腫瘤患者臨床營(yíng)養(yǎng)問(wèn)題與評(píng)估

1、,腫瘤患者臨床營(yíng)養(yǎng)問(wèn)題與評(píng)估,張 宇,,目錄,????,腫瘤患者營(yíng)養(yǎng)不良現(xiàn)狀營(yíng)養(yǎng)不良對(duì)腫瘤預(yù)后的影響營(yíng)養(yǎng)不良的腫瘤患者治療現(xiàn)狀腫瘤患者營(yíng)養(yǎng)治療方法選擇,,目錄,????,腫瘤患者營(yíng)養(yǎng)不良現(xiàn)狀營(yíng)養(yǎng)不良對(duì)腫瘤預(yù)后的影響營(yíng)養(yǎng)不良的腫瘤患者治療現(xiàn)狀腫瘤患者營(yíng)養(yǎng)評(píng)估,,腫瘤患者營(yíng)養(yǎng)代謝發(fā)生改變,Marín Caro MM, Laviano A, Pichard C. Nutritional int

2、ervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,,腫瘤患者隨分期升高，營(yíng)養(yǎng)攝入量,明顯下降，導(dǎo)致體重丟失,Ravasco P, Monteiro-Grillo I, Vidal PM, et al. Cancer: disease and nutrition are key determinants

3、of patients' quality of life. Support Care Cancer. 2004 Apr;12(4):246-52.,,眾多內(nèi)科疾病中，腫瘤是營(yíng)養(yǎng)不良,發(fā)生率最高的,Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, et al. Malnutrition prevalence in The Netherlands: results

4、 of the annual dutch national prevalencemeasurement of care problems. Br J Nutr. 2009 Feb;101(3):417-23.,,近年來(lái)多個(gè)研究中的腫瘤營(yíng)養(yǎng)風(fēng)險(xiǎn),發(fā)生率,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluat

5、e clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013Jul;67(7):732-7.,,不同部位腫瘤的營(yíng)養(yǎng)風(fēng)險(xiǎn)發(fā)生率比較,????????????,Figure 1. The prevalence ofnutritional risk at admission andat 2

6、weeks after admission ordischarge according to thedifferent sites of primary tumors.A at admission,B 2 weeks after admission ordischarge.PAN pancreas,CAR cardiac,STO stomach,ESO esophagus,COL colon,LIV liver,

7、REC rectus,UN lung,BRE breast.,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013Jul;67(7

8、):732-7.,,腫瘤患者發(fā)生營(yíng)養(yǎng)不良,的危險(xiǎn)因素,Pressoir M, Desné S, Berchery D, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010 Mar16;102(6):966-71.,,

9、化療本身會(huì)加重患者的營(yíng)養(yǎng)不良,Malihi Z, Kandiah M, Chan YM, et al. Nutritional status and quality of life in patients with acute leukaemia prior to and after induction chemotherapy in three hospitals inTehran, Iran: a prospective stud

10、y. J Hum Nutr Diet. 2013 Jul;26 Suppl 1:123-31.,,目錄,????,腫瘤患者營(yíng)養(yǎng)不良現(xiàn)狀營(yíng)養(yǎng)不良對(duì)腫瘤預(yù)后的影響營(yíng)養(yǎng)不良的腫瘤患者治療現(xiàn)狀腫瘤患者營(yíng)養(yǎng)評(píng)估,,腫瘤患者營(yíng)養(yǎng)狀態(tài)與全身炎癥水平,密切相關(guān),Gomes de Lima KV, Maio R. Nutritional status, systemic inflammation and prognosis of pat

11、ients with gastrointestinal cancer. Nutr Hosp. 2012 May-Jun;27(3):707-14.,,營(yíng)養(yǎng)不良的腫瘤患者，化療相關(guān)毒,副作用發(fā)生率顯著升高,Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic col

12、orectal cancer patients: results of an AGEO prospectivemulticenter study. Oncology. 2011;81(5-6):395-402.,,住院期間各種并發(fā)癥發(fā)生率的比較,（有營(yíng)養(yǎng)風(fēng)險(xiǎn) vs 無(wú)營(yíng)養(yǎng)風(fēng)險(xiǎn)）,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screeni

13、ng and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013Jul;67(7):732-7.,,腫瘤相關(guān)營(yíng)養(yǎng)不良降低腫瘤患者生,活質(zhì)量,Marín Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of

14、life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,,體重丟失≥10%者，生活質(zhì)量顯著下,降,Nourissat A, Vasson MP, Merrouche Y, et al. Relationship between nutritional status and quality of life in patients with cancer. Eu

15、r J Cancer. 2008 Jun;44(9):1238-42.,,嚴(yán)重營(yíng)養(yǎng)不良患者生存率顯著低于無(wú)營(yíng)養(yǎng)不良或輕度營(yíng)養(yǎng)不良的患者,Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic colorectal cancer patients: results

