Immunonutrition.

PURPOSE OF REVIEW: To outline recent findings on the efficacy of immunonutrients in patients undergoing inflammatory stress due to surgery, infection and cancer. RECENT FINDINGS: Enteral nutrition is more efficacious and poses lower risks than parenteral nutrition. It reduces infection rates and shortens ICU and hospital length of stay of critically ill patients. Beneficial effects of immunonutrition are most apparent in malnourished patients. Perioperative enteral nutrition is more effective than postoperative nutrition. In Crohn disease similar remission rates are achieved with enteral nutrition as with steroids. Glutamine, omega-3 fatty acids and antioxidants exert beneficial influences in diverse patient populations. L-arginine is an important immunonutrient having both beneficial and adverse effects. The former effect occurs in necrotizing enterocolitis; the latter influence is seen in septic patients. The gut plays a major role in whole body amino acid metabolism, particularly arginine homeostasis. Arginase and nitric oxide synthetase compete for arginine within immune cells and play a pivotal role in clinical outcome during infection. In cancer a range of antioxidants are able to ameliorate immunosuppression. Intravenous lipids may be deleterious due to the pro-inflammatory effects of omega-6 fatty acids. Omega-3 fatty acids are anti-inflammatory and combined with medium chain triglyceride (MCT) and olive oil may provide a more efficacious form of intravenous lipid. SUMMARY: Immunonutrition is effective in improving outcome in a wide range of patients when applied enterally, particularly in malnourished individuals. Parenteral immunonutrition carries a higher risk but can be efficacious in selected patient groups for whom enteral nutrition is problematic.