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%
INFECTIONS
Enteral TPN
Pneumonia
all patients 11.8 % 31 %
severely inj. 18 % 56 %
Abscess
all patients 3.9 % 17.8 %
severely inj. 9 % 33 %
INFECTIONS
Enteral TPN
Pneumonia
all patients 11.8 % 31 %
severely inj. 18 % 56 %
Abscess
all patients 3.9 % 17.8 %
severely inj. 9 % 33 %
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.
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
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
Degree of Enteral Stimulation
Chow > CED > IG-TPN > IV-TPN
IV-TPN prevents lethal malnutrition
Mucosal Immunity
Epithelium
PP
Naïve T/B lymphocyte
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
Naïve T/B lymphocyte
LPL
Plasma cell IgA
Secretory IgA
pIgR
MLN
Thoracic duct
Blood stream
Th 2 cytokines
Parenteral Nutrition
(No ENT stimulus)
Respiratory Tract
Secretory IgA
Entry into GALT: Cell/ Peyer’s
Patch Interactions
α4β7
L-selectin
Blockade
Peyer’s patch cells
Chow
0
20
40
60
80
100
120
(%)
Entry into GALT: Cell/ Peyer’s
Patch Interactions
α4β7
L-selectin
Blockade
Peyer’s patch cells
Chow α4β7
0
20
40
60
80
100
120
(%)
Entry into GALT: Cell/ Peyer’s
Patch Interactions
α4β7
L-selectin
Blockade
Peyer’s patch cells
Chow α4β7
0
20
40
60
80
100
120
(%)
Entry into GALT: Cell/ Peyer’s
Patch Interactions
α4β7
L-selectin
Blockade
Peyer’s patch cells
Chow α4β7
0
20
40
60
80
100
120
(%)
Entry into GALT: Cell/ Peyer’s
Patch Interactions
α4β7
L-selectin
Blockade
Peyer’s patch cells
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)
Okamoto, Fukatsu et al JPEN 2005; 29:56
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
Naïve T/B lymphocyte
LPL
Plasma cell IgA
Secretory IgA
pIgR
MLN
Thoracic duct
Blood stream
Th 2 cytokines
Parenteral Nutrition
(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
Naïve T/B lymphocyte
LPL
Plasma cell IgA
Secretory IgA
pIgR
MLN
Thoracic duct
Blood stream
Th 2 cytokines
IgA transport
Parenteral Nutrition
(No ENT stimulus)
Respiratory Tract
Human Lung Response After Injury
Total IgA
Control
Epithelial Lining Fluid
(Vol) IgA / ELF
Control Control
Human Lung Response After Injury
Total IgA
Control Trauma
*
Epithelial Lining Fluid
(Vol) IgA / ELF
Control Control
Human Lung Response After Injury
Total IgA
Control Trauma
* *
Epithelial Lining Fluid
(Vol) IgA / ELF
Control Control Trauma
Human Lung Response After Injury
Total IgA
Control Trauma
* *
Epithelial Lining Fluid
(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
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?
Can we reproduce GALT
effects in people who can’t
be fed enterally by adding
something to the TPN?
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
Naïve T/B lymphocyte
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
to Chow levels with bombesin
to Chow levels with bombesin
to Chow levels with bombesin
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
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
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
*
*