Diagnos av undernäring enl. GLIM utmaningar och implementering

Transkript

1 Diagnos av undernäring enl. GLIM utmaningar och implementering Tommy Cederholm, Seniorprofessor, Klinisk nutrition och metabolism, Uppsala Universitet Överläkare, Tema Åldrande, Karolinska Universitetssjukhuset

2 Tidigare försök att hitta en formel för undernäringsdiagnosen Subjective Global Assessment (SGA) 1987 Patient-Generated (PG)-SGA 1995 Mini Nutritional Assessment (MNA) 1999 Malnutrition Universal Screening Tool (MUST) 2000 Nutritional Risk Screening-2002 (NRS-2002) 2002 MNA-Short Form (MNA-SF) 2001 Cachexia (by Evans) 2008 Protein Energy Wasting 2008 ESPEN 2010 Cancer cachexia (by Fearon) 2011 AND/ASPEN 2012 ESPEN 2015

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4 ESPENs initiativ Nutrition indicators considered and decided Weight loss Reduced food intake Reduced appetite Low BMI Reduced lean mass Reduced fat mass Inflammation Subjective evaluation Functional measures Working Group Ballot ESPEN Working Group : Tommy Cederholm, Ingvar Bosaeus, Rocco Barazzoni, Juergen Bauer, Andre Van Gossum, Stanislaw Klek, Maurizio Muscaritoli, Ibolya Nyulasi, Johann Ochenga, Stéphane Schneider, Marian de van der Schueren, Pierre Singer Cederholm et al. Clin Nutr 2015;34:

5 ESPEN suggestion for diagnostic criteria for malnutrition Step 1. Risk screening by a validated instrument, e.g. NRS-2002, MUST, MNA(-SF), SNAQ,... i.e. BMI, Weight loss, Reduced food intake, Disease severity Step 2. Diagnosis is confirmed by BMI <18.5 kg/m 2 or Weight loss >10% (indefinite time)/>5% last 3 mo combined with either BMI <20 (<70 y)/<22 (>70 y) or FFMI <15 and 17 kg/m 2 in women and men, respect. Cederholm et al. Clin Nutr 2015;34:

6 Kritik riktad mot ESPENs diagnoskriterier För restriktiva gränsvärden; Låg prevalens och Minskad ersättning Teknik för mätning av kroppssammansättning finns vanligtvis inte tillgänglig Avsaknad av etiologiska kriterier, t.ex. mat-intag och inflammation

7 Global Leadership Initiative on Malnutrition A GLIM Pathway to Consensus ESPEN, ASPEN, FELANPE, PENSA Modified Delphi process GLIM face-to-face meetings CNW/Austin Jan 2016 ESPEN/Copenhagen Sept 2016 CNW/Orlando Feb 2017 ESPEN/The Hague Sept 2017 CNW/Las Vegas Jan 2018

8 GLIM Core committee GL Jensen / C Compher ASPEN T Cederholm / A Van Gossum ESPEN I Correia / MC Gonzalez FELANPE R Fukushima / T Higashiguchi PENSA Working group G Baptista, R Barazzoni, R Blaauw, A Crivelli, D Evans, L Gramlich, V Fuchs, S Jones, H Keller, A Malone, K Mogensen, M Muscaritoli, M Pirlich, V Pisprasert, M de van der Schueren, S Siltharm, P Singer, K Tappenden, D Waitzberg, NV Fuentes, L Lido, P Yamwong, J Yu, I Nyulasi

9 Kriterier som används i existerande instrument NRS MNA -SF MUST ESPEN 2015 ASPEN/ AND 2012 SGA Evans 2008 Fearon 2011 Etiologi Minskat matintag/food intake Y Y Y Y Y Y Y Svår sjukdom/inflammation Y Y Y Y Y Y Y Y Symtom Anorexi/nedsatt aptit Y Y Y Y Svaghet Y Y Y Tecken/fenotyp Viktförlust/Weight loss Y Y Y Y Y Y Y Y Body mass index Y Y Y Y Y Y Lean/fat free /muscle mass Y Y Y Y Y Y Fettmass/Fat mass Y Y Vätskeretention/Fluid retention Y Y Muscle function; e.g. grip strength Y Y

10 GLIMs konsensus - kriterier för malnutrition NRS MNA- SF MUST ESPEN 2015 ASPEN/ AND 2012 SGA Evans 2008 Fearon 2011 Etiologi Nedsatt matintag Y Y Y Y Y Y Y Svår sjukdom /Inflammation Y Y Y Y Y Y Y Y Tecken/Fenotyp Viktförlust Y Y Y Y Y Y Y Y Body mass index Y Y Y Y Y Y Y Y Y Y Y Y Fettfri massa /muskelmassa

