Efetividade das dietas enriquecidas com imunonutrientes na redução de complicações e mortalidade em pacientes críticos: abordagem pela utilização de metanálise / Effectiveness of diets enriched with imunonutrients in reducing complications and mortality in critical patients: metanalysis usage approach

Nutrientes específicos, denominados farmaconutrientes, demonstraram possuir a capacidade de modular a resposta imunológica e inflamatória de animais e seres humanos, em estudos clínicos e laboratoriais. Dentre os substratos conhecidos, os que têm maior relevância e açãoimunomoduladora são a arginina, glutamina, ácido graxo n-3 e nucleotídeos. No entanto, revisõessistemáticas e meta-análises buscam consenso em relação aos vários e controversos resultados publicados sobre os possíveis benefícios da imunonutrição em pacientes críticos. Objetiva avaliar a efetividade das dietas enriquecidas com Imunonutrientes na redução de complicações e mortalidade nos diferentes tipos de pacientes críticos. O presente estudo é umarevisão sistemática com metanálise onde foram inseridos ensaios clínicos randomizados avaliando o uso de nutrientes imunomoduladores em doente adulto de ambos os sexos, definido como crítico traumatizado, séptico, queimado ou cirúrgico; as dietas utilizadas deveriam conter um ou mais dosimunonutrientes, em qualquer dose, administradas por via enteral comparadas à dieta padrão pelamesma via em pelo menos um dos grupos de comparação. As bases de dados consultadas foram Pubmed e Cinhal, utilizando os termos: Immunonutrition, arginine, glutamine, n-3, nucleotides e criticall illness...

Glutamine, gene expression, and cell function.

Glutamine is the most abundant free amino acid in the body and is known to play a regulatory role at the gene and protein level in several cell specific processes including metabolism (e.g. oxidative fuel, gluconeogenic precursor and lipogenic precursor), cell integrity (survival, cell proliferation), protein synthesis and degradation, redox potential, respiratory burst, insulin resistance, insulin secretion and extracellular matrix synthesis. Glutamine has been shown to regulate the expression of many genes related to metabolism, signal transduction, cell defense and repair and to activate intracellular signaling pathways. Thus, the function of glutamine goes beyond that of a simple metabolic fuel or protein precursor as previously assumed. In this review, we have attempted to identify some of the common mechanisms underlying glutamine dependent changes in gene and protein expression and cellular function.

Molecular mechanisms of glutamine action.

Glutamine is the most abundant free amino acid in the body and is known to play a regulatory role in several cell specific processes including metabolism (e.g., oxidative fuel, gluconeogenic precursor, and lipogenic precursor), cell integrity (apoptosis, cell proliferation), protein synthesis, and degradation, contractile protein mass, redox potential, respiratory burst, insulin resistance, insulin secretion, and extracellular matrix (ECM) synthesis. Glutamine has been shown to regulate the expression of many genes related to metabolism, signal transduction, cell defense and repair, and to activate intracellular signaling pathways. Thus, the function of glutamine goes beyond that of a simple metabolic fuel or protein precursor as previously assumed. In this review, we have attempted to identify some of the common mechanisms underlying the regulation of glutamine dependent cellular functions.

Glutamine-dependent changes in gene expression and protein activity.

The functions of glutamine are many and include, substrate for protein synthesis, anabolic precursor for muscle growth, acid-base balance in the kidney, substrate for ureogenesis in the liver, substrate for hepatic and renal gluconeogenesis, an oxidative fuel for intestine and cells of the immune system, inter-organ nitrogen transport, precursor for neurotransmitter synthesis, precursor for nucleotide and nucleic acid synthesis and precursor for glutathione production. In the present review information on the mechanism of glutamine action is presented. This amino acid has been shown to regulate the expression of several genes (such as p47phox, p22phox, gp91phox, alpha-actin and fibronectin) and activate several proteins (such as ASK1, c-myc, c-jun and p70s6k).

Glutamine and glutamate as vital metabolites.

