1
|
Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Collapse
Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| |
Collapse
|
2
|
Zafirovska M, Zafirovski A, Rotovnik Kozjek N. Current Insights Regarding Intestinal Failure-Associated Liver Disease (IFALD): A Narrative Review. Nutrients 2023; 15:3169. [PMID: 37513587 PMCID: PMC10385050 DOI: 10.3390/nu15143169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a spectrum of liver disease including cholestasis, biliary cirrhosis, steatohepatitis, and gallbladder disease in patients with intestinal failure (IF). The prevalence of IFALD varies considerably, with ranges of 40-60% in the pediatric population, up to 85% in neonates, and between 15-40% in the adult population. IFALD has a complex and multifactorial etiology; the risk factors can be parenteral nutrition-related or patient-related. Because of this, the approach to managing IFALD is multidisciplinary and tailored to each patient based on the etiology. This review summarizes the current knowledge on the etiology and pathophysiology of IFALD and examines the latest evidence regarding preventative measures, diagnostic approaches, and treatment strategies for IFALD and its associated complications.
Collapse
Affiliation(s)
- Marija Zafirovska
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Association of General Practice/Family Medicine of South-East Europe (AGP/FM SEE), St. Vladimir Komarov No. 40/6, 1000 Skopje, North Macedonia
| | - Aleksandar Zafirovski
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- General Hospital Jesenice, Cesta Maršala Tita 112, 4270 Jesenice, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia
| | - Nada Rotovnik Kozjek
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Department for Clinical Nutrition, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
| |
Collapse
|
3
|
Secor JD, Yu L, Tsikis S, Fligor S, Puder M, Gura KM. Current strategies for managing intestinal failure-associated liver disease. Expert Opin Drug Saf 2020; 20:307-320. [PMID: 33356650 DOI: 10.1080/14740338.2021.1867099] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Intestinal failure-associated liver disease (IFALD) refers to hepatic dysfunction that results from prolonged parenteral nutrition (PN) use. IFALD is multifactorial in origin and remains a major cause of morbidity and mortality. Prior to 2004, IFALD was associated with mortality as high as 90% in infants who remained on PN greater than 1 year. The advent of new strategies for intravenous lipid emulsion (ILE) administration and improved catheter care now allow many patients to remain on PN and recover from this once fatal condition. Several additional treatment modalities are often used to further improve outcomes for IFALD patients and they are reviewed here.Areas covered: The etiology of IFALD is presented, as well as the rationale behind the use of ILEs that contain fish oil. Other management strategies are addressed, including the effects of several pharmacologic and nutritional interventions.Expert opinion: Like its etiology, the management of IFALD is multifactorial. Prompt recognition of patients at risk, avoiding macronutrient excess, and preventing central line associated bloodstream infections will improve outcomes. In patients who develop IFALD, the use of fish oil monotherapy seems to be efficacious. The most effective intervention, however, continues to be discontinuation of PN and achieving full enteral feedings.
Collapse
Affiliation(s)
- Jordan D Secor
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Lumeng Yu
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Savas Tsikis
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Scott Fligor
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Mark Puder
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
4
|
Burrin D, Sangild PT, Stoll B, Thymann T, Buddington R, Marini J, Olutoye O, Shulman RJ. Translational Advances in Pediatric Nutrition and Gastroenterology: New Insights from Pig Models. Annu Rev Anim Biosci 2020; 8:321-354. [PMID: 32069436 DOI: 10.1146/annurev-animal-020518-115142] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pigs are increasingly important animals for modeling human pediatric nutrition and gastroenterology and complementing mechanistic studies in rodents. The comparative advantages in size and physiology of the neonatal pig have led to new translational and clinically relevant models of important diseases of the gastrointestinal tract and liver in premature infants. Studies in pigs have established the essential roles of prematurity, microbial colonization, and enteral nutrition in the pathogenesis of necrotizing enterocolitis. Studies in neonatal pigs have demonstrated the intestinal trophic effects of akey gut hormone, glucagon-like peptide 2 (GLP-2), and its role in the intestinal adaptation process and efficacy in the treatment of short bowel syndrome. Further, pigs have been instrumental in elucidating the physiology of parenteral nutrition-associated liver disease and the means by which phytosterols, fibroblast growth factor 19, and a new generation of lipid emulsions may modify disease. The premature pig will continue to be a valuable model in the development of optimal infant diets (donor human milk, colostrum), specific milk bioactives (arginine, growth factors), gut microbiota modifiers (pre-, pro-, and antibiotics), pharmaceutical drugs (GLP-2 analogs, FXR agonists), and novel diagnostic tools (near-infrared spectroscopy) to prevent and treat these pediatric diseases.
Collapse
Affiliation(s)
- Douglas Burrin
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Per Torp Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Barbara Stoll
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Randal Buddington
- College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - Juan Marini
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA; .,Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Oluyinka Olutoye
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Robert J Shulman
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| |
Collapse
|
5
|
Chen K, Mu F, Xie J, Kelkar SS, Olivier C, Signorovitch J, Jeppesen PB. Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; 44:119-128. [PMID: 31006876 PMCID: PMC7004164 DOI: 10.1002/jpen.1588] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/22/2019] [Accepted: 03/13/2019] [Indexed: 11/14/2022]
Abstract
Background Teduglutide reduces or eliminates parenteral support (PS) dependency in patients with short bowel syndrome (SBS). Recent post hoc analyses demonstrated that effects are correlated with baseline PS volume. We assessed the SBS‐related quality‐of‐life (QoL) impact of teduglutide, particularly whether improvements are greater among subgroups achieving more PS volume reduction. Methods Using phase 3 trial data of teduglutide in patients with SBS (NCT00798967), change in Short Bowel Syndrome–Quality of Life (SBS‐QoL) scores from baseline were compared between teduglutide vs placebo in the overall population and subgroups classified by baseline PS volume requirement, disease etiology, and bowel anatomy. Generalized estimating equation models were fitted to assess impact of teduglutide on SBS‐related QoL using data from all visits, adjusted for baseline characteristics. Results Of 86 patients, 43 each were randomized to teduglutide or placebo (mean age: 51 vs 50 years, respectively). In adjusted analyses, teduglutide had a nonsignificant reduction (improvement) of −8.6 points (95% CI: 2.6 to −19.8) in SBS‐QoL sum score from baseline to Week‐24 vs placebo. The impact of teduglutide varied by subgroup. Patients treated with teduglutide experienced significantly greater reductions in SBS‐QoL sum score at Week‐24 vs placebo in 2 subgroups, ie, the third (highest) tertile baseline PS volume (−27.3, 95% CI: −50.8 to −3.7) and inflammatory bowel disease (IBD; −29.6, 95% CI: −46.3 to −12.9). Results were similar for SBS‐QoL subscale and item scores. Conclusions The impact of teduglutide treatment on SBS‐related QoL vs placebo varied among subgroups and was significant and most pronounced among patients with highest baseline PS volume requirement or IBD.
