Volume 5, Number 4,
Section 2
The 5th
International Symposium on Clinical Nutrition (4-7 Feb 1996)
VI. Impact of nutritional support on nutritional status in hospitalised
patients
20. Amino acids metabolism after hepatectomy
Nitta H, Murakami M, Hayakawa Y, Shimada H, Suto
T, Sasaki R, Ikeda K, Tamasawa Y, Okamoto K, Kanno S, Saito K
Background: Recently, enteral nutrition (EN)
has been reported to be useful in the condition after major surgery.
In order to investigate the amino acids metabolism after hepatectomy
treated in a combination of EN plus total parenteral nutrition (TPN),
we compared free amino acids content in four different blood samples,
which were femoral artery (FA), femoral vein (FV), hepatic vein (HV)
and portal vein (PV).
Methods: The subjects included 8 patients who
had undergone segmental hepatic resection or more. TPN and EN were
started on the 1st and 3rd postoperative day
(POD), respectively. All patients had catheters inserted in the hepatic
vein and portal vein before or during operation to collect blood samples.
Free amino acids in four kind of blood, retinol binding protein (RBP),
transferrin (Tf), prealbumin (PA) and urinary excretion of 3 MeHis
were measured before and on 1, 3, 5, 7 and 14POD. Nitrogen and potassium
balances were also calculated.
Results: The levels of total amino acid (TAA)
in all samples transiently increased on 1POD. BCAA gradually increased
and peaked on 5POD. FA-PV and PV-HV differences of TAA gradually increased
from 1POD to 5POD. FA-FV differences of TAA showed the minimum level
on 5POD. Glutamine and Alanine peaked on 1POD. Nitrogen and potassium
balances became positive on 12POD and 10POD, respectively. RBP and
Tf were the lowest on 1POD and gradually increased. PA continued to
decrease during these period. Urinary excretion of 3-MeHis was the
highest on 7POD and returned to preoperative value on 14POD.
Conclusion: These results suggest that catabolic
phase was finished on 5POD and Glutamine and Alanine were rapidly
mobilised from gut and muscle on 1POD.
21. A prospective randomised trial of postoperative nutritional management
for thoracic oesophageal cancer: enteral nutrition (EN) versus TPN
plus EN
K Otsuka, K Ikeda, N Sato, A Sasaki, K Aoki, K
Koeda, Y Kimura, M Kuboi, K Okamoto, K Ishida and K Saito
Introduction: In the past few years, the usefulness
of early enteral nutritional feeding has been recognised in the condition
of severe injury or the perioperative period compared with total parenteral
nutrition (TPN). In order to develop the optimal postoperative nutritional
management for thoracic oesophageal cancer patients, we performed
clinical prospective randomised trial, which was EN alone versus TPN
+ EN.
Patients and methods: Fourteen patients, who
underwent total oesophagectomy and reconstruction using gastric tube
with right thoraco-laparotomic cervical manipulation, were preoperatively
randomised to either TPN + EN (TPN) group (n=7) or EN alone group
(n=7). In both groups, EN was started on the 3rd postoperative
day (POD) at an introductory dose of 5kcal/kg/day and gradually increased
to full strength of over 30kcal/kg/day on 8POD through the jejunostomy
(non-protein calorie). In EN alone group, the main nutrient was EN
and intravenous infusion whose content was similar to extracellular
fluid or 5% glucose was added peripherally. In TPN group, 20kcal/kg/day
on 1POD and 30kcal/kg/day on 2POD were infused and total calorie of
over 30kcal/kg/day was kept by TPN plus EN on following days. Nitrogen
balances was calculated from O through 14POD. The nutritional parameters
such as total protein (TP), albumin (alb), retinal binding protein
(RBP), prealbumin (PA), transferrin (Tf) and urinary excretion of
3-Methylhistidine (3-MeHis) were measured on pre, 1, 3, 5, 7 and 14POD.
Other parameters, BUN, CRNN, CRP, Lymphocyte, GOT, Bilirubin were
also measured.
Results: The changes of nitrogen balance indicated
amonophasic curve in EN alone group and a biphasic curve in EN + TPN
group. TP, Alb, RBP, PA, Tf were the lowest on 3rd to 5th POD and
3-MeHis/CRNN was the highest on 3rd to 7th POD. All these parameters
returned to the preoperative values on 14 POD and, no statistical
difference between two groups was observed.
