纤维连接蛋白和前清蛋白在营养支持效果评价中的作用

目的:评价纤维连接蛋白和前清蛋白作为腹部外科术后营养支持效果指标的意义.方法:测定腹部外科术后病人行营养支持前后的血清清蛋白、转铁蛋白、前清蛋白和纤维连接蛋白水平,并测定营养支持期间每天氮平衡.结果:与营养支持前相比,血清转铁蛋白、前清蛋白和纤维连接蛋白水平在营养支持后明显升高(P＜0.05),前清蛋白与纤维连接蛋白水平的升高呈正相关.结论:血清纤维连接蛋白和前清蛋白对评价术后营养支持效果有一定的参考价值.     

Instant nutritional assessment

Instant nutritional assessment of the hospitalized patient is described based upon admission serum albumin levels and total lymphocyte counts. Abnormalities of these parameters are associated with markedly increased morbidity and mortality in a series of 500 consecutively admitted patient. It is suggested that instant nutritional assessment be performed on all hospitalized patients with appropriate alterations and therapy being made to allow for nutritional repletion.     

Influence of total parenteral nutrition on plasma fibronectin in malnourished subjects with or without inflammatory response

Plasma fibronectin, which is an alpha 2-glycoprotein of importance for the immunodefence, has been reported to decrease after starvation and in severely ill patients with cancer. To evaluate the usefulness of fibronectin as an indicator of nutritional repletion, 18 patients with gastrointestinal disorders were studied over a 2-wk period of total parenteral nutrition (TPN). According to nutritional assessment on admission the patients were divided into well nourished (n = 6) and malnourished (n = 12). For comparison nine patients with anorexia nervosa were also studied over a 3-wk period of TPN. Before and after TPN fibronectin, albumin, prealbumin, transferrin, and two acute-phase reactants, haptoglobin and orosomucoid were measured in plasma. The majority of the malnourished patients had an inflammatory reaction in contrast to only a few of the well-nourished and anorexia nervosa patients. Of the proteins measured, only fibronectin rose significantly in the malnourished patients (malnourished and anorexia nervosa), but not in the well nourished patients during TPN. Our results may indicate the usefulness of fibronectin as an indicator of short-term TPN in malnourished subjects, irrespective of the presence or absence of inflammatory response.     

低热量肠外营养加生长激素对严重应激和重度营养不良病人的治疗体会

目的：观察生长激素加强危重病人应用全肠外营养支持的效果。方法：对严重应激（７例）和重度营养不良（９例）共１６例病人采用低热量肠外营养加重组生长激素联合治疗，并与仅用ＴＰＮ治疗的同类病人作对照研究，治疗后分别测定体重、血清白蛋白，前白蛋白和转铁蛋白及免疫球蛋白，计算氮平衡，观察精神状态。结果：治疗组比对照组在氮平衡、前白蛋白和转铁蛋白有明显改善（Ｐ＜０．０１），血清白蛋白，免疫球蛋白亦有明显增高（Ｐ＜０．０５），精神状态普遍较好，获得了较好的临床疗效。结论：低热量肠外营养加重组生长激素联合治疗是机体病理状态下一种较为理想的营养支持方法     

Changes in plasma fibronectin during acute nutritional deprivation in healthy human subjects

1. Plasma fibronectin, a glycoprotein, is an opsonin of the reticuloendothelial system. 2. In ten healthy volunteers starved for 4.5 d, daily measurements showed a rapid reduction in plasma fibronectin, no alteration in either C3 or plasma transferrin and, at the end of the starvation period, an elevated serum albumin. 3. On refeeding, plasma fibronectin rapidly returned to its prestarvation level but plasma transferrin was significantly reduced and did not recover by the end of the study. 4. Changes in plasma fibronectin may be a sensitive index of nutritional status. The reduction of plasma fibronectin in short-term starvation may compromise host defence tolerance of injury and sepsis.     

