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Does nutritional status affect the cytokine and acute phase protein response to elective surgery?
52
ESPEN
RESEARCH
FELLOWS
SYMPOSIUM
The me\enteric response to TPN was a surprising observation. high degree of variability reflects the small number of patients involved, but increments in blood flow in response to parenteral feeding were observed in all. This highlights the need for more detailed study of the central cardiovascular and mesenteric responses to TPN (cardiac output, heart rate and blood pressure). The abnormal mesenteric response recorded in the patients feeding via gastrostomy also needs to be investigated further. It would be worthwhile investigating different patient groups to assess whether this is an effect of prolonged feeding via gastrostomy or a consequence of the underlying pathology. The
vcrw~ Gngle bolu\ enteral nutrmon. in human.
Am J Phyvol
3. Pithannn 0. Takala Nitrogen
J. Poyhonen
gntrointe\tinsl
ESPEN
Fellowship.
4. Pullicino
E. Goldberg
metabolism reccwing
Julie Taylor.
LIZ Simpson and Tracey
5. Vemet
cyclic and continuow
0. Chrlrtin
parenteral w’ojeas.
D H, Ashanasi 1, Kinney
J M. Parenteral
nutrition
in
comparison
Am J Physiol
and uhwatc m patlax\
nutmion.
Clin SCI I9Y I:
E Jr, Jequier E. Enteral vem\
nienergy
metabolism
m healthy
1986: 1.50: E17-E5J. I A. Cowlry
A J. Fullwood
and high-cabohydrate
L F. Card~ovscular
meals in healthy young
1991: 261: Hl33&Hl436.
I A.
The effect of meal \i~e on the
responses to food mgeytion.
L. Jequier E. Contmuous
Does nutritional
status affect the cytokine and acute phase protein response to elective surgery? G. E. Curtis*, C. McAtear*, L. Formelat, A. Walsh’ and A. Shenkin’, Depts of ‘Clinical Chemistry. ‘Dietetics and ~Surgeq. Royal Liverpool University Hospital. Prescot Street. Lil,erpool L7, 8XW. UK. Introduction Following injury and infection, various immunological, inflammatory and hormonal changes occur to promote repair and healing, including the acute phase protein response (APPR). These changes are mediated by a number of endogenous factors, including the cytokines, with Interleukin-IB (IL-1B) and Tumour Necrosis Factor (TNFc() the early initiators of activation of the cytokine network. It is generally accepted that Interleukin-6 (IL-6) is the major inducer of the APPR in the liver (I ). Any condition which impairs the APPR and hence the ability to restore homeostasis may limit survival from injury. We have shown that malnutrition prior to surgery. attenuates the APPR and may thus in part explain the associated increase in postoperative morbidity (2). The cause of the attenuated APPR is unknown but may be cytokine mediated. Previous studies from our group have demonstrated a marked increase in plasma IL-6 postoperatively but have been unable to detect a consistent rise in plasma IL-1B or TNFa (3). The failure to detect IL-lb or TNFa in plasma could be due to their local. transient. paracrine release and rapid proteolytic degradation or to assay difficulties due to receptor binding or assay insensitivity or non-specificity. Recent studies have demonstrated the release of soluble receptors of TNF and production of IL-1 receptor antagonist (IL-lra) in sepsis. It has been suggested that TNF induces shedding of the soluble receptors which bind TNF and inhibit its biological activity (4). Production of small amounts of IL- I but large amounts of IL- lra appears to be the natural response to inflammation as a protective mechanism against the degenerative actions of IL- I. thus limiting
A J, Macdonald
and high-cabohydrate
Proc Nutr Sot 1993:
I A. Cardiovaxular
meals in healthy elderly
response\ to cuhjects.
Clin SCI 1993: 84: 263-270. 9. Sidery M B. Blachshaw gastric emptying
1987: 46: 1040-1047. 0. Christin
mrljw
I: II):3647.
52: 37A.
septic patients: effect of increasing nitrogen intake. Am J Clin Nutr 2. Nacht C-A, Schutz Y. Vemet
calorimetr\,
tc%tl parentrral
L. Shutr Y. Dnnforth
nutrition:
cardiovascular
high-fat D. Elwyn
Clin Nutr 199
x0: 571-582.
