Nutrition and Immunological Factors in Spinal Cord Injury. Intensive Review Course: Denver 2017 Frederick Frost MD Heather Asthagiri MD

Transcription

1 Nutrition and Immunological Factors in Spinal Cord Injury Intensive Review Course: Denver 2017 Frederick Frost MD Heather Asthagiri MD

2 Nutrition Scope of the problem (acute setting) Initial weight loss is common 10% reduction in pre-injury weight at 1 month Tetraplegia (30-50#) Paraplegia (10-35#) Loss of lean body muscle mass Ileus interferes with feeding Early vs. late feeding (<72 hours) Dysphagia up to 40 % incidence in CSCI (Abel 2004, Wolf & Meiners 2003) PAB levels

3 Nutrition after Acute SCI Trauma patients --- hypermetabolic state? Elevated urinary nitrogen excretion Difficult to establish a positive nitrogen balance Daily delivery 2 grams protein per kilo IBW Calories (Rodriquez DJ 1991, 1997) Harris-Benedict equation Standard use may lead to overfeeding

4 Nutrition and Ventilator Weaning Glucose feeding: decreases endogenous fat utilization and increases C02 production High protein diets may increase respiratory drive in patients who cannot respond High fat and low carbohydrate diet is probably best - reduces CO2 elimination, lowers the RQ Al-Saady NM 1989 Van den Berg B 1994

5 Nutrition in Chronic SCI Scope of the problem: BMR is 14-27% lower in chronic SCI Anthropometry can use triceps skin fold in SCI Poor diet associated with poverty, smoking, social isolation

6 Diet in Chronic SCI SCI patients ingest lower calorie loads but High in fat Low in carbohydrates Fiber intake very low Micronutrients? Vitamins A,C,E generally low intake B12 -? iatrogenic Calcium and Vitamin D A-tocopherol and carotenoids

7 Lipids and Proteins Lipids Elevated LDL, low HDL, elevated TG Lowest HDL values in highest injuries Activity levels Pressure ulcer treatment and prevention??? 30 Kcal/kg/day, 1.5 gm protein/kg/day Multiple small meals Special care with supplements

8 Diet Recommendations: Chronic SCI Calcium intake: 1200 mg Calories Tetraplegia 23 Kcal/kg/day Paraplegia 28 Kcal/kg/day Protein 0.8 gm/kg/day Fiber intake At least 15 gm/day < 30 % of calories from fat

9 Key References: Nutrition Kearns PJ, Thompson JD, Werner PC, Pipp TL, Wilmot CB. Nutritional and metabolic response to acute spinal-cord injury. JPEN J Parenter Enteral Nutr 1992;16(1):11-5. Rajan S, McNeely MJ, Warms C, Goldstein B. Clinical assessment and management of obesity in individuals with spinal cord injury: a review. J Spinal Cord Med 2008;31(4): Cassidy J. Nutritional Health Issues in People with High-Level Tetraplegia. Top Spinal Cord Inj Rehabil 1997;2(3):64-69.

10 Key References: Nutrition Nutritional support after spinal cord injury. Neurosurgery 2002;50(3 Suppl):S81-4. Rodriguez DJ, Clevenger FW, Osler TM, Demarest GB, Fry DE. Obligatory negative nitrogen balance following spinal cord injury. JPEN J Parenter Enteral Nutr 1991;15(3): Barber D, Foster D, Rogers S. The importance of nutrition in the care of persons with spinal cord injury. J Spinal Cord Med 2003;26(2):122-3.

11 Immune System: SCI Importance Septicemia in chronic SCI Implications for spinal cord cure Chronic illness and inflammation

12 Implications for spinal cord cure (Popovich 2008) Immunostimulatory and immunosuppressive interventions have shown positive results Prevention of tissue damage Prevention of secondary cell death Diminished axonal degeneration Promotion of remyelination Stimulation of axonal regeneration Facilitation of functional recovery

13 Immune modulation and spinal cord injury cure Activated macrophage trial (Knoller & Auerbach 2005) Human trial ASIA A <14 days Peripheral blood retrieval, activation by skin Injection into the spinal cord Immunization for SCI (Huang DW, David S) Tag unhelpful proteins (e.g. Nogo) Vaccination for SCI (passive and active immunity)

14 Documented Alterations after SCI Reduction in T helper / T suppressor ratio Impaired NK cell lethality Reduction in NK cell numbers Impaired phagocytosis Reduced clonal expansion of T cells to mitogen challenge

15 Impaired Function in SCI: Why? CNS control of the immune response Central Peripheral Neurotransmitters Neurohormones Psychological

16 Impaired Function in SCI: Why? Additional factors Diet Metabolic / Inactivity (Washburn RA, Nash MS) Pharmacological Aging

17 Inflammatory Response: SCI

18 Inflammatory Response: SCI Non cellular response to stress and injury Elevated CRP Elevated acute phase proteins Effects Seen in acute and chronic phases Elevated complement and SAA Elevated serum leptin Anemia, osteoporosis, loss of muscle, hyponatremia, cachexia, damages lungs and kidneys

19 Practical Considerations Immunization after SCI Waites K (1998,2008) most persons with SCI responded immunologically to one or more representative pneumococcal serotypes after immunization Immune response was unrelated to vaccination timing post injury. antibody concentrations were maintained in most persons for at least 1 year. Immunologic testing for people with frequent infection?

20 Thank you