慢加急性肝衰竭患者营养管理的最佳证据总结

doi:10.3761/j.issn.0254-1769.2025.05.011

摘要/Abstract

摘要：

目的检索、评价及汇总慢加急性肝衰竭患者营养管理的最佳证据。方法系统检索国内外计算机决策系统、指南网站、专业协会网站及Cochrane Library、澳大利亚乔安娜布里格斯研究所循证卫生保健中心数据库、PubMed、Embase、CINAHL、Web of Science、维普数据库、中国知网、中国生物医学文献数据库中有关肝衰竭患者营养管理的临床决策、指南、专家共识、推荐实践、证据总结、系统评价等文献，检索时限为建库至2024年7月16日；由经过循证护理培训的研究人员采用权威工具对文献进行方法学质量评价，并根据主题对证据进行提取与综合。结果共纳入13篇文献，包括1篇临床决策、8篇指南和4篇专家共识。从营养支持团队、营养评估、能量与营养素摄入、口服营养支持、肠内与肠外营养支持和并发症的管理等6个方面，汇总26条证据。结论该研究总结了慢加急性肝衰竭患者营养管理的最佳证据，可为其规范管理提供依据，医护人员在应用证据时应多角度评估其可用性。

关键词: 肝衰竭, 慢加急性肝衰竭, 营养支持, 循证护理学

Abstract:

Objective To retrieve，evaluate and synthesize the best evidence for nutritional management in patients with acute-on-chronic liver failure. Methods Evidence on nutritional management of patients with acute-on-chronic liver failure was systemically retrieved from the clinical decision support systems，guideline websites，professional association websites and databases，such as Cochrane Library，Joanna Briggs Institute，PubMed，Embase，CINAHL，Web of Science，VIP database，CNKI and CBM，including clinical decisions，guidelines，expert consensuses，evidence summaries and systematic reviews from inception to July 16，2024.Researchers trained in evidence-based nursing used authoritative tools to evaluate the methodological quality of the literature，and extracted and synthesized evidence according to the theme. Results A total of 13 articles were included，including 1 clinical decision，8 guidelines，and 4 expert consensuses. The best evidence included 26 pieces of evidence in 6 areas，namely the nutrition support team，nutritional assessment，energy and protein intake，oral nutrition support，enteral and parenteral nutrition support，and management of complications. Conclusion This study summarizes the best evidence for nutritional management in patients with acute-on-chronic liver failure，which can provide a basis for their standardized management.Medical staff should evaluate the availability of evidence from multiple perspectives when applying it.

Key words: Liver Failure, Acute-on-Chronic Liver Failure, Nutritional Support, Evidence-Based Nursing

唐佳怡, 唐桂清, 张娜, 李晓波. 慢加急性肝衰竭患者营养管理的最佳证据总结[J]. 中华护理杂志, 2025, 60(5): 581-588.

TANG Jiayi, TANG Guiqing, ZHANG Na, LI Xiaobo. Best evidence summary of nutritional management in patients with acute-on-chronic liver failure[J]. Chinese Journal of Nursing, 2025, 60(5): 581-588.

图/表 3

表1 纳入文献的基本特征（n=13）

Table 1 Characteristics of included studies（n=13）

表2 纳入指南的方法学质量评价结果（n=8）

Table 2 Quality evaluation results of included guidelines（n=8）

表3 慢加急性肝衰竭患者营养管理的最佳证据总结

Table 3 Evidence summary of nutritional management in patients with acute-on-chronic liver failure

