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Fasting matters?不空腹抽血会影响哪些指标

2018-02-25 供稿:Major Tom 审稿:北京大学第一医院心血管内科 郑博副教授 壹周冠脉

尽管总是叮嘱患者空腹到医院抽血,但有时因为各种原因,可能并不能做到空腹抽血。我们这期来看一看空腹时与进食后化验检查指标的变化。

尽管总是叮嘱患者空腹到医院抽血,但有时因为各种原因,可能并不能做到空腹抽血。我们这期来看一看空腹时与进食后化验检查指标的变化。

先来看看欧洲临床化学和检验学联合会(EFLM)的一篇文章中提到的各国静脉采血前空腹时间:



Simundic A M, international journal of clinical chemistry, 2014

我们会发现在是否空腹采血上各国其实是有争议的。

除了特别提及的数据外,本期文章的数据主要来自于2014年发表于Clinical Biochemistry杂志上的一个设计比较严密的研究。该研究纳入了20-30岁之间10名健康男性和10名健康女性,分别在①晨起,空腹12小时后②早饭3小时后③午饭3小时后测量77项化验指标。为保证试验对象的餐食相同,餐食统一供应,早餐含有630kcal能量(碳水化合物80%,脂质11%,蛋白质9%),午餐含有850kcal能量(碳水化合物64%,脂质18%,蛋白质18%)。

下面我们按化验项目的顺序为大家梳理一下进食对各项检查会造成怎样的影响。

血常规

血常规中大部分项目并不会受到进食的影响,但非常重要的2项——白细胞和中性粒细胞在空腹与饭后发生了显著的变化。

白细胞在午饭后相比空腹时上涨了20%,而中性粒细胞则上升了30%!如此巨大的影响是不是证明了进餐对白细胞和中性粒细胞有影响呢?

1989年发表的一篇研究纳入了7685名中年男性,在一天中多次测量白细胞计数后发现,白细胞在进餐前后的变化趋势与两餐之间相同,都是从清晨到下午逐渐升高。因此,很可能是白细胞的昼夜节律而不是进食引起的白细胞变化。

下图中蓝线为实验中观察到的白细胞变化,而红线是1989年研究中白细胞的昼夜变化,进餐对白细胞的影响基本上完全可以用白细胞的昼夜节律解释。



Plumelle D, Clinical Biochemistry, 2014

但是,目前也有研究认为进餐会对血常规检查造成影响。比如一篇2010年纳入17名健康成年人的研究发现,相比空腹时的血常规,进餐2-3小时后淋巴细胞计数会显著减少(从2.24×10^9/L→1.82×10^9/L),其它一些指标变化尽管也在统计学上显著,但是没有临床价值。



Lippi G, Blood transfusion, 2010

目前暂时没有进食会影响血常规结果的决定性证据,但是很多研究都已经证明血常规会受到昼夜节律很大的影响。因此,注意血常规抽取的时间比是否空腹更为重要,傍晚的白细胞甚至可能比早上高20%。

凝血功能

凝血功能的三项指标:PT、aPTT和Fib不受进食影响。2014年意大利的另外一篇研究在对比空腹12小时与早餐后的aPTT、PT、Fib、抗凝血酶Ⅲ、蛋白C、蛋白S后,也认为进餐不会影响凝血功能检查。

血生化

肝功能

ALT、AST、ALP、GGT、总蛋白、白蛋白不受进食的影响,而总胆红素在进食后则会明显降低,降幅可达10%以上。另外一项纳入了135名健康男性和女性的研究也证实了随着空腹时间增加,血清胆红素水平逐渐增加,大约每空腹1小时,总胆红素增加0.43umol/L,可能与空腹胆汁淤积有关。但有另外的学者认为胆红素的变化是由于昼夜节律而非进食。

因此,肝功能受到进食的影响较小,非空腹肝功能应该是可信的。

肾功能

尿素氮、β2微球蛋白、尿酸不会受到进食影响,而肌酐在进食后会显著增加。另外一篇研究发现在进食肉类食物2小时后,15名健康受试者的肌酐平均上升了约34umol/L!而如果进食的是纯素食,肌酐不会受到影响。

