143 特 集 conditionally essential amino acid, グルタミンジペプチド (Glutamine dipeptide), 多臓器不全 Ⅰ はじめに 1980 2013 sepsis RE- 173 8605 2 11 1 Ⅱ 重症患者における生体内でのグルタミンの役割 1950 Eagle 1 1970 2 1/3 40 50
144 30 conditionally essential amino acid Ⅲ 実臨床におけるグルタミンの投与方法 L- S 99 L- 1 20 30 g 1 80 g 300 kcal L- 1.93 g glutamine dipeptide Fresenius Kabi Glamin Dipeptiven L- dipeptide Ⅳ 重症患者に対するグルタミン投与の臨床効果 2013 REDOXS meta analysis 1 meta analysis ICU 40RCT 3107 2013 Bollhalder meta analysis 11 RR 0.89 95 CI 0.77 1.04 RR 0.83 95 CI 0.72 0.95 2.35 95 CI 3.68 1.02 ESPEN 0.2 g/kg BW/day 9 3 critical illness 2014 Wischmeyer systematic review 26 RCT 2,484 RR 0.68, 95 CI 0.51 0.90, P 0.008 WMD 2.56, 95 CI 4.71 0.42, P 0.02 RR 0.86, 95 CI 0.73 1.02, P 0.09 4 Wischmeyer
145 RE- 0.5 g/ kg/day 19RCT 1243 Sandini WMD 2.67 95 CI 3.83 1.50 p 0.0001 RR 0.64 95 CI 0.38 1.07 p 0.087 5 RR 0.84, 95 CI 0.51 1.36 p 0.473 2 meta analysis 2009 Jiang meta analysis abstract APACHE score 10 30 RCT 3RCT 489 3RCT 6 van Zanten meta analysis Metaplus study 11RCT 1079 RR 0.94, 95 CI 0.65 1.36 p 0.74 RR 0.93, 95 CI 0.79 1.10 p 0.39 ICU WMD 1.36 days, 95 CI 5.51 2.78 p 0.52 WMD 4.73 days, 95 CI 8.53 0.90 p 0.02 subgroup RR 0.19, 95 CI 0.06 0.67 p 0.010 WMD 9.16, 95 CI 15.06 3.26 p 0.002 7 RCT randomized controlled trial, RR risk ratio, CI confidence interval, WMD weighted mean difference Ⅴ 重症患者に対するグルタミン投与は有害? 2009 SIGNET n 502 20.2 g odds ratio 1.18, 95 CI 0.82 1.70 8 2013 REDOXS n 1223 30 g+0.35 g/kg 28 32.4 vs 27.2 1.28 95 CI 1.00 1.64 P 0.049 9 1 50 g Na 2014 MetaPlus 72 ICU n 301 ω-3 IMHP
146 HP IMHP 1500ml 23 g 30 g 6 IMHP RR 1.57 95 CI 1.03 2.39 P 0.04 6 IMHP 54 vs 35 p 0.04 10 ICU 11,12 Ⅵ 最近のガイドライン変化 ESPEN 2006 13 2009 14 ICU 0.2 0.4 mg/kg/day L- e.g. 0.3 0.6 g/kg/day alanyl glutamine dipeptide REDOXS Heyland 15 REDOXS REDOXS 2013 2015 2015 5 meta analysis 2009 2013 2015 2014 MetaPlus SCCM/ASPEN 2009 16 2016 17 3 18 Ⅶ おわりに REDOXS RE-
147 文献 1 Eagle H, Oyama VI, Levy M et al. The growth response of mammalian cells in tissue culture to L glutamine and L glutamic acid. The Journal of biological chemistry 218 607 616, 1956 2 Windmueller HG, Spaeth AE Uptake and metabolism of plasma glutamine by the small intestine. The Journal of biological chemistry 249 5070 5079, 1974 3 Bollhalder L, Pfeil AM, Tomonaga Y et al. A systematic literature review and meta analysis of randomized clinical trials of parenteral glutamine supplementation. Clinical nutrition 32 213 223, 2013 4 Wischmeyer PE, Dhaliwal R, McCall M et al. Parenteral glutamine supplementation in critical illness a systematic review. Critical care 18 R76, 2014 5 Sandini M, Nespoli L, Oldani M et al. Effect of glutamine dipeptide supplementation on primary outcomes for elective major surgery systematic review and meta analysis. Nutrients 7 481 499, 2015 6 Jiang H, Chen W, Hu W et al. The impact of glutamine enhanced enteral nutrition on clinical outcome of patients with critical illness a systematic review of randomized controlled trials. Zhonghua shao shang za zhi Zhonghua shaoshang zazhi Chinese journal of burns 25 325 330, 2009 7 van Zanten AR, Dhaliwal R, Garrel D et al. Enteral glutamine supplementation in critically ill patients a systematic review and meta analysis. Critical care 19 294, 2015 8 Andrews PJ, Avenell A, Noble DW et al. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. BMJ 342 d1542, 2011 9 Heyland D, Muscedere J, Wischmeyer PE et al. A randomized trial of glutamine and antioxidants in critically ill patients. The New England journal of medicine 368 1489 1497, 2013 10 van Zanten AR, Sztark F, Kaisers UX et al. High protein enteral nutrition enriched with immune modulating nutrients vs standard high protein enteral nutrition and nosocomial infections in the ICU a randomized clinical trial. JAMA 312 514 524, 2014 11 Gottschalk A, Wempe C, Goeters C Glutamine in the ICU who needs supply? Clinical nutrition 32 668 669, 2013 12 Heyland DK, Elke G, Cook D et al. Glutamine and Antioxidants in the Critically Ill Patient A Post Hoc Analysis of a Large Scale Randomized Trial. JPEN Journal of parenteral and enteral nutrition 2014 13 Kreymann KG, Berger MM, Deutz NE et al. ESPEN Guidelines on Enteral Nutrition Intensive care. Clinical nutrition 25 210 223, 2006 14 Singer P, Berger MM, Van den Berghe G et al. ES- PEN Guidelines on Parenteral Nutrition intensive care. Clinical nutrition 28 387 400, 2009 15 http://wwwcriticalcarenutritioncom. 16 McClave SA, Martindale RG, Vanek VW et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine SCCM and American Society for Parenteral and Enteral Nutrition A.S.P.E.N.. JPEN Journal of parenteral and enteral nutrition 33 277 316, 2009 17 McClave SA et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine SCCM and American Society for Parenteral and Enteral Nutrition A.S.P.E.N. JPEN J Parenter Enteral Nutr 40 2 159 211, 2016 18. in press.