Freund H, Dienstag J, Lehrich J, Yoshimura N, Bradford R R, Rosen H, Atamian S, Slemmer E, Holroyde J, Fischer J E
Ann Surg. 1982 Aug;196(2):209-20. doi: 10.1097/00000658-198208000-00015.
Hospitalized patients with hepatic insufficiency often suffer from severe catabolic states and are in urgent need of nutritional support during their acute illness. Protein intolerence, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with nutritional support using a prototype high branched-chain amino acid solution (FO80) given by technique of total parenteral nutrition by the subclavian or internal jugular route with hypertonic dextrose. Sixty-three patients, of which 42 had chronic liver disease (cirrhosis) with acute decompensation and 17 with acute hepatic injury as well as four with hepatorenal syndrome, are the subject of this report. All required intravenous nutritional support and were either intolerant to commercially available parenteral nutrition solutions or were in hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 +/- 1.9 days before therapy, had a mean bilirubin of 13 mg/100 ml, and had been in coma for 4.8 +/- 0.7 days despite standard therapy. Patients with acute hepatitis had been in the hospital for 16.2 +/- 4.1 days before therapy, had a mean bilirubin of 25 mg/100 ml, and had been in coma 5.2 +/- 1.6 days before therapy. Routine tests of liver function, blood chemistries, amino acids, EEGs, and complex neurological testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 grams of synthetic amino acid solution with hypertonic dextrose was tolerated in these patients with improvement noted in encephalopathy of at least one grade in 87% of the patients with cirrhosis and 75% of the patients with hepatitis. Nitrogen balance was achieved when 75 to 80 grams of synthetic amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute hepatitis group. Encephalopathy appeared to correlate with individual amino acids differentially in the various groups and with the ratio between the aromatic and the branched-chain amino acids. Ammonia did not correlate with either the degree of encephalopathy or improvement therefrom. In 24 Patients therapy for hepatic encephalopathy was limited to infusion of the branched-chain enriched amino acid solution only, with wake-up in 66% of this group. The results strongly suggest that in protein intolerant patients requiring nutritional support, infusion with branchedchain enriched amino acid solutions is well tolerated with either no worsening of or improvement in hepatic encephalopathy coincident with the achievement of nitrogen equilibrium and adequate nutritional support.
肝功能不全的住院患者常处于严重的分解代谢状态，在急性发病期间急需营养支持。然而，无论是肠内还是肠外营养，蛋白质不耐受仍是提供充足营养方面的一个重大问题。以下报告是对一家大型城市医院连续63例患者的记录，这些患者前瞻性地接受了营养支持治疗，使用一种原型高支链氨基酸溶液（FO80），通过锁骨下或颈内静脉途径采用全胃肠外营养技术给予高渗葡萄糖。本报告的研究对象为63例患者，其中42例为慢性肝病（肝硬化）伴急性失代偿，17例为急性肝损伤，4例为肝肾综合征。所有患者均需要静脉营养支持，且最初就诊时要么对市售肠外营养溶液不耐受，要么处于肝性脑病状态。肝硬化患者在治疗前平均住院14.5±1.9天，平均胆红素为13mg/100ml，尽管接受了标准治疗，但仍昏迷4.8±0.7天。急性肝炎患者在治疗前住院16.2±4.1天，平均胆红素为25mg/100ml，治疗前昏迷5.2±1.6天。对这些患者进行了肝功能、血液化学、氨基酸、脑电图以及包括雷坦连线试验在内的综合神经学检测等常规检查。这些患者能够耐受高达120克的合成氨基酸溶液与高渗葡萄糖，87%的肝硬化患者和75%的肝炎患者的肝性脑病至少改善了一个等级。当给予75至80克合成氨基酸时实现了氮平衡。肝硬化组的生存率为45%，急性肝炎组为47%。肝性脑病在不同组中似乎与个别氨基酸以及芳香族氨基酸和支链氨基酸的比例存在差异相关。氨与肝性脑病的程度或改善情况均无相关性。在24例患者中，肝性脑病的治疗仅限于输注富含支链氨基酸的溶液，该组中有66%的患者苏醒。结果强烈表明，在需要营养支持的蛋白质不耐受患者中，输注富含支链氨基酸的溶液耐受性良好，肝性脑病不会恶化或有所改善，同时实现了氮平衡和充足的营养支持。