参考文献 33

[1]	Tonon M, Piano S. Acute on chronic liver failure in cirrhosis[J]. Clin Mol Hepatol, 2022, 28(2):273-275. DOI PMID
[2]	赵洁, 李力, 李秀惠, 等. 乙型肝炎病毒相关慢加急性肝衰竭患者短期预后模型的建立及预测价值研究[J]. 中华危重病急救医学, 2020, 32(8):988-993. PMID
	Zhao J, Li L, Li XH, et al. Value of a new predictive model in evaluating short-term prognosis of patients with hepatitis B virus related acute-on-chronic liver failure[J]. Chin Crit Care Med, 2020, 32(8):988-993. DOI PMID
[3]	中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35(1):38-44.
	Liver Failure and Artificial Liver Group,Chinese Society of Infectious Diseases,Chinese Medical Association; Severe Liver Disease and Artificial Liver Group,Chinese Society of Hepato-logy, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure(2018)[J]. J Clin Hepatol, 2019, 35(1):38-44.
[4]	Lucidi C, Lattanzi B, di Gregorio V, et al. A low muscle mass increases mortality in compensated cirrhotic patients with sepsis[J]. Liver Int, 2018, 38(5):851-857. DOI PMID
[5]	吴牧晨, 孟庆华. 慢加急性肝衰竭患者的营养评估及临床管理[J]. 临床肝胆病杂志, 2021, 37(4):770-774.
	Wu MC, Meng QH. Nutritional assessment and clinical manage-ment of patients with acute-on-chronic liver failure[J]. J Clin Hepatol, 2021, 37(4):770-774.
[6]	Puri P, Dhiman RK, Taneja S, et al. Nutrition in chronic liver disease:consensus statement of the Indian national association for study of the liver[J]. J Clin Exp Hepatol, 2021, 11(1):97-143.
[7]	孙慧慧, 张丙良, 娄连玉, 等. 肝移植患者术前预康复方案的构建[J]. 中华护理杂志, 2023, 58(18):2195-2202. DOI URL
	Sun HH, Zhang BL, Lou LY, et al. Construction of a preo-perative prehabilitation program for liver transplant recipients[J]. Chin J Nurs, 2023, 58(18):2195-2202.
[8]	Lai RM, Chen TB, Wu ZM, et al. Associations between body mass index and mortality in acute-on-chronic liver failure patients[J]. Ann Hepatol, 2019, 18(6):893-897. DOI PMID
[9]	薛红, 刘先进, 明芳, 等. 预后营养指数与乙型肝炎病毒相关慢加急性肝衰竭患者预后的关系[J]. 实用医学杂志, 2022, 38(10):1240-1245.
	Xue H, Liu XJ, Ming F, et al. Relationship between prognostic nutritional index and prognosis of patients with HBV related chronic plus acute liver failure[J]. J Pract Med, 2022, 38(10):1240-1245.
[10]	Alper BS, Haynes RB. EBHC pyramid 5.0 for accessing prea-ppraised evidence and guidance[J]. Evid Based Med, 2016, 21(4):123-125.
[11]	周芬, 郝玉芳, 丛雪, 等. 指南研究与评价工具AGREE Ⅱ及各领域分值的补充解释及思考[J]. 护理学报, 2018, 25(18):56-58.
	Zhou F, Hao YF, Cong X, et al. Guideline research and eva-luation tool AGREEⅡ and supplementary explanation and re-flection on scores in various fields[J]. J Nurs(China), 2018, 25(18):56-58.
[12]	王志稳, 韩舒羽. 护理领域专家共识论文的质量评价要点[J]. 中华护理杂志, 2024, 59(3):267-270. DOI URL
	Wang ZW, Han SY. The key points of quality criteria for expert consensus papers in nursing[J]. Chin J Nurs, 2024, 59(3):267-270. DOI URL
[13]	胡雁, 郝玉芳. 循证护理学[M]. 2版. 北京: 人民卫生出版社, 2018.
	Hu Y, Hao YF. Evidence-based nursing[M]. 2nd ed. Beijing: People’s Medical Publishing House, 2018.
[14]	中国医师协会器官移植医师分会移植免疫学专业委员会, 中国研究型医院学会加速康复外科委员会肝移植加速康复学组. 成人慢加急性肝衰竭肝移植围手术期管理专家共识[J]. 器官移植, 2020, 11(5):533-542.
	Transplant Immunology Committee of the Chinese Medical Doctor Association Organ Transplantation Physicians Branch,Hepatic Transplantation Enhanced Recovery Group of the Chinese Research Hospital Association Enhanced Recovery After Surgery Committee. Expert consensus on perioperative management of liver transplantation in adults with acute-on-chronic liver failure[J]. Organ Transplant, 2020, 11(5):533-542.
[15]	Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:Society of Critical Care Medicine(SCCM) and American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.)[J]. Crit Care Med, 2016, 44(2):390-438. DOI PMID
[16]	中华医学会肝病学分会, 中华医学会消化病学分会. 终末期肝病临床营养指南[J]. 中华肝脏病杂志, 2019, 27(5):330-342.
	Chinese Society of Hepatology,Chinese Medical Association; Chinese Society of Gastroenterology,Chinese Medical Associa-tion. Clinical guidelines on nutrition in end-stage liver disease[J]. Chin J Hepatol, 2019, 27(5):330-342.