Glucose is widely accepted as the primary nutrient for the maintenance and promotion of cell function. This metabolite leads to production of ATP, NADPH and precursors for the synthesis of macromolecules such as nucleic acids and phospholipids. We propose that, in addition to glucose, the 5-carbon amino acids glutamine and glutamate should be considered to be equally important for maintenance and promotion of cell function. The functions of glutamine/glutamate are many, i.e., they are substrates for protein synthesis, anabolic precursors for muscle growth, they regulate acid-base balance in the kidney, they are substrates for ureagenesis in the liver and for hepatic and renal gluconeogenesis, they act as an oxidative fuel for the intestine and cells of the immune system, provide inter-organ nitrogen transport, and act as precursors of neurotransmitter synthesis, of nucleotide and nucleic acid synthesis and of glutathione production. Many of these functions are interrelated with glucose metabolism. The specialized aspects of glutamine/glutamate metabolism of different glutamine-utilizing cells are discussed in the context of glucose requirements and cell function.

Glutamine plays a role in superoxide production and the expression of p47phox, p22phox and gp91phox in rat neutrophils.

The effect of glutamine on the activity of the NADPH oxidase complex from rat neutrophils was investigated. Superoxide anion (O(2)(-)) production was assessed: (1) by scintillation counting by using lucigenin, and (2) by reduction of cytochrome c over 10 min. The effects of glutamine and PMA on the expression of the NADPH oxidase components p22( phox ), gp91( phox ) and p47( phox ) were also determined. Glutamine at 1 and 2 mM increased O(2)(-) generation in the presence of PMA by 100% and 74% respectively, in neutrophils maintained previously for 3 h in medium deprived of this amino acid. DON (6-diazo-5-oxo-L-norleucine), an inhibitor of phosphate-dependent glutaminase and thus of glutamine metabolism, caused a significant decrease in O(2)(-) production by neutrophils stimulated with PMA both in the absence (44%) and in the presence (66%) of glutamine. PMA markedly increased the expression of gp91( phox ), p22( phox ) and p47( phox ) mRNAs. Glutamine (2 mM) increased the expression of these three proteins both in the absence and in the presence of PMA. We postulate that glutamine leads to O(2)(-) production in neutrophils, probably via the generation of ATP and regulation of the expression of components of NADPH oxidase.

Oral glutamine does not prevent bacterial translocation in rats subjected to intestinal obstruction and Escherichia coli challenge but reduces systemic bacteria spread.

OBJECTIVE: We investigated whether oral glutamine prevents bacterial translocation. METHODS: Male Wistar rats were fed with isocaloric and isoproteic standard rat chow and randomly assigned to receive glutamine (GLN) or glycine administered through an orogastric tube at 1.5 g.kg(-1).d(-1) for 7 d. On day 8 of the study, the animals were anesthetized and intestinal obstruction was produced by ligature of the terminal ileum. A suspension containing 10(9) colony-forming units per milliliter of Escherichia coli ATCC 25992 was injected into the lumen of the ileum. Twenty-four hours later, blood was withdrawn, and mesenteric lymph nodes and fragments of spleen, liver, and lung were sent for microbiological analysis. Cultures were done on blood agar and MacConkey agar. Student's t test and analysis of variance between two proportions were used. P < 0.05 was considered significant. RESULTS: Rats in both groups lost body weight during the experiment (not significant). Mesenteric lymph node cultures were positive in both groups. The GLN group had a smaller percentage of E. coli in blood and organ cultures (65.45% versus 82.67% in the glycine group; P = 0.027). Positive cultures of blood, spleen, liver and lung also were higher on glycine group, although not significantly. CONCLUSIONS: Oral GLN does not prevent bacterial translocation in rats after intestinal obstruction and E. coli challenge. No specific organ was protected by GLN. Nevertheless, its use was associated with a reduced number of positive E. coli cultures in blood and remote organs, and thus diminished bacteria spread. This association suggests a role for GLN in gut barrier protection, possibly by immune system enhancement.

Evidence that glutamine is involved in neutrophil function.

