Global Leadership Initiative on Malnutrition (GLIM):Guidance on Validation of the Operational Criteria for the Diagnosis of Protein-Energy Malnutrition in Adults

Background The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different healthcare settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing, as they are currently based solely on expert opinion. Methods Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. Results There are some aspects of GLIM that require refinement; research using large databases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut points and combinations of indicators for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that validation and reliability testing need to occur in a variety of sectors and populations and with diverse persons using GLIM criteria. Conclusion The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM

第913回千葉医学会例会・第28回麻酔科例会・第56回千葉麻酔懇話会

Introduction Pulmonary Surfactant reduces surface tension in the terminal airways thus facilitating breathing and contributes to host’s innate immunity. Surfactant Proteins (SP) A, B, C and D were recently identified as inherent proteins of the CNS. Aim of the study was to investigate cerebrospinal fluid (CSF) SP levels in hydrocephalus patients compared to normal subjects. Patients and Methods CSF SP A-D levels were quantified using commercially available ELISA kits in 126 patients (0–84 years, mean 39 years). 60 patients without CNS pathologies served as a control group. Hydrocephalus patients were separated in aqueductal stenosis (AQS, n = 24), acute hydrocephalus without aqueductal stenosis (acute HC w/o AQS, n = 16) and idiopathic normal pressure hydrocephalus (NPH, n = 20). Furthermore, six patients with pseudotumor cerebri were investigated. Results SP A—D are present under physiological conditions in human CSF. SP-A is elevated in diseases accompanied by ventricular enlargement (AQS, acute HC w/o AQS) in a significant manner (0.67, 1.21 vs 0.38 ng/ml in control, p<0.001). SP-C is also elevated in hydrocephalic conditions (AQS, acute HC w/o AQS; 0.87, 1.71 vs. 0.48 ng/ml in controls, p<0.001) and in Pseudotumor cerebri (1.26 vs. 0.48 ng/ml in controls, p<0.01). SP-B and SP-D did not show significant alterations. Conclusion The present study confirms the presence of SPs in human CSF. There are significant changes of SP-A and SP-C levels in diseases affecting brain water circulation and elevation of intracranial pressure. Cause of the alterations, underlying regulatory mechanisms, as well as diagnostic and therapeutic consequences of cerebral SP’s requires further thorough investigations

