1. Advanced Clinical Immuno Nutrition & Its Application
Soly James
Chief Dietician
S.L.Raheja hospital-A Fortis Associate
Mahim, Mumbai

2. A high proportion of patients in hospital are malnourished and that malnourishment impairs immune function.
The capacity for nutrients to modulate the actions of the immune system and, to affect clinical outcome has thus become an important issue in clinical practice.
(McWhirter & Pennington, 1994)

3. Immunonutrition Immunonutrition is defined as modulation of the
activities of the immune activation by nutrients or
specific food items fed in amounts above those normally
encountered in the diet
Immunomodulatory substance interfere with 3 basic area of the immune responses directly or indirectly;
the mucosal barrier function
the cellular defence function and
the local or systemic inflammatory response

4. Conditions associated with low immunity
Trauma
(Accidents & Burns)
Illness & Stress
Post Operative complication
Surgery
Cancer
Critically ill

5. Trauma , surgery & critically ill
Induce hormonal, metabolic & inflammatory changes
Stress response
Glycolysis, Lipolysis
Proteolysis
Auto-catabolism
Pro-inflammatory cascades
Immuno-suppression

6. Peripheral Blood Mononuclear Cell

7. Key Processes
Initiated by secretion of the pro-inflammatory cytokines interleukin (IL) 1, IL-6 and Tumour Necrosis Factor (TNF) α.
(1) creation of a hostile environment (for pathogens);
(2) provision of nutrients for the immune system from endogenous sources;
(3) strengthening of the protective and control systems against damage to healthy tissue by the immune response
(Grimble, 1998a)

8. Trauma and infection and burn Immuno-nutrition
Immune system activation
T& B Cells
Pro-inflammatory cytokines (IL-1&6, TNF)
glucose
Immunonutrients (glutamine)
Nutrient release from host tissue
S amino acid
Glutathione synthesis
Acute phase protein synthesis
Antioxidant defense strengthened

9. How can we enhance the Immunity?
Omega-3 fatty acids (PUFA-3)
“Conditionally Essential” amino acids
Arginine
Glutamine
Nucleotides
S. D. Heys et al Nutr. Hosp. (2004) XIX (6)
(Grimble,1998a; O.Flaherty & Bouchier Hayes, 1999)

10. IMF in the Critical Care…
Review of 26 studies (surgical, trauma, burn, mixed population)
Decreased infection rate:
Intra-abdominal abscess (74% reduction)
Nosocomial pneumonia (46% reduction)
Wound infections (54% reduction)
2.25 less vent days
1.6 less ICU days
3.4 less hospital days
reduces significantly the rate of severe mucosal toxicity during concomitant chemoradiotherapy for advanced local-regional squamous cell carcinomas of the head and neck.
Journal of Clinical Oncology, 2008 ASCO Annual Meeting Proceedings
Montejo, Clinical Nutrition, 2003, Kenneth A. Kudsk Annu. Rev. Nutr. 2006

11. Omega 3 Fatty Acids Inflammatory response Cardiac arrhythmias
Inflammatory response
Cardiac arrhythmias
Tissue microperfusion
Graft function
Cancer in cell lines
Limits omega-6 immune suppression
Maturation of CNS
Clearance
Biological regulators
Cell membrane structure and function
Influences membrane fluidity
Alters receptors activity
Eicosanoid metabolism
Cytokine production
Gene expression
Clinical data
Biochemical data
Intensive Care Med Nov;34(11): Crit Care. 2009;13(3):305.

12. L-Arginine
L-arginine is converted in the body into a chemical called nitric oxide.
Vasodilator
Stimulates the release of growth hormone & insulin
Improves recovery after surgery
L-arginine with RNA and EPA
reduce the recovery time
reduce infections
improve wound healing
Improves immune system in people with head and neck cancer
Improves helper T-cell numbers (lymphocyte proliferation)
American Journal of Critical Care. 2004
Heyland DK al (2001) JAMA 286,

13. Glutamine One of the 20 amino acids
Glutamine is a nonessential amino acid, which becomes “conditionally essential” during periods of catabolic stress
When the body is stressed, it releases high levels of hormone cortisol into the bloodstream which can lower the body's stores of glutamine
Buchman AL, Am J Clin Nutr, 2001

14. Why Glutamine?
During stress- drastic reduction in the glutamine level (more than 50%)
Requirement increases in critical illness
Synthesis rate is very less
Demand increases but rate of synthesis does not increase
Only BCAA – is not sufficient because synthesis of glutamine from BCAA is limited
Normal Diet might provide 3-5 gms glutamine/day

15. GLN Therapy GI Tract Major source of energy for enterocytes
Supports nucleotide biosynthesis
May protect epithelial cells against endotoxin
Enhances HSP expression post stress
Immune Cell function
Major source of energy for proliferating cells
Supports neutrophil killing & macrophage function
Vital for appropriate cytokine secretion
Kidney
Acid base regulation
NH3 metabolism
Muscle
Increase protein synthesis
Lungs
Major source of energy for endothelial cells

16. Glutamine & Cancer Chemotherapy Radiotherapy
Mucositis, Stomatitis, Enterocolitis, Bacterial translocation, Endotoximia
Radiotherapy
Abdominal pain, bloody diarrhea, malabsorption and bacterial translocation because of…
- Destruction of crypt cells
- Decreased villous height
- Ulceration
- Necrosis of GI epithelium
Glutamine and cancer. J Nutr. 2001;131
Clin J Oncol Nurs, 2002

17. Glutamine Dosage Clinical Condition Dosage Critical condition
0.57 g / kg bw /day
Before chemotherapy/radiation treatment
5-10 g / day
During chemotherapy/radiation treatment
20-30 g /day
BMT
Paediatric oncology
0.65 gm /kg bw/day

18. Contraindications End stage liver diseases End stage kidney diseases
Elderly people who have decreased kidney function

19. Dietary Nucleotides Building blocks for DNA and RNA.
Conditionally essential in stressed states
Improves T-cell function 
Required for almost all cell activity and growth
Essential for rapidly replicating cells to help support immune function
Benefits of supplementation:
Protein synthesis
Liver recovery
Digestion
Intestinal repair

20. When to feed an IMF?
Immune Modulating Formulations (supplemented with agents such as arginine, glutamine, nucleic acid, omega-3 fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), being cautious in patients with severe sepsis (Grade A).
SCCM/ASEPN Critical Care Nutrition Guidelines, 2009

21. (Cowley et al. 1996; Arnalich et al. 2000).

22. Pharmaconutrients can positively or negatively effect clinical outcome just as any other pharmacologic agent would
Administer the right nutrients, in the right amounts, at the right time

23. Thank You…

24. ZINC:3mg (as Zinc Sulphate monohydrate)
A critical element
Small deficiency is a disaster.
Role in tissue repair.
Helps the body use carbohydrate, protein, and fat.
Helps to maintain proper immune function, including promoting wound healing.
Maintaining a sense of taste and smell.
Maintaining normal vitamin A levels and usage.

25. SELENIUM: 15mcg (as L-Selenomethionine)
Essential trace mineral required for normal human health and reproduction.
Needed by certain enzymes that help with normal body functions.
Aids in protein synthesis, and enhances fertility and growth and development.
An anti-oxidant-thus helps protect the body from damaging effects of free radicals.
May also prevent or slow tumor growth.