不同脂肪乳剂对急性坏死性胰腺炎患者肝肾功能及脂肪代谢影响的前瞻性研究

Effects of different types of triglycerides on hepatic and renal function and lipometabolism of patients with acute necrotizing pancreatitis： a prospective study

目的 探讨结构脂肪乳与物理混合的中长链脂肪乳对急性坏死性胰腺炎（ANP）患者肝肾功能及脂肪代谢的影响.方法 选取2012年1月至2014年6月解放军总医院收治的30例ANP患者进行前瞻性研究.采用随机、双盲对照研究方法,通过随机数字表法将入组患者分为试验组和对照组,每组15例.两组患者接受≥5 d等氮等热量肠外营养支持治疗.其中试验组采用结构脂肪乳,对照组采用物理混合的中长链脂肪乳.在行营养支持治疗前、治疗后1、3、5 d抽取患者静脉血,测定ALT、AST、GGT、ALP、Cr、BUN、TG和TC水平.正态分布的计量资料采用（x）±s表示,偏态分布的计量资料采用M（范围）表示,采用独立样本t检验或重复测量方差分析,计数资料采用χ2检验.结果 筛选出符合研究条件患者共30例.两组患者ALT、AST、GGT、ALP、Cr、BUN、TG、TC水平于营养支持治疗前、治疗后1、3、5d内在一定范围内变化.试验组患者ALT、AST、GGT、ALP、Cr、BUN、TC分别由治疗前29.0 U/L、25.4 U/L、83.2 U/L、（193±115） U/L、（124±97）μmol/L、（8±6） mmol/L、（2.4±1.1）mmol/L变化为治疗后5d的29.4 U/L、33.0 U/L、77.7 U/L、（172±74） U/L、（117±103） μmol/L、（8±5）mmol/L、（2.3±1.0） mmol/L;对照组患者上述指标分别由治疗前23.8 U/L、22.9 U/L、96.2 U/L、（148±108） U/L、（82±57） μmol/L、（9±7）mmol/L、（2.5 ±0.7） mmol/L变化为21.3 U/L、24.5 U/L、127.4 U/L、（179±126） U/L、（80±54） μmol/L、（10±6） mmol/L、（2.4±0.8）mmol/L.两组各指标营养支持治疗前后变化趋势比较,差异无统计学意义（F=0.647,1.186,0.282,0.553,0.862,0.182,0.369,P＞0.05）.试验组患者TG由治疗前（1.5±0.6） mmol/L变化为治疗后5d的（1.5±0.7） mmol/L,其中治疗后l dTG水平较治疗前升高,至治疗后3、5 dTG水平恢复到治疗前水平;对照组患者TG治疗前（1.5±0.6） mmol/L变化为治疗后5d的（2.4±0.6） mmol/L,其中治疗后1 dTG水平较治疗前升高,至治疗后3、5 dTG水平仍高于治疗前水平.两组患者行营养支持治疗前后TG变化趋势比较,差异有统计学意义（F=7.940,P＜0.05）.结论 ANP患者行肠外营养支持治疗,结构脂肪乳和物理混合的中长链脂肪乳对患者肝肾功能没有影响,而对患者TG的代谢,结构脂肪乳影响要小于中长链脂肪乳.临床试验注册：在大学医院医疗信息网络（UMIN）临床试验注册中心注册,注册编号：UMIN000016958.

Objective To investigate the effects of structured triglyceride （STG） and physical mixed medium chain/long chain triglycerides （MCT/LCT） on hepatic and renal function and lipometabolism of patients with acute necrotizing pancreatitis （ANP）.Methods The clinical data of 30 patients with ANP who were admitted to the PLA General Hospital between January 2012 and June 2014 were prospectively analyzed.A double-blind,randomized,controlled study was performed in 30 patients who were allocated into the experimental group （15 patients received STG） and the control group （15 patients received physical mixed MCT/LCT）.All the patients received isometrical nitrogen and isocaloric parenteral nutrition more than 5 days.The levels of alanine transaminase （ALT）,aspartate transaminase （AST）,glutamyl-transpeptidase （GGT）,alkaline phosphatase （ALP）,creatinine （Cr）,blood urea nitrogen （BUN）,triglyceride （TG） and total cholesterol （TC） were assayed before nutritional support treatment and at day 1,3 and 5 after nutritional support therapy.The measurement data with normal distribution was presented as （x） ± s.The skew distribution data were described as M （range）.The comparison between groups were evaluated with an independent sample t test or one-way ANOVA.The count data were analyzed using the chi-square test.Results A total of 30 patients were screened for eligibility.The levels of ALT,AST,GGT,ALP,Cr,BUN,TG and TC were changed within a certain range at day 1,3 and 5 after nutritional support treatment.The levels of ALT,AST,GGT,ALP,Cr,BUN and TC before treatment and at day 5after treatment were changed from 29.0 U/L,25.4 U/L,83.2 U/L,（193 ± 115） U/L,（124 ± 97） μmol/L,（8±6）mmol/L and （2.4±1.1）mmol/L to 29.4 U/L,33.0 U/L,77.7 U/L,（172±74）U/L,（117 ±103）μmol/L,（8 ± 5） mmol/L and （2.3 ± 1.0） mmol/L in the experimental group,and from 23.8 U/L,22.9 U/L,96.2 U/L,（148 ± 108） U/L,（82 ± 57） μmol/L,（9 ± 7） mmol/L and （2.5 ± 0.7） mmol/L to 21.3 U/L,24.5 U/L,127.4 U/L,（179 ± 126） U/L,（80 ± 54） μmol/L,（10 ± 6） mmol/L and （2.4 ±0.8） mmol/L in the control group,respectively.There were no significant differences in the changing trends of the levels of ALT,AST,GGT,ALP,Cr,BUN and TC between the 2 groups （F =0.647,1.186,0.282,0.553,0.862,0.182,0.369,P〉0.05）.The level of TG in the experimental group from pre-treatment to day 5 after treatment was changed from （1.5 ± 0.6） mmol/L to （1.5 ± 0.7） mmol/L,with increasing trend from pre-treatment to day 1 after treatment and reaching the normal level at day 3 and 5 after treatment.The level of TG in the control group from pre-treatment to day 5 after treatment was changed from （1.5 ± 0.6） mmol/L to （2.4 ± 0.6） mmol/L,with increasing trend from pre-treatment to day 1,3 and 5 after treatments.There were significant differences in the changing trends of TG before and after nutritional support therapy between the 2 groups （F =7.940,P 〈 0.05）.Conclusion STG and physical mixed MCT/LCT don＇t influence the hepatic and renal function of patients with ANP undergoing parenteral nutritional support therapy,while STG has a better effect of lipometabolism compared with physical mixed MCT/LCT.Registry This study was registered with the UMIN Clinical Trial Registry with the registry number of UMIN000016958