褥瘡
褥瘡の治癒過程には多くの栄養素が関与している。炎症期でのタンパク質欠乏は、炎症を遷延化させる。増殖期でのタンパク質や亜鉛欠乏は線維芽細胞の機能を低下させる。また、銅やビタミンA、Cの欠乏によりコラーゲン合成機能の低下が起こる。褥瘡の治療では、炎症期から増殖期に速やかに移行させることが肝要である。このため、特に褥瘡の背景にある炎症を早期に改善させることが治癒促進を加速させる。すなわち、エネルギーやタンパクの投与量のみでなく、タンパク合成能の改善や創傷治癒に必須となる栄養素や抗炎症効果を促す栄養素の投与組成を考慮した栄養管理が重要である。また炎症を助長するアルギニンや鉄の摂取 (投与) に関しては...
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| Published in | 静脈経腸栄養 Vol. 27; no. 2; pp. 703 - 710 |
|---|---|
| Main Authors | , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本静脈経腸栄養学会
2012
|
| Subjects | |
| Online Access | Get full text |
| ISSN | 1344-4980 1881-3623 |
| DOI | 10.11244/jjspen.27.703 |
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| Abstract | 褥瘡の治癒過程には多くの栄養素が関与している。炎症期でのタンパク質欠乏は、炎症を遷延化させる。増殖期でのタンパク質や亜鉛欠乏は線維芽細胞の機能を低下させる。また、銅やビタミンA、Cの欠乏によりコラーゲン合成機能の低下が起こる。褥瘡の治療では、炎症期から増殖期に速やかに移行させることが肝要である。このため、特に褥瘡の背景にある炎症を早期に改善させることが治癒促進を加速させる。すなわち、エネルギーやタンパクの投与量のみでなく、タンパク合成能の改善や創傷治癒に必須となる栄養素や抗炎症効果を促す栄養素の投与組成を考慮した栄養管理が重要である。また炎症を助長するアルギニンや鉄の摂取 (投与) に関しては、十分に配慮するべきである。適切な栄養管理の結果として、タンパク合成能および脂質代謝が改善され、早期に褥瘡の治癒が得られる。タンパク質、アミノ酸や脂質、微量元素、ビタミンなど主要な栄養素についての知見を示し、病態に応じた栄養剤の使用について概説する。 |
|---|---|
| AbstractList | 褥瘡の治癒過程には多くの栄養素が関与している。炎症期でのタンパク質欠乏は、炎症を遷延化させる。増殖期でのタンパク質や亜鉛欠乏は線維芽細胞の機能を低下させる。また、銅やビタミンA、Cの欠乏によりコラーゲン合成機能の低下が起こる。褥瘡の治療では、炎症期から増殖期に速やかに移行させることが肝要である。このため、特に褥瘡の背景にある炎症を早期に改善させることが治癒促進を加速させる。すなわち、エネルギーやタンパクの投与量のみでなく、タンパク合成能の改善や創傷治癒に必須となる栄養素や抗炎症効果を促す栄養素の投与組成を考慮した栄養管理が重要である。また炎症を助長するアルギニンや鉄の摂取 (投与) に関しては、十分に配慮するべきである。適切な栄養管理の結果として、タンパク合成能および脂質代謝が改善され、早期に褥瘡の治癒が得られる。タンパク質、アミノ酸や脂質、微量元素、ビタミンなど主要な栄養素についての知見を示し、病態に応じた栄養剤の使用について概説する。 |
| Author | 田中, 芳明 浅桐, 公男 石井, 信二 |
| Author_FL | ISHII Shinji ASAGIRI Kimio TANAKA Yoshiaki |
| Author_FL_xml | – sequence: 1 fullname: TANAKA Yoshiaki – sequence: 2 fullname: ISHII Shinji – sequence: 3 fullname: ASAGIRI Kimio |
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| Copyright | 2012 日本静脈経腸栄養学会 |
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| References | 4) Jetter Ingerslev. Nutrition, age and wound heaing. Theoly-Advanced Wound Healing Resourse. Coloplast, Esperaegrde, Denmark: 1-26, 1992. 11) Ren J, Chung SH. Anti-inflammatory effect of alpha-linolenic acid and its mode of action through the inhibition of nitric oxide production and inducible nitric oxide synthase gene expression via NF-kappaB and mitogen-activated protein kinase pathways. J Agric Food Chem 55: 5073-5080, 2007. 5) Weisinger R, Fridovich I. Mitochondrial superoxide dismutase, Site of synthesis and intramitochondrial localization. J Biol Chem 248: 4793-4796, 1973. 39) Matsumoto S, Koga H, Kusaka J, et al. Effects of the Antioxidant-Enriched Concentrated Liquid Diet ANOM on Oxidative Stress and Multiple Organ Injury in Patients with Septic Shock: A Pilot Study. J Anesthe Clinic Res 2: 8, 2011. 21) Smidt LJ, Cremin FM, Grivetti LE, et al. Influence of thiamin supplementation on the health and general well-being of an elderly Irish population with marginal thiamin deficiency. J Genterol 46: M16-22, 1991. 33) 東海林 徹. 輸液製剤と微量元素―その意義と問題点―. JSPEN26: 1077-1083、2011. 22) Chandra RK. Effect of vitamin and trace element supplementation on immune responses and infection in elderly subjects. Lancet ii: 1124-1127, 1992. 30) 田中芳明、溝手博義、甲斐田徹. 創傷治癒促進因子を用いた褥瘡患者の栄養管理. 