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Liver cirrhosis is the end stage of chronic liver diseases with various complications, thereby imposing great burden to the patient's family and public health care. Abnormal nutritional status, mainly including malnutrition and overnutrition(overweight/obesity), are related to the occurrence of many chronic liver diseases, and have major impact on the progression and outcome of liver cirrhosis. Nutritional status of cirrhotic patients should be comprehensively assessed based on various factors, including underlying diseases, diet, clinical manifestations, and laboratory tests, etc. Cirrhotic patients with malnutrition should receive individualized nutritional support therapy in timely fashion, and those with overweight/obesity should undergo dietary intervention or physical activity to improve the quality of life and reduce the risk of death.

, correspAuthors=Xing-Shun Qi, Yong-Ping Yang, authorNote=null, correspAuthorsNote=
* Qi Xing-Shun, E-mail:
Yang Yong-Ping, E-mail:
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肝硬化是慢性肝脏疾病的终末期阶段,可导致多种并发症,给患者家庭及社会造成沉重的负担。机体营养状态异常主要包括营养不良及营养过剩(超重/肥胖),与多种慢性肝脏疾病的发生密切相关,更可影响肝硬化患者的病情进展及预后。对肝硬化患者机体营养状态的评估可综合基础疾病、饮食状况、临床表现及实验室指标等多个方面进行。针对营养不良的肝硬化患者,应及时予以个体化营养支持治疗;针对超重/肥胖的患者,应进行饮食干预及运动管理,从而改善肝硬化患者的生活质量并降低病死率。

, correspAuthors=祁兴顺, 杨永平, authorNote=null, correspAuthorsNote=
祁兴顺,E-mail:
杨永平,E-mail:
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殷悦,医学硕士,主要从事消化系统疾病诊治方面的研究

祁兴顺,医学博士,副主任医师,中华医学会消化病学分会第十一届委员会青年委员、肝胆疾病学组委员,辽宁省医学会消化病学分会第十届委员会委员,2019年辽宁省青年科技奖十大英才,入选2021年Elsevier中国高被引用学者。

杨永平,教授,主任医师,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头多项国家“十三·五”及“十二·五”重大专项课题,军队“十二·五”重点课题和北京市科委军民融合重点课题;享受国务院特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项。

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殷悦,医学硕士,主要从事消化系统疾病诊治方面的研究

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殷悦,医学硕士,主要从事消化系统疾病诊治方面的研究

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祁兴顺,医学博士,副主任医师,中华医学会消化病学分会第十一届委员会青年委员、肝胆疾病学组委员,辽宁省医学会消化病学分会第十届委员会委员,2019年辽宁省青年科技奖十大英才,入选2021年Elsevier中国高被引用学者。

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杨永平,教授,主任医师,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头多项国家“十三·五”及“十二·五”重大专项课题,军队“十二·五”重点课题和北京市科委军民融合重点课题;享受国务院特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项。

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杨永平,教授,主任医师,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头多项国家“十三·五”及“十二·五”重大专项课题,军队“十二·五”重点课题和北京市科委军民融合重点课题;享受国务院特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项。

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肝硬化患者营养状态的评估及管理
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殷悦 1 , 祁兴顺 1, * , 杨永平 2, *
解放军医学杂志 | 肝硬化及其并发症的评估与管理专题 2023,48(1): 13-17
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解放军医学杂志 | 肝硬化及其并发症的评估与管理专题 2023, 48(1): 13-17
肝硬化患者营养状态的评估及管理
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殷悦1, 祁兴顺1, * , 杨永平2, *
作者信息
  • 1北部战区总医院消化内科,辽宁沈阳 110840
  • 2解放军总医院第五医学中心肝病医学部,北京 100039
  • 殷悦,医学硕士,主要从事消化系统疾病诊治方面的研究

    祁兴顺,医学博士,副主任医师,中华医学会消化病学分会第十一届委员会青年委员、肝胆疾病学组委员,辽宁省医学会消化病学分会第十届委员会委员,2019年辽宁省青年科技奖十大英才,入选2021年Elsevier中国高被引用学者。

    杨永平,教授,主任医师,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头多项国家“十三·五”及“十二·五”重大专项课题,军队“十二·五”重点课题和北京市科委军民融合重点课题;享受国务院特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项。

通讯作者:

祁兴顺,E-mail:
杨永平,E-mail:
Assessment and management of nutritional status in patients with liver cirrhosis
Yue Yin1, Xing-Shun Qi1, * , Yong-Ping Yang2, *
Affiliations
  • 1Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
  • 2Faculty of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
出版时间: 2023-01-28 doi: 10.11855/j.issn.0577-7402.2023.01.0013
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肝硬化是慢性肝脏疾病的终末期阶段,可导致多种并发症,给患者家庭及社会造成沉重的负担。机体营养状态异常主要包括营养不良及营养过剩(超重/肥胖),与多种慢性肝脏疾病的发生密切相关,更可影响肝硬化患者的病情进展及预后。对肝硬化患者机体营养状态的评估可综合基础疾病、饮食状况、临床表现及实验室指标等多个方面进行。针对营养不良的肝硬化患者,应及时予以个体化营养支持治疗;针对超重/肥胖的患者,应进行饮食干预及运动管理,从而改善肝硬化患者的生活质量并降低病死率。

肝硬化  /  营养状态  /  营养不良  /  营养过剩  /  超重  /  肥胖

Liver cirrhosis is the end stage of chronic liver diseases with various complications, thereby imposing great burden to the patient's family and public health care. Abnormal nutritional status, mainly including malnutrition and overnutrition(overweight/obesity), are related to the occurrence of many chronic liver diseases, and have major impact on the progression and outcome of liver cirrhosis. Nutritional status of cirrhotic patients should be comprehensively assessed based on various factors, including underlying diseases, diet, clinical manifestations, and laboratory tests, etc. Cirrhotic patients with malnutrition should receive individualized nutritional support therapy in timely fashion, and those with overweight/obesity should undergo dietary intervention or physical activity to improve the quality of life and reduce the risk of death.

