Protein status in pancreatitis--transthyretin is a sensitive biomarker of malnutrition in acute and chronic pancreatitis.

Malnutrition may develop in acute pancreatitis (AP), accompanied by hypermetabolism and high nutritional requirements, and in chronic pancreatitis (CP). We measured the incidence of protein malnutrition in AP and CP by comparing different serum biomarkers of protein metabolism and inflammation. Thirty-five patients with acute (27 moderate, 8 severe), and 35 with chronic, pancreatitis were enrolled in the study. Serum transthyretin, albumin, transferrin and C-reactive protein (CRP) concentrations were measured in AP at admission, after 1 and 2 weeks of jejunal feeding, and in patients with CP at follow-up. In AP, at admission the transthyretin level was low in 74%, transferrin in 48%, and albumin in 29% of patients. In severe pancreatitis, transthyretin levels were significantly lower than in moderate forms (7.5 +/- 2.43 vs. 14.39 +/- 6.8 mg/dl, p < 0.005). Transthyretin levels increased significantly after 2 weeks of jejunal feeding (p < 0.05). In CP, transthyretin levels were decreased in 37%, transferrin in 27%, and albumin in 12% of patients. We found significantly lower transthyretin levels in alcohol-related CPthan in other forms (18.5 +/- 8.3 vs. 30.2 +/- 5.7, p < 0.01). Transthyretin correlated positively with albumin and transferrin and negatively with CRP Transthyretin seems to be a sensitive biomarker of protein status and metabolic stress. Monitoring nutritional status through measurement of serum proteins is important for optimal treatment of AP and CP.     

The role of visceral protein markers in protein calorie malnutrition.

Despite substantial evidence of the crucial role protein calorie malnutrition (PCM) plays in the occurrence of complications, increased length of stay, and cost of care in hospitalized populations, no standard approach for screening and monitoring the nutritional status of patients initially and throughout admission currently exists. Recognizing that there is a growing public and professional recognition of the importance of malnutrition, a large patient population (30-55%) at risk for PCM, and an even larger population experiencing declining nutritional status during hospitalization, this study examined the feasibility of a full-scale study to assess the value of two biochemical markers, transthyretin and albumin, for detecting and monitoring PCM in hospitalized patients. It was demonstrated that these two markers do provide important information predictive of outcomes for those they identify at risk for PCM. The patients who entered the study with or developed low transthyretin and albumin experienced poorer health outcomes and higher costs of care. Their discharge occurred in an early phase of recovery, with significant implications for after-discharge care. The full-scale study must consider severity of illness and other confounders during randomization and, preferably, be conducted in institutions that currently do not use transthyretin for nutrition assessment.     

Clinical indications for plasma protein assays: transthyretin (prealbumin) in inflammation and malnutrition.

A large number of circumstances are associated with reduced serum concentrations of transthyretin (TTR), or prealbumin. The most common of these is the acute phase response, which may be due to inflammation, malignancy, trauma, or many other disorders. Some studies have shown a decrease in hospital stay with nutritional therapy based on TTR concentrations, but many recent studies have shown that concentrations of albumin, transferrin, and transthyretin correlate with severity of the underlying disease rather than with anthropometric indicators of hypo- or malnutrition. There are few if any conditions in which the concentration of this protein by itself is more helpful in diagnosis, prognosis, or follow up than are other clinical findings. In the majority of cases, the serum concentration of C-reactive protein is adequate for detection and monitoring of acute phase responses and for prognosis. Although over diagnosis and treatment of presumed protein energy malnutrition is probably not detrimental to most patients, the failure to detect other causes of decreased concentrations (such as serious bacterial infections or malignancy) of the so-called visceral or hepatic proteins could possibly result in increased morbidity or even mortality. In addition to these caveats, assays for TTR have a relatively high level of uncertainty ("imprecision"). Clinical evaluation--history and physical examination--should remain the mainstay of nutritional assessment.     

Low levels of plasma proteins: malnutrition or inflammation?

Levels of several plasma proteins, including albumin, transferrin, and transthyretin (prealbumin), have been proposed as markers for protein energy malnutrition. However, many other factors, especially inflammatory disease and drug or hormone therapy, affect levels of these proteins. These factors probably account for the majority of low levels of transthyretin. Levels of albumin and other proteins may be helpful in determining increased risk of morbidity and mortality, but better markers are needed for diagnosis of protein energy malnutrition per se.     

Metabolism and clinical interest of serum transthyretin (prealbumin) in dialysis patients.

