Managing liver dysfunction in parenteral nutrition: BAPEN Symposium 4 on ‘Managing complications in long-term parenteral nutrition’

Genetic factors associated with alterations in liver function test results in adult hospitalized patients treated with parenteral nutrition: A substudy of a clinical trial

OBJECTIVES

The presence of phytosterols in vegetable-based lipid emulsions has been associated with alterations in the results of liver function tests (LFTs). Serum levels of phytosterols are under strict genetic control. T-allele carriers in rs41360247 and C-allele carriers in rs4245791 of ABCG8genes are associated with higher phytosterolemia. The objective of this study was to determine the association between these single-nucleotide polymorphisms (SNPs) and LFT result alterations in an adult hospitalized population treated with parenteral nutrition.

METHODS

This is a substudy of a previous clinical trial (EudraCT 2014-003597-17). It included adult hospitalized patients who had received at least 7 d of parenteral nutrition with 0.8 g/kg/d of an olive/soybean lipid emulsion, randomized 1:1 to receive the same olive/soybean emulsion or 100% fish oil at a dose of 0.4 g/kg/d for 7 d. Plasma phytosterols and their fractions, rs41360247 and rs4245791 of ABCG8 genes, and LFT were determined. Analyses of variance were performed to determine the association between the SNPs and LFT values, as well as total phytosterol values and their fractions. Simple linear regressions were performed to analyze LFT variations and the different interactions of the SNPs studied with phytosterols and their fractions. Interactions of the synergic variable plasma phytosterol and its fractions with SNPs allow us to study the interaction of the SNPs with phytosterols with a regression.

RESULTS

We included 19 participants. In the multivariate model, total phytosterols, sitosterol, and lanosterol were positively associated with increases in γ-glutamyltransferase. Significant increases with stigmasterol were associated with the T allele of rs41360247, whereas campesterol showed only a tendency to increase that was not significant. Increases in alkaline phosphatase were associated with T-rs41360247 independent of the presence of phytosterols. With stigmasterol, C-allele carriers of rs4245791 showed a tendency to increase, and also for sitosterol and lanosterol, although independent of the SNP analyzed. Increases in alanine aminotransferase were positively associated with total phytosterol and sitostanol, whereas lanosterol and stigmasterol were associated with the presence of the T allele of rs41360247.

CONCLUSIONS

With both SNPs rs41360247 and rs4245791, the alteration in parameters of liver function in adult patients with short-term parenteral nutrition is conditional.

Nutritional Feeding Strategies in Pediatric Intestinal Failure

Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.

Phytosterolemia and γ-glutamyl transferase in adults with parenteral nutrition: Fish versus vegetal lipids: A randomized clinical trial

OBJECTIVES

Fish oil (FO)-based lipid emulsions (LEs) have been reported to prevent hepatic dysfunction in patients treated with parenteral nutrition (PN). We studied patients with alterations of γ-glutamyl transferase (GGT) associated with the administration of PN containing olive/soybean (O/S)-based LE. The aim of this study was to determine whether the strategy of reducing the lipid dose by 50%, by changing to an FO-based LE, reduced plasma levels of phytosterols (PS) and GGT more effectively and safely, than the strategy of reducing lipid contribution by 50% while maintaining the same LE composition.

METHODS

A randomized double-blind clinical trial was carried out in patients with normal initial GGT, who after a minimum of 1 wk of daily PN (0.8 g/kg of O/S-based LE) presented with GGT values twice the upper normal value. At the time of randomization 1:1, lipids were reduced to 0.4 g/kg daily. Group A maintained O/S LE and group B changed to FO LE. The primary endpoints were reduction of plasmatic PS and GGT on day 7 after randomization, performed in the study population per protocol by Student's t test and simple linear regression. Secondary outcomes included alkaline phosphatase (AP), alanine transaminase (ALT), and total bilirubin (BIL), and safety variables.

RESULTS

Nineteen patients were included. On day 7 after randomization, GGT and AP values were higher in the O/S group (n = 10; GGT: median [Med], 4.99; interquartile range [IQR], 4.09; AP: Med, 2.59 μkat/L; IQR 1.74) than in the FO group (n = 9; GGT: Med, 2.26 μkat/L; IQR, 1.07; AP: Med, 1.2 μkat/L; IQR 1.44). Although there were no differences in ALT and BIL values, the ALT decrease was larger and more statistically significant in the FO group than in the O/S group (P = 0.009). Total PS (Med, 21.10 μg/mL; IQR, 5.50) in the O/S group was higher than in the FO group (Med, 13.4 μg/mL; IQR, 10.65; P = 0.002). Significant decreases in PS and their fractions were observed, with the exception of campesterol and stigmasterol.