liver cirrhosis  /  nutritional status  /  malnutrition  /  overnutrition  /  overweight  /  obesity
殷悦, 祁兴顺, 杨永平. 肝硬化患者营养状态的评估及管理. 解放军医学杂志, 2023 , 48 (1) : 13 -17 . DOI: 10.11855/j.issn.0577-7402.2023.01.0013
Yue Yin, Xing-Shun Qi, Yong-Ping Yang. Assessment and management of nutritional status in patients with liver cirrhosis[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (1) : 13 -17 . DOI: 10.11855/j.issn.0577-7402.2023.01.0013
肝硬化是以肝脏弥漫性纤维化、肝内外血管增殖及假小叶形成为主要病理特征的终末期阶段肝病[1]。在我国,肝硬化及其并发症导致的死亡率居疾病死因谱的第14位[2]。在肝硬化早期,由于肝脏的代偿能力较强,可无明显症状,但随着疾病的进展,晚期主要表现为肝功能损害及门静脉高压,易发生腹水[3]、自发性细菌性腹膜炎[4]、肝肾综合征[4]、肝性脑病[5-6]、食管胃底静脉曲张破裂出血[7]及肝癌[8]等严重并发症,已成为全球严重的公共卫生问题[9]。因此,准确评估肝硬化患者的预后对临床医师判断患者病情及选择治疗方案具有重要意义。
目前,已有多项生化指标及预后评分模型被用于临床评估肝硬化患者的预后。然而,营养状态对患者预后的影响常被忽视。机体的营养状态异常可分为营养不良及营养过剩(超重/肥胖)[10]。营养不良是一种以肌肉质量及脂肪组织含量减少为特征的慢性病理状态,超重/肥胖则是一种体内脂肪堆积过多的慢性疾病状态。营养不良或营养过剩均可对健康产生不良影响,也是多种慢性肝脏疾病的危险因素[11-13]。近年来多项研究表明,营养不良或超重/肥胖与肝硬化的病情进展及预后密切相关[14-17],但这一问题尚未得到充分重视,临床医师亦对其了解甚少[18]。本文从肝硬化与营养状态的相关性、营养状态评估方式及营养支持治疗等方面的最新研究进展出发,阐述肝硬化患者营养状态评估及管理的要点。
营养不良是肝硬化患者的常见并发症之一,常伴有蛋白质、脂溶性或水溶性维生素、矿物质及微量元素等多种营养物质的缺乏,并出现水、电解质紊乱,造成疾病恶化,进而影响患者预后[19]。随着肝硬化病情的加重,营养不良的患病率也随之增高[20]。肝硬化代偿期患者营养不良的患病率约为39.9%,而失代偿期患者营养不良的患病率约为44.1%[21]
营养不良与肝硬化患者的预后具有明显相关性。与营养充足的肝硬化患者相比,营养不良患者的住院率及病死率增加了1倍[22]。2001年,Alberino等[15]对212例肝硬化患者的营养状态随访2年发现,营养不良是肝硬化患者病死率增高的独立危险因素。肝硬化患者长期处于高代谢状态,能量消耗增加,且常因腹水及门静脉高压引起胃肠道淤血,导致食欲不振、恶心呕吐等症状,影响营养物质摄入,使得机体的葡萄糖及脂质代谢过程紊乱,进一步影响肝脏的营养储备及合成功能,导致患者肌肉质量及脂肪组织损失[23-24]。肝硬化还可引起体内胆汁酸代谢过程受损,影响脂肪消化及脂溶性维生素吸收过程中的胶束形成,导致脂肪吸收障碍[25-26]。近年来,肠道菌群被认为可参与人体的营养及能量代谢过程,其重要性受到了越来越多的关注。有研究发现,肠道微生物菌群失调可导致肝硬化患者营养吸收功能障碍,这也是肝硬化患者发生营养不良的可能原因之一[27]
超重/肥胖是一种以体内脂肪组织增多为特征的慢性病理状态,可对人体健康产生诸多不良影响。超重/肥胖的发病率逐年增高,男性的全球年龄标准化平均体重指数(body mass index,BMI)从1975年的21.7 kg/m2增长至2014年的24.2 kg/m2,女性从1975年的22.1 kg/m2增长至2014年的24.4 kg/m2[28]。肥胖对全球经济及健康造成的负担也呈逐年增加的趋势,已被世界卫生组织列入全球非传染性疾病6种可预防的风险因素之一[29]
超重/肥胖被认为是多种肝脏疾病,如非酒精性脂肪性肝病[30]、酒精性肝病[11]、肝硬化[12]、肝癌[31]的危险因素。然而,超重/肥胖与肝硬化预后的关系仍存在争议。一些研究认为,肥胖不仅与肝硬化病情的严重程度呈正相关性,而且会增加肝硬化患者的死亡及住院风险。Berzigotti等[12]对肝硬化患者平均随访59个月发现,肥胖与代偿期肝硬化患者发生失代偿期事件明显相关;校正门静脉压力及肝功能指标等混杂因素后,肥胖仍是失代偿期事件的独立预测指标。Ioannou等[16]对美国第一次全国健康与营养调查(the First National Health and Nutrition Examination Survey,NHANES I)数据库中11 465例肝硬化患者平均随访13年发现,肥胖为肝硬化相关死亡或住院的独立危险因素。肥胖患者体内游离脂肪酸释放增加,可激活多种细胞因子信号传导通路,诱发机体发生炎症反应且加剧肝脏血管内皮细胞功能障碍,并造成胰岛素抵抗[32]。另外,肥胖患者体内的脂肪组织可分泌多种具有促炎、促氧化及促纤维化作用的细胞因子,如白细胞介素-6、肿瘤坏死因子、单核细胞趋化蛋白-1等,进而提高肝内血管张力,增加门静脉血流阻力,加重肝硬化门静脉高压,进而造成预后不良[33-34]
