Bonkovsky H L, Singh R H, Jafri I H, Fiellin D A, Smith G S, Simon D, Cotsonis G A, Slaker D P
Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
Am J Gastroenterol. 1991 Sep;86(9):1209-18.
Patients with moderately severe or severe alcoholic hepatitis, described in a companion paper in this issue, had serial studies of energy and protein metabolism and elemental balances before and during treatment for 21 days with one of four randomly assigned regimens: 1) standard therapy, consisting of abstinence, a balanced, nutritionally adequate diet, and multivitamins; 2) oxandrolone (20 mg orally four times a day) plus standard therapy; 3) nutritional supplementation, consisting of 2 liters of 3.5% crystalline amino acids in 5% dextrose given by peripheral vein (PPN) plus standard therapy; and 4) a combination of the other three treatments. Dietary and intravenous intakes and weights were recorded daily, and weekly averages were calculated. Anthropometric measurements and blood studies were done weekly; blood studies included white blood cell counts and differentials, serum prealbumin, transferrin, and total protein and plasma aminograms. Four-days complete balance studies and measures of 15N,1-13C-leucine metabolism also were performed at baseline and after the treatment period. Major findings were as follows: a) Intakes of total calories and protein were significantly higher in PPN-treated than in other groups. b) All patients had positive elemental balances, both at baseline and at the end of the treatment period. However, those treated with PPN (with or without oxandrolone) had higher positive balances of nitrogen, potassium, phosphorus, and magnesium, indicating improvement in lean body mass. c) Anthropometric measurements showed no significant changes, but measures of the visceral protein compartment (serum prealbumin, transferrin, total protein, total lymphocyte count) improved significantly with time. For most of these variables, increases were significantly greater in those treated with PPN with or without oxandrolone than in the other groups. However, for prealbumin, the increase was greatest in the oxandrolone-treated group d) PPN treatment produced dramatic increases in levels of branched-chain amino acids and improvement in the ratio of plasma branched chain to aromatic amino acids. Other treatments had no effect on plasma aminograms. e) Metabolism of 15N,1-13C-leucine was normal and was not affected significantly by treatment. Therapy with PPN and/or oxandrolone was tolerated well. We conclude that PPN has favorable effects on energy and protein metabolism in florid alcoholic hepatitis; oxandrolone has lesser effects, although it may exert some additional action and particularly increases serum prealbumin levels. The results support the use of nutritional supplementation in therapy of moderately severe or severe alcoholic hepatitis.
本期一篇配套论文中描述的中度严重或重度酒精性肝炎患者，在接受四种随机分配治疗方案之一进行21天治疗之前和期间，进行了能量和蛋白质代谢以及元素平衡的系列研究：1）标准疗法，包括戒酒、均衡且营养充足的饮食以及多种维生素；2）氧雄龙（每天口服4次，每次20毫克）加标准疗法；3）营养补充，包括通过外周静脉给予2升含5%葡萄糖的3.5%结晶氨基酸（PPN）加标准疗法；4）其他三种治疗方法的组合。每天记录饮食和静脉摄入量以及体重，并计算每周平均值。每周进行人体测量和血液研究；血液研究包括白细胞计数及分类、血清前白蛋白、转铁蛋白、总蛋白和血浆氨基酸谱。在基线期和治疗期结束后还进行了为期四天的完全平衡研究以及15N、1-13C-亮氨酸代谢的测量。主要发现如下：a）接受PPN治疗的患者总热量和蛋白质摄入量显著高于其他组。b）所有患者在基线期和治疗期末元素平衡均为正值。然而，接受PPN治疗的患者（无论是否使用氧雄龙）氮、钾、磷和镁的正平衡更高，表明瘦体重有所改善。c）人体测量无显著变化，但内脏蛋白部分（血清前白蛋白、转铁蛋白、总蛋白、总淋巴细胞计数）的测量值随时间显著改善。对于这些变量中的大多数，接受PPN治疗的患者（无论是否使用氧雄龙）的增加幅度显著大于其他组。然而，对于前白蛋白，氧雄龙治疗组的增加幅度最大。d）PPN治疗使支链氨基酸水平显著升高，并改善了血浆支链氨基酸与芳香族氨基酸的比例。其他治疗对血浆氨基酸谱无影响。e）15N、1-13C-亮氨酸的代谢正常，且不受治疗的显著影响。PPN和/或氧雄龙治疗耐受性良好。我们得出结论，PPN对重度酒精性肝炎的能量和蛋白质代谢有有利影响；氧雄龙的影响较小，尽管它可能发挥一些额外作用，特别是可提高血清前白蛋白水平。这些结果支持在中度严重或重度酒精性肝炎治疗中使用营养补充。
