阻抗參數(shù)營(yíng)養(yǎng)不良臨床翻譯部分

Clinicalrelevanceandapplicabilityofimpedanceparameters-inthediagnosisofmalnutritionCHARITéUniversit?tsmedizinBerlinResearchGrouponGeriatriacsandInterdisciplinaryMetabolicCentreCharitéCampusVirchowKlinikumKristinaNorman,PhDOverviewMalnutrition–factsMalnutritionandbodycompositionMalnutritionandimpedanceparametersClinicalrelevanceofimpedanceparametersCasestudiesIntheclinicalsetting,bodycompositionisanattractivetooltoidentifypatientsatrisk(ofmalnutrition/sarcopenia)andtoassesschangesduringnutritionaltherapyUnintendedweightlossisthecardinalfeatureinmalnutritionorcachexia

(appr.10%in6months=clinicallyrelevant)Diseaserelatedweightloss-impact ProteincatabolismImmunedeficiencyReducedmusclemassImpairedwoundhealingMicronutrientdeficiencyNormanetal.ClinNutr2008:27DetrimentalconsequencesNormanetal.ClinNutr2008:27Prevalenceofmalnutrition(i.e.weightloss)athospitaladmissioninGermany20062006年在德國(guó)的住院的營(yíng)養(yǎng)不良患病率(減肥)Prevalenceofmalnutrition[%]010203040506070GYNAECOLOGY婦科SURGERY外科UROLOGY泌尿?qū)WCARDIOLOGY心臟病INTERNALMEDICINE內(nèi)科GASTROENTEROLOGY腸胃病學(xué)ONCOLOGY腫瘤學(xué)GERIATRICS老年病人172/30638/10089/27381/30544/20115/10270/5127/87GermanHospitalMalnutritionStudy,ClinNutr2006;25Oneinfourpatientsmalnourishedathospitaladmission四分之一的患者營(yíng)養(yǎng)不良住院n=1887Estimatedcosts

ofdiseaserelatedmalnutritioninGermany估算在德國(guó)營(yíng)養(yǎng)不良相關(guān)的疾病5billion€6billion€ 2,541,31,320072020Hospitalcare住院治療Homecare家庭護(hù)理Outpatientmedicalcare門(mén)診病人護(hù)理Cepton2007in2011–12:￡19.6billionGBP≈

morethan15%ofthetotalexpenditure onhealthandsocialcareintheUKAlteredbodycompositioninmalnutritionorcachexia改變身體成分營(yíng)養(yǎng)不良或惡病質(zhì)ReducedmusclemassReducedbodycellmass [3compartmentmodel]Reducedfatfreemass [2compartmentmodel]FMFMECMBCMFFMWeightDefinitionanddiagnosisofcachexiainbenignandmalignantdisease惡病質(zhì)良性和惡性疾病的診斷Evansetal.ClinNutr2008;27Fatfreemass/height2(FFMI)DiagnosticcriteriaformalnutritionESPENconsensusstatement/endorsedmendation營(yíng)養(yǎng)不良的診斷標(biāo)準(zhǔn)共識(shí)聲明/支持建議

?在不固定的時(shí)間，重量減輕（非故意性的）>10%?；蛘呓Y(jié)合過(guò)去的3個(gè)月

重量減輕>5%

?BMI<20kg/m2年齡<70歲,或者BMI<22kg/m2年齡≥70歲

?FFMI<15kg/m2(女)和FFMI<17kg/m2（男）Cederholmetal.ClinicalNutrition2015:34Fat-freemassindexandfatmassindexpercentiles不含脂肪的質(zhì)量指數(shù)和脂肪質(zhì)量指數(shù)百分位數(shù)Referencevalues(n=5635)apparentlyhealthyadultsfromamixednon-randomlyselectedCaucasianpopulationinSwitzerland2986menand2649women,between24to98y.TetrapolarBIA(Bio-Z2;RJL-109and101;Xitron4000B)Schutzetal.InternationalJournalofObesity2002:26Background“ClinicaluseofBIAinsubjectsatextremesofBMIrangesorwithabnormalhydrationcannotbemendedforroutineassessmentofpatientsuntilfurthervalidationhasprovenforBIAalgorithmtobeaccurateinsuchconditions.”ESPENGUIDELINESBioelectricalimpedanceanalysispartI:reviewofprinciplesandmethodsClinicalNutrition(2004)23RequirementsforalgorithmswithtetrapolarBIA:BMIrange16-34kg/m2undisturbedhydrationIncreasinguseofrawimpedanceparametersinclinicalresearchandpractise增加使用的阻抗參數(shù)在臨床研究和練習(xí)Impedance(Z)=Z2=R2+Xc2Resistance

