Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpital

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Troubles nutritionnels lors de la sclérose latérale amyotrophique (SLA)

Amyotrophic lateral sclerosis (ALS) is a rare neuromuscular disease, with a severe prognostic. Its consequences are not only neurological, but also nutritional, linked with a decrease of feeding, caused by swallowing and salivation disorders, a frequent anorexia or constipation, troubles due to a possible respiratory insufficiency, and sometimes important difficulties for going shopping, cooking and more simply putting the food into the mouth. Although fat-free mass is usually decreased during ALS, a paradoxical hypermetabolism is present in 50 to 70% cases, favouring nutritional alterations. The tools used for assessment, sometimes specific to the disability, are anthropometric criteria, body impedance analysis (BIA), dietetic surveys, dual X-ray absorptiometry and indirect calorimetry. Alimentary intakes, weight, fat-free mass and body mass index are progressively reduced, leading to malnutrition. BIA phase angle is largely decreased, reflecting severe cellular alterations. Disorders of lipid status are possible but inconsistent across studies and perhaps linked with cultural feeding habits. The loss of weight at diagnosis and malnutrition during evolution are independent prognostic factors for survival, justifying early nutritional assessment and care. During evolution of ALS, a higher level of fat mass seems to be a positive factor for survival. French, European and American recommendations give precisions on follow-up, modalities of fight against the causes of malnutrition, nutritional care, mainly including the use of oral energy and protein-enriched nutritional supplements and enteral nutrition.     

Nutrition en cancérologie : aspects pédiatriquesNutrition and cancer in children

Cancer is associated with a high risk of malnutrition in children. This risk is different from one tumor to another, at the time of diagnosis and at any time of the disease course. Numerous tumor-related and treatment-related factors are involved. High dose-chemotherapy, with its specific side effects is particularly deleterious. Growth curves are of major interest for the long-term follow up of the nutritional status in children. The systematic use of nutritional risk scores is recommended, in order to improve prevention and early treatment of malnutrition. Nutritional supplies should meet the high protein and energy needs associated with cancer and its treatments. Oral and tube-feeding should be used preferably, according to digestive function. Peripheral parenteral nutrition may serve only as a complementary, short-term nutritional support. Central lines are required for all total and/or long term parenteral nutrition periods. Whatever the nutritional support, it can help to fulfil chemotherapy programmes, with benefit on remission duration and survival.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

腹膜透析病人体内水分布与营养状况的关系

目的:了解持续性不卧床腹膜透析(CAPD)病人体内水的分布状况及其与营养之间的关系。方法:用生物电阻抗法对66名无临床水肿表现的CAPD病人进行体内水的测量,分别测出其细胞外液(ECW)、细胞内液(ICW)、总体水(TBW),同时对所有病人进行营养状况的主观综合评价(SGA)。相同年龄段的正常人作为对照。结果:临床无水肿的CAPD病人与相同年龄的正常人相比,体内水的分布存在明显异常,表现为细胞内液显著减少,细胞外液无明显变化,细胞外液与细胞内液之比(E/I)明显增加;当病人存在营养不良时,上述现象表现得更加明显。结论:持续性不卧床式腹膜透析(CAPD)病人体内水的分布是异常的,营养不良可以加重体内水的异常分布。因此,对于临床无明显水肿表现但存在营养不良的CAPD病人不能通过E/I来判断体内是否存在水负荷过多。     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

Le cirrhotique face à la chirurgie : rôle de la dénutrition dans les complications infectieuses

Postoperative complications, particularly infectious complications, are more frequent in cirrhotic than in non-cirrhotic patients after abdominal surgery. This is probably the result of a decrease in antiinfectious mechanisms in cirrhotic patients, including humoral and cellular immunodeficiency and an increase in bacterial translocation. The immunodeficient status of cirrhotic patients is partly related to malnutrition. Several clinical studies have recently suggested that enteral and parenteral nutrition improve nitrogen balance and nutritional parameters in patients with chronic liver disease. Chronic or acute encephalopathy has also been improved as well as survival. However the beneficial effect of artificial nutrition on postoperative septic complications in cirrhotic patients has so far never been confirmed in a well conducted randomized study. Giving protein and energy support to patients with cirrhosis undergoing abdominal surgery, together with specific measures such as prevention of intraoperative bleeding, treatment of sodium and water retention, and antibiotic prophylaxis against intestinal gram-negative bacteria needs to be further investigated.     

