老年住院患者营养风险、营养不足发生率及营养支持应用状况的调查

目的 调查老年住院患者营养风险、营养不足发生率以及营养支持应用状况.方法 以2007年4月～2009年6月在北京医院住院的2517例老年患者(≥65岁)为研究对象,入院后第2天早晨进行营养风险筛查2002 (NRS 2002),营养不足判断标准为体质量指数(BMI)＜ 18.5 kg/m2、血清白蛋白＜35 g/L.结果 2386例研究对象完成NRS 2002筛查,其适用率为94.8％,其中包括呼吸内科466例,普通外科580例,神经内科549例,肾内科180例,消化内科301例,胸外科310例.营养风险(NRS≥3分)的发生率为28.2％,其中呼吸内科、普通外科、神经内科、肾内科、消化内科和胸外科分别为27.5％、30.3％、28.5％、29.4％、25.9％和25.4％;营养不足的发生率为26.4％,呼吸内科、普通外科、神经内科、肾内科、消化内科和胸外科分别为26.2％、29.8％、26.9％、28.3％、22.3％和22.9％.具有营养风险获得营养支持的比例为48.1％,其中呼吸内科、普通外科、神经内科、肾内科、消化内科和胸外科的支持率分别为30.1％、85.2％、26.1％、18.2％、73.8％、64.9％.没有营养风险而获得营养支持的比例(NRS＜3分)的比例为15.1％,呼吸内科、普通外科、神经内科、肾内科、消化内科和胸外科的支持率分别为10.6％、25.2％、6.3％、3.8％、34.2％、17.4％.肠外营养和肠内营养的比例大于4∶1.结论 老年住院患者营养风险和营养不良发生率较高.临床上仍存在不合理的营养支持现象,应推广应用基于证据的肠外、肠内营养指南以改善此状况.     

举足轻重,持续关注肝病营养问题

正肝病营养,尤其是终末期和危重症患者的营养问题,在国际国内受到了越来越多的重视。在营养筛查、评定、营养支持治疗和随访管理等领域均涌现了一些有价值的新理念和新方法。1国际国内共识/指南陆续更新/出台,循证医学证据不断升级近年来,一些国际肝病和营养相关学会陆续发     

Prevalence of coeliac disease in patients with non-alcoholic fatty liver disease

Background and study aimsCoeliac disease (CD) may be associated with several liver disorders including primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis. Furthermore preliminary data suggest a causative role of CD in steatosis and steatohepatitis. The aim of present study was to determine the prevalence of CD in a series of patients with non-alcoholic fatty liver disease (NAFLD).Patients and methodsIn a cross sectional study (2008–2010), 403 consecutive NAFLD patients (127 female and 276 male) referred to GI clinics of the Zahedan University of Medical Sciences were included. IgA anti-tissue transglutaminase (Anti-tTG) was used for screening of coeliac disease. In the patients with a positive serologic test, duodenal biopsies were taken to confirm the diagnosis.ResultsThe mean ± SD of the age and BMI of patients were 37.4 ± 12.4 years and 28.3 ± 4.15 kg/m² respectively. BMIs lower than 25 kg/m² were found in 58 subjects (14.5%). Furthermore diabetes mellitus and hyperlipidaemia were diagnosed in 48 (11.9%) and 84 (20.8%) individuals respectively. Positive Anti-tTGs were found in 14/403 (3.4%) and 13/403 (3.2%, 95% CI 1.5–4.9) had coeliac disease according to the modified Marsh classification; 8 had type I, 3 type II, 1 type IIIA and 1 type IIIB lesions.ConclusionAccording to our data, prevalence of CD in the subjects with NAFLD is higher than the rates reported in the general population. Therefore screening for CD in selected cases of NAFLD may be appropriate.     