CONCLUSION

Plasma accumulation of PS and high values of GGT, AP, and ALT can be prevented with the exclusive administration of FO-based LE.

Risk factors of hepatic function alterations in hospitalized adult patients treated with short-term parenteral nutrition receiving the same lipid composition at the same dose

BACKGROUND

High doses and vegetable origin of lipid emulsions (LE) are prominent factors for liver test (LT) alterations in patients treated with parenteral nutrition (PN). This study aims to determine incidence of LT alterations, and risk factors related to these alterations in patients with short term PN with homogenous LE.

METHODS

Adult non-critically ill hospitalized patients, with normal LTs at the beginning of PN, receiving 0.8 g/kg/day of an olive/soybean LE were included. A paired Student t-test was applied to compare final with initial LT values. LT variation (end vs start of PN) according to type of surgery and infection was studied by means of an analysis of the variance. Univariate and multivariate analyses were constructed to relate the variations of each of the 4 LTs with the adjustment variables.

RESULTS

One hundred eighty one patients (66.57 ± 12.89 years; 72.4% men), 66.8% suffered from cancer. Final LT values increased from initial values for gamma-glutamyltransferase (GGT) 2.69 ± 2.49 μkat/L vs 0.55 ± 0.36 μkat/L, alkaline phosphatase (AP) 1.97 ± 1.49 μkat/L vs 1.04 ± 0.33 μkat/L, and alanine aminotransferase (ALT) 0.57 ± 0.92 μkat/L vs 0.32 ± 0.26 μkat/L. GGT and AP variations were associated with days of PN; GGT, AP and total bilirubin with surgical patients, AP variations with infection, and GGT with cancer. Multivariate analysis: elevation of GGT, AP and ALT was related to infection, days of PN and surgery.

CONCLUSIONS

Factors that increased the risk of LTs elevation during short term PN treatment were duration of PN, surgery, cancer, and infection associated with oxidative stress.

Medium and Long Chain Fatty Acids Differentially Modulate Apoptosis and Release of Inflammatory Cytokines in Human Liver Cells

Medium chain fatty acids (MCFA) can be more easily absorbed and supply energy more rapidly than long chain fatty acids (LCFA). However, little is known about the inflammatory response by the treatment of MCFA in human liver cells. Thus this study used human liver cells (LO2) to evaluate the effects of MCFA on apoptosis and inflammatory response. Tetrazolim-based colorimetric assay and lactate dehydrogenase assay were used to measure the viability of LO2 cells, isolated spleens and liver cells from BALB/C mice. Inverted fluorescence microscopy and flow cytometry were used to assess the cell apoptosis. Activity of superoxide dismutase and malondialdehyde level were measured to determine the oxidative damage. mRNA or protein levels of classical pro-inflammatory cytokines were analyzed by quantitative real-time polymerase chain reaction (qPCR), enzyme-linked immunosorbent assay and western blotting. The results showed that the liver cells treated with the fatty acids at 200 μM for 24 h exhibited good viability. Fatty acids induced inflammatory cytokines at transcriptional and translational levels to a lesser extent than lipopolysaccharide. LCFA (oleic acid) up-regulated tumor necrosis fator-α, monocyte chemoattractant-1 and interleukin-1β while down-regulated IL-6 and IL-8 secretion to a higher extent than MCFA in mRNA and protein levels. These findings suggested that MCFA may induce apoptosis to a less extent and exert more gentle inflammation than LCFA in human liver cells.

