Maintaining mucosal immunity during parenteral feeding with surrogates to enteral nutrition.

Pneumonia and intra-abdominal abscesses are significantly lower in trauma patients receiving enteral feeding compared with those receiving parenteral feeding. Extensive experimental evidence suggests that this is related to maintenance of the mucosal-associated lymphoid tissue, which provides immunologic protection for both the gastrointestinal and respiratory tracts against microbial flora and infectious pathogens. This system is exquisitely sensitive to the route and type of nutrition delivery that affects its functional effectiveness. Although parenteral nutrition decreases the effectiveness of this extraintestinal mucosal immunity, specialty nutrients like glutamine and neuropeptides such as gastrin-releasing peptide and cholecystokinin are capable of preventing some of the immune defects associated with parenteral nutrition. This review examines the mechanisms associated with the mucosal immunity and role of both glutamine and neuropeptides in normalizing defects induced by parenteral feeding. Based upon evolving data, specific nutrients and products of the enteric nervous system show promise as adjuncts to parenteral feeding that are capable of maintaining immune function in patients unable to be fed via the gastrointestinal tract.     

Significance of hypoalbuminemia in pediatric oncology patients--malnutrition or infection?

Nutritional status was evaluated on 210 occasions in 90 pediatric oncology inpatients during a 7-month period; 39 had solid tumors and 51 leukemia. Ages ranged from 3 months to 20 yr. Nutritional parameters were defined as normal, "at risk," or "probably malnourished." Fifty-seven and 29% of assessments revealed at least one parameter "at risk" or "probably malnourished," respectively. Prognosis was negatively related to the number of abnormal nutritional parameters. Serum albumin was most frequently abnormal. However, on most occasions, hypoalbuminemia was associated with weight/height, arm muscle area, and triceps skinfold measurements in the normal range. In order to further identify determinants of serum albumin, we analyzed dietary, chemotherapy, and temperature data in 10 prospectively studied leukemia patients, half of whom received parenteral nutrition. In these patients there was little relationship of serum albumin to chemotherapy or dietary intake. In all of these patients, especially those receiving total parenteral nutrition, low serum albumin was highly associated with fever (p less than 0.0005). We concluded that febrile illness is an important determinant of abnormal serum albumin concentrations. In pediatric cancer patients, abnormal serum albumin may more often reflect the acute metabolic response to fever and infection than depletion of body mass.     

Infection,multiple organ failure,and survival in the intensive care unit: influence of glutamine-supplemented parenteral nutrition on acquired infection

OBJECTIVE: We investigated the effect of a glutamine-supplemented parenteral nutrition on intensive-care-acquired infection (ICAI) and its relation to outcome.METHODS: We analyzed new data prospectively collected during a double-blind, randomized, and controlled trial in an adult general intensive care unit previously reported (Nutrition 1997;13:295). Eighty-four patients were randomized to receive glutamine-supplemented total parenteral nutrition or an isonitrogenous, isoenergetic control. Sepsis was present on admission in 71% of the patients. Clinical and microbiological data were collected on all new infective episodes and associated treatment decisions. Data were analyzed blind to the randomization and study outcome.RESULTS: There was no significant difference in the number of patients developing new infections or in the number occurring during the first 5 d. There was a non-significant trend to increased numbers of infections in those patients receiving the control feed for at least 5 d. In these patients the glutamine recipients showed significantly fewer catheter-related infections: 21 versus 12 (P = 0.026). The difference in overall 6-mo mortality was almost completely described by those patients fed for at least 5 d: 9 of 25 versus 18 of 27 using the control nutrition (P = 0.05). Of the deaths in the intensive care unit due to multiple organ failure, 8 of 8 in the glutamine group and 14 of 16 in the control group sustained one or more ICAI and accounted for 38% versus 74%, respectively, of the ICAIs occurring in those patients. In those patients, despite a similar high incidence of colonization with Candida, those receiving glutamine developed fewer Candida infections and none died, whereas six control patients who developed Candida infections died from multiple organ failure (P = 0.02). Survival was not related to the reduced occurrence of the first acquired infection; however, binary logistic regression analysis of glutamine and the incidence of ICAI after starting total parenteral nutrition to outcome showed that only glutamine was significantly associated with improved 6-mo survival (P = 0.027).CONCLUSIONS: In these severely ill patients, parenteral nutrition containing glutamine may not reduce the overall incidence of ICAI, but it may reduce the risk of dying from acquired infections. The improved survival seen at 6 mo appeared related mostly to reduced mortality in the intensive care unit from multiple organ failure in those patients in whom acquired infections are common.     

