Associação entre fatores nutricionais, inflamatórios e humorais com morbimortalidade 90 dias após acidente vascular encefálico
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Data
2018-02-21
Autores
Souza, Juli Thomaz de
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Universidade Estadual Paulista (Unesp)
Resumo
Introdução: O acidente vascular cerebral (AVC) é a principal causa de incapacidade na vida adulta e cerca de dois terços dos pacientes permanecem em estado de recuperação incompleta após o evento. O estado nutricional desses pacientes é de grande importância, pois nesta fase tornam-se mais susceptíveis às perdas de peso involuntárias, ocorrendo com frequência redução do apetite, disfagia, depressão e alterações da mobilidade, com consequente dependência funcional sendo comum observar inatividade física, alterações bioquímicas e carência nutricional de macro e micronutrientes. Entretanto, pouco se sabe sobre os desfechos nutricionais e a associação destes com incapacidade funcional após o evento. Metodologia: Foram realizadas avaliações clínica, nutricional, bioquímica e de composição corporal nas primeiras 72 horas de internação e repetidas 30 dias após alta hospitalar. Foi avaliada a capacidade funcional pela escala de Rankin modificada (eRm) 90 dias após o AVC. Para determinar as associações foram realizadas análises de regressão múltipla linear e logística, considerando nível de significância de 5%. Resultados: Foram incluídos 84 pacientes, a maioria idosos do sexo masculino, com AVC de baixa gravidade (NIHSS 5), 18,1% trombolisados. Apresentaram valores aumentados de IL-6, sobrepeso e obesidade, além de baixos valores de força de preensão manual na internação. Tiveram manutenção do peso, índice de massa corporal e área muscular do braço corrigida; redução das medidas de espessura do músculo adutor do polegar, circunferência do braço e prega cutânea tricipital; e aumento da força de preensão manual 30 dias após alta. Apresentaram aumento na %gordura corporal, massa de gordura corporal, massa magra da perna acometida, massa magra da perna não acometida, água da perna acometida, água da perna não acometida e redução no ângulo de fase médio, massa livre de gordura, massa magra livre de massa óssea, massa magra do braço acometido, massa magra do braço não acometido, água intracelular, água extracelular, água do braço acometido e água do braço não acometido. Em relação à associação entre as características iniciais com perda de massa magra 30 dias após AVC, somente índice de massa corporal, índice de massa livre de gordura e índice de massa magra livre de massa óssea tiveram significância estatística. A variação dos valores de área muscular do braço corrigida na internação e 30 dias após alta estava associada à incapacidade 90 dias após AVC. Foi verificado que a cada aumento de 1 mg/dl de HGT na internação aumentou em 2% a chance de incapacidade 90 dias após o evento. Discussão: Em relação à alteração de composição corporal 30 dias após o AVC observa-se que tanto o lado acometido quanto o não acometido sofrem alterações e os membros inferiores se comportam de forma diferente dos superiores. O ganho de massa magra visto nos membros inferiores pode não ser real e refletir a presença de edema. A força de preensão manual que aumenta um mês após o AVC mostra dado interessante sugerindo que a inflamação da fase aguda reduz a força do paciente. Apenas a variação da área muscular do braço corrigida se associou a pior capacidade funcional, quando ajustada por fatores que sabidamente associam-se ao pior prognóstico, como o NIHSS, sexo, idade e trombólise. Por fim, dentre os parâmetros iniciais apenas o HGT se mostrou associado ao pior eRm, quando ajustado por NIHSS, sexo, idade e trombólise. Conclusão: As mudanças na composição corporal de pacientes após AVC com manutenção de peso sugerem que é necessária intervenção nutricional precoce em todos os indivíduos independentemente do estado nutricional inicial no intuito de evitar prejuízos na capacidade funcional e ganho de força muscular.