因此,饮食的种类对肌酐影响较大,测定应该在尽量在空腹进行,纯素食后也勉强可以接受。

电解质

电解质是否受到进食的影响可能与饮食中所含的电解质浓度有关,而在研究中并没有发现正常饮食对于电解质的显著影响。

血脂

血脂检查前是否需要空腹近几年研究很热。目前许多国家的检验标准中都规定血脂检查前需要空腹8-16个小时不等,但2016年发表在European Heart Journal上的一篇重磅共识打破了这一常识。共识由欧洲动脉粥样硬化协会和欧洲临床化学和检验学联合会发布,列举了近年来数个较大的空腹时间对血脂影响的研究,发现无论是儿童



Nordestgaard, European Heart Journal, 2016

还是成年男性和女性:



Nordestgaard, European Heart Journal, 2016

空腹时间除对甘油三酯造成一些影响外,并不会显著影响其它血脂水平。在共识发布前丹麦已经开始常规使用非空腹血脂来作为监测手段,当患者非空腹甘油三酯>4.0mmol/L时可以复查空腹甘油三酯。

因此,为了增加患者的血脂监测依从性,共识认为可以常规监测非空腹血脂。

心肌损伤标志物和BNP

心肌损伤标志物在进食前后并不会改变。目前尚未发现进食影响心肌损伤标志物的报道,可能因为健康人心肌损伤标志物的浓度很低,饮食的影响甚至无法体现在数值上。

而BNP观察到了餐后的下降,最多可以下降接近30%。尽管目前发现BNP存在昼夜节律,但BNP的变化目前还没有完全证实可以用昼夜节律解释。

其它

血清铁、淀粉酶、脂肪酶、叶酸、维生素B12、维生素D、同型半胱氨酸、CRP未发现进食有影响。

内分泌功能

研究发现内分泌的多项指标在餐前与餐后存在显著变化,但这种变化究竟是由进食、昼夜节律或是两者共同所致,还无法彻底探明。ACTH在餐后下降接近50%,皮质醇在餐后下降接近60%,C肽在餐后升高80%,C末端肽降低接近50%,胰岛素升高90%,催乳素降低60%,甲状旁腺素降低20%,睾酮降低接近30%,TSH降低接近30%。这些指标不仅需要要求空腹,可能更重要的是抽取血样的时间。

不过还是有不少内分泌指标在餐前与餐后并没有显著变化,比如糖化血红蛋白、糖化白蛋白、脱氢表雄酮、雌激素、FSH、LH、FT3、FT4、IGF-1、性激素结合球蛋白。

