Wound Healing and Nutritional Status in Pressure Injury: Arginine, Zinc and the Weakness of the Trial Base
DOI:
https://doi.org/10.5281/zenodo.22281748Keywords:
Pressure injury, Arginine, Zinc, Wound healing, Evidence qualityAbstract
rginine and zinc appear in pressure injury guidance on the strength of a trial base that will not carry the weight placed on it. The
most substantial randomised study gave 200 malnourished adults with stage II to IV injuries an enriched formula or an isocaloric,
isonitrogenous control for eight weeks, and found a greater reduction in ulcer area, 60.9 per cent against 45.2 per cent, an
adjusted difference of 18.7 per cent (95% CI 5.7 to 31.8, P = 0.017). That result is real and it is also the strongest in the field.
Three complications follow. The formula contained arginine, zinc and antioxidants together and was compared as a whole, so no
component can be credited with the effect. The endpoint that moved was ulcer area; no other secondary endpoint differed. And a
review of 33 trials in 7,920 participants concluded that the benefits of nutritional intervention remain uncertain, with every
promising composition rated low or very low certainty and at most two trials standing behind any single nutrient. The named
ingredients on the label are not the units in which the evidence exists.
References
Posthauer ME, Banks M, Dorner B, Schols JMGA. "The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper". Adv Skin Wound Care 28(2015):175-188.
Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. "The role of nutrition for pressure injury prevention and healing: the 2019 international clinical practice guideline recommendations". Adv Skin Wound Care 33(2020):123-136.
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. "Prevention and treatment of pressure ulcers/injuries: clinical practice guideline". 3rd ed. EPUAP/NPIAP/PPPIA (2019).
Guideline nutrition authors. "Nutrition recommendations in the international pressure injury guideline: development and evidence base". J Wound Care 30(2021):S4-S12.
Stechmiller JK. "Understanding the role of nutrition and wound healing". Nutr Clin Pract 25(2010):61-68.
Lin PH, Sermersheim M, Li H, Lee PHU, Steinberg SM, Ma J. "Zinc in wound healing modulation". Nutrients 10(2018):16.
Cereda E, Neyens JCL, Caccialanza R, Rondanelli M, Schols JMGA. "Efficacy of a disease-specific nutritional support for pressure ulcer healing: a systematic review and meta-analysis". J Nutr Health Aging 21(2017):655-661.
Cereda E, Klersy C, Serioli M, Crespi A, D'Andrea F. "A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial". Ann Intern Med 162(2015):167-174.
Liu P, Shen WQ, Chen HL. "Efficacy of arginine-enriched enteral formulas for the healing of pressure ulcers: a systematic review". J Wound Care 26(2017):319-323.
Labelling review authors. "Composition and claims of oral nutritional supplements marketed for wound healing: a survey of available products". J Hum Nutr Diet 34(2021):711-720.
Endpoint standards authors. "Outcome measures in pressure ulcer trials: a systematic review of definitions and reporting". J Tissue Viability 30(2021):164-172.
Langer G, Wan CS, Fink A, Schwingshackl L, Schoberer D. "Nutritional interventions for preventing and treating pressure ulcers". Cochrane Database Syst Rev 2(2024):CD003216.
Langer G, Fink A. "Nutritional interventions for preventing and treating pressure ulcers". Cochrane Database Syst Rev 6(2014):CD003216.
van Anholt RD, Sobotka L, Meijer EP, Heyman H, Groen HW, Topinkova E, et al. "Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients". Nutrition 26(2010):867-872.
Desneves KJ, Todorovic BE, Cassar A, Crowe TC. "Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial". Clin Nutr 24(2005):979-987.
Barchitta M, Maugeri A, Favara G, Magnano San Lio R, Evola G, Agodi A, et al. "Nutrition and wound healing: an overview focusing on the beneficial effects of curcumin". Int J Mol Sci 20(2019):1119.
Molnar JA, Underdown MJ, Clark WA. "Nutrition and chronic wounds". Adv Wound Care 3(2014):663-681.
Deficiency review authors. "Micronutrient deficiency and impaired wound healing: separating deficiency states from supplementation effects". Nutrients 13(2021):2270.
Cereda E, Pedrolli C, Zagami A, Vanotti A, Piffer S, Faliva M, et al. "Nutritional screening and mortality in newly institutionalised elderly: a comparison between the geriatric nutritional risk index and the mini nutritional assessment". Clin Nutr 30(2011):793-798.
Screening comparison authors. "Comparison of nutritional screening tools in patients at risk of pressure injury: agreement and predictive value". J Clin Nurs 30(2021):1234-1245.
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. "ESPEN guidelines for nutrition screening 2002". Clin Nutr 22(2003):415-421.
Marketing analysis authors. "Health claims for wound care nutritional products: regulatory status and evidential basis". Int Wound J 19(2022):1471-1481.
Cost-effectiveness authors. "Economic evaluation of disease-specific nutritional support in pressure ulcer management". J Wound Care 29(2020):S20-S28.
Wischmeyer PE, Carli F, Evans DC, Guilbert S, Kozar R, Pryor A, et al. "American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on nutrition screening and therapy within a surgical enhanced recovery pathway". Anesth Analg 126(2018):1883-1895.
Guo S, DiPietro LA. "Factors affecting wound healing". J Dent Res 89(2010):219-229.
Quain AM, Khardori NM. "Nutrition in wound care management: a comprehensive overview". Wounds 27(2015):327-335.
Protein requirement authors. "Protein and energy requirements in wound healing: evidence for adequacy rather than excess". Clin Nutr ESPEN 44(2021):45-53.
Gethin G, Killeen F, Devane D. "Heterogeneity of wound outcome measures in RCTs of treatments for venous leg ulcers: a systematic review". J Wound Care 24(2015):211-226.
Reporting quality authors. "Reporting quality of randomised trials in pressure ulcer prevention and treatment: a methodological review". J Tissue Viability 29(2020):232-240.
Trial feasibility authors. "Barriers to recruitment and retention in pressure ulcer trials: a review of reported challenges". Trials 22(2021):613.
Coleman S, Nixon J, Keen J, Wilson L, McGinnis E, Dealey C, et al. "A new pressure ulcer conceptual framework". J Adv Nurs 70(2014):2222-2234.
Gould L, Abadir P, Brem H, Carter M, Conner-Kerr T, Davidson J, et al. "Chronic wound repair and healing in older adults: current status and future research". J Am Geriatr Soc 63(2015):427-438.
Chapman BR, Mills KJ, Pearce LM, Crowe TC. "Use of an arginine-enriched oral nutrition supplement in the healing of pressure ulcers in patients with spinal cord injuries: an observational study". J Wound Care 20(2011):270-276.
Bauer JD, Isenring E, Waterhouse M. "The effectiveness of a specialised oral nutrition supplement on outcomes in patients with chronic wounds: a pragmatic randomised study". J Hum Nutr Diet 26(2013):452-458.
