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De Nardi L, Sala M, Turoldo F, Zanon D, Maestro A, Barbi E, Faganel Kotnik B, Maximova N. Parenteral Nutrition in the Pediatric Oncologic Population: Are There Any Sex Differences? Nutrients 2023; 15:3822. [PMID: 37686854 PMCID: PMC10490019 DOI: 10.3390/nu15173822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Gender-based medicine is attracting increasing interest every day, but studies on pediatric populations are still limited. In this setting, sex differences among patients undergoing total parenteral nutrition (TPN) have not been previously reported. This study investigated the presence of sex differences in parenteral nutrition composition and outcomes among a cohort of pediatric patients admitted at the Oncohematology and Bone Marrow Transplant Unit of the Institute for Maternal and Child Health "Burlo Garofolo" of Trieste, Italy. For all 145 recruited patients (87 males, 58 females), the following data were collected: age, sex, volume and duration of TPN, macro- and micronutrient composition of TPN bags, electrolytic or blood gases imbalance, glycolipid alterations, liver damage during TPN, and the incidence of sepsis and thrombosis. The analysis showed that females required higher daily phosphate intake (p = 0.054) and essential amino acid supplementation (p = 0.07), while males had a higher incidence of hypertriglyceridemia (p < 0.05) and cholestasis. A higher incidence of sepsis was found in the non-transplanted male population (p < 0.05). No significant differences were appreciable in other analyzed variables. This study aims to create a basis for future gender-based nutritional recommendations in the pediatric field.
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Affiliation(s)
- Laura De Nardi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (L.D.N.); (M.S.); (F.T.); (E.B.)
| | - Mariavittoria Sala
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (L.D.N.); (M.S.); (F.T.); (E.B.)
| | - Federico Turoldo
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (L.D.N.); (M.S.); (F.T.); (E.B.)
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.Z.); (A.M.)
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy; (D.Z.); (A.M.)
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Piazzale Europa 1, 34127 Trieste, Italy; (L.D.N.); (M.S.); (F.T.); (E.B.)
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy
| | - Barbara Faganel Kotnik
- Department of Hematology and Oncology, University Children’s Hospital, 1000 Ljubljana, Slovenia;
| | - Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, Via dell’Istria 65/1, 34137 Trieste, Italy
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Marquart JP, Mukherjee D, Canales BN, Flynn-O'Brien KT, Szabo A, Wagner AJ. Factors Associated with Hospital Readmission One Year Post-Discharge in Infants with Gastroschisis. Fetal Diagn Ther 2023; 50:344-352. [PMID: 37285815 DOI: 10.1159/000531449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Gastroschisis is the most common congenital abdominal wall defect with a rising prevalence. Infants with gastroschisis are at risk for multiple complications, leading to a potential increased risk for hospital readmission after discharge. We aimed to find the frequency and factors associated with an increased risk of readmission. METHODS A retrospective analysis of infants born with gastroschisis between 2013 and 2019 who received initial surgical intervention and follow-up care in the Children's Wisconsin health system was performed. The primary outcome was the frequency of hospital readmission within 1 year of discharge. We also compared maternal and infant clinical and demographic variables between those readmitted for reasons related to gastroschisis, and those readmitted for other reasons or not readmitted. RESULTS Forty of 90 (44%) infants born with gastroschisis were readmitted within 1-year of the initial discharge date, with 33 (37%) of the 90 infants being readmitted due to reasons directly related to gastroschisis. The presence of a feeding tube (p < 0.0001), a central line at discharge (p = 0.007), complex gastroschisis (p = 0.045), conjugated hyperbilirubinemia (p = 0.035), and the number of operations during the initial hospitalization (p = 0.044) were associated with readmission. Maternal race/ethnicity was the only maternal variable associated with readmission, with Black race being less likely to be readmitted (p = 0.003). Those who were readmitted were also more likely to be seen in outpatient clinics and utilize emergency healthcare resources. There was no statistically significant difference in readmission based on socioeconomic factors (all p > 0.084). CONCLUSION Infants with gastroschisis have a high hospital readmission rate, which is associated with a variety of risk factors including complex gastroschisis, multiple operations, and the presence of a feeding tube or central line at discharge. Improved awareness of these risk factors may help stratify patients in need of increased parental counseling and additional follow-up.
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Affiliation(s)
- John P Marquart
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Bethany N Canales
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy J Wagner
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
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The risk factors for cholestasis in patients with duodenal atresia in a single institutional cohort. Pediatr Surg Int 2021; 37:929-935. [PMID: 33768347 DOI: 10.1007/s00383-021-04890-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The etiology of cholestasis in neonates is associated with several factors including gastrointestinal disease and surgery. We aimed to identify the potential risk factors for perioperative cholestasis in patients with duodenal atresia and determine specific cutoff values for the risk factors. METHODS This retrospective cohort study included 76 neonates diagnosed with duodenal atresia surgically treated during the neonatal period at our institution between January 1990 and March 2017. The neonates were categorized into two groups: those with and without cholestasis. Univariate and multivariate analyses were performed to identify the possible risk factors for cholestasis. RESULTS Among the 76 neonates with duodenal atresia, 21 (27%) developed cholestasis. The duration of total parenteral nutrition was identified as a risk factor in univariate analysis; however, it was not an independent risk factor for cholestasis. Gestational age and highest C-reactive protein (CRP) values were independent risk factors, with adjusted odds ratios of 0.53 and 1.25, respectively. To predict the occurrence of cholestasis, the cutoff value for gestational age was 35.0 weeks, and highest CRP value was 2.4 mg/dL. CONCLUSIONS The occurrence of cholestasis in patients with duodenal atresia was associated with preterm delivery and severity of the inflammatory response during the perioperative period.
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Knop V, Neuberger SC, Marienfeld S, Bojunga J, Herrmann E, Poynard T, Zeuzem S, Blumenstein I, Friedrich-Rust M. Intestinal failure-associated liver disease in patients with short bowel syndrome: Evaluation by transient elastography. Nutrition 2019; 63-64:134-140. [DOI: 10.1016/j.nut.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/27/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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Sujka JA, Weaver KL, Lim JD, Gonzalez KW, Biondo DJ, Juang D, Aguayo P, Hendrickson RJ. A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition. Pediatr Surg Int 2018; 34:1177-1181. [PMID: 30267193 DOI: 10.1007/s00383-018-4351-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Hepatic dysfunction in patients reliant on total parenteral nutrition (TPN) may benefit from cycled TPN. A concern for neonatal hypoglycemia has limited the use of cycled TPN in neonates less than 1 week of age. We sought to determine both the safety and efficacy of cycled TPN in surgical neonates less than 1 week of age. METHODS A retrospective chart review was conducted on surgical neonates placed on prophylactic and therapeutic cycled TPN from January 2013 to March 2016. Specific emphasis was placed on identifying incidence of direct hyperbilirubinemia and hypoglycemic episodes. RESULTS Fourteen neonates were placed on cycled TPN; 8 were prophylactically cycled and 6 were therapeutically cycled. Median gestational age was 36 weeks (34, 37). Sixty-four percent (n = 9) had gastroschisis. There was no difference between the prophylactic and therapeutic groups in incidence of hyperbilirubinemia > 2 mg/dL (3 (37%) vs 5 (83%), p = 0.08) or the length of time to development of hyperbilirubinemia [24 days (4, 26) vs 27 days (25, 67), p = 0.17]. Time on cycling was similar though patients who were prophylactically cycled had a shorter overall time on TPN. Three (21%) infants had documented hypoglycemia, but only one infant became clinically symptomatic. CONCLUSION Prophylactic TPN cycling is a safe and efficacious nutritional management strategy in surgical neonates less than 1 week of age with low rates of hypoglycemia and a shorter total course of TPN; however, hepatic dysfunction did not appear to be improved compared to therapeutic cycling.
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Affiliation(s)
- Joseph A Sujka
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Katrina L Weaver
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Joel D Lim
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | | | - Deborah J Biondo
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Role of the Gut⁻Liver Axis in Driving Parenteral Nutrition-Associated Injury. CHILDREN-BASEL 2018; 5:children5100136. [PMID: 30257520 PMCID: PMC6210809 DOI: 10.3390/children5100136] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/16/2018] [Accepted: 09/17/2018] [Indexed: 02/06/2023]
Abstract
For decades, parenteral nutrition (PN) has been a successful method for intravenous delivery of nutrition and remains an essential therapy for individuals with intolerance of enteral feedings or impaired gut function. Although the benefits of PN are evident, its use does not come without a significant risk of complications. For instance, parenteral nutrition-associated liver disease (PNALD)—a well-described cholestatic liver injury—and atrophic changes in the gut have both been described in patients receiving PN. Although several mechanisms for these changes have been postulated, data have revealed that the introduction of enteral nutrition may mitigate this injury. This observation has led to the hypothesis that gut-derived signals, originating in response to the presence of luminal contents, may contribute to a decrease in damage to the liver and gut. This review seeks to present the current knowledge regarding the modulation of what is known as the “gut–liver axis” and the gut-derived signals which play a role in PN-associated injury.