Prevalence of liver disease in patients with Streptococcus bovis bacteraemia

BACKGROUND: The relationship between Streptococcus bovis bacteraemia and gastrointestinal disease (mainly colon cancer) is well known. Patients with advanced liver disease are prone to bacteraemia. Less attention has been paid to the association between liver disease and Streptococcus bovis bacteraemia in the literature. AIMS: To evaluate the prevalence of liver disease in patients with S. bovis bacteraemia. PATIENTS AND METHODS: Twenty-two episodes of S. bovis bacteraemia in 20 adults (13 males and seven females, with a median age of 61 years, range 32-94 years) were detected in a single hospital over a 7-year period. Ten of them had endocarditis. Patients' clinical records were reviewed, with special focus on underlying liver and gastrointestinal disease. RESULTS: Eleven patients (55%) had a chronic liver disease. Nine of them were cirrhotics. Ten patients had a history of chronic alcohol abuse, and four patients had hepatitis C virus antibodies (associated with alcohol abuse in three cases). Large bowel disease was present in six out of 13 evaluable patients (adenocarcinoma in three cases). Patients with liver disease were younger than patients without it. Mortality related to S. bovis bacteraemia was particularly high among patients with advanced liver disease (Child-Pugh state C). Bacteraemia recurred two times in one alcoholic cirrhotic, who was diagnosed as having a Dukes-B colon cancer 4.5 years after the first episode of S. bovis bacteraemia. CONCLUSIONS: In our area, S. bovis bacteraemia is frequently associated with chronic liver disease. Liver disease may be a predisposing factor for S. bovis bacteraemia.     

Alcoholic liver disease and malnutrition

Malnutrition, both protein energy malnutrition (PEM) and deficiencies in individual nutrients, is a frequent complication of alcoholic liver disease (ALD). Severity of malnutrition correlates with severity of ALD. Malnutrition also occurs in patients with cirrhosis due to etiologies other than alcohol. The mechanisms for malnutrition are multifactorial, and malnutrition frequently worsens in the hospital due to fasting for procedures and metabolic complications of liver disease, such as hepatic encephalopathy. Aggressive nutritional support is indicated in inpatients with ALD, and patients often need to be fed through an enteral feeding tube to achieve protein and calorie goals. Enteral nutritional support clearly improves nutrition status and may improve clinical outcome. Moreover, late-night snacks in outpatient cirrhotics improve nutritional status and lean body mass. Thus, with no FDA-approved therapy for ALD, careful nutritional intervention should be considered as frontline therapy.     

Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure

BACKGROUND: Liver cholestasis can be a life-threatening complication during home parenteral nutrition and may lead to combined liver-intestinal transplantation. OBJECTIVE: To assess the prevalence of home parenteral nutrition-related liver disease and its contributing factors in patients with permanent intestinal failure. DESIGN: Prospective cohort study. SETTING: Two approved home parenteral nutrition centers. PATIENTS: 90 patients with permanent intestinal failure who were receiving home parenteral nutrition were enrolled from 1985 to 1996. INTERVENTION: Clinical, biological, endoscopic, and ultrasonographic follow-up. Histologic examination of the liver was done in 57 patients (112 liver biopsies). MEASUREMENTS: The Kaplan-Meier method was used to determine the actuarial occurrence of chronic cholestasis and complicated home parenteral nutrition-related liver disease (bilirubin level > or =60 micromol/L [3.5 mg/dL], factor V level < or =50%, portal hypertension, encephalopathy, ascites, gastrointestinal bleeding, or histologically proven extensive fibrosis or cirrhosis). Contributing factors were assessed by using univariate and multivariate (Cox model) analysis. RESULTS: 58 patients (65%) developed chronic cholestasis after a median of 6 months (range, 3 to 132 months), and 37 (41.5%) developed complicated home parenteral nutrition-related liver disease after a median of 17 months (range, 2 to 155 months). Of these patients, 17 showed extensive fibrosis after 26 months (range, 2 to 148 months) and 5 had cirrhosis after 37 months (range, 26 to 77 months). The prevalence of complicated home parenteral nutrition-related liver disease was 26%+/-9% at 2 years and 50%+/-13% at 6 years. Six patients died of liver disease (22% of all deaths). In multivariate analysis, chronic cholestasis was significantly associated with a parenteral nutrition-independent risk for liver disease, a bowel remnant shorter than 50 cm in length, and a parenteral lipid intake of 1 g/kg of body weight per day or more (omega-6-rich long-chain triglycerides), whereas complicated home parenteral nutrition-related liver disease was significantly associated with chronic cholestasis and lipid parenteral intake of 1 g/kg per day or more. CONCLUSION: The prevalence of complicated home parenteral nutrition-related liver disease increased with longer duration of parenteral nutrition. This condition was one of the main causes of death in patients with permanent intestinal failure. Parenteral intake of omega-6-rich long-chain triglycerides lipid emulsion consisting of less than 1 g/kg per day is recommended in these patients.     

