenium, systemic immune response syndrome, sepsis, and outcome in critically ill patients.  Crit Care Med. 1998;  26 1536-1544
  • 48 Hawker F H, Stewart P M, Snitch P J. Effects of acute illness on selenium homeostasis.  Crit Care Med. 1990;  18 442-446
  • 49 Gosling P, Rothe H M, Sheehan T M, Hubbard L D. Serum copper and zinc concentrations in patients with burns in relation to burn surface area.  J Burn Care Rehabil. 1995;  16 481-486
  • 50 Richard C, Lemonnier F, Thibault M, Couturier M, Auzepy P. Vitamin E deficiency and lipoperoxidation during adult respiratory distress syndrome.  Crit Care Med. 1990;  18 4-9
  • 51 Ogilvie A C, Groeneveld A B, Straub J P, Thijs L G. Plasma lipid peroxides and antioxidants in human septic shock.  Intensive Care Med. 1991;  17 40-44
  • 52 Cowley H C, Bacon P J, Goode H F, Webster N R, Jones J G, Menon D K. Plasma antioxidant potential in severe sepsis: a comparison of survivors and nonsurvivors.  Crit Care Med. 1996;  24 1179-1183
  • 53 Young B, Ott L, Kasarskis E, Rapp R, Moles K, Dempsey R J, Tibbs P A, Kryscio R, McClain C. Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury.  J Neurotrauma. 1996;  13 25-34
  • 54 Berger M M, Chiolero R. Relations between copper, zinc and selenium intakes and malondialdehyde excretion after major burns.  Burns. 1995;  21 507-512
  • 55 Berger M M, Spertini F, Shenkin A, Wardle C, Wiesner L, Schindler C, Chiolero R L. Trace element supplementation modulates pulmonary infection rates after major burns: a double blind, placebo controlled trial.  Am J Clin Nutr. 1998;  68 365-371
  • 56 Tanaka H, Matsuda T, Miyagantani Y, Yukioka T, Matsuda H, Shimazaki S. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration.  Arch Surg. 2000;  135 326-331
  • 57 Angstwurm M W, Schottdorf J, Schopohl J, Gaertner R. Selenium replacement in patients with severe systemic inflammatory response syndrome improves clinical outcome.  Crit Care Med. 1999;  27 1807-1813
  • 58 Porter J M, Ivatury R R, Azimuddin K, Swami R. Antioxidant therapy in the prevention of organ dysfunction syndrome and infectious complications after trauma: Early results of a prospective randomized study.  Am Surg. 1999;  65 478-483
  • 59 Kelly F. Vitamin E supplementation in the critically ill patient: too narrow a view?.  NCP. 1994;  9 19-25
  • 60 Packer L. Interactions among antioxidants in health and disease: Vitamin E and its redex cycle.  Proc Soc Exp Biol Med. 1992;  200 271-276
  • 61 Doba T, Burton G W, Ingold K U. Antioxidant and co-antioxidant activity of vitamin C. The effect of vitamin C either alone or in the presence of vitamine E or a water soluble Vitamin E analogue, upon the peroxidation of aqueous multilaminar phospholipid liposomes.  Biochem Biophys Data. 1985;  835 298-302
  • 62 Roger C R. The nutritional incidence of flavonoids: some physiological and metabolic considerations.  Experientia. 1988;  44 725-804
  • 63 Stocker R, Frei B. Oxidants and antioxidants. London; Academic Press 1991: 213-243
  • 64 Sies H, Stahl W. Antioxidant functions of vitamins: Vitamin E and C, Beta-carotene, and other carotenoids.  Ann NY Acad Sci. 1992;  669 7-20
  • 65 Vile G F, Winterbourn C C. Inhibition of adriamycin-promoted microsomal lipid peroxidation by β-carotene, α-tocopherol and retinol at high and low oxygen partial pressures.  FIBS-utt. 1988;  238 353-356
  • 66 Burton G W. Antioxidant action of carotenoids.  J Nutr. 1989;  119 109-111
  • 67 Hammarqvist F, Luo J L, Cotgreave I A, Andersson K, Wernerman J. Skeletal muscle glutathione is depleted in critically ill patients.  Crit Care Med. 1997;  25 78-84
  • 68 Matilla B, Ortiz J, Gonzalez P, Garcia-Diez F, Jorquera F, Culebras J M, Gonzalez-Gallego J, Tunon M J. Effects of parenteral nutrition supplemented with glutamine or glutamine dipeptides on liver antioxiant and detoxication systems in rats.  Nutrition. 2000;  16 125-128
  • 69 Gonce S J, Peck M D, Alexander J W, Miskell P W. Arginine supplementation and its effect on established peritonitis in guinea pigs.  JPEN J Parenter Enteral Nutr. 1990;  14 237-244
  • 70 Suchner U, Heyland D K, Peter K. Immune-modulatory actions of arginine in the critically ill.  British Journal of Nutrition. 2002;  87 S121-S132

Dr. Ulrich Suchner,Medizinischer Direktor 

KSBC-NT-Medical Affairs

Else-Kröner-Straße 1

61352 Bad Homburg v. d. H.

Email: Ulrich.Suchner@fresenius-kabi.com