Chronic renal failure is responsible for an increase in serum concentrations of transthyretin. Elevated serum transthyretin during renal insufficiency is secondary to the lack of retinol-binding protein degradation in renal tubules and to the subsequent increase in the fraction of transthyretin bound to retinol-binding protein. In both hemodialysis and peritoneal dialysis patients, serum transthyretin was demonstrated to be a reliable marker of nutritional status, exhibiting significant relationships with energy and protein intakes as well as with fat stores and lean body mass. Serum transthyretin levels less than 300 mg/l were shown to be associated with an increased risk of morbidity and mortality in dialysis patients. The predictive value of transthyretin was shown to be independent of serum albumin. Regular measurements of both serum albumin and transthyretin make it possible to detect patients whose prognosis is compromised by malnutrition and in whom an active nutritional therapy must be undertaken. Simultaneous measurements of inflammatory markers such as serum C-reactive protein are required to evaluate the role of inflammation in serum albumin and transthyretin variations. These low-cost protein parameters should be incorporated in the regular assessment of dialysis patients and measured every 1 to 3 months.     

中等医院住院病人营养风险筛查的调查与分析

目的调查部分科室住院病人营养不良发生率、营养风险发生率和实际应用营养支持率,为住院病人合理应用营养支持治疗提供参考依据。方法选择某中等医院消化内科、呼吸内科、神经内科、普外科和胸外科新住院病人1000例。病人人院后首先评估是否符合营养风险筛查评定条件,符合者第2天清晨进行评定;对不符合条件病人检测血清清蛋白（sALB）,sALB〈30g／L。判定为营养不良。人体质量指数（BMI）〈18．5kg／m^2判定为营养不良。采用营养风险筛查判定是否需要营养支持。结果1000例新住院病人营养风险筛查的完全适用率为77．8％,营养不良发生率为8．6％;营养风险发生率为20．3％。存在营养风险病人中,营养支持率为37．4％,不存在营养风险病人中,营养支持率为13．3％。各科室之间营养不良与营养风险的发生率比较均存在显著性差异（χ^2=20．79、35．95,P〈0．01）。结论住院病人因疾病及其严重程度不同,营养不良的发生率和特点亦不同,营养风险筛查可评估住院病人的营养不良和营养风险。     

维持性血液透析患者的营养状况及其影响因素

目的了解维持性血液透析患者的营养状况及其影响因素,以提高患者的生活质量和降低病死率。方法采用主观综合营养评估结合实验室生化指标及人体测量指标对66例维持性血液透析患者的营养状况进行综合评价,并观察患者蛋白质摄入量、透析充分性、透析龄、炎症状态及重组人促红细胞生成素（recombinant human erythropoietin,rhEPO）的使用对其营养状况的影响。结果 66例血液透析患者中营养良好者39例（59.1%）,轻、中度营养不良者21例（31.8%）,重度营养不良者6例（9.1%）,总体营养不良的发生率为40.9%。各营养状况组之间血清白蛋白、血红蛋白、肌酐、三头肌皮褶厚度差异有统计学意义（P〈0.01或P〈0.05）;营养良好组蛋白质摄入量和标准蛋白代谢率高于营养不良组（均P〈0.01）;透析充分、透析龄短于6个月、无慢性炎症及应用rhEPO的患者营养不良的发生率较低。结论血液透析患者营养不良的发生率较高,其发生与蛋白质摄入不足、透析不充分、透析龄较长、发生慢性炎症以及未应用rhEPO等因素有关。     

Observations with regard to the National Kidney Foundation K/DOQI clinical practice guidelines concerning serum transthyretin in chronic renal failure.

The National Kidney Foundation K/DOQI Guidelines state that, "Serum prealbumin is a valid and clinically useful measure of protein-energy nutritional status in maintenance dialysis (MD) patients." Prealbumin, also known as serum transthyretin (TTR), was not recommended as a nutritional parameter of the same usefulness as the serum albumin. This decision was made, in part, because published research at that time suggested that serum TTR was not a more sensitive index of nutritional status than serum albumin and there was much more clinical and research experience with serum albumin as a nutritional and inflammatory marker. Evidence, including more recently published research data, which is reviewed in this paper has led to the following conclusions by the current authors: 1) In MD patients either protein-energy malnutrition or inflammation can lead to a reduction in serum TTR concentrations. 2) Hence, in MD patients, serum TTR concentrations can be used as a measure of both nutritional and inflammatory status. 3) Serum TTR concentrations are typically increased in MD patients. 4) In maintenance hemodialysis (MHD) patients, serum TTR is a risk factor for mortality that is somewhat independent of serum albumin. 5) Current epidemiological evidence suggests that a serum TTR value of 25 or 30 mg/dl or greater is associated with increased survival and, hence, is desirable in MHD patients. 6) MHD patients with serum TTR levels less than 25-30 mg/dl should be evaluated for protein-energy malnutrition and inflammation.     

