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7. Perioperative nutrition: Recommendations from the ESPEN expert group

Author

Lobo, D, Gianotti, L, Adiamah, A, Barazzoni, R, Deutz, N, Dhatariya, K, Greenhaff, P, Hiesmayr, M, Hjort Jakobsen, D, Klek, S, Krznaric, Z, Ljungqvist, O, Mcmillan, D, Rollins, K, Panisic Sekeljic, M, Skipworth, R, Stanga, Z, Stockley, A, Stockley, R, Weimann, A, Lobo D. N., Gianotti L., Adiamah A., Barazzoni R., Deutz N. E. P., Dhatariya K., Greenhaff P. L., Hiesmayr M., Hjort Jakobsen D., Klek S., Krznaric Z., Ljungqvist O., McMillan D. C., Rollins K. E., Panisic Sekeljic M., Skipworth R. J. E., Stanga Z., Stockley A., Stockley R., Weimann A., Lobo, D, Gianotti, L, Adiamah, A, Barazzoni, R, Deutz, N, Dhatariya, K, Greenhaff, P, Hiesmayr, M, Hjort Jakobsen, D, Klek, S, Krznaric, Z, Ljungqvist, O, Mcmillan, D, Rollins, K, Panisic Sekeljic, M, Skipworth, R, Stanga, Z, Stockley, A, Stockley, R, Weimann, A, Lobo D. N., Gianotti L., Adiamah A., Barazzoni R., Deutz N. E. P., Dhatariya K., Greenhaff P. L., Hiesmayr M., Hjort Jakobsen D., Klek S., Krznaric Z., Ljungqvist O., McMillan D. C., Rollins K. E., Panisic Sekeljic M., Skipworth R. J. E., Stanga Z., Stockley A., Stockley R., and Weimann A.

Abstract

Background & aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14–15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Published
2020

8. Perioperative nutrition : Recommendations from the ESPEN expert group

Author

Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N. E. P., Dhatariya, K., Greenhaff, P. L., Hiesmayr, M., Hjort Jakobsen, D., Klek, S., Krznaric, Z., Ljungqvist, Olle, McMillan, D. C., Rollins, K. E., Panisic Sekeljic, M., Skipworth, R. J. E., Stanga, Z., Stockley, A., Stockley, R., Weimann, A., Lobo, D. N., Gianotti, L., Adiamah, A., Barazzoni, R., Deutz, N. E. P., Dhatariya, K., Greenhaff, P. L., Hiesmayr, M., Hjort Jakobsen, D., Klek, S., Krznaric, Z., Ljungqvist, Olle, McMillan, D. C., Rollins, K. E., Panisic Sekeljic, M., Skipworth, R. J. E., Stanga, Z., Stockley, A., Stockley, R., and Weimann, A.

Abstract

Background & aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14–15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient., Funding Agency:European Society for Clinical Nutrition and Metabolism (ESPEN), Luxemborg

Published
2020
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23. Carbohydrates and insulin resistance in clinical nutrition : Recommendations from the ESPEN expert group.

Author

Barazzoni, R, Deutz, N E P, Biolo, G, Bischoff, S, Boirie, Y, Cederholm, T, Cuerda, C, Delzenne, N, Leon Sanz, M, Ljungqvist, O, Muscaritoli, M, Pichard, C, Preiser, J C, Sbraccia, P, Singer, P, Tappy, L, Thorens, B, Van Gossum, A, Vettor, R, Calder, P C, Barazzoni, R, Deutz, N E P, Biolo, G, Bischoff, S, Boirie, Y, Cederholm, T, Cuerda, C, Delzenne, N, Leon Sanz, M, Ljungqvist, O, Muscaritoli, M, Pichard, C, Preiser, J C, Sbraccia, P, Singer, P, Tappy, L, Thorens, B, Van Gossum, A, Vettor, R, and Calder, P C

Abstract

Growing evidence underscores the important role of glycemic control in health and recovery from illness. Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to help lessen glycemic variability and its negative health consequences when nutritional support is administered. Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional recommendations for carbohydrate utilization and management in nutritional support. The main conclusions were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing glucose control relative to nutritional support.

