阻抗参数营养不良临床翻译部分

Clinicalrelevanceandapplicabilityofimpedanceparameters-inthediagnosisofmalnutritionCHARITÉUniversitätsmedizinBerlinResearchGrouponGeriatriacsandInterdisciplinaryMetabolicCentreCharitéCampusVirchowKlinikumKristinaNorman,PhDOverviewMalnutrition–factsMalnutritionandbodycompositionMalnutritionandimpedanceparametersClinicalrelevanceofimpedanceparametersCasestudiesIntheclinicalsetting,bodycompositionisanattractivetooltoidentifypatientsatrisk(ofmalnutrition/sarcopenia)andtoassesschangesduringnutritionaltherapyUnintendedweightlossisthecardinalfeatureinmalnutritionorcachexia

(appr.10%in6months=clinicallyrelevant)Diseaserelatedweightloss-impact ProteincatabolismImmunedeficiencyReducedmusclemassImpairedwoundhealingMicronutrientdeficiencyNormanetal.ClinNutr2008:27DetrimentalconsequencesNormanetal.ClinNutr2008:27Prevalenceofmalnutrition(i.e.weightloss)athospitaladmissioninGermany20062006年在德国的住院的营养不良患病率(减肥)Prevalenceofmalnutrition[%]010203040506070GYNAECOLOGY妇科SURGERY外科UROLOGY泌尿学CARDIOLOGY心脏病INTERNALMEDICINE内科GASTROENTEROLOGY肠胃病学ONCOLOGY肿瘤学GERIATRICS老年病人172/30638/10089/27381/30544/20115/10270/5127/87GermanHospitalMalnutritionStudy,ClinNutr2006;25Oneinfourpatientsmalnourishedathospitaladmission四分之一的患者营养不良住院n=1887Estimatedcosts

ofdiseaserelatedmalnutritioninGermany估算在德国营养不良相关的疾病5billion€6billion€ 2,541,31,320072020Hospitalcare住院治疗Homecare家庭护理Outpatientmedicalcare门诊病人护理Cepton2007in2011–12:£19.6billionGBP≈

morethan15%ofthetotalexpenditure onhealthandsocialcareintheUKAlteredbodycompositioninmalnutritionorcachexia改变身体成分营养不良或恶病质ReducedmusclemassReducedbodycellmass [3compartmentmodel]Reducedfatfreemass [2compartmentmodel]FMFMECMBCMFFMWeightDefinitionanddiagnosisofcachexiainbenignandmalignantdisease恶病质良性和恶性疾病的诊断Evansetal.ClinNutr2008;27Fatfreemass/height²(FFMI)DiagnosticcriteriaformalnutritionESPENconsensusstatement/endorsedmendation营养不良的诊断标准共识声明/支持建议

•在不固定的时间，重量减轻（非故意性的）>10%。或者结合过去的3个月

重量减轻>5%

•BMI<20kg/m²年龄<70岁,或者BMI<22kg/m²年龄≥70岁

•FFMI<15kg/m²(女)和FFMI<17kg/m²（男）Cederholmetal.ClinicalNutrition2015:34Fat-freemassindexandfatmassindexpercentiles不含脂肪的质量指数和脂肪质量指数百分位数Referencevalues(n=5635)apparentlyhealthyadultsfromamixednon-randomlyselectedCaucasianpopulationinSwitzerland2986menand2649women,between24to98y.TetrapolarBIA(Bio-Z2;RJL-109and101;Xitron4000B)Schutzetal.InternationalJournalofObesity2002:26Background“ClinicaluseofBIAinsubjectsatextremesofBMIrangesorwithabnormalhydrationcannotbemendedforroutineassessmentofpatientsuntilfurthervalidationhasprovenforBIAalgorithmtobeaccurateinsuchconditions.”ESPENGUIDELINESBioelectricalimpedanceanalysispartI:reviewofprinciplesandmethodsClinicalNutrition(2004)23RequirementsforalgorithmswithtetrapolarBIA:BMIrange16-34kg/m²undisturbedhydrationIncreasinguseofrawimpedanceparametersinclinicalresearchandpractise增加使用的阻抗参数在临床研究和练习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:决定和影响因素

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

Cancer癌症(pancreatic胰腺,lung肺,colorectal结肠直肠,breast乳房,mixed其他)HIV/AIDS艾滋病Liverdisease肝病Neurologicdisease(ALS)神经系统疾病Rheumaticdisease(systemicsclerosis)风湿性疾病Kidneydisease(haemodialysisandperitonealdialysis)肾病（血液透析和腹膜透析）Cardiacdisease心脏疾病Geriatrics老年病Surgery(cardiacandgastrointestinal)外科手术（心脏和肠胃）(…)NormanetalClinNutr.2012;31[Reviewarticle]Lowphaseanglevalues:低相角值

highlypredictiveofe(egdiseaseprogression) andmortality高度的预测结果（如疾病进展）和死亡率ImpactofphaseangleonmortalityinHIVHIV的相位角对死亡率的影响Schwenketal.AmJClinNutr2000;72n=257(234onHAART)39.7yold;85%male1.5yprospectivestudyn=305patientswithbiopsyprovenlivercirrhosis37%whodiedmeansurvivaltime:24±18months<5.4°:reducedsurvivaltimes(P<0.01)Impactofphaseangleonmortalityinlivercirrhosis肝硬化相位角对死亡率的影响Selbergetal.EurJApplPhysiol.2002:86

Impactofphaseangleonmortalityincoloncancer结肠癌相位角对死亡率的影响n=52PatientswithcoloncancerstageIV[57%male]3yretrospectivereview5.57°(median)asthecutoff>5.57°<5.57°GuptaetalAmJClinNutr2004;80Impactofphaseangleonmortalityincongestiveheartdisease相位角对死亡率的影响充血性心脏病n=41patientswithCHDProspectivestudyon5ymortalityAUCPhaseangle 0.86indexedEAT 0.82

ICW 0.83MM 0.82LV-EF 0.68FFM 0.66Döschetal.Obesity2010;10EATepicardialadiposetissueICWintracellularwaterMMmusclemassLV-EFleftventricularejectionfraction,FFMfatfreemassCutoffvaluesforclinicaluse?切断值的临床应用NormanetalClinNutr.2012;31[Reviewarticle]Bioelectricalimpedanceparametersinmalnutrition生物电阻抗参数决定营养不良

R

Xc

α(PhA)Phaseangledifferentiatesbetweendifferentformsofunderweight相角区分不同形式的减持p=<0.05;&comparedtocontrolsMarraetal.EJCN2009:63allPhaseangleisdecreasedinacutemalnutrition相角是减少急性营养不良Normanetal.Nutrition2007;23P=0.033P<0.0001Normanetal.BrJNutr.2008;100n=112elderlynursinghomeresidents

(meanage85.1y,78women)n=242patientswithbenignGIdisease (meanage58y,121women)>10%weightloss>5%weightlossImpactofmalnutritiononBIAparameters营养不良对BIA的影响Barbosa-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