Collapse
Affiliation(s)
- Kristina Chen
- Shire Human Genetic Therapies, Inc. (a member of the Takeda group of companies), Cambridge, Massachusetts, USA
| | - Fan Mu
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Jipan Xie
- Analysis Group, Inc., Los Angeles, California, USA
| | | | - Clément Olivier
- Shire International GmbH (a member of the Takeda group of companies), Zug, Switzerland
| | | | - Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
6
|
Norsa L, Nicastro E, Di Giorgio A, Lacaille F, D'Antiga L. Prevention and Treatment of Intestinal Failure-Associated Liver Disease in Children. Nutrients 2018; 10:nu10060664. [PMID: 29882922 PMCID: PMC6024802 DOI: 10.3390/nu10060664] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 01/01/2023] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a threatening complication for children on long-term parenteral nutrition because of intestinal failure. When progressive and intractable, it may jeopardize intestinal rehabilitation and lead to combined liver and intestinal transplantation. The institution of dedicated intestinal failure centers has dramatically decreased the incidence of such complication. IFALD may rapidly fade away if very early management aimed at preventing progression to end-stage liver disease is provided. In this review, we address the etiology and risk factors of IFALD in order to introduce pillars of prevention (nutritional management and catheter-related infections control). The latest evidence of therapeutic strategies, such as medical and surgical treatments, is also discussed.
Collapse
Affiliation(s)
- Lorenzo Norsa
- Pediatric Gastroenterology Hepatology and Nutrition, Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy.
| | - Emanuele Nicastro
- Pediatric Gastroenterology Hepatology and Nutrition, Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy.
| | - Angelo Di Giorgio
- Pediatric Gastroenterology Hepatology and Nutrition, Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy.
| | - Florence Lacaille
- Pediatric Gastroenterology Hepatology and Nutrition, Hôpital Necker Enfants Malades, 75015 Paris, France.
| | - Lorenzo D'Antiga
- Pediatric Gastroenterology Hepatology and Nutrition, Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy.
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW The goal of this review is to provide updates on the definition, pathophysiology, treatment, and prevention of intestinal failure-associated liver disease (IFALD) that are relevant to care of pediatric patients. RECENT FINDINGS Current literature emphasizes the multifactorial nature of IFALD. The pathogenesis is still largely unknown; however, molecular pathways have been identified. Key to these pathways are proinflammatory cytokines involved in hepatic inflammation and bile acids synthesis such as Toll-like receptor 4 and farnesoid X receptor, respectively. Research for prevention and treatment is aimed at alleviating risk factors associated with IFALD, principally those associated with parental nutrition. Multiple nutrients and amino acids are relevant to the development of IFALD, but lipid composition has been the primary focus. Lipid emulsions with a lower ratio of omega-6-to-omega-3 polyunsaturated fatty acids (FAs) appear to improve bile flow and decrease intrahepatic inflammation. Long-term consequences of these alternative lipid emulsions are yet to be determined. SUMMARY IFALD remains the greatest contributor of mortality in patients with intestinal failure. Many factors contribute to its development, namely, alterations in the gut microbiome, sepsis, and lack of enteral intake. Novel combinations of lipid formulations are promising alternatives to purely soy-based formulas to reduce cholestasis.
Collapse
Affiliation(s)
- Cathleen M Courtney
- aDivision of Pediatric Surgery, St. Louis Children's Hospital bDepartment of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | | |
Collapse
|
8
|
Al-Shahwani NH, Sigalet DL. Pathophysiology, prevention, treatment, and outcomes of intestinal failure-associated liver disease. Pediatr Surg Int 2017; 33:405-411. [PMID: 28028560 DOI: 10.1007/s00383-016-4042-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) remains a serious problem in the treatment of infants with nutritional problems and short bowel syndrome. METHODS A review of the recent literature from 2010 to 2016, concentrating on articles related to the pathophysiology of IFALD and to outcomes of novel nutritional and pharmacological therapies for neonatal cholestasis in the post-surgical neonate. RESULTS The pathophysiology of IFALD relates to an increase sensitivity of the neonatal liver to cholestasis in the non-fed state; prolonged cholestasis almost inevitably results in liver damage which will progress from fibrosis to cirrhosis. Clinically discerned risk factors include premature birth, inflammation, sepsis, disruption of the enterohepatic circulation by creation of a proximal stoma, and the duration and type of parenteral nutritional support. Within the hepatocyte, the regulatory enzyme farsanoid receptor X (FXR) appears to play a pivotal role in the development of cholestasis. Recent studies have shown that its activity is suppressed by sepsis, and by plant phytosterols found in soy-based lipid preparations. This paradigm is reflected in the emerging consensus for the care of post-surgical neonates, which is based around a multi-disciplinary team approach. Using an algorithm-driven approach, an appropriate balance between caloric support and prevention of IFALD can be achieved. CONCLUSIONS Further prospective studies are required to further refine the optimal sequence of use of these therapies and the long-term effects on neurological development and hepatic function. However, with optimal care, the number of IF patients progressing to end-stage liver disease because of IFALD should be very low.
Collapse
Affiliation(s)
| | - David L Sigalet
- Chair of Surgery, Sidra Medical and Research Center, PO Box 26999, Doha, Qatar.
- Surgery, Weill Cornell Medicine, New York, NY, USA.