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Yan W, Hong L, Wang Y, Feng Y, Lu L, Tao Y, Wu J, Ruan H, Tang Q, Cai W. Retrospective Dual-Center Study of Parenteral Nutrition-Associated Cholestasis in Premature Neonates: 15 Years' Experience. Nutr Clin Pract 2017; 32:407-413. [PMID: 28135431 DOI: 10.1177/0884533616687532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The pathogenesis of parenteral nutrition-associated cholestasis (PNAC) has not been clarified. The objective of this study was to explore the incidence of PNAC in premature infants without surgery and to identify associated risk factors. MATERIALS AND METHODS Premature neonates who received parenteral nutrition (PN) at least 14 days were included in a retrospective, dual-center study. Cholestasis was diagnosed as conjugated bilirubin ≥2 mg/dL. Infants with metabolic liver disease, cyanotic congenital heart disease, congenital syphilis, hepadnaviridae infection, and those who underwent surgery were excluded. Infants were divided into 3 groups chronologically: group A (2000-2004, n = 50), group B (2005-2009, n = 283), and group C (2010-2014, n = 741). A case-controlled study was conducted by comparing infants with PNAC to those without PNAC. RESULTS Of 1074 premature neonates, PNAC was confirmed in 53 infants (4.93%). There were 6.8% very low birth weight (BW) infants and 20.0% extremely low BW infants who developed PNAC. The incidence of PNAC decreased slightly during 2000-2014 (8.0%, 6.4%, and 4.2% in groups A, B, and C, respectively). Compared with those without PNAC, infants with PNAC (n = 53) had significantly younger gestational age, lower BW, longer PN duration, and higher rate of sepsis. Logistic regression showed male sex, PN duration ≥43 days, and sepsis were statistically correlated with PNAC. CONCLUSIONS Prolonged duration (≥43 days), male sex, and sepsis are probably independent risk factors for developing PNAC in premature neonates.
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Affiliation(s)
- Weihui Yan
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Li Hong
- 4 Department of Clinical Nutrition, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Yi Feng
- 4 Department of Clinical Nutrition, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lina Lu
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Yijing Tao
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Jiang Wu
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Huijuan Ruan
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Qingya Tang
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Wei Cai
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.,5 Department of Pediatric Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Spencer AU, Yu S, Tracy TF, Aouthmany MM, Llanos A, Brown MB, Brown M, Shulman RJ, Hirschl RB, Derusso PA, Cox J, Dahlgren J, Strouse PJ, Groner JI, Teitelbaum DH. Parenteral Nutrition–Associated Cholestasis in Neonates: Multivariate Analysis of the Potential Protective Effect of Taurine. JPEN J Parenter Enteral Nutr 2017; 29:337-43; discussion 343-4. [PMID: 16107596 DOI: 10.1177/0148607105029005337] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neonates receiving parenteral nutrition (PN) are at risk for PN-associated cholestasis (PNAC); however, no preventive factors for PNAC have been clearly identified. Despite reports suggesting that taurine may prevent PNAC in neonates, such an effect of taurine has not yet been definitively demonstrated. We determined whether taurine supplementation reduces the incidence of PNAC in premature or critically ill neonates. METHODS This study was part of a prospective, randomized, multi-institutional trial designed to assess cholecystokinin vs placebo as a potential preventive therapy of PNAC. Taurine supplementation of PN varied between institutions. The presence or absence of taurine in PN was analyzed by multivariate analysis, with a primary outcome measure of serum conjugated bilirubin (CB) as a measure of PNAC. RESULTS Taurine reduced PNAC in premature infants (estimated maximum CB [95% confidence interval] 0.50 mg/dL [-0.17 to 1.18] for those receiving taurine, vs 3.45 mg/dL [1.79-5.11] for neonates not receiving taurine, approaching significance, p = .07). Taurine significantly reduced PNAC in infants with necrotizing enterocolitis (NEC; estimated maximum CB 4.04 mg/dL [2.85-5.23], NEC infants receiving taurine, vs 8.29 mg/dL [5.61-10.96], NEC infants not receiving taurine, p < .01). There were too few neonates with surgical anomalies to evaluate the effect of taurine in this group. CONCLUSIONS Within specific subgroups of neonatal patients, taurine supplementation does offer a very significant degree of protection against PNAC. Patients with NEC or severe prematurity are most likely to benefit substantially from taurine supplementation.
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Affiliation(s)
- Ariel U Spencer
- Department of Surgery, University of Michigan, and C.S. Mott Children's Hospital, Ann Arbor, MI 48109, USA
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Hong L, Wu J, Cai W. Glutathione Decreased Parenteral Nutrition–Induced Hepatocyte Injury in Infant Rabbits. JPEN J Parenter Enteral Nutr 2017; 31:199-204. [PMID: 17463145 DOI: 10.1177/0148607107031003199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study was designed to explore the mechanisms in parenteral nutrition (PN)-associated hepatic dysfunction, and the possible effectiveness of glutathione (GSH) to alleviate this injury. METHODS Thirty 1-week-old New Zealand rabbits were divided into 3 groups: 10 in the control group (maternal fed); 10 in the PN group (PN for 10 days); and 10 in the GSH + PN group (PN plus glutathione for 10 days). At the end of the study, blood biochemistry analysis and liver histologic examination were performed by light and electronic microscope; malondialdehyde (MDA) content of liver tissues and apoptotic hepatocytes were also measured. RESULTS Direct bilirubin and bile acid in the PN group were significantly higher than that in the control group and in the GSH + PN group (p < .05, for both). In the PN group, there were some cholestatic or steatotic changes. In the GSH + PN group, histologic changes were reduced compared with the PN group. The electron microscopy appearances were in agreement with the histologic findings. MDA value was higher in the PN group than in the control group and in the GSH + PN group (p < .05, respectively). Terminal deoxynucleotidyl transferase mediated nick end labeling (TUNEL) assays showed that the rate of apoptotic hepatocytes in the PN group was the highest and the control group was the lowest among 3 groups (comparison between groups, p < .01, individually.) CONCLUSIONS The study showed that PN can induce hepatic dysfunction in infant rabbits. GSH can effectively reduce this injury. The study implies that oxidative stress and apoptosis contribute to PN-associated hepatic dysfunction.
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Affiliation(s)
- Li Hong
- Department of Pediatric Surgery, Xinhua Hospital and Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Jain AK, Sharma A, Arora S, Blomenkamp K, Jun IC, Luong R, Westrich DJ, Mittal A, Buchanan PM, Guzman MA, Long J, Neuschwander-Tetri BA, Teckman J. Preserved Gut Microbial Diversity Accompanies Upregulation of TGR5 and Hepatobiliary Transporters in Bile Acid-Treated Animals Receiving Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2016; 41:198-207. [PMID: 27503935 DOI: 10.1177/0148607116661838] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) is a lifesaving therapy but is associated with gut atrophy and cholestasis. While bile acids (BAs) can modulate intestinal growth via gut receptors, the gut microbiome likely influences gut proliferation and inflammation. BAs also regulate the bile salt export pump (BSEP) involved in cholestasis. We hypothesized that the BA receptor agonist oleanolic acid (OA) regulates gut TGR5 receptor and modulates gut microbiota to prevent PN-associated injury. MATERIALS AND METHODS Neonatal piglets were randomized to approximately 2 weeks of isocaloric enteral nutrition (EN), PN, or PN + enteral OA. Serum alanine aminotransferase, bilirubin, BAs, hepatic BSEP, gut TGR5, gut, liver morphology, and fecal microbiome utilizing 16S rRNA sequencing were evaluated. Kruskal-Wallis test, pairwise Mann-Whitney U test, and multilevel logistic regression analysis were performed. RESULTS PN support resulted in gut atrophy substantially prevented by OA. The median (interquartile range) for villous/crypt ratio was as follows: EN, 3.37 (2.82-3.80); PN, 1.73 (1.54-2.27); and OA, 2.89 (2.17-3.34; P = .006). Pairwise comparisons yielded P = .002 (EN vs PN), P = .180 (EN vs OA), P = .026 (PN vs OA). OA upregulated TGR5 and BSEP without significant improvement in serum bilirubin ( P = .095). A decreased microbial diversity and shift toward proinflammatory phylum Bacteroidetes were seen with PN, which was prevented by OA. CONCLUSIONS OA prevented PN-associated gut mucosal injury, Bacterioides expansion, and the decreased microbial diversity noted with PN. This study demonstrates a novel relationship among PN-associated gut dysfunction, BA treatment, and gut microbial changes.
