Renee M. Hinojosa NTDT 5340 December 12 th, 2011.
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Transcript of Renee M. Hinojosa NTDT 5340 December 12 th, 2011.
Renee M. HinojosaNTDT 5340
December 12th, 2011
Audience will be able to: ◦ Review the medical nutrition therapy for wound
healing◦ Identify the amino acids glutamine and arginine◦ Recognize glutamine and arginines’ metabolic
role in wound healing◦ Be familiar with the different studies that have
been done to establish these roles Pressure Ulcers, Diabetic Ulcers, Skin grafts, and Burns
◦ Discover future outlooks on glutamine and arginine in wound healing
20% protein loss within first two weeks of injury
Increased energy needs◦ 25-35 kcal/kg/d
Increased protein needs ◦ 1.5-2.0 g/kg/d
Additional vitamins and minerals◦ Selenium, Vitamin C, Vitamin A, Vitamin E, Zinc
Most abundant amino acid (AA) in the plasma
Conditionally essential Major metabolic fuel for intestinal mucosa
and cell proliferation◦ Fibroblasts, lymphocytes, epithelial cells,
macrophages Increases protein synthesis and
immunoglobulin a (IgA) Synthesized in muscle
Conditionally essential Beneficial in improving cardiovascular,
reproductive, pulmonary, gastrointestinal, liver and immune functions.
Facilitates wound healing, enhances insulin sensitivity, and maintains tissue integrity
Precursor for nitric oxide
Directly ◦ De novo synthesis
Citrulline◦ Synthesized FROM glutamine◦ Synthesis OF arginine.
Glutamine contributes 64% synthesis of arginine. Arginine can be hydrolyzed by hepatic
arginase to urea and ornithine which utlimately get converted to glutamine
Arginine and pressure ulcers◦ spinal cord injury
Observational study Dietitian involved
◦ Mini nutritional assessment◦ Weekly rounds
Oral nutrition supplement◦ Not exclusively arginine
Zinc and Vitamin C
Nutrition and Dietetics 2011 Dietitians Associations of Australia
2.5-fold greater rate of pressure ulcer healing for those who took supplement◦ Non-compliance – GI upset, dislike taste;
Dietitian recorded monitored weekly intake Wide Age range No exclusion of wounds Limited to one population Stages not specified
Multicenter, multicountry, randomized, controlled, double blind, parallel group trial◦ 43 participants ◦ Age: 18-90 years
Stage III or Stage IV Pressure Ulcer Excluded Diabetic Ulcers
◦ Also excluded patients on a dietary restrictive diet Not specified
Standard Nutritional Diets and Wound Care◦ Locally used protocols
Oral Nutrition Supplements◦ Arginine, Zinc, Vitamin A, Vitamin C, Selenium,
Copper, Folic Acid Suggests that healing could be multifactorial
Results◦ Significant differences in the reduction of the
ulcers and the difference in PUSH scores Most prominent in 1st weeks
Both Arginine and Glutamine Observational Study
◦ 16 participants Nutritional Supplement
◦ Arginine, Glutamine, Hydroxy-B-methylbutyrate (HMB)
◦ Energy needs: 20-22% of high quality protein Microalbuminuria – Kidney function
◦ Type II DM
Two Hypothesis◦ Reduction in Albuminuria◦ Arginine protects kidney
Results◦ Supplement decreased microalbuminuria by 47% ◦ 6 months
Food ulcers healed after this time Absence of randomization
◦ Role of HMB?