- Surgery, Weill Cornell Medicine, Doha, Qatar.
| |
Collapse
|
9
|
Guthrie G, Premkumar M, Burrin DG. Emerging Clinical Benefits of New-Generation Fat Emulsions in Preterm Neonates. Nutr Clin Pract 2017; 32:326-336. [PMID: 28129045 DOI: 10.1177/0884533616687500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Soybean oil-based intravenous fat emulsions (IVFEs) have been the predominant parenteral nutrition IVFE used in the United States for neonates over the past 45 years. Even though this emulsion has proven useful in supplying infants with energy for growth and essential fatty acids, there have been concerns over its composition in the development of several morbidities, ranging from sepsis to liver disease, bronchopulmonary dysplasia, and impaired neurodevelopment and growth. The exact mechanisms that drive these morbidities in preterm infants are multifactorial, but potential contributors include high ω-6 (n-6) fatty acid composition, low docosahexaenoic acid and antioxidant supplementation, and the presence of potentially harmful nonnutritive components (eg, phytosterols). To address these issues, new-generation IVFEs with various types and amounts of fat have been developed containing greater amounts of the medium-chain fatty acids, long-chain polyunsaturated fatty acid, docosahexaenoic acid, lower concentrations of ω-6 polyunsaturated fatty acids, supplemental vitamin E, and low or negligible amounts of phytosterols. This review examines the clinical outcomes associated with different morbidities of parenteral nutrition in neonates who have received either soybean oil-based or new-generation IVFEs and addresses whether the proposed benefits of new-generation IVFEs have improved outcomes in the neonatal population.
Collapse
Affiliation(s)
- Gregory Guthrie
- 1 USDA/ARS Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Muralidhar Premkumar
- 2 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Douglas G Burrin
- 1 USDA/ARS Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
10
|
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.
Collapse
Affiliation(s)
- Ariel U Spencer
- Department of Surgery, University of Michigan, and C.S. Mott Children's Hospital, Ann Arbor, MI 48109, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
Cholestasis in preterm infants has a multifactorial etiology. Risk factors include degree of prematurity, lack of enteral feeding, intestinal injury, prolonged use of parenteral nutrition (PN), and sepsis. Soy-based parenteral lipid emulsions have been implicated in the pathophysiology of PN-associated liver injury. Inflammation plays an important role. Medical therapies are used; however, their effects have not consistently proven effective. Evaluation of cholestasis involves laboratory work; direct bilirubin levels are used for diagnosis and trending. Adverse outcomes include risk for hepatobiliary dysfunction, irreversible liver failure, and death. Early enteral feedings as tolerated is the best way to prevent and manage cholestasis.
Collapse
Affiliation(s)
- Katie Satrom
- Division of Neonatology, Department of Pediatrics, University of Minnesota, 2450 Riverside Avenue, 6th Floor, East Building, Delivery Code: 8952A, Minneapolis, MN 55454, USA.
| | - Glenn Gourley
- Pediatric Gastroenterology, Department of Pediatrics, University of Minnesota, 2450 Riverside Avenue, 6th Floor, East Building, 8952A, Minneapolis, MN 55454, USA
| |
Collapse
|
12
|
Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 461] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
Collapse
Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | | |
Collapse
|
13
|
Dani C, Pratesi S, Raimondi F, Romagnoli C. Italian guidelines for the management and treatment of neonatal cholestasis. Ital J Pediatr 2015; 41:69. [PMID: 26428285 PMCID: PMC4591626 DOI: 10.1186/s13052-015-0178-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 09/22/2015] [Indexed: 02/08/2023] Open
Abstract
Hyperbilirubinemia is a frequent condition affecting newborns during the first two weeks of life and when it lasts more than 14 days it is defined as prolonged jaundice. This condition requires differential diagnosis between the usually benign unconjugated hyperbilirubinemia and the pathological conjugated hyperbilirubinemia, that is mainly due to neonatal cholestasis. It is important that the diagnosis of neonatal cholestasis be well-timed to optimize its management, prevent worsening of the patient’s outcome, and to avoid premature, painful, expensive, and useless tests. Unfortunately, this does not always occur and, therefore, the Task Force on Hyperbilirubinemia of the Italian Society of Neonatology presents these shared Italian guidelines for the management and treatment of neonatal cholestasis whose overall aim is to provide a useful tool for its assessment for neonatologists and family pediatricians.
Collapse
Affiliation(s)
- Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, Careggi University Hospital of Florence, Largo Brambilla 3, Florence, 50141, Italy.
| | - Simone Pratesi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy.
| | - Francesco Raimondi
- Division of Neonatology, Section of Pediatrics Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
| | - Costantino Romagnoli
- Division of Neonatology, Department of Pediatrics, Catholic University of Sacred Heart, Rome, Italy.
| | | |
Collapse
|
14
|
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.
Collapse
Affiliation(s)
- Giuseppe Lauriti
- Department of Surgery, UCL Institute of Child Health, London, UK
| | | | | | | | | | | | | |
Collapse
|
15
|
Tillman EM. Review and clinical update on parenteral nutrition-associated liver disease. Nutr Clin Pract 2012; 28:30-9. [PMID: 23087263 DOI: 10.1177/0884533612462900] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Parenteral nutrition-associated liver disease (PNALD) is a complex disease that is diagnosed by clinical presentation, biochemical markers of liver injury, concurrent use of parenteral nutrition (PN), and negative workup for other causes of liver disease. Since the first case of PNALD was reported more than 30 years ago, clinicians have had few effective treatments for PNALD, and when disease progressed to liver cirrhosis, it was historically associated with poor outcomes. Within the past 5 years, there has been much excitement about new treatments for PNALD, including use of both parenteral and enteral ω-3 polyunsaturated long-chain fatty acids (ω-3 PUFA) as well as restricting dosing of ω-6 PUFA. Scientists are also interested in uncovering the mechanisms associated with liver injury seen in PNALD. This article reviews the recent literature relating to the pathophysiology and treatment of PNALD.