Pediatric parenteral nutrition-associated liver disease and cholestasis: Novel advances in pathomechanisms-based prevention and treatment

Parenteral nutrition constitutes a life-saving therapeutic tool in patients unable to ingest/absorb oral or enteral delivered nutrients. Liver function tests abnormalities are a common therapy-related complication, thus configuring the so-called Parenteral Nutrition Associated Liver Disease (PNALD) or cholestasis (PNAC). Although the damage is frequently mild, and resolves after discontinuation of parenteral nutrition, in some cases it progresses into cirrhotic changes, especially in neonates and infants. We present a literature review focusing on the pathogenetic mechanisms-driven prevention and therapies for the cases where parenteral nutrition cannot be discontinued. Ursodeoxycholic acid has been proposed in patients with cholestatic hepatopathy, but its efficacy needs to be better established. Little evidence is available on efficacy of anti-oxidants, antibiotics, probiotics and anti TNFα. Lipid emulsions based on fish oil with a high content of long-chain polyunsaturated fatty acids ω-3 appear effective both in decreasing intrahepatic inflammation and in improving biliary flow. Most recent promising variations such as soybean/MCT/olive/fish oil emulsion [third generation lipid emulsion (SMOFlipid)] are under investigation. In conclusion, we remark the emergence of a number of novel pathomechanisms underlying the severe liver impairment damage (PNALD and PNAC) in patients treated with parenteral nutrition. Only few traditional and innovative therapeutic strategies have hitherto been shown promising.

[Motility disorders of the small intestine]

Chronic intestinal pseudo-obstruction (CIPO) is the most severe form of intestinal motility disorder, which leads to chronic or intermittent symptoms and signs of (sub-)ileus despite the absence of an intestinal obstruction. Small bowel motility disturbances may occur as primary diseases or secondary to a large number of other diseases and disturbances including rheumatological diseases and neurotoxic drugs. Pathological alterations affect the nervous system, smooth muscles, and/or mesenchymal structures such as the interstitial cells of Cajal or glia cells. Clinical symptoms are unspecific so that the initially suspected diagnosis is almost always wrong. Thus, extensive and stepwise diagnostic procedures are required involving specialized centers in order to exclude intestinal obstruction, to search for complications and potential causes of the disease, to quantify the extension and severity of the motility disorder, and to clarify the pathomechanism if possible. General therapeutic goals include maintenance of adequate nutritional status, improvement of propulsive motility, amelioration of abdominal symptoms, and avoidance and/or therapy of complications. Some CIPO patients require permanent parenteral nutrition. If this causes intolerable complications, small bowel transplantation can be considered in suitable patients as ultima ratio.

Dynamic changes in amino acid concentration profiles in patients with sepsis

Objectives

The goal of this work was to explore the dynamic concentration profiles of 42 amino acids and the significance of these profiles in relation to sepsis, with the aim of providing guidance for clinical therapies.

Methods

Thirty-five critically ill patients with sepsis were included. These patients were further divided into sepsis (12 cases) and severe sepsis (23 cases) groups or survivor (20 cases) and non-survivor (15 cases) groups. Serum samples from the patients were collected on days 1, 3, 5, 7, 10, and 14 following intensive care unit (ICU) admission, and the serum concentrations of 42 amino acids were measured.

Results

The metabolic spectrum of the amino acids changed dramatically in patients with sepsis. As the disease progressed further or with poor prognosis, the levels of the different amino acids gradually increased, decreased, or fluctuated over time. The concentrations of sulfur-containing amino acids (SAAs), especially taurine, decreased significantly as the severity of sepsis worsened or with poor prognosis of the patient. The serum concentrations of SAAs, especially taurine, exhibited weak negative correlations with the Sequential Organ Failure Assessment (SOFA) (r=-0.319) and Acute Physiology and Chronic Health Evaluation (APACHE) II (r=-0.325) scores. The areas under the receiver operating characteristic curves of cystine, taurine, and SAA levels and the SOFA and APACHE II scores, which denoted disease prognosis, were 0.623, 0.674, 0.678, 0.86, and 0.857, respectively.

Conclusions

Critically ill patients with disorders of amino acid metabolism, especially of SAAs such as cystine and taurine, may provide an indicator of the need for the nutritional support of sepsis in the clinic.

Trial Registration

ClinicalTrial.gov identifier NCT01818830.

Review article: the management of long-term parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

AIM

To summarise the major issues in delivering long-term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.

METHODS

A literature search using PubMed and MEDLINE databases was performed.

RESULTS

Safe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter-associated blood stream infection (reported incidence 0.14-0.83 episodes/patient-year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient-year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19-75%) and advanced liver disease (0-50%). Five-year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long-term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.

CONCLUSIONS

Home parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter-related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

Lipids and liver dysfunction in patients receiving parenteral nutrition

PURPOSE OF REVIEW

Abnormalities of liver function tests are common in patients with intestinal failure receiving parenteral nutrition. Lipid emulsions have been implicated in the development of hepatobiliary disease in patients receiving parenteral nutrition.