日臨外会誌 63: 1633-40、2002. 38) 田中芳明、朝川貴博、八木実. 侵襲下における酸化ストレス傷害に対するポリフェノール含有抗酸化栄養剤の効果. J. JSMUFF 4: 93-98、2006. 13) Borghaei H, Borghaei RC, Ni X, et al. Evidence that suppression of IL-1 induced collagenase mRNA expression by dihomogamma-linolenic acid (DGLA) involves inhibition of NFkB binding. Inflamm Res 46: S177-8, 1997. 41) 大塚百香、川口巧、田中芳明ほか. C型慢性肝疾患患者のインスリン抵抗性およびアンモニア代謝におよぼすANOMの影響. JSPEN24; 949-954、2009. 3) 美濃良夫. 褥瘡治療と栄養管理. 医学のあゆみ 218: 543-548、2006. 43) Ternowitz T, Fogh K, Kragballe K. 15-hydroxyeicosatetranoic acid (15-HETE) specifically inhibits LTB4-induced chemotaxis of human neutrophils. Skin Pharmacol 1: 93-99, 1988. 15) LührsH, Gerke T, Müller JG, et al. Butyrate inhibits NF-kappaB activation in lamina propria macrophages of patients with ulcerative colitis. Scand J Gastroenterol 37: 458-466, 2002. 36) Braga M, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Parenteral Nutirition : Surgery. Clinical Nutrition 28, P382. 23) Granner DK. Chapter 45, Pituitary and Hypothalamic Hormones. In Harper's Biochemistry 25th Edition. Edited by Murray RK. Mayes PA. Rodwell VW. et al. McGraw-Hill/Appleton & Lange. NY. USA, 1999, p550-560. 40) Fukuda T, Seto Y, Yamada K, et al. official journal of the International Society for Diseases of the Esophagus. Diseases of the esophagus 21: 708-711, 2008. 25) Rodwell VW. Chapter 30, Conversion of amino acids to specialized products. In Harper's Illustrated Biochemistry 27th Edition. Edited by Murray RK. Granner DK. Rodwell VW. LANGE medical books/McGraw-Hill. NY.USA, 2006, p270-280. 27) Jones NE, Heyland DK. Pharmaconutrition: a new emerging paradigm. Curr Opin Gastroenterol 24: 215-222, 2008. 32) Nancy CA. Chapter 27, Iron Deficiency and Related Disorders. Edited by John PG, John Foerster, George MR, et al. Wintrobe's Clinical Hematology. 12th edition., Wolters Kluwer, Alphen aan den Rijn, the Netherlands, 2009, p810. 35) ASPEN Board of Directors. JPEN 28: S39-70, 2004. 10) von Bulow V, Dubbon S, Engelhardt G, et al. Zinc-dependent suppression of TNF-alpha production is mediated by protein kinase A-induced inhibition of Raf-1, I kappa Bkinase beta, and NF-kappa B. J Immunol 179: 4180-4186, 2007. 1) 日本褥瘡学会. 第1章褥瘡の概要、褥瘡発生のメカニズム. 日本褥瘡学会編. 褥瘡予防・管理ガイドライン. 照林社、東京、2009、p18-19. 12) Zhao Y, Joshi-Barve S, Barve S, et al. Eicosapentaenoic acid prevents LPS-induced TNF-alpha expression by preventing NF-kappaB activation. J Am Coll Nutr 23: 71-78, 2004. 44) Ziboh VA, Naguwa S, Vang K, et al. Suppression of leukotriene B4 generation by ex-vivo neutrophils isolated from asthma patients on dietary supplementation with gammalinolenic acid-containing borage oil: possible implication in asthma. Clin Dev Immunol 11:13-21, 2004. 37) Abe S, Tanaka Y, Fujise N, et al. An antioxidative nutrient-rich enteral diet attenuates lethal activity and oxidative stress induced by lipopolysaccharide in mice. JPEN 31: 181-187, 2007. 8) Ebadi M, Sharma SK, Wanpen S, et al. Coenzyme Q10 inhibits mitochondrial complex-1 down-regulation and nuclear factor-kappa B activation. J. Cell. Mol. Med 2: 213-222, 2004. 6) Oka, Ogino K, Matsuura S, et al. Human serum immuno-reactive copper, zinc-superoxide dismutase assayed with an enzyme monoclonal immunosorbent in patients with digestive cancer. Clin Chim Acta 182: 209-219, 1989. 