A comparison of serum transferrin and serum prealbumin as nutritional parameters

Serum transferrin and prealbumin levels were determined at intervals of 3 to 4 days in 16 patients requiring nutritional support. Caloric and nitrogen intake were measured and nitrogen balance calculated. There were 117 intervals available for analysis. A mean decrease in transferrin of 12.95 mg/dl was associated with a mean decrease in nitrogen balance of 0.92 g/day, whereas a mean increase in transferrin of 21.04 mg/dl was associated with a mean increase in nitrogen balance of 1.49 g/day; the correlation between changes in transferrin with changes in nitrogen balance was statistically significant (p = 0.02). Upward and downward changes in prealbumin were also associated with corresponding changes in nitrogen balance, but the changes were not statistically significant. Decreases in transferrin and prealbumin were also associated with a lower caloric intake. Operation caused a significant decrease in prealbumin (p = 0.003) and nitrogen balance (p = 0.05); a decrease in transferrin also occurred, but was not statistically significant. There was a highly significant correlation between serum transferrin and prealbumin (p = 0.001) and also between the interval changes in transferrin and prealbumin (p less than 0.001). In conclusion, transferrin was found to correlate closely with prealbumin. Changes in transferrin were more significantly related to changes in nitrogen balance, and from the results of this study, measurement of serum transferrin can be recommended as a useful parameter in following the nutritional status of patients receiving nutritional support.     

The efficacy of nutritional support in the elderly.

One hundred two consecutively nutritionally supported patients were studied to determine the effect of age on the response to nutritional support and outcome of hospital stay. The patients were divided into two groups: group 1 (n = 37) consisted of all patients under 65 years of age, and group 2 (n = 65) consisted of patients 65 years of age and older. All patients underwent a complete nutritional assessment prior to the initiation of nutritional support and weekly thereafter. The patients' somatic compartments were assessed using weight, arm muscle circumference, creatinine height index, and triceps skinfold thickness. The visceral compartments were assessed using serum albumin level, transferrin total iron binding capacity (TIBC) level, and total lymphocyte count. Nitrogen balance was evaluated and cell-mediated immunity was determined using a standard battery of antigens. The patients' nutritional assessment parameters at the start of therapy were compared with those at discharge or death and correlated with outcome of hospital stay. The difference in crude mortality rates between the two groups was statistically significant; however, there was no significant difference between the type and degree of nutritional depletion and mean length of nutritional therapy between the two groups. There was also no significant difference between the degree of improvement or maintenance of somatic or visceral parameters, nitrogen balance, or cell-mediated immunity between the two groups. It is therefore concluded that age alone is not a deterrent to the use of aggressive nutritional support in the elderly.     

Nutritional assessment indications of postburn complications

This study evaluates the use of nutritional assessment indexes measured on the fifth day after injury to predict subsequent wound infections, episodes of septicemia, and other infectious complications in burned patients. Nutritional assessment data collected included anthropometric measurements (weight, height, triceps skinfold, and upper-arm circumference); biochemical testing (serum albumin concentration, serum transferrin concentration, total lymphocyte count, creatinine/height index, and nitrogen balance); and recall skin antigen testing. Seventy-four adult patients (mean age of 35 years) who had burn injuries ranging from 10% to 96% total body surface were studied. Indexes predictive of imminent wound infection include serum transferrin concentrations less than 150 mg/dl (p = .0006) and anergy to the skin test battery (p = .01). Those indexes were also prognostic of the development of septicemia (p = .0002 and p = .0001, respectively). Although statistically insignificant, total lymphocyte count also showed a similar trend toward predicting complications. Serum albumin concentration (less than 3.0 gm/dl), creatinine/height index (less than 60% standard), percent ideal body weight (less than 80%), percent weight change, and nitrogen balance did not contribute to group discrimination. Severe depletion of the visceral protein compartment was documented in a large percentage of patients on the fifth postburn day. Serum transferrin concentration and recall skin antigen testing can be helpful in identifying thermally injured patients who are at high risk of infectious complications.     

Evaluation of serum visceral protein levels as indicators of nitrogen balance in thermally injured patients

The use of serum visceral protein concentrations as predictors of nitrogen balance was assessed during the first 4 weeks following thermal injury. The correlation between nitrogen balance and serum albumin was not significant. Statistically significant correlations were found between nitrogen balance and serum prealbumin, retinol-binding protein, and transferrin. However, even the best correlation (retinol-binding protein, r = 0.388) was too weak to permit prediction of nitrogen balance on the basis of the visceral protein concentration. The correlation between change in direction of nitrogen balance and change in direction of protein concentration over time showed all four visceral proteins to be poor predictors of change in nitrogen balance. The efficiency was less than 50% for each visceral protein. Stepwise multiple regression analysis performed to determine which indices were most closely correlated with nitrogen balance showed that a calculation using readily available information (nitrogen intake, postburn day, percent total body surface burned, and age) provided better prediction of nitrogen balance (r = 0.765) than any of the visceral protein concentrations. In view of these findings, measurement of serum visceral protein concentrations to monitor adequacy of nutritional support seems an unwarranted expense in patients with thermal injury.     

