慢加急性肝衰竭患者的营养评估及临床管理

吴牧晨; 孟庆华

doi:10.3969/j.issn.1001-5256.2021.04.006

慢加急性肝衰竭患者的营养评估及临床管理

DOI: 10.3969/j.issn.1001-5256.2021.04.006

吴牧晨,
孟庆华^,

首都医科大学附属北京佑安医院肿瘤内科，北京 100069

基金项目:

北京市自然科学基金 (7192085);

中华人民共和国科学技术部艾滋病与病毒性肝炎等重大传染病防治专项 (2018ZX10302206)

利益冲突声明：所有作者均声明不存在利益冲突。

作者贡献声明：孟庆华、吴牧晨对文章的思路有关键贡献，参与起草或修改文章关键内容；孟庆华参与文章的最终定稿。

详细信息

作者简介:
吴牧晨(1996—)，女，主要从事慢加急性肝衰竭研究

通信作者:
孟庆华，meng_qh0805@ccmu.edu.cn

中图分类号: R575.3
计量
- 文章访问数: 975
- HTML全文浏览量: 158
- PDF下载量: 125
- 被引次数: 0
出版历程
- 收稿日期: 2020-12-28
- 录用日期: 2021-01-05
- 出版日期: 2021-04-20

Nutritional assessment and clinical management of patients with acute-on-chronic liver failure

Muchen WU,
Qinghua MENG^,

Department of Oncology, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China

摘要

摘要: 肝脏作为人体最重要的代谢脏器，是营养物质合成、储存的重要场所。慢加急性肝衰竭患者常由于多种营养物质的代谢异常出现不同程度的营养不良，而营养不良又可在一定程度上加速肝病的发生发展，进一步恶化疾病的预后。因此早期的营养评估和营养干预显得尤为重要。尽管有多种营养不良的评价方法，但针对慢性肝病、肝硬化患者，特别是针对慢加急性肝衰竭患者的营养评估方法仍有一定的缺陷。现就该类患者的营养评估及临床管理加以阐述，旨在为相关临床问题提供一定的参考。
- 慢加急性肝功能衰竭 /
- 营养评价 /
- 早期医疗干预
Abstract: As the most important visceral organ in human body for metabolism, the liver is an important place for the synthesis and storage of nutrients. Patients with acute-on-chronic liver failure suffer from varying degrees of malnutrition due to abnormal metabolism of various nutrients, and malnutrition might accelerate the development and progression of liver diseases and lead to poor prognosis. Therefore, it is of great importance to perform early nutritional assessment and nutritional intervention. Although there are a variety of nutritional assessment methods, there are still defects in the nutritional assessment methods for patients with chronic liver diseases and liver cirrhosis, especially those with acute-on-chronic liver failure. This article elaborates on the nutritional assessment and clinical management of such patients, so as to provide a reference for related issues in clinical practice.
- Acute-On-Chronic Liver Failure /
- Nutrition Assessment /
- Early Medical Intervention

HTML全文

参考文献(31)