42) Chapkin RS, Miller CC, Somers SD, et al. Ability of 15-hydroxyeicosatrienoic acid (15-OH-20:3) to modulate macrophage arachidonic acid metabolism. Biochem Biophys Res Commun 153: 799-804, 1988. 45) Williams JZ, Abumrad N, Barbul A. Effect of a specialized amino acid mixture on human collagen deposition. Ann Surg 236: 369-374, 2002. 16) Singleton KD, Beckey VE, Wischmeyer PE. Glutamine prevents activation of NF-kappaB and stress kinase pathways, attenuates inflammatory cytokine release, and prevents acute respiratory distress syndrome (ARDS) following sepsis. Shock 24: 583-539, 2005. 2) 江頭文江. 第11章3. 高齢期の栄養問題. 栢下淳、山東勤弥、田中芳明ほか編. 臨床栄養治療の実践基礎編. 金原出版、東京、2008、p196-198. 14) Segain JP, Raingeard de la Blétière D, Sauzeau V, et al. Butyrate inhibits inflammatory responses through NFkappaB inhibition. implications for Crohn's disease. Gut 47: 397-403, 2000. 24) Barbul A. Rettura G. Levenson SM. et al. Wound healing and thymotropic effects of arginine, a pituitary mechanism of action. American Journal of Clinical Nutrition 37: 786-94, 1983. 18) Malholland, J.H. et al. Protein metabolism and bedsores. Ann. Surgery 118:1015-1023, 1943. 28) Singleton KD, Beckey VE, Wischmeyer PE. Glutamine prevents activation of NF-kB and stress kinase pathways, attenuates inflammatory cytokine release, and prevents acute respiratory distress syndrome (ARDS) following sepsis. Schock 24: 583-589, 2005. 46) Aoki M, Komatsu M, Ochiai M, et al. Healing Effects of Oral Administration of L-citrulline or L-ornithine in a Rat Pressure-ulcer Model-Comparison with L-arginine-. Pharmacol Ther 38: 807-816, 2010. 7) Zhong Z, Froh M, Lehnert M, et al. Polyphenols from Camellia sinenesis attenuate experimental cholestasis-induced liver fibrosis in rats. Am J Physiol Gastrointest Liver Physiol 285: G1004-1013, 2003. 19) Chernoff, R.S. et al. The effect of a very highprotein liquid formula on decubitus ulcer healing in long-term tube-fed institutionalized patients. J.Am. Dietetic Assoc 90: A-130, 1990. 34) Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. JPEN 28S: S52-S57, 2004. 26) Kirk SJ, Hurson M, Regan MC et al. Argunine stimulates wound healing and immune function in elderly human beings. Surgery 114: 155-160, 1993. 29) Garrett-Cox RG, Stefanutti G, Booth C, et al. Glutamine decreases in-flammation in infant rat endotoxemia. J Pediatr. Surg 44: 523-529, 2009. 17) Garrett-Cox RG, Stefanutti G, Booth C, et al. Glutamine decreases inflammation in infant rat endotoxemia. J Pediatr Surg 44: 523-529, 2009. 20) Itoh R, Yamada K, Oka J, et al. Biochemical assessment of vitamin status in “healthy” elderly Japanese, relationship between intakes and biochemical measures of thiamine, riboflavin and ascorbic acids. Nutr Res Int 39: 509-519, 1989. 47) 日本静脈経腸栄養学会. 第III章成人の病態別栄養管理、褥瘡. 日本静脈経腸栄養学会編. 静脈経腸栄養ガイドライン-静脈経腸栄養を適切に実地するためのガイドライン-第2版. 南江堂、東京、2006、p54-55. 31) Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Ceriatr Soc 40: 744-58, 1992. 9) Youn HS, Lim HJ, Choi YJ. et al. Selenium suppresses the activation of transcription factor NF-kappa B and IRF3 induced by TLR3 or TLR4 agonists. Int Immunopharmacol 8: 495-501, 2008. |