Introduction: Stroke is the leading cause of disability in adult life and two-thirds of patients remain in an incomplete recovery condition after the event. These patients nutritional status is of great importance, as they become more susceptible to involuntary weight loss, with decreased appetite, dysphagia, depression, and changes in mobility, with consequent functional dependence, biochemical changes and nutritional deficiencies of macro and micronutrients. However, little is known about the nutritional outcomes and their association with functional disability after the stroke. Methodology: Clinical, nutritional, biochemical and body composition evaluations were performed in the first 72 hours of hospitalization and repeated 30 days after hospital discharge. Functional capacity was assessed by modified Rankin scale (mRs) 90 days after stroke. To determine the associations, linear and logistic multiple regressions were performed, considering a significance level 5%. Result s: A total of 84 patients were included, mostly elderly men, with low severity stroke (NIHSS 5) and 18.1% were thrombolysed. We found increased values of IL-6, overweight and obesity, as well as low values of handgrip strength at hospitalization. After 30 days of discharge, patients showed maintenance of weight, body mass index and arm muscle area; reduction of adductor pollicis muscle thickness, arm circumference and triceps skinfold; and increase of handgrip strength. They presented increase in %body fat, body fat mass, affected leg lean mass, unaffected leg lean mass, affected leg water, unaffected leg water and reduction in median phase angle, fat free mass, soft lean mass, affected arm lean mass, unaffected arm lean mass, intracellular water, extracellular water, affected arm water and unaffected arm water. Regarding the association between initial characteristics with loss of lean mass 30 days after stroke, only body mass index, fat free mass index and soft lean mass index had statistical significance. The variation of arm muscle area values at admission and 30 days after discharge was associated with disability 90 days after the stroke. We found that each increase of 1 mg/dl in glycemia at admission increased the chance of disability by 2% 90 days after the event. Discussion: Regarding the change in body composition 30 days after stroke, it is observed that both the affected and the non-affected sides undergo changes and the lower limbs behave differently from the upper limbs. The gain of lean mass observed in the lower limbs may not be real and reflect the presence of edema. The increase in handgrip strength one month after the stroke shows interesting data suggesting that the acute phase inflammation reduces patient's strength. Only the arm muscle area variation was associated with worse functional capacity, when adjusted for factors known to be associated with a worse prognosis, such as NIHSS, gender, age and thrombolysis. Finally, among the initial parameters only glycemia was associated with worse mRs, when adjusted by NIHSS, gender, age and thrombolysis. Conclusion: Changes in body composition of patients who maintain weight after stroke suggest that early nutritional intervention is required in all individuals regardless of initial nutritional status in order to avoid impairment of functional capacity and gain of muscle strength.
Introduction: Stroke is the leading cause of disability in adult life and two-thirds of patients remain in an incomplete recovery condition after the event. These patients nutritional status is of great importance, as they become more susceptible to involuntary weight loss, with decreased appetite, dysphagia, depression, and changes in mobility, with consequent functional dependence, biochemical changes and nutritional deficiencies of macro and micronutrients. However, little is known about the nutritional outcomes and their association with functional disability after the stroke. Methodology: Clinical, nutritional, biochemical and body composition evaluations were performed in the first 72 hours of hospitalization and repeated 30 days after hospital discharge. Functional capacity was assessed by modified Rankin scale (mRs) 90 days after stroke. To determine the associations, linear and logistic multiple regressions were performed, considering a significance level 5%. Result s: A total of 84 patients were included, mostly elderly men, with low severity stroke (NIHSS 5) and 18.1% were thrombolysed. We found increased values of IL-6, overweight and obesity, as well as low values of handgrip strength at hospitalization. After 30 days of discharge, patients showed maintenance of weight, body mass index and arm muscle area; reduction of adductor pollicis muscle thickness, arm circumference and triceps skinfold; and increase of handgrip strength. They presented increase in %body fat, body fat mass, affected leg lean mass, unaffected leg lean mass, affected leg water, unaffected leg water and reduction in median phase angle, fat free mass, soft lean mass, affected arm lean mass, unaffected arm lean mass, intracellular water, extracellular water, affected arm water and unaffected arm water. Regarding the association between initial characteristics with loss of lean mass 30 days after stroke, only body mass index, fat free mass index and soft lean mass index had statistical significance. The variation of arm muscle area values at admission and 30 days after discharge was associated with disability 90 days after the stroke. We found that each increase of 1 mg/dl in glycemia at admission increased the chance of disability by 2% 90 days after the event. Discussion: Regarding the change in body composition 30 days after stroke, it is observed that both the affected and the non-affected sides undergo changes and the lower limbs behave differently from the upper limbs. The gain of lean mass observed in the lower limbs may not be real and reflect the presence of edema. The increase in handgrip strength one month after the stroke shows interesting data suggesting that the acute phase inflammation reduces patient's strength. Only the arm muscle area variation was associated with worse functional capacity, when adjusted for factors known to be associated with a worse prognosis, such as NIHSS, gender, age and thrombolysis. Finally, among the initial parameters only glycemia was associated with worse mRs, when adjusted by NIHSS, gender, age and thrombolysis. Conclusion: Changes in body composition of patients who maintain weight after stroke suggest that early nutritional intervention is required in all individuals regardless of initial nutritional status in order to avoid impairment of functional capacity and gain of muscle strength.
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Palavras-chave
Acidente vascular cerebral, avaliação nutricional, composição corporal, Stroke, nutritional assessment, body composition