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Affiliation(s)
- Ajay Kumar Jain
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | - Abhineet Sharma
- 2 Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sumit Arora
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | - Keith Blomenkamp
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | - Ik Chan Jun
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | - Robert Luong
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | - David John Westrich
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
| | | | - Paula M Buchanan
- 4 Center for Outcomes Research, Saint Louis University, St. Louis, Missouri, USA
| | - Miguel A Guzman
- 5 Department of Pathology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - John Long
- 6 Department of Comparative Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | | | - Jeffery Teckman
- 1 Department of Pediatrics, Saint Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St. Louis, Missouri, USA
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Choi AY, Lee YW, Chang MY. Modification of nutrition strategy for improvement of postnatal growth in very low birth weight infants. KOREAN JOURNAL OF PEDIATRICS 2016; 59:165-73. [PMID: 27186226 PMCID: PMC4865639 DOI: 10.3345/kjp.2016.59.4.165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/28/2015] [Accepted: 11/05/2015] [Indexed: 11/27/2022]
Abstract
Purpose To identify the effects of modified parenteral nutrition (PN) and enteral nutrition (EN) regimens on the growth of very low birth weight (VLBW) infants. Methods The study included VLBW infants weighing <1,500 g, admitted to Chungnam National University Hospital between October 2010 and April 2014, who were alive at the time of discharge. Subjects were divided according to 3 periods: period 1 (n=37); prior to the PN and EN regimen being modified, period 2 (n=50); following the PN-only regimen modification, period 3 (n=37); following both PN and EN regimen modification. The modified PN regimen provided 3 g/kg/day of protein and 1 g/kg/day of lipid on the first day of life. The modified EN regimen provided 3.5-4.5 g/kg/day of protein and 150 kcal/kg/day of energy. We investigated growth rate, anthropometric measurements at 40 weeks postconceptional age (PCA) and the incidence of extrauterine growth restriction (EUGR) at 40 weeks PCA. Results Across the 3 periods, clinical characteristics, including gestational age, anthropometric measurements at birth, multiple births, sex, Apgar score, surfactant use and PDA treatment, were similar. Growth rates for weight and height, from time of full enteral feeding to 40 weeks PCA, were higher in period 3. Anthropometric measurements at 40 weeks PCA were greatest in period 3. Incidence of weight, height and head circumference EUGR at 40 weeks PCA decreased in period 3. Conclusion Beginning PN earlier, with a greater supply of protein and energy during PN and EN, is advantageous for postnatal growth in VLBW infants.
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Affiliation(s)
- Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Yong Wook Lee
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Mea-Young Chang
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Orso G, Mandato C, Veropalumbo C, Cecchi N, Garzi A, Vajro P. Pediatric parenteral nutrition-associated liver disease and cholestasis: Novel advances in pathomechanisms-based prevention and treatment. Dig Liver Dis 2016; 48:215-22. [PMID: 26698410 DOI: 10.1016/j.dld.2015.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/27/2015] [Accepted: 11/06/2015] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Giuseppe Orso
- Pediatrics AORN "Santobono-Pausilipon", Naples, Italy
| | | | - Claudio Veropalumbo
- Pediatric Residency Program, Department of Translational Medical Sciences, University of Naples "Federico II", Salerno, Italy
| | - Nicola Cecchi
- Pediatrics AORN "Santobono-Pausilipon", Naples, Italy
| | - Alfredo Garzi
- Chairs of Pediatric Surgery, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Pietro Vajro
- Pediatrics, Department of Medicine and Surgery, University of Salerno, Salerno, Italy; European Laboratory of Food Induced Disease (ELFID), Naples, Italy.
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13
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Hirano K, Kubota A, Nakayama M, Kawahara H, Yoneda A, Tazuke Y, Tani G, Ishii T, Goda T, Umeda S, Hirno S, Shiraishi J, Kitajima H. Parenteral nutrition-associated liver disease in extremely low-birthweight infants with intestinal disease. Pediatr Int 2015; 57:677-81. [PMID: 25728615 DOI: 10.1111/ped.12609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 01/03/2015] [Accepted: 02/04/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND The aim of this study was to investigate factors associated with the development of parenteral nutrition-associated liver disease (PNALD) and to examine the clinicopathological relationship of PNALD in extremely low-birthweight infants (ELBWI). METHODS The subjects were 13 ELBWI who had received PN because of intestinal perforation or functional ileus between 2000 and 2013. We measured the serum levels of biochemical parameters, including aspartate aminotransferase, alanine aminotransferase, and direct bilirubin. Liver histopathology was examined in relation to outcome. The subjects were categorized into two groups on liver histopathology: F(+), development of hepatic fibrosis and necrosis with/without cholestasis; and F(-), no hepatic fibrosis. RESULTS Of 13 ELBWI, five died of hepatic failure, five died of sepsis, and the other three were alive at the time of the study. Of the five infants who died of hepatic failure, two developed fulminant hepatitis without cholestasis, and the other three developed chronic cholestasis and finally hepatic failure. Postmortem histopathology in F(+) indicated not only massive hepatic necrosis, but also massive hepatic fibrosis. These histopathological findings explained the clinical presentation of portal hypertension. There were significant differences in the fasting period after intestinal disease onset between the two groups. CONCLUSION The prolonged fasting with PN is responsible for severe hepatocellular necrosis with fibrosis and consequent lethal portal hypertension.
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Affiliation(s)
- Katsuhisa Hirano
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Akio Kubota
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Masahiro Nakayama
- Clinical Laboratory Medicine and Anatomic Pathology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hisayoshi Kawahara
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Akihiro Yoneda
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Yuko Tazuke
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Gakuto Tani
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Tomohiro Ishii
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Taro Goda
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Satoshi Umeda
- Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shinya Hirno
- Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Jun Shiraishi
- Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hirnoyuki Kitajima
- Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
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14
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Kumar JA, Teckman JH. Controversies in the Mechanism of Total Parenteral Nutrition Induced Pathology. CHILDREN-BASEL 2015; 2:358-70. [PMID: 27417369 PMCID: PMC4928764 DOI: 10.3390/children2030358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/11/2015] [Accepted: 07/14/2015] [Indexed: 12/20/2022]
Abstract
Over 30,000 patients are permanently dependent on Total Parenteral Nutrition (TPN) for survival with several folds higher requiring TPN for a prolonged duration. Unfortunately, it can cause potentially fatal complications. TPN infusion results in impairment of gut mucosal integrity, enhanced inflammation, increased cytokine expression and trans-mucosal bacterial permeation. It also causes endotoxin associated down regulation of bile acid transporters and Parenteral Nutrition Associated Liver Disease (PNALD), which includes steatosis, disrupted glucose metabolism, disrupted lipid metabolism, cholestasis and liver failure. Despite multiple theories, its etiology and pathophysiology remains elusive and is likely multifactorial. An important cause for TPN related pathologies appears to be a disruption in the normal enterohepatic circulation due to a lack of feeding during such therapy. This is further validated by the fact that in clinical settings, once cholestasis sets in, its reversal occurs when a patient is receiving a major portion of calories enterally. There are several other postulated mechanisms including gut bacterial permeation predisposing to endotoxin associated down regulation of bile acid transporters. An additional potential mechanism includes toxicity of the TPN solution itself, such as lipid mediated hepatic toxicity. Prematurity, leading to a poor development of bile acid regulating nuclear receptors and transporters has also been implicated as a causative factor. This review presents the current controversies and research into mechanisms of TPN associated injury.
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Affiliation(s)
- Jain Ajay Kumar
- Department of Pediatrics, St. Louis University School of Medicine, Cardinal Glennon Children's Medical Center, SSM Cardinal Glennon Hospital 1465 South Grand Blvd., St. Louis, MO 63104, USA.
| | - Jeffery H Teckman
- Department of Pediatrics, St. Louis University School of Medicine, Cardinal Glennon Children's Medical Center, SSM Cardinal Glennon Hospital 1465 South Grand Blvd., St. Louis, MO 63104, USA.
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine.
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15
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Jain AK, Wen JX, Blomenkamp KS, Arora S, Blaufuss TA, Rodrigues J, Long JP, Neuschwander-Tetri BA, Teckman JH. Oleanolic Acid Improves Gut Atrophy Induced by Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2015; 40:67-72. [PMID: 25921560 DOI: 10.1177/0148607115583536] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/24/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutrition support with parenteral nutrition (PN) is associated with gut atrophy. Prior studies have shown improvement with enteral chenodeoxycholic acid, a dual agonist for the farnesoid X receptor (FXR) and bile acid receptor TGR5. We hypothesized that gut growth is induced by TGR5 activation, and gut atrophy during PN administration could be prevented with the TGR5-specific agonist oleanolic acid (OA). METHODS Neonatal pigs were implanted with duodenal and jugular vein catheters. Animals were provided equi-nutritious PN or enteral swine milk. A PN subgroup received enteral OA at 50 mg/kg/d. RESULTS PN caused marked gut atrophy compared with enterally fed (EN) control animals. OA treatment led to preservation of gut mass demonstrated grossly and histologically. The mean ± SD gut weight as a percentage of body weight was 4.30 ± 0.26 for EN, 1.92 ± 0.06 for PN (P < .05, EN vs PN), and 3.39 ± 0.79 for PN+OA (P < .05, PN+OA vs PN). Mean ± SD gut density (g/cm) was 0.31 ± 0.03 for EN, 0.18 ± 0.03 for PN (P < .05 EN vs PN), and 0.27 ± 0.01 for PN+OA (P < .05 PN+OA vs PN). Histologically, a markedly decreased villous to crypt ratio was noted with PN, and OA significantly prevented this decrease. The mean ± SD v/c ratio was 3.51 ± 0.59 for EN, 1.69 ± 0.10 for PN (P < .05, EN vs PN), and 2.90 ± 0.23 for PN+OA (P < .05, PN+OA vs PN). Gut TGR5 messenger RNA expression was significantly elevated with OA treatment compared with both PN and EN. CONCLUSION The bile acid-activated G protein-coupled receptor TGR5 agonist OA prevented gut atrophy associated with PN.