8. Sidery M B. Cowley
References I. Greig P
P. Albava E.
G R, Ella M. Energy expendituw
7. Sidery M B. Macdonatd
Stubbs for their help.
to TPN.
measured hy 24 h \+hot+hody
FubJects. Am J Physiol Trust and an
The authors would like to thank Jo Rawlings,
M. Ksri A. Miettinen
surgery: reaponw
responses to high-fat
This work was supported by a grant from the Wellcome
ot energy merabohm
xnd energy balance in depleted patjentr undergoing
6. Sidery M B. Macdonald
Acknowledgement
comparison
19X6; E524-E519.
csrhohydrate
P E. Macdonald
1 A. Mesenteric
in man and the deferential effect\
meal\.
blood flow and
of high fat and high
Gut 199.1: (In pres\).
the severity of the disease (5). IL-lra does not interact directly with either IL-la or IL-IB, but does inhibit IL-1 biological activity by competing with both IL- I a and IL- 1p for occupancy of the type I and type II IL- 1 receptors. The aims of the present study were to investigate the effect of nutritional status on the cytokine response. particularly IL-6. to elective surgery and to confirm the activation of the IL- I and TNF systems. Methods 19 patients. 10 male and 9 female. undergoing elective surgery for gastro-intestinal malignancies (gastrectomy n = 6, colectomy n = 5 and pancreatectomy n = 8) were studied. Their pre-operative nutritional status was assessed and patients classified as wellnourished or malnourished (cachectic) on the basis of recent weight loss (< or > 10%) and by anthropometric measurements, including body mass index (BMI) (> or < 18). mid-upper arm circumference and triceps skin fold thickness (above the 10th centile or below the 5th centile) (6). Blood samples were taken peri-operatively. pre-operatively at time of incision. 0. %. I, 2, 4. 6. and 8 h. and postoperatively at 12 h and on days l-5. EDTA plasma and serum were separated immediately and stored at -70°C until analysis for the measurement of C-reactive protein (CRP) as a marker of the APPR by immunoturbidimetry (Bayer Diagnostics Ltd), cortisol by radioimmunoassay (RIA) (Coat-A-Count, Diagnostic Products Corporation), IGF-1 by RIA following acid-ethanol extraction of binding proteins (Nichols Institute Diagnostics) and IL-6 by in-house Eluted STain bioAssay (ESTA bioassay), in which growth stimulation of a mouse B-cell hybridoma B9 cell line was measured by thiazolyl blue dye incorporation and cell numbers estimated on a microplate reader. The assay was standardized with recombinant human IL-6 (No 88/514) obtained from NIBSC, South Mimms. All samples were analysed at 8 doubling dilutions in duplicate to eliminate effects of inhibitors. IL-1B and TNFa were analysed by immunoenzymetric assay (EASIA, Medgenix Diagnostics). and IL-6 soluble receptor (IL-6sR). IL-l receptor antagonist (IL-lra), and
C‘l.lhK‘.\l. a......
200
AV-
150
CRF mg/l
IL-6 wh
I RI I’IOY
i:
IL-6 -
-
,,,,,,,,.....................“““’ *- -
4000
NI
(Jqp
I;-&,?