Conclusion: These results suggest that only
enteral nutritional feeding as postoperative nutritional management
for thoracic oesophageal cancer is simple and safe method.
22. Early postoperative enteral feeding against thoracic oesophageal cancer
K Aoki, K Ikeda, N Sato, K Otsuka, K Koeda, S
Ogasawara, Y Kimura, Y Yaegashi, A Sasaki, K Okamoto, K Ishida, K
Saito
Introduction: Enteral nutrition (EN) recently
has been considered to be a useful means of nutritional supplementation
for critical ill patients. We have performed only enteral nutrition
without total parenteral nutrition (TPN) as a nutritional support
for thoracic oesophageal cancer surgery. In order to make clear the
availability of this management, we studied the changes of nutritional
parameters and the kinetics of amino acid.
Patients and Methods: The subjects included
8 operated thoracic oesophageal cancer patients. The nutrition was
given by EN starting on 3rd postoperative day (POD) without TPN. Nitrogen
and potassium balances, total protein (TP), albumin (Alb), rapid turnover
proteins (RTP), and 3-Methylhistidine (3-MeHis) in urine were measured.
Furthermore, blood samples were collected from femoral artery and
vein to measure free amino acids content.
Result: Nitrogen and Potassium balances became
positive on 9 and 6 POD, respectively. TP, Alb and RTP decreased from
1 POD to 5 POD and 3-MeHis peaked on 3 POD, however all these parameters
returned to the preoperative value on 14 POD. The difference between
artery and vein of total amino acid showed a negative level during
1 to 3 POD and became positive level from 5 POD. As to BCAA, glutamine
and alanine, they showed negative levels from 1 to 7 POD and the greatest
difference was observed on 5 POD.
Conclusion: These results suggest that postoperative
nutritional management against thoracic oesophageal cancer can be
performed by only EN without TPN.
23. Effect of oral nutritional therapy with a BCAA-riched nutrient (Hepan ED) on
the patients with decompensated liver cirrhosis
Nakajima H, Imamura M, Saito M, Tokuue H, Yokoyama
T, Takasu M, Takahashi S, Saito S
Aim: Development of malnutrition causes difficulty
in management of decompensated liver cirrhosis patients with ascites
and hepatic encephalopathy. Therefore, nutritional therapy has been
considered very important for such patients. Thus, the aim of this
study was to evaluate the effects of long term nutritional supplemental
therapy with BCAA-riched nutrients on outpatients with decompensated
liver cirrhosis.
Subjects and Methods: Subjects were 66 outpatients
(33 female, 33 male, mean age 59.9 years) with decompensated liver
cirrhosis who had a history of hospitalisation. In addition to regular
low protein diet (40g protein/day) for management of hepatic encephalopathy,
the patients were orally given a nutrient (Hepan ED®).
The average doses were 120g: 465kcal and the administration period
was 16.3 months. During the course of this study, the presence of
ascites and signs of hepatic encephalopathy were regularly checked.
Counts of red blood cells and total lymphocytes, blood levels of albumin,
cholesterol, cholinesterase, ammonia, and Fisher's ratio were also
measured. The Pugh score was calculated as an index of severity of
hepatic condition.
Results: 1) Improvement of edema and ascites
as well as improvement of hepatic encephalopathy, especially asterixis,
were observed in most patients after administration of the nutrient
preparation. 2) Nutritional indices relating to the hepatic capacity
for protein synthesis including blood levels of total protein, albumin,
cholinesterase, and cholesterol were improved. The patients with lower
values of these indicates at pretherapy showed more improvement compared
with the patients with higher values. 3) A tendency for decreased
ammonia blood levels was observed. 4) Hepatic anaemia was improved.
5) During the administration of the nutrient preparation, the Pugh
score was significantly decreased.
Conclusion: Nutritional therapy with long-term
oral administration of the nutrient preparation for hepatic failure
(Hepan ED®) is considered to be useful in improvement of
malnutrition associated with decompensated liver cirrhosis and in
prevention of hepatic encephalopathy. We concluded that this therapy
will improve patient's quality of life.
