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

  • David A. J. Lloyd (a1) and Simon M. Gabe (a1) (a2)

Parenteral nutrition is life saving in patients with intestinal failure but liver dysfunction is commonly encountered, especially in neonates. Although abnormal liver function tests associated with short-term parenteral nutrition are usually benign and transient, liver dysfunction in both children and adults receiving long-term parenteral nutrition can progress to end-stage liver disease and liver failure. The aetiology of parenteral nutrition-associated liver disease is complex and multifactorial, with a range of patient, disease and nutrition-related factors implicated. Sepsis is of particular importance, as is the lack of enteral nutrition and overfeeding with intravenous glucose and/or lipid. Deficiencies of a number of amino acids including choline and taurine have also been implicated. Management of hepatic dysfunction in parenteral nutrition should initially focus on preventing its occurrence. Sepsis should be managed appropriately, enteral nutrition should be encouraged and maximised where possible and parenteral overfeeding should be avoided. Provision of parenteral lipid should be optimised to prevent the adverse effects of both deficiency and excess, and cyclical rather than continuous parenteral feeding should be administered. There is some evidence of benefit in neonates from oral antibiotics to prevent intestinal bacterial overgrowth and from oral ursodeoxycholic acid, but less to support their use in adults. Similarly, data to support widespread use of parenteral choline or taurine supplementation are lacking at present. Ultimately, severe parenteral nutrition-associated liver disease may necessitate referral for small intestine and/or liver transplantation.

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*Corresponding author: Dr Simon Gabe, fax +44 2082354001, email
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VH Peden , CL Witzleben & MA Skelton (1971) Total parenteral nutrition. J Pediatr 78, 180181.

KD Lindor , CR Fleming , A Abrams & MA Hirschkorn (1979) Liver function values in adults receiving total parenteral nutrition. JAMA 241, 23982400.

BM Wolfe , BK Walker , DB Shaul , L Wong & BH Ruebner (1988) Effect of total parenteral nutrition on hepatic histology. Arch Surg 123, 10841090.

W Luman & JL Shaffer (2002) Prevalence, outcome and associated factors of deranged liver function tests in patients on home parenteral nutrition. Clin Nutr 21, 337343.

S Chan , KC McCowen , BR Bistrian , A Thibault , M Keane-Ellison , RA Forse , T Babineau & P Burke (1999) Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition. Surgery 126, 2834.

M Cavicchi , P Beau , P Crenn , C Degott & B Messing (2000) Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med 132, 525532.

SV Beath , P Davies , A Papadopoulou , AR Khan , RG Buick , JJ Corkery , P Gornall & IW Booth (1996) Parenteral nutrition-related cholestasis in postsurgical neonates: multivariate analysis of risk factors. J Pediatr Surg 31, 604606.

JM Nightingale (2003) Hepatobiliary, renal and bone complications of intestinal failure. Best Pract Res Clin Gastroenterol 17, 907929.

BS Reddy , J MacFie , M Gatt , L Macfarlane-Smith , K Bitzopoulou & AM Snelling (2007) Commensal bacteria do translocate across the intestinal barrier in surgical patients. Clin Nutr 26, 208215.

AL Buchman , K Iyer & J Fryer (2006) Parenteral nutrition-associated liver disease and the role for isolated intestine and intestine/liver transplantation. Hepatology 43, 919.

JM Langrehr , MJ Reilly , B Banner , VJ Warty , KK Lee & WH Schraut (1991) Hepatic steatosis due to total parenteral nutrition: the influence of short-gut syndrome, refeeding, and small bowel transplantation. J Surg Res 50, 335343.

G Hernandez , N Velasco , C Wainstein , L Castillo , G Bugedo , A Maiz , F Lopez , S Guzman & C Vargas (1999) Gut mucosal atrophy after a short enteral fasting period in critically ill patients. J Crit Care 14, 7377.

AA Moukarzel , KA Dahlstrom , AL Buchman & ME Ament (1992) Carnitine status of children receiving long-term total parenteral nutrition: a longitudinal prospective study. J Pediatr 120, 759762.

YN Berner , WA Larchian , SF Lowry , RR Nicroa , MF Brennan & M Shike (1990) Low plasma carnitine in patients on prolonged total parenteral nutrition: association with low plasma lysine. J Parenter Enteral Nutr 14, 255258.

AL Buchman , A Moukarzel , DJ Jenden , M Roch , K Rice & ME Ament (1993) Low plasma free choline is prevalent in patients receiving long term parenteral nutrition and is associated with hepatic aminotransferase abnormalities. Clin Nutr 12, 3337.

AL Buchman , M Sohel , A Moukarzel (2001) Plasma choline in normal newborns, infants, toddlers, and in very-low-birth-weight neonates requiring total parenteral nutrition. Nutrition 17, 1821.

AL Buchman , M Dubin , D Jenden , A Moukarzel , MH Roch , K Rice , J Gornbein , ME Ament & CD Eckhert (1992) Lecithin increases plasma free choline and decreases hepatic steatosis in long-term total parenteral nutrition patients. Gastroenterology 102, 13631370.

AL Buchman , ME Ament , M Sohel , M Dubin , DJ Jenden , M Roch , H Pownall , W Farley , M Awal & C Ahn (2001) Choline deficiency causes reversible hepatic abnormalities in patients receiving parenteral nutrition: proof of a human choline requirement: a placebo-controlled trial. J Parenter Enteral Nutr 25, 260268.

DC Belli , CC Roy , LA Fournier , B Tuchweber , R Giguere & IM Yousef (1991) The effect of taurine on the cholestatic potential of sulfated lithocholate and its conjugates. Liver 11, 162169.