S-N:
g
.---
S-N=
p
l --
IL-Ire
3000
100
2000
50 1000
0
0 0.5
Time
the soluble TNF receptors RI and RI1 (sTNFR-I and sTNFR-II) hy sandwich enzyme immunoassay (Quantikine, British Bio-technology Products Ltd). Results Significant increases were seen postoperatively in serum CRP. cortisol and IL-6, with the IL-6 peak concentration between 6-X h preceding thar of CRP. There was an attenuated CRP response in the cachectic group which was statistically significant (p < 0.05) on days 2 and 3 postoperatively (cachectic group 164 * 58 mg/l and I28 k 42 mg/l respectively, wellnourished group 205 f 64 mg/l and X)9 * 44 mg/l respectively). There was no significant effect of pre-operative nutritional status on the IL-6 response. although the IL-6 tended to rise and fall earlier in the cachectic group. The plasma cortisol tended to rise more rapidly and fall more slowly in the cachectic group but with a significant difference only at 24 h postoperatively. This may reflect feedback between the adrenocortical and the cytokine systems. The figure exemplifies the CRP. IL-6 and soluble receptor response to elective surgery in a 6l-year-old cachectic male undergoing oesophago-gastrectomy for adenocarcinoma of stomach. Similar patterns of response were seen in al1 patients, whether cachectic or well-nourished. There was a significant APPR, meacured as CRP. which was preceded by a rapid rise and fall in IL-6. peaking at 6 h. The IL-6sR did not show a significant increase above pre-operative concentrations, but was present in serum at .5-200 times higher concentration than the IL-6. No rise in plasma IL-10 or TNFc( was observed throughout the time period of study for any of the patients with mean preoperative plasma concentrations of IO and 22 pg/ml respectively. However the IL-lra and sTNFI&I and sTNFR-II did increase Ggnificantly within 4-X h. In the above patient the rapid increa\e
(days)
and fall in IL-lra, detectable within I h and pcahing at 1 h with a concentration 3000 times greater than the plasma IL I. clexl! precedes the IL-6 peak which has a similar profile. The \TNF RI and sTNF RI1 both rose Ggnificantly with concentration\ 200 and 300 times higher than the plasma TNF respeclively. hut maintained a plateau level or continued to rise. The presence 01’ the soluble receptors of TNF and IL-lra in plasma reilecl the prior release of TNF and Il.-l, not detectable in the plasma. Indicating the pdracrine release and action of TNF and IL- I. Prellminsry \tudieh have not. to date. demonstrated an cl’fcct of nutritional status on the Il.-I or TNF re\pon\c\ III \urgcrv. hut will be further investigated. In conclusion therefore the IL-I and TNF \>stern\ WCI-~actlvalc‘d in responac to elective \urgery and preceded IL-h release mttr plasma. Nutritional status does alter the APPR but ha\ no \ignficant effect on the IL-6 response. The APPR therctorc depend\ upon a complex interaction of cytokine\. hormones and nutritional ctatus. Acknowledgement
References I. Hemrlch PC. Ca?tellJ V. Andu\ T. RlochcmJ IYYO::hT: h?l t, if, 2. CruickahanhA M. Hansel1D 7‘. Burn\ H J G. ShcnhmA Br I Surp lY89: 7’). Ifl-IhX. i. CruickhhanhA M. FraserW D. Bum\ H J (;. V:II~Damme J. ShenhlllA Clin SC11490: 7’): lhl&lhS
ESPEN
RESEARCH
FELLOWS
SYMPOSIUM
The me\enteric response to TPN was a surprising observation. high degree of variability reflects the small number of patients involved, but increments in blood flow in response to parenteral feeding were observed in all. This highlights the need for more detailed study of the central cardiovascular and mesenteric responses to TPN (cardiac output, heart rate and blood pressure). The abnormal mesenteric response recorded in the patients feeding via gastrostomy also needs to be investigated further. It would be worthwhile investigating different patient groups to assess whether this is an effect of prolonged feeding via gastrostomy or a consequence of the underlying pathology. The
vcrw~ Gngle bolu\ enteral nutrmon. in human.
Am J Phyvol
3. Pithannn 0. Takala Nitrogen
J. Poyhonen
gntrointe\tinsl
ESPEN
Fellowship.
4. Pullicino
E. Goldberg
metabolism reccwing
Julie Taylor.
LIZ Simpson and Tracey
5. Vemet
cyclic and continuow
0. Chrlrtin
parenteral w’ojeas.
D H, Ashanasi 1, Kinney
J M. Parenteral
nutrition
in
comparison
Am J Physiol
and uhwatc m patlax\
nutmion.
Clin SCI I9Y I:
E Jr, Jequier E. Enteral vem\
nienergy
metabolism
m healthy
1986: 1.50: E17-E5J. I A. Cowlry
A J. Fullwood
and high-cabohydrate
L F. Card~ovscular
meals in healthy young
1991: 261: Hl33&Hl436.
I A.
The effect of meal \i~e on the
responses to food mgeytion.
