الفهرس 
Disease and host related factorsOnly 14 pages are availabe for public view
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Abstract
Among critically ill patients, malnutrition has been associated with increased infectious morbidity and prolonged hospital stay. Providing nutrition support has become the standard of care for critically ill patients. Several specific nutrients called immunonutrition such as arginine, glutamine, nucleotides, and omega-3 fatty acids, either alone or in combination, have been shown in laboratory and clinical studies to influence nutritional, immunological, and inflammatory parameters.
The term “immunonutrition” has been coined for studies on the effects of nutrients that show pharmacologic effects on immune and inflammatory parameters. Glutamine is the most abundant amino acid in free blood, and constitutes 60% of the total free amino acid pool in skeletal muscle. In patients with cancer, marked glutamine de¬pletion develops over time; cancer cachexia is marked by massive depletion of skeletal muscle glutamine. This can have a negative impact on the function of host tissues that are dependent upon adequate stores of glutamine for optimal functioning (e.g. intestinal epithelial cells and lymphocytes).Though glutamine is readily synthesized by body tissues, free glutamine and plasma concentrations are diminished in metabolic stress.
The general aim of the present study was to assess the effect of parenteral supplementation with glutamine dipeptide on neutrophil recovery among patients with acute myeloid leukaemia; while specific objectives wereto investigate the effect of supplementation of glutamine dipeptide on:side effects of chemotherapy (neutropenia and neutropenic fever), patient’s immunity as indicated by neutrophil recovery, length of hospital stay upon admission.
During a period of eight months, intervention study (randomized Pre-test post-test control group design) including two groups, supplemented and control, the study was conducted in hematology department in Alexandria Main University Hospital.
Forty six male and female patients with confirmed diagnosis of acute myeloid leukaemia undergoing chemotherapy were selected for the study.
All selected participants on admission, were interviewed to answer a pre-designed questionnaire s at the start of the chemotherapy protocol. The initial data collected included the socio-demographic data. Weight, height were measured, and body mass index was calculated, dietary Consumption was done using a 24 hour dietary recall method for the day before the interview, the following tests were done for all patients of both groups using the appropriate method: white blood cells count and absolute neutrophil count to monitor the side effects of chemotherapy, hemoglobin level and RBCs counts, serum total protein , Serum albumin levels, urea, creatinine , uric acid levels, and liver enzymes.
Patients in the supplemented group received a supplement of 40 gm glutamine dipeptide ”dipeptivene®” in a dose of 200 ml containing 13.46 g% of glutamine for 5 days of the chemotherapy cycle. Each bottle of dipeptivene® (100 ml) was diluted in 250 ml normal saline 0.9% infused over 4-6 hours twice daily; while the control group did not receive the supplement of glutamine dipeptide. Before patient’s discharge, all theLaboratory testsdone were repeated.In addition measurements of superoxide anion generation (SAG) measured when absolute neutrophil count recovered to reach >500 µl, weight measurements and BMI calculation were repeated, and use of CSF’s were noted.
Characteristics of the study sample:
The majority of supplemented group fell in age group˂20 years and 30-<40 years; while control group nearly one third fell in age group 30-<40 years, 74% of the supplemented and control groups were males and 26% were females, education levelof both groups show no difference, unemployment was common among both groups, nearly half of both groups were married.
The main conclusions of the present study were:
• Minimization of weight loss and in some extent BMI reduction for AML patients receiving high doses of chemotherapy which is affecting treatment outcomes, improve the ability of patients to eat and survival.
• Significant reduction in days of neutropenia, and induction neutrophil recovery.
• Prescribing a combination of the appropriate dosage of CSF’s together with early parenteral glutamine dipeptide supplementation to AML patients receiving chemotherapy might provide further benefit over the use of CSF’s alone.
• The increase of neutrophil activity which is indicated by superoxide anion generation.
• Significant decrease in days of neutropenic fever that leads to decrease in antibiotic, antifungal, and antiviral consumption.
• Significant reduction in complications other than neutropenic fever.
• The supplementation of glutamine dipeptide for patients with normal renal and hepatic function do not cause any side effects which is demonstrated through laboratory analysis.
• The dilution of 20 gm glutamine dipeptide (100 ml) in 250 ml normal saline over 4 hours twice daily through peripheral line for five days (the length of the chemotherapy cycle) do not cause any side effects and is tolerated by the patient.
• Improvement of serum total protein and serum albumin levels as a result of glutamine dipeptide supplementation due to preservation of visceral protein, skeletal muscle mass, and reducing negative nitrogen balance.
• The significant reduction in length of hospital stay which is our main aim from the study.
• The days of neutropenia is positively correlated with: length of neutropenic fever, complications other than neutropenic fever, and length of hospital stay.
The main recommendations of the study were:
• Nutritional screening:On patient’s admission, recording of the weight and height is a must not only for chemotherapy dose calculations but for evaluation of nutritional status.
• A supplementation dose of 40 gm/day glutamine dipeptide for 5 days from starting of chemotherapy cycle is recommended. After checking renal and liver functions, they must be within normal ranges, with continuous monitoring.
• Weekly dietary assessment of AML patients using 24-hour recall is recommended to monitor oral food intake.
• Routine weighing of patients motivated them to reduce loss of body weight.
• Early supplementation with glutamine dipeptide is recommended to be set as a protocol for all AML patients to minimize the cost of treatment.
• Creation of awareness about the importance of ingestion of foods even with the presence of gastrointestinal symptoms as a result of chemotherapy.
• Further research is needed to establish the early effect of glutamine supplementation for all other oncohematological patient and to confirm these results.