Abstract
Parenteral nutrition associated liver disease (PNALD) is a significant complication in infants receiving long-term parenteral nutrition (PN). Chronic administration of PN has been associated with its development. Our purpose is to characterize our incidence of PNALD over an extended period and identify risk factors for its development, including administration of soybean-based injectable lipid emulsions (ILEs) as we transit to novel ILEs in our practice. Infants receiving 30 days or more of PN were included. PNALD was defined as a direct bilirubin ≥ 2 mg/dL. Data collected included: patient demographics, clinical and enteral feeding characteristics. Macronutrient intake was recorded using these cut-offs: glucose infusion rate (GIR) of ≤14 mg/kg/min or above, protein doses of ≤3 g/kg/day or above and lipid doses of ≤2 g/kg/day or above. A total of 349 infants were included, with an annual incidence of PNALD ranging between 34% - 54%. Infants with PNALD were younger by gestation (27 vs. 29.5 weeks) and smaller by birthweight (900 vs. 1248 grams). Sepsis, GI disease including necrotizing enterocolitis and bowel resection were significantly associated with an increased risk for development of PNALD. PNALD infants received lower protein doses (3.0 vs 3.3 g/kg/day, p = 0.014) while receiving higher GIR (11.4 vs 10.7 mg/kg/min, p = 0.012) compared to non-PNALD infants. Low birth weight, sepsis and bowel resection remain strong indicators of risk for PNALD. No single macronutrient increased our infants’ risk for PNALD. The use of newer ILEs when available should be evaluated for their impact on PNALD development.
Highlights
Parenteral nutrition (PN) plays a significant role in achieving adequate growth and development in infants unable to be fed enterally [1]
GI disease including necrotizing enterocolitis and bowel resection were significantly associated with an increased risk for development of Parenteral nutrition associated liver disease (PNALD)
The primary outcome of the study was the annual incidence of PNALD that ranged between 34% - 54% (Figure 1)
Summary
Parenteral nutrition (PN) plays a significant role in achieving adequate growth and development in infants unable to be fed enterally [1]. PN is not benign, and prolonged courses can lead to increased risk of serious complications such as central line associated bloodstream infections, metabolic bone disease, and cholestasis. Cholestasis, or parenteral nutrition associated liver disease (PNALD), is a known risk factor for patients receiving prolonged PN [2] [3]. Once PNALD ensues, medical teams implement changes primarily in 2 ways, by modifying PN/EN regimens or initiating medications. Agents such as cholecystokinin-octapeptide, ursodeoxycholic acid, and enteral fish oil have been studied [15] [16] [17] [18]. Any one intervention has only been shown to have modest efficacy in resolution of PNALD, leading organizations such as the American Society of Parenteral and Enteral Nutrition (ASPEN) to give inconclusive recommendations regarding some of these interventions in patients at risk of PNALD [24]
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