早期肠内营养干预对老年肺部炎性疾病伴营养不良患者的治疗效果

目的探究早期肠内营养(EEN)干预对老年肺部炎性疾病伴营养不良患者营养及肺功能的影响。方法选取2017年5月至2018年12月唐山市开滦总医院营养科收治的老年肺部炎性疾病伴营养不良患者96例,按随机数表法分为对照组及研究组,各组48例。对照组仅给予常规饮食干预,研究组在对照组基础上加用EEN干预。观察并比较2组患者治疗前后营养状态[血清总蛋白(TP)、白蛋白(ALB)及血红蛋白(Hb)]、肺功能[用力肺活量(FVC)、第1秒用力呼气容积(FEV1)及FEV1/FVC]、免疫功能指标(CD3~+、CD4~+、CD4~+/CD8~+及IgA、IgG、IgM)、炎性指标[白细胞介素-10(IL-10)、白细胞介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)]。采用SPSS 21.0统计软件进行数据分析。组间比较采用独立样本t检验。结果 (1)营养状态。对照组患者TP、Hb及ALB干预前分别为(56.03±2.81)、(28.53±2.85)和(109.74±10.97)g/L,干预后分别为(56.15±2.82)、(28.92±2.89)和(123.86±12.39)g/L;研究组患者TP、Hb及ALB干预前分别为(56.17±2.82)、(28.57±2.86)和(112.96±11.30)g/L,干预后分别为(59.77±2.99)、(32.47±3.25)和(131.07±13.11)g/L。干预前2组患者TP、ALB及Hb比较差异不显著(P0.05);干预后,与对照组比较,研究组患者TP、ALB及Hb水平显著升高,差异有统计学意义(P0.05)。(2)肺功能。对照组患者FEV1、FVC及FEV1/FVC干预前分别为(1.40±0.14)L、(2.33±0.42)L和(62.11±6.26)%,干预后分别为(1.63±0.18)L、(2.51±0.41)L和(66.93±6.70)%;研究组患者FEV1、FVC及FEV1/FVC干预前分别为(1.42±0.12)L、(2.41±0.37)L和(62.48±6.31)%,干预后分别为(1.93±0.27)L、(2.79±0.36)L和(72.54±7.23)%。干预前2组患者FEV1、FVC及FEV1/FVC水平比较差异不显著(P0.05);干预后,研究组FVC、FEV1、及FEV1/FVC水平均显著高于对照组(P0.05)。与干预前比较,干预后2组患者FVC、FEV1及FEV1/FVC水平均显著升高,差异有统计学意义(P0.05)。(3)免疫指标及炎性指标。干预前,2组患者免疫功能相关指标和炎症指标差异均不显著(P0.05)。干预后,与对照组比较,研究组患者上述免疫功能相关指标及炎性指标IL-10水平均显著升高,同时IL-6和TNF-α水平显著降低,差异有统计学意义(P0.05)。结论 EEN能有效改善老年肺部炎性疾病患者营养状态,提高患者免疫力并减弱其炎症反应,进而提高患者肺功能,具有临床推广意义。     

Prevalence of malnutrition in hospitalized medical patients: impact of underlying disease

BACKGROUND/AIMS: Malnutrition is common among hospitalized patients. We investigated whether certain diseases predispose more frequently for malnutrition than others. METHODS: Nutritional state was assessed by clinical scores, anthropometry and bioimpedance analysis in 502 consecutively admitted patients in the departments of internal medicine in two hospitals in Berlin (n = 300, university hospital; n = 202, district hospital). The prevalence of malnutrition was compared in patient groups with a different diagnosis. RESULTS: Malnutrition was present in 24.2% of all patients. A clear association between diagnoses and malnutrition was found: the prevalence of malnutrition was significantly higher in malignant than in non-malignant diseases (50.9 vs. 21.0%, p < 0.0001). High prevalence rates >30% were observed in subgroups of patients with inflammatory bowel diseases, chronic heart failure and benign lung diseases. Patients with gastrointestinal diseases, however, were not more frequently malnourished than other medical patients (28.8 vs. 22.0%). Malnourished patients were significantly older (70.0 +/- 13.6 vs. 58.3 +/- 15.6 years, p < 0.0001) and had a 40% longer hospital stay (13.1 +/- 8.1 vs. 9.3 +/- 6.8 days, p < 0.0001) than well-nourished patients. CONCLUSIONS: Patients with malignancies, inflammatory bowel disease, chronic heart failure and benign lung diseases need special attention due to the high prevalence of malnutrition.     