Glutamine-supplemented total parenteral nutrition improves immunological status in anorectic patients

ObjectiveGlutamine is an important substrate for critical cells of the immune system, in particular lymphocytes and macrophages, and it is considered a conditionally essential amino acid. Several studies have indicated that glutamine-enriched total parenteral nutrition improves immunologic status and shortens length of stay of critically ill patients. We investigated the effect of total parenteral nutrition supplemented with glutamine on the immune system in anorectic patients.MethodsThirty-six anorectic patients were randomized to receive standard parenteral nutrition or parenteral nutrition supplemented with glutamine 0.18 g · kg^?1 · d^?1 for 20 d. To evaluate the immune system status, we determined serum levels of neopterin and insulin growth factor-1 and lymphocyte count at baseline and after 10 and 20 d from the beginning of the therapy.Results and ConclusionsThe results showed a significant increase of the serum levels of neopterin after 10 d of treatment with glutamine (26.44 ± 3.08 versus 6.75 ± 1.73 nmol/L, P < 0.001), thus proving a probable stimulating action carried out by glutamine on the immune system, as testified by the increase of lymphocytes.     

Effects of parenteral nutrition supplemented with glutamine or glutamine dipeptides on liver antioxidant and detoxication systems in rats

Our aim was to determine the effects of glutamine or alanyl glutamine parenteral supplementation on the liver oxidant/antioxidant balance and on cytochrome-P450-mediated detoxication in rats. Animals were infused for 5 d with standard total parenteral nutrition (TPN), glutamine-enriched TPN, or alanyl glutamine-enriched TPN. The hepatic concentration of glutathione was reduced, and the levels of thiobarbituric-acid-reactive substances (TBARS) were increased in animals receiving standard TPN. Both glutamine and alanyl glutamine supplementation normalized glutathione, but thiobarbituric-acid-reactive substance concentration was only decreased by ananyl glutamine. This effect was parallel to a partial recovery of the activity of antioxidant enzymes. Cytochrome-P450 liver content, cytochrome-P450-dependent monooxygenases, and antipyrine clearance were not modified by glutamine or alanyl glutamine. Our data suggest a better protection against free radicals by alanyl glutamine supplementation and an absence of effects of both glutamine and alanyl glutamine on liver oxidative metabolism.     

进展期胰腺癌化疗的肠外营养支持

目的：探讨进展期胰腺癌化疗中的肠外营养支持对病人营养、免疫状态及肿瘤疗效的影响。方法：33例病人均给予联合化疗（FCMP／A）,随机分为治疗组（肠外营养）,对照组（常规治疗）。检验两组病人的营养、免疫状态、肿瘤治疗的有效率、生存期。结果：治疗组的前白蛋白、转铁蛋白、外周淋巴细胞总数、自然杀伤细胞活性、白介素Ⅰ受体阳性细胞、生活质量评分、化疗药物毒性作用的消失时间均优于对照组（P＜0．05或P＜0．01）。减黄手术后化疗加营养支持的生存时间平均11．5个月,长于非减黄术（P＜0．05）。结论肠外营养支持有可干预化疗药物消化道副反应所导致的营养状况下降,提高机体免疫力,改善生活质量,减黄术后化疗加营养支持能延长生存期。     