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    2018-03-19 JR19860219
  3. 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objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=7248, encryptionId=3836e24819, topicName=FAS)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=872f168, createdName=gracezdd, createdTime=Wed Sep 19 14:44:00 CST 2018, time=2018-09-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=299327, encodeId=d22129932e63, content=外文文献要收费.楼主能提供一下PDF吗?万分感谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=101, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/03/16/f8a7289c012efae3c89a93cab6062ed0.jpg, createdBy=9e352268777, createdName=MiDo2323, createdTime=Sat Mar 24 21:31:14 CST 2018, time=2018-03-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291785, encodeId=a678291e8592, content=学习., beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDcVAydhtcpjiaxLrZD7Eb5YnKPgf7ypGpfyl7FflFyAenvQLbib6T0LPXIhXo9SPNPXYYFFJbEgykztwJ0HQ61I3F9GxIVKWsgQ/0, createdBy=f38d2052407, createdName=周周人, createdTime=Wed Feb 28 21:15:05 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291771, encodeId=89dc291e71f8, content=学习.收藏!, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKxOtU2LLg9E2KbPibBdq6POoY0QAwC8oLj6zIKgS4VfrflMDbSwSu1GS3SBDw1J4jul1VXybeyyUg/0, createdBy=c6192196125, createdName=Zoe.D, createdTime=Wed Feb 28 20:27:35 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291485, encodeId=be3129148583, content=非常好.受益匪浅!, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76d12257050, createdName=12177770m58暂无昵称, createdTime=Tue Feb 27 22:55:08 CST 2018, time=2018-02-27, status=1, ipAttribution=)]
    2018-04-11 anminleiryan
  4. 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  5. 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  6. 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objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDcVAydhtcpjiaxLrZD7Eb5YnKPgf7ypGpfyl7FflFyAenvQLbib6T0LPXIhXo9SPNPXYYFFJbEgykztwJ0HQ61I3F9GxIVKWsgQ/0, createdBy=f38d2052407, createdName=周周人, createdTime=Wed Feb 28 21:15:05 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291771, encodeId=89dc291e71f8, content=学习.收藏!, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKxOtU2LLg9E2KbPibBdq6POoY0QAwC8oLj6zIKgS4VfrflMDbSwSu1GS3SBDw1J4jul1VXybeyyUg/0, createdBy=c6192196125, createdName=Zoe.D, createdTime=Wed Feb 28 20:27:35 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291485, encodeId=be3129148583, content=非常好.受益匪浅!, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76d12257050, createdName=12177770m58暂无昵称, createdTime=Tue Feb 27 22:55:08 CST 2018, time=2018-02-27, status=1, ipAttribution=)]
    2018-09-19 gracezdd
  7. 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GetPortalCommentsPageByObjectIdResponse(id=291485, encodeId=be3129148583, content=非常好.受益匪浅!, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76d12257050, createdName=12177770m58暂无昵称, createdTime=Tue Feb 27 22:55:08 CST 2018, time=2018-02-27, status=1, ipAttribution=)]
    2018-03-24 MiDo2323

    外文文献要收费.楼主能提供一下PDF吗?万分感谢

    0

  8. 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objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDcVAydhtcpjiaxLrZD7Eb5YnKPgf7ypGpfyl7FflFyAenvQLbib6T0LPXIhXo9SPNPXYYFFJbEgykztwJ0HQ61I3F9GxIVKWsgQ/0, createdBy=f38d2052407, createdName=周周人, createdTime=Wed Feb 28 21:15:05 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291771, encodeId=89dc291e71f8, content=学习.收藏!, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKxOtU2LLg9E2KbPibBdq6POoY0QAwC8oLj6zIKgS4VfrflMDbSwSu1GS3SBDw1J4jul1VXybeyyUg/0, createdBy=c6192196125, createdName=Zoe.D, createdTime=Wed Feb 28 20:27:35 CST 2018, time=2018-02-28, status=1, ipAttribution=), 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    2018-02-28 周周人

    学习.

    0

  9. 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objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDcVAydhtcpjiaxLrZD7Eb5YnKPgf7ypGpfyl7FflFyAenvQLbib6T0LPXIhXo9SPNPXYYFFJbEgykztwJ0HQ61I3F9GxIVKWsgQ/0, createdBy=f38d2052407, createdName=周周人, createdTime=Wed Feb 28 21:15:05 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291771, encodeId=89dc291e71f8, content=学习.收藏!, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKxOtU2LLg9E2KbPibBdq6POoY0QAwC8oLj6zIKgS4VfrflMDbSwSu1GS3SBDw1J4jul1VXybeyyUg/0, createdBy=c6192196125, createdName=Zoe.D, createdTime=Wed Feb 28 20:27:35 CST 2018, time=2018-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291485, encodeId=be3129148583, content=非常好.受益匪浅!, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76d12257050, createdName=12177770m58暂无昵称, createdTime=Tue Feb 27 22:55:08 CST 2018, time=2018-02-27, status=1, ipAttribution=)]
    2018-02-28 Zoe.D

    学习.收藏!

    0

  10. 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GetPortalCommentsPageByObjectIdResponse(id=291485, encodeId=be3129148583, content=非常好.受益匪浅!, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76d12257050, createdName=12177770m58暂无昵称, createdTime=Tue Feb 27 22:55:08 CST 2018, time=2018-02-27, status=1, ipAttribution=)]
    2018-02-27 12177770m58暂无昵称

    非常好.受益匪浅!

    0

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