16、of an AGEO prospectivemulticenter study. Oncology. 2011;81(5-6):395-402.,,營(yíng)養(yǎng)支持治療對(duì)體重下降/不良反應(yīng)發(fā)生率的影響,RR=相對(duì)危險(xiǎn)度；95% CI=95%可信限,a 以年齡、性別、分期、手術(shù)和放化療進(jìn)行校正b以年齡、性別、分期和放化療進(jìn)行校正,Pan H, Cai S, Ji J, et al. The impact of nutritional stat

17、us, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center,prospective cohort study in Chinese teaching hospitals. Nutr Cancer. 2013;65(1):62-70.,,營(yíng)養(yǎng)支持顯著減少化療

18、相關(guān)毒副反,應(yīng)的發(fā)生,Hasenberg T, Essenbreis M, Herold A, et al. Early supplementation of parenteral nutrition is capable of improving quality of life, chemotherapy-related toxicity and bodycomposition in patients with advanced c

19、olorectal carcinoma undergoing palliative treatment: results from a prospective, randomized clinical trial. Colorectal Dis. 2010Oct;12(10 Online):e190-9.,,腫瘤患者營(yíng)養(yǎng)治療能改善生活質(zhì)量,Marín Caro MM, Laviano A, Pichard C. Nutrit

20、ional intervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,,接受積極營(yíng)養(yǎng)治療的腫瘤患者，生,存率得到改善,? The Kaplan–Meier survival plot of,patients who did (n= 23) and didnot(n= 30) receive inva

21、sive,nutritional support before self-expanding metal stent insertion(83.9 vs. 151.3 days,P= 0.053),Gray RT, O'donnell ME, Scott RD, et al. Impact of nutritional factors on survival in patients with inoperable oesop

22、hageal cancer undergoing self-expanding metal stentinsertion. Eur J Gastroenterol Hepatol. 2011 Jun;23(6):455-60.,,目錄,????,腫瘤患者營(yíng)養(yǎng)不良現(xiàn)狀營(yíng)養(yǎng)不良對(duì)腫瘤預(yù)后的影響營(yíng)養(yǎng)不良的腫瘤患者治療現(xiàn)狀腫瘤患者營(yíng)養(yǎng)評(píng)估,,我國(guó)腫瘤患者營(yíng)養(yǎng)治療現(xiàn)狀,? 營(yíng)養(yǎng)治療的患者比例,– 所有住院腫瘤患者中，有34.9

23、%接受營(yíng)養(yǎng)治療– 有營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者，僅46.7%得到營(yíng)養(yǎng)治療– 無(wú)營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者，17.1%實(shí)施了營(yíng)養(yǎng)治療,? 腸外營(yíng)養(yǎng)（PN） vs 腸內(nèi)營(yíng)養(yǎng)（EN）,– 30.6%的住院腫瘤患者接受PN– 4.4%的住院腫瘤患者接受EN– PN：EN = 7：1,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and eval

24、uate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013Jul;67(7):732-7.,臨床營(yíng)養(yǎng)的現(xiàn)狀,腸內(nèi)營(yíng)養(yǎng) 腸外營(yíng)養(yǎng)歐洲 8 ： 1美國(guó) 10 ： 1中國(guó) 1 : 6,,我國(guó)腫瘤患者營(yíng)養(yǎng)治療現(xiàn)狀,惡

25、性腫瘤營(yíng)養(yǎng)不良的患病率高達(dá) 40%一 80%住院的惡性腫瘤患者中營(yíng)養(yǎng)不良的發(fā)生率就高達(dá)到63%存在營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者中僅有46%得到了營(yíng)養(yǎng)治療20%的惡性腫瘤患者死于營(yíng)養(yǎng)不良,,目錄,????,腫瘤患者營(yíng)養(yǎng)不良現(xiàn)狀營(yíng)養(yǎng)不良對(duì)腫瘤預(yù)后的影響營(yíng)養(yǎng)不良的腫瘤患者治療現(xiàn)狀腫瘤患者營(yíng)養(yǎng)評(píng)估,,營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查,,,,,,2,,,1,早期發(fā)現(xiàn)患者是否已發(fā)生營(yíng)養(yǎng)不良或是否存在發(fā)生營(yíng)養(yǎng)不良的危險(xiǎn),判定營(yíng)養(yǎng)不良的嚴(yán)重度及原因，指導(dǎo)制定合理

26、的營(yíng)養(yǎng)支持的方案,用以評(píng)估營(yíng)養(yǎng)支持的效果,在腫瘤患者營(yíng)養(yǎng)支持的實(shí)施中，關(guān)鍵的第一步就是早期及動(dòng)態(tài)地進(jìn)行營(yíng)養(yǎng)狀態(tài)的評(píng)定。,2,3,,營(yíng)養(yǎng)篩選,營(yíng)養(yǎng)的綜合評(píng)定,,營(yíng)養(yǎng)評(píng)定兩步走,營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查工具,NRS-2002PG-SGA,2002 年6 月歐洲腸外腸內(nèi)營(yíng)養(yǎng)學(xué)會(huì)(ESPEN) 在RCT 證據(jù)的基礎(chǔ)上制訂了適用于住院患者的營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查方法NRS-2002 (nutritionalrisk screening 2002)目前唯一基于循證醫(yī)