[1]	Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association; Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure(2018)[J]. J Clin Hepatol, 2019, 35(1): 38-44. DOI: 10.3969/j. issn. 1001-5256.2019.01.007. 中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35(1): 38-44. DOI: 10.3969/j. issn. 1001-5256.2019.01.007.
[2]	HUISMAN EJ, TRIP EJ, SIERSEMA PD, et al. Protein energy malnutrition predicts complications in liver cirrhosis[J]. Eur J Gastroenterol Hepatol, 2011, 23(11): 982-989. DOI: 10.1097/MEG.0b013e32834aa4bb.
[3]	MENG QH, YU HW, FENG YM, et al. Energy metabolism in patients with severe chronic viral hepatitis[J]. Natl Med J China, 2007, 87(42): 2982-2985. DOI: 10.3760/j.issn:0376-2491.2007.42.009. 孟庆华, 于红卫, 冯岩梅, 等. 慢性重型病毒性肝炎患者的能量代谢特点及相关性研究[J]. 中华医学杂志, 2007, 87(42): 2982-2985. DOI: 10.3760/j.issn:0376-2491.2007.42.009.
[4]	MENG QH, HOU W, YU HW, et al. Resting energy expenditure and substrate metabolism in patients with acute-on-chronic hepatitis B liver failure[J]. J Clin Gastroenterol, 2011, 45(5): 456-461. DOI: 10.1097/MCG.0b013e31820f7f02.
[5]	LI SD, LUE W, MOBARHAN S, et al. Nutrition support for individuals with liver failure[J]. Nutr Rev, 2000, 58(8): 242-247. DOI: 10.1111/j.1753-4887.2000.tb01873.x.
[6]	TANDON P, LOW G, MOURTZAKIS M, et al. A model to identify sarcopenia in patients with cirrhosis[J]. Clin Gastroenterol Hepatol, 2016, 14(10): 1473-1480.e3. DOI: 10.1016/j.cgh.2016.04.040.
[7]	Chinese Society of Hepatology, Chinese Society of Gastroenterology, Chinese Medical Association. Clinical guidelines on nutrition in end-stage liver disease[J]. J Clin Hepatol, 2019, 35(6): 1222-1230. DOI: 10.3969/j.issn.1001-5256.2019.06.010. 中华医学会肝病学分会, 中华医学会消化病学分会. 终末期肝病临床营养指南[J]. 临床肝胆病杂志, 2019, 35(6): 1222-1230. DOI: 10.3969/j.issn.1001-5256.2019.06.010.
[8]	Chinese Society of Osteoporosis and Bone Mineral Research. Consensus on sarcopenia[J]. Chin J Osteoporosis Bone Miner Res, 2016, 9(3): 215-227. DOI: 10.3969/j.issn.1674-2591.2016.03.001. 中华医学会骨质疏松和骨矿盐疾病分会. 肌少症共识[J]. 中华骨质疏松和骨矿盐疾病杂志, 2016, 9(3): 215-227. DOI: 10.3969/j.issn.1674-2591.2016.03.001.
[9]	ABY ES, SAAB S. Frailty, sarcopenia, and malnutrition in cirrhotic patients[J]. Clin Liver Dis, 2019, 23(4): 589-605. DOI: 10.1016/j.cld.2019.06.001.
[10]	LI TZ, KONG M, SONG WY, et al. Relationship between skeletal muscle index of third lumbar vertebrae and clinical characteristics in patients with acute on chronic liver failure[J]. J Prac Hepatol, 2020, 23(4): 467-470. DOI: 10.3969/j.issn.1672-5069.2020.04.004. 李侗曾, 孔明, 宋文艳, 等. 慢加急性肝衰竭患者第三腰椎骨骼肌指数与临床指标的关系[J]. 实用肝脏病杂志, 2020, 23(4): 467-470. DOI: 10.3969/j.issn.1672-5069.2020.04.004.
[11]	WANG CW, FENG S, COVINSKY KE, et al. A comparison of muscle function, mass, and quality in liver transplant candidates: Results from the functional assessment in liver transplantation study[J]. Transplantation, 2016, 100(8): 1692-1698. DOI: 10.1097/TP.0000000000001232.
[12]	TANDON P, RAMAN M, MOURTZAKIS M, et al. A practical approach to nutritional screening and assessment in cirrhosis[J]. Hepatology, 2017, 65(3): 1044-1057. DOI: 10.1002/hep.29003.
[13]	TANIGUCHI E, KAWAGUCHI T, ITOU M, et al. Subjective global assessment is not sufficient to screen patients with defective hepatic metabolism[J]. Nutrition, 2011, 27(3): 282-286. DOI: 10.1016/j.nut.2009.10.016.
[14]	YU HW, HOU W, SHI SY, et al. Comparison of different nutritional assessments and a try of a new method in nutritional assessment for liver disease[J]. Parenter Enteral Nutr, 2016, 23(2): 82-86. DOI: 10.16151/j.1007-810x.2016.02.005. 于红卫, 侯维, 时淑云, 等. 不同营养评价方法在肝病病人中的比较及适宜肝病营养评价的方法[J]. 肠外与肠内营养, 2016, 23(2): 82-86. DOI: 10.16151/j.1007-810x.2016.02.005.
[15]	CEDERHOLM T, JENSEN GL, CORREIA M, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community[J]. J Cachexia Sarcopenia Muscle, 2019, 10(1): 207-217. DOI: 10.1002/jcsm.12383.
[16]	ALLARD JP, KELLER H, GRAMLICH L, et al. GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator[J]. Clin Nutr, 2020, 39(9): 2771-2777. DOI: 10.1016/j.clnu.2019.12.004.
