Different enteral nutrition formulas and their effect on glucose homeostasis in critically ill patients

Hintergrund: Stress-induzierte Hyperglykämie findet sich häufig bei kritisch Kranken und ist mit einer erhöhten Sterblichkeit assoziiert. Studien in unterschiedlichen Patientenpopulationen legen den Schluss nahe, dass fettreiche Ernährungslösungen den Glukosestoffwechsel positiv beeinflussen können. Studienziele: In dieser prospektiven, randomisierten, klinischen Kohortenstudie, untersuchten wir, welchen Effekt eine glukosereiche bzw. fettreiche kontinuierliche enterale Ernährung auf unterschiedliche Parameter des Glukosestoffwechsels bei internistischen Intensivpatienten ausübt. Weiters evaluierten wir, wie sich verschiedene metabolische Parameter, gemessen mittels indirekter Kalorimetrie, unter diesen beiden Ernährungslösungen verändern. Patienten und Methodik: Insgesamt wurden 60 kritisch kranke Patienten, die auf unserer Stufe 3 Intensivstation aufgenommen wurden, randomisiert. Sie erhielten entweder eine fettreiche (Gruppe A, n=30) oder eine glukosereiche (Gruppe B, n=30) enterale Ernährung kontinuierlich für 7 Tage. Um den Energiebedarf jedes Patienten festzustellen, wurde am ersten Studientag, im nüchternen Zustand, eine indirekte Kalorimetrie durchgeführt. Diese wurde unter laufender Ernährungstherapie an den Tagen 3 und 7 wiederholt. Während dessen wurden täglich die Blutzuckerwerte, die Fläche unter der Kurve (AUC) für Glukose, der exogene Insulinbedarf, die Glukosevariabilität, Kalorien- und Substratzufuhr pro 24 Stunden sowie ernährungsbedingte Nebenwirkungen aufgezeichnet. Ergebnisse: Über die gesamte Studiendauer hatten die Patienten beider Gruppen vergleichbare für Glukosekonzentrationen (p=0.655), Glukose AUC (A: 758 (641-829) mg/dl/Tag vs. B: 780 (733-845) mg/dl/Tag, p=0.283) und einen vergleichbaren Insulinbedarf (A: 153.5 (45.3-281.5) IE vs. B: 167.9 (82.3-283.8) IE, p=0.525). Sie erhielten ähnliche Mengen enteraler Ernährung pro 24 Stunden. Der Grundumsatz war ebenfalls in beiden Gruppen ähnlich (A: 1556 (1227-1808) kcal/Tag vs. B: 1563 (13061789) kcal/Tag, p=0.882). Der Energieverbrauch stieg im Verlauf der Studie in Gruppe A signifikant an (p<0.0001), während er sich in Gruppe B nicht veränderte (p=0.097). Schlussfolgerung: Kontinuierlich verabreichte fettreiche bzw. glukosereiche enterale Ernährungslösungen beeinflussen den Blutzuckerspiegel und Insulinbedarf bei internistischen Intensivpatienten in ähnlicher Art und Weise. Jedoch zeigt sich nur bei jenen Patienten, die fettreich ernährt wurden, ein Anstieg in der ernährungsbedingten Thermogenese.Background: Stress hyperglycemia in critically ill patients is common and associated with increased mortality. Previous studies in different patient populations suggest that nutrition formulas high in fat content may beneficially influence blood glucose concentrations. Objectives: In this prospective randomized clinical cohort study, we compared various parameters of glucose homeostasis in response to either fat-based or glucose-based continuous enteral nutrition in medical critically ill patients. Furthermore, we evaluated how metabolic parameters, assessed by indirect calorimetry, change under those different nutrition formulas. Subjects and Methods: In total, 60 medical critically ill patients admitted to our tertiary intensive care unit were randomized to receive fat-based (group A, n=30) or glucosebased enteral nutrition (group B, n=30) continuously for seven days. To determine energy demand, we performed indirect calorimetry in a fasting state at baseline. It was repeated on days 3 and 7 under nutrition therapy to evaluate energy expenditure. Glucose levels and glucose area under the curve (AUC), insulin demand, glucose variability, and calorie and substrate intake per 24 hours, as well as nutrition related side effects were assessed for 7 days. Results: Over the study duration, patients had similar average daily glucose concentrations (p=0.655), glucose AUC (A: 758 (641-829) mg/dl/day vs. B: 780 (733845) mg/dl/day, p=0.283), similar exogenous insulin demand (A: 153.5 (45.3-281.5) IE vs. B: 167.9 (82.3-283.8) IE, p=0.525), and received similar amounts of enteral nutrition per 24 hours. Resting energy expenditure was similar at baseline (A: 1556 (1227-1808) kcal/day vs. B: 1563 (1306-1789) kcal/day, p=0.882). Energy expenditure increased substantially over time in group A (p<0.0001), but not in group B (p=0.097). Conclusion: Fat-based and glucose-based enteral nutrition formulas influence plasma glucose concentrations and insulin demand similarly, yet diet-induced thermogenesis only increased in critically ill patients receiving fat-based enteral nutrition.Abweichender Titel laut Übersetzung der Verfasserin/des VerfassersArbeit an der Bibliothek noch nicht eingelangt - Daten nicht geprüftMedizinische Universität Wien, Diss., 2019(VLID)514858

Fasting Serum Taurine-Conjugated Bile Acids Are Elevated in Type 2 Diabetes and Do Not Change With Intensification of Insulin

