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Immunonutrition

Was ist das und wo hilft sie wirklich?

Immunonutrition – meaning and efficacy

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Intensivmedizin und Notfallmedizin

Abstract

Immunonutrition describes the enteral or parenteral administration of certain substrates (arginine, omega-3 fatty acids, nucleotides, glutamine and antioxidants) with a putative immunomodulating function. Thus far, with the exception of glutamine and antioxidants, these immunomodulating substrates have not been examined separately but only in various combinations to establish their clinical efficacy.

In critically ill patients who predominantly require parenteral nutrition, there is evidence from large meta-analyses that parenteral glutamine supplementation may significantly lower septic morbidity and mortality. Therefore, parenteral glutamine supplementation is currently part of all concepts and recommendations addressing nutritional issues in critical care.

With respect to selective parenteral or enteral application of arginine or omega-3 fatty acids, there are still insufficient data on clinical effects or side effects to allow a definitive conclusion for nutritional care in the critically ill.

Only one metaanalysis addressed the clinical importance of a selective antioxidant therapy. It was concluded that such a therapy lowered mortality rates by about one third. However, this effect was unrelated to an improvement of infectious morbidity. Still, parenteral antioxidant supplementation (especially of selenium) is currently considered beneficial in critically ill patients.

At the moment, two different substrate mixtures of various immunomodulating compounds are commercially available. One type contains arginine, omega-3 fatty acids, and antioxidants±glutamine (classic mixture), the other omega-3 fatty acids, dihomogamma linoleic acid and antioxidants (modified mixture). Due to the mixture concept, only summary effects can be examined clinically, and interactions between different substrates cannot be excluded.

According to large metaanalyses, there are neither beneficial nor detrimental effects of the classic mixture when used in unselected cohorts of critically ill patients. In patients with severe sepsis, negative side effects of the classical mixture may possibly exist (enhancement of immunosuppression in the specific immune system). Therefore, use of the classical mixture is not recommended in the latter patients.

On the other hand, there is increasing evidence for beneficial clinical effects of the modified mixtures in critically ill and also in septic patients. The modified mixture improved pulmonary function and outcome in ventilated patients significantly, and is currently incorporated into nutritional recommendations of various societies.

Zusammenfassung

Die Immunonutrition umfasst die enterale oder parenterale Zufuhr von Substraten (Arginin, Omega-3-Fettsäuren, Nukleotide, Glutamin und Antioxidantien), die alle immunmodulierend sein können. In der Praxis wurden diese immunmodulatorischen Substrate mit Ausnahme von Glutamin und den Antioxidantien bisher nicht getrennt, sondern nur in unterschiedlichen Kombinationen auf ihre klinischen Wirkungen hin untersucht.

Bei kritisch kranken Patienten, die überwiegend parenteral ernährt werden müssen, lässt sich anhand von großen Metaanalysen zeigen, dass eine parenterale Glutamin-Supplementierung die septische Morbidität und die Letalität allgemein signifikant senken kann. Somit ist die zusätzliche Glutaminzufuhr heute fester Bestandteil aller parenteralen Ernährungskonzepte und Therapieempfehlungen.

Für die isolierte Zufuhr von Fischöl oder Arginin ist die Datenlage zur klinischen Effizienz derzeit sehr mangelhaft. Empfehlungen für den ernährungsmedizinischen Einsatz dieser Substrate bei Intensivpatienten sind deswegen nicht möglich.

Zur klinischen Relevanz einer selektiven Antioxidantien-Therapie existiert bisher nur eine einzige Metaanalyse. Zentrales Ergebnis war, dass eine derartige Therapie die Letalität signifikant um etwa ein Drittel senken kann, ohne jedoch gleichzeitig die infektiöse Morbidität relevant zu verändern. Trotzdem wird derzeit die routinemäßige parenterale Zufuhr speziell von Selen bei Intensivpatienten als günstig erachtet.

Zur enteralen Kombinationstherapie existieren derzeit zwei verschiedene Ansätze, nämlich einmal die klassische Immunonutrition (kombinierte Zufuhr von Arginin, Fischöl, Antioxidantien ± Glutamin) und dann die selektiveren Kombinationspräparate mit gleichzeitiger Zufuhr von Fischöl, Dihomogamma-Linolensäure und Antioxidantien. Aufgrund der unterschiedlichen Substratkombinationen können in der Praxis nur die Summationseffekte klinisch beurteilt werden, wobei Interaktionen zwischen einzelnen Substraten nicht ausgeschlossen werden können.

Nach aktueller Datenlage (große Metaanalysen) lässt sich für die klassische Immunonutrition bei Intensivpatienten im Allgemeinen weder ein klinischer Vorteil noch Nachteil zeigen. Bei Patienten mit schwerer Sepsis scheinen negative Auswirkungen (Verstärkung der Immunschwäche) denkbar, so dass gegenwärtig der Einsatz dieser klassischen Kombinationspräparate bei kritisch kranken Patienten nicht empfohlen wird.

Andererseits zeichnet sich für die selektiveren Kombinationspräparate eine Therapieempfehlung ab, die auch den kritisch kranken, septischen Patienten mit einschließt. Die kombinierte Zufuhr von Fischöl, Dihomogamma-Linolensäure und Antioxidantien verbesserte in mehreren kontrollierten Studien die Lungenfunktion bei ARDS-Patienten und die Letalität in der Sepsis.

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  1. Chirurgische Klinik, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Germany

    W. H. Hartl, P. Rittler & K.-W. Jauch

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  1. W. H. Hartl
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Hartl, W.H., Rittler, P. & Jauch, KW. Immunonutrition. Intensivmed 44, 64–73 (2007). https://doi.org/10.1007/s00390-007-0772-z

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