24. The effects of total parenteral nutrition on protein-energy status
in surgical patients
Thamrongyouth U, Tanphaichitr V, Leelahagul P,
Kanjanapitak A
The purpose of this study is to evaluate the effects
of total parenteral nutrition (TPN) in 7 surgical patients with carcinoma
of the gastro-intestinal (GI) tract. Their means ± SEM of nonprotein
energy and nitrogen intake during receiving TPN are shown in the Table.
The preoperative TPN regimens (D-7 to D-1) were adequate
to maintain their protein-energy status evidenced by no significant
differences in their body mass index (BMI), serum albumin, transferrin
and retinol-binding protein (RBP) levels between D0 and D-7 as well
as positive nitrogen balance during D-7 to D-1. The inadequate protein-energy
supply in the presence of stress response to surgery (D0) affecting
the protein-energy status was evidenced by the significant decreases
in their serum total protein, albumin and RBP levels at D+1 as well
as negative nitrogen balance at D0 and D+1. The importance of adequate
protein-energy supply in postoperative patients was supported by no
further decreases in their BMI, significant increases in serum RBP
level at D+7, and less negative nitrogen balance during D+2 to D+7.
In conclusion, our study has shown the beneficial effects of TPN in
surgical patients undergoing surgery for improving their protein-energy
status.
| Parameter |
D-7 to D-1 |
D0 |
D+1 |
D+2 to D+7 |
| Nonprotein energy (kcal/kg/day) |
41.80 ± 1.91
|
19.93 ± 1.55
|
30.40 ± 3.68
|
42.85 ± 2.13
|
| Nitrogen intake (g/kg/day) |
0.23 ± 0.02
|
0.03 ± 0.01
|
0.15 ± 0.03
|
0.23 ± 0.02
|
25. Effect of enteral glutamine on intestinal permeability and bacterial translocation
after abdominal radiation injury in rats
Chun H, Sasaki M, Nambu T, Fujiyama Y, Bamba T
We investigated the effect of enteral glutamine on
intestinal permeability and bacterial translocation after whole abdominal
radiation in rats. Rats irradiated 10Gy to the abdomen were divided
into a glutamine-free diet group and glutamine-rich diet group. After
3 days of feeding of each diet, the 6 hour urinary recoveries of the
orally administered polyethylene glycol (PEG) 4000 and phenolsulfonphthalein
(PSP) were measured in both groups of rats. The endotoxin concentration
in the plasma was also measured. A gavage containing 107
of Escherichia (E) coli labelled by 14C-glucose
was given via a stomach tube in two other groups of rats, and the
distribution of bacterial translocations into the mesenteric lymph
nodes, liver, spleen, lung and blood was also evaluated.
The 6 hr urinary recovery of PEG 4000 was significantly
decreased in the glutamine-fed group compared to the glutamine-free
diet group. The 6 hr urinary recovery of PSP was also decreased in
the glutamine-fed group. And the endotoxin concentration was significantly
lower in the glutamine-fed group compared to the glutamine-free diet
group. The detection ratio of the 14C-labelled E coli in the
mesenteric lymph nodes was significantly lower in the rats fed glutamine-rich
diet.
These findings suggest that enteral glutamine maintains
intestinal barrier and reduces bacterial translocation in rats with
intestinal injury induced by irradiation.
26. The microbiological safety of tube feeding formulas given to patients with
carcinoma of the larynx
Putwatana P, Srimwang S, Tanphaichitra D, Leelahagul
P, Tanphaichitr V
Bacterial contamination in the tube feeding formula
may lead to various infectious complications especially in compromised
host. The purpose of this study was to evaluate 2 types of enteral
formulas, Isocal RTU (a commercial one) and Ramathibodi blenderised
formula (RBF: a dietetic-prepared formula) on their bacterial contamination
in 60 patients with carcinoma of the larynx. The first 20 patients
on Isocal RTU were fed by continuously closed system, the second 20
patients on Isocal RTU by continuously semi-closed system, whereas
the remaining 20 patients on RBF were fed by opened intermittent system.
Bacterial contamination was determined by pour plate method with dilution
before and after each feeding period. Isocal RTU in Tetrapak was sterile.
