《2009ESPEN/ESPEN肠外营养指南：肝病》内容预览

Comments: The prognostic signi?cance of a poor nutritionalstate is documented for patients with ASH (III ).Simple bedsidemethods like the ‘‘Subjective Global Assessment’’ or anthropometryare recommended to identify patients at risk.

PN supplemental to oral nutrition ad libitum was studied inseven controlled trials using conventional amino acid solutions.The parenteral intake ranged from 200 to 3000 kcal dproviding35–130 g amino acids per day while the oral intake ranged from 13to 39 kcal kgNone of these trials showed a change inmortality; this may be due to the inclusion of patients with a lowrisk and only moderate disease severity. No adverse effects ofincreased nitrogen intake were observed but hepatic encephalop-athy was graded by clinical assessment only. In the majority of trialsthere was an improvement in visceral proteins as a measure of thenutritional state. An improvement in liver function (galactoseelimination, serum bilirubin) was also described.In patients with cirrhosis, after an overnight fast glycogen storesare depleted and metabolic conditions are similar to prolongedstarvation in healthy individuals. It has been shown that a lateevening carbohydrate snack is associated with improved proteinmetabolism in cirrhotic patients.Therefore, it is recommendedthat patients who need to be managed nil by mouth should begiven glucose i.v. at a rate equal to the endogenous hepatic glucoseproduction.1.2. Energy intake

In practice it can safely be assumed that ASH patients have anenergy requirement of 1.3 times the basal metabolic rate (C).

Comments: One studyshowed that in ASH patients the rela-tionship between measured and predicted resting energy expen-diture was no different from healthy individuals. ASH patients did,however, show a higher energy expenditure when related to theirreduced muscle mass as assessed by 24 h urinary creatinineexcretion.In cirrhotics without ascites actual body weight should be usedfor the calculation of the basal metabolic rate using formulae suchas that proposed by Harris and Benedict. In patients with ascites theideal weight according to body height should normally be used,despite a series of 10 patients with liver cirrhosis of whom only 4were completely evaluated,from whom it was suggested thatascites mass should not be omitted when calculating energyexpenditure by use of body mass

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