Early Nutrition Support Modifies Immune Function in Patients Sustaining Severe Head Injury

Abstract

Background: Immunosuppression after severe head injury has been characterized by a depressed CD4 (T-helper/inducer)-CD8 (T-suppressor/cytotoxic) ratio and decreased T-lymphocyte responsiveness. Some investigators propose that this immunocompromized state is the result of an injury-associated hypermetabolic response and inadequate nutrient delivery during the immediate postinjury recovery phase. Previous observations from our institution demonstrated a preserved CD4-CD8 ratio in severe closed-head injury (CHI) patients receiving early parenteral nutrition (PN). It was unclear whether early PN or other aspects of patient care eliminated the characteristic depression in cellular immunity. The purpose of this study was to further investigate the effect of early PN on the immune function of CHI patients. Methods: Nine patients sustaining severe CHI were prospectively randomized to either early PN (n = 4) at day 1 or delayed PN (n = 5) at day 5. Total nutrient administration was delivered at 2 g of protein/kg per day and 40 nonprotein kcal/kg per day for at least the first 14 days of hospitalization. Analysis for T-lymphocyte expression of CD4 and CD8 cell surface antigens and interleukin-6 was performed on days 1, 3, 7, and 14 of hospitalization. T-lymphocyte activation in response to stimulation by concanavalin A (Con A), phytohemagglutinin (PHA), and pokeweed mitogens (PWM) was also assessed on these days. Results: Significant increases in total CD4 cell counts (2048 ± 194 to 2809 ± 129 vs 1728 ± 347 to 1825 ± 563, p < .05) and CD4% (42.6 ± 4.4% to 56.2 ± 2.6% vs 36.6 ± 6.6% to 36.6 ± 11.3%, p < .05) were observed at day 14 in patients receiving early vs delayed PN. An improved lymphocyte response from baseline to day 14 after Con A stimulation was demonstrated in the early PN group (3850 ± 1596 to 16144 ± 5024 cpm, p < .05). A significant rise in the CD4-CD8 ratio over baseline to day 14 was also noted in the early PN group (1.43 ± 0.17 to 2.38 ± 0.54, p < .05). Conclusions: The early aggressive nutrition support of CHI patients appears to modify immunologic function by increasing CD4 cells, CD4-CD8 ratios, and T-lymphocyte responsiveness to Con A. (Journal of Parenteral and Enteral Nutrition 19:387-392, 1995)

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References

Helling TS , Evans LL , Fowler DL , et al: Infectious complications in patients with severe head injury . J Trauma 11:1575-1577, 1988

Quattrocchi KB , Frank EH , Miller CH , et al: Impairment of helper T-cell function and lymphokine-activated killer cytotoxicity after severe head injury. J Neurosurg 75:766-773, 1991

Hoyt DB , Ozkan AN , Hansbrough JF , et al: Head injury: An immunologic deficit in T-cell activation. J Trauma 7:759-767, 1990

Lin CN , Howng SL , Liu WJ , et al: The significance of immunosuppression and hormonal alteration in neurotraumatology. Kaohsiung J Med Sci 8:202-212, 1992

Kudsk KA , Mowatt-Larssen C. , Oellerich S. , et al: Effect of rhIGF-1 and early TPN on immune depression after severe head injury. Arch Surg 129:66-71, 1994

Rosner B. : Fundamentals of Biostatistics. 2nd ed, Duxbury Press, Boston, 1986, p 505

Paulson G. , Ray R. , Sternberg J. : A rate sensing approach to urea measurement. Clin Chem 17:644, 1971

Ford TC , Rickwood D. : The routine isolation of blood-cell populations by centrifugation using single-step density barriers. Focus 15:2-5, 1993

Ott L. , Young B. : Nutrition in the neurologically injured patient. NCP 6:223-229, 1991

10.

Boop FA , Andrassy RJ , Brown WE , et al: Excessive nitrogen losses in severe brain injury. Neurosurgery 16:725, 1985

11.

Deutschman CS , Konstantinides FN , Raup S. , et al: Physiological and metabolic response to isolated closed-head injury. Part 2: Effects of steroids on metabolism. Potentiation of protein wasting and abnormalities of substrate utilization. J Neurosurg 66:388-395, 1987

12.

Alverdy JC , Chi HS , Sheldon GS The effect of parenteral nutrition on gastrointestinal immunity: The importance of enteral stimulation. Ann Surg 202:681-692, 1985

13.

Lutz H. , Peter K. , Van Ackern K. : Total parenteral alimentation in neurosurgical and neurological patients . IN Total Parenteral Alimentation, Manni C , Magalini SI , Serascio E. (eds) Excerpta Medica, Amsterdam, 1976, pp 214-217

14.

Twyman D. , Young AB , Ott L. , et al: High protein enteral feedings: A means of achieving positive nitrogen balance in head injured patients. JPEN 9:679-684, 1985

15.

Norton JA , Ott LG , McClain C. , et al: Intolerance to enteral feeding in the brain-injured patient . J Neurosurg 68:62-66, 1988

16.

Clifton GL , Robertson CS , Contant CF : Enteral hyperalimentation in head injury. J Neurosurg 62:186-193, 1985

17.

Hunt D. , Rowlands B. , Allen S. , et al: The inadequacy of enteral nutritional support in head injury patients during the early postinjury period [Abstract]. JPEN 9:121, 1985

18.

Rapp RP , Young B. , Twyman D. , et al: The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58:906-912, 1983

19.

Hoyt DB , Ozkan AN , Hansbrough JF et al: Head injury: An immunologic deficit in T-cell activation. J Trauma 30:759-767, 1990

20.

Lin CN Howng SL Liu WJ et al: The significance of immunosuppression and hormonal alteration in neurotramatology. Kaohsiung J Med Sci 8:202-212, 1992

21.

Wilmore DW , Smith RJ , O'Dwyer ST , et al: The gut: A central organ after surgical stress. Surgery 104;917-923, 1988

22.

Kudsk KA , Croce MA , Fabian TC , et al: Enteral versus parenteral feeding; Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 215;503-513, 1992

23.

Alverdy JC , Aoys E. , Moss GS : Total parenteral nutrition promotes bacterial translocation from the gut. Surgery 104:185-190, 1988

24.

Page C. : Early postoperative feeding: Pathophysiology, safety, and utility . Contemp Surg 32:14-20, 1987

25.

Graham TW , Zadrozny DB , Harrington T. : The benefits of early jejunal hyperalimentation in the head-injured patient . Neurosurgery 25:729-735, 1989

26.

Rapp RP , Hatton J. , Ott L. , et al: Specific problems associated with enteral nutrition in patients with head injury. Clin Nutr 12 (Suppl 1):S70-74, 1993

27.

Calandra T. , Gerain J. , Heumann D. , et al: High circulating levels of interleukin-6 in patients with septic shock: Evolution during sepsis, prognostic value, and interplay with other cytokines. Am J Med 91:23-29, 1991

28.

Pinsky MR , Vincent JL , Deviere J. , et al: Serum cytokine levels in human septic shock: Relation to multiple-system organ failure and mortality. Chest 103:565-575, 1993

29.

Casey LC , Balk RA , Bone RC Plasma cytokine and endotoxin levels correlate with survival in patients with sepsis syndrome. Ann Intern Med 119:771-778, 1993

30.

Schlüter B. , König B. , Bergmann U. , et al: Interleukin 6-A potential mediator of lethal sepsis after major thermal trauma: Evidence of increased IL-6 production by peripheral blood mononuclear cells. J Trauma 31:1663-1670, 1991