肠内营养在肝硬化治疗中的应用
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摘要
营养不良是肝硬化患者常见的临床问题,是影响肝硬化预后的重要因素之一。早期开展营养支持对肝硬化治疗具有重要作用。由于肝硬化患者特殊的代谢状态和疾病进程,如何准确进行营养评估和合理管理患者的能量和营养素摄入是临床医生面临的难题。近年来支链氨基酸、微生态制剂在肠内营养的应用已越来越得到关注,其对于治疗肝性脑病有一定作用。该文对以上内容进行综述,以更好地提高对于肝硬化肠内营养的认识。
Malnutrition is a common clinical problem in patients with cirrhosis and is one of the important factors affecting the prognosis of cirrhosis. Early nutritional support plays an important role in the treatment of cirrhosis. Due to the special metabolic status and disease progression of patients with cirrhosis, how to accurately conduct nutritional assessment and rational management of patients' energy and nutrient intake is a difficult problem for clinicians. In recent years, the application of branched-chain amino acids and microecological preparations in enteral nutrition has been paid more and more attention, and it has a certain effect on the treatment of hepatic encephalopathy. This article reviews the above to better improve the understanding of enteral nutrition in cirrhosis.
Malnutrition is a common clinical problem in patients with cirrhosis and is one of the important factors affecting the prognosis of cirrhosis. Early nutritional support plays an important role in the treatment of cirrhosis. Due to the special metabolic status and disease progression of patients with cirrhosis, how to accurately conduct nutritional assessment and rational management of patients' energy and nutrient intake is a difficult problem for clinicians. In recent years, the application of branched-chain amino acids and microecological preparations in enteral nutrition has been paid more and more attention, and it has a certain effect on the treatment of hepatic encephalopathy. This article reviews the above to better improve the understanding of enteral nutrition in cirrhosis.
引文
[1]Maharshi S,Sharma BC,Srivastava S.Malnutrition in cirrhosis increases morbidity and mortality[J].Journal of Gastroenterology&Hepatology,2015,5(10):S46-S47.
[2]G oktürk HS,Selc,uk H.Importance of malnutrition in patients with cirrhosis[J].Turkish Journal of Gastroenterology:the Official Journal of Turkish Society of Gastroenterology,2015,26(4):291.
[3]Mandato C,Di Nuzzi A,Vajro P.Nutrition and Liver Disease[J].Nutrients,2018,10(1):9.
[4]Floch MH.Walker WA.Sanders ME,et a1.Recommendations for probiotie use一2015 update:proceedings and consensus opinion[J].J ClinGastroenterol,2015,49 Suppl 1:S69-S73.
[5]索思卓,胡豪,王一涛.特殊医学用途配方食品在中国的发展概况[J].中国食品卫生杂志,2016,28(2):182-186.
[6]Mueller C,Comphe RC,Ellen DM,et al.ASPEN clinical guidelines:nutrition screening,assessment,and intervention in adults[J].JPEN J Parenter Enteral Nutr,2011,35(1):16-24.
[7]Singer P,Blaser AR,Berger MM,et al.ESPEN guideline on clinical nutrition in the intensive care unit[J].Clinical Nutrition,2018.
[8]杨剑,张明,蒋朱明,等.营养筛查与营养评定:理念、临床实用及误区[J].中华临床营养杂志,2017,25(1):59-64.
[9]Mcclave SA,Dibaise JK,Mullin GE,et al.ACG Clinical Guideline:Nutrition Therapy in the Adult Hospitalized Patient[J].American Journal of Gastroenterology,2016,111(3):315-334.
[10]McClave SA,Taylor BE,Martindale RG,et al.Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient:Society of Critical Care Medicine(SCCM)and American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.)[J].JPEN J Parenter Enteral Nutr,2016,40(2):159-211.
[11]Cederholm T,Barazzoni R,Austin P,et al.ESPEN guidelines on definitions and terminology of clinical nutrition[J].Clinical Nutrition,2017,36(1):49-64.
[12]Plauth M,CabréE,Riggio O,et al.ESPEN guidelines on enteral nutrition:liver disease[J].Clin 5(2):285-294.
[13]Tandon P,Raman M,Mourtzakis M,et al.A practical approach to nutritional screening and assessment in cirrhosis[J].Hepatology,2017,65(3):1044.