L. Jequier E. Contmuous
Does nutritional
status affect the cytokine and acute phase protein response to elective surgery? G. E. Curtis*, C. McAtear*, L. Formelat, A. Walsh’ and A. Shenkin’, Depts of ‘Clinical Chemistry. ‘Dietetics and ~Surgeq. Royal Liverpool University Hospital. Prescot Street. Lil,erpool L7, 8XW. UK. Introduction Following injury and infection, various immunological, inflammatory and hormonal changes occur to promote repair and healing, including the acute phase protein response (APPR). These changes are mediated by a number of endogenous factors, including the cytokines, with Interleukin-IB (IL-1B) and Tumour Necrosis Factor (TNFc() the early initiators of activation of the cytokine network. It is generally accepted that Interleukin-6 (IL-6) is the major inducer of the APPR in the liver (I ). Any condition which impairs the APPR and hence the ability to restore homeostasis may limit survival from injury. We have shown that malnutrition prior to surgery. attenuates the APPR and may thus in part explain the associated increase in postoperative morbidity (2). The cause of the attenuated APPR is unknown but may be cytokine mediated. Previous studies from our group have demonstrated a marked increase in plasma IL-6 postoperatively but have been unable to detect a consistent rise in plasma IL-1B or TNFa (3). The failure to detect IL-lb or TNFa in plasma could be due to their local. transient. paracrine release and rapid proteolytic degradation or to assay difficulties due to receptor binding or assay insensitivity or non-specificity. Recent studies have demonstrated the release of soluble receptors of TNF and production of IL-1 receptor antagonist (IL-lra) in sepsis. It has been suggested that TNF induces shedding of the soluble receptors which bind TNF and inhibit its biological activity (4). Production of small amounts of IL- I but large amounts of IL- lra appears to be the natural response to inflammation as a protective mechanism against the degenerative actions of IL- I. thus limiting
A J, Macdonald
and high-cabohydrate
Proc Nutr Sot 1993:
I A. Cardiovaxular
meals in healthy elderly
response\ to cuhjects.
Clin SCI 1993: 84: 263-270. 9. Sidery M B. Blachshaw gastric emptying
1987: 46: 1040-1047. 0. Christin
mrljw
I: II):3647.
52: 37A.
septic patients: effect of increasing nitrogen intake. Am J Clin Nutr 2. Nacht C-A, Schutz Y. Vemet
calorimetr\,
tc%tl parentrral
L. Shutr Y. Dnnforth
nutrition:
cardiovascular
high-fat D. Elwyn
Clin Nutr 199
x0: 571-582.
8. Sidery M B. Cowley
References I. Greig P
P. Albava E.
G R, Ella M. Energy expendituw
7. Sidery M B. Macdonatd
Stubbs for their help.
to TPN.
measured hy 24 h \+hot+hody
FubJects. Am J Physiol Trust and an
The authors would like to thank Jo Rawlings,
M. Ksri A. Miettinen
surgery: reaponw
responses to high-fat
This work was supported by a grant from the Wellcome
ot energy merabohm
xnd energy balance in depleted patjentr undergoing
6. Sidery M B. Macdonald
Acknowledgement
comparison
19X6; E524-E519.
csrhohydrate
P E. Macdonald
1 A. Mesenteric
in man and the deferential effect\
meal\.
blood flow and
of high fat and high
Gut 199.1: (In pres\).
the severity of the disease (5). IL-lra does not interact directly with either IL-la or IL-IB, but does inhibit IL-1 biological activity by competing with both IL- I a and IL- 1p for occupancy of the type I and type II IL- 1 receptors. The aims of the present study were to investigate the effect of nutritional status on the cytokine response. particularly IL-6. to elective surgery and to confirm the activation of the IL- I and TNF systems. Methods 19 patients. 10 male and 9 female. undergoing elective surgery for gastro-intestinal malignancies (gastrectomy n = 6, colectomy n = 5 and pancreatectomy n = 8) were studied. Their pre-operative nutritional status was assessed and patients classified as wellnourished or malnourished (cachectic) on the basis of recent weight loss (< or > 10%) and by anthropometric measurements, including body mass index (BMI) (> or < 18). mid-upper arm circumference and triceps skin fold thickness (above the 10th centile or below the 5th centile) (6). Blood samples were taken peri-operatively. pre-operatively at time of incision. 0. %. I, 2, 4. 6. and 8 h. and postoperatively at 12 h and on days l-5. EDTA plasma and serum were separated immediately and stored at -70°C until analysis for the measurement of C-reactive protein (CRP) as a marker of the APPR by immunoturbidimetry (Bayer Diagnostics Ltd), cortisol by radioimmunoassay (RIA) (Coat-A-Count, Diagnostic Products Corporation), IGF-1 by RIA following acid-ethanol extraction of binding proteins (Nichols Institute Diagnostics) and IL-6 by in-house Eluted STain bioAssay (ESTA bioassay), in which growth stimulation of a mouse B-cell hybridoma B9 cell line was measured by thiazolyl blue dye incorporation and cell numbers estimated on a microplate reader. The assay was standardized with recombinant human IL-6 (No 88/514) obtained from NIBSC, South Mimms. All samples were analysed at 8 doubling dilutions in duplicate to eliminate effects of inhibitors. IL-1B and TNFa were analysed by immunoenzymetric assay (EASIA, Medgenix Diagnostics). and IL-6 soluble receptor (IL-6sR). IL-l receptor antagonist (IL-lra), and
C‘l.lhK‘.\l. a......
