Альманах клинической медицины. 2019; 47: 518-524
Клинические варианты трофологического статуса у пациентов с хроническим панкреатитом
https://doi.org/10.18786/2072-0505-2019-47-065Аннотация
Обоснование. Одним из предикторов неблагоприятного прогноза хронического панкреатита (ХП) служит наличие трофологической недостаточности (ТН). В нашем предыдущем исследовании распространенность ТН у больных с ХП составила 92%, индекс массы тела (ИМТ)≤19 кг/м2 был отмечен лишь у 15,5%.
Цель – выделить клинические варианты трофологического статуса (ТС) у пациентов с ХП. Материал и методы. Проанализированы данные первого этапа открытого проспективного рандомизированного исследования. Обследованы 148 пациентов (80 мужчин) с ХП разной этиологии в возрасте от 22 до 82 лет (средний возраст 51,8±13,2 года). В соответствии с классификацией TIGAR-O сформированы две группы: хронического алкогольного панкреатита (ХАП) – 71 пациент (57 мужчин и 14 женщин; средний возраст 46,3±11,2 года), хронического обструктивного панкреатита (ХОП) – 77 пациентов (29 мужчин и 48 женщин; средний возраст 56,81±3 года). Экзокринную функцию поджелудочной железы оценивали по уровню фекальной эластазы-1. ТС определяли по классификации В.М. Луфта на основании сравнения различных антропометрических показателей, а также ряда лабораторных параметров (содержания гемоглобина, общего белка, альбуминов, лимфоцитов и др.). Проведен корреляционный анализ, включающий антропометрические, лабораторные показатели и вредные привычки (хроническую алкогольную интоксикацию, табакокурение).
Результаты. В группе ХАП курящие пациенты встречались в 2,5 раза чаще, чем в группе ХОП (р<0,001). У курящих пациентов ИМТ был ниже, чем у некурящих (р=0,002), как и содержание преальбумина (р=0,04). Установлена связь между количеством выкуриваемых сигарет и величиной употребляемого алкоголя (r=0,55), индексом курения и толщиной кожно-жировой складки над трицепсом (r=-0,4), выраженностью хронической алкогольной интоксикации и степенью ТН (r=-0,5), длительностью алкоголизации и толщиной кожно-жировой складки над трицепсом (r=-0,4), уровнем гемоглобина и степенью ТН (r=0,5), уровнем гемоглобина и окружностью плеча (r=0,47), уровнем холестерина и окружностью плеча (r=0,37), уровнем липопротеинов низкой плотности и окружностью плеча (r=0,41). Выделены 4 основных клинических варианта ТС: ТН различной степени тяжести (66%), избыточная масса тела /ожирение без ТН (3%), саркопеническое ожирение с признаками ТН (26%), эйтрофия (5%). У пациентов с ТН, но без саркопении этиология ХП не влияла на частоту развития ТН. При этом среди пациентов с экзокринной недостаточностью поджелудочной железы и ТН гипоальбуминемия выявлена в 54% (80/98) случаев, что указывает на риск развития саркопении. Вариант с саркопеническим ожирением и ТН преобладает при ХОП (24 против 14 пациентов с ХАП) у людей более старшего возраста (56,8 против 46,3 года соответственно, р<0,001).
Заключение. Табакокурение, хроническая алкогольная интоксикация, снижение гемоглобина ассоциированы (отрицательная корреляция) с развитием ТН у пациентов с ХП. Наиболее частые клинические варианты ТС у больных ХП – наличие ТН различной степени тяжести, а также ТН в сочетании с саркопеническим ожирением.
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Almanac of Clinical Medicine. 2019; 47: 518-524
Clinical types of nutritional status in patients with chronic pancreatitis
https://doi.org/10.18786/2072-0505-2019-47-065Abstract
Background: Malnutrition is among the predictors of unfavorable outcome of chronic pancreatitis (CP). Our previous study has shown that the malnutrition prevalence in CP patients was 92%; body mass index (BMI) ≤ 19 kg/m2 was found only in 15.5%.
Aim: To identify clinical variants of nutrition status in CP patients. Materials and methods: We have analyzed the data from the first step of an open-label randomized prospective study on 148 patients (80 male) with CP of various etiologies, aged from 22 to 82 years (mean age, 51.8 ± 13.2 years). According to TIGAR-O, the patients were allocated into two groups: the first group with chronic alcoholic pancreatitis (CAP) included 71 patients (57 male and 14 female, mean age 46.3 ± 11.2 years), the second one with chronic obstructive pancreatitis (COP) consisted of 77 patients (29 male and 48 female; mean age 56.81 ± 3 years). Exocrine pancreatic function was assessed by fecal elastase 1 levels. Nutritional status was determined by V.M. Luft classification based on comparison of various anthropometrical parameters, as well as on some laboratory parameters (hemoglobin, total protein, albumin levels, lymphocyte counts, etc.). The anthropometrical and laboratory parameters, as well as smoking and alcohol overconsumption were included into the correlational analysis.
Results: In the CAP group, the number of smoking patients was 2.5-fold higher than that in the COP group (р < 0.001). The smokers had a lower BMI (р = 0.002) and lower pre-albumin levels (р = 0.04), compared to the non-smokers. There were associations between: the number of cigarettes per day and the daily amount of alcohol (r = 0.55), the smoking index and thickness of the skin/fat fold over the triceps muscle of the arm (r = -0.4), severity of chronic alcohol abuse and malnutrition grade (r = -0.5), duration of excess alcohol consumption and thickness of the skin/fat fold over the triceps (r = -0.4), hemoglobin levels and malnutrition grade (r = 0.5), hemoglobin level and shoulder circumference (r = 0.47), blood cholesterol level and shoulder circumference (r = 0.37), low density lipoprotein level and shoulder circumference (r = 0.41). Four basic clinical types of nutrition status could be identified: malnutrition of various grades (66%), overweight/obesity without malnutrition (3%), sarcopenic obesity with some malnutrition (26%), euthrophic type (5%). In the patients with malnutrition without sarcopenia, the etiology of CP had no effect on the prevalence of malnutrition. Low albumin levels were found in 54% (80/98) of the patients with pancreatic exocrine insufficiency and malnutrition, indicating a risk of sarcopenia. Sarcopenic obesity with malnutrition was most prevalent in COP (24 vs. 14 patients with CAP) and at higher age (56.8 vs. 46.3 years, respectively, р < 0.001).
Conclusion: Smoking, chronic alcohol abuse, low hemoglobin levels are associated (negative correlation) with the development of malnutrition in CP patients. The most prevalent clinical types of nutrition status in CP patients are characterized by various degrees of malnutrition, as well as by malnutrition with sarcopenic obesity.
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