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背景:营养支持已成为慢性阻塞性肺疾病的重要治疗措施之一,然而部分营养不良的慢性阻塞性肺疾病患者存在营养支持“无反应”的现象,可能与其炎症反应过度、能量消耗增加有关。近年来免疫营养和代谢支持已成为近代营养支持范畴中的研究重点。目的:探讨营养底物谷氨酰胺对慢性阻塞性肺疾病免疫调理和代谢支持的作用。设计:随机对照实验。单位:上海第二医科大学附属新华医院。对象:选择2002-02/2002-07慢性阻塞性肺疾病急性发作患者44例,均为男性。随机分为2组:治疗组14例和对照组18例,年龄(75±9)岁。干预:对照给予单纯营养支持,治疗组给予谷氨酰胺治疗。全部患者由营养师指导按1.5×静息能量消耗的总热量饮食,其中蛋白质占热量的20%,脂肪占热量的30%,碳水化合物占热量的50%,治疗组减少蛋白质30g,以L-谷氨酰胺30g替代,10g/次,3次/d,口服。10d后检测营养指标(包括体质量、体质量指数、肱三头肌皮褶厚度、肌酐升高指数、血清白蛋白、白蛋白、转铁蛋白、脂群等)和免疫指标(包括免疫球蛋白、补体、T细胞亚群、白介素2、肿瘤坏死因子-α,C反应蛋白等)及静息能量的消耗。主要观察指标:观察治疗前后两组患者营养和免疫指标的变化。结果:32例患者均进入结果分析。①肱三头肌皮褶厚度:治疗组组内比较治疗前明显低于治疗后犤(6.3±1.8),(8.7±1.6)mm,(P<0.05)犦,两组治疗后比较对照组明显低于治疗组(7.3±1.3,8.7±1.6)mm,(P<0.05)犦。②前白蛋白:治疗组组内比较治疗前明显低于治疗后犤(0.15±0.04,0.23±0.05)g/L,(P<0.01)犦,两组治疗后比较治疗组高于对照组犤(0.23±0.05,0.22±0.08)g/L,(P<0.05)犦。③T细胞亚群:CD3治疗组组内比较治疗前明显低于治疗后犤(59±10,72±10),(P<0.01)犦,两组治疗后比较对照组明显低于治疗组犤(62±9,72±10),(P<0.01)犦④肿瘤坏死因子-α:治疗组组内比较治疗前明显高于治疗后犤(72±7,56±5)ng/mL,(P<0.05)犦,两组治疗后比较治疗组明显低于对照组犤(56±5)vs(67±11)ng/mL,(P<0.05)犦。⑤免疫球蛋白:IgG治疗组组内比较治疗后高于治疗前犤(13±3,12±3)g/L,(P<0.05)犦,两组治疗后比较治疗组高于对照组犤(13±3,12±4)g/L,(P<0.05)犦。结论:在营养支持时给予谷氨酰胺强化治疗,不仅能改善慢性阻塞性肺疾病患者的细胞免疫功能、抑制炎症反应过度表达、降低机体的能量代谢消耗,还能更进一步增加营养支持的疗效。
BACKGROUND: Nutritional support has become one of the most important therapeutic measures for chronic obstructive pulmonary disease. However, some patients with partially obstructive chronic obstructive pulmonary disease have nutritional support “no reaction”, which may be related to their over-inflammation and increased energy expenditure. In recent years, immune nutrition and metabolic support have become the focus of research in the field of nutritional support in modern times. Objective: To investigate the role of nutritional substrate glutamine in immune regulation and metabolic support of chronic obstructive pulmonary disease. Design: Randomized controlled experiment. Unit: Xinhua Hospital Affiliated to Shanghai Second Medical University. PARTICIPANTS: A total of 44 acute exacerbations of chronic obstructive pulmonary disease (COPD) in 2002-02 / 2002-07 were selected, all of whom were male. Randomly divided into two groups: the treatment group of 14 patients and the control group of 18 patients, aged (75 ± 9) years. Interventions: Controlled patients received simple nutritional support, and patients in the treatment group received glutamine treatment. All patients were fed by dietitian with the total calorie consumption of 1.5 × resting energy, of which protein accounted for 20% of calories, fat accounted for 30% of calories, carbohydrates accounted for 50% of calories, and the treatment group reduced protein 30g. L- 30g glutamine replacement, 10g / times, 3 times / d, orally. After 10 days, the indexes of nutrition (including body weight, body mass index, triceps skinfold thickness, creatinine rise index, serum albumin, albumin, transferrin, lipid group, etc.) and immune indexes (including immunoglobulin , Complement, T cell subsets, interleukin 2, tumor necrosis factor-α, C-reactive protein, etc.) and resting energy expenditure. MAIN OUTCOME MEASURES: The changes of nutritional and immune parameters in two groups before and after treatment were observed. Results: All 32 patients entered the result analysis. ① Triceps skinfold thickness: The treatment group before treatment was significantly lower than the post-treatment 犤 (6.3 ± 1.8), (8.7 ± 1.6) mm, (P <0.05) 犦, the two groups after treatment compared with the control group was significantly Lower than the treatment group (7.3 ± 1.3,8.7 ± 1.6) mm, (P <0.05) 犦. Pre-albumin: Compared with the control group, the pre-treatment group was significantly lower than the control group before treatment (0.15 ± 0.04, 0.23 ± 0.05) g / L (P <0.01) (0.23 ± 0.05,0.22 ± 0.08) g / L, (P <0.05) 犦. ③T cell subsets: The CD3-treated group was significantly lower than that before treatment (59 ± 10,72 ± 10), (P <0.01) 犦, the control group was significantly lower than the control group after treatment 62 ± 9,72 ± 10), (P <0.01) 犦④Tumor necrosis factor-α: Compared with the treatment group, the tumor necrosis factor-α in the treatment group was significantly higher than that before treatment (72 ± 7, 56 ± 5) ng / (P <0.05) 犦. After treatment, the treatment group was significantly lower than the control group (56 ± 5 vs 67 ± 11 ng / mL, P <0.05). (5) Immunoglobulin: IgG in treatment group was higher than that before treatment (13 ± 3,12 ± 3) g / L, (P <0.05) 犦, the treatment group was higher than control group (13 ± 3,12 ± 4) g / L, (P <0.05) 犦. CONCLUSIONS: Intensive glutamine supplementation in nutritional support not only improves cellular immune function, inhibits overexpression of inflammatory responses, reduces energy expenditure in the body, but also increases the efficacy of nutritional support.