成人重症疾患の低栄養の定義と診断

成人重症疾患の低栄養の定義と診断に関するレビュー論文を紹介します。先程紹介したアメリカ栄養士会とASPENの成人低栄養コンセンサス論文に引用されていた論文です。

Jensen GL, Wheeler D. A new approach to defining and diagnosing malnutrition in adult critical illness. Curr Opin Crit Care. 2012 Apr;18(2):206-11.

低栄養の病態として急性および慢性の炎症が重要です。低栄養はstarvation-associated malnutrition（飢餓）、chronic disease-associated malnutrition（悪液質）、acute disease or injury-associated malnutrition（侵襲）に分類できます。

炎症によって低栄養が進行し、栄養介入の効果も炎症で制限されます。特に重症疾患では侵襲に飢餓や悪液質を合併することは珍しくありません（例えば慢性腎不全患者が肺炎と急性呼吸不全になるなど）。CRPには感度、特異度の問題がありますが、炎症判断の目安になります。

今後は急性疾患・損傷、慢性疾患、社会生活環境の3つに低栄養の病態を分類して、リハ栄養評価と介入をしていくべきでしょう。マラスムス、クワシオルコル、混合型は社会生活環境による低栄養に含まれると考えますが、日本では社会生活環境単独の低栄養は稀です（拒食症、児童虐待など）。

Abstract

PURPOSE OF REVIEW:

This review will highlight a new approach to defining malnutrition syndromes for critically ill adults that incorporates a modern understanding of the contributions of inflammatory response. A systematic approach to nutrition assessment is described to help support diagnosis.

RECENT FINDINGS:

Recent findings suggest that varying degrees of acute or chronic inflammation are key contributing factors in the pathogenesis of malnutrition in the setting of disease or injury. Newly proposed malnutrition syndromes include: 'starvation-associated malnutrition', when there is chronic starvation without inflammation; 'chronic disease-associated malnutrition', when inflammation is chronic and of mild to moderate degree; and 'acute disease or injury-associated malnutrition', when inflammation is acute and of severe degree.

SUMMARY:

Inflammation and malnutrition have an intimate interplay; the presence of inflammation contributes to the development of malnutrition and often limits the effectiveness of nutritional interventions. In turn, the associated malnutrition may blunt the effectiveness of medical therapies. A new approach to defining and diagnosing malnutrition syndromes can help to guide intervention and expected outcomes.