口服营养补充剂治疗营养不良老年住院成人的再入院率与死亡率

　　住院老年成人存在营养不良的高度风险，这对随后的临床和经济结局产生负面影响，包括更大的死亡风险和更高的再入院率。

　　为了探讨口服营养补充对营养不良的老年住院患者临床结局的影响，德克萨斯农工大学、南卡罗来纳医科大学、东卡罗来纳大学、雅培营养、伊利诺伊大学、埃默里大学于2012年5月至2014年10月对652例心力衰竭、心肌梗死、肺炎、慢性阻塞性肺病的营养不良（SGA评分B或C级）老年（≥65岁）患者进行了前瞻性、多中心、随机、安慰剂对照、平行组研究（NOURISH）。

　　两组在入院后分别给予高蛋白质（HP，40g/d）加β-羟基-β-甲基丁酸酯（HMB，3.0g/d）和安慰剂口服，直至出院后90天。

　　结果发现，HP-HMB组与对照组相比，SGA评分显著改善（P=0.009），体重显著增加（P=0.035），30天、60天血清25-羟维生素D水平显著升高（P=0.035、0.008），30、60、90天死亡率显著降低（P=0.049、0.020、0.018），30、60、90天再入院率无显著差异。

　　因此，口服营养补充可改善老年住院患者的营养状况和死亡率，对再入院率无显著影响。

JPEN J Parenter Enteral Nutr. 2016;40(4):127-128.

A Randomized Placebo-Controlled Clinical Trial of Readmission and Mortality in Malnourished Older Hospitalized Adults Treated With a Specialized Oral Nutrition Supplement.

Nicolaas E. Deutz; Eric M. Matheson; Laura E. Matarese; Menghua Luo; Jeffrey Nelson; Maria Geraldine E. Baggs; Refaat Hegazi; Kelly A. Tappenden; Thomas Ziegler.

Texas A&M University, College Station, TX, USA; Medical University of South Carolina, Charleston, SC, USA; Brody School of Medicine, East Carolina University, Greenville, NC, USA; Abbott Nutrition, Columbus, OH, USA; University of Illinois at Urbana-Champaign, Urbana, IL, USA; Emory University, Atlanta, GA, USA.

PURPOSE: Hospitalized older adults are at high risk of malnutrition, which has a negative impact on subsequent clinical and economic outcomes, including a greater risk of mortality and a high rate of hospital readmission. We report the largest prospective randomized placebo-controlled trial in the United States of oral nutrition supplementation (ONS) therapy for up to 90 days postdischarge on clinical outcomes in malnourished hospitalized older adults (≥65 years).

METHODS: The prospective multicenter NOURISH study (Nutrition Effect on Unplanned Readmissions and Survival in Hospitalized Patients) was a double-blind, placebo-controlled, parallel-group study conducted in the United States between May 2012 and October 2014 (ClinicalTrials.gov NCT01626742). Patients (n = 652) who were older (≥65 years), malnourished (Subjective Global Assessment [SGA] class B or C), and hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease were randomized within 72 hours of hospitalization to receive medical and nutrition standard of care plus either the experimental ONS containing high protein (HP; 20 g/serving) and β-hydroxy-β-methylbutyrate (HMB; 1.5 g/serving) or a low-calorie protein-free placebo supplement. Two servings of HP-HMB or placebo ONS were given daily in the hospital and for up to 90 days postdischarge. A primary composite end point of 90-day postdischarge mortality or nonelective readmission was predefined before data unblinding and analysis. Other end points included 30- and 60-day rates of readmission and/or death, SGA class, body weight, length of stay, activities of daily living, and serum concentration of 25-hydroxyvitamin D at 30 and 60 days. Efficacy analyses were performed with all available data from the intention-to-treat population (HP-HMB, n = 313; placebo, n = 309).

RESULTS: Baseline characteristics were comparable between groups. The primary composite end point was similar between HP-HMB (31.1%) and placebo (26.8%). Individual components showed no differences between groups for 90-day readmission rate; however, 90-day mortality was significantly decreased with HP-HMB relative to placebo (4.8% vs 9.7%; relative risk = 0.49, 95% CI = 0.27-0.90, P = .018; Figure 13-1); the estimated number needed to treat was 20.3 (95% CI = 10.9-121.4) to prevent 1 death. Evaluation at 30 and 60 days postdischarge showed no significant difference between groups for the composite end point or for readmission, but mortality was significantly lower in the HP-HMB group relative to placebo at 30 and 60 days (respectively, 2.9% vs 6.2%, P = .049; 4.2% vs 8.7%, P = .020). Relative to placebo, HP-HMB administration resulted in significantly more patients with improved SGA nutrition class (OR = 2.04, 95% CI = 1.28-3.25, P = .009; Figure 13-2). At day 30, body weight was significantly increased by 0.55 ± 0.32 kg (LSM ± SD) with HP-HMB but decreased by 0.26 ± 0.34 kg in placebo (P = .035). Serum levels of 25-hydroxyvitamin D were significantly higher with HP-HMB treatment than placebo at days 30 and 60 (respectively, P = .035 and P = .008). Length of stay and activities of daily living were similar between treatments.

CONCLUSIONS: Although we did not observe a significant effect for the primary composite end point of nonelective readmission or death at 90 days in selective malnourished older adults, the HP-HMB formulation decreased mortality and improved indices of nutrition status during the observation period.

FINANCIAL SUPPORT: Abbott Nutrition (Columbus, OH).