[14]Amodio P,Bemeur C,Butterworth R,et al.The nutritional management of hepatic encephalopathy in patients with cirrhosis:International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus[J].Hepatology,2013,58(1):325-336.
[15]Nunes G,Santos CA,Barosa R,et al.Outcome and nutritional assessment of chronic liver disease patients using anthropometry and subjective global assessment[J].ArqGastroenterol,2017,54.
[16]Li H,Zhang L.Research advances in indices and methods for nutritional status evaluation in patients with liver cirrhosis[J].Zhonghuaganzangbingzazhi=Zhonghuaganzangbingzazhi=Chinese journal of hepatology,2017,25(3):237.
[17]Anand AC.Nutrition and muscle in cirrhosis[J].J ClinExpHepatol,2017,7(4):340-357.
[18]Aoyama K,Tsuchiya M,Mori K,et al.Effect of a late evening snack on outpatients with liver cirrhosis[J].Hepatology Research the Official Journal of the Japan Society of Hepatology,2010,37(8):608-614.
[19]Guo YJ,Tian ZB,Jiang N,et al.Effects of late evening snack on cirrhotic patients:asystematic review and eetaanalysis[J].Gastroenterology Research&Practice,2018,2018(3):9189062.
[20]Codner PA,Taylor B,Patel JJ.Nutrition therapy in acute and chronic liver failure[J].2018.
[21]Campollo O,Sprengers D,Dam G,et al.Protein tolerance to standard and high protein meals in patients with liver cirrhosis[J].World Journal of Hepatology,2017,9(14):667-676.
[22]Hole o ek M.Branched-chain amino acid supplementation in treatment of liver cirrhosis:Updated views on how to attenuate their harmful effects on cataplerosis and ammonia formation[J].Nutrition,2017,41:80-85.
[23]Park JG,Tak WY,Park SY,et al.Effectsof branchedchain amino acids(BCAAs)on the progression of advanced liver disease:A Korean nationwide,multicenter,retrospective,observational,cohort study[J].Medicine,2017,96(24):e6580.
[24]Gluud LL,Dam G,Les I,et al.Branched-chain amino acids for people with hepatic encephalopathy[M].The Cochrane Library.John Wiley&Sons,Ltd,2017:CD001939.
[25]Kawaguchi T,Shiraishi K,Ito T,et al.Branched-chain amino acids prevent hepatocarcinogenesis and prolong survival of patients with cirrhosis[J].Clinical Gastroenterology&Hepatology,2014,12(6):1012-1018.
[26]Fukui A,Kawabe N,Hashimoto S,et al.Additional BCAA-enriched nutrient mixture improves the nutritional condition in cirrhotic patients with hypoalbuminemia despite treatment with regular BCAA granules:A pilot study[J].Turkish Journal of Gastroenterology the Official Journal of Turkish Society of Gastroenterology,2015,26(4).
[27]Ruiz-Margáin A,Macías-Rodríguez RU,Ríos-Torres S,et al.Effect of a high-protein,high-fiber diet plus supplementation with branched-chain amino acids on the nutritional status of patients with cirrhosis[J].Revistade Gastroen terología de México(English Edition),2018,83(1):9-15.
[28]Nie C,He T,Zhang W,et al.Branched Chain Amino Acids:Beyond Nutrition Metabolism[J].International Journal of Molecular Sciences,2018,19(4):954.
[29]Ney M,Vandermeer B,Zanten SJVV,et al.Meta-analysis:oral or enteral nutritional supplementation in cirrhosis[J].Alimentary Pharmacology&Therapeutics,2013,37(7):672-9.
[30]Zhang C,Zhao L,Ding Y,et al.Enhanced LL‐37 expression following vitamin D supplementation in patients with cirrhosis and spontaneous bacterial peritonitis[J].Liver International Official Journal of the International Association for the Study of the Liver,2016,36(1):68-75.
[31]LubnaK,Hafeezullah S.Zinc level assessment in patients having Viral Cirrhosis[J].Pakistan Journal of Medical Sciences,2018,34(2).
[32]Burk RF,Hill KE,Motley AK,et al.Selenium deficiency occurs in some patients with moderate-to-severe cirrhosis and can be corrected by administration of selenate but not selenomethionine:a randomized controlled trial.[J].American Journal of Clinical Nutrition,2015,102(5):1126-1133.