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Affiliation(s)
- Ajay Kumar Jain
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - Joy X Wen
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - Keith S Blomenkamp
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - Sumit Arora
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - Timothy A Blaufuss
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - Jonathan Rodrigues
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
| | - John P Long
- Department of Biochemistry and Molecular Biology, St Louis University School of Medicine, St Louis, Missouri
| | | | - Jeffery H Teckman
- Department of Pediatrics, St Louis University School of Medicine, Cardinal Glennon Children's Medical Center, St Louis, Missouri
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Using volume index and lateral hepatic angle to differentiate biliary atresia from TPN-associated cholestasis. J Pediatr Gastroenterol Nutr 2014; 59:403-8. [PMID: 24821537 DOI: 10.1097/mpg.0000000000000433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Differential diagnosis between biliary atresia (BA) and total parenteral nutrition-associated cholestasis (TPN-AC) and early treatment for cholestatic infants are challenges for evaluating neonatal or infantile cholestasis. The aim of our retrospective study was to apply noninvasive indices of magnetic resonance images to differentiate BA from TPN-AC. METHODS A total of 44 patients diagnosed as having BA (n = 30) or TPN-AC (n = 14) were included in the present retrospective study and underwent abdominal magnetic resonance imaging to evaluate the possibility of BA. The left lateral hepatic angle was determined from the coronal image of the left portal vein and portal vein of segment II. Adjusted volume indices of the right hepatic lobe (AVIR) and left lateral segment (AVILL) were calculated as the product of 3 diameters (centimeters) divided by each patient's body weight. RESULTS The left lateral hepatic angles of patients with BA (74° ± 21°) were significantly larger than for patients with TPN-AC (33° ± 9°) and controls (36° ± 5°, P < 0.05). AVILL of the BA (0.037 ± 0.012 cm/g) and TPN-AC groups (0.042 ± 0.030 cm/g) were not significantly different (P = 0.61) but were significantly larger than for controls (0.020 ± 0.011 cm/g) (P < 0.05). The right hepatic lobe to left lateral hepatic segment ratio (RLR) of patients with BA was significantly (P < 0.05) smaller (1.61 ± 0.58) than for patients with TPN-AC (3.08 ± 2.43) and controls (2.98 ± 0.92). Patients with BA could have relative sparing and selective enlargement of the left lateral liver with a resultant lobar difference and blunt left lateral hepatic angle. CONCLUSIONS Noninvasive indices of lobar difference and left lateral hepatic angle help differentiate patients with BA from those with TPN-AC.
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17
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Impact of standardized feeding guidelines on enteral nutrition administration, growth outcomes, metabolic bone disease, and cholestasis in the NICU. J Pediatr Gastroenterol Nutr 2014; 59:93-8. [PMID: 24517917 DOI: 10.1097/mpg.0000000000000314] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The objectives of this study were to determine whether the implementation of standardized feeding guidelines (SFGs) in a neonatal intensive care unit had an impact on the administration of enteral nutrition, growth, and bone and liver health. METHODS This was a retrospective chart review of infants ≤ 32 weeks' gestation and ≤ 1500 g at birth who received enteral nutrition either via traditional care (TC) or via SFGs. The outcomes of the study were to determine the day of life the first enteral feedings were started, the day of life full, fortified enteral feedings were established, the day of life the infant returned to birth weight, the change in weight z score from birth to day of life 30, and the presence of metabolic bone disease and cholestasis. RESULTS There were 128 infants in the TC group and 125 infants in the SFG group. Based on the Cox regression, no significant differences were found between the 2 groups in the length of time to the first feed (P=0.110; CI 1.03-1.70), in the length of time to full, fortified enteral feedings (P=0.334; CI 0.87-1.44), in the length of time to return to birth weight (P=0.545; CI 0.77-1.28), incidence of metabolic bone disease (P=0.990), or incidence of cholestasis (P=0.926). CONCLUSIONS This study provides preliminary evidence that SFGs have an effect on enteral nutrition administration, growth, and morbidity for preterm infants. Although the findings were not statistically significant, they are clinically relevant.
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18
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Nghiem-Rao TH, Cassidy LD, Polzin EM, Calkins CM, Arca MJ, Goday PS. Risks and benefits of prophylactic cyclic parenteral nutrition in surgical neonates. Nutr Clin Pract 2013; 28:745-52. [PMID: 24107391 DOI: 10.1177/0884533613502813] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cyclic parenteral nutrition (PN) is used for both the treatment and prevention of parenteral nutrition-associated liver disease (PNALD). Early initiation of prophylactic cyclic PN may not be well tolerated in young neonates. Our objective was to test the hypothesis that prophylactic cyclic PN initiated prior to the onset of hyperbilirubinemia is associated with younger age at initiation, lower bilirubin levels, and similar rates of adverse events compared to therapeutic cyclic PN initiated after established cholestasis in surgical neonates. METHODS A retrospective review of infants with gastrointestinal disorders requiring surgical intervention who received cyclic PN 2006-2011 was performed. RESULTS Of the 43 infants eligible for analysis, 23 received prophylactic and 20 received therapeutic cyclic PN. Infants in both groups were comparable in demographics, surgical diagnoses, and illness severity. At initiation of cyclic PN, infants with prophylactic cyclic PN were significantly younger in chronologic (P = .003) and postmenstrual age (P = .029). Prophylactic cyclic PN was associated with a significantly lower incidence of hyperbilirubinemia (P = .001), lower maximum conjugated bilirubin (P < .0001), and lower last checked conjugated bilirubin (P = .032) compared to the therapeutic cyclic PN. The incidence of hypoglycemia, hyperglycemia, and hypertriglyceridemia was similar for the 2 groups. CONCLUSIONS There may be a potential benefit to initiating cyclic PN prior to the development of hyperbilirubinemia in surgical neonates. Early initiation of prophylactic cyclic PN does not appear to increase the risk for adverse events.
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Affiliation(s)
- T Hang Nghiem-Rao
- T. Hang Nghiem-Rao, Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, PO Box 1997, 999 N 92 St, Milwaukee, WI 53226, USA.
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Abstract
BACKGROUND AND OBJECTIVES Cholestasis affects 50% of extremely low-birth-weight infants. Its etiology remains poorly understood and the extent of liver injury in these infants is unclear. The premature baboon model provides an opportunity to study neonatal liver disease. We characterize hepatic histopathologic changes in this model. METHODS Archival tissue and data were obtained from the Southwest Foundation for Biomedical Research Primate Center, San Antonio, TX. Animals were selected based on history of antenatal steroid therapy and absence of sepsis or necrotizing enterocolitis with a protocol duration of at least 21 days and no early death (n = 45). Baboons had been treated per protocol in the neonatal intensive care unit (NICU). At necropsy, liver tissue was harvested and stored. Tissues from fetal gestational controls at similar ages were used for comparison (n = 28). Histologic changes were scored by consensus of 2 pathologists blinded to treatment group. Descriptive and comparative statistics were performed. RESULTS Control fetal livers had extramedullary hematopoiesis (EMH) that decreased across the gestational range. There was evidence of hepatocyte iron storage and ongoing portal tract development. Livers of NICU-treated baboons had increased Kupffer cell hypertrophy and hemosiderosis. There was a shift away from erythroid EMH toward increased myeloid EMH. There was increased cholestasis, ductular proliferation, portal tract fibrosis, and steatosis in treated animals. CONCLUSIONS We found pathologic changes in NICU-treated baboons comparable with findings reported in human infants. The baboon model of prematurity may be a useful tool to explore cholestasis and liver dysfunction in extremely low-birth-weight infants.
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20
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Lauriti G, Zani A, Aufieri R, Cananzi M, Chiesa PL, Eaton S, Pierro A. Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. JPEN J Parenter Enteral Nutr 2013; 38:70-85. [PMID: 23894170 DOI: 10.1177/0148607113496280] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cholestasis is a significant life-threatening complication in children on parenteral nutrition (PN). Strategies to prevent/treat PN-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) have reached moderate success with little supporting evidence. Aims of this systematic review were (1) to determine the incidence of PNAC/IFALD in children receiving PN for ≥ 14 days and (2) to review the efficacy of measures to prevent/treat PNAC/IFALD. METHODS Of 4696 abstracts screened, 406 relevant articles were reviewed, and studies on children with PN ≥ 14 days and cholestasis (conjugated bilirubin ≥ 2 mg/dL) were included. Analyzed parameters were (1) PNAC/IFALD incidence by decade and by PN length and (2) PNAC/IFALD prevention and treatment (prospective studies). RESULTS Twenty-three articles (3280 patients) showed an incidence of 28.2% and 49.8% of PNAC and IFALD, respectively, with no evident alteration over the last decades. The incidence of PNAC was directly proportional to the length of PN (from 15.7% for PN ≤ 1 month up to 60.9% for PN ≥ 2 months; P < .0001). Ten studies on PNAC met inclusion criteria. High or intermediate-dose of oral erythromycin and aminoacid-free PN with enteral whey protein gained significant benefits in preterm neonates (P < .05, P = .003, and P < .001, respectively). None of the studies reviewed met inclusion criteria for treatment. CONCLUSIONS The incidence of PNAC/IFALD in children has no obvious decrease over time. PNAC is directly correlated to the length of PN. Erythromycin and aminoacid-free PN with enteral whey protein have shown to prevent PNAC in preterm neonates. There is a lack of high-quality prospective studies, especially on IFALD.
