栄養状態と切断後の機能予後の関連

今日は栄養状態と切断後の機能予後の関連を見た論文を紹介します。

Kalbaugh CA, et al: Does Obesity Predict Functional Outcome in the Dysvascular Amputee? Am Surg. 2006 Aug;72(8):707-12; discussion 712-3.

肥満患者では血管性下肢切断患者の機能予後が悪いのではないかという仮説で調査した論文です。低栄養（BMI：0 to 18.4 kg/m2）、正常栄養（BMI：18.5 to 24.9 kg/m2）、過体重（BMI：25 to 29.9 kg/m2）、肥満（BMI:> or = 30 kg/m2）の4群で比較した結果、むしろ低栄養患者のほうが義足使用の割合や移動自立の割合が低いという結果でした。ただ、多変量解析ではBMIによる統計学的有意差は認められませんでした。

この研究からは、肥満は下腿切断後のリハに悪影響を与えないと思われます。別の論文でほぼ同様な結果のものがありましたが、BMI40以上では悪影響があるようです。切断患者では肥満よりはむしろ低栄養に留意したほうがよいのかもしれません。日本はアメリカよりも肥満が少なく低栄養が多いので、より切断患者の栄養改善が重要になる可能性があります。

Abstract
Limited information is available concerning the effects of obesity on the functional outcomes of patients requiring major lower limb amputation because of peripheral arterial disease (PAD). The purpose of this study was to examine the predictive ability of body mass index (BMI) to determine functional outcome in the dysvascular amputee. To do this, 434 consecutive patients (mean age, 65.8 +/- 13.3, 59% male, 71.4% diabetic) undergoing major limb amputation (225 below-knee amputation, 27 through-knee amputation, 132 above-knee amputation, and 50 bilateral) as a complication of PAD from January 1998 through May 2004 were analyzed according to preoperative BMI. BMI was classified according to the four-group Center for Disease Control system: underweight, 0 to 18.4 kg/m2; normal, 18.5 to 24.9 kg/m2; overweight, 25 to 29.9 kg/m2; and obese, > or = 30 kg/m2. Outcome parameters measured included prosthetic usage, maintenance of ambulation, survival, and maintenance of independent living status. The chi2 test for association was used to examine prosthesis wear. Kaplan-Meier curves were constructed to assess maintenance of ambulation, survival, and maintenance of independent living status. Multivariate analysis using the multiple logistic regression model and a Cox proportional hazards model were used to predict variables independently associated with prosthetic use and ambulation, survival, and independence, respectively. Overall prosthetic usage and 36-month ambulation, survival, and independent living status for the entire cohort was 48.6 per cent, 42.8 per cent, 48.1 per cent, 72.3 per cent, and for patients with normal BMI was 41.5 per cent, 37.4 per cent, 45.6 per cent, and 69.5 per cent, respectively. There was no statistically significant difference in outcomes for overweight patients (59.2%, 50.7%, 52.5%, and 75%) or obese patients (51.8%, 46.2%, 49.7%, and 75%) when compared with normal patients. Although there were significantly poorer outcomes for underweight patients for the parameters of prosthetic usage when compared with the remaining cohort (25%, P = 0.001) and maintenance of ambulation when compared with overweight patients (20.8%, P = 0.026), multivariate analysis adjusting for medical comorbidities and level of amputation showed that BMI was not a significant independent predictor of failure for any outcome parameter measured. In conclusion, BMI failed to correlate with functional outcome and, specifically, obesity did not predict a poorer prognosis.