谷氨酰胺强化肠外营养在外科危重患者中的作用

目的:探讨全胃肠外营养(TPN)加丙胺酰-谷氨酰胺注射液对外科危重症患者营养及免疫功能的影响。方法:将94例外科重症需要TPN的患者随机分为治疗组和对照组,均给予8dTPN治疗,其中治疗组患者每天加用丙胺酰-谷氨酰胺注射液0.4g/kg。检测患者TPN前、TPN后2d及8d的营养及免疫指标并进行分析。结果:治疗组、对照组与TPN前比较,TPN后2d血清ALB、PAB、TRF水平、PNI均有不同程度恢复,CD4的百分比、CD4/CD8比值、IgG、IgA、IgM有不同程度下降,治疗组优于对照组,在TPN后8d两组比较差异有统计学意义(t=2.235,t=2.167;P<0.05);而CD8的百分比与上述相反(t=2.178,P<0.01)。结论:外科危重症患者在TPN治疗基础上加用丙胺酰-谷氨酰胺注射液能有效改善机体营养和免疫状况,从而促进预后。     

Effects of parenteral nutrition support and chemotherapy on the phasic composition of tumor cells in gastrointestinal cancer.

BACKGROUND: Some clinical studies report the effects of parenteral nutrition in malnourished cancer patients, but few discuss the tumor response to parenteral nutrition plus chemotherapy. If used in combination, the antitumor activity of chemotherapeutic agents may compensate for the tumor stimulation of parenteral nutrition. METHODS: Ninety-two patients with operable gastrointestinal cancer and malnutrition were randomly assigned to four interventions that were administered for 7 days preoperatively: parenteral nutrition alone, parenteral nutrition plus chemotherapy, chemotherapy alone, or no treatment (control). The preintervention and postintervention DNA content, DNA index, percentage of cells in S phase, and tumor cell sensitivity to chemotherapy were measured using image cytometry. RESULTS: Parenteral nutrition resulted in a significant proliferation of tumor cells and a significant increase in the sensitivity of tumor cells to chemotherapy; these effects were not seen in tumors of patients receiving parenteral nutrition plus chemotherapy. There was, however, a nonsignificant increase in tumor cell proliferation and sensitivity to chemotherapy in the tumors of subjects receiving combined therapy compared with those of subjects who received chemotherapy alone. The postintervention nutritional status of both the parenteral nutrition group and the parenteral nutrition plus chemotherapy group were significantly better than that of the control group and the chemotherapy group. The short-term, postoperative clinical outcomes in the chemotherapy group were significantly worse than those in the other three groups. CONCLUSIONS: These results indicate that combining chemotherapy and nutrition support preoperatively for malnourished patients with gastrointestinal cancer improves short-term nutritional status without increasing the proliferation of tumor cells and prevents the postoperative complications that occur when such patients are given chemotherapy without nutrition support. The results also suggest--but do not prove--that parenteral nutrition may increase the effectiveness of chemotherapy in malnourished patients.     

脂肪乳剂对老年肿瘤患者肠外营养相关肝功能损伤影响的回顾性分析

目的研究脂肪乳剂在老年肿瘤患者术后肠外营养相关肝功能损伤（PNALD）中的作用。方法回顾性分析2003年1月至2008年12月仁济医院402例老年肿瘤患者接受肠外营养后肝功能损伤的发生情况。纳入标准：年龄≥60岁;确诊为恶性肿瘤,无远处转移且接受肠外营养前肿瘤已完全切除;接受肠外营养前患者的肝肾功能正常;接受肠外营养≥7d;采用“全合一”方式配制肠外营养液,且经过中心静脉输注。排除标准：病毒性肝炎患者;接受肠外营养期间患者死亡。年龄（71．7±6．8）岁,平均接受了（10．2±5．9）（7～61）d肠外营养支持。77．4％（311／402）患者使用了脂肪乳剂,22．6％（91／402）患者输注了不含脂肪乳剂的肠外营养液。碳水化合物、脂肪和氨基酸的平均供给量分别为（1．8±0．7）、（0．9±0．4）和（0．7±0．2）g·kg^-1·d^-1平均供热量和热氮比分别为（69．8±27．2）kJ·kg^-1·d^-1和（660．4±255．4）kJ：1g氮。结果402例老年肿瘤患者PNALD的发生率为15．2％（61／402）。接受不含脂肪乳剂肠外营养支持老年患者PNALD的发生率为8．8％（8／91）,而接受脂肪乳剂老年患者PNALD的发生率为17．0％（53／311）,两者的差异无统计学意义（X^2=3．72,P〉0．05）。脂肪乳剂种类和用量对PNALD发生率无显著影响（P〉0,05）。Logistic回归分析显示,体温升高天数（P〈0．001）、丙氨酸氨基转移酶（P〈0．001）和γ-谷氨酰转移酶（P〈0．001）是PNALD发生的危险因素。结论给老年肿瘤患者术后应用脂肪乳剂是安全的,且对PNALD的发生未产生显著影响。     