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Affiliation(s)
- Giuseppe Lauriti
- Department of Surgery, UCL Institute of Child Health, London, UK
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21
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Lee SM, Namgung R, Park MS, Eun HS, Kim NH, Park KI, Lee C. Parenteral nutrition associated cholestasis is earlier, more prolonged and severe in small for gestational age compared with appropriate for gestational age very low birth weight infants. Yonsei Med J 2013; 54:839-44. [PMID: 23709416 PMCID: PMC3663238 DOI: 10.3349/ymj.2013.54.4.839] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We hypothesized that parenteral nutrition associated cholestasis (PNAC) would be more severe in small for gestational age (SGA) compared with appropriate for gestational age (AGA) very low birth weight (VLBW) infants. MATERIALS AND METHODS Sixty-one VLBW infants were diagnosed as PNAC with exposure to parenteral nutrition with elevation of direct bilirubin≥2 mg/dL for ≥14 days. Twenty-one SGA infants and 40 AGA infants matched for gestation were compared. RESULTS Compared with AGA infants, PNAC in SGA infants was diagnosed earlier (25±7 days vs. 35±14 days, p=0.002) and persisted longer (62±36 days vs. 46±27 days, p=0.048). Severe PNAC, defined as persistent elevation of direct bilirubin≥4 mg/dL for more than 1 month with elevation of liver enzymes, was more frequent in SGA than in AGA infants (61% vs. 35%, p=0.018). The serum total bilirubin and direct bilirubin levels during the 13 weeks of life were significantly different in SGA compared with AGA infants. SGA infants had more frequent (76% vs. 50%, p=0.046), and persistent elevation of alanine aminotransferase. CONCLUSION The clinical course of PNAC is more persistent and severe in SGA infants. Careful monitoring and treatment are required for SGA infants.
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Affiliation(s)
- Soon Min Lee
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Park
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Hyo Kim
- Department of Pediatrics, Sung-Ae General Hospital, Seoul, Korea
| | - Kook In Park
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul Lee
- Division of Neonatology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Systemic causes of cholestasis constitute a diverse group of diseases across organ systems. The pathophysiology of cholestasis in systemic disease can be a consequence of direct involvement of a disease process within the liver or extrahepatic biliary system or secondary to immune-mediated changes in bile flow. Evaluating a patient with cholestasis for a systemic cause requires an understanding of the patient's risk factors, clinical setting (eg, hospitalized or immunosuppressed patient), clinical features, and pattern of laboratory abnormalities.
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Affiliation(s)
- Andrew S. deLemos
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA,Harvard Medical School, Boston, MA 02115, USA
| | - Lawrence S. Friedman
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA,Harvard Medical School, Boston, MA 02115, USA,Tufts University School of Medicine, Boston, MA 02111, USA,Department of Medicine, Newton-Wellesley Hospital, Newton, MA 02462, USA,Corresponding author. Department of Medicine, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462.
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Chang MI, Puder M, Gura KM. The use of fish oil lipid emulsion in the treatment of intestinal failure associated liver disease (IFALD). Nutrients 2012; 4:1828-50. [PMID: 23363993 PMCID: PMC3546610 DOI: 10.3390/nu4121828] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 11/11/2012] [Accepted: 11/19/2012] [Indexed: 01/07/2023] Open
Abstract
Since 2004, fish oil based lipid emulsions have been used in the treatment of intestinal failure associated liver disease, with a noticeable impact on decreasing the incidence of morbidity and mortality of this often fatal condition. With this new therapy, however, different approaches have emerged as well as concerns about potential risks with using fish oil as a monotherapy. This review will discuss the experience to date with this lipid emulsion along with the rational for its use, controversies and concerns.
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Cohen-Wolkowiez M, Poindexter B, Bidegain M, Weitkamp JH, Schelonka RL, Randolph DA, Ward RM, Wade K, Valencia G, Burchfield D, Arrieta A, Mehta V, Walsh M, Kantak A, Rasmussen M, Sullivan JE, Finer N, Rich W, Brozanski BS, van den Anker J, Blumer J, Laughon M, Watt KM, Kearns GL, Capparelli EV, Martz K, Berezny K, Benjamin DK, Smith PB. Safety and effectiveness of meropenem in infants with suspected or complicated intra-abdominal infections. Clin Infect Dis 2012; 55:1495-502. [PMID: 22955430 DOI: 10.1093/cid/cis758] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intra-abdominal infections are common in young infants and lead to significant morbidity and mortality. Meropenem is a broad-spectrum antimicrobial with excellent activity against pathogens associated with intra-abdominal infections. The purpose of this study was to determine the safety and effectiveness of meropenem in young infants with suspected or complicated intra-abdominal infections. METHODS Preterm and term infants <91 days of age with suspected or confirmed intra-abdominal infections hospitalized in 24 neonatal intensive care units were studied in an open-label, multiple-dose study. Adverse events and serious adverse events were collected through 3 and 30 days following the last meropenem dose, respectively. Effectiveness was assessed by 3 criteria: death, bacterial cultures, and presumptive clinical cure score. RESULTS Of 200 subjects enrolled in the study, 99 (50%) experienced an adverse event, and 34 (17%) had serious adverse events; no adverse events were probably or definitely related to meropenem. The most commonly reported adverse events were sepsis (6%), seizures (5%), elevated conjugated bilirubin (5%), and hypokalemia (5%). Only 2 of the serious adverse events were determined to be possibly related to meropenem (isolated ileal perforation and an episode of fungal sepsis). Effectiveness was evaluable in 192 (96%) subjects, and overall treatment success was 84%. CONCLUSIONS Meropenem was well tolerated in this cohort of critically ill infants, and the majority of infants treated with meropenem met the definition of therapeutic success. CLINICAL TRIALS REGISTRATION NCT00621192.
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Cholestasis and growth in neonates with gastroschisis. J Pediatr Surg 2012; 47:1529-36. [PMID: 22901912 DOI: 10.1016/j.jpedsurg.2011.12.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 12/11/2011] [Accepted: 12/30/2011] [Indexed: 11/20/2022]
Abstract
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.
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Abstract
OBJECTIVES We prospectively evaluated incidence of prolonged (>28 days) parenteral nutrition (PN), associated complications, and significance of parenteral plant sterols (PS) in neonatal intestinal failure-associated liver disease (IFALD) compared with children. METHODS We recruited 28 neonates (mean age 50 days, range 28-126) and 11 children (6.9 y, 2.1-16.6) in all of Finland. Patients underwent repeated measurements of serum cholesterol, noncholesterol sterols, including PS, cholestanol and cholesterol precursors, and liver biochemistry during and 1 month after discontinuation of PN. Healthy matched neonates (n=10) and children (n=22) served as controls. RESULTS IFALD occurred more frequently among neonates (63%) than children (27%; P<0.05). Ratios of serum PS, including stigmasterol, sitosterol, avenasterol, and campesterol, and total PS were increased among neonates compared with healthy controls and children on PN by 2- to 22- and 2- to 5-fold (P<0.005), respectively. Neonates with IFALD had significantly higher ratios of serum PS and cholestanol compared with neonates without IFALD (P<0.05). Total duration of PN associated with serum cholestanol, stigmasterol, avenasterol, alanine aminotransferase, and aspartate aminotransferase (r=0.472-0.636, P<0.05). Cholestanol and individual serum PS, excluding campesterol, reflected direct bilirubin (r=0.529-0.688, P<0.05). IFALD persisted after discontinuation of PN in 25% of neonates with 4.2- and 2.2-times higher ratios of serum stigmasterol and cholestanol compared with neonates without IFALD (P<0.05). CONCLUSIONS Frequent occurrence of IFALD among neonates on PN displays an association to duration of PN and markedly increased serum PS, especially stigmasterol, in comparison to healthy neonates and children on PN. Striking accumulation of parenteral PS may contribute to IFALD among neonates.
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Koseesirikul P, Chotinaruemol S, Ukarapol N. Incidence and risk factors of parenteral nutrition-associated liver disease in newborn infants. Pediatr Int 2012; 54:434-6. [PMID: 22449297 DOI: 10.1111/j.1442-200x.2012.03627.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of the present study was to determine the incidence and risk factors of parenteral nutrition-associated liver disease (PNALD) in neonates. METHODS A 1 year prospective cohort study was carried out at the neonatal intensive care unit and sick neonatal wards, Chiang Mai University Hospital. Newborns >1000 g, receiving >7 days of parenteral nutrition (PN), were enrolled. Liver function tests were done by the end of first, second, and fourth week, and then every 4 weeks until the PN was discontinued and the jaundice resolved. The diagnosis of PNALD relied on a history of PN, direct bilirubin >2 mg/dL, and exclusion of other causes of neonatal cholestasis. Selected patient factors and PN compositions were analyzed to determine the risks for development of PNALD. RESULTS A total of 24 infants with a mean gestational age and birthweight of 32.5 weeks and 1840 g were enrolled. Eight of the 24 developed PNALD. Compared to those without PNALD, gastrointestinal surgery, duration of enteral starvation, duration of PN, maximum PN caloric intake, and maximum carbohydrate intake were significantly associated with the development of liver disease. Despite the lack of statistical significance, there was a trend towards cholestasis in patients with sepsis. Elevation of direct bilirubin was the earliest biochemical change, observed in the first week after PN, followed by increased transaminases. CONCLUSION Gastrointestinal surgery, duration of enteral starvation, duration of PN, maximum caloric and carbohydrate intake in PN were significant risks of PNALD in newborn infants.