Phosphate-dependent glutaminase (PDG) activity, a key enzyme of glutamine metabolism, was determined in neutrophils obtained from the intra-peritoneal cavity (PC) or bronchoalveolar space (BAS) after administration of 1 ml or 100 microl, respectively of saline, glycogen solution (1%) or lipopolysaccharide (LPS 0.1 mg (100 microl)(-1)). Neutrophils were obtained by lavage of both sites with 20 ml saline 24 h after the administration of the stimuli. Glycogen and LPS, depending on the site the cells were obtained from, differently modulated PDG activity. Cells from BAS stimulated by glycogen or LPS had raised PDG activity to 30.5 +/- 5.2 and 42.7 +/- 12.1 nmol min(-1) mg(-1) protein, respectively, when compared with saline (9.1 +/- 0.9 nmol min(-1) mg(-1) protein); mean +/- SEM. On the other hand, cells from PC showed different PDG activity: 52.0 +/- 12.6 nmol min(-1) mg(-1) for saline, 36.5 +/- 9.5 nmol min(-1) mg(-1) for glycogen, and 76.6 +/- 11.2 nmol min(-1) mg(-1) for LPS; mean +/- SEM. Therefore, PDG activity varies with the site from which neutrophils are obtained and the stimulus imposed. The effect of glutamine on nitric oxide (NO) and tumour necrosis factor (TNF) production by peritoneal neutrophils, obtained after glycogen administration, cultured in the presence of LPS (0.5 microg ml(-1)) was also examined. The addition of glutamine at concentrations varying from 2 to 20 mM did not markedly affect NO production. Glutamine alone at 2 mM did not modify the production of TNF but in the presence of LPS caused a significant decrease. So, glutamine may preserve the function of neutrophils during infections and injuries.

Importância nutricional da glutamina / Nutritional importance of glutamine

Sao abordados aspectos atuais sobre a importância nutricional da glutamina, que é o mais abundante aminoácido no organismo. É um aminoácido neutro glucogênico que pode ser sintetizado amplamente nos tecidos que possuam a enzima glutamina sintetase. A glutamina aumenta a síntese portéica no músculo e é o principal transportador do nitrogênio no organismo. Aproximadamente 50 por cento dos aminoácidos livres correspondem à glutamina. É também considerado o substrato mais utilizado em uma grande variedade de células, tais como, enterócitos, reticulócitos, linfócitos, fibroblastos e células de tumores. Essas células compartem algumas características bioquímicas, tais como: rápido crescimento, glicólise acentuada e atividade aumentada da enzima glutamina sintetase. No entanto, em algumas condiçoes clínicas, tais como, trauma ou sepsis, a concentraçao de glutamina nesses tecidos diminui. Este fato pode ter sérias conseqüências para o organismo. Diminui a síntese protéica e a funçao da mucosa do trato gastrointestinal fica prejudicada. Isto pode levar ao desenvolvimento de um quadro de sepsis em pacientes catabólicos. Nesses casos a infusao com glutamina passa a ser relevante, observando-se imediatamente um aumento da concentraçao de glutamina nos tecidos e da síntese protéica.

[Nutritional importance of glutamine]. / Importância nutricional da glutamina.

The aim of this paper is to review nutritional aspects about this amino acid. Glutamine is the most abundant amino acid in the body. It is a neutral glucogenic amino acid that can be synthesized in the body by a wide variety of tissues rich in glutamine syntetase. Glutamine may promote muscle protein synthesis. Furthermore, glutamine is the principal carrier of nitrogen in the body, as it comprises approximately 50% of the whole-body pool of free amino acid. It is considered to be a major fuels for many cells including enterocytes, reticulocytes, stimulated lymphocytes, fibroblast and malignant cells. These cells share the common characteristics of relative rapid growth rates, high glicolitic rates, relative poor glucose oxidative capacity, and high glutaminase activity. In some clinical conditions, however, like trauma and sepsis, glutamine concentrations in tissues is decreased. These may have serious consequences for the organism, such as decreased in protein synthesis and impairement of the barrier functions of the mucosa of the gastrointestinal tract, and thereby contributy to the development of sepsis in catabolic patients. Infusion of glutamine may have therapeutic value in such conditions.