Suchner U, Kuhn K S, Fürst P
Clinic of Anesthesiology, Grosshadern, Ludwig Maximilians University, Marchioninistrasse 15, 81377 Munich, Germany.
Proc Nutr Soc. 2000 Nov;59(4):553-63. doi: 10.1017/s0029665100000793.
Substrates with immune-modulating actions have been identified among both macro- and micronutrients. Currently, the modes of action of individual immune-modulating substrates, and their effects on clinical outcomes, are being examined. At present, some enteral formulas are available for the clinical setting which are enriched with selected immune-modulating nutrients. The purpose of the present paper is to review the scientific rationale of enteral immunonutrition. The major aspects considered are mucosal barrier structure and function, cellular defence function and local or systemic inflammatory response. It is notable that in critical illness the mucosal barrier and cellular defence are impaired and a reinforcement with enteral immunonutrition is desirable, while local or systemic inflammatory response should be down regulated by nutritional interventions. The results available from clinical trials are conflicting. Meta-analyses of recent trials show improvements such as reduced risk of infection, fewer days on a ventilator, and reduced length of intensive care unit and hospital stay. Thus, a grade A recommendation was proclaimed for the clinical use of enteral immune-modulating diets. Improvement in outcome was only seen when critical amounts of the immune-modulating formula were tolerated in patients classified as being malnourished. However, in other patients with severe sepsis, shock and organ failure, no benefit or even disadvantages from immunonutrition were reported. In such severe conditions we hypothesize that systemic inflammation might be undesirably intensified by arginine and unsaturated fatty acids, directly affecting cellular defence and inflammatory response. We therefore recommend that in patients suffering from systemic inflammatory response syndrome great caution should be exercised when immune-enhancing substrates are involved which may aggravate systemic inflammation.
在大量营养素和微量营养素中均已发现具有免疫调节作用的底物。目前，正在研究各种免疫调节底物的作用模式及其对临床结局的影响。目前，有一些肠内配方产品可用于临床，这些产品富含选定的免疫调节营养素。本文的目的是综述肠内免疫营养的科学依据。所考虑的主要方面包括黏膜屏障结构与功能、细胞防御功能以及局部或全身炎症反应。值得注意的是，在危重病中，黏膜屏障和细胞防御功能受损，肠内免疫营养有助于增强这些功能，而营养干预应下调局部或全身炎症反应。临床试验的结果相互矛盾。近期试验的荟萃分析显示出一些改善，如感染风险降低、机械通气天数减少、重症监护病房和住院时间缩短。因此，对于肠内免疫调节饮食的临床应用发布了A级推荐。只有当营养不良患者能够耐受关键量的免疫调节配方产品时，才会观察到结局改善。然而，在其他患有严重脓毒症、休克和器官衰竭的患者中，免疫营养并未显示出益处，甚至还出现了不利情况。在这种严重情况下，我们推测精氨酸和不饱和脂肪酸可能会不适当地加剧全身炎症，直接影响细胞防御和炎症反应。因此，我们建议，对于患有全身炎症反应综合征的患者，在使用可能加重全身炎症的免疫增强底物时应格外谨慎。