序贯肠内外营养支持对慢性阻塞性肺疾病急性加重期合并呼吸衰竭患者的影响

目的 探讨序贯肠内外营养支持对慢性阻塞性肺疾病急性加重期(AECOPD)合并呼吸衰竭患者营养状况及预后的影响.方法 将60例AECOPD合并呼吸衰竭患者随机分为对照组和观察组,每组30例.对照组给予肠内营养支持,观察组采用序贯肠内外营养支持.比较2组营养状况、康复指标及并发症发生率.结果 营养支持1周后,观察组血清白蛋...     

Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology

ObjectivePatients with cancer and malnutrition are more likely to experience poor treatment tolerance, prolonged length of hospital stay, and decreased quality of life. Early and sustained nutrition risk screening is the first step to tackling this patient and health care burden. Yet, malnutrition remains largely overlooked and undertreated. Malnutrition mismanagement could be indicative of a systemic misunderstanding. With this narrative review, we aimed to (1) define malnutrition, (2) address common malnutrition misconceptions, and (3) summarize nutrition recommendations for patients with cancer.Data SourcesPubMed and international clinical practice guidelines.ConclusionMalnutrition represents an unbalanced nutritional state that alters body composition and diminishes function. Malnutrition is not always physically obvious, and albumin is not a reliable marker of nutritional status; therefore, systematically screening all patients with a validated nutrition risk screening tool at time of cancer diagnosis, and periodically throughout treatment, is necessary to provide optimal, equitable care. Nutrition risk screening takes less than 1 minute to complete and can be completed by any health care professional. Patients that screen positive for nutrition risk should be referred to a registered nutritionist or dietitian for comprehensive nutritional assessment, diagnosis, and treatment.Implications for Nursing PracticeAll health care professionals can and should be responsible for preventing and treating malnutrition. Registered nurses can actively participate in improving patient outcomes by screening patients for nutrition risk, weighing patients at every visit, referring patients to dietitians for nutrition treatment, and providing supportive medical management of nutrition impact symptoms such as nausea.     

慢性阻塞性肺疾病患者营养状态与血浆生长素释放肽水平的相 关性

目的了解慢性阻塞性肺疾病(COPD)患者血浆生长素释放肽(Ghrelin)水平及其营养不良和疾病严重程度之间的关系。方法采用放射免疫法测定80例稳定期COPD患者(分营养不良COPD组42例,非营养不良COPD组38例)及32例健康对照者血浆Ghrelin水平。酶联免疫吸附试验法测定肿瘤坏死因子-α、白细胞介素-1β,并测定身高体质量指数、三头肌皮肤皱厚度、上臂中部臂围、血清白蛋白。计算分析血浆Ghrelin水平与营养参数、细胞因子的关系。结果营养不良COPD组血浆Ghrelin水平显著高于健康对照组及非营养不良COPD组(P<0.01),营养不良COPD组细胞因子水平显著高于健康对照组及非营养不良COPD组（P<0.01）。血浆Ghrelin水平与绝大多数营养参数呈负相关（P<0.01）。血浆Ghrelin水平与细胞因子水平呈正相关。但无统计学意义（P>0.05）。结论COPD患者Ghrelin水平升高;病情越重,营养状况越差,Ghrelin水平越高,炎症反应越严重。       

Laboratory monitoring of nutritional status in burn patients.

Most nutrition laboratory testing relies on serum concentrations of ingested nutrients, their coenzymes, proteins, or lipids. Alternatively, functional tests measure a specific physiological process or biochemical reaction. We compared these two approaches to nutritional assessment in intensive-care burn patients, in whom the serum concentrations of transthyretin (prealbumin), albumin, transferrin, carotene, retinol, ascorbic acid, copper, cholesterol, iron, and calcium were all below established reference ranges. In contrast, serum triglyceride concentrations were often above the reference range. Functional tests for thiamin, riboflavin, pyridoxine, and iron (by zinc protoporphyrin/heme ratio) in these patients all showed normal values. Dietary intake, weight trends, and nitrogen balances all indicated that these patients' estimated caloric and protein needs had been met. These findings suggest that static measurements of serum concentrations may be unreliable indicators of nutritional status in burn patients.     

