腫瘤患者臨床營(yíng)養(yǎng)問(wèn)題及其評(píng)估(ppt)課件

1、腫瘤患者臨床營(yíng)養(yǎng)問(wèn)題及其評(píng)估(ppt)（優(yōu)選）腫瘤患者臨床營(yíng)養(yǎng)問(wèn)題及其評(píng)估目錄腫瘤患者營(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Marn Caro MM, Laviano A, Pichard C. Nutritional intervention 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 P

2、M, et al. Cancer: disease and nutrition are key determinants 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 of the annual dutch nationa

3、l 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 evaluate 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)

4、生率比較Figure 1. The prevalence ofnutritional risk at admission andat 2 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,REC rectus,UN lung,BRE

5、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):732-7.腫瘤患者發(fā)生營(yíng)養(yǎng)不良的危險(xiǎn)因素Pressoir M, Desn S, Berchery D, et al. Prevalence, risk factors and clinical implica

6、tions of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010 Mar16;102(6):966-71.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:

7、a prospective study. 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 patients with gastrointestinal cancer. Nutr Hosp. 2012 May-Jun;27(3):707-14.營(yíng)養(yǎng)不良的腫瘤患者，

8、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 colorectal 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 multice

9、ntre 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):732-7.腫瘤相關(guān)營(yíng)養(yǎng)不良降低腫瘤患者生活質(zhì)量Marn Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr.

10、 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. Eur 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 affect

11、s treatment tolerability and survival in metastatic colorectal cancer patients: results of an AGEO prospectivemulticenter study. Oncology. 2011;81(5-6):395-402.狀態(tài)和風(fēng)險(xiǎn)例數(shù)體重下降不良反應(yīng)RR（95% CI）a校正RR （95% CI）RR（95% CI）b校正RR （95% CI）非胃腸道相關(guān)營(yíng)養(yǎng)不良無(wú)營(yíng)養(yǎng)支持有營(yíng)養(yǎng)支持195136591.001.08（0.50-2.32）1.000.92（0.38-2.22）1.002.22（1.

12、10-4.47）1.002.95（1.36-6.36）營(yíng)養(yǎng)風(fēng)險(xiǎn)無(wú)營(yíng)養(yǎng)支持有營(yíng)養(yǎng)支持195140551.003.13（1.21-8.05）1.002.88（0.86-9.65）1.000.58（0.21-1.58）1.000.72（0.22-2.33）胃腸道相關(guān)營(yíng)養(yǎng)不良無(wú)營(yíng)養(yǎng)支持有營(yíng)養(yǎng)支持2471031441.001.28（0.58-2.83）1.001.40（0.47-4.17）1.000.64（0.26-1.55）1.006.83（1.67-27.88）營(yíng)養(yǎng)風(fēng)險(xiǎn)無(wú)營(yíng)養(yǎng)支持有營(yíng)養(yǎng)支持3591442151.001.14（0.70-1.86）1.000.9（0.50-1.62）1.000.33（0

13、.18-0.56）1.000.79（0.41-1.52）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 status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center,prospectiv

14、e 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 advance

15、d colorectal 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Marn Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;

16、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 KaplanMeier survival plot ofpatients who did (n= 23) and didnot(n= 30) receive invasivenutritional support before self-expanding metal stent insertion(83.9 vs. 151.3 days,P= 0.053)Gray RT, Odonnell ME, Scott RD, et al. Impact of nutritional factors on survival

17、 in patients with inoperable oesophageal 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%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)（E

18、N） 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 = 7：1Yu 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):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)狀惡性腫瘤營(yíng)

19、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 21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。23 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-SGA2002 年6 月歐洲腸外腸

20、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)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)篩查初選表篩查項(xiàng)目是否1 BMI5% 在之前的一周中攝入量為正常的50%75%？輕度（1分） 臀部骨折 慢性疾病伴隨著急性的并發(fā) 肝硬化 COPD 長(zhǎng)期血透 糖尿病 腫瘤中度（2分） 2個(gè)月體重丟失5% BMI18.5-20.

21、5及一般狀況差 在之前的一周中攝入量為正常的25%-50%中度（2分） 大的腹部手術(shù) 中風(fēng)應(yīng)激狀況 血液系統(tǒng)的惡性腫瘤重度（3分） 1個(gè)月體重丟失5%（15%3個(gè)月） BMI18.5及一般狀況差 在之前的一周攝入量為正常的025%重度（3分） 頭部損傷 骨髓移植 ICU病人營(yíng)養(yǎng)評(píng)分 + 疾病評(píng)分 +年齡評(píng)分 = 總分年齡 ： 如果70歲者，加1分 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：患者處于營(yíng)養(yǎng)風(fēng)險(xiǎn), 開始制訂營(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 Ass