Collapse
Affiliation(s)
- Emma M Tillman
- Departments of Clinical Pharmacy and Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, State of Tennessee Center of Excellence in Pediatric Pharmacokinetics and Therapeutics, Children's Foundation Research Institute at Le Bonheur Children's Hospital, 50 N Dunlap, Memphis, TN 38103, USA.
| |
Collapse
|
16
|
Burns DL, Gill BM. Reversal of Parenteral Nutrition–Associated Liver Disease With a Fish Oil–Based Lipid Emulsion (Omegaven) in an Adult Dependent on Home Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2012; 37:274-80. [DOI: 10.1177/0148607112450301] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- David L. Burns
- Department of Gastroenterology, Lahey Clinic Medical Center, Burlington, Massachusetts
| | - Brian M. Gill
- Department of Gastroenterology, Lahey Clinic Medical Center, Burlington, Massachusetts
| |
Collapse
|
17
|
Bogie AL, Guthrie C. High-Technology Gastroenterology Disorders in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
18
|
Rangel SJ, Calkins CM, Cowles RA, Barnhart DC, Huang EY, Abdullah F, Arca MJ, Teitelbaum DH. Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2012; 47:225-40. [PMID: 22244423 DOI: 10.1016/j.jpedsurg.2011.10.007] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/05/2011] [Accepted: 10/06/2011] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children. DATA SOURCE Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews. STUDY SELECTION The review of PNAC/PNALD has been divided into 4 areas to simplify one's understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC. RESULTS The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized. CONCLUSIONS Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.
Collapse
|
19
|
Malone FR, Horslen SP. Medical and surgical management of the pediatric patient with intestinal failure. ACTA ACUST UNITED AC 2011; 10:379-90. [PMID: 17897576 DOI: 10.1007/s11938-007-0038-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Until recently, extreme short bowel due primarily to massive resection in the neonatal period had been considered incompatible with long-term survival. Indeed, parents of infants with midgut volvulus or other causes of very extensive intestinal necrosis still may be informed that resection is futile. The advent of intestinal transplantation as a potential therapy and its evolution into a standard therapy for irreversible intestinal failure have led to changing attitudes regarding these catastrophic gastrointestinal events. The experience gained from aggressively maintaining infants with little if any functional small bowel while awaiting transplantation has led to the increasing recognition that long-term survival is possible in many of these children with and often without intestinal transplantation. Even children with very small lengths of residual intestine ultimately may adapt and grow sufficiently to allow enteral autonomy. Achievement of these outcomes requires early referral to a dedicated multidisciplinary intestinal care team well versed in the management options for such children. Initial assessment often involves an inpatient evaluation followed by very close outpatient follow-up. Aggressive management is imperative for all patients with intestinal failure, allowing time for full enteral adaptation before complications become life-threatening; those with no possibility of significant adaptation can achieve optimal growth while awaiting transplantation. Along with medical and nutritional therapy and nontransplant surgery, intestinal transplantation should be seen as one of many modalities available for the optimal management of this population of patients. Thus, patients with irreversible intestinal failure and those with indications for transplantation (even those for whom hope remains that sufficient enteral adaptation still may occur) should be evaluated by the transplant team. If there is no intestinal transplant program at the center undertaking the intestinal failure management, strong links and regular communication with an intestinal transplant program that can partner in the care of these patients should be established. Multicenter collaborative and interventional studies are necessary to clearly demonstrate outcomes and to move the field forward.
Collapse
Affiliation(s)
- Frances R Malone
- Frances R. Malone, ARNP, PhD Children’s Hospital Regional Medical Center, Seattle, WA 98105, USA.
| | | |
Collapse
|
20
|
The Prevention and Treatment of Intestinal Failure-associated Liver Disease in Neonates and Children. Surg Clin North Am 2011; 91:543-63. [PMID: 21621695 DOI: 10.1016/j.suc.2011.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
21
|
Tillman EM, Helms RA. Omega-3 Long Chain Polyunsaturated Fatty Acids for Treatment of Parenteral Nutrition–Associated Liver Disease: A Review of the Literature. J Pediatr Pharmacol Ther 2011. [DOI: 10.5863/1551-6776-16.1.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ABSTRACTParenteral nutrition–associated liver disease (PNALD) is a complex disease that is diagnosed by clinical presentation, biochemical markers of liver injury, concurrent use of parenteral nutrition (PN), and negative workup for other causes of liver disease. For the past 30 years, clinicians have had few effective treatments for PNALD and when disease progressed to liver cirrhosis it was historically associated with poor outcomes. Within the past 5 years there has been some encouraging evidence for the potential benefits of fish oils, rich in omega-3 long-chain polyunsaturated fatty acids (ω3PUFA), in reversing liver injury associated with PN. This article reviews the current literature relating to ω3PUFA and PNALD.
Collapse
Affiliation(s)
- Emma M. Tillman
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center,
- Children's Research Foundation at Le Bonheur Children's Hospital,
- State of Tennessee Center of Excellence in Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| | - Richard A. Helms
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center,
- Department of Pediatrics, The University of Tennessee Health Science Center,
- Children's Research Foundation at Le Bonheur Children's Hospital,
- State of Tennessee Center of Excellence in Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| |
Collapse
|
22
|
Parenteral Nutrition–Associated Conjugated Hyperbilirubinemia in Hospitalized Infants. ACTA ACUST UNITED AC 2010; 110:1684-95. [DOI: 10.1016/j.jada.2010.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 07/08/2010] [Indexed: 11/23/2022]
|
23
|
Fernandes RM, van der Lee JH, Offringa M. A systematic review of the reporting of Data Monitoring Committees' roles, interim analysis and early termination in pediatric clinical trials. BMC Pediatr 2009; 9:77. [PMID: 20003383 PMCID: PMC2801486 DOI: 10.1186/1471-2431-9-77] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 12/13/2009] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Decisions about interim analysis and early stopping of clinical trials, as based on recommendations of Data Monitoring Committees (DMCs), have far reaching consequences for the scientific validity and clinical impact of a trial. Our aim was to evaluate the frequency and quality of the reporting on DMC composition and roles, interim analysis and early termination in pediatric trials. METHODS We conducted a systematic review of randomized controlled clinical trials published from 2005 to 2007 in a sample of four general and four pediatric journals. We used full-text databases to identify trials which reported on DMCs, interim analysis or early termination, and included children or adolescents. Information was extracted on general trial characteristics, risk of bias, and a set of parameters regarding DMC composition and roles, interim analysis and early termination. RESULTS 110 of the 648 pediatric trials in this sample (17%) reported on DMC or interim analysis or early stopping, and were included; 68 from general and 42 from pediatric journals. The presence of DMCs was reported in 89 of the 110 included trials (81%); 62 papers, including 46 of the 89 that reported on DMCs (52%), also presented information about interim analysis. No paper adequately reported all DMC parameters, and nine (15%) reported all interim analysis details. Of 32 trials which terminated early, 22 (69%) did not report predefined stopping guidelines and 15 (47%) did not provide information on statistical monitoring methods. CONCLUSIONS Reporting on DMC composition and roles, on interim analysis results and on early termination of pediatric trials is incomplete and heterogeneous. We propose a minimal set of reporting parameters that will allow the reader to assess the validity of trial results.