A Cooper , JM Betts , GR Pereira & MM Ziegler (1984) Taurine deficiency in the severe hepatic dysfunction complicating total parenteral nutrition. J Pediatr Surg 19, 462466.

AU Spencer , S Yu , TF Tracy (2005) Parenteral nutrition-associated cholestasis in neonates: multivariate analysis of the potential protective effect of taurine. J Parenter Enteral Nutr 29, 337343.

SM Schneider , F Joly , MF Gehrardt , AM Badran , A Myara , F Thuillier , C Coudray-Lucas , L Cynober , F Trivin & B Messing (2006) Taurine status and response to intravenous taurine supplementation in adults with short-bowel syndrome undergoing long-term parenteral nutrition: a pilot study. Br J Nutr 96, 365370.

MA Schepens , HM Roelofs , WH Peters & GJ Wanten (2006) No evidence for oxidative stress in patients on home parenteral nutrition. Clin Nutr 25, 939948.

JC Lavoie , P Chessex , C Gauthier , E Levy , F Alvarez , P St-Louis & T Rouleau (2005) Reduced bile flow associated with parenteral nutrition is independent of oxidant load and parenteral multivitamins. J Pediatr Gastroenterol Nutr 41, 108114.

S Li , MS Nussbaum , D Teague , CL Gapen , R Dayal & JE Fischer (1988) Increasing dextrose concentrations in total parenteral nutrition (TPN) causes alterations in hepatic morphology and plasma levels of insulin and glucagon in rats. J Surg Res 44, 639648.

FW Guglielmi , D Boggio-Bertinet , A Federico (2006) Total parenteral nutrition-related gastroenterological complications. Dig Liver Dis 38, 623642.

MM Meguid , MP Akahoshi , S Jeffers , RJ Hayashi & WG Hammond (1984) Amelioration of metabolic complications of conventional total parenteral nutrition. A prospective randomized study. Arch Surg 119, 12941298.

C Bigorgne , A Le Tourneau , B Messing , B Rio , V Giraud , T Molina , J Audouin & J Diebold (1996) Sea-blue histiocyte syndrome in bone marrow secondary to total parenteral nutrition including fat-emulsion sources: a clinicopathologic study of seven cases. Br J Haematol 95, 258262.

PT Clayton , P Whitfield & K Iyer (1998) The role of phytosterols in the pathogenesis of liver complications of pediatric parenteral nutrition. Nutrition 14, 158164.

PT Clayton , A Bowron , KA Mills , A Massoud , M Casteels & PJ Milla (1993) Phytosterolemia in children with parenteral nutrition-associated cholestatic liver disease. Gastroenterology 105, 18061813.

YA Carpentier , M Richelle , D Haumont & RJ Deckelbaum (1990) New developments in fat emulsions. Proc Nutr Soc 49, 375380.

KM Gura , CP Duggan , SB Collier , RW Jennings , J Folkman , BR Bistrian & M Puder (2006) Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management. Pediatrics 118, e197e201.

GL Klein (1991) The aluminum content of parenteral solutions: current status. Nutr Rev 49, 7479.

JF Kennedy & JM Nightingale (2005) Cost savings of an adult hospital nutrition support team. Nutrition 21, 11271133.

SV Beath , IW Booth , MS Murphy , JA Buckels , AD Mayer , PJ McKiernan & DA Kelly (1995) Nutritional care and candidates for small bowel transplantation. Arch Dis Child 73, 348350.

SG Spurr , LJ Grylack & NR Mehta (1989) Hyperalimentation-associated neonatal cholestasis: effect of oral gentamicin. J Parenter Enteral Nutr 13, 633636.

A Kubota , A Okada , K Imura , H Kawahara , R Nezu , S Kamata & Y Takagi (1990) The effect of metronidazole on TPN-associated liver dysfunction in neonates. J Pediatr Surg 25, 618621.

JM Nightingale , JE Lennard-Jones , DJ Gertner , SR Wood & CI Bartram (1992) Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gall stones in patients with a short bowel. Gut 33, 14931497.

K Wallis , DA Lloyd & SM Gabe (2007) Promoting intestinal adaptation. Br J Hosp Med 68, 1114.

S Chan , KC McCowen & B Bistrian (1998) Medium-chain triglyceride and n-3 polyunsaturated fatty acid-containing emulsions in intravenous nutrition. Curr Opin Clin Nutr Metab Care 1, 163169.

CY Chen , PN Tsao , HL Chen , HC Chou , WS Hsieh & MH Chang (2004) Ursodeoxycholic acid (UDCA) therapy in very-low-birth-weight infants with parenteral nutrition-associated cholestasis. J Pediatr 145, 317321.

G De Marco , D Sordino , E Bruzzese , S Di Caro , D Mambretti , A Tramontano , C Colombo , P Simoni & A Guarino (2006) Early treatment with ursodeoxycholic acid for cholestasis in children on parenteral nutrition because of primary intestinal failure. Aliment Pharmacol Ther 24, 387394.

AL Buchman , MD Dubin , AA Moukarzel , DJ Jenden , M Roch , KM Rice , J Gornbein & ME Ament (1995) Choline deficiency: a cause of hepatic steatosis during parenteral nutrition that can be reversed with intravenous choline supplementation. Hepatology 22, 13991403.

S Misra , C Ahn , ME Ament , HJ Choi , DJ Jenden , M Roch & AL Buchman (1999) Plasma choline concentrations in children requiring long-term home parenteral nutrition: a case control study. J Parenter Enteral Nutr 23, 305308.

D Grant , K Abu-Elmagd , J Reyes , A Tzakis , A Langnas , T Fishbein , O Goulet & D Farmer (2005) 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg 241, 607613.

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Proceedings of the Nutrition Society
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