Published
2017
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24. Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group

Author

UCL - SSS/LDRI - Louvain Drug Research Institute, Barazzoni, R, Deutz, N E P, Biolo, G, Bischoff, S, Boirie, Y, Cederholm, T, Cuerda, C, Delzenne, Nathalie M., Leon Sanz, M, Ljungqvist, O, Muscaritoli, M, Pichard, C, Preiser, J C, Sbraccia, P, Singer, P, Tappy, L, Thorens, B, Van Gossum, A, Vettor, R, Calder, P C, UCL - SSS/LDRI - Louvain Drug Research Institute, Barazzoni, R, Deutz, N E P, Biolo, G, Bischoff, S, Boirie, Y, Cederholm, T, Cuerda, C, Delzenne, Nathalie M., Leon Sanz, M, Ljungqvist, O, Muscaritoli, M, Pichard, C, Preiser, J C, Sbraccia, P, Singer, P, Tappy, L, Thorens, B, Van Gossum, A, Vettor, R, and Calder, P C

Abstract

Growing evidence underscores the important role of glycemic control in health and recovery from illness. Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to help lessen glycemic variability and its negative health consequences when nutritional support is administered. Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional recommendations for carbohydrate utilization and management in nutritional support. The main conclusions were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing glucose control relative to nutritional support.

Published
2017

26. Glutamine extraction by the gut is reduced in depleted [corrected] patients with gastrointestinal cancer

Author

van der Hulst, R R, von Meyenfeldt, M F, Deutz, N E, and Soeters, P B

Subjects
Male, Intestinal Absorption, Glutamine, Humans, Female, Research Article, Aged, Gastrointestinal Neoplasms
Abstract

OBJECTIVE AND SUMMARY BACKGROUND DATA: Glutamine is an important fuel for the intestinal mucosa. However, glutamine pools may become depleted in the cancer-bearing host as a result of tumor consumption and diminished production due to nutritional depletion. As human data are lacking, the authors investigated glutamine extraction by different sites of the human intestine, including tumor and the potential relation with the degree of nutritional depletion. METHODS: Thirty-two patients with gastrointestinal malignancies were studied. Blood from an artery and veins draining jejunum, ileum, colon, or tumor were sampled. Depletion was estimated by the percentage ideal body weight. RESULTS: Fractional glutamine extraction rate in the jejunum was 24%, three times higher than in ileum and colon. Percentage ideal body weight correlated with arterial glutamine levels (r = 0.5275, p = 0.003). In addition, arterial glutamine concentrations were correlated with extraction in the ileum (r = -0.8411, p < 0.001). Colon-containing tumor did not extract more glutamine than did nontumor-containing colon. CONCLUSIONS: Glutamine is a quantitatively more important substrate for the proximal intestine than for the distal gut. Nutritional depletion results in decreased arterial glutamine concentration, which in turn results in diminished extraction. Colon cancer does not function as a glutamine trap and does not contribute to glutamine depletion.

Published
1997

27. In vivo amino acid fluxes in regenerating liver after two-thirds hepatectomy in the rat

Author

Brand, H. S., Deutz, N. E., Meijer, A. J., Jörning, G. G., Chamuleau, R. A., and Other departments