Collapse
Affiliation(s)
- Ricardo M Fernandes
- Departamento da Criança e da Família, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte-EPE; and Laboratório de Farmacologia Clínica e Terapêutica, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal
- Department of Pediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Johanna H van der Lee
- Department of Pediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Martin Offringa
- Department of Pediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| |
Collapse
|
24
|
Hsieh MH, Pai W, Tseng HI, Yang SN, Lu CC, Chen HL. Parenteral nutrition-associated cholestasis in premature babies: risk factors and predictors. Pediatr Neonatol 2009; 50:202-7. [PMID: 19856863 DOI: 10.1016/s1875-9572(09)60064-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND One of the most common complications in infants under parenteral nutrition treatment is parenteral nutrition-associated cholestasis (PNAC). The etiology of PNAC is thought to be multifactorial. The aims of this study were to evaluate the risk factors for PNAC in our neonatal intensive care unit and determine useful predictors. METHODS This study enrolled premature infants (gestational age <36 weeks) who were admitted to our neonatal intensive care unit and treated with parenteral nutrition infusion for at least 2 weeks between January 2004 and January 2007. Multiple possible risk factors were analyzed by a retrospective review study design. PNAC was defined as direct bilirubin greater than 1.5 mg/dL during parenteral nutrition. RESULTS A total of 62 premature infants with prolonged course of parenteral nutrition were eligible for this study; 11 (17.74%) of the infants developed PNAC. There were significant differences in terms of gestational age, birth body weight, duration of parenteral nutrition, septic episodes, and average energy intake during the 2nd and 3rd weeks of life between infants with cholestasis and those without cholestasis. Of these risk factors, the duration of parenteral nutrition was most significant after multivariate logistic regression analysis. CONCLUSION Young gestational age, low birth body weight, more sepsis episodes, and long duration of parenteral nutrition were significant risk factors for PNAC in our study. Low energy intake during the 2nd and 3rd weeks of life is a predictor for PNAC.
Collapse
Affiliation(s)
- Meng-Han Hsieh
- Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | | | | | | | | | | |
Collapse
|
25
|
Willis TC, Carter BA, Rogers SP, Hawthorne KM, Hicks PD, Abrams SA. High rates of mortality and morbidity occur in infants with parenteral nutrition-associated cholestasis. JPEN J Parenter Enteral Nutr 2009; 34:32-7. [PMID: 19587385 DOI: 10.1177/0148607109332772] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extremely few data are available about the natural history of parenteral nutrition (PN)-associated cholestasis. The authors evaluated a cohort of infants at a large center to determine the outcome of PN-associated cholestasis in infants with some gastrointestinal function. METHODS The authors reviewed the records of all infants admitted to a level 3 neonatal intensive care unit over a 16-month period who had the diagnosis of PN-associated cholestasis. Records were reviewed in these infants for course of cholestasis, laboratory values, outcome, and infection rate. RESULTS Sixty-six patients were admitted who met the study criteria. There were 10 deaths and 1 referral for liver transplant (Death/TPlant) (17%) in the first year of life. All Death/TPlant infants had at least 1 positive blood culture after the onset of cholestasis. Maximum conjugated bilirubin (MaxCB) in Death/TPlant infants was 15.7 +/- 2.2 (SEM) compared to 8.4 +/- 1.0 mg/dL in babies who recovered. Of 21 infants with a MaxCB > or =10.0, Death/TPlant occurred in 8/21 (38%). Of 40 babies with positive blood cultures, 11 were in the Death/TPlant group vs no deaths among the 25 without positive blood cultures. Average time to resolution from the MaxCB to a CB <2.0 mg/dL was 66 +/- 7 days (n = 49). CONCLUSIONS Infants with PN-associated cholestasis have high rates of mortality despite the presence of some gastrointestinal function. These data support further evaluation and the development of novel forms of therapy for babies with parenteral-associated CB > or =2 mg/dL with emphasis on interventions for infants with a CB >10 mg/dL.
Collapse
Affiliation(s)
- Theresa C Willis
- United States Department of Agriculture/Agricultural Research Service, Children's Nutrition Research Center and Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | | | | |
Collapse
|
26
|
Garzón L, Ledo A, Cubells E, Sáenz P, Vento M. [Cholestasis associated with prolonged parenteral nutrition in neonates: the role of urso-deoxycholic acid]. An Pediatr (Barc) 2009; 70:547-52. [PMID: 19443280 DOI: 10.1016/j.anpedi.2009.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 03/12/2009] [Accepted: 03/16/2009] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION The morbidity associated with prematurity occasionally leads to the use of prolonged parenteral nutrition, with the subsequent development of cholestasis being one of its complications. PATIENTS AND METHODS This is a two year retrospective study which compared biochemical markers of liver damage and cholestasis in premature babies who received or did not receive urso-deoxycholic acid for parenteral nutrition associated cholestasis. RESULTS Of a total of 24 recruited patients 17 received urso-deoxycholic acid and 7 did not. In the treated group significant decreases (P<0.05) in gamma-glutamyltranspeptidase and conjugated bilirubin were found after four and five weeks of treatment, respectively. Moreover, a significant correlation (P<0.01) between conjugated bilirubin and duration of total parenteral nutrition was established. CONCLUSIONS Patients who were promptly treated with urso-deoxycholic acid showed a more rapid decrease in biochemical markers of cholestasis, but not of cytotoxicity in the hepatobiliary complications secondary to prolonged parenteral nutrition. However, the present study has limitations derived from its design and therefore it would be desirable launch a randomized trial with sufficient power to evaluate the benefits derived from prophylactic or therapeutic use of urso-deoxycholic acid in the hepatobiliary conditions associated with the prolonged use of parenteral nutrition in the premature infants.
