Effects of Nutritional Rehabilitation on Intestinal Function and on CD4 Cell Number in Children With HIV.

Reference: J Pediatr Gastroenterol Nutr 2002;34(4):366-71.

BACKGROUND: A complex interplay of malnutrition, intestinal dysfunction, and immune
impairment increases the progression of human immunodeficiency virus (HIV) disease in children.
The authors tested the hypothesis that nutritional support improves intestinal and immune
functions in children infected with human immunodeficiency virus (HIV). METHODS: A
questionnaire was circulated through reference centers for pediatric HIV infection to evaluate the
effects of nutritional rehabilitation, total parenteral nutrition (TPN) and enteral nutrition (EN), in
children. Information included changes in body weight, CD4 cell numbers, and intestinal
absorption-as judged by the xylose load-before and after clinical nutritional support and the
outcome of children. RESULTS: Sixty-two children underwent nutritional support: 46 received
TPN and 16 received EN. All but three had full-blown acquired immunodeficiency syndrome,
and all were severely malnourished. Baseline clinical conditions were worse in children receiving
TPN than in those receiving EN. Intestinal dysfunction was detected in all children who received
xylose oral load. A significant increase in CD4 cell count, xylose levels, and body weight
followed EN. A similar pattern was observed after TPN, but none of the parameters significantly
changed. Twenty-seven children who received TPN and three who received EN eventually died.
Fourteen who received TPN and eight who received EN were shifted to oral feeding, and five
who received TPN and five who received EN continued with clinical nutritional support at the
end of the observation period. CONCLUSIONS: Nutritional intervention may restore intestinal
absorption and increase CD4 cell numbers. The efficacy of nutritional intervention is enhanced if
provided before a terminal stage of HIV infection. These data provide evidence of a close
association among nutritional condition, intestinal absorption, and immune impairment.

Feeding the gut early after digestive surgery: results of a nine-year experience.

Reference: Clin Nutr 2002;21(1):59-65.

BACKGROUND AND AIMS: Early enteral nutrition (EEN) after surgery should be preferred
to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI)
adverse effects and feeding tube-related complications. Thus we evaluated our experience
focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors
for gastrointestinal adverse effects.

METHODS: 650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied.

RESULTS: 402 patients had a jejunostomy and 248 patients a NJ tube.EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650).

CONCLUSIONS: The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.

Qualitative manipulation of amino acid supply during total parenteral nutrition in surgical patients.

Reference: JPEN 2002;26(2):136-43.

We investigated whether a qualitative manipulation of amino acid mixture could improve the
nutritional status of patients undergoing surgery. Patients received total parenteral nutrition for 2
consecutive 5-day periods. Energy and nitrogen supplies were calculated using a modified
Harris-Benedict equation, with an energy-to-nitrogen ratio of 125 kcal/g nitrogen (N). The mean
kilocalorie lipids-to-glucose ratio was 35% to 65%. There were 6 patients in the control group
and 7 patients in the experimental group. The control group received the same standard amino
acid solution (Vintene, Baxter-Clintec, Maurepas, France) for the entire 10 days. The
experimental group received the standard solution during the first 5 days but was switched to a
more individualized solution during the last 5 days. The second solution was determined from a
linear regression performed on day 3 comparing rate of infusion of each amino acid and its
plasma variations after 3 hours of infusion with basal values. Amino acids were defined as
oversupplied or undersupplied when not within the 95% confidence interval (above or below the
curve, respectively). Daily nitrogen balance and urinary excretion of 3-methylhistidine were
measured from day 1 to day 10 in all patients. For the patients in whom these measures were
made, amino acid variations except those of lysine (11 of 12), ornithine (6 of 12), alanine (5 of
12), arginine (5 of 12), and glutamate (5 of 12) were within the 95% confidence interval. During
the second 5-day period, imbalances persisted in the control group but were almost gone in the
experimental group. Daily nitrogen balance was not significantly different between groups.
However, when expressed as a mean over each period, nitrogen balance was significantly higher
during the second period in the experimental group than in the control group: 4.5+/-0.8 g N/d
versus 0.2+/-0.7 g N/d, p < .01. The ratio of urinary 3-methylhistidine to creatinine decreased
from day 1 to day 10 in both groups. These findings suggest that the relationship between rate of
infusion and plasma amino acid variation may offer a rational basis for choosing the most
appropriate amino acid mixture for catabolic patients. An appropriate mixture would limit plasma
amino acid imbalances and improve nitrogen retention. This therapy must now be tested in a
larger population of patients.

Immunomodulation by perioperative administration of n-3 fatty acids.

Reference: Br J Nutr 2002;87(S1):S89-94.

It has been increasingly reported that administration of n-3 fatty acids is beneficial in patients with
inflammatory processes. This effect is most likely caused by different biological characteristics,
including an immunomodulating effect of the products derived from n-3 fatty acids through
eicosanoid metabolism. The aim of this study was to investigate the effect of perioperative
administration of n-3 fatty acids on inflammatory and immune responses as well as on the
postoperative course of patients with extended surgical interventions of the abdomen. In
particular, the effect of n-3 fatty acids on interleukin-6 release and on granulocyte/monocyte
function (HLA-DR expression) was studied. There was a downregulation of the inflammatory
response, and, simultaneously, a smaller postoperative immune suppression in the n-3 fatty acid
group. In addition, we observed shorter postoperative periods in the intensive care unit and on
the regular medical wards as well as lower rates of severe infections. The results suggest that
perioperative administration of n-3 fatty acids may have a favourable effect on outcome in
patients with severe surgical interventions by lowering the magnitude of inflammatory response
and by modulating the immune response.