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Duman L, Büyükyavuz BI, Akcam M, Koroglu M, Tepeli H. Percutaneous management of bile-plug syndrome: a case report. J Pediatr Surg 2011; 46:e37-41. [PMID: 22152905 DOI: 10.1016/j.jpedsurg.2011.09.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 08/25/2011] [Accepted: 09/09/2011] [Indexed: 11/25/2022]
Abstract
Bile-plug syndrome is defined as an obstruction of the common bile duct by bile sludge in full-term infants. It is a correctable cause of obstructive jaundice in infants and is generally treated surgically. Here, we present a case of a 5-month-old infant with bile-plug syndrome, which was treated by percutaneous biliary interventions. To the best of our knowledge, percutaneous treatment of bile-plug syndrome is reported for the first time in an infant. This minimal invasive treatment modality may be a useful alternative to surgery in infants with bile-plug syndrome.
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Affiliation(s)
- Levent Duman
- Department of Pediatric Surgery, Süleyman Demirel University Medical School, Isparta, Turkey.
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A preliminary report on the significance of excessively long segment congenital hypoganglionosis management during early infancy. J Pediatr Surg 2011; 46:1572-7. [PMID: 21843726 DOI: 10.1016/j.jpedsurg.2011.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 03/16/2011] [Accepted: 03/16/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND/PURPOSE Excessively long segment of congenital hypoganglionosis is rare, and therapeutic strategies to treat this disorder are not well established. The purpose of this study is to describe the significance of management in the neonatal and early infancy period. PATIENTS AND METHODS Four patients (aged 1-4 years) with hypoganglionosis were selected for this study, of which 3 were treated at our hospital. In the initial treatment of 3 cases, an intraoperative pathological diagnosis was made on the basis of findings from simultaneous biopsies taken from the jejunum and sigmoid colon. Retrospective reviews of these patients were performed. RESULTS Initial double-barrel jejunostomy at less than 50 cm from the ligament of Treitz allowed patients to start oral nutrition within a week following surgery. Subsequent refashioning of the initial jejunostomy to the Bishop-Koop type was performed at 3 to 6 months of age. Intravenous hyperalimentation was required to meet less than 50% of nutritional requirements, and patients were able to maintain their body weight within 1.5 SD of the normal mean body weight. Liver function test results were also within normal limits in the 3 patients treated at our hospital. CONCLUSION Early diagnosis and treatment may help improve the management of patients in the early stages of hypoganglionosis.
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Tazuke Y, Teitelbaum D, Wasa M, Fukuzawa M, Iiboshi Y, Fujimoto J. Parenteral Nutrition Administration Leads to Specific Alterations in the Expression of Adipocytokines and Peroxisome Proliferator-Activated Receptors in a Rat Model. JPEN J Parenter Enteral Nutr 2011; 35:329-36. [DOI: 10.1177/0148607110381266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Yuko Tazuke
- Osaka University Graduate School of Medicine, Osaka, Japan
- Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Masafumi Wasa
- Osaka University Graduate School of Medicine, Osaka, Japan
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Pediatric Patients With Liver Cholestasis Due to Parenteral Nutrition-Associated Liver Disease. TOP CLIN NUTR 2011. [DOI: 10.1097/tin.0b013e31821930a4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arsenault DA, Potemkin AK, Robinson EM, Fallon EM, Ozonoff A, de Meijer VE, Puder M. Surgical intervention in the setting of parenteral nutrition-associated cholestasis may exacerbate liver injury. J Pediatr Surg 2011; 46:122-7. [PMID: 21238652 DOI: 10.1016/j.jpedsurg.2010.09.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 09/30/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE This study compares postoperative markers of liver injury in patients receiving intravenous fish oil (IFO) with parenteral nutrition (PN)-associated cholestasis (PNAC) to patients with resolved PNAC. METHODS A retrospective review of all cholestatic-IFO patients undergoing abdominal laparotomy between March 1, 2007, and July 1, 2009, led to inclusion of 23 patients who collectively underwent 27 abdominal operations (13 pre-PNAC resolution and 14 post-PNAC resolution). Direct bilirubin (DB), total bilirubin, and alanine aminotransferase levels were examined over time in relation to operations. The time to resume presurgical trend of decreasing DB was calculated. RESULTS Sixty-nine percent (9/13) of pre-PNAC resolution procedures were associated with postoperative increase in DB compared with 7% (1/14) of post-PNAC resolution procedures associated with a recurrence of cholestasis (P = .02; odds ratio, 29.3; 95% confidence interval, 2.79-306.8). The median time to return to the preoperative downward trend of DB was 21 days. CONCLUSIONS Operations before PNAC resolution may be associated with an increased postoperative DB, possibly reflecting an exacerbation of liver injury. Operations post-PNAC resolution on IFO had a comparatively low incidence of postoperative cholestasis recurrence. Excepting clinical indication otherwise, it may be advisable to delay surgical intervention in the setting of PNAC in certain cases.
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Affiliation(s)
- Danielle A Arsenault
- Department of Surgery and The Vascular Biology Program, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Hao W, Wong OY, Liu X, Lee P, Chen Y, Wong KKY. ω-3 fatty acids suppress inflammatory cytokine production by macrophages and hepatocytes. J Pediatr Surg 2010; 45:2412-8. [PMID: 21129557 DOI: 10.1016/j.jpedsurg.2010.08.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 08/12/2010] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Long-term total parenteral nutrition (TPN) in children is often complicated by parental nutrition-associated liver disease and may even lead to liver failure. Recently, the addition of ω-3 fatty acids to TPN has been shown to reduce the risk of parental nutrition-associated liver disease. The purpose of this study was to explore the anti-inflammatory effects of ω-3 fatty acids (eicosapentaenoic acid [EPA]) to demonstrate the protection of the liver against hepatic steatosis and damage. MATERIALS AND METHODS Lipopolysaccharide (LPS) and prostaglandin E(2) (PGE(2)) were used to stimulate human macrophages and hepatocytes (THLE-3) to induce in vitro inflammatory condition. The cells were then incubated with either ω-3 (EPA) or ω-6 (arachidonic acid) fatty acids. Supernatants were collected at different time points for the measurement of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), and interleukin 10 (IL-10) using enzyme-linked immunosorbent assay. Furthermore, pretreated macrophages by LPS stimulation and after incubation with EPA were added to prestimulated hepatocytes for the subsequent measurement of cytokine response. RESULTS Eicosapentaenoic acid effectively reduced LPS-induced or PGE(2)-induced TNF-α and IL-6 expression, and increased IL-10 expression significantly when compared with arachidonic acid. Furthermore, supernatant collected after co-culturing EPA with macrophages also suppressed the levels of TNF-α and IL-6 in hepatocytes. This would suggest that EPA not only had an anti-inflammatory effect on macrophages and hepatocytes directly, it could indirectly reduce hepatocyte inflammation through activated macrophages. CONCLUSIONS The addition of ω-3 fatty acids in TPN suppresses the inflammatory response via direct and indirect routes. The findings may help explain the clinical benefits of EPA in pediatric patients receiving long-term TPN.
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Affiliation(s)
- Wei Hao
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
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Javid PJ, Malone FR, Reyes J, Healey PJ, Horslen SP. The experience of a regional pediatric intestinal failure program: Successful outcomes from intestinal rehabilitation. Am J Surg 2010; 199:676-9. [PMID: 20466115 DOI: 10.1016/j.amjsurg.2010.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 01/21/2010] [Accepted: 01/21/2010] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick J Javid
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA.
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Le HD, Fallon EM, de Meijer VE, Malkan AD, Puder M, Gura KM. Innovative parenteral and enteral nutrition therapy for intestinal failure. Semin Pediatr Surg 2010; 19:27-34. [PMID: 20123271 PMCID: PMC2819138 DOI: 10.1053/j.sempedsurg.2009.11.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Children with intestinal failure (IF) suffer from insufficient intestinal length or function, making them dependent on parenteral nutrition (PN) for growth and survival. PN and its components are associated with many complications ranging from simple electrolyte abnormalities to life-threatening PN-associated liver disease, which is also called intestinal failure-associated liver disease (IFALD). From a nutrition perspective, the ultimate goal is to provide adequate caloric requirements and make the transition from PN to full enteral nutrition (EN) successful. Upon review of the literature, we have summarized the most effective and innovative PN and EN therapies for this patient population. Antibiotic-coated catheters and antibiotic or ethanol locks can be implemented, as they appear effective in reducing catheter-related infection and thus further reduce the risk of IFALD. Lipid emulsions should be given judiciously. The use of an omega-3 fatty acid-based formulation should be considered in patients who develop IFALD. Trophic feeding is important for intestinal adaptation, and EN should be initiated early to help wean patients from PN. Long-term management of children with IF continues to be an emerging field. We have entered uncharted territory as more children survive complications of IF and IFALD. Careful monitoring and individualized management to ensure maintenance of growth while avoiding complications are the keys to successful patient outcomes.
