Parenteral nutrition-associated cholestasis

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Extreme short bowel syndrome in a full-term neonate--a case report

Massive small bowel resection often leads to long-term parenteral nutrition. The authors present a term-born, 3-day-old boy with midgut volvulus in whom only 17 cm of small bowel was left after resection. This patient was weaned from parenteral nutrition after 7 months. Temporary parenteral nutrition-associated cholestasis was treated with ursodeoxycholic acid.

Increased incidence of parenteral nutrition-associated cholestasis with aminosyn PF compared to trophamine

OBJECTIVE

To compare the incidence of parenteral nutrition-associated cholestasis (PNAC) between two pediatric parenteral amino-acid formulations, Aminosyn PF (APF) and Trophamine (TA).

SETTING

Tertiary newborn intensive-care nursery.

SUBJECTS

A total of 661 neonates who received either TA or APF.

DESIGN

Retrospective. The incidence of PNAC was determined in three groups: Group I (TA, 8/19/97 to 8/19/98, n=335), Group II (APF, 8/20/98 to 1/28/99, n=157), and Group III (TA, 1/29/99 to 8/1/99, n=169).

RESULTS

No PNAC developed in any infant receiving parenteral nutrition (PN) for < 3 weeks. Of 141 patients given PN for > or =21 days, 24 were diagnosed with PNAC: Group I (TA, 10/78, 12.8%), Group II (APF, 9/27, 33.3%), and Group III (TA, 5/36, 13.9%). The incidence of PNAC was significantly higher in infants who received APF (p=0.043). Using logistic regression, only birth weight, duration of PN, and use of APF were significant risk factors for the development of PNAC. Despite an earlier initiation of enteral feedings, APF recipients developed PNAC sooner, had higher peak direct bilirubin levels, and remained jaundiced longer.

CONCLUSIONS

The use of APF was temporally associated with a greater than two-fold increase in the incidence of PNAC compared to periods of exclusive TA use. In the absence of significant differences in parenteral nutrient or energy intake in neonates who developed PNAC, we speculate that possible differences between the amino-acid compositions of TA and APF may be responsible for the observed differences in the incidence of PNAC.

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Cholestatic syndromes

Further insights into the molecular regulation of bile acid transport and metabolism have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Novel insights into the mechanisms of action of ursodeoxycholic acid should advance our understanding of the treatment of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes in both infants and adults as well as cholesterol gallstone disease. Important studies have been published on the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, drug-induced cholestasis, and cholestasis of pregnancy.

Update on management and treatment of short gut

Management of patients with short-bowel syndrome represents a formidable challenge. Aggressive treatment including nutritional care and anticipation of potential complications and rapid treatment of complications enhance outcome. New therapies offer the promise of significantly improving morbidity and mortality. Intestinal transplant is appropriate for infants who would otherwise die from liver disease, recurrent sepsis, or lack of venous access.

Changing profile of parenteral nutrition in pediatric surgery: a 30-year experience at one institute

BACKGROUND

Due to technical refinements and steady advances in the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients, parenteral nutrition (PN) is now playing an important role in patient management. However, some PN-associated complications, such as catheter-related sepsis (CRS) and cholestasis, continue at high incidence, particularly in neonates. The objective of this study was to investigate the changing profiles of PN over the past 30 years in our department.

METHODS

The medical records of 893 children (225 neonates, 245 infants, 261 preschool-age children, and 162 school-age children) who were placed on PN for >7 days in our department were reviewed, and the following data were extracted: birth weight, underlying disease, indications for PN, PN delivery route, type of catheter used, duration of PN, substrate and energy intake, type of amino acid solution used, and incidence of complications including CRS and liver dysfunction. The results were analyzed by dividing the patients into 3 groups according to their basic stages in management of PN and consisted of group 1 (1970 to 1979), group 2 (1980 to 1989), and group 3 (1990 to 1999). The parameters were compared in each group.

RESULTS

The total number of patients in each group showed no significant difference; however, the percentage of low birth-weight neonates increased in group 3. In group 1, 85% of PN was administered through the peripheral vein; in group 2, 51.2%; and in group 3, 9.7%. The total calorie and nutrient intake decreased in groups 2 and 3 compared with group 1, particularly regarding fat intake. In groups 1 and 2, commercially available amino acid solution based on the Food and Agriculture Organization/World Health Organization formula was usually used as the nitrogen source, but in group 3, it was changed to an amino acid solution for children. CRS decreased significantly, particularly in neonates, and occurred at a rate of 45.4% in group 1, 10.7% in group 2, and 1.5% in group 3. The incidence of liver dysfunction also showed a decrease: 35.7% in group 1, 22.3% in group 2, and 18.0% in group 3. A multivariate analysis showed a strong relationship between PN-related liver dysfunction and the duration of PN, the presence of infection, and the type of amino acid solution used.

CONCLUSIONS

PN via central venous catheters has been regarded as safe and effective treatment in pediatric surgical patients. Over the past 30 years, the incidence of CRS has decreased. However, PN-related liver dysfunction remains a problem, particularly in patients receiving long-term PN.