添加谷氨酰胺的营养支持对肝功能不全患者术后的影响

Influence of Gln in postoperative patients with poor liver function

目的评价手术后使用添加谷氨酰胺的营养支持对肝功能不全患者胃肠黏膜功能、免疫功能及肝脏功能的影响。方法(1)10例健康志愿者取血行PCR检测细菌DNA作为空白对照;(2)40例符合入选标准的大手术患者,随机分为使用不含谷胺酰胺的全肠外营养组(TPN)与使用含谷氨酰胺的全肠外营养组(GTPN),每组20例。两组在外科手术后以等氮等热卡营养摄入行全胃肠外营养10d,分别于手术后第5天和第10天观察比较患者血生化指标、胃肠道通透性指标及免疫学指标。结果(1)健康志愿者外周血行PCR检测细菌DNA结果均为阴性。(2)TPN组和GTPN组患者术后5d血浆转氨酶水平与术前相比升高,术后10dGTPN组血浆转氨酶水平明显高于TPN组(P<0.05)。(3)GTPN组术后第10天血浆总蛋白(TP)水平与白蛋白(ALB)水平与术前相比无明显降低(P>0.05),TPN组则明显降低(P<0.001)。(4)GTPN组手术后第10天肠黏膜通透性无明显升高(P>0.05),TPN组则升高明显(P<0.05)。(5)术后第10天GTPN组外周血淋巴细胞亚群CD4/CD8比值明显高于TPN组(P<0.01),GTPN组术后10dIL-6浓度未见明显变化,TPN组IL-6浓度明显升高(P<0.01)。结论肝功能不全患者手术后使用添加谷氨酰胺的营养支持可以较好地维护术后血浆蛋白水平,保护肠黏膜屏障,提高患者的免疫功能,但有可能影响患者的肝功能。

Objective To evaluate the impact of alanyl-glutamine（Ala-Gln） dipeptide-enriched nutritional support on gastrointestinal mucosal function, immune function and liver function in postoperative patients with poor liver function. Methods （ 1 ） In 10 healthy volunteers, bacterial DNA was detected in peripheral blood as healthy control group; （2） Forty patients with poor liver function undergoing elective major surgery were randomly allocated to two groups ： TPN group were given standard TPN and the GTPN group were given Ala-Gln enriched TPN isonitrogenously and isocaloricly for 10 days. The biochemical standard, the immune standard and the standard of intestinal permeability were observed and compared. Results （1） In healthy control group, peripheral blood bacteria DNA was negative;（2） In both TPN and GTPN groups, the levels of AST and ALT were increased at the 5th day. In GTPN group, the increasing was significantly higher than in TPN group and the increasing in TPN group was the highest; （3） In GTPN and TPN groups, the levels of TP and ALB in blood at the 10th day postoperation were the same as those preoperation, but it was lower in TPN group with the difference being significant; （4） In groups with addition of Gin, the standard of intestinal permeability postoperation was the same as that preoperation and was better than in TPN group;（5） The increase of CD4/CD8 could be easily observed in groups with Gin and the level of IL-6 was stable, but in TPN group, IL-6 was increased significantly. Conclusion （1） Gin-enriched nutritional support postoperatively can do help in keeping the level of protein in plasma, protect the gut barrier and improve the immune function in patients with poor liver function, but it may have negative effect on patient＇s liver function.