Oral and parenteral glutamine in bone marrow transplantation: a randomized, double-blind study.

BACKGROUND: Total parenteral nutrition (TPN) supplemented with glutamine (GLN) has been reported to be effective for patients with bone marrow transplantation (BMT). Our aim was to evaluate enteral and parenteral glutamine in patients undergoing BMT. METHODS: For evaluation of GLN in BMT, 66 patients with 43 hematologic and 23 solid malignancies (21 breast carcinomas), were randomized, double-blinded, to either oral GLN (n = 35) or glycine-control (GLY) (n = 31), 10 g three times daily. When TPN became necessary, patients who received GLN orally were given TPN with GLN (0.57 g/kg). Those who received GLY received standard TPN, isocaloric and isonitrogenous. Patients with hematologic malignancies received high-dose chemotherapy, total body irradiation, and either allogeneic (ALLO) BMT (n = 18) or autologous (AUTO) stem cell transplantation (n = 25). Patients with solid malignancies (n = 23) received AUTO. RESULTS: There were 14 in-hospital deaths without relationship to GLN administration. For respective comparisons of ALLO and AUTO transplants in the GLN and GLY hematologic groups and AUTO in the solid tumor groups, there were no significant differences in hospital stay, duration of stay after BMT, TPN days, neutrophil recovery >500/mm3, incidence of positive blood cultures, sepsis, mucositis, and diarrhea. Acute graft us host disease occurred in 1 of 10 hematologic patients receiving GLN and in 3 of 8 patients receiving GLY placebo (p > .05). Possible reduction in need for TPN and a suggestion of improved long-term survival were associated with GLN. CONCLUSIONS: Oral and parenteral GLN seemed to be of limited benefit for patients having AUTO or ALLO BMT for hematologic or solid malignancies. Further study of long-term effects of GLN in BMT seems warranted.     

Glutamine as a modulator of the immune system of critical care patients: effect on Toll-like receptor expression. A preliminary study

OBJECTIVE: We evaluated the expression of Toll-like receptors 2 and 4 (TLR-2 and TLR-4) in circulating monocytes from peripheral blood of critical care patients treated with and without glutamine. Because no research has been published to date on the effect of glutamine on TLR receptors in critical patients, it was determined in an initial sample of 30 patients. METHODS: This was a prospective, randomized, single-blind study with 15 patients assigned to receive parenteral nutrition with a daily glutamine supplement of 0.35 g/kg. The control group received isocaloric-isonitrogenous parenteral nutrition. Blood samples were extracted before beginning the treatment and at 5 and 14 d. Expressions of CD14, TLR-2, and TLR-4 were determined by flow cytometry. Levels of TLRs were expressed as mean fluorescence intensity (mfi). RESULTS: Basal characteristics were similar in both groups. The expressions of TLR-2 in the treatment group with glutamine were 4.67 +/- 3.82 mfi before treatment, 3.91 +/- 2.04 mfi at 5 d, and 4.28 +/- 2.47 mfi at 14 d. The expressions of TLR-2 in the control group were 5.49 +/- 3.20 mfi before treatment, 4.48 +/- 2.15 mfi at 5 d, and 4.36 +/- 2.36 mfi at 14 d. The expressions of TLR-4 in the treatment group were 1.65 +/- 1.89 mfi before treatment, 1.23 +/- 1.10 mfi at 5 d, and 1.77 +/- 1.97 at 14 d. The expressions of TLR-4 in the control group were 1.51 +/- 1.76 mfi before treatment, 1.36 +/- 0.99 mfi at 5 d, and 1.26 +/- 0.59 mfi at 14 d. Infections were detected in 11 patients who received glutamine and 13 control patients (P = 0.51). CONCLUSION: In critical care patients, parenteral nutrition supplemented with glutamine does not increase the expression of TLR-2 or TLR-4 in peripheral blood monocytes.     