Collapse
Affiliation(s)
- L Garzón
- Departamento de Pediatría, Servicio de Neonatología, Hospital Universitario La Fe, Valencia, Spain
| | | | | | | | | |
Collapse
|
27
|
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
| |
Collapse
|
28
|
Tazuke Y, Teitelbaum DH. Alteration of canalicular transporters in a mouse model of total parenteral nutrition. J Pediatr Gastroenterol Nutr 2009; 48:193-202. [PMID: 19179882 PMCID: PMC2633488 DOI: 10.1097/mpg.0b013e3181852201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Parenteral nutrition-associated liver disease (PNALD) is a major problem with prolonged total parenteral nutrition (TPN) administration. Our laboratory previously demonstrated significant changes in the expression of multidrug resistance genes (MDRs) 1 and 2, hepatocyte transporters, in a TPN mouse model. The present study hypothesized that these changes would lead to functional changes in the liver, and would contribute to the development of liver dysfunction. MATERIALS AND METHODS Mice received either intravenous saline and standard chow or TPN with or without intravenous lipids. Functional assays were performed after 7 days of infusion. RESULTS TPN with lipids led to a significant increase in serum bile acid levels, consistent with an early state of PNALD. Use of TPN without lipids prevented an elevation in bile acid levels. In both TPN groups, MDR2 expression was significantly (68%) lower than controls and bile phosphatidylcholine content, a functional measure of MDR2, was 40% less than controls. MDR1 expression in the TPN with lipid group was 31% higher than controls, whereas in the TPN without lipids mice there was no significant change. Hepatocyte extrusion of rhodamine dye, a measure of MDR1 function, declined only in the TPN with lipid group. Peroxisome proliferator-activated receptor-alpha expression decreased in both TPN groups. Fenofibrate given with TPN resulted in an increased expression of MDR1 and MDR2, and functionally increased hepatocyte rhodamine extrusion and presence of bile phosphatidylcholine in the TPN with lipid group. CONCLUSIONS The study shows that TPN led to alterations in the function of MDR1- and MDR2-expressed proteins. The changes help in the understanding of the mechanisms leading to PNALD, and suggest that fibrate administration may palliate these changes.
Collapse
MESH Headings
- ATP Binding Cassette Transporter, Subfamily B/analysis
- ATP Binding Cassette Transporter, Subfamily B/genetics
- ATP Binding Cassette Transporter, Subfamily B/metabolism
- ATP Binding Cassette Transporter, Subfamily B, Member 1/analysis
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- Animals
- Chemical and Drug Induced Liver Injury
- Disease Models, Animal
- Fat Emulsions, Intravenous
- Fenofibrate/pharmacology
- Gene Expression
- Genes, MDR/genetics
- Liver/metabolism
- Liver/physiology
- Liver Diseases/etiology
- Liver Diseases/metabolism
- Male
- Mice
- Mice, Inbred C57BL
- PPAR alpha/metabolism
- Parenteral Nutrition, Total/adverse effects
- Random Allocation
- Specific Pathogen-Free Organisms
- ATP-Binding Cassette Sub-Family B Member 4
Collapse
Affiliation(s)
- Yuko Tazuke
- Department of Surgery, University of Michigan Medical School, Ann Arbor, USA
| | | |
Collapse
|
29
|
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.
Collapse
Affiliation(s)
- Aaron R Jensen
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | | | | | | | | | | |
Collapse
|
30
|
Fan BG. Effects of Parenteral Nutrition on the Exocrine Pancreas in Response to Cholecystokinin. JPEN J Parenter Enteral Nutr 2008; 32:57-62. [PMID: 18165448 DOI: 10.1177/014860710803200157] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Bo-Guang Fan
- From the Centre for Gastrointestinal Disease, Taizhou Hospital, Zhejiang, China
| |
Collapse
|
31
|
Wales PW, Brindle M, Sauer CJE, Patel S, de Silva N, Chait P. Percutaneous cholangiography for the treatment of parenteral nutrition-associated cholestasis in surgical neonates: preliminary experience. J Pediatr Surg 2007; 42:1913-8. [PMID: 18022446 DOI: 10.1016/j.jpedsurg.2007.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Parenteral nutrition-associated cholestasis (PNAC) occurs in up to 60% of surgical neonates with intestinal failure, and 10% will develop end-stage liver failure. Our aim was to evaluate the effectiveness of percutaneous transhepatic transcholecystic cholangiography (PTTC) in the treatment of PNAC in surgical neonates. METHODS A retrospective double cohort study of surgical neonates with PNAC was conducted. Patients with PNAC who received PTTC were compared to controls matched by gestational age, birth weight, sex, and parenteral nutrition duration. Percutaneous transhepatic transcholecystic cholangiography was performed under general anesthesia with ultrasound guidance. Analysis was performed using paired Student's t test and McNemar chi2 test. RESULTS Nine PTTC patients and 9 controls were similar in mean age (35.5 +/- 3.1 vs 35.6 +/- 4.2 weeks, P = .85), birth weight (2531 +/- 879 vs 2692 +/- 1052 g, P = .28), sex (all males), and parenteral nutrition duration (51.2 +/- 29.8 vs 53.3 +/- 33.3 days, P = .74). Percutaneous transhepatic transcholecystic cholangiography was performed in 9 patients at mean corrected age of 5.5 +/- 3.4 weeks and weight of 3621 +/- 546 g. All control patients and 8 (88.9%) of 9 PTTC patients had eventual resolution of hyperbilirubinemia. Percutaneous transhepatic transcholecystic cholangiography patients experienced a more rapid rate of resolution of their cholestasis, and the mean time to resolution of conjugated bilirubin was less in the PTTC group (8.5 +/- 3.2 vs 18.5 +/- 7.6 weeks, P = .02). CONCLUSION Therapeutic PTTC results in a 50% reduction in the time to PNAC resolution. Percutaneous transhepatic transcholecystic cholangiography may have a role as active therapy to slow progression of PNAC in surgical neonates with intestinal failure.
