title: Early nutrition support modifies immune function in patients sustaining severe head injury.
abstract: BACKGROUND
  Immunosuppression after severe head injury has been characterized by a depressed CD4 (T-helper/inducer)-CD8 (T-suppressor/cytotoxic) ratio and decreased T-lymphocyte responsiveness. Some investigators propose that this immunocompromized state is the result of an injury-associated hypermetabolic response and inadequate nutrient delivery during the immediate postinjury recovery phase. Previous observations from our institution demonstrated a preserved CD4-CD8 ratio in severe closed-head injury (CHI) patients receiving early parenteral nutrition (PN). It was unclear whether early PN or other aspects of patient care eliminated the characteristic depression in cellular immunity. The purpose of this study was to further investigate the effect of early PN on the immune function of CHI patients.
  
  
  METHODS
  Nine patients sustaining severe CHI were prospectively randomized to either early PN (n = 4) at day 1 or delayed PN (n = 5) at day 5. Total nutrient administration was delivered at 2 g of protein/kg per day and 40 nonprotein kcal/kg per day for at least the first 14 days of hospitalization. Analysis for T-lymphocyte expression of CD4 and CD8 cell surface antigens and interleukin-6 was performed on days 1, 3, 7, and 14 of hospitalization. T-lymphocyte activation in response to stimulation by concanavalin A (Con A), phytohemagglutinin (PHA), and pokeweed mitogens (PWM) was also assessed on these days.
  
  
  RESULTS
  Significant increases in total CD4 cell counts (2048 +/- 194 to 2809 +/- 129 vs 1728 +/- 347 to 1825 +/- 563, p < .05) and CD4% (42.6 +/- 4.4% to 56.2 +/- 2.6% vs 36.6 +/- 6.6% to 36.6 +/- 11.3%, p < .05) were observed at day 14 in patients receiving early vs delayed PN. An improved lymphocyte response from baseline to day 14 after Con A stimulation was demonstrated in the early PN group (3850 +/- 1596 to 16144 +/- 5024 cpm, p < .05). A significant rise in the CD4-CD8 ratio over baseline to day 14 was also noted in the early PN group (1.43 +/- 0.17 to 2.38 +/- 0.54, p < .05).
  
  
  CONCLUSIONS
  The early aggressive nutrition support of CHI patients appears to modify immunologic function by increasing CD4 cells, CD4-CD8 ratios, and T-lymphocyte responsiveness to Con A.
authors.affiliation: Department of Clinical Pharmacy, University of Tennessee, Memphis 38163, USA.
authors.forename: G S
authors.initials: GS
authors.lastname: Sacks
authors.forename: R O
authors.initials: RO
authors.lastname: Brown
authors.forename: D
authors.initials: D
authors.lastname: Teague
authors.forename: R N
authors.initials: RN
authors.lastname: Dickerson
authors.forename: E A
authors.initials: EA
authors.lastname: Tolley
authors.forename: K A
authors.initials: KA
authors.lastname: Kudsk
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016516:CD4-CD8 Ratio; D003208:Concanavalin A / Q000494:pharmacology; D006259:Craniocerebral Trauma / Q000150:complications / Q000276:immunology*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D015850:Interleukin-6 / Q000097:blood; D008213:Lymphocyte Activation / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D010288:Parenteral Nutrition / Q000592:standards*; D010835:Phytohemagglutinins / Q000494:pharmacology; D010940:Plant Proteins / Q000494:pharmacology; D011043:Pokeweed Mitogens / Q000494:pharmacology; D011446:Prospective Studies; D013601:T-Lymphocytes / Q000187:drug effects / Q000276:immunology
chemical_list: D015850:Interleukin-6; D010835:Phytohemagglutinins; D010940:Plant Proteins; D011043:Pokeweed Mitogens; D003208:Concanavalin A