| References_xml | – reference: 34) Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. JPEN 28S: S52-S57, 2004. – reference: 22) Chandra RK. Effect of vitamin and trace element supplementation on immune responses and infection in elderly subjects. Lancet ii: 1124-1127, 1992. – reference: 1) 日本褥瘡学会. 第1章褥瘡の概要、褥瘡発生のメカニズム. 日本褥瘡学会編. 褥瘡予防・管理ガイドライン. 照林社、東京、2009、p18-19. – reference: 36) Braga M, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Parenteral Nutirition : Surgery. Clinical Nutrition 28, P382. – reference: 12) Zhao Y, Joshi-Barve S, Barve S, et al. Eicosapentaenoic acid prevents LPS-induced TNF-alpha expression by preventing NF-kappaB activation. J Am Coll Nutr 23: 71-78, 2004. – reference: 31) Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Ceriatr Soc 40: 744-58, 1992. – reference: 40) Fukuda T, Seto Y, Yamada K, et al. official journal of the International Society for Diseases of the Esophagus. Diseases of the esophagus 21: 708-711, 2008. – reference: 14) Segain JP, Raingeard de la Blétière D, Sauzeau V, et al. Butyrate inhibits inflammatory responses through NFkappaB inhibition. implications for Crohn's disease. Gut 47: 397-403, 2000. – reference: 25) Rodwell VW. Chapter 30, Conversion of amino acids to specialized products. In Harper's Illustrated Biochemistry 27th Edition. Edited by Murray RK. Granner DK. Rodwell VW. LANGE medical books/McGraw-Hill. NY.USA, 2006, p270-280. – reference: 41) 大塚百香、川口巧、田中芳明ほか. C型慢性肝疾患患者のインスリン抵抗性およびアンモニア代謝におよぼすANOMの影響. JSPEN24; 949-954、2009. – reference: 21) Smidt LJ, Cremin FM, Grivetti LE, et al. Influence of thiamin supplementation on the health and general well-being of an elderly Irish population with marginal thiamin deficiency. J Genterol 46: M16-22, 1991. – reference: 7) Zhong Z, Froh M, Lehnert M, et al. Polyphenols from Camellia sinenesis attenuate experimental cholestasis-induced liver fibrosis in rats. Am J Physiol Gastrointest Liver Physiol 285: G1004-1013, 2003. – reference: 20) Itoh R, Yamada K, Oka J, et al. Biochemical assessment of vitamin status in “healthy” elderly Japanese, relationship between intakes and biochemical measures of thiamine, riboflavin and ascorbic acids. Nutr Res Int 39: 509-519, 1989. – reference: 15) LührsH, Gerke T, Müller JG, et al. Butyrate inhibits NF-kappaB activation in lamina propria macrophages of patients with ulcerative colitis. Scand J Gastroenterol 37: 458-466, 2002. – reference: 4) Jetter Ingerslev. Nutrition, age and wound heaing. Theoly-Advanced Wound Healing Resourse. Coloplast, Esperaegrde, Denmark: 1-26, 1992. – reference: 38) 田中芳明、朝川貴博、八木実. 侵襲下における酸化ストレス傷害に対するポリフェノール含有抗酸化栄養剤の効果. J. JSMUFF 4: 93-98、2006. – reference: 47) 日本静脈経腸栄養学会. 第III章成人の病態別栄養管理、褥瘡. 日本静脈経腸栄養学会編. 静脈経腸栄養ガイドライン-静脈経腸栄養を適切に実地するためのガイドライン-第2版. 南江堂、東京、2006、p54-55. – reference: 39) Matsumoto S, Koga H, Kusaka J, et al. Effects of the Antioxidant-Enriched Concentrated Liquid Diet ANOM on Oxidative Stress and Multiple Organ Injury in Patients with Septic Shock: A Pilot Study. J Anesthe Clinic Res 2: 8, 2011. – reference: 42) Chapkin RS, Miller CC, Somers SD, et al. Ability of 15-hydroxyeicosatrienoic acid (15-OH-20:3) to modulate macrophage arachidonic acid metabolism. Biochem Biophys Res Commun 153: 799-804, 1988. – reference: 13) Borghaei H, Borghaei RC, Ni X, et al. Evidence that suppression of IL-1 induced collagenase mRNA expression by dihomogamma-linolenic acid (DGLA) involves inhibition of NFkB binding. Inflamm Res 46: S177-8, 1997. – reference: 32) Nancy CA. Chapter 27, Iron Deficiency and Related Disorders. Edited by John PG, John Foerster, George MR, et al. Wintrobe's Clinical Hematology. 