慢性肾脏病患者蛋白质-能量消耗研究新进展

蛋白质-能量消耗在慢性肾脏病患者中发病率较高,临床上主要表现为饮食摄入、生化指标、体重指数、肌肉质量等方面的异常,其发病机制非常复杂,跟摄入不足、炎症、代谢性酸中毒、激素水平紊乱、透析相关因素等有关,严重影响透析患者的预后,因此早期发现、诊断和防治显得非常重要,将营养评估列入慢性肾脏病患者诊疗的日常工作当中,并对照诊断标准,及早诊断和采取各种措施防治蛋白质-能量消耗,最终提高慢性肾脏病患者的预后和生存率.本文对慢性肾脏病引起的蛋白质-能量消耗流行病学特点、发病机理、评估方式、治疗及干预措施等进行阐述.     

Bedside Ultrasound Is a Practical and Reliable Measurement Tool for Assessing Quadriceps Muscle Layer Thickness

Background: Critically ill patients commonly experience skeletal muscle wasting that may predict clinical outcome. Ultrasound is a noninvasive method that can measure muscle quadriceps muscle layer thickness (QMLT) and subsequently lean body mass (LBM) at the bedside. However, currently the reliability of these measurements are unknown. The objectives of this study were to evaluate the intra‐ and interreliability of measuring QMLT using bedside ultrasound. Methods: Ultrasound measurements of QMLT were conducted at 7 centers on healthy volunteers. Trainers were instructed to perform measurements twice on each patient, and then a second trainee repeated the measurement. Intrarater reliability measured how consistently the same person measured the subject according to intraclass correlation (ICC). Interrater reliability measured how consistently trainer and trainee agreed when measuring the same subject according to the ICC. Results: We collected 42 pairs of within operator measurements with an ICC of .98 and 78 pairs of trainer‐to‐trainee measurements with an ICC of .95. There were no statistically significant differences between the trainer and trainee results (trainer and trainee mean = ?0.028 cm, 95% CI = ?0.067 to ?0.011, P = .1607). Conclusions: Excellent intra‐ and interrater reliability for ultrasound measurements of QMLT in healthy volunteers was observed when performed by a range of providers with no prior ultrasound experience, including dietitians, nurses, physicians, and research assistants. This technique shows promise as a method to evaluate LBM status in ICU or hospital settings and as a method to assess the effects of nutrition and exercise‐based interventions on muscle wasting.     

Soin nutritionnel et amélioration clinique dans un service de néphrologie : une approche pilote multidisciplinaire

Malnutrition is an independent factor associated with morbi-mortality in chronic kidney disease. It is particularly common and may increase during hospitalization.ObjectivesTo measure nutritional and physical performance evolution as well as patients’ physical autonomy during a hospitalization in a university hospital renal ward. Treatments were adjusted according to different diagnoses (nutritional care, body composition, physical activity) along with a multidisciplinary approach. In this way, it can show the impact of this care on nutritional status of the patient.DesignRegardless of their nutritional status and kidney disease (acute or chronic kidney disease, chronic hemodialysis), patients were included at day 0, within 2 days from admission; nutritional interventions and measurements were assessed on day 7, day 14 and day 21. The study was run from December 2011 till June 2012, and 48 patients were included.ResultsOn admission, patients had a low energy intake (20.9 ± 8.6 kcal/kg/day). This intake was improved by means of a dietetic intervention (28.1 ± 6.5 kcal/kg/day after two weeks of hospitalization, 29 ± 6.1 kcal/kg/day after three weeks and 29 ± 8.4 kcal/kg/day after four weeks). Seventy-three percent of the hospitalized patients were malnourished, among them 91% had a decreased serum albumin (26.8 ± 6.6 g/L). Weight and muscle mass (measured by impedancemetry) were maintained, prealbumin increased by 16.5 mg/L after two weeks (n = 48; P = 0.61), 27.8 mg/L after three weeks (n = 31; P = 0.018), 52.3 mg/L after four weeks (n = 13; P = 0.002) and albuminemia by 1.8 g/L (n = 13 patients monitoring four weeks; P = 0.13). Both physical autonomy (assessed with Test moteur minimum) and muscle strength (Hand Grip Test) were significantly improved.ConclusionA systematic screening of wasting and a multidisciplinary care improved nutritional status and physical ability of patients hospitalized in a renal ward.     