Abstract

Recent reports in the literature suggest that liver cell swelling following amino acid influx exerts anabolic and anti-catabolic effects. We have tested the possibility that rapid liver growth after partial hepatectomy is promoted by an increased amino acid-influx and that this is associated with an increased hepatic water content and a decreased rate of proteolysis. Two-thirds hepatectomy was performed in rats. Plasma liver flow and amino acid fluxes were measured after 24 or 48 h. Plasma liver flow was increased 24 and 48 h after partial hepatectomy or sham-operation in pair-fed animals. At these time points, in both groups there was a specific two- to threefold increased net hepatic uptake of the amino acids alanine and glycine, both being transported by the sodium-coupled amino acid transport system A/ASC. No changes in uptake of system N transported amino acids were observed. Both in partially hepatectomized and sham-operated pair-fed animals, the hepatic uptake of alanine and glycine was accompanied by a minor increase in tissue water (from 68 to 70%). Proteolysis, measured by leucine efflux, was only reduced in regenerating livers. We conclude that cell swelling is not an important factor in the stimulation of net protein synthesis during liver regeneration

Published
1995

48. Effects of long-term intravenous and intragastricl-arginine intervention on jejunal motility and visceral nitric oxide production in the hyperdynamic compensated endotoxaemic pig.

Author

Bruins, M. J., Luiking, Y. C., Soeters, P. B., Lamers, W. H., Akkermans, L. M. A., and Deutz, N. E. P.

Subjects
ARGININE, NITRIC oxide, ENDOTOXINS, GASTROINTESTINAL motility, NEUROTRANSMITTERS
Abstract

Alterations inl-arginine availability and nitric oxide (NO) synthesis in the intestinal muscularis may contribute to disturbed small intestinal motility that is observed during endotoxaemia. The aim of this study was to evaluate the effect ofl-arginine infusion on visceral NO production and jejunal motility in hyperdynamic compensated endotoxaemic pigs. Fasted and saline-resuscitated pigs were intravenously infused for 24 h with endotoxin (lipopolysaccharide, 50 ng kg−1 min−1) or saline (n = 6). Endotoxaemic pigs received either intravenousl-arginine (n = 6, 5.3 μmol kg−1 min−1) orl-alanine (isocaloric,n = 6). After 24 h, intravenousl-arginine orl-alanine infusion was continued intragastrically for 32-h in an enteral meal. During (0–24 h) and 1 day postendotoxaemia (48–56 h), jejunal motility was recorded by manometry and analysed for migrating motor complex (MMC) characteristics. Visceral NO production was measured at 24 and 48 h by15 N2-arginine-to-15 N-citrulline conversion. Visceral NO production was increased during endotoxaemia and was higher inl-arginine than inl-alanine-treated pigs. One day postendotoxaemia, visceral NO synthesis was still increased inl-arginine but not inl-alanine-treated animals. Endotoxaemia shortened the MMC cycle duration and accelerated the MMC propagation velocity. Both were restored byl-arginine. Similar motility disturbances were observed one day postendotoxaemia and were also compensated byl-arginine infusion. [ABSTRACT FROM AUTHOR]

Published
2004
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49. In vivo whole body and organ arginine metabolism during endotoxemia (sepsis) is dependent on mouse strain and gender.

Author

Luiking, Y. C., Hallemeesch, M. M., Vissers, Y. L. J., Lamers, W. H., and Deutz, N. E. P.

Subjects
ARGININE, METABOLISM, KIDNEYS, INTESTINES, LIVER, PROTEIN synthesis, LABORATORY mice, ARGININE metabolism, ANIMAL experimentation, HUMAN body, COMPARATIVE studies, HUMAN reproduction, IMMUNITY, RESEARCH methodology, MEDICAL cooperation, MICE, RESEARCH, EVALUATION research, ENDOTOXEMIA, SKELETAL muscle, LIPOPOLYSACCHARIDES
Abstract