RECENT FINDINGS

Lipid emulsions with reduced polyunsaturated fatty acids and specific ω6 : ω3 fatty acid ratios have been shown to have some beneficial effects on liver function, although the studies are small and generally of short duration in paediatric and adult patients.

SUMMARY

There is good evidence to suggest that the parenteral lipid dose should be less than 1 g/kg body weight/day, but this may not apply to all patients. The evidence is presented for the different lipid emulsions and their effect on liver function. The benefit of these emulsions compared with simply giving a lower lipid dose has yet to be studied.

Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding

Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.

Cholestasis and growth in neonates with gastroschisis

PURPOSE

The aim of this study was to determine the incidence of cholestasis and the correlation between cholestasis and weight-for-age z scores in parenteral nutrition-dependent neonates with gastroschisis.

METHODS

A single-center retrospective review of 59 infants born with gastroschisis from January 2000 to June 2007 was conducted. Demographic and clinical data were collected and analyzed. Subjects were divided into cholestatic and noncholestatic groups. Statistical analyses included the Student t test, Wilcoxon rank sum test, Fisher exact test, and a general linear model.

RESULTS

Fifty-nine neonates with gastroschisis were identified, and 16 (28%) of 58 patients developed cholestasis. Younger gestational age and cholestasis were found to be independently associated with weight-for-age z score in 30 of 58 patients with available long-term follow-up data.

CONCLUSIONS

Parenteral nutrition-dependent neonates with gastroschisis remain at considerable risk for the development of cholestasis. Both gestational age and cholestasis were found to be independent risk factors, predisposing these neonates to poor postnatal growth.

Steroidal compounds in commercial parenteral lipid emulsions

Parenteral nutrition lipid emulsions made from various plant oils contain steroidal compounds, called phytosterols. During parenteral administration of lipid emulsions, phytosterols can reach levels in the blood that are many fold higher than during enteral administration. The elevated phytosterol levels have been associated with the development of liver dysfunction and the rare development of liver failure. There is limited information available in the literature related to phytosterol concentrations in lipid emulsions. The objective of the current study was to validate an assay for steroidal compounds found in lipid emulsions and to compare their concentrations in the most commonly used parenteral nutrition lipid emulsions: Liposyn(®) II, Liposyn(®) III, Lipofundin(®) MCT, Lipofundin(®) N, Structolipid(®), Intralipid(®), Ivelip(®) and ClinOleic(®). Our data demonstrates that concentrations of the various steroidal compounds varied greatly between the eight lipid emulsions, with the olive oil-based lipid emulsion containing the lowest levels of phytosterols and cholesterol, and the highest concentration of squalene. The clinical impression of greater incidences of liver dysfunction with soybean versus MCT/LCT and olive/soy lipid emulsions may be reflective of the levels of phytosterols in these emulsions. This information may help guide future studies and clinical care of patients with lipid emulsion-associated liver dysfunction.

Chronic intestinal failure in children

BACKGROUND

Chronic intestinal failure (CIF) in childhood is caused by congenital malformations and inflammatory diseases of the gut. Its reported prevalence is 13.7 per million population. Long-term home parenteral nutrition has dramatically improved the life expectancy and quality of life of children with CIF. The affected children are now treated with parenteral nutrition at home as soon as their medical state and family circumstances allow.

METHODS

The authors present data from a patient registry and review publications retrieved by a selective literature search.

RESULTS AND CONCLUSION

Children with CIF can now be expected to survive beyond adolescence, at the very least, and enjoy good quality of life. This goal can only be achieved if nutritional therapy is carried out safely and the affected children's development is closely monitored by an interdisciplinary team that consists of primary care physicians/family doctors, neonatologists, pediatric gastroenterologists, and pediatric surgeons. Moreover, the prevention, early detection, and appropriate treatment of complications such as infection, liver disease, renal dysfunction, and disturbances of bone metabolism is of vital importance. The patients' families must be supported by specially qualified ambulatory nurses and social workers. Treatment with parenteral, enteral, and oral nutrition and surgery enables most infants with CIF to meet all their nutritional needs orally by the time they start going to school. For children who suffer from intractable complications, intestinal transplantation provides a real and increasing chance of survival.

