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Amino Acid Composition in Parenteral Nutrition

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Diet and Nutrition in Critical Care

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Abstract

Commercial parenteral nutrition (PN) solutions contain l-amino acid preparations that typically include all nine essential amino acids (AA) and varying numbers of nonessential amino acids over a range of concentrations. Data remain limited from rigorous randomized clinical trials (RCTs) and comparative effectiveness research (CER) on optimal doses of amino acids in PN. In addition, with some exceptions (e.g., glutamine (GLN)), little rigorous research on the clinical and metabolic impact of altered specific amino acid composition of the PN amino acid component has been performed in children or adults. An exception is the growing number of studies on the efficacy of GLN added to PN and emerging amino acid dose-response studies in very low birth weight infants requiring PN. Parenteral GLN added to complete PN may confer benefit in selected patients; however, several recent studies show no difference in clinical outcomes in intensive care unit (ICU) patients with use of PN supplemented with GLN dipeptides, while high-dose intravenous GLN dipeptide combined with high-dose enteral GLN in adult critically ill patients with multiple organ failure and/or shock may be deleterious. Additional data to define optimal GLN dosing and the patient subgroups may benefit after organ recovery are needed. Very limited data on the efficacy of PN supplemented with branched-chain amino acids (BCAA), arginine, taurine, or cysteine are available. Few clinical efficacy data are available to conclusively guide total or specific amino acid dosing in adult and pediatric patients in PN. Adequately powered RCTs are needed to better determine optimal amino acid dosing and PN amino acid composition in critically ill patients who require PN support.

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Abbreviations

AA:

Amino acids

ASPEN:

American Society for Parenteral and Enteral Nutrition

BCAA:

Branched-chain amino acids

BMT:

Bone marrow transplant

CER:

Comparative effectiveness research

CI:

Confidence interval

CPGs:

Clinical practice guidelines

EAA:

Essential amino acids

GLN:

Glutamine

HR:

Hazard ratio

ICU:

Intensive care unit

IV:

Intravenous

NEAA:

Nonessential amino acids

NEC:

Necrotizing enterocolitis

PN:

Parenteral nutrition

RCT:

Randomized controlled trial

References

  • Allingstrup MJ, Esmailzadeh N, Wilkens-Knudsen A, et al. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012;31:462–8.

    Article  PubMed  Google Scholar 

  • Amin HJ, Zamora SA, McMillan DD, Fick GH, Butzner JD, Parsons HG, Scott RB. Arginine supplementation prevents necrotizing enterocolitis in the premature infant. J Pediatr. 2002;140:425–31.

    Article  CAS  PubMed  Google Scholar 

  • Andrews PJ, Avenell A, Noble DW, et al. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. BMJ. 2011;342:d1542.

    Article  PubMed  Google Scholar 

  • ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 Suppl):1SA–38.

    Google Scholar 

  • Asrani V, Chang WK, Dong Z, et al. Glutamine supplementation in acute pancreatitis: a meta-analysis of randomized controlled trials. Pancreatology. 2013;13(5):468–74.

    Article  CAS  PubMed  Google Scholar 

  • Balasubramanian H, Nanavati RN, Kabra NS. Effect of two different doses of parenteral amino acid supplementation on postnatal growth of very low birth weight neonates, a randomized controlled trial. Indian Pediatr. 2013;50:1131–6.

    Article  PubMed  Google Scholar 

  • Biolo G. Protein metabolism and requirements. World Rev Nutr Diet. 2013;105:12–20.

    Article  PubMed  Google Scholar 

  • Bistrian BR. Glutamine and antioxidants in critically ill patients. N Engl J Med. 2013;369:482.

    Article  PubMed  Google Scholar 

  • Bollhalder L, Pfeil AM, Tomonaga Y, et al. A systematic literature review and meta-analysis of randomized clinical trials of parenteral glutamine supplementation. Clin Nutr. 2013;32:213–23.

    Article  CAS  PubMed  Google Scholar 

  • Brown RO, Compher C, American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. J Parenter Enteral Nutr. 2010;34:366–77.

    Article  Google Scholar 

  • Brown RO, Minard G, Ziegler TR. Parenteral nutrition. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern nutrition in health and disease. 11th ed. Philadelphia: Lippincott Williams and Wilkins; 2012. p. 1136–61.

    Google Scholar 

  • Btaiche IF, Mohammad RA, Alaniz C, et al. Amino acid requirements in critically ill patients with acute kidney injury treated with continuous renal replacement therapy. Pharmacotherapy. 2008;28:600–13.

