肝衰竭营养代谢特点及营养支持的研究进展

郭金; 石春霞; 邓威; 陈倩; 龚作炯

doi:10.3969/j.issn.1001-5256.2022.03.043

肝衰竭营养代谢特点及营养支持的研究进展

DOI: 10.3969/j.issn.1001-5256.2022.03.043

武汉大学人民医院感染科，武汉 430060

基金项目:

国家自然科学基金 (82070609)

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：郭金负责课题设计，资料分析，撰写论文；石春霞、邓威、陈倩参与收集数据，修改论文；龚作炯负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
龚作炯，zjgong@163.com

计量
- 文章访问数: 666
- HTML全文浏览量: 249
- PDF下载量: 85
- 被引次数: 0
出版历程
- 收稿日期: 2021-07-16
- 录用日期: 2021-08-16
- 出版日期: 2022-03-20

Research advances in the features of nutrition metabolism and nutritional support in liver failure

Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China

Research funding:

National Natural Science Foundation of China (82070609)

More Information

Corresponding author: GONG Zuojiong, zjgong@163.com(ORCID: 0000-0002-4676-5856)

摘要

摘要: 肝脏是机体进行物质代谢的主要场所，在多种因素引起严重肝损伤时，其合成、代谢以及生物转化功能会出现明显障碍。总结了肝衰竭时糖、氨基酸、脂质等营养物质代谢的特点，以及营养不良的评估和临床干预的措施。对于肝功能衰竭患者应尽早识别并及时纠正营养不良，以改善能量代谢及炎症状态，提高患者生存率。
- 肝功能衰竭 /
- 能量代谢 /
- 营养支持
Abstract: The liver is the main place for metabolism in human body, and when severe liver injury is induced by various factors, there will be disorders in the functions of synthesis, metabolism, and biological conversion. This article summarizes the features of the metabolism of nutrients such as glucose, amino acids, and lipids in the presence of liver failure, as well as the assessment of malnutrition and clinical interventions. For patients with liver failure, it is of great importance to identify and correct malnutrition in a timely manner, so as to improve energy metabolism and inflammation and increase survival rate.
- Liver Failure /
- Energy Metabolism /
- Nutritional Support

HTML全文

表 1 营养不良的评估工具和方法

筛查工具	评估内容	优点	缺点
BMI	体质量/身高(kg/m²)	简单易行	易受水钠潴留(如腹水)等干扰因素影响
上臂肌围	上臂围(肱三头肌皮褶厚度×0.314)	简单易行，不受水钠潴留的干扰	与预后关系的研究目前局限于男性
主观全面评价法	饮食、体质量变化、胃肠道症状等6个方面	简单易行	主观性强
英国皇家自由医院-营养优先工具量表	饮食、体质量变化、并发症情况等临床问题	简单易行	易受主观因素干扰
握力	骨骼肌收缩功能	简单易行，敏感度高	特异度低，只能间接反映肌肉容积
生物电阻抗分析	分段检测肢体电阻抗以明确非脂肪质量	简单易行，低成本	易受机体水合状态影响
骨骼肌指数	CT测量第3腰椎腰大肌及脊柱旁、腹壁骨骼肌总横截面积，计算其与身高比值(cm²/m²)	可量化肌肉减少程度	经济成本、辐射问题
全身双能X线吸收测量法	测量骨密度、脂肪量、非脂肪质量	排除了水等混杂因素的影响	经济成本、辐射问题
生化评估	血清白蛋白、前白蛋白、转铁蛋白、视黄醇蛋白	可用于营养状态监测	蛋白水平可能会受到肝损伤等因素的影响

下载: 导出CSV

参考文献(50)

