谷氨酰胺对慢性阻塞性肺疾病免疫调理和代谢支持的作用

摘要

BACKGROUND: Nutritional support has become one of the most important therapeutic measures for malnutrition patients with chronic obstructive pulmonary disease (COPD), but some of the patients may fail to respond to nutritional treatment, which might be attributed to excessive inflammatory reaction that increases energy expenditure. Current nutritional support strategies have primarily focused on immunonutrition and metabolic support.OBJECTIVE: To study the effect of glutamine (Gln) on immunomodulation and metabolic support for patients with COPD.DESIGN: Randomized controlled trial.SETTING: Xinhua Hospital Affiliated to Shanghai Second Medical UniversityPARTICIPANTS: Totally 44 male patients with acute episode of COPD aged (75±9) years admitted between February and July 2002 were recruited in this study and randomly divided into treatment group (n=14) and control group (n=18).INTERVENTIONS: Only nutritional support was given in the control group while the treatment group received also glutamine treatment. All the patients received nutritional support with the total calorie intake of 1.5times of resting energy expenditure and dietary counseling for a regular diet (20% protein, 30% fat, and 50% carbohydrate) provided by a nutritionist. In the treatment group, the protein intake was reduced by 30 g and replaced by 30 g of Gln given at 10 g each time for three times a day via oral therapy. The nutritional indices were measured including body mass,body mass index, triceps skinfold thickness (TSF), creatinine-height index (CHI), prealbumin (PAlb), albumin (ALB), transferrin (TRF), fat mass (FM)]and the immune indices examined including immunoglobulin, complements, T cell subsets, interleukin (IL)-2, tumor necrosis factor-α (TNF-α),and C-reactive protein etc with also measurement of resting energy expenditure.MAIN OUTCOME MEASURES: Changes in nutritional and immune indices of patients before and after treatment.RESULTS: Thirty-two patients all entered the result analysis. [1] TSF: In the treatment group, TSF increased significantly from (6.3±1.8) mm before treatment to (8.7±1.6) mm after treatment (P ＜ 0.05), which was significantly greater than that in the control group after treatment [(7.3±1.3) mm,P ＜ 0.05]. [2]Palb: Palb was significantly increased after treatment in the treatment group from (0.15±0.04) to (0.23±0.05) g/L (P ＜ 0.01), which was significantly higher than that in the control group [(0.22±0.08) g/L, P＜ 0.05)]. [3]T cell subsets: in the treatment group, CD3 in creased significantly from 59±10 before treatment to 72±10 after treatment (P ＜ 0.01), a level significantly higher than that in the control group after treatment (62±9, P ＞ 0.01). [4] TNF-α :TNF-α in the treatment group before treatment was significantly higher than that after treatment [(72±7) vs (56±5) ng/mL,P ＜ 0.05)], and after treatment TNF-α in the treatment group was significantly lower than that in the control group [(67±11) ng/mL, (P ＜ 0.05)]. [5]Immunoglobin: IgG increased slightly after treatment in the treatment group[(12±3) vs (13±3) g/L, P ＜ 0.05)], which was higher than that in the control group [(12±4) g/L], but the difference was not significant (P ＜ 0.05).CONCLUSION: Gln treatment in addition to nutritional support can promote cellular immune function, depress excessive inflammatory reaction and lower energy expenditure in patients with COPD, and such strategy also further enhance the effect of nutritional support.%背景:营养支持已成为慢性阻塞性肺疾病的重要治疗措施之一,然而部分营养不良的慢性阻塞性肺疾病患者存在营养支持"无反应"的现象,可能与其炎症反应过度、能量消耗增加有关.近年来免疫营养和代谢支持已成为近代营养支持范畴中的研究重点.目的:探讨营养底物谷氨酰胺对慢性阻塞性肺疾病免疫调理和代谢支持的作用.设计:随机对照实验.单位:上海第二医科大学附属新华医院.对象:选择2002-02/2002-07慢性阻塞性肺疾病急性发作患者44例,均为男性.随机分为2组:治疗组14例和对照组18例,年龄(75±9)岁.干预:对照给予单纯营养支持,治疗组给予谷氨酰胺治疗.全部患者由营养师指导按1.5×静息能量消耗的总热量饮食,其中蛋白质占热量的20%,脂肪占热量的30%,碳水化合物占热量的50%,治疗组减少蛋白质30 g,以L-谷氨酰胺30 g替代,10 g/次,3次/d,口服.10 d后检测营养指标(包括体质量、体质量指数、肱三头肌皮褶厚度、肌酐升高指数、血清白蛋白、白蛋白、转铁蛋白、脂群等)和免疫指标(包括免疫球蛋白、补体、T细胞亚群、白介素2、肿瘤坏死因子-α,C反应蛋白等)及静息能量的消耗.主要观察指标:观察治疗前后两组患者营养和免疫指标的变化.结果:32例患者均进入结果分析.[1]肱三头肌皮褶厚度:治疗组组内比较治疗前明显低于治疗后[(6.3±1.8),(8.7±1.6)mm,(P＜0.05)],两组治疗后比较对照组明显低于治疗组(7.3±1.3,8.7±1.6)mm,(P＜0.05)].[2]前白蛋白:治疗组组内比较治疗前明显低于治疗后[(0.15±0.04,0.23±0.05)g/L,(P＜0.01)],两组治疗后比较治疗组高于对照组[(0.23±0.05,0.22±0.08)g/L,(P＜0.05)].[3]T细胞亚群:CD3治疗组组内比较治疗前明显低于治疗后[(59±10,72±10),(P＜0.01)],两组治疗后比较对照组明显低于治疗组[(62±9,72±10),(P＜0.01)][4]肿瘤坏死因子-α:治疗组组内比较治疗前明显高于治疗后[(72±7,56±5)ng/mL,(尸＜0.05)],两组治疗后比较治疗组明显低于对照组[(56±5)vs(67±11)ng/mL,(P＜0.05)].[5]免疫球蛋白:IgG治疗组组内比较治疗后高于治疗前[(13±3,12±3)g/L,(P＜0.05)],两组治疗后比较治疗组高于对照组[(13±3,12±4)g/L,(P＜0.05)].结论:在营养支持时给予谷氨酰胺强化治疗,不仅能改善慢性阻塞性肺疾病患者的细胞免疫功能、抑制炎症反应过度表达、降低机体的能量代谢消耗,还能更进一步增加营养支持的疗效.