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Affiliation(s)
- Hau D. Le
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Erica M. Fallon
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Vincent E. de Meijer
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Alpin D. Malkan
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Mark Puder
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Kathleen M. Gura
- Department of Pharmacy, Children’s Hospital Boston, Boston, MA 02115
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Lee SI, Valim C, Johnston P, Le HD, Meisel J, Arsenault DA, Gura KM, Puder M. Impact of fish oil-based lipid emulsion on serum triglyceride, bilirubin, and albumin levels in children with parenteral nutrition-associated liver disease. Pediatr Res 2009; 66:698-703. [PMID: 19687773 PMCID: PMC3377973 DOI: 10.1203/pdr.0b013e3181bbdf2b] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Parenteral nutrition is known to cause liver injury in babies. The aim of this study is to investigate the effects of different lipid emulsions on parenteral nutrition-associated cholestasis in infants. In addition, there may be a relationship between the lipid emulsion and triglyceride levels. Furthermore, triglyceride levels may correlate with direct bilirubin and albumin, as markers of liver impairment and nutritional status. Patients with parenteral nutrition-associated cholestasis who were treated with a fish oil-based lipid emulsion (n = 18) were prospectively followed for triglyceride, direct bilirubin, and albumin levels and compared with patients who were maintained on a soy-based lipid emulsion (n = 59). Triglyceride levels decreased in the fish oil cohort from a mean of 140 mg/dL at wk 0 to 40 mg/dL at wk 20 but remained unchanged at approximately 140 mg/dL in the soybean cohort. Triglyceride levels of patients treated with fish oil declined over time, while those receiving soybean oil did not. Also, changes in triglyceride levels over time were directly correlated with direct bilirubin and inversely related to albumin levels. These findings may indicate an added benefit of reduced triglyceride levels for patients treated with fish oil and this effect coincides with markers for improved liver function and nutritional status.
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Affiliation(s)
- Sang I Lee
- Department of Surgery, Harvard Medical School, 11 Priscilla Road, No. 1, Boston, MA 02135, USA.
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Parenteral fish oil improves outcomes in patients with parenteral nutrition-associated liver injury. Ann Surg 2009; 250:395-402. [PMID: 19661785 DOI: 10.1097/sla.0b013e3181b36657] [Citation(s) in RCA: 311] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective was to determine the safety and efficacy of a fish oil-based intravenous lipid emulsion (ILE) in the treatment of parenteral nutrition-associated liver disease (PNALD). SUMMARY AND BACKGROUND DATA PNALD can be a lethal complication in children with short bowel syndrome (SBS). ILE based on soybean oil administered with parenteral nutrition (PN) may contribute to its etiology. METHODS We performed an open-labeled trial of a fish oil-based ILE in 42 infants with SBS who developed cholestasis (serum direct bilirubin >2 mg/dL) while receiving soybean oil-based ILE. Safety and efficacy outcomes were compared with those from a contemporary cohort of 49 infants with SBS and cholestasis whose PN course included soybean ILE only. The primary efficacy end-point was time to reversal of cholestasis (direct bilirubin <=2 mg/dL). RESULTS Three deaths and 1 liver transplantation occurred in the fish oil cohort, compared with 12 deaths and 6 transplants in the soybean oil cohort (P = 0.005). Among survivors not transplanted during PN, cholestasis reversed while receiving PN in 19 of 38 patients in the fish oil cohort versus 2 of 36 patients in the soybean oil cohort. Based on Cox models, subjects receiving fish oil-based ILE experienced reversal of cholestasis 6 times faster (95% CI: 2.0-37.3) than those receiving soybean oil-based ILE. The provision of fish oil-based ILE was not associated with hypertriglyceridemia, coagulopathy, or essential fatty acid deficiency. Moreover, hypertriglyceridemic events and abnormal international normalized ratio levels were more common among controls. CONCLUSIONS Fish oil-based ILE is safe, may be effective in treating PNALD, and may reduce mortality and organ transplantation rates in children with SBS.
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Alabbad SI, Ryckman J, Puligandla PS, Shaw K, Nguyen LT, Laberge JM. Use of transanastomotic feeding tubes during esophageal atresia repair. J Pediatr Surg 2009; 44:902-5. [PMID: 19433166 DOI: 10.1016/j.jpedsurg.2009.01.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 01/15/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE Esophageal atresia (EA) with tracheoesophageal fistula (TEF) type C accounts for 85% of all EA. In our center, patients were previously started on total parenteral nutrition (TPN) postoperatively and oral feedings initiated only after a contrast esophagogram. Our aim is to assess the benefit of intraoperatively placed transanastomotic feeding tubes (TAFTs). METHODS A 7-year retrospective review analyzed the outcomes of children with EATEF type C as they relate to the use of TAFT. Demographics, associated anomalies, operative findings, complications, duration of TPN, resumption of oral feeding, length of stay, and follow-up were examined. RESULTS Twenty-one patients had EATEF type C. Eleven (55%) and 9 (45%) patients were identified as nonfeeding tube (NFT) and TAFT groups, respectively. There were no differences in gestational age, birth weight, associated anomalies, and interval to operative intervention or operative time. Excluding one patient with a severe cardiac malformation in the NFT group, there were no significant differences in anastomotic leak (8% vs 22%), stenosis (36% vs 22%), TPN duration (20 days vs 12 days), and cholestasis (36% vs 11%). CONCLUSION Transanastomotic feeding tube may lead to shorter TPN duration and decreased cholestasis, but a larger prospective study would be required to prove these benefits and ensure that it does not increase anastomotic leaks. This could be done through an expanded Canadian Pediatric Surgery Network study.
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Affiliation(s)
- Saleh I Alabbad
- Division of Pediatric Surgery, The Montreal Children's Hospital, Montréal, Québec, Canada.
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Hagadorn JI, Wolkoff L, Esposito P, Brumberg HL, Emerick K, Gerace JR. Medical therapies for parenteral nutrition-associated cholestasis in term and preterm infants. Hippokratia 2009. [DOI: 10.1002/14651858.cd007831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- James I Hagadorn
- University of Connecticut School of Medicine; Division of Neonatology; Connecticut Childreh's Medical Center 282 Washington Street Hartford Connecticut USA 06106
| | - Leslie Wolkoff
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
| | - Patricia Esposito
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
| | - Heather L Brumberg
- New York Medical College-Westchester Medical Center; Division of Newborn Medicine; The Regional Neonatal Center Valhalla NY USA 10595
| | - Karan Emerick
- Connecticut Children's Medical Center; Division of Gastroenterology; 282 Washington Street Hartford Connecticut USA 06106
| | - James R Gerace
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
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Hagadorn JI, Wolkoff L, Esposito P, Brumberg HL, Emerick K, Gerace JR. Alterations in parenteral nutrition management for the treatment of parenteral nutrition-associated cholestasis in term and preterm infants. Hippokratia 2009. [DOI: 10.1002/14651858.cd007833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- James I Hagadorn
- University of Connecticut School of Medicine; Division of Neonatology; Connecticut Childreh's Medical Center 282 Washington Street Hartford Connecticut USA 06106
| | - Leslie Wolkoff
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
| | - Patricia Esposito
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
| | - Heather L Brumberg
- New York Medical College-Westchester Medical Center; Division of Newborn Medicine; The Regional Neonatal Center Valhalla NY USA 10595
| | - Karan Emerick
- Connecticut Children's Medical Center; Division of Gastroenterology; 282 Washington Street Hartford Connecticut USA 06106
| | - James R Gerace
- Connecticut Children's Medical Center; Division of Neonatology; 282 Washington Street Hartford Connecticut USA 06106
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Abstract
Short bowel syndrome (SBS) is the most common cause of intestinal failure. This article discusses the prognostic factors that predict weaning from parenteral nutrition in SBS. The article also delineates an approach to enteral feeding in SBS.
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Jensen AR, Goldin AB, Koopmeiners JS, Stevens J, Waldhausen JHT, Kim SS. The association of cyclic parenteral nutrition and decreased incidence of cholestatic liver disease in patients with gastroschisis. J Pediatr Surg 2009; 44:183-9. [PMID: 19159741 DOI: 10.1016/j.jpedsurg.2008.10.033] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of the study was to investigate the effect of prophylactic cycling of parenteral nutrition (PN) on PN-induced cholestasis in patients with gastroschisis. METHODS Retrospective review of initial hospital admission charts for each patient with gastroschisis from 1996 to 2007 was performed. RESULTS One hundred seven patients were analyzed (36 prophylactically cycled, 71 control). Prophylactic cycling of PN was initiated at a mean age of 23 days (range, 7-89 days). Patients were followed for a total of 4255 days with 27 developing hyperbilirubinemia (cycled, 5; continuous, 22). Time to hyperbilirubinemia was longer in the prophylactically cycled group (P = .005). Cumulative incidence of hyperbilirubinemia at 25 and 50 days of PN exposure was 5.7% and 9.8% (cycled) vs 22.3% and 48.8% (continuous). At any given time, children in the continuous group were 4.76 times more likely to develop hyperbilirubinemia (95% confidence interval, 1.62-14.00). After adjusting for confounding factors, children in the continuous group were 2.86 times more likely to develop hyperbilirubinemia (95% confidence interval, 0.86-9.53), but the difference was not significant (P = .088). CONCLUSIONS Prophylactic cyclic PN is associated with a decreased incidence and prolonged time to onset of hyperbilirubinemia. Other factors, however, significantly affect this relationship. Prospective randomized investigation is warranted to investigate for a possible causal relationship.