[1]	SARIN SK, CHOUDHURY A, SHARMA MK, et al. Acute-on-chronic liver failure: Consensus recommendations of the Asian Pacific association for the study of the liver (APASL): An update[J]. Hepatol Int, 2019, 13(4): 353-390. DOI: 10.1007/s12072-019-09946-3.
[2]	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.
[3]	ZHANG J, GAO S, DUAN Z, et al. Overview on acute-on-chronic liver failure[J]. Front Med, 2016, 10(1): 1-17. DOI: 10.1007/s11684-016-0439-x.
[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]	CHEN LY, YANG B, ZHOU L, et al. Promotion of mitochondrial energy metabolism during hepatocyte apoptosis in a rat model of acute liver failure[J]. Mol Med Rep, 2015, 12(4): 5035-5041. DOI: 10.3892/mmr.2015.4029.
[6]	LLIBRE-NIETO G, LIRA A, VERGARA M, et al. Micronutrient deficiencies in patients with decompensated liver cirrhosis[J]. Nutrients, 2021, 13(4): 1249. DOI: 10.3390/nu13041249.
[7]	PERUMPAIL BJ, LI AA, CHOLANKERIL G, et al. Optimizing the nutritional support of adult patients in the setting of cirrhosis[J]. Nutrients, 2017, 9(10): 1114. DOI: 10.3390/nu9101114.
[8]	YAO J, ZHOU X, WANG H, et al. Persistently increased resting energy expenditure predicts short-term mortality in patients with acute-on-chronic liver failure[J]. Ann Nutr Metab, 2018, 73(1): 2-9. DOI: 10.1159/000487604.
[9]	BERNARDI M, ANGELI P, CLARIA J, et al. Albumin in decompensated cirrhosis: New concepts and perspectives[J]. Gut, 2020, 69(6): 1127-1138. DOI: 10.1136/gutjnl-2019-318843.
[10]	ENGELMANN C, SHEIKH M, SHARMA S, et al. Toll-like receptor 4 is a therapeutic target for prevention and treatment of liver failure[J]. J Hepatol, 2020, 73(1): 102-112. DOI: 10.1016/j.jhep.2020.01.011.
[11]	FREIRE JORGE P, WIERINGA N, de FELICE E, et al. The association of early combined lactate and glucose levels with subsequent renal and liver dysfunction and hospital mortality in critically ill patients[J]. Crit Care, 2017, 21(1): 218. DOI: 10.1186/s13054-017-1785-z.
[12]	MOREAU R, CLÀRIA J, AGUILAR F, et al. Blood metabolomics uncovers inflammation-associated mitochondrial dysfunction as a potential mechanism underlying ACLF[J]. J Hepatol, 2020, 72(4): 688-701. DOI: 10.1016/j.jhep.2019.11.009.
[13]	DONG V, NANCHAL R, KARVELLAS CJ. Pathophysiology of acute liver failure[J]. Nutr Clin Pract, 2020, 35(1): 24-29. DOI: 10.1002/ncp.10459.
[14]	ZACCHERINI G, AGUILAR F, CARACENI P, et al. Assessing the role of amino acids in systemic inflammation and organ failure in patients with ACLF[J]. J Hepatol, 2021, 74(5): 1117-1131. DOI: 10.1016/j.jhep.2020.11.035.
[15]	NISHIKAWA T, BELLANCE N, DAMM A, et al. A switch in the source of ATP production and a loss in capacity to perform glycolysis are hallmarks of hepatocyte failure in advance liver disease[J]. J Hepatol, 2014, 60(6): 1203-1211. DOI: 10.1016/j.jhep.2014.02.014.
[16]	MANSOURI A, GATTOLLIAT CH, ASSELAH T. Mitochondrial dysfunction and signaling in chronic liver diseases[J]. Gastroenterology, 2018, 155(3): 629-647. DOI: 10.1053/j.gastro.2018.06.083.
[17]	FAITOT F, RUHLAND E, ONCIOIU C, et al. Metabolomic profiling highlights the metabolic bases of acute-on-chronic and post-hepatectomy liver failure[J]. HPB (Oxford), 2019, 21(10): 1354-1361. DOI: 10.1016/j.hpb.2019.02.008.