Enteral and Parenteral Applications of Ketogenic Diet Therapy

Ketogenic diet therapy is a high-fat, low-carbohydrate, moderate-protein regimen that results in a sustained metabolic state of ketosis. The diet was originally designed in the 1920s for treatment of epilepsy, but its use has expanded in recent years to other disorders. Most individuals who undergo this therapy are able to consume the diet orally, but those with restricted oral intake require alternative methods of nutrition. Many of our patients have feeding tubes in place for receiving part or all of their nutrition. It is possible to administer the diet during an acute condition or illness in patients who have previously received their nutrition orally. This may be accomplished enterally via a feeding tube or intravenously as parenteral nutrition. This article addresses enteral and parenteral applications of ketogenic diet therapy and provides examples of the modifications that have been successfully implemented at 4 medical centers.

Utility of liver function tests including aminotransferase-to-platelet ratio index in monitoring liver dysfunction in short-gut infants of varying ages and intestinal lengths

BACKGROUND/PURPOSE

Aspartate aminotransferase-to-platelet ratio index (APRI) has good correlation with liver fibrosis progression in the infant and toddler short-gut population. This study applies laboratory liver function testing, including APRI, to monitor liver dysfunction over time for short-gut infants, with further analysis of at-risk subpopulations.

METHODS

Study inclusion criteria included infants younger than 1 year at initial intestinal resection with subsequent continuous parenteral nutrition dependence of 3 months minimum. Bilirubin, aspartate aminotransferase, alanine aminotransferase, APRI, and biopsies were collected for 26 weeks postresection. Subgroup analysis was stratified by (1) estimated gestational age, (2) age at intestinal resection (AGE), and (3) remaining intestinal length.

RESULTS

Thirty-one children were included, all with AGE younger than 2 months at initial intestinal resection (mean, 13 days). Aminotransferase-to-platelet ratio index was the only marker associated with fibrosis progression (median, APRI by METAVIR grade: F0/F1/F2, 1.9; F3, 5.7; F4, 14.7 [P = .02]). At 8 and 18 weeks postresection, there are separations seen within study subgroups, indicating the onset and progression of liver dysfunction.

CONCLUSION

Aminotransferase-to-platelet ratio index is associated with liver fibrosis progression in this population. There are marked changes in liver dysfunction at 8 and 18 weeks postresection, with subgroup differences within estimated gestational age, AGE, and remaining intestinal length.

Systematic review: medical and nutritional interventions for the management of intestinal failure and its resultant complications in children

BACKGROUND

Intestinal failure (IF) affects a growing number of children due to increasing numbers of preterm infants surviving intestinal resection for necrotising enterocolitis and improving surgical techniques for congenital gut anomalies. Parenteral nutrition (PN) is the mainstay of therapy; enteral nutrition may have trophic effects on the gut.

AIM

To review systematically evidence for the effectiveness of medical and nutritional interventions in the treatment of IF in children.

METHODS

Retrieval of data from studies of patients aged <18 years and receiving >28 days of PN. Outcome measures were improvement in intestinal function, intestinal adaptation, growth, prevention and treatment of IF-associated liver disease, and mortality. Cochrane Database (November 2009), MEDLINE (1950-November 2009) and CINAHL (1982-November 2009) electronic database searches were made using keyword and subject headings (MeSH): IF, Short Bowel Syndrome (SBS), PN and Child. The level of the evidence (EL) was assessed using SIGN (Scottish Intercollegiate Guidelines Network) methodology (http://www.sign.ac.uk).

RESULTS

From 1 607 620 hits, 720 abstracts were reviewed. Thirty-three original articles were included. No studies were of high methodological quality.

CONCLUSIONS

The evidence base for medical and nutritional interventions in paediatric IF is limited and of poor quality. In the absence of randomised-controlled trials, this evidence base can improve through case control and cohort research; and with better multiagency communication, the study of inter-centre differences is possible. Achievable short-term goals would include the study of: optimal ursodeoxycholic usage, novel intralipid formulations, cycled enteral antibiotics, enteral probiotics and new enteral feeding strategies.