11 GLIM-kriterierna samtidigt publicerade i Clin Nutr, JPEN och JCSM ESPEN, ASPEN, FELANPE, PENSA Modified Delphi process GLIM face-to-face meetings CNW/Austin Jan 2016 ESPEN/Copenhagen Sept 2016 CNW/Orlando Feb 2017 ESPEN/The Hague Sept 2017 ASPEN/Las Vegas Jan 2018 ESPEN/Madrid Sept communications

12 GLIMs schema för risk-bedömning och diagnos av malnutrition Risk screening At risk for malnutrition Use validated screening tools Diagnostic Assessment Diagnostic Criteria Phenotype o Weight loss o Low BMI/underweight o Reduced muscle mass Etiology o Decreased food intake or absorption o Disease burden/inflammatory condition Diagnosis Meets criteria for malnutrition diagnosis Requires at least 1 Phenotype Criterion and 1 Etiology Criterion Severity grading Determine severity of malnutrition Severity determined based on phenotypic criteria Cederholm T, Jensen GL et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. Clin Nutr Jensen GL, Cederholm T et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. JPEN 2018.

13 The Global Leadership Initiative on malnutrition (GLIM) Diagnos av malnutrition kräver minst 1 fenotypiskt och 1 etiologiskt kriterium Viktförlust (%) Fenotypiska kriterier >5% under de senaste 6 mån >10% under mer än 6 mån Lågt BMI (kg/m 2 ) <20 om <70 år eller <22 om >70 år Asien: <18,5 om <70 år eller <20 om >70 år Låg muskelmassa Mätt med validerad BC-teknik Etiologiska kriterier Minskat matintag eller malabsorption <50% av energibehovet >1 v, eller reducerat matintag (öht) >2 v, eller kronisk gastrointestinal malabsorption Inflammation/ hög sjukdomsbörda Akut sjukdom/ skada eller kronisk sjdrelaterad inflammation + Svårighetsgradering; Stadium 1/moderat vs. Stadium 2/svår + Etiologi-baserade diagnoser ESPEN Madrid 2018 Cederholm. Clin Nutr 2018

14 Svårighetsgradering av malnutrition Weight loss (%) Fenotypiska kriterier Low body mass index (kg/m 2 ) Reduced muscle mass Stage 1 Moderate Malnutrition (Requires 1 phenotypic criterion that meets this grade) 5-10% within the past 6 mo, or 10-20% beyond 6 mo <20 if <70 yr <22 if 70 yr Mild to moderate deficit (per validated assessment methods, see EWGSOP2) Stage 2 Severe Malnutrition (Requires 1 phenotypic criterion that meets this grade) >10% within the past 6 mo, or >20% beyond 6 mo <18.5 if <70 yr <20 if 70 yr Severe deficit (per validated assessment methods)

15 Viktförlust (%) NRS 2002 Mild >5% in 3 mo Moderate >5% in 2 mo Severe >5% in 1 mo MNA-SF Mild 1-3 kg in last months Moderate Does not know Severe >3 kg last months MUST Medium risk 5-10% in 3-6 mo High risk >10% in 3-6 mo SGA Moderate Stage B 5-10% past 6 mo Severe Stage C >10% past 6 mo Evans 2008 Cachexia >5% in <12 mo Fearon 2011 Precachexia <5% Cachexia >5% in 6 mo (>2%) ASPEN 2012 Moderate 1-2% in 1 w to <20% in I y Severe >2% in 1 w to >20% in I year ESPEN 2015 Malnourished >5% past 3 mo or >10% GLIM: Viktförlust >5% inom senaste 6 mån, eller >10% bortom 6 mån Grad 1/Moderat 5-10% under de senaste 6 mån, eller 10-20% under mer än 6 mån Grad 2/Svår >10% inom 6 mån, eller >20% bortom 6 mån

16 Body Mass Index (kg/m 2 ) NRS 2002 Mild - Moderate Severe <18.5 MNA-SF Mild Moderate Severe <19 MUST Medium risk High risk <18.5 SGA Moderate Stage B - Severe Stage C - Evans 2008 Cachexia <20 Fearon 2011 Precachexia - Cachexia <20 (when comb. with WL>2%) ASPEN 2012 Moderate - Severe - ESPEN 2015 Malnourished <18.5, or <20 (<70y)/<22(>70y) GLIM: BMI <20 om <70 år, eller <22 om >70 år Asia: <18.5 om <70 år, eller <20 om >70 år Grad 1/Moderat <20 if <70 år, eller <22 om >70 år Asia: <18.5 om <70 y, eller <20 om >70 år Grad 2/Svår <18.5 om <70 år, eller <20 om >70 år Asia: TBD