Use of fibronectin and somatomedin-C as markers of enteral nutrition support in traumatized patients using a modified amino acid formula

The purpose of this study was to evaluate the use of serum fibronectin and serum somatomedin-C as nutritional markers during enteral nutrition support (ENS) of critically ill, traumatized patients using an enteral product containing high concentrations of branched-chain amino acids. Twelve critically injured patients received a standard enteral formula with 30 g of a 44% branched-chain amino acid supplement added to each liter of formula. Fibronectin concentration, somatomedin-C concentration, and nitrogen balance were measured on study days 1, 4, 7, 14, 21, 28 or until adequate oral intake began. Both fibronectin and somatomedin-C concentrations increased significantly from baseline by day 7 of ENS. Nitrogen balance increased significantly from baseline by day 4. On days 14 and 21, only somatomedin-C and nitrogen balance increased significantly from baseline. Nitrogen balance was significantly correlated with somatomedin-C concentration (r = 0.53, p less than 0.01), cumulative caloric intake (r = 0.68, p less than 0.01), and cumulative nitrogen intake (r = 0.72, p less than 0.01). The results of this study suggest that serum somatomedin-C is useful and serum fibronectin has potential in monitoring nutrition support response in critically ill, traumatized patients.     

Utilization of prealbumin as a nutritional parameter

The response of prealbumin was compared to that of albumin and transferrin in 16 patients following 7 days of metabolic/nutritional support. Baseline values were compared to day 7 results to assess the degree of change. Prealbumin demonstrated a significant increase in the mean serum concentration (13.0 vs 19.6 mg/100 ml) in the presence of a positive nitrogen balance. Transferrin exhibited a similar significant response (168.8 vs 223.7 mg/100 ml). Albumin, body weight, and serum iron concentration did not change significantly during the 7-day period. Prealbumin effectively demonstrated an anabolic response in the study sample and could possibly be used as an early indicator of visceral protein anabolism in patients receiving metabolic/nutritional support.     

The Importance of a Source of Sufficient Protein in Postoperative Hypocaloric Partial Parenteral Nutrition Support

A comparison of postoperative metabolic and nutritional responses to different hypocaloric parenteral nutrition supports was performed in 42 patients with various gastric lesions. Sixteen patients (group A) received 3000 mL of a 5% glucose in water or glucose in saline infusion per day after surgery (approximately 10 kcal/kg per day). Another 14 patients (group B) received 2000 mL of 5% glucose in water or saline plus 1000 mL of 5% amino acid solution per day (approximately 10 kcal/kg per day and 1 g of protein per kilogram per day). The other 12 patients (group C) received 2000 mL of 5% glucose in water or saline plus 500 mL of 5% amino acid solution and 500 mL of 10% fat emulsion (approximately 20 kcal/kg per day and 0.5 g of protein per kilogram per day). After 7 days of study, all three groups were found to have a decrease in body weight, mid-arm circumference, triceps skin-fold, and serum albumin level, and the differences among them were not significant. Groups B and C had significantly less negative mean nitrogen balance than group A (—5.54 ± 0.63 g/ d and -6.07 ± 0.49 g/d vs -9.20 ± 0.68 g/d). Group B also had a significantly greater increase of transferrin (from 175.5 ± 9.9 mg/dL to 185.4 ± 9.3 mg/dL) than group A and a significantly greater increase in total lymphocyte count (from 956 ± 113 cells/mm³ to 1196 ± 176 cells/mm³) than groups A and C. We concluded that postoperative hypocaloric nutrition support with a sufficient protein source, at least 1 g/kg per day, achieved better nitrogen balance, improved short half-life of visceral protein levels, and higher total lymphocyte count. (Journal of Parenteral and Enteral Nutrition 17: 254–256, 1993)     