After it was hung for 12hrs in the closed or semi-closed system, it
was bacterially contaminated. RBF was bacterially contaminated prior
to administration and all were contaminated at the end of 1 to 1½hr
feeding. The feeding set was also bacterial 0 contaminated. The most
common bacterial contamination was Acinetobacter calcoaceticus.
Our findings warrant proper care for tube feeding formulas given to
hospitalised patients.
27. Effect of dietary counselling in chronic haemodialysis patients
Surat Komindr, Jarunee Thirawitayakom, Sunard Taechangam,
Oravan Puchaiwatananon, Sriwatana Songchitsomboon, Somnuek Domrongkitchaiporn
Although nutritional support is important for end-stage
renal failure patients, it has been neglected in most patients undergoing
haemodialysis. Dietary intake in these patients is often inadequate
and leads to malnutrition. Therefore, this study was performed to
evaluate the effect of dietary counselling on the nutritional status
of these patients.
Nutritional status of 21 chronic haemodialysis patients
was evaluated before and two months after counselling. They were advised
on a dietary intake of 35-40kcal and 1.0-1.2g protein per kg IBW/day.
After dietary counselling, the protein and energy intake (mean ± SD)
were significantly increased (0.7±0.2 vs. 0.9±0.2g protein/kg IBW/day,
p<0.05 and 24±4 vs. 27±4kcal/kg IBW/day, p<0.005). However,
they were still lower than the recommendation. Whereas body weight
and %Std triceps skinfold thickness were unchanged, %Std mid-upper
arm circumference and %Std mid-upper arm muscle circumference were
increased (86±12 vs. 88±12, p<0.05 and 100±14 vs. 102±14, p<0.005).
Mean serum albumin level and lipid profile were within normal ranges
during both periods. Although improvement of serum zinc level was
seen after counselling it was still low (67±16 vs. 70±13 ug/dL). Most
patients had normal serum copper level in both periods. Slight improvement
of thiamin and riboflavin statuses were seen. These data demonstrate
that continuous dietary counselling and evaluation are necessary and
useful for haemodialysis patients to maintain good nutritional status.
In addition to thiamin and riboflavin, zinc supplementation should
be considered in these patients.
28. Metabolic nutritional approach to critically ill patients: Problems
and difficulties
Iapichino G
The metabolic nutritional support to the critically
ill patients is a mix of nutritional, metabolic and specific organ
approaches. The three phases are ranked according to an usual priority
time-table linked to severity and timing of ICU stay. We will discuss
factors influencing the priority and goals of support in patients
with organ failures.
29. Impact of nutritional support on essential fatty acid and carnitine status
in hospitalised patients
Tanphaichitr V, Leelahagul P, Suwan K, Prasapairin
A, Kanthatasiri J
Inadequate linoleate and carnitine status usually
coexist in patients with protein-energy malnutrition (PEM). Such a
condition may not only derange protein metabolism but also other physiologic
and biochemical functions depending on linoleic acid and carnitine.
The impact of the administration of a nutritionally complete enteral
formula, GEN-FORMULA®, with dietary energy distribution
of 15% protein, 30% fat, and 55% carbohydrate calories, as the sole
source of dietary intake for 7 days on essential fatty acid (EFA)
and carnitine status was evaluated in 11 adult hospitalised patients
with PEM from various diseases. The fat source of this formula is
soybean oil which provides 16.14% and 2.13% of total calories as 18:2n-6
and 18:3n-3. Each 100g of GEN-FORMULA® also contains 54.84umol
(8.84 mg) of carnitine. Their mean (±SEM) positive nitrogen balance
of 1.35±0.72g/day during D1-7 indicates that the mean daily intakes
of 1,764±57kcal and 66.3±2.1g of protein with a nonprotein calorie:
nitrogen ratio of 141 : 1 were adequate to improve their protein-energy
status. The bioavailability of 18:2n-6 and 18:3n-3 from GEN-FORMULA®
is evidenced by the significant increases in serum 18:2n-6 level and
the maintenance of serum 18:3n-3 level. The bioavailability of daily
preformed carnitine intake of 214umol (34.5mg) in these patients is
also shown by significant increases in their serum acyl and total
carnitine levels at D7 as well as in their urinary free and total
carnitine excretions during D1-7. These findings are consistent with
the role of carnitine in modulating the intramitrochondrial acyl CoA/CoA
ratio.
