第7天热量摄入作为吞咽困难老年患者后续死亡的早期动态预后标志物：一项里程碑队列分析

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中文摘要

背景： 早期营养状况可能影响接受人工营养的吞咽困难老年人的预后。然而，开始肠内或肠外营养后不久的热量摄入的预测价值仍不清楚。本研究旨在探讨日本吞咽困难老年患者第7天热量摄入与后续全因死亡率之间的关联，并评估其作为早期动态预后标志物的潜力。
方法： 我们对246名在开始经皮内镜下胃造瘘术（PEG）或全肠外营养（TPN）后存活超过7天的老年人进行了第7天里程碑队列分析。第7天热量摄入既作为连续变量（每100 kcal/天）分析，也作为分类变量（<900 vs. ≥900 kcal/天）分析。使用多变量Cox比例风险模型估计后续全因死亡的风险比（HRs），并调整年龄、性别、营养途径、重度痴呆、吸入性肺炎、慢性心力衰竭、血清白蛋白、血红蛋白、C反应蛋白和临床衰弱量表。应用Kaplan-Meier生存曲线、亚组分析和365天时的时间依赖性受试者工作特征（ROC）曲线来评估稳健性和预测区分度。
结果： 在所有模型中，较高的第7天热量摄入始终与较低的后续全因死亡率相关。在完全调整模型中，每增加100 kcal/天与较低的后续死亡率相关（HR，0.82；95% CI 0.72-0.93；P = 0.002）。在次要分类分析中，接受≥900 kcal/天的患者死亡率低于<900 kcal/天的患者（HR，0.47；95% CI 0.26-0.83；P = 0.010）。Kaplan-Meier曲线显示高摄入组的生存概率更高（P = 0.01），亚组分析显示在预设分层之间没有统计学显著的交互作用（所有交互作用P > 0.05）。时间依赖性ROC分析显示，在基线模型中加入第7天热量摄入后AUC略有增加，表明预测区分度有所改善。
结论： 在存活超过第7天里程碑的吞咽困难老年患者中，较高的记录第7天热量摄入与较低的后续全因死亡率相关。因此，第7天热量摄入可作为该人群风险分层的早期动态预后标志物。未来需要进行多中心前瞻性研究来验证这些发现，并探讨早期营养优化是否能改善生存率和以患者为中心的结局。

英文摘要

BACKGROUND: Early nutritional status may influence prognosis in older adults with dysphagia receiving artificial nutrition. However, the predictive value of caloric intake shortly after initiation of enteral or parenteral nutrition remains unclear. This study aimed to investigate the association between day-7 caloric intake and subsequent all-cause mortality in older Japanese patients with dysphagia and assess its potential as an early dynamic prognostic marker.
METHODS: We conducted a day-7 landmark cohort analysis of 246 older adults who survived beyond 7 days after initiation of percutaneous endoscopic gastrostomy (PEG) or total parenteral nutrition (TPN). Day-7 caloric intake was analyzed both as a continuous variable (per 100 kcal/day) and categorically (<900 vs. ≥900 kcal/day). Multivariable Cox proportional hazards models adjusted for age, sex, nutritional route, severe dementia, aspiration pneumonia, chronic heart failure, serum albumin, hemoglobin, C-reactive protein, and Clinical Frailty Scale were used to estimate hazard ratios (HRs) for subsequent all-cause mortality. Kaplan-Meier survival curves, subgroup analyses, and time-dependent receiver operating characteristic (ROC) curves at 365 days were applied to evaluate robustness and predictive discrimination.
RESULTS: Higher day-7 caloric intake was consistently associated with lower subsequent all-cause mortality across all models. Each 100 kcal/day increase was associated with lower subsequent mortality in the fully adjusted model (HR, 0.82; 95% CI 0.72-0.93; P = 0.002). In secondary categorical analysis, patients receiving ≥900 kcal/day had lower mortality than those with <900 kcal/day (HR, 0.47; 95% CI 0.26-0.83; P = 0.010). Kaplan-Meier curves showed higher survival probability in the high-intake group (P = 0.01), and subgroup analyses showed no statistically significant interactions across prespecified strata (all P for interaction > 0.05). Time-dependent ROC analysis showed a modest increase in AUC after adding day-7 caloric intake to the baseline model, indicating improved predictive discrimination.
CONCLUSION: Among older patients with dysphagia who survived beyond the day-7 landmark, higher recorded day-7 caloric intake was associated with lower subsequent all-cause mortality. Day-7 caloric intake may therefore serve as an early dynamic prognostic marker for risk stratification in this population. Future multicenter prospective studies are warranted to validate these findings and explore whether early nutritional optimization can improve survival and patient-centered outcomes.