肿瘤患者临床营养问题与评估

,肿瘤患者临床营养问题与评估,张 宇,目录,肿瘤患者营养不良现状营养不良对肿瘤预后的影响营养不良的肿瘤患者治疗现状肿瘤患者营养治疗方法选择,目录,肿瘤患者营养不良现状营养不良对肿瘤预后的影响营养不良的肿瘤患者治疗现状肿瘤患者营养评估,肿瘤患者营养代谢发生改变,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.,肿瘤患者随分期升高，营养摄入量,明显下降，导致体重丢失,Ravasco P, Monteiro-Grillo I, Vidal PM, et al. Cancer: disease and nutrition are key determinants of patients quality of life. Support Care Cancer. 2004 Apr;12(4):246-52.,众多内科疾病中，肿瘤是营养不良,发生率最高的,Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, et al. Malnutrition prevalence in The Netherlands: results of the annual dutch national prevalencemeasurement of care problems. Br J Nutr. 2009 Feb;101(3):417-23.,近年来多个研究中的肿瘤营养风险,发生率,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.,不同部位肿瘤的营养风险发生率比较,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 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.,肿瘤患者发生营养不良,的危险因素,Pressoir M, Desn 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.,化疗本身会加重患者的营养不良,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 study. J Hum Nutr Diet. 2013 Jul;26 Suppl 1:123-31.,目录,肿瘤患者营养不良现状营养不良对肿瘤预后的影响营养不良的肿瘤患者治疗现状肿瘤患者营养评估,肿瘤患者营养状态与全身炎症水平,密切相关,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.,营养不良的肿瘤患者，化疗相关毒,副作用发生率显著升高,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.,住院期间各种并发症发生率的比较,（有营养风险 vs 无营养风险）,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.,肿瘤相关营养不良降低肿瘤患者生,活质量,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.,体重丢失10%者，生活质量显著下,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.,严重营养不良患者生存率显著低于无营养不良或轻度营养不良的患者,Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic colorectal cancer patients: results of an AGEO prospectivemulticenter study. Oncology. 2011;81(5-6):395-402.,营养支持治疗对体重下降/不良反应发生率的影响,RR=相对危险度；95% CI=95%可信限,a 以年龄、性别、分期、手术和放化疗进行校正b以年龄、性别、分期和放化疗进行校正,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,prospective cohort study in Chinese teaching hospitals. Nutr Cancer. 2013;65(1):62-70.,营养支持显著减少化疗相关毒副反,应的发生,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 colorectal carcinoma undergoing palliative treatment: results from a prospective, randomized clinical trial. Colorectal Dis. 2010Oct;12(10 Online):e190-9.,肿瘤患者营养治疗能改善生活质量,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.,接受积极营养治疗的肿瘤患者，生,存率得到改善, The KaplanMeier survival plot of,patients who did (n= 23) and didnot(n= 30) receive invasive,nutritional 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 in patients with inoperable oesophageal cancer undergoing self-expanding metal stentinsertion. Eur J Gastroenterol Hepatol. 2011 Jun;23(6):455-60.,目录,肿瘤患者营养不良现状营养不良对肿瘤预后的影响营养不良的肿瘤患者治疗现状肿瘤患者营养评估,我国肿瘤患者营养治疗现状, 营养治疗的患者比例, 所有住院肿瘤患者中，有34.9%接受营养治疗 有营养风险的患者，仅46.7%得到营养治疗 无营养风险的患者，17.1%实施了营养治疗, 肠外营养（PN） vs 肠内营养（EN）, 30.6%的住院肿瘤患者接受PN 4.4%的住院肿瘤患者接受EN PN：EN = 7：1,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013Jul;67(7):732-7.,临床营养的现状,肠内营养 肠外营养欧洲 8 ： 1美国 10 ： 1中国 1 : 6,我国肿瘤患者营养治疗现状,恶性肿瘤营养不良的患病率高达 40%一 80%住院的恶性肿瘤患者中营养不良的发生率就高达到63%存在营养风险的患者中仅有46%得到了营养治疗20%的恶性肿瘤患者死于营养不良,目录,肿瘤患者营养不良现状营养不良对肿瘤预后的影响营养不良的肿瘤患者治疗现状肿瘤患者营养评估,营养风险筛查,2,1,早期发现患者是否已发生营养不良或是否存在发生营养不良的危险,判定营养不良的严重度及原因，指导制定合理的营养支持的方案,用以评估营养支持的效果,在肿瘤患者营养支持的实施中，关键的第一步就是早期及动态地进行营养状态的评定。,2,3,营养筛选,营养的综合评定,营养评定两步走,营养风险筛查工具,NRS-2002PG-SGA,2002 年6 月欧洲肠外肠内营养学会(ESPEN) 在RCT 证据的基础上制订了适用于住院患者的营养风险筛查方法NRS-2002 (nutritionalrisk screening 2002)目前唯一基于循证医学证据（128个RCT的循证医学基础的）营养风险筛查工具2006年中华医学会肠外肠内营养学分会推荐为住院患者营养风险筛查工具简便易行 (3个项目)、快速(5分钟),NRS-2002,营养风险筛查初选表,如果任一问题回答是, 则进入第二步 如果所有问题回答否, 每周复查一次,B.营养筛查复筛表,NRS2002内容,疾病严重程度评分,营养状态低减评分,年龄评分,内容,NRS-2002营养风险筛查结论,总分值3：患者处于营养风险, 开始制订营养计划总分值 3：每周进行营养风险筛查,主观整体营养评量表（PG-SGA）,PG-SGA（Patient-Generated Subjective Global Assessment，患者主观整体评估）是在主观整体评估（Subjective Global Assessment， SGA）的基础上发展起来的。美国Ottery FD于1994年提出，是专门为肿瘤患者设计的营养状况评估方法。临床研究提示，PG-SGA是一种有效的肿瘤患者特异性营养状况评估工具，因而得到美国营养师协会（American Dietetic Association，ADA）等单位的大力推荐与广泛应用。中国抗癌协会肿瘤营养与支持治疗专业委员会建议采用PG-SGA进行肿瘤患者营养状况调查。,评分法PG-SGA包括7项：体重变化，不适症状，食欲，体力状况及与营养相关的疾病状态，代谢状态，体格检查。前4项主要由患者完成，后3项主要由医护人员完成根据评分将患者进行营养分类，分为营养