肠外营养对大肠癌术后早期腹腔内热灌注化疗的价值

目的：探讨肠外在大肠癌术后早期腹腔内热灌注化疗中的临床价值。方法：选择３２例进展期大肠癌病人于术后当天至术后第４天给予ＩＰＨＰ化疗及肠外营养支持,并观察其毒性,并发症,营养指标及免疫功能变化。结果：３２例病人顺利完成治疗而出院,病人毒副反应小,营养及免疫指标明显改善。     

Prophylactic antibiotic treatment of neutropenic patients

There is no special signs of neutropenia therefore it is usually diagnosed due to an acute infection or laboratory control. Infections acquired during chemotherapy induced myelosuppression may further deteriorate the neutropenia in cancer patients. There are many possible cause of fever in cancer patients but in case of neutropenia infection is the most likely reason. If febrile neutropenia occurs immediately broad spectrum intravenous antibiotic treatment should be initiated. Recently introduced aggressive chemotherapy protocols further increased the number of neutropenic patients. Therefore it would be important to prevent febrile neutropenia. Unfortunately the available data still insufficient to make any conclusions regarding the efficacy of short or long term prophylactic treatment. While there are generally accepted recommendations of empiric antibiotic therapy no such options are available regarding prophylactic treatments. The decision regarding prophylactic treatment (similarly to empiric therapy) should be based on the resistance of the dominant pathogens in a therapeutic unit. Several study had been conducted regarding prophylactic administration of antibiotics the results however contradictory. Considering the advantages and disadvantages, the prophylactic antibiotic treatment of neutropenic patients could be suggested only in certain cases.     

Effect of glutamine-enriched total parenteral nutrition in patients with acute pancreatitis

BACKGROUND: The management of acute pancreatitis (AP) frequently includes parenteral nutrition, but conditionally essential amino acids such as glutamine are not included in conventional total parenteral nutrition (TPN).AIM: This study was conducted to determine whether the inclusion of glutamine has a beneficial effect in patients with AP receiving TPN. METHODS: In a randomized, controlled study 28 patients with AP received either a standard TPN with 1.5 g/kg body weight protein or an isonitrogen, isocaloric TPN which contains 0.3 g/kg L -alanine- L -glutamine. Patients were assessed for nutritional and inflammatory parameters, infectious complications, length of TPN, length of hospital stay (LOS) and cost of TPN. RESULTS: There were no side-effects related to glutamine substitution observed. Glutamine was associated with a significant increase of cholinesterase, albumin and lymphocyte count in AP as well a decrease of C-reactive protein compared to standard TPN at day 14. There was a reduced length of TPN (10 [6-16] vs 16 [10-18] days, P<0.05) and a trend of reduced LOS (21 [14-32] vs 25 [19-40] days) in AP patients receiving glutamine. The overall cost per patient for TPN did not differ (gln+: 929+/-586 vs gln-: 981+/-507 euro/patient). CONCLUSION: Our results suggest that glutamine substitution is beneficial and does not increase the overall cost of parenteral feeding in patients with acute pancreatitis.     

