Nutrition & Gut Immunity - Atlantic Health · LP B cell phenotype changes Unactivated naïve (IgD+) Ag-stimulated (IgD-LPAM-1+) Effector/memory (CD44+) + LP 0 5 10 15 20 25 30 35

Nutrition & Gut Immunity

Kenneth A. Kudsk, MD FACS

Professor of Surgery

University of Wisconsin - Madison

Madison, Wisconsin

No conflicts of interest to disclose

Survival vs. Malnutrition (after septic peritonitis with E. coli)

% S

urv

ival

25

50

75

100

70%

Well

Nourished

10%

Depleted

60%

Depleted +

Re-fed

0%

TPN TPN + Fat

5%

Survival After Septic Peritonitis %

Surv

ival

20

60

80

100

Day 1 2

40

IG-TPN

Chow

IV-TPN

INFECTIONS

Enteral TPN

Pneumonia

all patients 11.8 % 31 %

severely inj. 18 % 56 %

Abscess

all patients 3.9 % 17.8 %


INFECTIONS

Enteral TPN

Pneumonia



Abscess

all patients 3.9 % 17.8 %


INFECTIONS

Enteral TPN

Pneumonia



WHY ????

The Principle

If nutrition support and enteral

feeding really make a difference,

there should be a reason... and it

should be measurable…and it should

be testable in clinical populations.

What is it?

OFFENSE ?

(the bacteria)

Bacterial Response to Stress

Bacterial Gene Expression

Non-Hostile Environment

Virulence Genes Downregulated

Stressors

Genes Upregulated

Adherence Appendages Attachment (e.g. Ps Lectins)

Stressors of Host - Microbe Status

Antibiotics

Vasoactive drugs

Block gastric acid

Opiates - Motility

TPN

Starvation

Mortality, Stress and Adhesion

Exotoxin A

or PA-1

%

Mortality

Alverdy, Ann Surg 2000

Exotoxin A

and PA-1

Stress

(Hepatectomy)

with PA-1 or

Exotoxin A

blocked

Stress

(Hepatectomy)

with PA-1 or

Exotoxin A

0

50

100

or the defense?

DEFENSE:

Mucosal immunity

Innate immunity

Cells and molecules that defend the

intestinal mucosal surface

Mucosal Immunity

Epithelium

PP

Naïve T/B lymphocyte

LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines

Organization

Respiratory Tract

Feeding Models

Chow

CED

IV-TPN

IG-TPN

Complexity,

Intermittency Route

Complexity

ISONIT / ISOCAL

Feeding Models

Chow

CED

IV-TPN

IG-TPN

Complexity,

Intermittency Route

Complexity

ISONIT / ISOCAL

Degree of Enteral Stimulation

Chow > CED > IG-TPN > IV-TPN

IV-TPN prevents lethal malnutrition

Mucosal Immunity

Epithelium

PP


LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines

Parenteral Nutrition

(No ENT stimulus)

Respiratory Tract

Secretory IgA

IgA Levels

0

50

100

150

200

250

300

0 1 2 3 4 5

0

50

100

150

200

250

300

0 1 2 3 4 5

Intestinal Respiratory

* *

*

* * *

* p < 0.05 vs Day 0

TPN days TPN days

Arch Surg. 1997;132:1303-1309.

0

20

40

60

80

100

% V

iral

Sh

ed

din

g

Route of Diet and Established Respiratory

Immunity

Chow IV-TPN CED 0

20

40

60

80

100

% M

ort

ali

ty a

t

48h

rs

(Ps. P

neu

mo

nia

)

Chow TPN CED Non-

immune Ann Surg. 1996;223(6):629-638. Ann Surg. 1999;229(2):272-278.

Mucosal Immunity: Cell Entry

Epithelium

PP


LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines


(No ENT stimulus)

Respiratory Tract

Secretory IgA

Entry into GALT: Cell/ Peyer’s

Patch Interactions

α4β7

L-selectin


Patch Interactions

α4β7

L-selectin

Blockade

Peyer’s patch cells

Chow

0

20

40

60

80

100

120

(%)


Patch Interactions

α4β7

L-selectin

Blockade


Chow α4β7

0

20

40

60

80

100

120

(%)


Patch Interactions

α4β7

L-selectin

Blockade


Chow α4β7

0

20

40

60

80

100

120

(%)