Transferrin--a poor measure of nutritional status

The present study evaluated the sensitivity and specificity of the serum transferrin concentration as a measure of the nutritional state. Serum transferrin was derived from total iron-binding capacity measurements in 74 patients on 114 occasions and correlated with body composition as measured by multiple isotope dilution. Highly significant correlations (p less than 0.001) existed between serum transferrin and both the body cell mass and the nutritional state as measured by the Nae/Ke ratio. However, the 95% confidence limits about both regressions were wide. The false-positive rate was 60% while the false-negative rate was 31%. Body composition and transferrin were measured before and after 2 wk of total parenteral nutrition in 34 malnourished patients. Eighteen patients restored body cell mass toward normal after 2 wk of total parenteral nutrition while in 16 patients the body cell mass continued to decrease in size, despite 2 wk of total parenteral nutrition. The changes in serum transferrin were not significant over this period of time in either group, despite significant changes in the nutritional state in both groups. The presence of a statistically significant relationship between the serum transferrin concentration and the nutritional state indicates that the serum transferrin concentration accurately reflects a population's nutritional status, and is therefore useful in epidemiologic surveys. However, because of the large variance of the data, as demonstrated by the wide 95% confidence limits, and because of the poor sensitivity and specificity, in an individual patient it is of little value as a measure of the nutritional status.     

The response of fibronectin to differing parenteral caloric sources in normal man

The relationship between circulating fibronectin concentration and nutritional status was examined in eight healthy male (31 +/- 1 yr old) volunteers in three nutritional states: the postabsorptive state, after 10 days of protein-caloric starvation, and during the 10th day of refeeding by total parenteral nutrition. Plasma fibronectin was significantly decreased from 330 +/- 22 to 154 +/- 11 micrograms/ml (p less than 0.001) from the postabsorptive to starved state which was accompanied by appropriate changes in body weight, anthropometric measurements, and nitrogen balance. Plasma fibronectin levels were restored to 402 +/- 39 micrograms/ml following 10 days of total parenteral nutrition. The plasma fibronectin response was greater (p less than 0.05) during total parenteral nutrition with dextrose as the nonprotein calorie source as compared to a 50% dextrose/50% lipid regimen. These results suggest that the calorie source must be considered during interpretation of plasma fibronectin levels in patients undergoing parenteral nutrition.     

低热量PN联合rhGH在严重腹腔感染病人的应用

目的：探讨低热量肠外营养和重组人生长激素联合应用对严重腹腔感染病人的作用。方法：我院从１９９６年８月至１９９８年１２月，对４０例严重腹腔感染伴低蛋白血症的病人、采用低热量ＰＮ，配合短程小剂量ｒｈＧＨ进行营养治疗，监测体重，血清白蛋白，转铁蛋白，肝酐身高指数，总淋巴细胞计数和计算氮平衡，并进行治疗前，后自身对照观察。     

Use of plasma somatomedin-C/insulin-like growth factor I measurements to monitor the response to nutritional repletion in malnourished patients

Changes in plasma somatomedia-C/insulin-like growth factor I (Sm-C/IGF-I) concentrations are a sensitive indicator of the anabolic response of normal human volunteers to alterations in nutritional intake. To determine if measurement of this peptide could be used to monitor the response to nutritional repletion in malnourished patients, six patients were studied while receiving nutritional support for periods of 10-16 days. Plasma Sm-C/IGF-I increased from a mean basal level of 0.67 +/- 0.15 U/ml (+/-1 SD) to a peak of 1.80 +/- 0.44 U/ml on day 10, then declined to a concentration of 1.28 +/- 0.49 U/ml by day 16. All patients entered positive nitrogen balance by day 2 and nitrogen accretion continued throughout the study. Changes in serum concentrations of prealbumin, transferrin, and retinol-binding protein were compared to changes in Sm-C/IGF-I during nutritional support. Prealbumin increased to a posttreatment mean of 121 +/- 23% of control by the end of the study (p greater than 0.05, NS). Likewise, there was minimal change in retinol-binding protein, a peak value of 118 +/- 21% of control being reached by day 12 of treatment (p greater than 0.05, NS). Transferrin also showed minimal change, increasing to a mean value of 110% +/- 13% of control by day 12 (p greater than 0.05, NS). Measurement of plasma Sm-C/IGF-I concentrations appears to be a much more sensitive index of acute directional changes in nutritional status than other plasma proteins commonly used to monitor nutritional responses. The increase of Sm-C/IGF-I correlated temporally with entry into positive nitrogen balance.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nutritional assessment in gynecology patients