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka,Bangladesh

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000–40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m², mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m²), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60–90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.     

The Extracellular Mass to Body Cell Mass Ratio as a Predictor of Mortality Risk in Hemodialysis Patients

The extracellular mass/body cell mass ratio (ECM/BCM ratio) is a novel indicator of nutritional and hydration status in hemodialysis (HD) patients. This study aimed to explore the ECM/BCM ratio as a predictor of mortality risk with nutritional-inflammatory markers in HD patients. A prospective observational study was conducted in 90 HD patients (male: 52.2%; DM: 25.60%). Clinical and biochemical parameters [serum albumin, serum C-reactive protein (s-CRP), interleukine-6 (IL-6)] were analysed and bioelectrical impedance analysis (BIA) was performed. Protein-energy wasting syndrome (PEW) was diagnosed using malnutrition-inflammation score (MIS). Based on BIA-derived measurements, the ECM/BCM ratio with a cut-off point of 1.20 was used as a PEW-fluid overload indicator. Comorbidity by Charlson index and hospital admissions were measured. Out of 90 HD patients followed up for 36 months, 20 patients (22.22%) died. PEW was observed in 24 survivors (34.28%) and all non-survivors. The ECM/BCM ratio was directly correlated with MIS, s-CRP, Charlson index and hospital admissions but was negatively correlated with phase angle and s-albumin (all, p < 0.001). Values of the ECM/BCM ratio ≥ 1.20 were associated with higher probability of all-cause mortality (p = 0.002). The ECM/BCM ratio ≥ 1.20, IL-6 ≥ 3.1 pg/mL, s-CRP and s-albumin ≥ 3.8 g/dL and Charlson index were significantly associated with all-cause mortality risk in multivariate adjusted analysis. This study demonstrates that the ECM/BCM ratio ≥ 1.20 as a nutritional marker and/or fluid overload indicator had a significant prognostic value of death risk in HD patients.     

颅咽管瘤全切除术后钠代谢紊乱及处理

目的分析颅咽管瘤全切除术后钠代谢紊乱的病理生理、诊断及处理。方法对我科86例巨大颅咽管瘤(直径>3.5cm)全切除患者进行回顾性分析,根据血钠、尿钠、渗透压以及中心静脉压等确定钠代谢紊乱类型,并进行相应处理。结果发生低钠血症29例(33.7％,29/86)、高钠血症13例(15.1％,13/86)、高钠及低钠血症交替9例(10.5％,9/86)。高钠及低钠血症平均开始时间分别为术后(2.3±0.7)d和(4.8±1.6)d。2例死于严重下丘脑反应,其余钠代谢紊乱均纠正良好,平均住院时间26 d。结论钠代谢紊乱是颅咽管瘤全切除术后常见表现之一。高钠血症与尿崩症关系密切,而低钠血症主要有两个原因:脑性盐耗综合征和抗利尿激素不适当分泌综合征,二者要仔细区分,前者着重补液、补盐,而后者应在补盐的基础上要适当限水和利尿。     

神经外科低钠血症的鉴别诊断和处理

目的探讨各型低钠血症的诊断和处理原则。方法回顾性分析562例低钠血症的临床资料,分出不同的类型给以不同的处理。结果562例中因利尿引起430例,补钠不足46例,尿崩症56例,抗利尿激素分泌不当综合征18例,恼性盐耗综合征11例,1例由肾小管损伤引起。结论因补钠不足或利尿引起的补钠即可,尿崩症以补充抗利尿激素为主,抗利尿激素分泌不当综合征应以限水为主,脑性盐耗综合征须采取综合治疗,肾小管损伤低钠血症会随着肾小管功能恢复而纠正。     

急性脑血管疾病中的脑耗盐综合征：附29例临床分析

目的 :观察急性脑血管病病程中并发的脑耗盐综合征。方法 :依次从我院神经科 1年中收治的各种急性脑血管病中筛选出低钠血症病例 ;根据脑耗盐综合征的诊断标准确定该综合征的病例。结果 :在 6 36例各种急性脑血管疾病中发现低钠血症 38例 ,其中脑耗盐综合征 2 9例。结论 :急性脑血管疾病的低钠血症 ,大部分是脑耗盐综合征 ,妥善处理脑耗盐综合征 ,能提高急性脑血管病的疗效