    Article  CAS  PubMed  Google Scholar 

  • Bulbul A, Okan F, Bulbul L, et al. Effect of low versus high early parenteral nutrition on plasma amino acid profiles in very low birth-weight infants. J Matern Fetal Neonatal Med. 2012;25:770.

    Article  CAS  PubMed  Google Scholar 

  • Burattini I, Bellagamba MP, Spagnoli C, et al. Targeting 2.5 versus 4 g/kg/day of amino acids for extremely low birth weight infants: a randomized clinical trial. J Pediatr. 2013;163:1278–82.

    Article  CAS  PubMed  Google Scholar 

  • Cano NJ, Aparicio M, Brunori G, et al. ESPEN guidelines on parenteral nutrition: adult renal failure. Clin Nutr. 2009;28:401–14.

    Article  CAS  PubMed  Google Scholar 

  • Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370:1227–36.

    Article  CAS  PubMed  Google Scholar 

  • Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–17.

    Article  CAS  PubMed  Google Scholar 

  • Casaer MP, Wilmer A, Hermans G, et al. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med. 2013;187:247–55.

    Article  PubMed  Google Scholar 

  • Coeffier M, Dechelotte P. Combined infusion of glutamine and arginine: does it make sense? Curr Opin Clin Nutr Metab Care. 2010;13:70–4.

    Article  CAS  PubMed  Google Scholar 

  • Courtney-Martin G, Chapman KP, Moore AM, et al. Total sulfur amino acid requirement and metabolism in parenterally fed postsurgical human neonates. Am J Clin Nutr. 2008;88:115–24.

    CAS  PubMed  Google Scholar 

  • da Gama Torres HO, Vilela EG, da Cunha AS, et al. Efficacy of glutamine-supplemented parenteral nutrition on short-term survival following allo-SCT: a randomized study. Bone Marrow Transplant. 2008;41:1021–7.

    Article  PubMed  Google Scholar 

  • Déchelotte P, Hasselmann M, Cynober L, et al. l-alanyl-l-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study. Crit Care Med. 2006;34:598–604.

    Article  PubMed  Google Scholar 

  • Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. J Parenter Enteral Nutr. 2008;32:389–402.

    Article  CAS  Google Scholar 

  • Go YM, Jones DP. Thiol/disulfide redox states in signaling and sensing. Crit Rev Biochem Mol Biol. 2013;48(2):173–81.

    Article  CAS  PubMed  Google Scholar 

  • González-Contreras J, Villalobos Gámez JL, Gómez-Sánchez AI, et al. Cholestasis induced by total parenteral nutrition: effects of the addition of Taurine (Tauramin®) on hepatic function parameters; possible synergistic action of structured lipids (SMOFlipid®). Nutr Hosp. 2012;27:1900–7.

    PubMed  Google Scholar 

  • Grau T, Bonet A, Miñambres E, et al. The effect of l-alanyl-l-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients. Crit Care Med. 2011;39:1263–8.

    Article  CAS  PubMed  Google Scholar 

  • Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr. 2003;27:355–73.

    Article  Google Scholar 

  • Heyland D, Muscedere J, Wischmeyer PE, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013;368:1489–97.

    Article  CAS  PubMed  Google Scholar 

  • Hoffer LJ. How much protein do parenteral amino acid mixtures provide? Am J Clin Nutr. 2011;94:1396–8.

    Article  CAS  PubMed  Google Scholar 

  • Hoffer LJ, Bistrian BR. Appropriate protein provision in critical illness: a systematic and narrative review. Am J Clin Nutr. 2012;96:591–600.

    Article  CAS  PubMed  Google Scholar 

  • Jo S, Choi SH, Heo JS, et al. Missing effect of glutamine supplementation on the surgical outcome after pancreaticoduodenectomy for periampullary tumors: a prospective, randomized, double-blind, controlled clinical trial. World J Surg. 2006;30:1974–82.

    Article  PubMed  Google Scholar 

  • Kim M, Wischmeyer PE. Glutamine. World Rev Nutr Diet. 2013;105:90–6.

    Article  PubMed  Google Scholar 

  • Koletzko B, Agostoni C, Ball P, et al. ESPEN/ESPGHAN guidelines on paediatric parenteral nutrition. J Pediatr Gastroenterol Nutr. 2005;41:S1–87.