Patch Interactions

α4β7

L-selectin

Blockade


Chow α4β7

0

20

40

60

80

100

120

(%)


Patch Interactions

α4β7

L-selectin

Blockade


Chow α4β7

0

20

40

60

80

100

120

(%)

0

0.01

0.02

0.03

0.04

0.05

0.06

MA

dC

AM

-1 E

xp

res

sio

n (

mg

Ab

/ T

ota

l P

P)

0 4 8 12 24 48 72

MAdCAM-1Expression in PP

Hrs of TPN

0 4 8 12 24 48

Hrs of Refeeding

± SEM *p<.04 vs 0 and 4 hrs ± SEM †p<.02 vs 0 hrs

* *

† † †

Surgical Forum. 2001;52:194-196.

0

20

40

60

80

100

20

40

60

80

100

Lymphocyte Mass: PP & LP

% of

Chow

Chow 1 2 3 4 5 0 1 2 3 4

TPN Day Chow Recovery

Arch Surg. 1997;132:1303-1309.

GALT T Cells in Small Intestine of Adults:

Enteral Fed (21) vs. Without (6)

Okamoto, Fukatsu et al JPEN 2005; 29:56

GALT T Cells in Small Intestine of Adults:

Enteral Fed (21) vs. Without (6)


What happens to the cytokines?

Normal control of IgA by T cell

cytokines

Th1

IFN

TNF

Th2

IL-4

IL-5

IL-6

IL-10

IgA + -

What happens to the cytokines?

Control of IgA by T cell cytokines: IV-TPN

Th1

IFN

TNF

Th2

IL-4

IL-5

IL-6

IL-10

IgA + -

Mucosal Immunity: IgA Transport

Epithelium

PP


LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines


(No ENT stimulus)

TRANSPORT

Respiratory Tract

IgA Transport through the Epithelial Cell

Lamina propria

Plasma cell

Dimeric IgA

IgA-pIgR complex pIgR

Lumen

Mucosal epithelial cell

Secretory IgA

Chow CED IG-PN IV-PN

0

20

40

60

80

100

*

* †

†

~ 120 kDa

~ 94 kDa

Sm

all

In

tes

tin

al

pIg

R e

xp

res

sio

n (

%)

Intestinal pIgR Expression

* p<0.05 vs. Chow

† p<0.05 vs. CED

Sano Y,et al.JPEN 2007; 31:(5) 351-357 .

Mucosal Immunity

Epithelium

PP


LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines

IgA transport


(No ENT stimulus)

Respiratory Tract

Does any of this happen in

humans?


Does any of this happen in

injured humans?

Human Lung Response After Injury

Total IgA

Control

Epithelial Lining Fluid

(Vol) IgA / ELF

Control Control


Total IgA

Control Trauma

*


(Vol) IgA / ELF

Control Control


Total IgA

Control Trauma

* *


(Vol) IgA / ELF

Control Control Trauma


Total IgA

Control Trauma

* *


(Vol) IgA / ELF

Control Control Trauma Trauma

Respirato

ry I

gA

(ng)

200

150

100

50

* * p<0.05 vs all other groups

0 h 4 h 8 h 24 h

*

8 h w/

TNF blockade

* p<0.05 vs no blockade

Mouse Respiratory IgA Response to Trauma

Murine IgA response to injury

after PN ?

Completely stopped!

DEFENSE:

Mucosal immunity

Innate immunity

Cells and molecules that defend the

intestinal mucosal surface

Gut innate immunity

• Paneth cells are secretory

epithelial cells located at

the end of intestinal crypts

• Paneth cells secret the

antimicrobial proteins

lysozyme, defensins, and

secretory phospholipase

A2 type IIA (sPLA2-IIA)

into the crypt lumen.

Phospholipase A2

• 5 major families; ≥ 30 different enzymes

• Secretory PLA2 (sPLA2) ~ 10 sPLA2 enzymes ; Ca2+ dependent

- Catalytically → Phospholipid Release

- Inflammatory Regulation (Host)

- Bactericidal (Gut Lumen)