Glutamine supplementation in cancer patients

OBJECTIVES: Three series of studies investigated whether 1) glutamine deficiency occurs in tumor-bearing rats, 2) glutamine supplementation improves protein metabolism during chemotherapy in tumor-bearing rats, and 3) oral glutamine supplement improves systemic immune and gut-barrier function in patients with esophageal cancer receiving radiochemotherapy. METHODS: In the animal studies, AH109A hepatoma cells or Yoshida sarcoma cells were inoculated into male Donryu rats to induce tumors. Glutamine production was measured by U-14C-glutamine infusion and the conversion of arginine to glutamine was measured by infusion of U-14C-arginine. The effect of glutamine on protein metabolism was investigated by 1-14C-leucine infusion. In the clinical study, 13 patients with esophageal cancer were randomized into two groups, control and glutamine supplemented (30 g/d), for 4 wk. RESULTS: Glutamine levels in plasma and skeletal muscle were decreased in tumor-bearing rats, although glutamine production and the conversion of arginine to glutamine were increased. Glutamine-supplemented total parenteral nutrition reduced whole-body protein breakdown rate during chemotherapy in tumor-bearing rats. Oral supplementation of glutamine to the patients with esophageal cancer enhanced lymphocyte mitogenic function and reduced permeability of the gut during radiochemotherapy. CONCLUSIONS: Glutamine depletion in host tissues occurs in tumor-bearing rats. Glutamine supplementation can attenuate loss of protein in the muscle in tumor-bearing animals and protect immune and gut-barrier function during radiochemotherapy in patients with advanced cancer.     

谷氨酰胺对危重患者免疫功能影响的随机对照研究

目的探讨危重患者补充谷氨酰胺(Gln)的肠外营养和标准肠外营养比较能否改善免疫功能。方法将60例外科危重患者随机分为实验组和对照组,每组30例,其中实验组由于Gln应用时间不够以及病情变化突然死亡等原因剔除5例。实验组给予强化Gln的全肠外营养支持,对照组为标准全肠外营养支持,两组等热等氮供给。检测治疗前、后血浆总蛋白、白蛋白、血红蛋白浓度,外周血IgA、IgG、IgM、总淋巴细胞数及T细胞亚群CD3、CD4百分率及CD4/CD8比值。结果实验组的总淋巴细胞数、IgG、CD4百分率和CD4/CD8比值均高于营养支持前及对照组(P<0.05)。结论强化Gln的肠外营养支持能改善外科危重患者机体的免疫功能,促进患者的康复,为危重患者有效的营养支持治疗提供临床研究依据。     

Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients

BACKGROUND: Nosocomial infections are an important cause of morbidity and mortality in the surgical intensive care unit (SICU). Clinical benefits of glutamine-supplemented parenteral nutrition may occur in hospitalized surgical patients, but efficacy data in different surgical subgroups are lacking. The objective was to determine whether glutamine-supplemented parenteral nutrition differentially affects nosocomial infection rates in selected subgroups of SICU patients. METHODS: This was a double-blind, randomized, controlled study of alanyl-glutamine dipeptide-supplemented parenteral nutrition in SICU patients requiring parenteral nutrition and SICU care after surgery for pancreatic necrosis, cardiac, vascular, or colonic surgery. Subjects (n = 59) received isocaloric/isonitrogenous parenteral nutrition, providing 1.5 g/kg/d standard glutamine-free amino acids (STD-PN) or 1.0 g/kg/d standard amino acids + 0.5 g/kg/d glutamine dipeptide (GLN-PN). Enteral feedings were advanced as tolerated. Nosocomial infections were determined until hospital discharge. RESULTS: Baseline clinical/metabolic data were similar between groups. Plasma glutamine concentrations were low in all groups and were increased by GLN-PN. GLN-PN did not alter infection rates after pancreatic necrosis surgery (17 STD-PN and 15 GLN-PN patients). In nonpancreatic surgery patients (12 STD-PN and 15 GLN-PN), GLN-PN was associated with significantly decreased total nosocomial infections (STD-PN 36 vs GLN-PN 13, P < .030), bloodstream infections (7 vs 0, P < .01), pneumonias (16 vs 6, P < .05), and infections attributed to Staphylococcus aureus (P < .01), fungi, and enteric Gram-negative bacteria (each P < .05). CONCLUSIONS: Glutamine dipeptide-supplemented parenteral nutrition did not alter infection rates following pancreatic necrosis surgery but significantly decreased infections in SICU patients after cardiac, vascular, and colonic surgery.     