200
AV-
150
CRF mg/l
IL-6 wh
I RI I’IOY
i:
IL-6 -
-
,,,,,,,,.....................“““’ *- -
4000
NI
(Jqp
I;-&,?
S-N:
g
.---
S-N=
p
l --
IL-Ire
3000
100
2000
50 1000
0
0 0.5
Time
the soluble TNF receptors RI and RI1 (sTNFR-I and sTNFR-II) hy sandwich enzyme immunoassay (Quantikine, British Bio-technology Products Ltd). Results Significant increases were seen postoperatively in serum CRP. cortisol and IL-6, with the IL-6 peak concentration between 6-X h preceding thar of CRP. There was an attenuated CRP response in the cachectic group which was statistically significant (p < 0.05) on days 2 and 3 postoperatively (cachectic group 164 * 58 mg/l and I28 k 42 mg/l respectively, wellnourished group 205 f 64 mg/l and X)9 * 44 mg/l respectively). There was no significant effect of pre-operative nutritional status on the IL-6 response. although the IL-6 tended to rise and fall earlier in the cachectic group. The plasma cortisol tended to rise more rapidly and fall more slowly in the cachectic group but with a significant difference only at 24 h postoperatively. This may reflect feedback between the adrenocortical and the cytokine systems. The figure exemplifies the CRP. IL-6 and soluble receptor response to elective surgery in a 6l-year-old cachectic male undergoing oesophago-gastrectomy for adenocarcinoma of stomach. Similar patterns of response were seen in al1 patients, whether cachectic or well-nourished. There was a significant APPR, meacured as CRP. which was preceded by a rapid rise and fall in IL-6. peaking at 6 h. The IL-6sR did not show a significant increase above pre-operative concentrations, but was present in serum at .5-200 times higher concentration than the IL-6. No rise in plasma IL-10 or TNFc( was observed throughout the time period of study for any of the patients with mean preoperative plasma concentrations of IO and 22 pg/ml respectively. However the IL-lra and sTNFI&I and sTNFR-II did increase Ggnificantly within 4-X h. In the above patient the rapid increa\e
(days)
and fall in IL-lra, detectable within I h and pcahing at 1 h with a concentration 3000 times greater than the plasma IL I. clexl! precedes the IL-6 peak which has a similar profile. The \TNF RI and sTNF RI1 both rose Ggnificantly with concentration\ 200 and 300 times higher than the plasma TNF respeclively. hut maintained a plateau level or continued to rise. The presence 01’ the soluble receptors of TNF and IL-lra in plasma reilecl the prior release of TNF and Il.-l, not detectable in the plasma. Indicating the pdracrine release and action of TNF and IL- I. Prellminsry \tudieh have not. to date. demonstrated an cl’fcct of nutritional status on the Il.-I or TNF re\pon\c\ III \urgcrv. hut will be further investigated. In conclusion therefore the IL-I and TNF \>stern\ WCI-~actlvalc‘d in responac to elective \urgery and preceded IL-h release mttr plasma. Nutritional status does alter the APPR but ha\ no \ignficant effect on the IL-6 response. The APPR therctorc depend\ upon a complex interaction of cytokine\. hormones and nutritional ctatus. Acknowledgement
References I. Hemrlch PC. Ca?tellJ V. Andu\ T. RlochcmJ IYYO::hT: h?l t, if, 2. CruickahanhA M. Hansel1D 7‘. Burn\ H J G. ShcnhmA Br I Surp lY89: 7’). Ifl-IhX. i. CruickhhanhA M. FraserW D. Bum\ H J (;. V:II~Damme J. ShenhlllA Clin SC11490: 7’): lhl&lhS