Moldawer L L, Copeland E M
Department of Surgery, University of Florida College of Medicine, Gainesville 32610, USA.
Cancer. 1997 May 1;79(9):1828-39.
Protein calorie malnutrition remains endemic in hospitalized patients with both acute and chronic inflammation secondary to either cancer, chronic infectious processes, surgical injury, trauma, or burns. For the patients who cannot support themselves by enteral feeding, total parenteral nutrition remains an essential tool to minimize nitrogen losses and replete the depleted patient. However, in patients with active inflammation, nitrogen retention and lean tissue accretion are often impaired during total parenteral nutrition. Production of humoral factors, including proinflammatory cytokines, regulates many of the anabolic and catabolic processes that accompany inflammation.
The investigators' experience with total parenteral nutrition and proinflammatory cytokines is reviewed.
Cytokines such as interleukin-1, tumor necrosis factor-alpha, and, in particular, interleukin-6 appear to play central roles in both the loss of skeletal muscle protein and the initiation of the acute phase response to inflammation, as well as in modulating the utilization of exogenously administered nutrients.
Although innovative second- and third-generation nutritional formulations for the acutely ill patient may represent one approach for improving the effectiveness of total parenteral nutrition, understanding the humoral response to inflammation and modifying cytokine actions pharmacologically may prove equally effective in improving the utility of exogenously administered nutrients. Future studies need to determine whether the effectiveness of exogenously administered nutrients in the patient with inflammation can be improved by efforts to modulate the proinflammatory cytokine response through cytokine inhibitors or antagonists.
蛋白质热量营养不良在继发于癌症、慢性感染过程、手术损伤、创伤或烧伤的急慢性炎症住院患者中仍然普遍存在。对于无法通过肠内喂养维持自身营养的患者，全胃肠外营养仍然是尽量减少氮损失和补充衰竭患者营养的重要手段。然而，在有活动性炎症的患者中，全胃肠外营养期间氮潴留和瘦组织增加往往受损。包括促炎细胞因子在内的体液因子的产生，调节着许多伴随炎症的合成代谢和分解代谢过程。
回顾了研究人员在全胃肠外营养和促炎细胞因子方面的经验。
白细胞介素-1、肿瘤坏死因子-α，尤其是白细胞介素-6等细胞因子，似乎在骨骼肌蛋白丢失、炎症急性期反应的启动以及调节外源性营养物质的利用方面都起着核心作用。
尽管针对急性病患者的创新型第二代和第三代营养制剂可能是提高全胃肠外营养效果的一种方法，但了解对炎症的体液反应并通过药理学方法调节细胞因子作用，在提高外源性营养物质的效用方面可能同样有效。未来的研究需要确定，通过细胞因子抑制剂或拮抗剂调节促炎细胞因子反应的努力，是否能够提高炎症患者外源性营养物质的有效性。