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Affiliation(s)
- Aaron R Jensen
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
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Sterol profiling in red blood cell membranes and plasma of newborns receiving total parenteral nutrition. J Pediatr Gastroenterol Nutr 2008; 47:645-51. [PMID: 18955867 DOI: 10.1097/mpg.0b013e318170956a] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Total parenteral nutrition (TPN) is a lifesaving therapy in children with intestinal failure, frequently complicated by liver dysfunction. Plant sterols (phytosterols) of lipid emulsions have been supposed to contribute to cholestasis in TPN-treated children. The present study aimed to evaluate the plasma and red blood cell membrane (RBCM) phytosterol levels in newborns after a short period of TPN. PATIENTS AND METHODS Phytosterols, cholesterol, and other sterol levels were quantified by gas chromatography-mass spectrometry in 15 healthy control infants, 22 patients after TPN, and 11 patients before TPN. Sterols of lipid emulsions were quantified. RESULTS Plasma and RBCM phytosterol levels were, respectively, on average 56 micromol/L and 83 micromol/g per protein in patients after TPN, 13 micromol/L and 15 micromol/g per protein in patients before TPN, and 9 micromol/L and 13 micromoL/g per protein in control infants (P < 0.05 for differences). The days of TPN and the total amount of infused lipids correlated significantly with RBCM phytosterol (P < 0.05); correlations for plasma were positive but not significant. No correlation was observed with plasma bilirubin, gamma-glutamyltransferase, or alanine transaminase. CONCLUSIONS Plasma and RBCM phytosterols increase significantly in newborns after a short period of TPN. Higher phytosterol levels were observed in some patients that could have been due to their individual variability in phytosterol metabolism and/or clearance. A greater accumulation of phytosterols in membranes may induce TPN-related cholestasis.
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Biank VF. Comment on:
Safety and Efficacy of a Fish-Oil-Based Fat Emulsion in the Treatment of Parenteral Nutrition-Associated Liver Disease. Nutr Clin Pract 2008. [DOI: 10.1177/0884533608321135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Vincent F. Biank
- Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ekema G, Falchetti D, Boroni G, Tanca AR, Altana C, Righetti L, Ridella M, Gambarotti M, Berchich L. Reversal of severe parenteral nutrition-associated liver disease in an infant with short bowel syndrome using parenteral fish oil (Omega-3 fatty acids). J Pediatr Surg 2008; 43:1191-5. [PMID: 18558205 DOI: 10.1016/j.jpedsurg.2008.01.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 01/03/2008] [Accepted: 01/04/2008] [Indexed: 11/18/2022]
Abstract
Total parenteral nutrition is an important adjunct in the care of neonates with surgical disorders. Cholestasis is at present the most worrisome complication of this technique; it is difficult to treat and may progress to eventual cirrhosis and liver failure. This article reviews the pertinent clinical and nutritional data in a surgical patient with short bowel syndrome who developed parenteral nutrition-associated liver disease successfully treated with fish-oil based lipids.
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Affiliation(s)
- George Ekema
- Department of Pediatric Surgery, University of Brescia and Civil Hospitals, Brescia, Italy.
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Gura KM, Lee S, Valim C, Zhou J, Kim S, Modi BP, Arsenault DA, Strijbosch RAM, Lopes S, Duggan C, Puder M. Safety and efficacy of a fish-oil-based fat emulsion in the treatment of parenteral nutrition-associated liver disease. Pediatrics 2008; 121:e678-86. [PMID: 18310188 DOI: 10.1542/peds.2007-2248] [Citation(s) in RCA: 368] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Parenteral nutrition-associated liver disease can be a progressive and fatal entity in children with short-bowel syndrome. Soybean-fat emulsions provided as part of standard parenteral nutrition may contribute to its pathophysiology. METHODS We compared safety and efficacy outcomes of a fish-oil-based fat emulsion in 18 infants with short-bowel syndrome who developed cholestasis (serum direct bilirubin level of > 2 mg/dL) while receiving soybean emulsions with those from a historical cohort of 21 infants with short-bowel syndrome who also developed cholestasis while receiving soybean emulsions. The primary end point was time to reversal of cholestasis (3 consecutive measurements of serum direct bilirubin level of < or = 2 mg/dL). RESULTS Among survivors, the median time to reversal of cholestasis was 9.4 and 44.1 weeks in the fish-oil and historical cohorts, respectively. Subjects who received fish-oil-based emulsion experienced reversal of cholestasis 4.8 times faster than those who received soybean emulsions and 6.8 times faster in analysis adjusted for baseline bilirubin concentration, gestational age, and the diagnosis of necrotizing enterocolitis. A total of 2 deaths and 0 liver transplantations were recorded in the fish-oil cohort and 7 deaths and 2 transplantations in the historical cohort. The provision of fish-oil-based fat emulsion was not associated with essential fatty acid deficiency, hypertriglyceridemia, coagulopathy, infections, or growth delay. CONCLUSIONS Parenteral fish-oil-based fat emulsions are safe and may be effective in the treatment of parenteral nutrition-associated liver disease.
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Affiliation(s)
- Kathleen M Gura
- Department of Pharmacy, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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Use of N-acetyl cysteine for the treatment of parenteral nutrition-induced liver disease in children receiving home parenteral nutrition. J Pediatr Gastroenterol Nutr 2008; 46:220-3. [PMID: 18223385 DOI: 10.1097/mpg.0b013e3180653ce6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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48
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Abstract
Parenteral nutrition is a life-saving treatment for patients who have acute and chronic intestinal failure. Severe cholestasis induced by total parental nutrition (TPN-IC) is characterized by bile duct regeneration, portal inflammation, and fibrosis. Its progression could be very rapid, and in some patients liver cirrhosis may develop in few months. This article describes the definition, incidence, hepatic changes, histopathologic findings, risk factors, pathogenesis, and clinical implications of TPN-IC. The goal is to improve hospital and home management, quality of life, and prognosis of patients requiring parenteral nutrition.
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Stehle P. Development of liver dysfunction under artificial nutrition: a reason to modify nutrition therapy in the intensive care unit? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:112. [PMID: 17316464 PMCID: PMC2151851 DOI: 10.1186/cc5679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Actual research suggests that artificial nutrition in critically ill patients can be associated with alterations in liver dysfunction biomarkers such as enzymes and serum bilirubin. In addition to known patient-dependent and nutrient-dependent factors, the time of initiation of nutrition therapy seems to influence the risk of altered biomarkers, whereas age and gender, weight, range of clinical scores, type of primary diagnosis, necessity for mechanical ventilation, and the composition of the lipid emulsion used within total parenteral nutrition had no significant effects. This commentary analyzes these new results in the light of known relationships between illness and artificial nutrition therapy.
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Affiliation(s)
- Peter Stehle
- Department of Nutrition and Food Sciences--Nutrition Physiology, University of Bonn, Bonn, Germany.
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Christensen RD, Henry E, Wiedmeier SE, Burnett J, Lambert DK. Identifying patients, on the first day of life, at high-risk of developing parenteral nutrition-associated liver disease. J Perinatol 2007; 27:284-90. [PMID: 17344923 DOI: 10.1038/sj.jp.7211686] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prolonged use of parenteral nutrition (PN) in neonates can lead to parenteral nutrition-associated liver disease (PNALD), manifested by elevated direct bilirubin concentrations, and in some cases progressing to hepatic failure. When new potential means of preventing PNALD in the neonatal intensive care unit (NICU), such as Omegaven usage, are tested in clinical trials, the studies should enroll neonates at a very high risk of developing PNALD. However, it is not always clear, in the first days of life, which neonates are most likely to develop PNALD. Therefore, preparatory to devising studies of prophylaxis against PNALD, we conducted an evaluation of all NICU patients who received PN for >or=14 day, assessing their likelihood of developing PNALD. METHODS We performed an historic cohort analysis of all neonates in the Intermountain Healthcare system, receiving PN for 14 days or more during their stay, with dates of birth between 1 January, 2002 and 30 June, 2006. RESULTS During the 4(1/2)-year period, 9861 neonates were cared for in the Intermountain Healthcare NICUs. Of these, 9547 (96.8%) survived for at least 28 days, and of these 6543 (68.5%) received PN. Twenty-one percent (1366 patients) of those receiving PN, received it for >or=14 days. PNALD was ascertained in this group by a direct bilirubin >or=2.0 mg/dl. Neonates receiving PN for 14-28 days had a 14% incidence of PNALD, those receiving PN for 29-56 days had a 43% incidence, those receiving PN for 57-100 days had a 72% incidence and those receiving PN for >100 days had a 85% incidence. Groups of patients identifiable on the first day of life as having the highest risk of developing PNALD were birth weight <500 g (odds ratio (OR), 30.7), birth weight 500-749 g (OR, 13.1), gastrochisis (OR, 20.3) and jejunal atresia (OR, 24.0). Among 357 patients who developed PNALD, the highest direct bilirubin concentrations correlated with the highest serum alkaline phosphatase and transaminase concentrations. Deaths after 28 days were much more common in those with the highest direct bilirubin and transaminase concentrations (P<0.0001). CONCLUSIONS In the first days of life, certain NICU patients can be identified as being at very high risk for developing PNALD. These are patients <750 g birth weight, those with gastrochisis and those with jejunal atresia. We speculate that these groups would be reasonable subjects for including in a PNALD prophylaxis trial, testing new preventative strategies such as Omegaven usage.
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MESH Headings
- Cohort Studies
- Fat Emulsions, Intravenous/adverse effects
- Female
- Hospital Mortality
- Humans
- Infant, Newborn
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/mortality
- Infant, Very Low Birth Weight
- Intensive Care, Neonatal
- Jaundice, Neonatal/diagnosis
- Jaundice, Neonatal/etiology
- Jaundice, Neonatal/mortality
- Liver Failure/diagnosis
- Liver Failure/etiology
- Liver Failure/mortality
- Liver Function Tests
- Long-Term Care
- Male
- Neonatal Screening
- Parenteral Nutrition, Total/adverse effects
- Retrospective Studies
- Risk Factors
- Survival Rate
- Utah
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