- Non-Catalytically → Prime Neutrophils

SIWF sPLA2 activity

0

2

4

6

8

10

12

14

Chow PN

sPL

A2 a

ctiv

ity (

FI/

min

/μL

) p<0.05

Unpaired t-test, Means ± SE

Intestinal Fluid sPLA2 Activity

0

1

2

3

4

5

Activity

CED Chow IG-PN PN

* vs. Chow, p < 0.001

† vs. PN, p < 0.001

*

*

*

†

†

†

Concentration sPLA2-IIA

Comparison of bactericidal activity in

chow and PN culture medium

-15

-10

-5

0

5

10

15

20

25

Chow

-LPS0

Chow

-LPS10

HBSS PN

-LPS0

PN

-LPS10

(% of HBSS)

ANOVA, Means ± SE, *p<0.05 vs. HBSS, †p<0.05 vs. PN-LPS0, ‡p<0.05 vs. PN-

LPS10

†

*†

*†‡

*

Can we reproduce GALT

effects in people who can’t

be fed enterally by adding

something to the TPN?





i.e. is it the lack of enteral

feeding or is it the TPN

itself?





Neuropeptides

Enteric Nervous System & Mucosal Immunity

Bombina

bombina

Gastrin-releasing peptide analogue

Gastrointestinal neuropeptide

Stimulates gut hormone release

- gastrin, CCK, neurotensin

Bombesin (BBS)

Mucosal Immunity on Bombesin

Epithelium

PP


LPL

Plasma cell IgA

Secretory IgA

pIgR

MLN

Thoracic duct

Blood stream

Th 2 cytokines

?

Respiratory Tract

Secretory IgA

T cell phenotype changes

LP CD4+CD25+LPAM-1+

0

5

10

15

20

25

30

35

LP

% o

f ly

mphocyte

s

Chow

PN

PN-BBS

P<.05

P<.05

with PN/DES

to Chow levels with bombesin

No CD8+ T cell changes anywhere

Almost all increase is Tregs

LP B cell phenotype changes

Unactivated naïve (IgD+)

Ag-stimulated (IgD-LPAM-1+)

Effector/memory (CD44+)

LP

0

5

10

15

20

25

30

35

40

45

IgD+ IgD-LPAM-1+ CD44+

% o

f ly

mphocyte

s

Chow

PN

PN-BBS

P<.05

P<.05

P<.05 P<.05

P<.05 P<.05

with PN/DES

with PN/DES

with PN/DES




SIWF sPLA2 activity

0

2

4

6

8

10

12

14

Chow PN

sPL

A2 a

ctiv

ity (

FI/

min

/μL

) p<0.05

Unpaired t-test, Means ± SE

Chow sPLA2 PN sPLA2 PN+BBS sPLA2

sPLA2 in Paneth Cell Granules: Chow, PN, PN+BBS

BOMBESIN

Lamina propria:

Increases T (Tregs) & B cells

Increases IgA- Airway and SI

Reverses PN-induced defect in

bacterial and viral immunity

Increases sPLA2 in Paneth cell

after PN but not SIWF-

bethanecol necessary as well

Systemic effects with lack

of enteral stimulation?

IgA

IgA

IL-4

IL-10

IFN ICAM-1

ICAM-1

Mucosa Endothelium

GALT

Cytokines and GALT Function

+ o

o

o o

o o

+

Mucosa Endothelium

GALT

Vascular Function + IV-PN

+

+

+ +

+

+

+

o o o o

o o

o

op

op

op

op

op

op

op

IL-10

IL-4

IFN

Gut PMN Priming (hemorrhagic shock)

Lung PMN Localization

Pulmonary injury

2ND Insult

Moore EE et al. J Trauma 1994; 37: 881-887

Does IV-PN prime the cells to a

second insult?

Feed Chow, IG-TPN or IV-TPN 5 days

Add stress: 15 minutes

of gut ischemia and 2 hours of reperfusion

Route of Feeding: Effects After

Gut I/R Injury

0

10

20

30

40

50

60

70

80

90

100

Chow IG-PN IV-PN

15 min I/R

Mortality at 72

hrs

*

0

0.1

0.2

0.3

0.4

0.5

Chow IG-PN IV-PN Chow IG-PN IV-PN

PERMEABILITY

Lung Liver

*

*

Lung Stain for CD18

(activation) after I/R Injury

IV-TPN

Chow IG-TPN

Fukatsu et al.Ann

Surg. 2001; 233

(5):660-668.

Documents

Nutrition & Gut Immunity - Atlantic Health · LP B cell phenotype changes Unactivated naïve (IgD+) Ag-stimulated (IgD-LPAM-1+) Effector/memory (CD44+) + LP 0 5 10 15 20 25 30 35