Pathogenesis and treatment of parenteral nutrition-associated liver disease

BACKGROUND: Parenteral nutrition-associated liver disease (PNALD) has been common in patients who require long-term parenteral nutrition. PNALD develops in 40%-60% of infants on long-term parenteral nutrition compared with 15%-40% of adults on home parenteral nutrition for intestinal failure. The pathogenesis of PNALD is multifactorial and remains unclear There is no specific treatment. Management strategies for its prevention and treatment depend on an understanding of many risk factors. This review aims to provide an update on the pathogenesis and treatment of this disease. DATA SOURCES: A literature search was performed on the MEDLINE and Web of Science databases for articles published up to October 2011, using the keywords: parenteral nutrition associated liver disease, intestinal failure associated liver disease lipid emulsions and fish oil. The available data reported in the relevant literatures were analyzed. RESULTS: The literature search provided a huge amount of evidence about the pathogenesis and management strategies on PNALD. Currently, lack of enteral feeding, extended duration of parenteral nutrition, recurrent sepsis, and nutrient deficiency or excess may play important roles in the pathogenesis of PNALD. Recent studies found that phytosterols present as contaminants in soy-based lipid emulsions, are also an important factor in the pathogenesis. Moreover, the treatment of PNALD is discussed. CONCLUSIONS: The use of lipid emulsions, phytosterols in particular, is associated with PNALD. Management strategies for the prevention and treatment of PNALD include consideration of early enteral feeding, the use of specialized lipid emulsions such as fish oil emulsions, and isolated small bowel or combined liver and small bowel transplantation. A greater understanding of the pathogenesis of PNALD has led to promising interventions to prevent and treat this condition. Future work should aim to better understand the mechanisms of PNALD and the long-term outcomes of its treatment.

Fish oil-based lipid emulsion:current updates on a promising novel therapy for the management of parenteral nutrition-associated liver disease

Intestinal failure is characterized by loss of enteral function to absorb necessary nutrients and water to sustain life.Parenteral nutrition(PN)is a lifesaving therapeutic modality for patients with intestinal failure.Lifelong PN is also needed for patients who have short bowel syndrome due to extensive resection or a dysmotility disorder with malabsorption.However,prolonged PN is associated with short-term and long-term complications.Parenteral nutrition-associated liver disease(PNALD)is one of the long-termcomplications associated with the use of an intravenous lipid emulsion to prevent essential fatty acid deficiency in these patients.PNALD affects 30–60%of the adult population on long-term PN.Further,PNALD is one of the indications for isolated liver or combined liver and intestinal transplantation.There is no consensus on how to manage PNALD,but fish oil-based lipid emulsion(FOBLE)has been suggested to play an important role both in its prevention and reversal.There is significant improvement in liver function in those who received FOBLE as lipid supplement compared with those who received soy-based lipid emulsion.Studies have also demonstrated that FOBLE reverses hepatic steatosis and reduces markers of inflammation in patients on long-term PN.Future prospective studies with larger sample sizes are needed to further strengthen the positive role of FOBLE in PNALD.

重症急性胰腺炎患者肠外营养相关性肝损伤的风险模型构建

目的 构建重症急性胰腺炎(severe acute pancreatitis, SAP)患者肠外营养相关性肝损伤(parenteral nutrition-associated liver disease, PNALD)的风险模型,探讨造成PNALD的相关因素。方法 选择2020年1月至2023年8月我院收治的264例SAP患者为研究对象。采用计算机产生随机数法以2∶1的比例分为训练集(n=176)和测试集(n=88)。训练集患者根据是否发生PNALD,分为PNALD组(n=43)和非PNALD组(n=133)。通过单因素和多因素分析SAP患者发生PNALD的独立危险因素,并构建分类树模型。结果 与非PNALD组比较,PNALD组患者病程较长,NRS2002评分较高,全胃肠外营养(TPN)持续时间较久,胰腺坏死和急性呼吸窘综迫综合征(ARDS)人数占比较高,尿素氮(BUN)、血清肌酐(SCr)、C反应蛋白(CRP)水平较高,白蛋白(ALB)和前血蛋白(PAB)水平较低(P均<0.05)。多因素Logistic回归分析显示,病程和TPN持续时间为SAP患者发生PNALD的独立危险因素(P<0.05),ALB和PAB为独立保护因素(P<0.05)。分类树模型显示,TPN持续时间是患者发生PNALD的重要预测因素,收益图和索引图显示模型预测良好。校准曲线和ROC曲线提示该模型具有良好的准确性和区分度。结论 TPN持续时间对SAP患者PNALD发病风险的影响最大,病程、ALB和PAB也应予以重点关注,及时制定预防策略,以期降低PNALD的发病风险。

添加鱼油脂肪乳全合一静脉营养对肝功能的影响

目的:了解添加n-3鱼油脂肪乳全合一静脉营养是否可改善肠外营养引起的肝功能损害和胆汁淤积。方法:将100例需要中长期全合一静脉营养支持的患者随机分为2组:对照组50例,使用普通脂肪乳剂250m L;实验组50例,使用普通脂肪乳剂250m L加鱼油脂肪乳剂100m L。输注肠外营养1w后,比较输注前后2组患者血浆转氨酶、胆红素及血浆蛋白水平。结果:肠外营养治疗前后,实验组患者自身对比,血清平均总胆红素(TBIL)、直接胆红素(DBIL)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)均明显降低(P<0.05)。对照组患者自身对比,血清平均ALT、碱性磷酸酶(ALP)、γ-谷氨酰转移酶(γ-GT)均明显升高(P<0.05)。实验组在肠外营养支持后血清平均TBIL、DBIL、ALT、AST、ALP、γ-GT均明显低于对照组(P<0.01)。结论:添加n-3鱼油脂肪乳可改善患者的肝功能损害和胆汁淤积。