+ Effects of L-Carnosine and Its Zinc Complex (Polaprezinc) on PU Healing

ASPEN- The American Society for Parenteral &

Enteral NutritionPresented by: Emily Macieiski

+Background Information

Pressure Ulcers (PU) range from a few to 30% of patients in acute and long term care.

Increase mortality rate

Factors that cause them: Pressure Advanced age Malnutrition Deterioration of underlying dx

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+CAR and Zn

L-carnosine (CAR)- dipeptide composed of B-alanine and L-histidine that is abundant in long-living cells (muscles and nerves) Antioxidation, antiglycation, pH buffering, metal ion-

chelating, and antiaging activity

Zinc (Zn)- essential trace element required by various enzymes or transcription factors that are involved in cell replication, PRO synthesis, & repair systems after injury Significant role in wound healing Deficiency delays wound healing Excess amounts may inhibit healing and induce Cu and Fe

deficiencies

+PLZ

Polaprezinc (PLZ)- complex consisting of CAR and Zn with 1:1 molar ratio a synergistic effect of its 2 components on would healing is

anticipated

Animal study showed PLZ increased healing of skin incisions

In Europe and US, CAR and PLZ are available as dietary supplements

Aims of this study: Show effects of CAR and PLZ on PU healing Show how Zn contributes to PU healing by comparing effects of

CAR and PLZ Examine nutrition status including Zn in patients with PUs

+Methods

Patients recruited between October 2008- October 2012 from Japan

Inclusion criteria: At least 20 years old Must have at least 1 Stage II, III, or IV PU for ≥ 4 wks ESA for 1 ulcer no more than 24 cm Capable or oral ingestion

Exclusion criteria: Presence of clinical suspicion or diagnosis of osteomyelitis DM, peripheral VD, malignant tumor, acute illness, or severe dx Being in terminal phase of illness Use of corticosteroids Receiving T/P feeding d/t limited ability to consent to study participation

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+Methods cont…

Nonrandomized controlled trial, max 4 week follow up

42 patients 14 control 10PLZ (orally given 2 doses 75 mg/d PLZ – 116 mg CAR +

34 mg Zn) 18CAR (orally given 2 doses 58 mg/d)

Assessments made 1 x/week for PU severity. PUSH tool

Risk for PU development assessed by Braden Scale

Ulcer infection controlled during the study

+Methods cont…

Body weight measurements at week 0 and 4

Dietary intake recorded for 3 meals/day Mean intakes of energy, protein, Zn, Cu, Fe, and vitamins A, C, E

Blood biochemistry assessed CBC, liver fxn tests, transthyretin, CRP, urea, creatinine,

electrolytes, uric acid, total and HDL cholesterols, serum Zn, Cu, & Fe

Outcomes: Primary PU healing by PUSH score; Secondary changes in nutritional variables

A P value of <.05 was considered statistically significant.

+Results

Baseline: No significant difference in demographic and nutrition

parameters, the level of PU risk, and PU characteristics, except for PU location Most on sacrum

Use of supplements comparable

MWI of PUSH total score: Control: 0.8 ± 0.2, CAR: 1.6 ± 0.2, PLZ 1.8 ± 0.2

+Dietary Intakes

No significant differences among the 3 groups in any of these nutrient intakes.

Energy and protein daily intake comparable as well

Vitamins A,C,E- no significant differences among the group

+Blood biochemistry

After CAR treatment, serum Zn, Cu, Fe showed no significant changes

After PLZ treatment, serum Zn gradually and significantly increased, whereas serum Cu gradually and significantly decreased, serum Fe showed no changes

Serum transthyretin and albumin levels below RR. CRP elevated. No significant changes in any.

On average, CBC, liver fxn tests (except serum albumin), urea, creatinine, electrolytes, uric acid, and total and HDL cholesterol showed little deviation from RR, with no significant changes

+Discussion

First controlled clinical trial focusing on CAR or PLZ for treatments of PUs.

PU healed 2-2.2x more during the trial than the control group

No significant differences between the effects of the 2 agents Even though the effects of PLZ were greater than those of CAR

Few studies done to show effects of oral Zn alone

Couldn’t show how Zn alone helped with healing since the complex PLZ was used 36/42 in the study were already Zn deficient Serum Zn gradually after 4 wks d/t PLZ CAR did not affect serum Zn

+Discussion cont…

PLZ caused serum Cu to significantly Before: 65 ug/dL 48 in one pt Prolonged use can cause anemia

No pt experienced GI distress, impaired immune fxn, or HDL chol d/t high-dose Zn use

Compromised nutrition status (recent wt loss, underweight, reduced oral intake) are risk factors for PUs. 31% significant wt loss, 69% underweight, 74%

underweight at end Avg 38.19 kcal/kg & 1.52 g PRO/kg

+Discussion cont…

This study had high frequency of underweight patients ( cytokines in schizophrenia) that possibly triggered hypercatabolism and muscle wasting Ex: low serum albumin levels and high CRP Energy requirements may have needed to be more than the

recommended

Energy, protein, Cu, Fe, vitamins A, C, E related to PU healing, but intake of these didn’t differ significantly

Limitations: small sample size, lack of randomization, nonblinded, supplements

Conclusion: Results show that CAR and its Zn complex PLZ may be almost equally promising treatments for PUs. Shortened healing time- costs and improve quality of life

+Thought of the Day???

What as health professionals can we do to help treat pressure ulcers?