Malnutrition in the elderly: its recognition and treatment

Malnutrition plays a critical role in morbidity and mortality of the elderly. It is unacceptable to deny any patient, regardless of age, adequate nutrition when there are so many alternate methods of nutritional rehabilitation. Healthcare professionals must be concerned with the important role of nutritional therapy in the overall management of the elderly. It is extremely important to maintain the patient's nutritional status throughout periods of stress, disease, injury, and during periods of recovery. In developing a nutritional support plan, the clinician must consider the degree of malnutrition; the degree of hypermetabolism and specific organ dysfunction; the goals of nutritional therapy; and the route of nutrient delivery. The clinician must recognize the earliest signs of malnutrition and should be acquainted with the modalities of nutritional intervention to repair the deficit and prevent further deterioration. Another important consideration is that malnutrition is frequently a systemic manifestation of disease. Therapeutic nutritional support is cost-effective, reduces morbidity, and saves lives.     

消化内科住院患者营养风险筛查分析

目的：研究消化内科住院患者营养风险的发生率、营养支持率及营养风险筛查与营养指标的相关性。方法采用欧洲营养风险筛查方法（ NRS2002）对消化内科139例入院患者进行营养风险筛查,分析筛查结果与客观营养指标之间的关系。结果入院时营养风险（ NRS≥3分）发生率为48％;应用营养支持率为37．5％。营养风险组前白蛋白（142．56±68．23） mg/L低于无风险组（208．45±59．65）mg/L,差异有统计学意义（t＝23．95,P＝0．023）;营养风险筛查结果与营养指标中的血清前白蛋白、白蛋白、血红蛋白呈负相关（ r＝-0．882,-0．713,-0．689;P＜0．05）。结论对新入院患者进行筛查,有利于了解患者现有的营养状况,操作简便,且NRS2002与血清前白蛋白具有较好的一致性,用NRS2002来预测消化内科患者营养风险值得进一步推广。     

Assessment of nutritional status in organ transplant: is transthyretin a reliable indicator?

Transthyretin has been proposed as a nutritional index to screen for malnutrition and monitor the metabolic response to dietary intervention. In the presence of inflammation, circulating transthyretin levels drop regardless of optimal caloric intake. In this case, due to its rapid turnover, the pattern of transthyretin, monitored by means of repeated measures, could indicate the metabolic status (catabolism vs. anabolism). The aim of this review is to investigate the possible role of transthyretin as a nutritional parameter in organ transplantation. The literature on nutritional assessment in transplantation was reviewed and all the data regarding circulating transthyretin levels were analyzed. It appears that, on the one hand, the transthyretin level reflects closely dietary manipulations; on the other hand, it is affected by the inflammatory status. Consequently, interpretation could be difficult during the acute phase immediately after the transplant. Moreover, the role of transthyretin in monitoring the hepatic synthetic function in liver transplant is discussed. In conclusion, transthyretin is a reliable indicator of nutritional status in transplant candidates and potentially useful in the post-transplant phase if the inflammatory status is taken into account.     

中国热带海岛患者营养相关指标与压力性损伤风险的相关性研究

目的探讨中国热带海岛患者营养与压力性损伤风险的相关性,为压力性损伤集束化管理中个体化营养指导和定期监测的指标提供依据。方法2019年1-2月采取便利抽样法选取海南省某三级甲等医院住院患者1078例患者为研究对象,采用营养风险筛查表(nutritional risk screening2002,NRS-2002)及Braden压力性损伤评估量表对其进行调查,分析两者的相关性。结果是否有压力性损伤风险(NRS≤18分)的两组患者在营养风险(NRS≥3分)、体质量指数、上臂围、小腿围、血清白蛋白、水肿、ICU治疗、营养支持、过去3个月体重下降、过去1周摄入减少等方面差异有统计学意义(P<0.05);Logistics结果表明,小腿围是独立的保护因素,营养风险(NRS≥3分)、营养不良、水肿、ICU治疗、过去3个月体重下降是独立危险因素。结论对住院患者进行有效的营养及压力性损伤风险评估,警惕营养不良、ICU治疗、水肿患者,动态监控实验室指标和营养状态,有助于预防压力性损伤和营养不良的形成。     

Outcomes of continuous process improvement of a nutritional care program incorporating TTR measurement.