30. Trace element status in nutrition support
Okada A, Takagi Y, Nezu R, Sando K
With the development and widespread use of total parenteral
nutrition (TPN), abnormalities of trace elements related to their
metabolism and pharmacokinetics have received much attention.
There are possibilities that deficiencies of essential
trace elements occur when long-term TPN or any other types of artificial
nutrition is performed without enough supplementation. Concentration
of trace elements as a contaminant in nutrient solutions are variable
and often extraordinarily low, so that they are far from sufficient
to meet the nutritional requirements of each patient.
Copper deficiency in 1972 and zinc deficiency in 1975
have been reported in TPN patients. Subsequently, a number of cases
documenting deficiencies of selenium, chromium, molybdenum and manganese
have been reported from various parts of the world. These experiences
followed by further research provided numerous information concerning
not only diagnosis and treatment of their abnormalities but also bioavailability
and metabolism of each element in the human body. And attention is
paid to the possible participation of trace elements in certain diseases
or pathologic conditions. The current knowledge about the role of
those elements is presented and their daily requirement is discussed.
31. Nutritional evaluation of branched-chain amino acids enriched infusion
to the patients with liver cirrhosis using indirect calorimetry
Kato A, Endo R, Kaneta H, Nakadate I, Suzuki K,
Sato S, Kondo M
Although branched-chain amino acids (BCAA) enriched
infusion has been used widely for the patients with hepatic encephalopathy
and cirrhosis, it is still obscure whether the BCAA enriched infusion
has beneficial properties or not, nutritionally. Thus our aim
is to assess the effect of BCAA enriched infusion to energy expenditure
and metabolic fuel composition in cirrhosis using indirect calorimetry.
Subjects and methods: Ten patients with cirrhosis (5 male,
5 female) were studied. Resting energy expenditure (REE) and utilisation
rate of carbohydrate, fat and protein (%CHO, %FAT and %PRO) was assessed
by DELTATRAC metabolic computer (DATEX Co Ltd) before and after addition
of BCAA enriched infusion (0.5g amino acids/kg BW, 100ml/hour). Results:
Before addition of BCAA enriched infusion, low %CHO and %PRO and high
%FAT were observed. After infusion, REE was significantly (p<0.001)
increased. %CHO also increased, whereas %FAT decreased. Conclusion:
These data suggested that BCAA enriched infusion was well used
as nutritional substrate and may be useful to improve the metabolic
fuel composition in cirrhosis.
Table: Resting energy expenditure and utilisation
rate of substrates
| |
Basal |
Post infusion
|
| REE (kcal/day) |
1,280 ± 293
|
1,442 ± 323*
|
| %CHO (%) |
15.1 ± 8.4 |
24.9 ± 16.1
|
| %FAT (%) |
59.1 ± 10.1
|
52.0 ± 15.4
|
| %PRO (%) |
23.2 ± 7.7 |
20.5 ± 6.6 |
*p<0.001 compared with the value of basal condition
mean ± SD
32. Effect of Ramathibodi blenderised formula on lipid metabolism in patients with
carcinoma of the larynx
Tantibul V, Pakpeankitvatana R, Clongsusuck P,
Tanphaichitr V
The purpose of this study is to evaluate the effect
of Ramathibodi blenderised formula (RBF) on lipid metabolism in 20
patients with carcinoma of the larynx. All of them received RBF via
nasogastric tube from the second postoperative day onwards for 5-9
days with a mean daily energy intake of 1902 kcal derived from 12.67%,
37.43% and 49.90% of total calories as protein, fat and carbohydrate,
respectively. Their mean daily 18:2n-6, 18:3n-3, 20:4n-6, 22:5n-3
and 22:6n-3 intake were 7.41, 0.72, 0.27, 0.018 and 0.045% of total
calories and their mean cholesterol intake was 2918mg. Before the
operation, the patients had biochemical linoleate depletion evidenced
by lower serum 18:2n-6 but higher 16:1n-7 and 18:1n-9 levels than
normal subjects. Two days after receiving fat-free partial parenteral
nutrition they exhibited significant decrease in serum 18:2n-6 level.