Chronic parenteral nutrition induces hepatic inflammation, steatosis, and insulin resistance in neonatal pigs

Prematurity and overfeeding in infants are associated with insulin resistance in childhood and may increase the risk of adult disease. Total parenteral nutrition (TPN) is a major source of infant nutritional support and may influence neonatal metabolic function. Our aim was to test the hypothesis that TPN induces increased adiposity and insulin resistance compared with enteral nutrition (EN) in neonatal pigs. Neonatal pigs were either fed enteral formula orally or i.v. administered a TPN mixture for 17 d; macronutrient intake was similar in both groups. During the 17-d period, we measured body composition by dual-energy X-ray absorptiometry scanning; fasting i.v. glucose tolerance tests (IVGTT) and hyperinsulinemic-euglycemic clamps (CLAMP) were performed to quantify insulin resistance. On d 17, tissue was collected after 1-h, low-dose CLAMP for tissue insulin signaling assays. TPN pigs gained less lean and more body fat and developed hepatic steatosis compared with EN pigs. After 7 and 13 d, IVGTT showed evidence of insulin resistance in the TPN compared with the EN group. Fasting plasma glucose and insulin also were higher in TPN pigs. CLAMP showed that insulin sensitivity was markedly lower in TPN pigs than in EN pigs. TPN also reduced the abundance of the insulin receptor, insulin receptor substrate 1, and phosphatidylinositol 3 kinase in skeletal muscle and liver and the proliferation of total pancreatic cells and β-cells. Hepatic proinflammatory genes as well as c-Jun-N-terminal kinase 1 phosphorylation, plasma interleukin 6, and tumor necrosis factor-α were all higher in TPN pigs than in EN pigs. The results demonstrate that chronic TPN induces a hepatic inflammatory response that is associated with significant insulin resistance, hepatic steatosis, and fat deposition compared with EN in neonatal pigs. Further studies are warranted to establish the mechanism of TPN-induced insulin resistance and hepatic metabolic dysfunction and whether there are persistent metabolic consequences of this lifesaving form of infant nutritional support.

Use of the aspartate aminotransferase to platelet ratio index to follow liver fibrosis progression in infants with short gut

BACKGROUND

Infants with parenteral nutrition dependence may develop liver dysfunction and progress to liver failure requiring transplantation. The aspartate aminotransferase-to-platelet ratio index (APRI) has good correlation with liver fibrosis progression in adults. This study applies APRI scoring to parenteral nutrition-dependant, short-gut infants to determine hepatic fibrosis progression.

METHODS

Laboratory values and biopsies were collected from initial intestinal resection (time 0) up to transplantation (end). Fibrosis scoring ranged from F0 (normal) to F4 (cirrhosis). Children were divided into 3 groups: (1) isolated intestine; and combined liver/intestine with gestational age (2) 34 weeks or greater and (3) 30 weeks or less. Liver function values over time, including calculated APRI, were analyzed as predictors of fibrosis.

RESULTS

Fifteen children who had 33 biopsies were included. Median APRI by fibrosis grade was F < or = 2: 1.88, F3: 3.23, and F4: 14.16 (P < .01). Median APRI at transplant by study group was (1) isolated intestine: 2.47, (2) liver/intestine 35 weeks or longer EGA: 14.16, and (3) liver/intestine 30 weeks or less EGA: 14.74 (P = .04).

CONCLUSION

Progression of APRI up to 60 days initially demonstrates similar values among study groups, but over time the score distinguishes those children with impending liver cirrhosis and differentiates fibrosis grade and study group.

Pediatric parenteral nutrition: putting the microscope on macronutrients and micronutrients

Parenteral nutrition can be a life-saving therapy, but its benefits need to be balanced with a unique set of risks and complications. Methods of practice vary because there is a dearth of research in the area of pediatric parenteral nutrition. This article reviews the available literature on parenteral nutrition in children and provides suggestions on prevention and management of parenteral nutrition-associated liver disease. Some of the issues discussed in this article include glucose infusion rates, cycling of parenteral nutrition, copper and manganese toxicity, and the provision of glutamine, selenium, and carnitine.

Stem cells as a potential future treatment of pediatric intestinal disorders

All surgical disciplines encounter planned and unplanned ischemic events that may ultimately lead to cellular dysfunction and death. Stem cell therapy has shown promise for the treatment of a variety of ischemic and inflammatory disorders where tissue damage has occurred. As stem cells have proven beneficial in many disease processes, important opportunities in the future treatment of gastrointestinal disorders may exist. Therefore, this article will serve to review the different types of stem cells that may be applicable to the treatment of gastrointestinal disorders, review the mechanisms suggesting that stem cells may work for these conditions, discuss current practices for harvesting and purifying stem cells, and provide a concise summary of a few of the pediatric intestinal disorders that could be treated with cellular therapy.