(R)=pureoppositionofabiologicalconductortoalternatingelectriccurrentReactance(Xc)=capacitiveeffectproducedbythetissueinterfacesandcellmembranesBIOELECTRICALIMPEDANCEVECTORANALYSIS–IndividualInterpretation/UseCholerapatientsbeforeandafterfluidinfusionMcDonaldetal.Lancet1993;341MenWomenClimbersbeforeandafterhighaltitudedehydrationPiccolietal.MedSciSportsExerc1996;28HDpatientsbeforeandafterfluidremovalPiccolietal.KidneyInt1998;53Piccolietal.Nutrition2002;18overhydrationdehydrationImpedance(Z)=Z2=R2+Xc2Resistance

(R)=pureoppositionofabiologicalconductortoalternatingelectriccurrentReactance(Xc)=capacitiveeffectproducedbythetissueinterfacesandcellmembranes

Reactance

180

Resistance

πxPhaseAngle(α)Indisease:疾病Determinantsandinfluencingfactors:決定和影響因素

WeightlossBosy-Westphaletal.JPEN2006;30Barbosa-Silvaetal.AmJClinNutr2005;82Stob?usetal.BrJNutr2012;107Johansenetal.AmJClinNutr2003;77AgeSexBMIInflammationImpedanceparametersInhealth:健康Phys.inactivity

Cancer癌癥(pancreatic胰腺,lung肺,colorectal結(jié)腸直腸,breast乳房,mixed其他)HIV/AIDS艾滋病Liverdisease肝病Neurologicdisease(ALS)神經(jīng)系統(tǒng)疾病Rheumaticdisease(systemicsclerosis)風(fēng)濕性疾病Kidneydisease(haemodialysisandperitonealdialysis)腎?。ㄑ和肝龊透鼓ね肝觯〤ardiacdisease心臟疾病Geriatrics老年病Surgery(cardiacandgastrointestinal)外科手術(shù)（心臟和腸胃）(…)NormanetalClinNutr.2012;31[Reviewarticle]Lowphaseanglevalues:低相角值

highlypredictiveofe(egdiseaseprogression) andmortality高度的預(yù)測(cè)結(jié)果（如疾病進(jìn)展）和死亡率ImpactofphaseangleonmortalityinHIVHIV的相位角對(duì)死亡率的影響Schwenketal.AmJClinNutr2000;72n=257(234onHAART)39.7yold;85%male1.5yprospectivestudyn=305patientswithbiopsyprovenlivercirrhosis37%whodiedmeansurvivaltime:24±18months<5.4°:reducedsurvivaltimes(P<0.01)Impactofphaseangleonmortalityinlivercirrhosis肝硬化相位角對(duì)死亡率的影響Selbergetal.EurJApplPhysiol.2002:86

Impactofphaseangleonmortalityincoloncancer結(jié)腸癌相位角對(duì)死亡率的影響n=52PatientswithcoloncancerstageIV[57%male]3yretrospectivereview5.57°(median)asthecutoff>5.57°<5.57°GuptaetalAmJClinNutr2004;80Impactofphaseangleonmortalityincongestiveheartdisease相位角對(duì)死亡率的影響充血性心臟病n=41patientswithCHDProspectivestudyon5ymortalityAUCPhaseangle 0.86indexedEAT 0.82

ICW 0.83MM 0.82LV-EF 0.68FFM 0.66D?schetal.Obesity2010;10EATepicardialadiposetissueICWintracellularwaterMMmusclemassLV-EFleftventricularejectionfraction,FFMfatfreemassCutoffvaluesforclinicaluse?切斷值的臨床應(yīng)用NormanetalClinNutr.2012;31[Reviewarticle]Bioelectricalimpedanceparametersinmalnutrition生物電阻抗參數(shù)決定營(yíng)養(yǎng)不良