After receiving RBF, their serum 18:2n-6 level was still lower than
normal whereas their serum 20:4n-6, 20:5n-3 and 22:6n-3 levels increased
significantly with normal serum 18:3n-3 level. Before the operation,
their serum total cholesterol and LDL-Chol (low-density lipoprotein
cholesterol) levels were in the borderline-high risk levels, HDL-Chol
(high-density lipoprotein cholesterol) level was on the border-line
to low level and serum triglyceride level was within the desirable
level. After receiving RBF, their serum triglyceride rose to the high
risk level which was most likely due to their high sucrose intake
of 37% of total calories. The study indicates the need for improvement
of RBF in order to achieve adequate linoleate status and normal serum
lipid levels.
33. Nutritional status in patient with laryngeal carcinoma receiving
blenderised diet via nasogastric feeding tube
Patcharaporn Aree, Sukanya Linpisarn, Varaporn
Vipatswong, Supranee Fuanan, Somporn Wareerat, Wichit Srisuphan
The purpose of this study was to assess the nutritional
status and lipid status in patients with laryngeal carcinoma receiving
blenderised diet via nasogastric feeding tube. Nineteen subjects,
(18 male, 1 female) parti-cipated in this study The study was divided
into 3 periods: pre-surgery (PSP), before receiving the blenderised
diet (BRP), and the 7 day period of receiving the blenderised diet
(PRP) The results of this study are summarised as follows: In PSP
and BRP the subjects received inadequate energy for nutritional requirements.
After the subjects received the blenderised diet, the protein and
energy intake increased subsequently from 0.65±0.57 to 1.65±0.67g/kg,
and 1114.81±712.01 to 1989.47± 867.24kcal/d, on day 1 and day 7, respectively.
Their cholesterol intake increased from 1053.98±926.03 on day 1 to
2716.29±1139.17mg/d on day 7. The subjects had protein-calorie malnutrition
before they had surgery. In the BRP group, blood cholesterol, LDL-Chol,
HDL-Chol, triglyceride, protein, albumin, haemoglobin, and haematocrit
levels were decreased significantly compared to the PSP. When the
subjects received the blenderised diet for 7 days, their body weight,
% weight for height, BMI, blood cholesterol, LDL-Chol, HDL-Chol, triglyceride,
haemoglobin, and haematocrit levels were decreased significantly compared
to the PSP, and also their blood cholesterol, LDL-Chol, haemoglobin,
and haematocrit levels were decreased significantly compared to the
BRP. Whereas HDL-Chol and protein levels were significantly increased.
There was a tendency for the albumin level to be increased although
this was not significant. The N-balance of these subjects in BRP was
negative and in PRP was positive There was no significant difference
in the skinfold thicknesses (triceps, biceps, subscapular, and suprailiac)
and blood glucose level in BSP and PRP. The blood urea-nitrogen and
urinary creatinine were not significantly different in the three periods.
34. Total body nitrogen as a prognostic marker in maintenance dialysis
CA Pollock, LS lbels, W Ayass, RJ Caterson, D Waugh,
C Macadam, Y Pennock, JF Mahony, BJ Allen
In order to assess long term nutritional adequacy,
154 patients on maintenance dialysis (78 on haemodialysis (HD), 76
on continuous ambulatory peritoneal dialysis (PD)), underwent measurement
of total body nitrogen (TBN) with concurrent recording of dietary
history, anthropometrics and serum albumin. Seventy-one patients were
assessed 23.3 (2.2) months later. In cross-sectional analyses, anthropometric
measurements and dietary intake remained stable over time for all
patients. However, a significant fall in TBN occurred in the HD population
with increasing time on dialysis (P<0.05). In the prospective analyses,
PD (N=26) had a significant increase in TBN (P<0.02). In contrast,
longitudinal measurements of TBN in HD patients (N=36) tended to fall
but did not reach significance (P=0.18). TBN correlated with total
caloric intake estimated from the dietary history (P<0.05) but
not with estimated protein intake.
During follow-up, 38 patients died. These patients
were older (P<0.05), and in the PD population had been on dialysis
a longer time (P<0.05). Those who died had a lower TBN expressed
both as g/kg lean body mass (P<0.005) and as nitrogen index (P<0.05).