Disease-related malnutrition: influence on body composition and prognosis

Titelblatt und Inhaltsverzeichnis Einleitung Eigene Arbeiten Diskussion LiteraturverzeichnisMangelernährung ist ein häufiges, in der klinischen Praxis unterschätztes, aber medizinisch und ökonomisch sehr relevantes Problem. In der vorliegenden Arbeit werden Studien zusammengefasst, die sich sowohl mit der Analyse der Körperzusammensetzung als auch mit Risikofaktoren, der Prävalenz und der prognostischen Bedeutung der Mangelernährung befassen. Bezüglich der Diagnostik einer Mangelernährung stellen Patienten mit Leberzirrhose aufgrund der Hyperhydratation eine besondere Herausforderung dar. Bei diesen Patienten ist eine Bestimmung der Körperzusammensetzung sinnvoll. Wir konnten zeigen, dass Patienten mit Leberzirrhose eine ausgeprägte Proteinkatabolie mit Verlust der Körperzellmasse (BCM) um 25 % aufweisen, und dass sich diese Proteindepletion sowohl mit der Urinkreatininmethode als auch mittels Bioelektrischer Impedanzanalyse (BIA) quantifizieren lässt. Beide Methoden haben allerdings Limitationen: Bezüglich der Kreatininmethode wurde deutlich, dass nicht die eingeschränkte Leberfunktion – wie in früheren Arbeiten postuliert -, sondern eine begleitende Niereninsuffizienz die Validität bei Zirrhosepatienten einschränkt. Die Übereinstimmung der BIA zur Erfassung der BCM mit der 40K-Messung war bei Patienten mit massivem Aszites für die individuelle Einschätzung zu gering, ist allerdings ausreichend für Gruppenanalysen. In einer weiteren Studie an Patienten mit Cushing-Syndrom konnten wir erstmals zeigen, dass endogener Hyperkortisolismus nicht nur zu einer relativen Verminderung, sondern zu einem absoluten Abbau des Gesamtkörper-Proteinbestandes führt (um ca. 20 %). Wir beobachteten auch hier eine hohe Diskrepanz zwischen BIA-Algorithmen zur Bestimmung der BCM und der 40K-Messung. Diese lässt sich auf die veränderte Körpergeometrie mit unproportionaler Zunahme der Rumpffettmasse zurückführen. Wir versuchten daher mit einer segmentalen Messanordnung (getrennte Messung der Extremitäten und des Rumpfes) und Entwicklung spezifischer Formeln die Prädiktion der BCM zu optimieren. Wir konnten zeigen, dass sich bei Patienten mit stabiler Leberzirrhose, bei Patienten mit Cushing-Syndrom und bei der Akromegalie dadurch eine exzellente Übereinstimmung zwischen der BIA und der 40K-Messung erzielen lässt. Bei Patienten mit massivem Aszites blieben die Ergebnisse jedoch unbefriedigend, was auf die interindividuell starke Variation des Hydratationsgrades der fettfreien Masse zurückzuführen ist. Des Weiteren untersuchten wir Häufigkeit und Bedeutung der Mangelernährung bei Klinikpatienten. Zu dieser Fragestellung existieren aus Deutschland keine repräsentativen Untersuchungen. Unter Anwendung von zwei gut validierten Screening-Instrumenten konnten wir an über 800 konsekutiv aufgenommenen Patienten zeigen, dass jeder 4. stationär aufgenommene Patient Zeichen der Mangelernährung aufweist. Darüber hinaus beobachteten wir bei mangelernährten Patienten eine durchschnittlich 40 % längere Klinikaufenthaltsdauer. In einer Subgruppe von 300 Patienten fanden wir 2 Jahre nach der Entlassung aus dem Krankenhaus eine 4fach erhöhte Mortalität bei den mangelernährten Patienten. Der dritte Themenkomplex befasste sich mit Risikofaktoren für eine Mangelernährung. Unsere Arbeiten zeigten ein besonders hohes Risiko (> 60 %) bei Patienten mit malignen Erkrankungn. Interessanterweise beobachteten wir eine nahezu exponentielle Beziehung zwischen steigendem Lebensalter und der Prävalenz der Mangelernährung. Dieser Einfluss war so dominierend, dass in höherem Lebensalter die Dignität der Grunderkrankung in den Hintergrund trat. In der Altersgruppe der über 60jährigen waren soziale Isolation und Polymorbidität die wesentlichen Risikofaktoren. Unter Berücksichtigung der demographischen Veränderungen unserer Gesellschaft sowie der durch Mangelernährung deutlich erhöhten Mortalität selbst zwei Jahre nach Entlassung aus der Klinik wird die Bedeutung einer adäquaten Diagnostik zur rechtzeitigen Ernährungstherapie in dieser Altersgruppe klar.Disease-related malnutrition is a frequent clincal problem with severe medical and economic impact. This work summarizes studies on body composition analysis, risk factors, prevalence and prognostic impact of malnutrition. The diagnosis of malnutrition in patients with chronic liver disease is hampered by hyperhydration and requires body composition analysis. Using four different methods for body composition analysis (total body potassium counting, anthropometry, bioelectrical impedance analysis, and urinary creatinine approach) we could clearly show that patients with liver cirrhosis are in a catabolic state. The average loss of body protein was 25 %. Moreover, we could demonstrate that bioelectrical impedance analysis (BIA) is a valid method for estimation of body cell mass (BCM). A further study on patients with Cushing´s syndrome revealed a similar decrease of body cell mass. Surprisingly, BCM was not recovered 6 months after surgical cure of hypercortisolism. Since there were no representative data on hospital malnutrition in Germany we also carried out a large multicentre study demonstrating that every fourth patient admitted to hospital has signs of malnutrition. Malnourished patients had a 40 % longer hospital stay and a 4fold increase of mortality even two years after hospital discharge. The highest risk for malnutriton was observed in patients with malignancies. However, age emerged as one of the most powerful contributors for malnutrition. In the age group above 60 years polymorbidity and social isolation were independent risk factors. Thus, adequate assessment of the nutritional state is mandatory in these patients in order to initiate early nutritional therapy

Malnutrition in Older Adults—Recent Advances and Remaining Challenges

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements

Prognostic impact of disease-related malnutrition

This review focuses on the studies investigating the prognostic implications of disease-related malnutrition. Malnutrition is a common problem in patients with chronic or severe diseases. Prevalence of hospital malnutrition ranges between 20% and 50% depending on the criteria used in order to determine malnutrition and the patient's characteristics. Furthermore, nutritional status is known to worsen during hospital stay which is partly due to the poor recognition by the medical staff and adverse clinical routines. Studies have repeatedly shown that clinical malnutrition however has serious implications for recovery from disease, trauma and surgery and is generally associated with increased morbidity and mortality both in acute and chronic diseases. Length of hospital stay is significantly longer in malnourished patients and higher treatment costs are reported in malnutrition. Since it has been demonstrated that proper nutritional care can reduce the prevalence of hospital malnutrition and costs, nutritional assessment is mandatory in order to recognise malnutrition early and initiate timely nutritional therapy