Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
J Clin Endocrinol Metab. 2019 Nov 1;104(11):5507-5518. doi: 10.1210/jc.2019-00842.
Changes in the GH axis during critical illness resemble fasting in healthy adults and contribute to hypercatabolism, which potentially affects outcome. Accepting macronutrient deficits by withholding parenteral nutrition (PN) during the first week in the intensive care unit (ICU; late PN) reduced complications and accelerated recovery as compared with early use of PN (early PN).
To investigate how late PN affects the GH axis in relation to its clinical outcome benefits.
Preplanned subanalysis of the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients randomized controlled trial.
A total of 1128 patients for time-course study, 20 patients investigated for nocturnal GH pulsatility, and 600 patients investigated for muscle weakness, with early PN and late PN patients having comparable baseline characteristics.
Withholding PN during the first ICU week (late PN) vs early PN.
Changes in serum GH, IGF-I, IGF-binding protein (IGFBP) 3, and IGFBP1 concentrations from ICU admission to day 4 or last ICU day for patients with a shorter ICU stay (d4/LD) and association in multivariable analyses with likelihood of earlier live ICU discharge, risk of new infection, and muscle weakness.
Late PN attenuated a rise in serum GH and IGF-I (P < 0.0001), did not affect IGFBP3, and attenuated a decrease in IGFBP1 concentrations from admission to d4/LD (P < 0.0001) as compared with early PN. Late PN decreased nonpulsatile (P = 0.005), but not pulsatile, GH secretion. Adjusting the multivariable models for the observed GH axis alterations increased the independent benefit of late PN for all outcomes. GH axis alterations induced by late PN were independently associated with adverse outcomes (P ≤ 0.03).
Accepting macronutrient deficits early during critical illness further suppressed the GH axis, which statistically attenuated its clinical outcome benefits.
危重病患者的 GH 轴变化类似于健康成年人的禁食，导致过度分解代谢，这可能会影响预后。与早期使用肠外营养（PN）相比，在重症监护病房（ICU）的第一周内通过限制 PN（晚期 PN）来接受宏量营养素不足减少了并发症并加速了恢复。
研究晚期 PN 如何影响 GH 轴与其临床获益的关系。
早期肠外营养完成重症成人患者的肠内营养随机对照试验的预先计划的亚分析。
总共 1128 名患者进行时间进程研究，20 名患者进行夜间 GH 脉冲性研究，600 名患者进行肌肉无力研究，早期 PN 和晚期 PN 患者具有可比的基线特征。
在 ICU 第一周（晚期 PN）期间限制 PN。
从 ICU 入院到第 4 天或 ICU 住院时间较短的最后一天（d4/LD）的血清 GH、IGF-I、IGF 结合蛋白（IGFBP）3 和 IGFBP1 浓度的变化，以及多变量分析与更早的 ICU 出院可能性、新发感染风险和肌肉无力的相关性。
与早期 PN 相比，晚期 PN 减弱了血清 GH 和 IGF-I 的升高（P < 0.0001），对 IGFBP3 没有影响，并减弱了入院至 d4/LD 时 IGFBP1 浓度的降低（P < 0.0001）。晚期 PN 减少了非脉冲性（P = 0.005），但不影响脉冲性 GH 分泌。将观察到的 GH 轴改变纳入多变量模型后，增加了晚期 PN 对所有结局的独立益处。晚期 PN 引起的 GH 轴改变与不良结局独立相关（P ≤ 0.03）。
在危重病期间早期接受宏量营养素不足进一步抑制了 GH 轴，这在统计学上减弱了其临床获益。
