Glutamine to ICU patients
Author: Berg, Agneta
Date: 2007-12-07
Time: 09.00
Department: Institutionen för klinisk vetenskap / Department of Clinical Sciences
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thesis.pdf (380.0Kb)
Abstract
Intravenous glutamine supplementation to intensive care patients using a
glutamine containing dipeptide is now widely accepted in clinical
practice. There are evidences that glutamine supplementation of ICU
patients in need of parenteral nutrition improves mortality and
morbidity. The beneficial effects may be extended also to ICU patients on
combined enteral and parenteral nutrition and perhaps also to ICU
patients on enteral nutrition only. The effect of intravenous and/or
enteral glutamine supplementation to these patient groups is presently
not conclusive.
To facilitate clinical use of glutamine supplementation a number of
safety aspects are considered in this thesis work. The possibility to
administer the concentrated glutamine containing dipeptide solution in
peripheral vessels, and the metabolic tolerance of the dipeptide
formulation in ICU patients. Metabolic tolerance was assessed as the
absence of accumulation of the dipeptide, the absence of urinary losses
of the dipeptide, and the clearance of dipeptide and constituent amino
acids over time. Furthermore, the possible losses of the dipeptide and
the constituent amino acids during continuous renal replacement therapies
in ICU patients with kidney failure have not been clarified. The extent
of glutamine losses into the ultrafiltrate and the possibility that
exogenous supplemented glutamine will be lost into the ultrafiltrate to a
high degree have been addressed. Finally the concern that exogenous
provided glutamine may be converted into glutamate in the brain of head
trauma patients has been a concern. Head trauma patients some times
suffer from multiple organ failure and hence maybe treated with exogenous
glutamine. The suggestion of a connection between elevated intracerebral
glutamate levels and an unfavourable outcome in the head trauma patients
has been suggested. Therefore the possible connection between exogenous
glutamine supplementations and the level of free glutamate interstitially
in the brain and the balance of free glutamate and glutamine across the
brain was investigated.
The results show that a glutamine containing dipeptide in a concentrated
solution may be administered in the peripheral vein without any signs of
inflammatory reaction. In addition, the glutamine containing dipeptide is
metabolically well tolerated in ICU patients. The losses of exogenously
provided glutamine into the ultrafiltrate during continuous renal
replacement therapy are not different from a situation where no exogenous
supply is given. The increased loss into the ultrafiltrate is on the
contrary an argument to increase the exogenous supplementation of
glutamine. Finally, there was no connection between glutamine
supplementation and the level of free glutamate interstitially in the
brain and the balance of glutamate across the brain in head trauma
patients.
In addition, posthoc analyses were performed demonstrating that the
endogenous rate of appearance of glutamine (estimate of glutamine
production) in ICU patients is of the same magnitude as in healthy
individuals. And it is suggested that this endogenous production is not
inhibited by exogenous glutamine supplementation.
The results presented in this thesis work provide evidence that studies
to elucidate outcome advantages for ICU patients in relation to
intravenous glutamine supplementation are safe and can be encouraged.
Furthermore new insights in glutamine production and handling of
exogenous glutamine supplementation were gained.
List of papers:
I. Berg A, Forsberg E, Wernerman J. (2002). "The local vascular tolerance to an intravenous infusion of a concentrated glutamine solution in ICU patients." Clin Nutr 21(2): 135-9
Pubmed
II. Berg A, Rooyackers O, Norberg A, Wernerman J. (2005). "Elimination kinetics of L-alanyl-L-glutamine in ICU patients." Amino Acids 29(3): 221-8
Pubmed
III. Berg A, Norberg A, Martling CR, Gamrin L, Rooyackers O, (2007). "Glutamine kinetics during intravenous glutamine supplementation in ICU patients on continuous renal replacement therapy." Intensive Care Med. 33(4): 660-6
Pubmed
IV. Berg A, Bellander BM, Wanecek M, Gamrin L, Elving A, Rooyackers O, Ungerstedt U, Wernerman J. (2006). "Intravenous glutamine supplementation to head trauma patients leaves cerebral glutamate concentration unaffected." Intensive Care Med 32(11): 1741-6
Pubmed
V. Berg A, Bellander BM, Wanecek M, Norberg Å, Ungerstedt U, Rooyackers O, Wernerman J. (1970). "The pattern of amino acids exchanges across the brain is unaffected by intravenous glutamine supplementation in head trauma patients." Clinical Nutrition (Submitted)
I. Berg A, Forsberg E, Wernerman J. (2002). "The local vascular tolerance to an intravenous infusion of a concentrated glutamine solution in ICU patients." Clin Nutr 21(2): 135-9
Pubmed
II. Berg A, Rooyackers O, Norberg A, Wernerman J. (2005). "Elimination kinetics of L-alanyl-L-glutamine in ICU patients." Amino Acids 29(3): 221-8
Pubmed
III. Berg A, Norberg A, Martling CR, Gamrin L, Rooyackers O, (2007). "Glutamine kinetics during intravenous glutamine supplementation in ICU patients on continuous renal replacement therapy." Intensive Care Med. 33(4): 660-6
Pubmed
IV. Berg A, Bellander BM, Wanecek M, Gamrin L, Elving A, Rooyackers O, Ungerstedt U, Wernerman J. (2006). "Intravenous glutamine supplementation to head trauma patients leaves cerebral glutamate concentration unaffected." Intensive Care Med 32(11): 1741-6
Pubmed
V. Berg A, Bellander BM, Wanecek M, Norberg Å, Ungerstedt U, Rooyackers O, Wernerman J. (1970). "The pattern of amino acids exchanges across the brain is unaffected by intravenous glutamine supplementation in head trauma patients." Clinical Nutrition (Submitted)
Issue date: 2007-11-16
Rights:
Publication year: 2007
ISBN: 978-91-7357-423-5
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