    Article  PubMed  Google Scholar 

  • Kuhn KS, Muscaritoli M, Wischmeyer P, et al. Glutamine as indispensable nutrient in oncology: experimental and clinical evidence. Eur J Nutr. 2010;49(4):197–210.

    Article  CAS  PubMed  Google Scholar 

  • Mager DR, Marcon M, Wales P, et al. Use of N-acetyl cysteine for the treatment of parenteral nutrition-induced liver disease in children receiving home parenteral nutrition. J Pediatr Gastroenterol Nutr. 2008;46:220–3.

    Article  PubMed  Google Scholar 

  • McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr. 2009;33:277–316.

    Article  Google Scholar 

  • Mehta NM, Compher C, A.S.P.E.N. Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support of the critically ill child. J Parenter Enteral Nutr. 2009;33:260–76.

    Article  Google Scholar 

  • Mohamad Ikram I, Quah BS, Noraida R, et al. A randomised controlled trial of glutamine-enriched neonatal parenteral nutrition in Malaysia. Singapore Med J. 2011;52:356–560.

    CAS  PubMed  Google Scholar 

  • Morris Jr SM. Arginine: beyond protein. Am J Clin Nutr. 2006;83:508S–12.

    CAS  PubMed  Google Scholar 

  • Murray SM, Pindoria S. Nutrition support for bone marrow transplant patients. Cochrane Database Syst Rev. 2009;(1):CD0029.

    Google Scholar 

  • Ong EG, Eaton S, Wade AM, et al. Randomized clinical trial of glutamine-supplemented versus standard parenteral nutrition in infants with surgical gastrointestinal disease. Br J Surg. 2012;99:929–38.

    Article  CAS  PubMed  Google Scholar 

  • Plauth M, Cabré E, Campillo B, et al. ESPEN guidelines on parenteral nutrition: hepatology. Clin Nutr. 2009;28:436–44.

    Article  PubMed  Google Scholar 

  • Poindexter BB, Ehrenkranz RA, Stoll BJ, et al. Parenteral glutamine supplementation does not reduce the risk of mortality or late-onset sepsis in extremely low birth weight infants. Pediatrics. 2004;113(5):1209–15.

    Article  PubMed  Google Scholar 

  • Preiser JC, Wernerman J. REDOXs: important answers, many more questions raised! J Parenter Enteral Nutr. 2013;37:566.

    Article  Google Scholar 

  • Riedijk MA, van Beek RH, Voortman G, et al. Cysteine: a conditionally essential amino acid in low-birth-weight preterm infants? Am J Clin Nutr. 2007;86:1120–5.

    CAS  PubMed  Google Scholar 

  • Rodas PC, Rooyackers O, Hebert C, et al. Glutamine and glutathione at ICU admission in relation to outcome. Clin Sci (Lond). 2012;122:591–7.

    Article  CAS  Google Scholar 

  • Scattolin S, Gaio P, Betto M, et al. Parenteral amino acid intakes: possible influences of higher intakes on growth and bone status in preterm infants. J Perinatol. 2013;33:33–9.

    Article  CAS  PubMed  Google Scholar 

  • Scheinkestel CD, Kar L, Marshall K, et al. Prospective randomized trial to assess caloric and protein needs in critically ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition. 2003;19:909–16.

    Article  CAS  PubMed  Google Scholar 

  • Schneider SM, Joly F, Gehrardt MF, et al. Taurine status and response to intravenous taurine supplementation in adults with short-bowel syndrome undergoing long-term parenteral nutrition: a pilot study. Br J Nutr. 2006;96:365–70.

    Article  CAS  PubMed  Google Scholar 

  • Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr. 2009;28:387–400.

    Article  PubMed  Google Scholar 

  • Soghier LM, Brion LP. Cysteine, cystine or N-acetylcysteine supplementation in parenterally fed neonates. Cochrane Database Syst Rev. 2006;CD004869.

    Google Scholar 

  • Spencer AU, Yu S, Tracy TF, et al. Parenteral nutrition-associated cholestasis in neonates: multivariate analysis of the potential protective effect of taurine. J Parenter Enteral Nutr. 2005;29:337–43.

    Article  CAS  Google Scholar 

  • Struijs MC, Schaible T, van Elburg RM, et al. Efficacy and safety of a parenteral amino acid solution containing alanyl-glutamine versus standard solution in infants: a first-in-man randomized double-blind trial. Clin Nutr. 2013;32:331–7.