R

Xc

α(PhA)Phaseangledifferentiatesbetweendifferentformsofunderweight相角區(qū)分不同形式的減持p=<0.05;&comparedtocontrolsMarraetal.EJCN2009:63allPhaseangleisdecreasedinacutemalnutrition相角是減少急性營(yíng)養(yǎng)不良Normanetal.Nutrition2007;23P=0.033P<0.0001Normanetal.BrJNutr.2008;100n=112elderlynursinghomeresidents

(meanage85.1y,78women)n=242patientswithbenignGIdisease (meanage58y,121women)>10%weightloss>5%weightlossImpactofmalnutritiononBIAparameters營(yíng)養(yǎng)不良對(duì)BIA的影響B(tài)arbosa-Silvaetal.Nutrition2003;19279patientshospitalizedforelectivegastrointestinalsurgery****SubjectiveGlobalAssessmentBCM,bodycellmass;ECM,extracellularmass;PA,phaseangle>10%weightloss>5%weightlossAgreementbetweenmalnutritionandBIAparametersBarbosa-Silvaetal.Nutrition2003;19

LowtomoderateagreementAgreementbetweenmalnutritionandphaseangleGuptaetalNutritionJournal2008;7AUC=0.773patientswithstagesIIIandIVcolorectalcancerComparedtoSubjectiveGlobalAssessmentClassBandC

LowtomoderateagreementKyleetal.ClinicalNutrition2013:32Agreementbetweenmalnutritionandphaseanglen=983patientsandn=983controlsLowphaseangle=<5°

LowtomoderateagreementWeseereducedphaseanglesinmalnutritionbutinsufficientagreementbetweenmalnutritiondiagnostictoolsandsinglephaseanglecutoffs.

Phaseangleishighlypredictiveofmortalityandmorbiditybutverydifferentphaseanglecutoffshavebeenidentified

ConclusionsInterpretationinclinicalpractice:

??Phaseangle

5.0°

23yrs22.6kg/m2

71yrs26.3kg/m2…….…….Age.…….…….…….…….BMI.…….…….

Sex,ageandBMI-stratifiedreferencevaluesBosy-Westphaletal.JPEN2006;30Barbosa-Silvaetal.AmJClinNutr2005;82Clinicalcase:Phaseangle:5.0°male71yrsoldBMI26.3kg/m2

abovethe10threferencepercentile

4.45Bosy-Westphaletal.JPEN2006;30Clinicalcase:Phaseangle:5.0°

female23yrsoldBMI22.6kg/m2belowthe5th

referencepercentile

5.01Bosy-Westphaletal.JPEN2006;305threferencepercentileofphaseangleincancer:Prognosticimpacton6-momortalityNormanetal.AmJClinNutr2010;92<5threfperc:OR:4.0;[95%CI:2.4,6.8]P<0.001Phaseangleand5threferencepercentileasindicatorofstrengthincancerpatients:Normanetal.AmJClinNutr2010;925threferencepercentile:n=3995threferencepercentileofBIAphaseangleinoldcancerpatients:impactonstrength,functionalityandfatiguen=433(m/f(243/190)age:60-95JMalnourished(SGAB+C):51.5%Advanceddisease:66.3(%)Normanetal.JAmDirAssociation2015;16=<5.RefPerc.n=197

=>5.RefPerc.n=236Phaseangle:FunctionalparametersandqualityoflifeinelderlycancerpatientsEORTCfunctionscalesandsymptomsPhaseangle<5threferencepercentile>5threferencepercentileNormanetal.presentedasPosterPP136-SUN,ESPEN2013

StandardizationofrawvaluesZ-scorestandardizedphaseangle=(observedphaseangle-mean*phaseangle)