Collapse
Affiliation(s)
- Paul W Wales
- Division of General Surgery, Faculty of Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada.
| | | | | | | | | | | |
Collapse
|
32
|
Carter BA, Shulman RJ. Mechanisms of disease: update on the molecular etiology and fundamentals of parenteral nutrition associated cholestasis. ACTA ACUST UNITED AC 2007; 4:277-87. [PMID: 17476210 DOI: 10.1038/ncpgasthep0796] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 02/06/2007] [Indexed: 12/11/2022]
Abstract
Since its introduction into clinical practice, parenteral nutrition has revolutionized the care of premature neonates. Serum transaminase and bilirubin levels are commonly elevated in infants on parenteral nutrition, but their normalization is typical in the setting of short-term administration of parenteral nutrition uncomplicated by sepsis. Premature infants who require long-term parenteral nutrition are, however, at severe risk for developing life-threatening hepatic complications. These complications include cirrhosis, liver failure, and the concomitant risks of sepsis, coagulopathy and death. Premature infants and those with short-bowel syndrome are most susceptible to these morbid outcomes. Although it has been more than a quarter of a century since parenteral nutrition was first introduced and its association with hepatic complications described, the precise etiology of parenteral nutrition associated cholestasis (PNAC) remains a mystery; however, our understanding of the molecular components that contribute to PNAC has improved substantially. In this Review, we summarize the fundamentals of PNAC, describe animal models of the disease, review the hepatic bile acid transporters that are crucial for bile acid homeostasis, and define the roles that endotoxin, genetics, and the components of parenteral nutrition are likely to have in the molecular pathogenesis of this life-threatening condition.
Collapse
Affiliation(s)
- Beth A Carter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, TX 77030, USA.
| | | |
Collapse
|
33
|
Aspirot A, Su W, Flageole H, Puligandla PS, Shaw K, Laberge JM. Cholestasis associated with small bowel atresia: do we always need to investigate? J Pediatr Surg 2007; 42:873-7. [PMID: 17502203 DOI: 10.1016/j.jpedsurg.2006.12.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Cholestasis occurs frequently in patients with small bowel atresia (SBA) and is often attributed to prolonged parental nutrition. When severe or prolonged, patients may undergo unnecessary intensive or invasive investigation. We characterized cholestasis and analyzed the pertinence of investigating this patient population. METHODS With Research Ethics Board approval, patients with SBA between 1996 and 2005 were retrospectively reviewed. Demographics, location of atresia, operative findings, complications, investigations, resumption of feeding, duration of prolonged parental nutrition, and follow-up information were examined. Cholestasis was evaluated for incidence, severity, and evolution. RESULTS Fifty-five patients (29 male, 26 female), with a median gestational age and birth weight of 36 weeks and 2025 g, respectively, were reviewed. Care was withdrawn for 2 patients before repair. For the remaining 53 patients, SBA were duodenal atresia in 18, jejunoileal atresia in 32, and multiple atresia in 3. Of 53, 24 (45%) patients developed cholestasis postoperatively (direct/total bilirubin >20%). All patients with short bowel (4) and 60% (6/10) of patients with a delay of enteral feeding more than 14 days postoperatively had cholestasis. Ten patients (36%) proceeded with in-depth evaluations for cholestasis, with 8 (28%) undergoing liver biopsy. No patient had biliary atresia. No deaths were related to isolated cholestasis/cirrhosis. Cholestasis resolved spontaneously in all the survivors. CONCLUSIONS Small bowel atresia is frequently associated with postoperative cholestasis that will resolve with time. We recommend a more selective and expectant approach to SBA-associated cholestasis to minimize unnecessary investigations.
Collapse
Affiliation(s)
- Ann Aspirot
- Division of Pediatric Surgery, The Montreal Children's Hospital, Montréal, Québec, Canada H3H 1P3
| | | | | | | | | | | |
Collapse
|
34
|
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.
Collapse
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
Collapse
|
35
|
Abstract
Parenteral nutrition plays a vital role for patients with intestinal failure and those who are unable to maintain oral or enteral nutrition alone. Parenteral nutrition has been shown to improve clinical outcome in patients with malnutrition and intestinal tract dysfunction. The use of parenteral nutrition is not without risk of serious complications. Parenteral nutrition complications can be divided into mechanical related to vascular access, septic, and metabolic. This article provides a review on the short- and long-term complications of parenteral nutrition and their management.
Collapse
Affiliation(s)
- Andrew Ukleja
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
| | | |
Collapse
|
36
|
Schmidt B, Roth B, Stützer H, Benz-Bohm G. Prospective volumetric analysis of gallbladders in critically ill newborns: the impact of nutrition. Neonatology 2007; 92:201-4. [PMID: 17476120 DOI: 10.1159/000102058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 01/01/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neonatal reference values of gallbladder size have been assessed in healthy newborns with enteral feeding regimen. Their applicability to critically ill patients under total parenteral nutrition (TPN) remains to be questioned. OBJECTIVE Our aim was to evaluate the impact of short-term TPN versus enteral nutrition (EN), gender and birth weight on neonatal gallbladder volume. METHOD A prospective pilot study was initiated with a single sonographic investigator blinded towards feeding regimen. In total, 61 neonates (33 males, 28 females) were consecutively enrolled on the intensive care unit; 31 newborns were examined both under TPN and bolus EN (breast milk/formula). Patients with malformations of the biliary tract were excluded. Prior to ultrasound examinations, a minimum fasting period of 2 h was maintained. Sonographic measurements of gallbladder length, depth and width were performed to calculate gallbladder volume using the ellipsoid formula. RESULTS Neonatal gallbladder volume differed significantly between TPN and EN (p < 0.001). Using TPN, range of gallbladder length, width and volume exceeded reference values. Birth weight was weakly correlated with gallbladder volume (correlation index 0.3776, p = 0.01). We found no gender-related differences. CONCLUSIONS Neonatal gallbladder volume under TPN was significantly larger compared to EN. Using TPN, gallbladder dimensions exceeded reference values without causing clinical complications. The benign course of gallbladder enlargement required no specific medication or surgical treatment.