[18]	TREFTS E, GANNON M, WASSERMAN DH. The liver[J]. Curr Biol, 2017, 27(21): r1147-r1151. DOI: 10.1016/j.cub.2017.09.019.
[19]	MASSAFRA V, MILONA A, VOS HR, et al. Farnesoid X receptor activation promotes hepatic amino acid catabolism and ammonium clearance in mice[J]. Gastroenterology, 2017, 152(6): 1462-1476. DOI: 10.1053/j.gastro.2017.01.014.
[20]	KINNY-KÖSTER B, BARTELS M, BECKER S, et al. Plasma amino acid concentrations predict mortality in patients with end-stage liver disease[J]. PLoS One, 2016, 11(7): e0159205. DOI: 10.1371/journal.pone.0159205.
[21]	DEJONG CH, van de POLL MC, SOETERS PB, et al. Aromatic amino acid metabolism during liver failure[J]. J Nutr, 2007, 137(6 Suppl 1): 1579s-1585s; discussion 1597s-1598s. DOI: 10.1093/jn/137.6.1579S.
[22]	NATESAN V, MANI R, ARUMUGAM R. Clinical aspects of urea cycle dysfunction and altered brain energy metabolism on modulation of glutamate receptors and transporters in acute and chronic hyperammonemia[J]. Biomed Pharmacother, 2016, 81: 192-202. DOI: 10.1016/j.biopha.2016.04.010.
[23]	DRUML W, FISCHER M, PIDLICH J, et al. Fat elimination in chronic hepatic failure: Long-chain vs medium-chain triglycerides[J]. Am J Clin Nutr, 1995, 61(4): 812-817. DOI: 10.1093/ajcn/61.4.812.
[24]	CHEN EQ, WANG ML, ZHANG DM, et al. Plasma apolipoprotein A-V predicts long-term survival in chronic hepatitis B patients with acute-on-chronic liver failure[J]. Sci Rep, 2017, 7: 45576. DOI: 10.1038/srep45576.
[25]	LIAN J, LI X, WANG Y, et al. Metabolite variations between acute-on-chronic liver failure and chronic liver failure caused by hepatitis B virus based on ultra-performance liquid chromatography mass spectrometry[J]. Biomed Pharmacother, 2016, 84: 994-1000. DOI: 10.1016/j.biopha.2016.09.079.
[26]	SANTOS BC, CORREIA M, ANASTÁCIO LR. Energy expenditure and liver transplantation: What we know and where we are[J]. JPEN J Parenter Enteral Nutr, 2021, 45(3): 456-464. DOI: 10.1002/jpen.1985.
[27]	CLEMMESEN JO, HØY CE, JEPPESEN PB, et al. Plasma phospholipid fatty acid pattern in severe liver disease[J]. J Hepatol, 2000, 32(3): 481-487. DOI: 10.1016/s0168-8278(00)80400-6.
[28]	MANKA P, OLLIGES V, BECHMANN LP, et al. Low levels of blood lipids are associated with etiology and lethal outcome in acute liver failure[J]. PLoS One, 2014, 9(7): e102351. DOI: 10.1371/journal.pone.0102351.
[29]	SCHWARZKOPF KM, QUECK A, THOMAS D, et al. Omega-3 and -6 fatty acid plasma levels are not associated with liver cirrhosis-associated systemic inflammation[J]. PLoS One, 2019, 14(1): e0211537. DOI: 10.1371/journal.pone.0211537.
[30]	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.
[31]	MARAS JS, MAIWALL R, HARSHA HC, et al. Dysregulated iron homeostasis is strongly associated with multiorgan failure and early mortality in acute-on-chronic liver failure[J]. Hepatology, 2015, 61(4): 1306-1320. DOI: 10.1002/hep.27636.
[32]	ZIEGLER TR. Parenteral nutrition in the critically ill patient[J]. N Engl J Med, 2009, 361(11): 1088-1097. DOI: 10.1056/NEJMct0806956.
[33]	KAPPUS MR. Acute hepatic failure and nutrition[J]. Nutr Clin Pract, 2020, 35(1): 30-35. DOI: 10.1002/ncp.10462.
[34]	PLAUTH M. Nutritional intervention in chronic liver failure[J]. Visc Med, 2019, 35(5): 292-298. DOI: 10.1159/000502125.