[17]	SCHUETZ P, FEHR R, BAECHLI V, et al. Individualised nutritional support in medical inpatients at nutritional risk: A randomised clinical trial[J]. Lancet, 2019, 393(10188): 2312-2321. DOI: 10.1016/S0140-6736(18)32776-4.
[18]	FAN CL, WU YJ, DING HG, et al. Energy metabolism and substrate oxidation in patients with severe chronic hepatitis B[J]. Chin J Clin Nutr, 2006, 2: 110-114. DOI: 10.3760/cma.j.issn.1674-635X.2006.02.010. 范春蕾, 吴燕京, 丁惠国, 等. 慢性重型病毒性肝炎的能量代谢及糖、蛋白质、脂肪氧化[J]. 中国临床营养杂志, 2006, 2: 110-114. DOI: 10.3760/cma.j.issn.1674-635X.2006.02.010.
[19]	ZHAO J, WANG JH, LI J, et al. Energy metabolism in patients with acute-on-chronic liver failure[J]. Guangdong Med J, 2015, 36(2): 203-207. https://www.cnki.com.cn/Article/CJFDTOTAL-GAYX201502014.htm 赵娟, 王金环, 李娟, 等. 慢加急性肝衰竭患者的能量代谢状况[J]. 广东医学, 2015, 36(2): 203-207. https://www.cnki.com.cn/Article/CJFDTOTAL-GAYX201502014.htm
[20]	PLAUTH M, BERNAL W, DASARATHY S, et al. ESPEN guideline on clinical nutrition in liver disease[J]. Clin Nutr, 2019, 38(2): 485-521. DOI: 10.1016/j.clnu.2018.12.022.
[21]	Beijing Medical Association, Committee of Parenteraland Enteral Nutrition; Expert Panelon Consensuson the Clinical Nutritional Intervention for Patients with Chronic Liver Diseases. Consensus on the clinical nutritional intervention for patients with chronic liver diseases[J]. J Clin Hepatol, 2017, 33(7): 1236-1245. DOI: 10.3969/j.issn.1001-5256.2017.07.006. 北京医学会肠外肠内营养学专业委员会, 《慢性肝病患者肠外肠内营养支持与膳食干预专家共识》专家委员会. 慢性肝病患者肠外肠内营养支持与膳食干预专家共识[J]. 临床肝胆病杂志, 2017, 33(7): 1236-1245. DOI: 10.3969/j.issn.1001-5256.2017.07.006.
[22]	LIU X, KONG M, HUA X, et al. Effects of an individualized nutrition intervention on the respiratory quotient of patients with liver failure[J]. Asia Pac J Clin Nutr, 2019, 28(3): 428-434. DOI: 10.6133/apjcn.201909_28(3).0001.
[23]	OWEN OE, REICHLE FA, MOZZOLI MA, et al. Hepatic, gut, and renal substrate flux rates in patients with hepatic cirrhosis[J]. J Clin Invest, 1981, 68(1): 240-252. DOI: 10.1172/jci110240.
[24]	HOU W, LI J, LU J, et al. Effect of a carbohydrate-containing late-evening snack on energy metabolism and fasting substrate utilization in adults with acute-on-chronic liver failure due to hepatitis B[J]. Eur J Clin Nutr, 2013, 67(12): 1251-1256. DOI: 10.1038/ejcn.2013.163.
[25]	NAKAYA Y, OKITA K, SUZUKI K, et al. BCAA-enriched snack improves nutritional state of cirrhosis[J]. Nutrition, 2007, 23(2): 113-120. DOI: 10.1016/j.nut.2006.10.008.
[26]	LI XM, HOU W, HUANG PL, et al. The deficiency and supplementation of vitamin B1 in patients with acute on chronic liver failure[J]. Parenter Enteral Nutr, 2013, 20(2): 72-74. DOI: 10.3969/j.issn.1007-810X.2013.02.003. 李雪梅, 侯维, 黄沛力, 等. 慢加急性肝功能衰竭病人维生素B1的缺乏与补充[J]. 肠外与肠内营养, 2013, 20(2): 72-74. DOI: 10.3969/j.issn.1007-810X.2013.02.003.
[27]	European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease[J]. J Hepatol, 2019, 70(1): 172-193. DOI: 10.1016/j.jhep.2018.06.024.
[28]	ZHAO J, LI J, YU HW, et al. Dietary intake of selenium and serum selenium in patients with chronic hepatitis B, liver cirrhosis and acute-on-chronic liver failure[J]. J Clin Hepatol, 2015, 31(7): 1103-1106. DOI: 10.3969/j.issn.1001-5256.2015.07.025. 赵娟, 李娟, 于红卫, 等. 慢性乙型肝炎、肝硬化与慢加急性肝衰竭患者饮食摄入硒及血清硒水平的对比分析[J]. 临床肝胆病杂志, 2015, 31(7): 1103-1106. DOI: 10.3969/j.issn.1001-5256.2015.07.025.
[29]	HOU W, WANG ZY, DONG JL, et al. Application of enteral nutrition and late evening snacks in patients with liver cirrhosis[J]. Clin Medicat J, 2019, 17(4): 33-37. DOI: 10.3969/j.issn.1672-3384.2019.04.008. 侯维, 王忠英, 董金玲, 等. 肠内营养及睡前加餐在肝硬化患者中的应用效果评价[J]. 临床药物治疗杂志, 2019, 17(4): 33-37. DOI: 10.3969/j.issn.1672-3384.2019.04.008.
[30]	MAHARSHI S, SHARMA BC, SACHDEVA S, et al. Efficacy of nutritional therapy for patients with cirrhosis and minimal hepatic encephalopathy in a randomized trial[J]. Clin Gastroenterol Hepatol, 2016, 14(3): 454-460. DOI: 10.1016/j.cgh.2015.09.028.
[31]	ZHAO ZY, WU YD. Community nutrition support for discharged patients[J]. Chin J Gen Pract, 2019, 18(2): 187-189. DOI: 10.3760/cma.j.issn.1671-7368.2019.02.021. 赵志云, 吴咏冬. 住院患者营养支持及其对社区应用的启发[J]. 中华全科医师杂志, 2019, 18(2): 187-189. DOI: 10.3760/cma.j.issn.1671-7368.2019.02.021.