[17]	Moreau R, Tonon M, Krag A, et al. EASL clinical practice guidelines on acute-on-chronic liver failure[J]. J Hepatol, 2023, 79(2):461-491. DOI PMID
[18]	中华医学会肠外肠内营养学分会. 中国成人患者肠外肠内营养临床应用指南(2023版)[J]. 中华医学杂志, 2023, 103(13):946-974.
	Chinese Society of Parenteral and Enteral Nutrition. Guideline for clinical application of parenteral and enteral nutrition in adults patients in China(2023 edition)[J]. Natl Med J China, 2023, 103(13):946-974.
[19]	王春青, 胡雁. JBI证据预分级及证据推荐级别系统(2014版)[J]. 护士进修杂志, 2015, 30(11):964-967.
	Wang CQ, Hu Y. JBI evidence pre-classification and evidence recommendation level system(2014 edition)[J]. J Nurses Train, 2015, 30(11):964-967.
[20]	Siparsky N. Postoperative parenteral nutrition in adults[EB/OL].(2024-03-12)[2024-07-16]. https://www.uptodate.cn/con-tents/postoperative-parenteral-nutrition-in-adults.
[21]	Plauth M, Cabré E, Campillo B, et al. ESPEN guidelines on parenteral nutrition:hepatology[J]. Clin Nutr, 2009, 28(4):436-444.
[22]	Bischoff SC, Bernal W, Dasarathy S, et al. ESPEN practical gui-deline:clinical nutrition in liver disease[J]. Clin Nutr, 2020, 39(12):3533-3562. DOI PMID
[23]	Merli M, Berzigotti A, Zelber-Sagi S, et al. EASL clinical practice guidelines on nutrition in chronic liver disease[J]. J Hepatol, 2019, 70(1):172-193. DOI PMID
[24]	Nanchal R, Subramanian R, Karvellas CJ, et al. Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU:cardiovascular,endocrine,hematologic,pul-monary,and renal considerations[J]. Crit Care Med, 2020, 48(3):e173-e191.
[25]	Karvellas CJ, Bajaj JS, Kamath PS, et al. AASLD practice gui-dance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis[J]. Hepatology, 2024, 79(6):1463-1502.
[26]	北京医学会肠外肠内营养学专业委员会, 《慢性肝病患者肠外肠内营养支持与膳食干预专家共识》专家委员会. 慢性肝病患者肠外肠内营养支持与膳食干预专家共识[J]. 临床肝胆病杂志, 2017, 33(7):1236-1245.
	Beijing Medical Association for Parenteral and Enteral Nutri-tion, Expert Committee on “Expert Consensus on Parenteral and Enteral Nutrition Support and Dietary Intervention for Patients with Chronic Liver Disease”. Consensus on the clinical nutritional intervention for patients with chronic liver diseases[J]. Clin Hepatol, 2017, 33(7):1236-1245.
[27]	中国中西医结合学会. 慢加急性肝衰竭中西医结合诊疗专家共识[J]. 临床肝胆病杂志, 2021, 37(9):2045-2053.
	Chinese Association of Integrative Medicine. Expert consensus on the diagnosis and treatment of acute-on-chronic liver fai-lure with integrated traditional Chinese and Western medi-cine[J]. J Clin Hepatol, 2021, 37(9):2045-2053.
[28]	鲍向英, 冯佳, 赵华, 等. 泛血管疾病患者融合病房多学科协作护理管理模式的构建与实践[J]. 中华护理杂志, 2024, 59(13):1548-1555. DOI URL
	Bao XY, Feng J, Zhao H, et al. Construction and practice of a multidisciplinary collaborative nursing management model in the integrated ward for pan-vascular disease patients[J]. Chin J Nurs, 2024, 59(13):1548-1555. DOI URL
[29]	Hadjihambi A, Arias N, Sheikh M, et al. Hepatic encephalo-pathy:a critical current review[J]. Hepatol Int, 2018, 12(Suppl 1):135-147. DOI PMID
[30]	Yamada T, Shojima N, Noma H, et al. Glycemic control,morta-lity,and hypoglycemia in critically ill patients:a systematic review and network meta-analysis of randomized controlled trials[J]. Intensive Care Med, 2017, 43(1):1-15.
[31]	何娜, 江淑贤, 郑子梅, 等. 慢加急性肝衰竭患者低血糖发生现状及危险因素分析[J]. 中华护理杂志, 2022, 57(7):846-852. DOI URL
	He N, Jiang SX, Zheng ZM, et al. Status and risk factors of hypoglycemia in patients with acute-on-chronic liver failure[J]. Chin J Nurs, 2022, 57(7):846-852. DOI URL
[32]	Praktiknjo M, Book M, Luetkens J, et al. Fat-free muscle mass in magnetic resonance imaging predicts acute-on-chronic liver failure and survival in decompensated cirrhosis[J]. Hepatolo-gy, 2018, 67(3):1014-1026.
[33]	Cioffi I, Ponzo V, Pellegrini M, et al. The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature[J]. Clin Nutr, 2021, 40(6):3688-3701. DOI PMID