The probability of death within 12 months in the patients with a NI
less than 80% of the predicted normal value was 48%. The relative
risk of death in this population was 4.1. A lower serum albumin was
associated with increased mortality in PD patients (P<0.05), but
this relationship was not observed in the HD group. Anthropometric
measurements and dietary history were similar in those who died compared
with survivors.
We conclude that PD favours TBN and that anabolism
is possible. No such effect was observed in the HD patients. In both
populations, TBN is inversely associated with increased mortality,
which is not predictable from anthropometric measurements or serum
albumin.
35. Safety and efficacy of Nandrolone Decanoate for treatment of wasting in
patients with HIV infection
J Gold, HA High, Y Li, H Michelmore, NJ Bodsworth,
R Finlayson, CJ Oliver, BJ Allen
To study the safety and efficacy of the anabolic steroid,
Nandrolone Decanoate, in male patients with HIV wasting, we conducted
an open clinical trial. Twenty-subjects were enrolled who had middle
to late stage HIV disease, who had lost between 5% and 15% of their
usual body weight, and whose weight did not increase after intensive
nutritional management. Subjects had detailed laboratory and body
composition assessments including anthropometry, bioelectrical impedance
and total body nitrogen assessment.
The treatment regimen was Nandrolone Decanoate 100mg
second weekly for sixteen weeks. There were statistically significant
improvements in weight (mean=0.14kg/week, P<0.05) and lean body
mass (mean increase of 3.0kg by anthropometry, P<0.05). Quality
of life parameters, especially functionality, significantly improved
during the trial. No subjects experienced toxicity in any clinical,
biochemical, haematological or immunological measurements. These findings
indicate that Nandrolone Decanoate has beneficial effects in selected
patients who have mild to moderate HIV wasting.
36. A cross-sectional study on the nutritional status of haemodialysis patients
attending a Malaysian clinic
Chee SS, T Karupaiah
Undernutrition has been reported to contribute to
the morbidity and mortality of dialysis patients. There is a paucity
of information in Malaysia, regarding this aspect. This cross-sectional
study reports on the nutritional status of 60 patients undergoing
haemodialysis at a Kuala Lumpur clinic. Nutritional intake, anthropometric
measurements and bio-chemical parameters formed the criteria for assessment.
Measurements included were triceps skinfold thickness (TST), mid arm
muscle circum-ference (MAMC), serum albumin and transferrin, total
iron binding capacity (TIBC) and blood lipid levels. Dietary intake
information using the 24-hour recall method was collected for 3 days
representative of a weekend, dialysis and non-dialysis days. The rate
of infection amongst the study group was recorded. Dietary intake
and anthropometric data were then correlated with biochemical parameters
and incidence of infection. This study is in progress and results
will be reported at the 5th Clinical Nutrition Symposium in Bangkok.
37. Is measurement of total body nitrogen (TBN) a useful predictor of chemotherapy
(C/T) toxicity in breast cancer?
A Aslani, SD Begbie, RC Smith, BJ Allen
Controversy exists as to reliance on body surface
area in determining C/T dose, particularly with obese patients. Measurement
of TBN has been suggested as a more accurate predictor of clinical
course and prognosis in serious illness. We tested the hypothesis
that a depletion of TBN may also be associated with increased toxicity
in patients receiving standard CMF (Cyclophosphamide, Methotrexate,
5-Fluorouracil) C/T for breast cancer. Absolute neutrophil count nadir
(ANCN) was used as a measure of toxicity. 26 patients with breast
adenocarcinoma had serial measurements of TBN, whilst receiving intravenous
CMF. Their calculated Nitrogen Index (NI) was then compared with ANCN.
Patient characteristics: median age: 48.5 (range: 26-78). C/T indication:
adjuvant-18 (lymph node +ve 10, -ve 8), metastatic-6, neoadjuvant-1,
local recurrence-1. The protocol was completed by 13 patients and
continues for 3, while 10 patients had fewer than 5 measurements due
to death, refusal or inconvenience. The confounding clinical events
included 2 deaths due to progressive disease, 3 major infections in
2 patients and in 1 case G-CSF was started by the clinician.