Arginine metabolism involves various organs such as the kidney, the intestines, and the liver, which act together in an interorgan axis. Major pathways for arginine production are protein breakdown and de novo arginine production from citrulline; disposal of arginine is mainly used for protein synthesis or used by the enzymes arginase and nitric oxide synthase (NOS). To assess in vivo organ arginine metabolism under normal conditions and during endotoxemia we used a mouse model, and analyzed for gender and strain differences. Male and female inbred FVB and C57BL6/J mice were anesthetized and catheterized to study whole body, gut, liver, renal and muscle metabolism, using a stable isotope infusion protocol. Animals were treated with saline or lipopolysaccharide. Plasma arginine levels tended to be higher in female mice, although levels were not significantly different from male mice (P = 0.09). Although not all significantly different, whole body arginine production and arginine clearance tended to be higher in C57BL6/J mice (P < 0.1), while citrulline (P = 0.05), NO (P = 0.08), and de novo arginine (P < 0.01) production were higher in FVB mice. During endotoxemia, NO production increased in general (P < 0.05), while whole body arginine clearance increased in FVB mice, but decreased in C57BL6/J mice (P < 0.01). At the organ level, portal-drained viscera (PDV) arginine metabolism was higher in FVB than in C57BL6/J mice (P < 0.05). During endotoxemia, liver arginine metabolism decreased in general (P < 0.05), while strain differences existed for PDV, muscle, and renal arginine metabolism. In conclusion, stable isotope techniques in multicatheterized mice allow measurements of arginine metabolism on whole body and organ level. Strain and gender differences are present in arginine metabolism under physiological conditions and during endotoxemia. [ABSTRACT FROM AUTHOR]

Published
2004
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50. Overexpression of arginase alters circulating and tissue amino acids and guanidino compounds and affects neuromotor behavior in mice.

Author

de Jonge, Wouter J., Marescau, Bart, D'Hooge, Rudi, De Deyn, Peter P., Hallemeesch, Marcella M., Deutz, Nicolaas E.P., Ruijter, Jan M., Lamers, Wouter H., de Jonge, W J, Marescau, B, D'Hooge, R, De Deyn, P P, Hallemeesch, M M, Deutz, N E, Ruijter, J M, and Lamers, W H

Subjects
ARGININE, GUANIDINE, NEUROMUSCULAR diseases, PHYSIOLOGY, ARGININE metabolism, AMINO acids, ANALYSIS of variance, ANIMAL behavior, ANIMAL experimentation, COMPARATIVE studies, HYDROLASES, INTESTINES, RESEARCH methodology, MEDICAL cooperation, MICE, ORGANIC compounds, RESEARCH, EVALUATION research
Abstract

Arginine is an intermediate of the ornithine cycle and serves as a precursor for the synthesis of nitric oxide, creatine, agmatine and proteins. It is considered to be a conditionally essential amino acid because endogenous synthesis only barely meets daily requirements. In rapidly growing suckling neonates, endogenous arginine biosynthesis is crucial to compensate for the insufficient supply of arginine via the milk. Evidence is accumulating that the intestine rather than the kidney plays a major role in arginine synthesis in this period. Accordingly, ectopic expression of hepatic arginase in murine enterocytes by genetic modification induces a selective arginine deficiency. The ensuing phenotype, whose severity correlates with the level of transgene expression in the enterocytes, could be reversed with arginine supplementation. We analyzed the effect of arginine deficiency on guanidine metabolism and neuromotor behavior. Arginine-deficient transgenic mice continued to suffer from an arginine deficiency after the arginine biosynthetic enzymes had disappeared from the enterocytes. Postweaning catch-up growth in arginine-deficient mice was characterized by increased levels of all measured amino acids except arginine. Furthermore, plasma total amino acid concentration, including arginine, was significantly lower in adult male than in adult female transgenic mice. Decreases in the concentration of plasma and tissue arginine led to significant decreases in most metabolites of arginine. However, the accumulation of the toxic guanidino compounds, guanidinosuccinic acid and methylguanidine, corresponded inversely with circulating arginine concentration, possibly reflecting a higher oxidative stress under hypoargininemic conditions. In addition, hypoargininemia was associated with disturbed neuromotor behavior, although brain levels of toxic guanidino compounds and ammonia were normal. [ABSTRACT FROM AUTHOR]

Published
2001
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