A nutritional assessment was performed upon 72 patients admitted for major elective gynecologic surgery for nonmalignant diseases. This nutritional assessment included body weight, triceps skinfold, arm muscle circumference, creatinine-height index, serum albumin and transferrin, total lymphocyte count, and dermal antigen testing. We found that 29 patients (42%) had at least one test result indicating a nutritional deficiency. Of the 72 patients, 19 (26%) experienced a postoperative complication. The occurrence of a complication did not correlate with any nutritional parameter other than albumin (p = 0.013), but even then, the positive predictive value of albumin was only 40%. Age also correlated with complication status (p = 0.002).     

Nutritional assessment in gynecology patients.

A nutritional assessment was performed upon 72 patients admitted for major elective gynecologic surgery for nonmalignant diseases. This nutritional assessment included body weight, triceps skinfold, arm muscle circumference, creatinine-height index, serum albumin and transferrin, total lymphocyte count, and dermal antigen testing. We found that 29 patients (42%) had at least one test result indicating a nutritional deficiency. Of the 72 patients, 19 (26%) experienced a postoperative complication. The occurrence of a complication did not correlate with any nutritional parameter other than albumin (p = 0.013), but even then, the positive predictive value of albumin was only 40%. Age also correlated with complication status (p = 0.002).     

Nutrition in patients undergoing orthotopic liver transplant

Thirteen patients with severe liver disease had nutritional assessment in the weeks prior to orthotopic liver transplantation. Parameters measured included height and weight, upper arm anthropometry, delayed cutaneous hypersensitivity, total lymphocyte count, serum levels of albumin and transferrin, and plasma amino acids. Weight, when expressed as a percentage of ideal body weight, was greater than 85%, considered the normal lower limit, in all but two patients. However, mean triceps skinfold and arm muscle circumference were 49 +/- 25 and 78 +/- 9% standard, respectively. Mean serum albumin was 2.7 +/- 0.6 g/dl and although mean serum transferrin level was 184 +/- 86, eight patients had levels less than normal. Seven patients were anergic to Multitest CMI (58%) and 12 patients had depressed total lymphocyte count. All these later measurements in the aggregate support a diagnosis of protein-calorie malnutrition. High preoperative levels of amino acids, especially aspartate, phenylalanine, tyrosine, and methionine, were returned to normal by transplantation. We conclude that protein-calorie malnutrition is common in the group of patients likely to require liver transplant, although individual nutritional assessment parameters may lack sensitivity and specificity in determining nutritional status.     

Effects of a low calorie,low protein diet on nutritional parameters,and routine laboratory values in nonobese young and elderly subjects.

The effect of a low calorie (1100 kcal), low protein (35 g) intake for 9 days on nutritional and laboratory parameters was studied in six young and six elderly healthy subjects. All subjects lost weight on the test diet (an average of 2.0 kg in the young and 2.1 kg in the elderly). Basal serum albumin, serum transferrin, creatinine height index, and creatinine clearance in the elderly subjects were lower than in the young (p less than 0.05). Serum albumin remained unchanged at the end of diet in both groups. There was, however, a significant decrease in the transferrin level in the younger subjects (p less than 0.01). The decrease in creatinine height index was not significant in either group. Baseline nitrogen balance of the elderly was -1.1 g/day compared to +0.5 g/day (p less than 0.01) in the young subjects. The test diet caused a negative nitrogen balance of about -5 g/day in both groups (p less than 0.005). Blood urea nitrogen was significantly lower at the end of the test diet and was related to the intake of protein in both groups. At the end of the diet the serum potassium and GGT were significantly lower in the young (p less than 0.01); serum creatinine was unchanged but creatinine clearance was significantly lower in both groups. From this study it appears that significant changes occur in nutritional and laboratory parameters within 9 days on a diet deficient in calories and protein in normal healthy subjects. These changes need to be recognized as having nutritional basis and should not be attributed to illness or drug therapy.