《2020年欧洲临床营养和代谢学会实践指南：肝病的临床营养》解读

贾丹丹; 朱桂英; 廖诗瑶; 章慧; 郭慧; 杨莉莉; 王长淼

doi:10.3969/j.issn.1001-5256.2021.07.015

《2020年欧洲临床营养和代谢学会实践指南：肝病的临床营养》解读

DOI: 10.3969/j.issn.1001-5256.2021.07.015

大连医科大学附属第一医院中西医结合普外科，辽宁大连 116000

基金项目:

国家自然科学基金 (81774082)

利益冲突声明：所有作者均声明不存在利益冲突。

作者贡献声明：贾丹丹负责写作设计，搜集资料并分析，撰写修改论文；朱桂英、廖诗瑶负责构思设计；章慧、郭慧和杨莉莉负责修改论文；王长淼负责写作设计，思路指导及论文修改并最后定稿。

详细信息

通信作者:
王长淼，wangchangmiaodl@sohu.com

中图分类号: R575
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出版历程
- 收稿日期: 2021-01-22
- 录用日期: 2021-02-20
- 出版日期: 2021-07-20

Interpretation of European Society for Clinical Nutrition and Metabolism practical guideline : Clinical nutrition in liver disease (2020)

Department of General Surgery of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116000, China

Research funding:

National Natural Science Foundation of China (81774082)

摘要

摘要: 2020年12月，欧洲临床营养和代谢学会(ESPEN)发布了最新的肝病临床营养实践指南，该指南基于已发表的ESPEN肝病临床营养指南及最新临床证据，对急性肝衰竭、酒精和非酒精性脂肪性肝炎、肝硬化、肝移植患者的营养和代谢管理提出103条陈述和建议，全面概括了临床营养诊治原则和诊疗措施，提供了较为全面的营养方案指导。
- 肝疾病 /
- 营养不良 /
- 欧洲 /
- 诊疗准则
Abstract: In December 2020, European Society for Clinical Nutrition and Metabolism (ESPEN) issued the latest practical guidelines for clinical nutrition in liver disease on the basis of the published ESPEN guidelines for clinical nutrition in liver disease and the latest clinical evidence. The guideline proposes 103 statements and recommendations for the nutritional and metabolic management of patients with acute liver failure, alcohol and nonalcoholic steatohepatitis, liver cirrhosis, and liver transplantation, which summarizes the principles and measures for clinical nutrition in diagnosis and treatment and provides more comprehensive guidance for nutrition program.
- Liver Disease /
- Malnutrition /
- Europe /
- Practice Guideline

HTML全文

表 1 ALF营养方案

项目	推荐意见	等级
口服	仅轻度HE且咳嗽、吞咽反射完好的ALF患者首选口服	GPP级，强烈共识100%
	伴轻度HE的ALF患者口服营养不能达到喂养目标的，应使用口服ONS	GPP级，共识85%
EN	无营养不良的ALF患者若被认为不太可能在未来5~7 d内恢复正常的口服营养，应像其他重病患者一样使用EN	GPP级，强烈共识96%
PN	营养不良的ALF患者应像其他重病患者一样，立即开始EN和/或PN	GPP级，强烈共识96%
	不能口服和/或EN无法满足营养需求ALF患者，开始PN治疗(PN为二线治疗)	GPP级，共识90%

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表 2 ASH营养方案

项目	推荐意见	等级
口服	咳嗽和吞咽反射完好的严重ASH者，首选口服	GPP级，强烈共识100%
	患有严重ASH的患者无法通过正常食物满足热量需求时，应选ONS	B级，强烈共识100%
	严重ASH的患者无法通过正常食物满足热量需求时，应将ONS作为傍晚或夜间补剂使用(ONS为一线治疗)	GPP级，强烈共识100%
EN	严重ASH的患者无法通过正常食物和/或ONS满足热量需求时，应使用EN	B级，强烈共识100%
PN	严重ASH的患者禁食期持续超过72 h时，应开始全PN支持	GPP级，强烈共识100%
	伴有中重度营养不良ASH患者，无法通过口服和/或肠内途径补充营养的患者，应立即开始PN	GPP级，强烈共识100%
	在气道未受保护和HE患者中，当咳嗽和吞咽反射受损或EN是禁忌或不可行时，应考虑使用PN	GPP级，多数同意72%
	对于严重ASH患者应像其他重症患者给予PN	GPP级，强烈共识100%

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表 3 NAFL/NASH营养方案

项目	推荐意见	等级
口服	伴有乳糜泻的NAFL/NASH的患者应遵循无麸质饮食	B级，强烈共识96%
	无糖尿病的NASH成人患者给予维生素E(α-生育酚800 IU/d)	B级，强烈共识100%
	不建议使用抗氧化剂(例如维生素C、白藜芦醇、花青素等)、ω-3脂肪酸	0级，强烈共识100%
	包含选定的益生菌或合生元的营养补品可用于改善NAFL/NASH患者的肝酶	0级，共识89%
EN/PN	伴有严重并发症的NAFL/NASH、口服无法满足或禁忌不可行时，应给予EN或PN	GPP级，强烈共识96%
	BMI＜30 kg/m²的NAFL/NASH患者，应按照ASH患者的建议进行EN和/或PN	GPP级，强烈共识100%
	伴有并发疾病的肥胖NAFL/NASH患者应给予EN和/或PN，目标能量摄入量为25 kcal·kg^-1IBW·d^-1，目标蛋白摄入量增加为2.0~2.5 g·kg^-1IBW·d^-1	GPP级，多数同意71%

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表 4 肝移植术前阶段营养管理建议

术前	推荐意见	等级
对计划进行择期手术或列	应筛查评估营养不良状况	B级，强烈共识100%
为移植的肝硬化患者	按照肝硬化的建议进行营养管理	GPP级，强烈共识100%
	建议摄入量：总能量30~35 kcal·kg^-1·d^-1(126~147 kJ·kg^-1·d^-1)和蛋白质摄入1.2~1.5 g·kg^-1·d^-1	GPP级，强烈共识100%
安排手术后	应根据ERAS方法对进行治疗管理	GPP级，强烈共识100%
肥胖患者	给予EN和/或PN，目标能量摄入量为25 kcal·kg^-1IBW·d^-1，目标蛋白摄入量为2.0~2.5 g·kg^-1IBW·d^-1	GPP级，强烈共识93%
计划进行择期手术的超重/肥胖NASH患者	应按照NASH的建议进行治疗	GPP级，强烈共识100%
等待移植的成人	应采用标准的营养方案	A级，强烈共识100%
等待移植的儿童	应使用富含BCAA的营养配方	B级，强烈共识93%
捐献者	不建议使用特定的营养方案	GPP级，强烈共识100%

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