L-arginine-enriched parenteral nutrition affects lymphocyte phenotypes of gut-associated lymphoid tissue

BACKGROUND: Experimentally, total parenteral nutrition (TPN) diminishes gut-associated lymphoid tissue (GALT) cell numbers and function. Although glutamine supplementation is known to reverse TPN-induced changes in GALT, effects of another conditionally essential amino acid, L-arginine (ARG), on GALT remain unclear. METHODS: Twenty-two male Institute of Cancer Research mice were randomized to standard TPN (0.3% arginine, STD-total parenteral nutrition) or 1% ARG-enriched TPN (ARG-total parenteral nutrition). After 5 days of feeding, lymphocytes were harvested from Peyer's patches (PP), the lamina propria, and intraepithelial (IE) spaces of the small intestine to determine cell yields. Lymphocyte phenotypes (alphabetaTCR, gammadeltaTCR, CD4, CD8, and B220 as a B cell marker) were determined using flow cytometry. IgA levels in washings of the small intestine, upper respiratory tract, and lungs were measured with ELISA. RESULTS: ARG-total parenteral nutrition did not affect lymphocyte yields. The percentages of CD4+ cells in PP and IE, and alphabetaTCR+ cells in PP, were significantly higher in the ARG-total parenteral nutrition than in the STD-total parenteral nutrition mice, without marked differences in other phenotypes examined. There were no significant differences in intestinal and respiratory tract IgA levels between the 2 groups of mice. CONCLUSIONS: One percent ARG supplementation of TPN does not improve GALT cell number or mucosal IgA level but benefits to increase CD4+ cell percentages in GALT.     

肠外营养支持对胃癌新辅助化疗病人围术期营养状态和免疫功能的影响

目的:探讨肠外营养(PN)支持对胃癌新辅助化疗病人营养状态和免疫功能的影响。方法:选择局部进展期胃癌病人60例,随机分为PN组和对照组,每组各30例,两组病人均可经口进食。对照组病人经口进食;PN组经口进食+术前化疗期间行PN支持,比较两组病人化疗前后、手术前后的营养状况、免疫功能和术后恢复情况。结果:(1)两组病人化疗2周期后血清清蛋白(ALB)、转铁蛋白(TF)、前清蛋白(PA)呈下降趋势,与化疗前比差异有显著性统计学差异(P0.05),而PN组各指标高于对照组(P0.05)。(2)两组病人化疗2周期后IgA、IgG、IgM、CD4+、CD4+/CD8+呈下降趋势,与化疗前比差异有显著性统计学差异(P0.05),而PN组各指标高于对照组(P0.05)。(3)PN组病人化疗的不良反应少于对照组(P0.05)。(4)术后第7天,PN组病人ALB、TF、PA和IgA、IgG、IgM、CD4+、CD4+/CD8+水平均高于对照组,差异有显著性统计学意义(P0.05)。结论:胃癌新辅助化疗病人在化疗期间给予PN支持有助于提高其化疗期间和术后的营养状态,减少免疫功能损伤和化疗的不良反应。     

