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Aktuelle Ernährungsmedizin 2019; 44(04): 269-284
DOI: 10.1055/a-0843-6733
CME-Fortbildung
© Georg Thieme Verlag KG Stuttgart · New York

Protein in der klinischen Ernährung kritisch kranker Patienten

Protein in Clinical Nutrition
Karl Georg Kreymann
,
Geraldine de Heer
Subject Editor: Wissenschaftlich verantwortlich gemäß Zertifizierungsbestimmungen für diesen Beitrag ist Prof. Dr. med. Christian Löser, Kassel.
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Publication History

Publication Date:
20 August 2019 (online)

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Aminosäuren sind die biologischen Baustoffe für alle Struktur- und Funktionsproteine. Da jede Erkrankung mit einem Abbau dieser Proteine einhergeht, ist die Zufuhr von Protein bzw. Aminosäuren essenziell für deren Resynthese. Derzeit gibt es keine Möglichkeit, die endogene Aminosäurefreisetzung zu bestimmen. So bleiben Zeitpunkt und Dosierung der Proteinzufuhr beim kritisch Kranken weiterhin Gegenstand der Diskussion.

Abstract

Critical illness is associated with a loss of body protein and skeletal muscle. Of 18 heterogenous randomized studies evaluating different doses of protein, 15 (83 %) found better results with a higher dose, which ranged from 1.1 to 3.6 g/kg/day. As the degree of catabolism varies with different diseases, there can be no optimal protein dose for all patients. However, clinical evidence is still week as only nitrogen balance was the primary endpoint in most of these trials. Observational studies showed a time dependency of the protein dose and lowest mortality with a dose ≥ 1.2 g/kg/day on and after day 4 or 6. However, in septic patients in the acute phase of infection the provision of > 1.2 g/kg/day of protein was associated with a higher mortality in one observational study. For future research, randomized studies should be performed on groups of patients with a defined protein loss. Also, protein dose should be related to lean body mass.

Kernaussagen

  • Eine schwere Erkrankung kann innerhalb kurzer Zeit zu einem erheblichen Verlust von Körperprotein und Skelettmuskulatur führen.

  • Unterschiedliche Erkrankungen gehen mit einem unterschiedlichen Grad der Katabolie und des Proteinverlustes einher. Aus diesem Grund kann es die eine optimale Proteindosis für alle kritisch Kranken in allen Krankheitsstadien nicht geben.

  • Die vorliegenden 18 randomisierten Studien weisen deshalb sehr unterschiedliche Proteindosierungen als optimal aus. Allerdings ist ihre Evidenz als gering zu bewerten, da mehr als die Hälfte nur die Stickstoffbilanz als primären Zielpunkt hatte.

  • Zukünftige Studien sollten eher auf eng definierte Patientenkollektive mit einem bestimmten Proteinverlust zugeschnitten sein.

  • Mehrere Beobachtungsstudien kommen zu dem Ergebnis, dass eine höhere Proteindosis (≥ 1,2 g/kg/Tag an und nach Tag 4 – 6) mit einer niedrigeren Mortalität verbunden ist. Allerdings sollte diese Dosis über eine kontinuierliche Steigerung, beginnend mit < 0,8 g/kg/Tag an Tag 1, erreicht werden.

  • Bei septischen Patienten sollte in der Frühphase eine niedrigere Proteindosis gewählt werden, die dann allerdings in der Erholungsphase deutlich gesteigert werden muss.

  • Die Proteindosierung sollte zukünftig, wenn in der klinischen Routine möglich, pro Körpermagermasse angegeben werden, da eine Dosis pro kg Körpergewicht nicht den geschlechtsbedingten Unterschieden gerecht wird.

  • Die biologische Äquivalenz von enteral zugeführtem Protein und parenteral zugeführten Aminosäuren ist wahrscheinlich eher 1:1.

Schlüsselwörter

Proteindosis - kritisch Kranke - Körpermagermasse - Proteinäquivalent

Keywords

protein dose - critically ill - lean body mass
 

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