    Article  CAS  PubMed  Google Scholar 

  • Sun LC, Shih YL, Lu CY, et al. Randomized, controlled study of branched chain amino acid-enriched total parenteral nutrition in malnourished patients with gastrointestinal cancer undergoing surgery. Am Surg. 2008;74:237–42.

    PubMed  Google Scholar 

  • Tubman TR, Thompson SW, McGuire W. Glutamine supplementation to prevent morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2008;CD001457.

    Google Scholar 

  • Umber A, Wolley MJ, Golper TA, et al. Amino acid losses during sustained low efficiency dialysis in critically ill patients with acute kidney injury. Clin Nephrol. 2014;81:93–9.

    Article  CAS  PubMed  Google Scholar 

  • Vanek VW, Matarese LE, Robinson M, et al. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract. 2011;26(4):479–94.

    Article  PubMed  Google Scholar 

  • Verbruggen SC, Coss-Bu J, Wu M, et al. Current recommended parenteral protein intakes do not support protein synthesis in critically ill septic, insulin-resistant adolescents with tight glucose control. Crit Care Med. 2011;39:2518–25.

    Article  CAS  PubMed  Google Scholar 

  • Vlaardingerbroek H, Vermeulen MJ, Rook D, et al. Safety and efficacy of early parenteral lipid and high-dose amino acid administration to very low birth weight infants. J Pediatr. 2013;163:638–44.

    Article  CAS  PubMed  Google Scholar 

  • Wang XY, Li N, Gu J, Li WQ, et al. The effects of the formula of amino acids enriched BCAA on nutritional support in traumatic patients. World J Gastroenterol. 2003;9:599–602.

    CAS  PubMed  Google Scholar 

  • Wernerman J. Glutamine supplementation. Ann Intensive Care. 2011;1:25.

    Article  PubMed Central  PubMed  Google Scholar 

  • Wernerman J, Kirketeig T, Andersson B, et al. Scandinavian glutamine trial: a pragmatic multi-centre randomised clinical trial of intensive care unit patients. Acta Anaesthesiol Scand. 2011;55:812–8.

    Article  CAS  PubMed  Google Scholar 

  • Wischmeyer PE, Dhaliwal R, McCall M, Ziegler TR, Heyland DK. Parenteral glutamine supplementation in critical illness: a systematic review. Crit Care. 2014;18:R76.

    Article  PubMed Central  PubMed  Google Scholar 

  • Wu G, Bazer FW, Davis TA, et al. Arginine metabolism and nutrition in growth, health and disease. Amino Acids. 2009;37:153–68.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Yue C, Tian W, Wang W, et al. The impact of perioperative glutamine-supplemented parenteral nutrition on outcomes of patients undergoing abdominal surgery: a meta-analysis of randomized clinical trials. Am Surg. 2013;79:506–13.

    PubMed  Google Scholar 

  • Ziegler TR. Parenteral nutrition in the critically ill patient. N Engl J Med. 2009;361:1088–97.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Ziegler TR. Glutamine. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, editors. Modern nutrition in health and disease. 11th ed. Philadelphia: Lippincott Williams and Wilkins; 2012. p. 464–76.

    Google Scholar 

  • Ziegler T, May A, Hebbar G, et al. Glutamine dipeptide-supplemented parenteral nutrition in surgical ICU patients: results of an American randomized, double-blind, multicenter trial. Clin Nutr Suppl. 2012;7:265.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Medical Intensive Care, Department of Medicine, Erciyes University School of Medicine, Kayseri, Turkey

    Kursat Gundogan

  2. Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA

    Thomas R. Ziegler

  3. Nutrition and Metabolic Support Service, Atlanta Clinical and Translational Science Institute, Emory University Hospital, Room GG-23, 1364 Clifton Road, 30322, Atlanta, GA, USA

    Thomas R. Ziegler

Authors
  1. Kursat Gundogan
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  2. Thomas R. Ziegler
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Correspondence to Thomas R. Ziegler .

Editor information

Editors and Affiliations

  1. Department of Nutrition, King's College London, London, United Kingdom

    Rajkumar Rajendram

  2. School of Medicine, King's College London, London, United Kingdom

    Victor R. Preedy

  3. Department of Biomedical Sciences, University of Westminster, London, United Kingdom

    Vinood B. Patel

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Gundogan, K., Ziegler, T.R. (2014). Amino Acid Composition in Parenteral Nutrition. In: Rajendram, R., Preedy, V., Patel, V. (eds) Diet and Nutrition in Critical Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8503-2_158-1

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  • DOI: https://doi.org/10.1007/978-1-4614-8503-2_158-1

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