另有研究发现,超重/肥胖的肝硬化患者死亡率反而比正常体重的患者低。2016年,Karagozian等[14]对美国国家住院样本(Nationwide Inpatient Sample,NIS)数据库中32 605例急诊入院的肝硬化患者进行了一项回顾性、观察性研究,发现与非肥胖的肝硬化患者相比,肥胖的肝硬化患者院内病死率更低。Li等[35]发现,肝硬化合并肝癌患者的BMI水平越高,病死率就越低,生存时间也越长。本研究团队于2021年开展的一项回顾性队列研究也发现,与正常体重肝硬化患者相比,超重/肥胖患者的累积生存率更高[36]。这种现象被称为“肥胖悖论”,也体现在其他慢性疾病研究中,如高血压、2型糖尿病及冠心病等[37-38],但其形成机制尚存争议。可能与以下几种原因有关:第一,超重/肥胖的肝硬化患者可能有着更充足的营养储备,脂肪提供了充足的能量以供应慢性消耗性疾病病程的能量代谢需求,从而降低了病死率[39];第二,超重/肥胖者可能接受了更积极的治疗措施,从而改善了他们的健康状况;第三,脂肪组织可释放多种具有抗炎及抗纤维化作用的脂肪因子,如脂联素及分泌型卷曲相关蛋白-5,对患者的免疫调节及代谢过程均会产生重要的影响[33,40]。总的来说,当前探讨超重/肥胖与肝硬化患者死亡率之间关系的研究仍较少,各项研究纳入患者的病情严重程度也有所不同,各种假说仍有待进一步探讨,未来需要进行更多高质量的研究以明确它们之间的关系。
肝硬化患者的营养状态与其临床结局密切相关,选择合理的评价方式对准确评估机体的营养状态具有重要意义。目前,用于评价人体营养状态的指标/方式主要包括:(1)人体测量指标,如BMI、三头肌皮褶厚度、上臂围及腰臀比等;(2)实验室指标,如白蛋白、前白蛋白、转铁蛋白、维生素及微量元素等;(3)整体营养评价工具,如营养不良风险筛查量表及主观整体评价工具等;(4)影像学检查,如计算机断层扫描(computed tomography,CT)、磁共振成像(magnetic resonance imaging,MRI)及超声波成像技术等;(5)人体成分分析,如生物电阻抗分析及双能X线吸收法等。
然而,以上评估方式对于肝硬化患者均存在一定局限性。直接的人体测量结果及实验室指标简单易得,可较为客观地对营养状态进行评估,其中BMI更是因操作简便且实用性强等优点,成为临床工作中最常用的营养评价指标之一,但其特异性差,易受腹水及外周水肿等液体潴留的影响,且不能区分肌肉及脂肪组织分布[41],无法准确地反映肝硬化患者真实的营养状况,还需结合其他指标具体评估。综合营养评价工具主要使用病史及体格检查指标无创评估患者的营养状态,并可对其进行动态监测,目前已用于临床工作中[42],但其极易受主观因素影响。CT、MRI及超声等影像学检查可区分肌肉与脂肪组织含量,能客观地评估患者的营养状况,对预测临床结局有重要的指导意义[41],但其价格昂贵,且存在电离辐射等缺陷。人体成分分析法具有无创及测量精准等优点[43-44],但需配备专业设备及人员进行操作,临床实用性较差。
早期营养干预可明显改善肝硬化合并营养不良患者的结局并减少并发症的发生[45-46]。本研究团队摘译的《2021年美国肝病学会实践指导:肝硬化患者营养不良、衰弱和肌肉减少症》一文指出,针对营养不良的肝硬化患者,应采用多学科团队进行个体化营养咨询,及早进行系统科学的营养干预,并要保证患者充足的营养摄入[47]。2020年,欧洲临床营养和代谢学会(European Society for Clinical Nutrition and Metabolism,ESPEN)更新了肝病的临床营养相关指南并指出:对于肝硬化伴营养不良和(或)肌肉减少症患者,应经口进食摄入蛋白1.5 g/(kg·d);对于“不能耐受”蛋白质的患者,应口服植物蛋白或支链氨基酸补充剂25 g/(kg·d),以满足患者对蛋白质的摄入要求;对于经口进食无法满足营养及能量需求的患者,可考虑给予肠内营养或肠外营养支持[48]。此外,也应仔细寻找肝硬化患者发生营养功能障碍的原因,以明确潜在的治疗目标。
针对超重/肥胖的肝硬化患者,应进行饮食干预或运动管理,既需要保证患者吸收足量的营养物质,不损害正常的营养及能量代谢过程,也需限制摄入过高的热量[49]。肝硬化患者所需热量取决于患者个体情况,应尽量减少超重/肥胖肝硬化患者的禁食时间或频率,可采取分餐进食及夜间加餐的方式[48]。一项前瞻性多中心研究发现,对于合并超重/肥胖的代偿期肝硬化患者,采用16周的量身定制饮食及适度运动等非药物干预措施可有效减轻体重并降低门静脉压力[50]。然而,失代偿期肝硬化患者的病情较为危重,对合并超重/肥胖的失代偿期肝硬化患者进行体重干预应慎重。
营养不良与肝硬化病情的严重程度及其预后密切相关,但超重/肥胖与肝硬化患者预后的相关性仍有待进一步研究。未来需进行基于大规模人群的前瞻性研究,以更准确地判断肝硬化患者营养状态与临床结局之间的关系,提高临床医师对营养状态重要性的认识。总的来说,目前尚无统一的“金标准”用于评估肝硬化患者的营养状态,临床常用的几种营养评价方式也各有利弊,对肝硬化患者营养状态的评估仍需综合考虑基础疾病、饮食状况、临床表现及实验室指标等多个方面,以便能更准确地判断患者的病情。肝硬化患者应定期进行营养筛查,及时准确地评估营养状态,并对营养状态异常的肝硬化患者予以个体化营养支持治疗,这些措施将有助于改善患者的生活质量并降低病死率。
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2023年第48卷第1期
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doi: 10.11855/j.issn.0577-7402.2023.01.0013
  • 接收时间:2022-04-07
  • 首发时间:2025-12-03
  • 出版时间:2023-01-28
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  • 收稿日期:2022-04-07
  • 录用日期:2022-06-07
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    1北部战区总医院消化内科,辽宁沈阳 110840
    2解放军总医院第五医学中心肝病医学部,北京 100039

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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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