27、學(xué)證據(jù)（128個(gè)RCT的循證醫(yī)學(xué)基礎(chǔ)的）營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查工具2006年中華醫(yī)學(xué)會(huì)腸外腸內(nèi)營(yíng)養(yǎng)學(xué)分會(huì)推薦為住院患者營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查工具簡(jiǎn)便易行 (3個(gè)項(xiàng)目)、快速(5分鐘),NRS-2002,營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查初選表,如果任一問(wèn)題回答是, 則進(jìn)入第二步 如果所有問(wèn)題回答否, 每周復(fù)查一次,B.營(yíng)養(yǎng)篩查復(fù)篩表,NRS2002內(nèi)容,,疾病嚴(yán)重程度評(píng)分,,營(yíng)養(yǎng)狀態(tài)低減評(píng)分,,年齡評(píng)分,,,,,內(nèi)容,NRS-2002營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查結(jié)論,總分值≥3：患者處于

28、營(yíng)養(yǎng)風(fēng)險(xiǎn), 開(kāi)始制訂營(yíng)養(yǎng)計(jì)劃總分值< 3：每周進(jìn)行營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查,主觀整體營(yíng)養(yǎng)評(píng)量表（PG-SGA）,PG-SGA（Patient-Generated Subjective Global Assessment，患者主觀整體評(píng)估）是在主觀整體評(píng)估（Subjective Global Assessment， SGA）的基礎(chǔ)上發(fā)展起來(lái)的。美國(guó)Ottery FD于1994年提出，是專門(mén)為腫瘤患者設(shè)計(jì)的營(yíng)養(yǎng)狀況評(píng)估方法。臨床研究提示，

29、PG-SGA是一種有效的腫瘤患者特異性營(yíng)養(yǎng)狀況評(píng)估工具，因而得到美國(guó)營(yíng)養(yǎng)師協(xié)會(huì)（American Dietetic Association，ADA）等單位的大力推薦與廣泛應(yīng)用?！吨袊?guó)抗癌協(xié)會(huì)腫瘤營(yíng)養(yǎng)與支持治療專業(yè)委員會(huì)》建議采用PG-SGA進(jìn)行腫瘤患者營(yíng)養(yǎng)狀況調(diào)查。,評(píng)分法PG-SGA包括7項(xiàng)：體重變化，不適癥狀，食欲，體力狀況及與營(yíng)養(yǎng)相關(guān)的疾病狀態(tài)，代謝狀態(tài)，體格檢查。前4項(xiàng)主要由患者完成，后3項(xiàng)主要由醫(yī)護(hù)人員完成根據(jù)評(píng)分將患者進(jìn)

30、行營(yíng)養(yǎng)分類，分為營(yíng)養(yǎng)正常（0～3 分）、中度營(yíng)養(yǎng)不良（4～8分）及嚴(yán)重營(yíng)養(yǎng)不良（＞8分），據(jù)此決定是否需要進(jìn)行營(yíng)養(yǎng)支持,PG-SGA評(píng)分法,評(píng)估內(nèi)容,病史,身體評(píng)估,能很好預(yù)測(cè)并發(fā)癥，包括透析、肝移植和HIV感染者 主觀評(píng)價(jià)方式，特異性功能狀況評(píng)估為主適合慢性或已經(jīng)存在的營(yíng)養(yǎng)不足評(píng)估,營(yíng)養(yǎng)評(píng)估特點(diǎn),,兩種營(yíng)養(yǎng)篩查方法比較,NRS2002易于發(fā)現(xiàn)早期營(yíng)養(yǎng)不良的患者，有利于營(yíng)養(yǎng)不良的預(yù)防PG-SGA側(cè)重于營(yíng)養(yǎng)不良的治療,營(yíng)養(yǎng)的綜合評(píng)

31、定,常用客觀指標(biāo)--人體組成參數(shù),身高與體重體重指數(shù)：BMI=體重/身高2三頭肌或肩胛下皮褶厚度上臂肌圍和面積,常用客觀指標(biāo)--生化指標(biāo),血清白蛋白 <3.5g/dl血清前白蛋白 <17mg/dl淋巴細(xì)胞計(jì)數(shù) <1500cell/mm3血清轉(zhuǎn)鐵蛋白

32、 <140mg/dl總鐵結(jié)合力 <250mcg/dl血清膽固醇 <150mg/dl,Heymsfield SB, et al. In: Modern Nutrition in Health and Disease. Philadelphia, PA: Lea & Febiger;1994:812-