BIA法评估44例CKD患者的营养状况及分析

摘要:目的　运用生物电阻抗分析（Bioelectric Impedance Analysis,BIA）评价慢性肾脏病（Chronic Kidney Disease,CKD）患者的营养状况,并将其和生化指标评估结果对比,为早期发现CKD患者营养不良状态、及时给予营养干预提供有效参考。方法　随机选择2014年11月-12月期间在某三甲医院CKD管理中心注册的CKD患者57例,根据其浮肿指数、依从性等共纳入研究对象44例,应用BIA法评估研究对象的营养状况并与生化指标评价结果比较。结果　BIA和生化检查营养不良率（含营养不良风险）分别为45.4%和25%,且差异有统计学意义（χ2＝4.034,P＜0.05）。女性身体细胞量、细胞内水分和蛋白质的质量均显著高于男性（P＜0.05）,而男、女性ALB水平差异无统计学意义。在ALB水平正常的CKD患者中,其体细胞量、细胞内水分、蛋白质、骨骼肌、体脂肪均低于正常范围。BIA营养不良的研究对象的骨骼肌量和血清白蛋白（serum Albumin,ALB）水平显著相关（r＝0.58,P＜0.05）。结论　CKD患者营养不良率较高;与生化检查相比,BIA可早期发现CKD患者的营养不良状态和营养不良风险,有利于医生对营养不良患者及时采取有效的营养干预。     

Évaluation des apports alimentaires des malades hospitalisésFood intakes in in-hospital patients

Studies have shown that malnutrition may affect more than 50% of hospitalized patients. They observe a further deterioration in nutritional status during hospital stay. This deterioration may be explained by imbalance between energy and protein needs and low voluntary intake by patients. Although underfeeding is often attributable to disease or treatments, authors observe that more than 50% of causes are imputable to inadequate organization. This results in high food wastage with medical and economical consequences whose rate may be greater than 40%. Improvements of dietary intakes depend on the development of a screening and assessment system. This includes to promote an educational program for doctors and nurses, to modify the hospital diet according to the patients’ preferences and needs, to help and monitor dietary intakes in patients with undernutrition at admission or at risk of malnutrition.     

Évaluation nutritionnelle chez le dialysé

Malnutrition is common among patients with end stage renal disease treated by hemodialysis or peritoneal dialysis. It is a major cause of morbidity and mortality. Nutritional status may be assessed by several clinical markers including dietary records, anthropometric measurements and subjective global assessment. Among biochemical parameters, albumin is the most commonly examined nutritional index and transthyretin the most useful. Protein catabolic rate reflects dietary protein intake. Body composition analysis by bioelectrical impedance analysis or better by dual energy X-ray absorptiometry offers a reasonable estimation of body compartments such as total body water, fat mass and lean body mass. Periodic assessment of nutritional status must take into account the limitations of all the criteria used.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Body composition by X-ray absorptiometry and bioelectrical impedance in chronic respiratory insufficiency patients

Nutrition assessment is important during chronic respiratory insufficiency to evaluate the level of malnutrition or obesity and should include body composition measurements. The appreciation of fat-free and fat reserves in patients with chronic respiratory insufficiency can aid in designing an adapted nutritional support, e.g., nutritional support in malnutrition and food restriction in obesity. The purpose of the present study was to cross-validate fat-free and fat mass obtained by various bioelectric impedance (BIA) formulas with the fat-free and fat mass measured by dual-energy X-ray absorptiometry (DXA) and determine the formulas that are best suited to predict the fat-free and fat mass for a group of patients with severe chronic respiratory insufficiency. Seventy-five patients (15 women and 60 men) with chronic obstructive and restrictive respiratory insufficiency aged 45–86 y were included in this study. Body composition was calculated according to 13 different BIA formulas for women and 12 for men and compared with DXA. Because of the variability, calculated as 2 standard deviations, of ± 5.0 kg fat-free mass for women and ± 6.4 kg for men for the best predictive formula, the use of the various existing BIA formulas was considered not clinically relevant. Therefore disease-specific formulas for patients with chronic respiratory insufficiency should be developed to improve the prediction of fat-free and fat mass by BIA in these patients.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.