[35]	O'BRIEN A, WILLIAMS R. Nutrition in end-stage liver disease: Principles and practice[J]. Gastroenterology, 2008, 134(6): 1729-1740. DOI: 10.1053/j.gastro.2008.02.001.
[36]	KORETZ RL, AVENELL A, LIPMAN TO. Nutritional support for liver disease[J]. Cochrane Database Syst Rev, 2012, (5): CD008344. DOI: 10.1002/14651858.CD008344.pub2.
[37]	TSAI JJ, KUO HC, LEE KF, et al. Proteomic analysis of plasma from rats following total parenteral nutrition-induced liver injury[J]. Proteomics, 2015, 15(22): 3865-3874. DOI: 10.1002/pmic.201500128.
[38]	WALSH TS, WIGMORE SJ, HOPTON P, et al. Energy expenditure in acetaminophen-induced fulminant hepatic failure[J]. Crit Care Med, 2000, 28(3): 649-654. DOI: 10.1097/00003246-200003000-00008.
[39]	SOSA HENRÍQUEZ M, GÓMEZ DE TEJADA ROMERO MJ. Cholecalciferol or calcifediol in the management of vitamin D deficiency[J]. Nutrients, 2020, 12(6): 1617. DOI: 10.3390/nu12061617.
[40]	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.
[41]	BIGOT A, TCHAN MC, THOREAU B, et al. Liver involvement in urea cycle disorders: A review of the literature[J]. J Inherit Metab Dis, 2017, 40(6): 757-769. DOI: 10.1007/s10545-017-0088-5.
[42]	BLAAUW R, NEL DG, SCHLEICHER GK. Plasma glutamine levels in relation to intensive care unit patient outcome[J]. Nutrients, 2020, 12(2): 402. DOI: 10.3390/nu12020402.
[43]	CLÀRIA J, STAUBER RE, COENRAAD MJ, et al. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure[J]. Hepatology, 2016, 64(4): 1249-1264. DOI: 10.1002/hep.28740.
[44]	WU W, SUN S, WANG Y, et al. Circulating neutrophil dysfunction in HBV-related acute-on-chronic liver failure[J]. Front Immunol, 2021, 12: 620365. DOI: 10.3389/fimmu.2021.620365.
[45]	ARROYO V, ANGELI P, MOREAU R, et al. The systemic inflammation hypothesis: Towards a new paradigm of acute decompensation and multiorgan failure in cirrhosis[J]. J Hepatol, 2021, 74(3): 670-685. DOI: 10.1016/j.jhep.2020.11.048.
[46]	FERNÁNDEZ J, CLÀRIA J, AMORÓS A, et al. Effects of albumin treatment on systemic and portal hemodynamics and systemic inflammation in patients with decompensated cirrhosis[J]. Gastroenterology, 2019, 157(1): 149-162. DOI: 10.1053/j.gastro.2019.03.021.
[47]	PRADELLI L, KLEK S, MAYER K, et al. Omega-3 fatty acid-containing parenteral nutrition in ICU patients: Systematic review with meta-analysis and cost-effectiveness analysis[J]. Crit Care, 2020, 24(1): 634. DOI: 10.1186/s13054-020-03356-w.
[48]	KULKARNI AV, ANAND L, VYAS AK, et al. Omega-3 fatty acid lipid emulsions are safe and effective in reducing endotoxemia and sepsis in acute-on-chronic liver failure: An open-label randomized controlled trial[J]. J Gastroenterol Hepatol, 2021, 36(7): 1953-1961. DOI: 10.1111/jgh.15400.
[49]	ZACHARIAS T, FERREIRA N, CARIN AJ. Preoperative immunonutrition in liver resection-a propensity score matched case-control analysis[J]. Eur J Clin Nutr, 2014, 68(8): 964-969. DOI: 10.1038/ejcn.2014.113.
[50]	LÓPEZ-VICARIO C, CHECA A, URDANGARIN A, et al. Targeted lipidomics reveals extensive changes in circulating lipid mediators in patients with acutely decompensated cirrhosis[J]. J Hepatol, 2020, 73(4): 817-828. DOI: 10.1016/j.jhep.2020.03.046.