Early assessment of protein calorie malnutrition (PCM) can improve the outcome for hospitalized patients by allowing the initiation of nutrition support if required. In addition, monitoring nutritional status during the hospital stay can identify a decline in or improvement of PCM so that alterations to treatment regimens can be made if needed. The visceral protein albumin is the traditional laboratory indicator of PCM. In the past decade another protein has been lauded as a superior marker that can be used in conjunction. We undertook several studies to test the effectiveness of TTR as an aid in nutritional assessment. We found TTR to be a sensitive measure of nutritional status, allowing for earlier assessment and intervention, thus reducing length of stay and other hospital associated costs. Based on these findings, our hospital generated and implemented a multidisciplinary nutrition care program. Transthyretin is an integral portion of this program; levels are determined on admission and repeated twice weekly until discharge.     

Reference distributions for the negative acute-phase serum proteins, albumin, transferrin and transthyretin: a practical, simple and clinically relevant approach in a large cohort

Inflammation is associated with diverse clinical conditions accompanied by characteristic changes in serum levels of the acute-phase proteins that can be used to stage the inflammatory process and evaluate the impact of treatment. Some acute-phase proteins increase during inflammation, while others, such as albumin, transferrin, and transthyretin, decrease. The current study reports reference ranges for serum levels of albumin, transferrin, and transthyretin based on a cohort of over 124,000 Caucasian individuals from northern New England, tested in our laboratory between 1986 and 1998. Measurements were standardized against CRM 470 (RPPHS) and analyzed using a previously validated statistical approach. Individuals with laboratory evidence of inflammation (C-reactive protein of 10 mg/L or higher) were excluded. The levels of all three analytes varied by age, generally rising until the second or third decade of life and then decreasing thereafter. Albumin and transthyretin levels were higher during midlife among males as compared to females; the maximum being at 25 years for albumin (5%) and 35 years for transthyretin (16%). In contrast, above the age of 10 years, transferrin levels were increasingly higher among females (7% at 20 years). When values were expressed as multiples of the age- and gender-specific median levels, the resulting distributions fitted a log-Gaussian distribution. When patient data are normalized in this manner, the distribution parameters can be used to assign a corresponding centile to an individual's measurement simplifying interpretation. The ultimate interpretation of an individual's measurement relies upon the clinical setting.     

Surveillance et évaluation de l’efficacité de la nutrition artificielle en réanimation

In the intensive care unit (ICU), nutrition support is a part of patients’ management. As for ventilation and hemodynamics, nutrition and metabolism monitoring is mandatory for improving tolerance and efficacy of nutrition support. Enteral nutrition (EN) is commonly associated with protein-energy deficiency, which is related to poor prognosis. Early detection of deficiency should lead to increase protein and energy delivery, including EN-parenteral nutrition (PN) combination. Overfeeding-related metabolic complications of PN should be screened. Glycaemic monitoring is requested since glycaemic control may result in decreased mortality. In the ICU, macro- and micronutriment intakes, energy expenditure, and matching between protein-energy target and delivery, should be tightly monitored. This monitoring should be computer-based and integrated in patients’ management. An ICU dedicated dietitian may allow to decrease energy deficiency. Since weight, height, serum albumin, and transthyretin could be unsufficient for any definitive diagnosis, assessment of body composition may be useful to allow an accurate assessment of nutrition support efficacy during ICU stay. By limiting protein-energy deficiency and overfeeding and by optimizing glycaemic control, nutrition and metabolism monitoring should improve clinical outcome. Future studies will be helpful to determine the medico-economic impact of nutrition and metabolism monitoring.     

A sensible approach to the nutritional support of mechanically ventilated critically ill patients

Objectives The goal of this review is to educate physicians in the details of nutritional support of mechanically ventilated critically ill patients.Design The subtopics of this review include: introduction, goals of nutritional treatment, assessment of nutritional status, estimation of nutritional requirements, estimation of protein requirements, recommended approach to the initial nutritional regimen, routs of nutrition, and monitoring the response to nutrition.Setting The information is primarily germane to the medical management of patients with acute respiratory failure superimposed on chronic lung disease and malnutrition.Conclusion Malnutrition is prevalent in mechanically ventilated critically ill patients. Undernutrition is associated with respiratory muscle weakness and may contribute to ventilator dependency. Overnutrition may increase CO₂ production and increase ventilatory demands. This review advocates a titrated approach to nutritional management based on protein balance. Careful monitoring is necessary to ensure a regimen which maintains or improves body protein composition. Preliminary data exists which indicates that careful nutritional support may improve clinical outcome but more information is needed to recommend a universal approach.