[33]Moratalla A,Ampuero J,Bellot P,et al.Lactulose reduces bacterial DNA translocation,which worsens neurocognitive shape in cirrhotic patients with minimal hepatic encephalopathy[J].Liver International,2017,37(2).
[34]Saab S,Suraweera D,Au J,et al.Probiotics are helpful in hepatic encephalopathy:A meta-analysis of randomized trials[J].Liver International Official Journal of the International Association for the Study of the Liver,2016,36(7):986-993.
[35]Viramontes HD,Avery A,Stow R.The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy:A Systematic Review[J].Journal of Clinical Gastroenterology,2017,51(4):312-323.
[36]Pratap Mouli V,Benjamin J,Bhushan Singh M,et al.Effect of probiotic VSL#3 in the treatment of minimal hepatic encephalopathy:A non‐inferiority randomized controlled trial[J].Hepatology Research,2015,45(8):880-889.
[37]Dalal R,Mcgee RG,Riordan SM,et al.Probiotics for people with hepatic encephalopathy[J].Cochrane Database of Systematic Reviews,2017,2:CD008716.
[38]The effect of short term treatment with probiotic VSL#3 on various clinical and biochemical parameters in patients with liver cirrhosis[J].Journal of Physiology&Pharmacology An Official Journal of the Polish Physiological Society,2016,67(6):867.
[39]Shavakhi A,Hashemi H,Tabesh E,et al.Multistrain probiotic and lactulose in the treatment of minimal hepatic encephalopathy[J].Journal of Research in Medical Sciences the Official Journal of Isfahan University of Medical Sciences,2014,19(8):703.
[40]Dhiman RK,Rana B,Agrawal S,et al.Probiotic VSL#3 reduces liver disease severity and hospitalization in patients with cirrhosis:a randomized,controlled trial[J].Gastroenterology,2014,147(6):1327-1337.e3.
[41]Guarner F,Ellen M.World Gastroenterology Organisation Global Guidelines:Probiotics and prebiotics.[EB/OL].http://www.worldgastroenterology.org/guidelines/global-guidelines/probiotics-and-prebiotics,2017-02.
[42]Recommendations for Probiotic Use-2015 Update:Proceedings and Consensus Opinion:Erratum[J].Journal of Clinical Gastroenterology,2016,50(9):800.
[43]Douillard FP,Mora D,Eijlander RT,et al.Comparative genomic analysis of the multispecies probiotic-marketed product VSL#3.[J].Plos One,2018,13(2):e0192452.
[44]Nath A,Haktanirlar G,Vargaá.,Molnár MA,et al.Biological activities of Lactose-derived Prebiotics and Symbiotic with Probiotics on Gastrointestinal system.Medicina[J],2018,54:18.
[45]Kim G,Kang SH,Kim MY,et al.Prognostic value of sarcopenia in patients with liver cirrhosis:A systematic review and meta-analysis[J].Plos One,2017,12(10):e0186990.
[46]Dasarathy S,Merli M.Sarcopenia from mechanism to diagnosis and treatment in liver disease[J].Journal of Hepatology,2016,65(6):1232-1244.
[47]Tsien C,Davuluri G,Singh D,et al.Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis[J].Hepatology,2015,61(6):2018-2029.
[2]G oktürk HS,Selc,uk H.Importance of malnutrition in patients with cirrhosis[J].Turkish Journal of Gastroenterology:the Official Journal of Turkish Society of Gastroenterology,2015,26(4):291.
[3]Mandato C,Di Nuzzi A,Vajro P.Nutrition and Liver Disease[J].Nutrients,2018,10(1):9.
[4]Floch MH.Walker WA.Sanders ME,et a1.Recommendations for probiotie use一2015 update:proceedings and consensus opinion[J].J ClinGastroenterol,2015,49 Suppl 1:S69-S73.
[5]索思卓,胡豪,王一涛.特殊医学用途配方食品在中国的发展概况[J].中国食品卫生杂志,2016,28(2):182-186.
[6]Mueller C,Comphe RC,Ellen DM,et al.ASPEN clinical guidelines:nutrition screening,assessment,and intervention in adults[J].JPEN J Parenter Enteral Nutr,2011,35(1):16-24.
[7]Singer P,Blaser AR,Berger MM,et al.ESPEN guideline on clinical nutrition in the intensive care unit[J].Clinical Nutrition,2018.