12th edition., Wolters Kluwer, Alphen aan den Rijn, the Netherlands, 2009, p810. – reference: 6) Oka, Ogino K, Matsuura S, et al. Human serum immuno-reactive copper, zinc-superoxide dismutase assayed with an enzyme monoclonal immunosorbent in patients with digestive cancer. Clin Chim Acta 182: 209-219, 1989. – reference: 2) 江頭文江. 第11章3. 高齢期の栄養問題. 栢下淳、山東勤弥、田中芳明ほか編. 臨床栄養治療の実践基礎編. 金原出版、東京、2008、p196-198. – reference: 27) Jones NE, Heyland DK. Pharmaconutrition: a new emerging paradigm. Curr Opin Gastroenterol 24: 215-222, 2008. – reference: 18) Malholland, J.H. et al. Protein metabolism and bedsores. Ann. Surgery 118:1015-1023, 1943. – reference: 16) Singleton KD, Beckey VE, Wischmeyer PE. Glutamine prevents activation of NF-kappaB and stress kinase pathways, attenuates inflammatory cytokine release, and prevents acute respiratory distress syndrome (ARDS) following sepsis. Shock 24: 583-539, 2005. – reference: 11) Ren J, Chung SH. Anti-inflammatory effect of alpha-linolenic acid and its mode of action through the inhibition of nitric oxide production and inducible nitric oxide synthase gene expression via NF-kappaB and mitogen-activated protein kinase pathways. J Agric Food Chem 55: 5073-5080, 2007. – reference: 8) Ebadi M, Sharma SK, Wanpen S, et al. Coenzyme Q10 inhibits mitochondrial complex-1 down-regulation and nuclear factor-kappa B activation. J. Cell. Mol. Med 2: 213-222, 2004. – reference: 37) Abe S, Tanaka Y, Fujise N, et al. An antioxidative nutrient-rich enteral diet attenuates lethal activity and oxidative stress induced by lipopolysaccharide in mice. JPEN 31: 181-187, 2007. – reference: 45) Williams JZ, Abumrad N, Barbul A. Effect of a specialized amino acid mixture on human collagen deposition. Ann Surg 236: 369-374, 2002. – reference: 19) Chernoff, R.S. et al. The effect of a very highprotein liquid formula on decubitus ulcer healing in long-term tube-fed institutionalized patients. J.Am. Dietetic Assoc 90: A-130, 1990. – reference: 24) Barbul A. Rettura G. Levenson SM. et al. Wound healing and thymotropic effects of arginine, a pituitary mechanism of action. American Journal of Clinical Nutrition 37: 786-94, 1983. – reference: 29) Garrett-Cox RG, Stefanutti G, Booth C, et al. Glutamine decreases in-flammation in infant rat endotoxemia. J Pediatr. Surg 44: 523-529, 2009. – reference: 46) Aoki M, Komatsu M, Ochiai M, et al. Healing Effects of Oral Administration of L-citrulline or L-ornithine in a Rat Pressure-ulcer Model-Comparison with L-arginine-. Pharmacol Ther 38: 807-816, 2010. – reference: 28) Singleton KD, Beckey VE, Wischmeyer PE. Glutamine prevents activation of NF-kB and stress kinase pathways, attenuates inflammatory cytokine release, and prevents acute respiratory distress syndrome (ARDS) following sepsis. Schock 24: 583-589, 2005. – reference: 23) Granner DK. Chapter 45, Pituitary and Hypothalamic Hormones. In Harper's Biochemistry 25th Edition. 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