SD*ofthephaseangle*meanandSDarefromsex-,age-,andBMI-stratifiedreferencevalues.Absolutevs.standardizedphaseangleincancerpatientsNormanetal.AmJClinNutr2010;92[°]Phaseangle–absolutevaluesn=399Standardizedphaseangleincancer:Prognosticimpacton6-momortalityNormanetal.AmJClinNutr2010;921=399.Age,sex,standardizedphaseangle,SubjectiveGlobalAssessment(SGA),BMI,handgripstrength,tumortype,diseaseseverity,andtypeoftreatmentwereintroducedintothegeneralizedlinearmodelregressionmodel.(weightloss)Standardizedphaseangleincancer:Prognosticimpacton6-momortalityAUCStandardizedphaseangle 0.734SubjectiveGlobalAssessment 0.697UICC 0.622Normanetal.AmJClinNutr2010;92Standardizedphaseangleinchemotherapy:prognosticimpacton3ymortality195patientsbefore1.chemotherapycycle3yprospectivestudyCutoffforstandardizedphaseangle-1.65SDPaivaetal.SupportCareCancer2011;19RR2.35CI:1.41–3.90;p=0.001MultivariateCoxregressionanalysisPhaseangleisagoodpredictorofclinicale,particularlyforshorttermmortalityPhaseangleishoweverinfluencedbysexandage,hydrationandnutritionalstatusaswellasdiseaseseverityandinflammation!doesnotreflectnutritionalstatusalone!InterpretationinclinicaluseisfacilitatedbyreferencevaluesConclusionsBIOELECTRICALIMPEDANCEVECTORANALYSISR/H[Ohm/m]LessfluidsMorefluidsXc/H[Ohm/m]LesssofttissuesmoresofttissuesαBIVAandnutritionalstatusBMICategoriesI: <18.5II: 18.5-24.9Normanetal.BrJNutr.2008;100GewichtsstabilGewichtsverlust

>5%Gewichtsverlust>10%01020304050600100200300400500600R/H,Ohm/mXc/H,Ohm/mDisease-relatedweightloss

III: 25-29.9IV: ≥30kg/m20102030400100200300400500R/H,Ohm/mXc/H,Ohm/mIIIIIIIVn=242patientswithbenignGIdisease;withandwithoutmalnutritionwellnourishedweightloss>5%weightloss>10%01020304050600100200300400500600R/H,Ohm/mXc/H,Ohm/mBIVAinthecourseofnutritionaltherapyInterventionwithprotein-andenergyrichoralnutritionalsupplementationinmalnourishedpatients–arandomisedcontrolledstudyn=80malnourishedpatientswithbenigndisease(52.9±16.5y)Intervention:3-moposthospitalsupplementationwithONS(+505±145ml/d,47.5g protein/d)Control: dietarycounsellingatdischargeNormanetal.ClinNutr2008:27(1):48-56.InterventionpatientsControlpatientsIncreaseinBCMinbothgroups,butimprovementinfunctionalparametersandqualityoflifeintheinterventionpatientsonlyBIVAinthecourseofnutritionaltherapyForcalculationofBCM: age,sex,heightand weight,RandPhAInterventionpatientsControlpatientsBIVAandstrengthparametersn=363patientsweakeststrongestIncreaseinR/heightwasassociatedwith-0.063kggripstrengthperOhm/meterincreaseinXc/heightwasassociatedwith0.573kggripstrengthperOhm/meterNormanetal.ClinNutr2009:28BIOELECTRICALIMPEDANCEVECTORANALYSIS–IndividualInterpretation/UseAthleticObeseOedemaLeanCachecticDehydration50th

75th

95th

referencevectorpercentilesZ(R)Z(Xc)BIVA–Casestudy:56yearoldfemale,endometrialcancer(FigoIII).58kg,1.65m;BMI:21.3kg/m2;phaseangle:4.48°(<5thref.perc.:4.94)1234Chemotherapyinitiated(taxol+carboplatin)3weekslater,-0.5kg,anorexia,fatigue,parenteralnutrition(PN)initiated3weekslater,+1kg,PNstopped,radiotherapyinitiated3weekslater,-1kg,fatigue,diarrhoea,anorexia,PNrestarted1Referenceellipses:Females,White,BMI18.0-24.9;Age15-91(Median36),Analyzer:Data-InputBIA2000-MLowproportionofcellsHighproportionofwater-3-2-1123-3-2-112323400Z(R)Z(Xc)BIVA–Casestudy:Referenceellipses:Male,BMI18.0-26;Age15-69(Median36),Data-InputBIA2000-M-3-2-1123-3-1123A2-2A1A140yoldman,BMI:34.4kg/m2(phaseangle4.75°)weightlossof6kg,diagnosis:acutenecrotizingpancreatitis,NIDDM2monthslater:Furtherweightlossof5kgLowproportionofcellsHighproportionofwaterA2MalnutritioningeriatricpatientsMalnutritionintheoldHighestprevalenceofmalnutritionintheoldComplexsituationofmultimorbidity,polypharmacy,lowphysicalactivityandage-relatedphysiologicalchangesLowresponsetonutritionalt