[8]杨剑,张明,蒋朱明,等.营养筛查与营养评定:理念、临床实用及误区[J].中华临床营养杂志,2017,25(1):59-64.
[9]Mcclave SA,Dibaise JK,Mullin GE,et al.ACG Clinical Guideline:Nutrition Therapy in the Adult Hospitalized Patient[J].American Journal of Gastroenterology,2016,111(3):315-334.
[10]McClave SA,Taylor BE,Martindale RG,et al.Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient:Society of Critical Care Medicine(SCCM)and American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.)[J].JPEN J Parenter Enteral Nutr,2016,40(2):159-211.
[11]Cederholm T,Barazzoni R,Austin P,et al.ESPEN guidelines on definitions and terminology of clinical nutrition[J].Clinical Nutrition,2017,36(1):49-64.
[12]Plauth M,CabréE,Riggio O,et al.ESPEN guidelines on enteral nutrition:liver disease[J].Clin 5(2):285-294.
[13]Tandon P,Raman M,Mourtzakis M,et al.A practical approach to nutritional screening and assessment in cirrhosis[J].Hepatology,2017,65(3):1044.
[14]Amodio P,Bemeur C,Butterworth R,et al.The nutritional management of hepatic encephalopathy in patients with cirrhosis:International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus[J].Hepatology,2013,58(1):325-336.
[15]Nunes G,Santos CA,Barosa R,et al.Outcome and nutritional assessment of chronic liver disease patients using anthropometry and subjective global assessment[J].ArqGastroenterol,2017,54.
[16]Li H,Zhang L.Research advances in indices and methods for nutritional status evaluation in patients with liver cirrhosis[J].Zhonghuaganzangbingzazhi=Zhonghuaganzangbingzazhi=Chinese journal of hepatology,2017,25(3):237.
[17]Anand AC.Nutrition and muscle in cirrhosis[J].J ClinExpHepatol,2017,7(4):340-357.
[18]Aoyama K,Tsuchiya M,Mori K,et al.Effect of a late evening snack on outpatients with liver cirrhosis[J].Hepatology Research the Official Journal of the Japan Society of Hepatology,2010,37(8):608-614.
[19]Guo YJ,Tian ZB,Jiang N,et al.Effects of late evening snack on cirrhotic patients:asystematic review and eetaanalysis[J].Gastroenterology Research&Practice,2018,2018(3):9189062.
[20]Codner PA,Taylor B,Patel JJ.Nutrition therapy in acute and chronic liver failure[J].2018.
[21]Campollo O,Sprengers D,Dam G,et al.Protein tolerance to standard and high protein meals in patients with liver cirrhosis[J].World Journal of Hepatology,2017,9(14):667-676.
[22]Hole o ek M.Branched-chain amino acid supplementation in treatment of liver cirrhosis:Updated views on how to attenuate their harmful effects on cataplerosis and ammonia formation[J].Nutrition,2017,41:80-85.
[23]Park JG,Tak WY,Park SY,et al.Effectsof branchedchain amino acids(BCAAs)on the progression of advanced liver disease:A Korean nationwide,multicenter,retrospective,observational,cohort study[J].Medicine,2017,96(24):e6580.
[24]Gluud LL,Dam G,Les I,et al.Branched-chain amino acids for people with hepatic encephalopathy[M].The Cochrane Library.John Wiley&Sons,Ltd,2017:CD001939.
[25]Kawaguchi T,Shiraishi K,Ito T,et al.Branched-chain amino acids prevent hepatocarcinogenesis and prolong survival of patients with cirrhosis[J].Clinical Gastroenterology&Hepatology,2014,12(6):1012-1018.
[26]Fukui A,Kawabe N,Hashimoto S,et al.Additional BCAA-enriched nutrient mixture improves the nutritional condition in cirrhotic patients with hypoalbuminemia despite treatment with regular BCAA granules:A pilot study[J].Turkish Journal of Gastroenterology the Official Journal of Turkish Society of Gastroenterology,2015,26(4).
[27]Ruiz-Margáin A,Macías-Rodríguez RU,Ríos-Torres S,et al.Effect of a high-protein,high-fiber diet plus supplementation with branched-chain amino acids on the nutritional status of patients with cirrhosis[J].Revistade Gastroen terología de México(English Edition),2018,83(1):9-15.
[28]Nie C,He T,Zhang W,et al.Branched Chain Amino Acids:Beyond Nutrition Metabolism[J].International Journal of Molecular Sciences,2018,19(4):954.