Context: Bile acids (BAs) are newly recognized signaling molecules in glucose and energy homeostasis. Differences in BA profiles with type 2 diabetes mellitus (T2D) remain incompletely understood. Objective: The objective of the study was to assess serum BA composition in impaired glucose-tolerant, T2D, and normal glucose-tolerant persons and to monitor the effects of improving glycemia on serum BA composition in T2D patients. Design and Setting: This was a cross-sectional cohort study in a general population (cohort 1) and nonrandomized intervention (cohort 2). Patients and Interventions: Ninety-nine volunteers underwent oral glucose tolerance testing, and 12 persons with T2D and hyperglycemia underwent 8 weeks of intensification of treatment. Main Outcome Measures: Serum free BA and respective taurine and glycine conjugates were measured by HPLC tandem mass spectrometry. Results: Oral glucose tolerance testing identified 62 normal-, 25 impaired glucose-tolerant, and 12 T2D persons. Concentrations of total taurine-conjugated BA were higher in T2D and intermediate in impaired-compared with normal glucose-tolerant persons (P = .009). Univariate regression revealed a positive association between total taurine-BA and fasting glucose (R = 0.37, P <.001), postload glucose (R = 0.31, P <.002), hemoglobin A(1c) (R = 0.26, P <.001), fasting insulin (R = 0.21, P = .03), and homeostatic model assessment-estimated insulin resistance (R = 0.26, P = .01) and an inverse association with oral disposition index (R = -0.36, P <.001). Insulin-mediated glycemic improvement in T2D patients did not change fasting serum total BA or BA composition. Conclusion: Fasting taurine-conjugated BA concentrations are higher in T2D and intermediate in impaired compared with normal glucose-tolerant persons and are associated with fasting and postload glucose. Serum BAs are not altered in T2D in response to improved glycemia. Further study may elucidate whether this pattern of taurine-BA conjugation can be targeted to provide novel therapeutic approaches to treat T2

DDRGK1 in urine indicative of tubular cell injury in intensive care patients with serious infections

Background: Acute kidney injury (AKI) is a life threatening condition. Despite intensive care treatment the occurrence cannot be predicted as very little indicators exist for direct measurement when tubular epithelial cell injury takes place. We therefore searched for novel peptide indicators expressed at intracellular level at the proximal kidney tubule for its appearance in urine samples. Objectives: Establishing a test for urinary C20orf116 protein measurement. Patients and Methods: Generation of immunoreagents against C20orf116 also named DDRGK1. These were used to measure its presence in urine collected at 8-24 hours interval in a prospective study from 99 ICU patients at 4-6 time points. These patients received therapy because of serious infection and were categorized into 4 groups. Results: 1) Ten tested highly for C20orf116 undergoing AKI graded Failure or Loss (3210 ± 4268 ng/mL) according to RIFLE criteria, all requiring renal replacement therapy (RRT) out of them 9 died. 2) Six patients with pre-existing kidney disease developed AKI and required RRT but had much lower C20orf116 levels of (33 ± 19), two of them died. 3) In contrast, out of 11 patients undergoing AKI grade Risk or Injury, four tested positive for C20orf116 but to much lower extent (66 ± 43) who recovered fully. 4) Out of 72 patients 25 tested positive (18 ± 12 ng/mL) not fulfilling criteria of AKI but with serum creatinine (sCr) rises of 1.2-1.4 (n = 52). Healthy donors (n = 48) showed no detectable C20orf116 at any time point. Conclusions:C20orf116 excretion was detectable more than 24 hours before sCr rise could be measured; high level seemed to indicate severity of organ failure

Effects of Gastric Bypass and Gastric Banding on Bone Remodeling in Obese Patients with Type 2 Diabetes

CONTEXT: Roux-en-Y gastric bypass (RYGB) leads to high-turnover bone loss, but little is known about skeletal effects of laparoscopic adjustable gastric banding (LAGB) or mechanisms underlying bone loss after bariatric surgery. OBJECTIVE: To evaluate effects of RYGB and LAGB on fasting and postprandial indices of bone remodeling. DESIGN AND SETTING: Ancillary investigation of a prospective study at 2 academic institutions. PARTICIPANTS: Obese adults aged 21–65 years with type 2 diabetes who underwent RYGB (n = 11) or LAGB (n = 8). OUTCOMES: Serum C-terminal telopeptide (CTX), procollagen type 1 N-terminal propeptide (P1NP), and PTH were measured during a mixed meal tolerance test at baseline, 10 days and 1 year after surgery. Changes in 25-hydroxyvitamin D, polypeptide YY (PYY), glucagon-like peptide-1, glucose-dependent insulinotropic peptide, and insulin were also assessed. RESULTS: Fasting CTX increased 10 days after RYGB but not LAGB (+69 ± 23% vs +12±12%, P < .001), despite comparable weight loss at that time. By 1 year, fasting CTX and P1NP increased more after RYGB than LAGB (CTX +221 ± 60% vs +15 ± 6%, P<0.001; P1NP +93 ± 25% vs −9 ± 10%, P < .001) and weight loss was greater with RYGB. Changes in CTX were independent of PTH and 25-hydroxyvitamin D but were associated with increases in fasting PYY. Postprandial suppression of CTX was more pronounced after RYGB than LAGB at 10 days and 1 year postoperatively. CONCLUSIONS: RYGB is accompanied by early increases in fasting indices of bone remodeling, independent of weight loss or changes in PTH or 25-hydroxyvitamin D. LAGB did not affect bone markers. PYY and other enterohormonal signals may play a role in RYGB-specific skeletal changes