谷氨酰胺双肽对接受造血干细胞移植患儿肠道保护作用的临床研究

目的研究谷氨酰胺双肽[N（2）-L-alanyl—L—glutamine;dipeptide grutamine;dipeptiven,DPT]对造血干细胞移植（hematopoietic stem cell transplantation,HSCT）患儿并发症及恢复的影响。方法选取2004年3月至2007年11月,在中山大学附属第二医院儿科接受造血干细胞移植的56例患儿为研究对象,将其按疾病种类作分层抽样分为谷氨酰胺双肽组（DPT组,n=28）和对照组（n=28）（本研究遵循的程序符合本院人体试验委员会所制定的伦理学标准,得到该委员会批准,分组征得受试患儿监护人的知情同意,并与其签署临床研究知情同意书）。DPT组患儿除接受全胃肠外营养（total parenteral nutrition;TPN）支持外,每天给予谷氨酰胺双肽,剂量为1．5mL／（kg·d）,共计21d。对照组采用不含谷氨酰胺（glutamine,Gln）的全胃肠外营养支持。检测DPT组和对照组应用谷氨酰胺双肽前1天、第7、第14、第21天患儿体重、肝功生化、血常规,并对造血干细胞植入和移植后30d内并发症发生情况进行分析。结果DPT组发生肠炎为12例,对照组为26例,两组比较,DPT组发生率低于对照组,且差异有显著意义（P〈0．05）。DPT组患儿的腹泻、腹痛、呕吐、口腔溃疡持续时间,腹泻、腹痛、呕吐次数均短于或少于对照组,两组比较,差异有显著意义（P〈0．05）。两组患儿发生鹅口疮、肛裂等持续时间比较,DPT组短于对照组,且差异无显著意义（P〈0．05）。DPT组患儿长期发热（≥14d）为2例,对照组为10例,两组比较,DPT组的发热总持续时间、最长持续发热时间短于对照组,平均每天最高体温低于对照组,且差异有显著意义（P〈0．05）。DPT组患儿发生口腔溃疡为14例、鹅口疮为4例、肛裂为3例、血真菌培养呈阳性为0例、血细菌培养呈阳性为6例,而对照组分别为19例、5例、1例、1例和7例,两组比较,差异无显著意义（P〉0．05）。DPT组患儿静脉应用抗生素时间为（20．0±7．1）d、入无菌层流室治疗时间为（20．2±6．7）d,对照组分别为（25．4±6．4）d和（24．1±6．9）d,两组比较,差异有显著意义（P〈0．05）。DPT组造血干细胞植入成功为22例,对照组为21例;DPT组发生肠道急性移植物抗宿主病（acute graft versus host disease,aGVHD）为3例、肝静脉闭塞病（venous occlusive disease,COD）为0例,对照组分别为5例和1例,两组移植成功率和肠道急性移植物抗宿主病、肝静脉闭塞病发生率方面比较,差异无显著意义（P〉0．05）。DPT组白细胞（white blood cell,WBC）植入时间为（15．3±5．1）d,血小板（plateiet,PLT）植人时间为（29．0±14．4）d,对照组分别为（16．2±5．8）d和（32．5±18．6）d,两组比较,差异无显著意义（P〉0．05）。两组在DPT组患儿应用谷氨酰胺双肽的第7、第14、第21天的天冬氨酸转氨酶（aspartate aminotransferase,AST）,丙氨酸转氨酶（alanine aminotransferase,ALT）,血尿素氮（blood urea nitrogen,BUN）,肌酐（creatinine,Cr）、葡萄糖（glucose,Glu）、总蛋白（total protein,TP）、白蛋白（albumin,ALB）、球蛋白（globulin,GLB）、白细胞、红细胞（red blood cell,RBC）、血小板、血红蛋白（hemoglobin,Hb）比较,差异无显著意义（P〉0．05）。在应用谷氨酰胺双肽的第7、第14、第21天,DPT组患儿的体重下降幅度与对照组相应指标比较,下降幅度较少,差异有显著意义（P〈0．05）;且于第21天,DPT组患儿平均体重已恢复至造血干细胞移植前水平,而对照组尚未恢复。结论谷氨酰胺双肽对造血重建恢复无影响,但能改善造血干细胞移植患儿的营养状态,减少黏膜炎、肠炎的发生率及症状持续时间,减少长期发热发生率及发热持续时间,缩短抗生素治疗时间及无菌层流室治疗时间,同时不增加肠道急性移植物抗宿主疾病。