17 Fett-fri/muskel-/ lean massa NRS 2002 Mild - Moderate - Severe - MNA-SF Mild - Moderate Does not go out Severe Bed or chair bound MUST Medium risk - High risk - SGA Moderate Stage B Mild to moderate deficits in function or muscle mass Severe Stage C Severe deficit in function and muscle mass Evans 2008 Low FFMI, decreased muscle strength Fearon 2011 Precachexia - Cachexia Sarcopenia - ALM 7.26/5.45 kg/m 2 (m/w) comb. with WL >2% ASPEN 2012 Moderate Mild muscle loss Severe Moderate to severe muscle loss, or measurably reduced grip strength ESPEN 2015 Malnourished FFMI <15 kg/m2 (f), <17 kg/m2 (m) GLIM: Muskelmassa Males Females Appendicular Skeletal Muscle Index (ASMI, kg/m 2 ) (EWGSOP1) ASMI, kg/m 2 (EWGSOP2) <7 <6/5.5 ASMI, kg/m 2 (AWGS) - DXA Reduced by validated body composition <7.26 <5.25 (BC) measuring techniques Asia: Adapted Grad 1/Moderat Mild/moderate reduction by validated <7 (BC) <5.4 assessment techniques <7 <5.7 Asia: Adapted - BIA Fat free mass index (kg/m 2 ) (ESPEN) <17 <15 Appendicular lean mass (kg) (Baumgartner1998) <21.4 <14.1 Appendicular lean mass adjusted for BMI = ALM/BMI (FNIH) Grad 2/Svår Severe reduction by validated <0.725 (BC) <0.591 assessment techniques Asia: Adapted

18 Matintag/malabsorption NRS 2002 Mild 50-75% of required preceding week Moderate 25-60% of required preceding week Severe 0-25% of required preceding week MNA-SF Mild - Moderate Moderate loss of appetite past 3 mo Severe Severe loss of appetite past 3 mo MUST Medium risk - High risk Acute illness AND no food intake for >5 d SGA Moderate Stage B Definite decrease Severe Stage C Severe deficit Evans 2008 Anorexia Fearon 2011 Precachexia Anorexia Cachexia Often reduced food intake ASPEN 2012 Moderate <75% of ER for 7 d -3 mo Severe <50% of ER for >5 d - >1 mo ESPEN 2015 Malnourished - GLIM: Matintag/ malabsorption <50% av energibehovet >1 v, eller reducerat >2 v eller kronisk gastro-intestinal malabsorption

19 Svår sjukdom/inflammation NRS 2002 Mild Eg. hip fracture, chronic disease Moderate Eg. major abdominal surgery, stroke Severe Eg. head injury, bone marrow tr., ICU MNA-SF Mild Moderate Mild dementia Severe Acute disease past 3 mo, or severe dementia/depression MUST Medium risk - High risk - SGA Moderate Stage B Yes Severe Stage C Yes Evans 2008 Increased CRP/IL-6, low se-alb (3,2 g/l) Fearon 2011 Precachexia Metabolic change Cachexia Cancer w. systemic inflammation ASPEN 2012 Moderate Yes Severe Yes ESPEN 2015 Malnourished - GLIM: Inflammation/ severe disease Akut sjukdom/skada, eller kronisk sjukdomsrelaterad inflammation

20 Kliniska exempel Fall Kriterier Grad/Diagnos 58 y, m. Lung cancer. 66 kg. BMI 24. Lost 5 kg in 5 mo (7%). Reduced food intake (FI). 28 y, f. Crohn s disease. 71 kg. BMI 24. Lost 3 kg in 4 mo (4%). ASMI 5.3 kg/m 2. 4 stools/day. CRP 61 y, m. Pancreatic cancer. 96 kg. BMI Lost 15 kg in 7 mo (14%). Reduced FI 78 y, f. Parkinson s dis. Dysphagia. 55 kg. BMI Lost 15 kg in 10 y (21%). Reduced FI 36 y, m. POW. 49 kg. BMI Lost 18 kg in 15 mo (26%). Reduced FI. P: WL 7%/<6 mo. E: FI. Severe disease. P: ASMI <5.5 kg E: Malabsorpt. Inflam. disease. P: WL 14%/<6 mo E: FI. Severe disease P: WL >20%/>6 mo. BMI <20 E: FI P: WL 26%/>6 mo. BMI <18.5 E: FI St 1/Moderate D: DRM w infl St 1/Moderate D: DRM w infl St 2/Severe D: DRM w infl St 1/Moderate D: DRM wo infl St 2/Severe D: Hunger

21 Pågående GLIM-aktiviteter Implementering Validering WHO-diskussioner ICD-11 Andra klassificeringssystem Planering för revidering med 3-5 års intervall

22 Aktuella utmaningar Validitet Muskelmassa Mätteknik? Gränsvärden? Hur definiera sjukdomsbörda/inflammation? ICU/IVA Fungerar GLIM i det sammanhanget? Etnicitet, ssk avseende BMI och muskelmassa Avgränsning mot Sarkopeni Kakexi