Prospective Study Healthy adults - skin transplantation
◦Reconstructive Surgery Mechanisms of Arginine
◦Compared healing Surgical wounds and normal skin
Inducible Nitric Oxide ◦Activated by arginine
Cells observed after supplementation◦PMNs and Marcrophages
Increased NO levels and wound tensile strength
Arginine was increased in all wounds Not increased in non-surgical wounds
◦Fibroblasts Increase in NO
More specific◦Arginine 2
Double Blind Control Study Skin Graft
◦ 35 subjects Intravenous Arginine Wound healing evaluated at donor site
◦ Angiogenesis◦ Reepithilialization◦ Neutrophil influx
Plasma arginine AA concentrations measured
Burns 37 (2011)
Two groups comparable◦ Age, nutritional status, metabolic and
inflammatory state No differences found in arginine group or
placebo Conclusion
◦ Arginine does not improve angiogenesis, reepethilialization or neutrophil influx
Arginine and Glutamine◦ No effect on pressure ulcers in elderly
Randomized control study Dietitian involved in assessment
◦ 26% were at risk for malnutrition Nutritional supplement
◦ Agrinine Did not increase NO in this population Did not enhance lympocyte proliferation
Lack of other vitamins and minerals Did not provide immune benefit
Randomized, controlled double blind clinical trial
Burn patients◦ 30-75% total surface area burned
Glutamine Supplementation – enteral nutrition and oral supplementation◦ Glutamine granules and glycine
Nutrition◦ All patients receiving the same amount of
nitrogen and energy Did not specify grams or kcals/kg
Immune function improved in glutamine groups
Hospital stay◦ 9 days shorter fro supplemented group
Results◦ Glutamine supplementation improves immune
function and facilitates wound healing
Arginine studied more than Glutamine◦ Individalization
Mixed results Bigger study groups needed for generalization
◦ Nutritional supplements Had more benefit
Vitamins, minerals, antioxidants Most subjects were not malnourished in all studies
Wound healing◦ Multifactorial
More studies needed◦ Individualizing both amino acids
Questions?
Eleanor S., Long S. Essentials of Nutrition Diet Therapy. St. Louis, MO: Sauders Elsevier: 2008. 125.
Wu, G. et al. Arginine Metabolism and Nutrition in Growth, Health and Disease. Amino Acids 2009;37:153-168.
Isenberg, J., Ridnour, L., Espey, M., Wink, D., Roberts, D. Nitric Oxide in Wound Healing. Microsurgery. 2005;25(5):442-451.
Coeffier, M., Dechelotte, P. Combined Infusion of Glutamine and Arginine: Does it Make Sense? Current Opinion in clinical Nutrition and Metabolic Care. 2010; 12:70-74.
Peng, X., Yan H., You, Z., Wang, P., Wang, S. Glutamine Granule-supplemented Enteral Nutrition Maintains Immunological Function in Severely Burned Patients. J Burns. 2006;32:589-593.
Atalay, M., Oksala, N., Lappalainen, J., Laaksonen, D., Sen, C., Roy, S. Heat Shock Proteins in Diabetes and Wound Healing. Curr. Protein Pept. Sci 2009;10(1):85-95.
Chapman, B., Mills, K., Pearce, L., Crowe, T. Use of an Arginine-Enriched Oral Nutrition Supplement in the Healing of Pressure Ulcers in Patients with Spinal Cord Injuries: An Observational Study. Nutrition and Dietetics. 2011;68: 208-213.
Van Anholt, et al,. Specific Nutritional Support Accelerates Pressure Ulcer Healing and Reduces Wound Care Intensity in Non-Malnourished Patients. J. Nut. 2010;26: 867-872.
Stechmiller J., et al., Arginine Supplementation Does Not enhance Serum Nitric Oxide Levels in Elderly Nursing Home Residents with Pressure Ulcers. Biological Research for Nursing. 2005;6:289-299.
Tatti, P., Masselli, L., Di Mauro, P., Pipicelli., Pipicelli, A., Barber, A. Effect of Nutritional Supplement Used for Diabetic Foot Ulcers on Microalbuminuria. Mediterr J Nutr Metab. 2011; 10.
Debats, I., Koneman, M., Booi, D., Bekers, O., Van der Hulst, R. Intravenous Arginine and Human Skin Graft Donor Site Healing: A Randomized Controlled Trial. J. Burns. 2011;37:420-426.
Campos, A., Groth, A., Branco, A. Assessment and Nutritional Aspects of Wound Healing. Current Opinion in Clinical Nutrition and Metabolic Care 2008 11;281-288.