Determination of glycated hemoglobin in patients with advanced liver disease

AIM: To evaluate the glycated hemoglobin (HbA(1c)) determination methods and to determine fructosamine in patients with chronic hepatitis, compensated cirrhosis and in patients with chronic hepatitis treated with ribavirin. METHODS: HbA(1c) values were determined in 15 patients with compensated liver cirrhosis and in 20 patients with chronic hepatitis using the ion-exchange high performance liquid chromatography and the immunoassay methods. Fructosamine was determined using nitroblue tetrazolium. RESULTS: Forty percent of patients with liver cirrhosis had HbA(1c) results below the non-diabetic reference range by at least one HbA(1c) method, while fructosamine results were either within the reference range or elevated. Twenty percent of patients with chronic hepatitis (hepatic fibrosis) had HbA(1c) results below the non-diabetic reference range by at least one HbA(1c) method. In patients with chronic hepatitis treated with ribavirin, 50% of HbA(1c) results were below the non-diabetic reference using at least one of the HbA(1c) methods. CONCLUSION: Only evaluated in context with all liver function parameters as well as a red blood count including reticulocytes, HbA(1c) results should be used in patients with advanced liver disease. HbA(1c) and fructosamine measurements should be used with caution when evaluating long-term glucose control in patients with hepatic cirrhosis or in patients with chronic hepatitis and ribavirin treatment.     

Prevalence of metabolic syndrome in patients with clinically advanced peripheral vascular disease

The aim of this cross-sectional study was to determine the prevalence of metabolic syndrome (MetS) and its components among 100 patients with progressive peripheral arterial disease (PAD) referred for diagnostic angiography in preparation for a revascularization procedure. The prevalence of MetS was more than 95%. Diabetes mellitus was the most prevalent component followed by hypertension and low high-density lipoprotein. Almost half the patients aggregated in the highest metabolic score category. A direct relationship was identified between the number of MetS components and serum uric acid (P = .001) and C-reactive protein (P = .826), whereas an inverse relationship was seen between the clustering of components and androgen levels in men (P < .001). For PAD, which could have a benign clinical course, early screening for MetS might identify those at greater risk of failing conservative therapy and progressing to a more aggressive atherosclerotic disease typically associated with high morbidity and mortality.     

Nutritional management of patients with chronic liver disease

The focus of the nutritional management in liver disease has swung from micronutrients with the supplementation of vitamins back to the problems of the macronutrients and especially the importance of protein metabolism. Whether the considerable activity in this area in the last few years, particularly in patients with acute alcoholic hepatitis, will result in significant improvements not only in the overall medical management and consequently the quality of life, but also on life itself, still remains to be seen.     

Monitoring and management of hyperglycemia in patients with advanced diabetic kidney disease

Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.     

肝硬化患者营养不良、肌肉减少症及骨质疏松的防治

营养不良、肌肉减少症(肌少症)及骨质疏松是肝硬化患者常见的营养相关并发症,肌少症是营养不良的重要表现,而营养不良、肌少症又是骨质疏松发生的危险因素,三者相互关系密切,且都对肝硬化患者的临床结局和预后产生不良影响,故要及早发现,积极防治。营养物质摄入不足、代谢紊乱、激素水平异常、身体活动缺乏等促使肝硬化患者易出现营养不良、肌少症及骨质疏松。此外,肝病治疗常用药物如糖皮质激素、某些抗病毒药物等可能影响骨代谢,需引起临床关注。合理的营养干预、适当的运动和基础疾病的治疗是防治营养不良、肌少症及骨质疏松的基础。一些针对性治疗药物可有助于改善患者的上述营养相关并发症,但仍需进一步研究证实。