Collapse
Affiliation(s)
- Beate Schmidt
- Department of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany.
| | | | | | | |
Collapse
|
37
|
Berna MJ, Jensen RT. Role of CCK/gastrin receptors in gastrointestinal/metabolic diseases and results of human studies using gastrin/CCK receptor agonists/antagonists in these diseases. Curr Top Med Chem 2007; 7:1211-31. [PMID: 17584143 PMCID: PMC2718729 DOI: 10.2174/156802607780960519] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In this paper, the established and possible roles of CCK1 and CCK2 receptors in gastrointestinal (GI) and metabolic diseases are reviewed and available results from human agonist/antagonist studies are discussed. While there is evidence for the involvement of CCK1R in numerous diseases including pancreatic disorders, motility disorders, tumor growth, regulation of satiety and a number of CCK-deficient states, the role of CCK1R in these conditions is not clearly defined. There are encouraging data from several clinical studies of CCK1R antagonists in some of these conditions, but their role as therapeutic agents remains unclear. The role of CCK2R in physiological (atrophic gastritis, pernicious anemia) and pathological (Zollinger-Ellison syndrome) hypergastrinemic states, its effects on the gastric mucosa (ECL cell hyperplasia, carcinoids, parietal cell mass) and its role in acid-peptic disorders are clearly defined. Furthermore, recent studies point to a possible role for CCK2R in a number of GI malignancies. Current data from human studies of CCK2R antagonists are presented and their potential role in the treatment of these conditions reviewed. Furthermore, the role of CCK2 receptors as targets for medical imaging is discussed.
Collapse
Affiliation(s)
- Marc J. Berna
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert T. Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
38
|
Helin R, Bhat R, Rao B. Ultrasound-guided percutaneous cholecystostomy for acute neonatal biliary obstruction. Neonatology 2007; 91:266-70. [PMID: 17568158 DOI: 10.1159/000098174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 08/15/2006] [Indexed: 11/19/2022]
Abstract
Use of a percutaneously-inserted cholecystostomy drainage tube is an effective therapeutic option for acute hyperbilirubinemia in severely-ill adult patients, but to our knowledge has not been previously reported in infants. We describe an infant who developed acute extrahepatic biliary tract obstruction with marked conjugated (direct) hyperbilirubinemia, and who was determined to be an unsuitable surgical candidate. Ultrasound-guided percutaneous cholecystostomy was performed and resulted in prompt, significant, and sustained decline in serum bilirubin levels. Potential risks and benefits, as well as suggested indications for the procedure are discussed.
Collapse
Affiliation(s)
- Radley Helin
- Department of Pediatrics, University of Illinois Medical Center, Chicago, IL 60612, USA.
| | | | | |
Collapse
|
39
|
Kumpf VJ. Parenteral nutrition-associated liver disease in adult and pediatric patients. Nutr Clin Pract 2006; 21:279-90. [PMID: 16772545 DOI: 10.1177/0115426506021003279] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There are essentially 3 types of hepatobiliary disorders associated with parenteral nutrition (PN) therapy: steatosis, cholestasis, and gallbladder sludge/stones. Reported prevalence rates of PN-associated liver disease (PNALD) vary greatly, and there are distinct differences between adult and pediatric patients. Various etiologic factors have been evaluated for significance in contributing to PNALD, including enteral feeding history, septic events, bacterial overgrowth, length of intestinal resection, and prematurity/low birth weight. Etiologic factors specifically related to the PN formulation or nutrient intake have also been evaluated, including excessive calorie intake, dextrose-to-lipid ratio, amino acid dose, taurine deficiency, IV fat emulsion (IVFE) dose, carnitine deficiency, choline deficiency, and continuous vs cyclic infusion. Minor increases in serum aminotransferase concentrations are relatively common in patients receiving PN therapy and generally require no intervention. The primary indicator of cholestasis is a serum conjugated bilirubin >2 mg/dL. When a patient receiving PN develops liver complications, it is necessary to rule out all treatable causes and minimize other risk factors. All potential hepatotoxic medications and herbal supplements should be eliminated. Modifications to the PN regimen that may be helpful include reduction of calories, reduction of IVFE dose to <1 g/kg/d, supplementation of taurine in the infant, and use of cyclic infusion. Initiation of even small amounts of enteral nutrition and use of ursodiol may be beneficial in stimulating bile flow. In the long-term PN patient with severe and progressive liver disease, intestinal or liver transplantation may be the only remaining treatment option.
Collapse
Affiliation(s)
- Vanessa J Kumpf
- Vanderbilt University Medical Center, Center for Human Nutrition, 1211 21st Ave South, Suite 514 Medical Arts Building, Nashville, TN 37232, USA.
| |
Collapse
|
40
|
Gura KM, Duggan CP, Collier SB, Jennings RW, Folkman J, Bistrian BR, Puder M. Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management. Pediatrics 2006; 118:e197-201. [PMID: 16818533 DOI: 10.1542/peds.2005-2662] [Citation(s) in RCA: 239] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Here we report the reversal of cholestasis in 2 infants with intestinal failure and parenteral nutrition-associated liver disease. Treatment involved the substitution of a conventional intravenous fat emulsion with one containing primarily omega-3 fatty acids. Biochemical tests of liver function improved significantly. One child was removed from the liver transplantation list because of improved hepatic function, and the second child had complete resolution of cholestasis while solely on parenteral nutrition. This suggests that fat emulsions made from fish oils may be an effective means of treating and preventing this often-fatal condition. A randomized, controlled trial is necessary to study the efficacy of this new approach to parenteral nutrition-associated liver disease.
Collapse
Affiliation(s)
- Kathleen M Gura
- Department of Pharmacy, Children's Hospital Boston, 300 Longwood Ave, Boston, Massachusetts 02115, USA
| | | | | | | | | | | | | |
Collapse
|