There was no significant change in TBN, NI or % body
fat during treatment. Following C/T: when NI<0.9, 9 of 15 (40%)
courses led to neutropoenia (ANCN<1.0), and for NI>0.9, 20 of
78 (26%) courses led to ANCN<1.0 (Fisher Exact Test: p<0.001).
The 2 deaths, but none of the infections, occurred in patients with
NI<0.89. We conclude that low NI is indicative of neutropoenia.
38. Measurement of total body nitrogen levels in patients receiving
adjuvant chemotherapy for breast cancer
A Aslani, SD Begbie, RC Smith, BJ Allen
Malignant disease produces a reduction in total body
nitrogen (TBN) levels. It has been proposed that chemotherapy itself
inhibits protein synthesis, and may therefore reduce TBN. We tested
this hypothesis by measuring TBN levels, using In Vivo Neutron Capture
Analysis, in 18 patients receiving adjuvant intravenous CMF (Cyclophosphamide,
Methotrexate, 5-Fluorouracil) for adenocarcinoma of the breast.
Measurements were taken on the day of the CMF courses
2 to 6 in order to assess progressive changes in TBN, nitrogen index
(NI), body weight and percentage body fat. Friedman two way ANOVA
was used to statistically test changes. Patient characteristics: All
female, median age 45.5 (range: 26-78). Surgical management had been
mastectomy and axillary clearance in 13, and lumpectomy, axillary
clearance + radio-therapy in 15. Nodal status was +ve in 10, and -ve
in 8. The protocol was completed by 11 patients, and continues for
2, while 5 patients had fewer than 5 measurements, due to inconvenience
or refusal. There were 2 confounding clinical events, an episode of
radiation pneumonitis, and one of cellulitis arising from a tissue
expander.
We conclude that in women without macroscopic residual
breast carcinoma, adjuvant CMF chemotherapy does not significantly
reduce total body nitrogen, an important measure of overall nutritional
status. Further, we propose that the significant increase in body
weight, in the setting of stable protein and fat measures, is due
to an increase in body water, and we are currently testing this hypothesis.
39. Energy metabolism in patients with liver diseases
Tajika M, Kato M, Miwa Y, Hiraoka T, Sugihara J,
Moriwaki H, Muto Y
The aim of this study is to evaluate energy metabolism
in patients with liver diseases. Energy metabolism was analysed by
indirect calorimetry in 11 patients with fuluminant hepatitis (FH),
11 patients with severe type of acute hepatitis (AHS), 10 patients
with acute hepatitis (AH), 14 patients with chronic hepatitis (CH),
3 patients with subacute hepatitis (SAH), 41 patients with liver cirrhosis
(LC) and 18 patients as healthy controls (HC). We measured resting
energy expenditure (REE), non protein respiratory quotient (npRQ)
and oxidation rates for major substrates after an overnight fast.
Predict basal energy expenditures (BEE) were calculated according
to Harris-Benedict formula. REE/BEE was increased in FH, AHS, AH,
SAH and LC as compared with HC (1.28±0.20, 1.14±0.13, 1.12±0.04, 1.15±0.16,
1.06±0.09 vs. 0.98±0.09; mean±SD; P<0.01). npRQ was decreased in
AHS, AH and LC as compared with HC (0.80±0.10, 0.81±0.08, 0.83±0.06
vs. 0.90±0.05; P<0.01). Oxidation rate for glucose (%) was lower
in AHS, AH, SAH and LC as compared with HC (26.9±18.5, 32.2±24.8,
40.4±26.1, 39.5±18.0 vs. 57.8±13.0; P<0.01, P<0.01, P<0.05,
P<0.01). Oxidation rate for fat (%) was higher in AH, SAH and LC
as compared with HC (57.2±25.2, 44.9±18.1, 48.6±18.3 vs. 26.7±15.4;
P<0.01). Oxidation rate for protein (%) was lower in AHS, AH, SAH
and LC as compared with HC (28.2±23.0, 10.6±5.3, 27.3±7.6, 11.9±5.0
vs. 15.5±5.3; P<0.05, P<0.05, P<0.01, P<0.01). In summary,
it is likely that REE is increased and fat seemed to be utilised more
preferably than glucose and protein in patients with liver diseases.
Copyright © 1996 [Asia Pacific Journal
of Clinical Nutrition]. All rights reserved.
Revised:
January 19, 1999
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