[29]Ney M,Vandermeer B,Zanten SJVV,et al.Meta-analysis:oral or enteral nutritional supplementation in cirrhosis[J].Alimentary Pharmacology&Therapeutics,2013,37(7):672-9.
[30]Zhang C,Zhao L,Ding Y,et al.Enhanced LL‐37 expression following vitamin D supplementation in patients with cirrhosis and spontaneous bacterial peritonitis[J].Liver International Official Journal of the International Association for the Study of the Liver,2016,36(1):68-75.
[31]LubnaK,Hafeezullah S.Zinc level assessment in patients having Viral Cirrhosis[J].Pakistan Journal of Medical Sciences,2018,34(2).
[32]Burk RF,Hill KE,Motley AK,et al.Selenium deficiency occurs in some patients with moderate-to-severe cirrhosis and can be corrected by administration of selenate but not selenomethionine:a randomized controlled trial.[J].American Journal of Clinical Nutrition,2015,102(5):1126-1133.
[33]Moratalla A,Ampuero J,Bellot P,et al.Lactulose reduces bacterial DNA translocation,which worsens neurocognitive shape in cirrhotic patients with minimal hepatic encephalopathy[J].Liver International,2017,37(2).
[34]Saab S,Suraweera D,Au J,et al.Probiotics are helpful in hepatic encephalopathy:A meta-analysis of randomized trials[J].Liver International Official Journal of the International Association for the Study of the Liver,2016,36(7):986-993.
[35]Viramontes HD,Avery A,Stow R.The effects of probiotics and symbiotics on risk factors for hepatic encephalopathy:A Systematic Review[J].Journal of Clinical Gastroenterology,2017,51(4):312-323.
[36]Pratap Mouli V,Benjamin J,Bhushan Singh M,et al.Effect of probiotic VSL#3 in the treatment of minimal hepatic encephalopathy:A non‐inferiority randomized controlled trial[J].Hepatology Research,2015,45(8):880-889.
[37]Dalal R,Mcgee RG,Riordan SM,et al.Probiotics for people with hepatic encephalopathy[J].Cochrane Database of Systematic Reviews,2017,2:CD008716.
[38]The effect of short term treatment with probiotic VSL#3 on various clinical and biochemical parameters in patients with liver cirrhosis[J].Journal of Physiology&Pharmacology An Official Journal of the Polish Physiological Society,2016,67(6):867.
[39]Shavakhi A,Hashemi H,Tabesh E,et al.Multistrain probiotic and lactulose in the treatment of minimal hepatic encephalopathy[J].Journal of Research in Medical Sciences the Official Journal of Isfahan University of Medical Sciences,2014,19(8):703.
[40]Dhiman RK,Rana B,Agrawal S,et al.Probiotic VSL#3 reduces liver disease severity and hospitalization in patients with cirrhosis:a randomized,controlled trial[J].Gastroenterology,2014,147(6):1327-1337.e3.
[41]Guarner F,Ellen M.World Gastroenterology Organisation Global Guidelines:Probiotics and prebiotics.[EB/OL].http://www.worldgastroenterology.org/guidelines/global-guidelines/probiotics-and-prebiotics,2017-02.
[42]Recommendations for Probiotic Use-2015 Update:Proceedings and Consensus Opinion:Erratum[J].Journal of Clinical Gastroenterology,2016,50(9):800.
[43]Douillard FP,Mora D,Eijlander RT,et al.Comparative genomic analysis of the multispecies probiotic-marketed product VSL#3.[J].Plos One,2018,13(2):e0192452.
[44]Nath A,Haktanirlar G,Vargaá.,Molnár MA,et al.Biological activities of Lactose-derived Prebiotics and Symbiotic with Probiotics on Gastrointestinal system.Medicina[J],2018,54:18.
[45]Kim G,Kang SH,Kim MY,et al.Prognostic value of sarcopenia in patients with liver cirrhosis:A systematic review and meta-analysis[J].Plos One,2017,12(10):e0186990.
[46]Dasarathy S,Merli M.Sarcopenia from mechanism to diagnosis and treatment in liver disease[J].Journal of Hepatology,2016,65(6):1232-1244.
[47]Tsien C,Davuluri G,Singh D,et al.Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis[J].Hepatology,2015,61(6):2018-2029.