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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.
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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.
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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.
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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
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Koelfat KVK, Schaap FG, Hodin CMJM, Visschers RGJ, Svavarsson BI, Lenicek M, Shiri-Sverdlov R, Lenaerts K, Olde Damink SWM. Parenteral nutrition dysregulates bile salt homeostasis in a rat model of parenteral nutrition-associated liver disease. Clin Nutr 2016; 36:1403-1410. [PMID: 28029505 DOI: 10.1016/j.clnu.2016.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 07/23/2016] [Accepted: 09/13/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN), a lifesaving therapy in patients with intestinal failure, has been associated with hepatobiliary complications including steatosis, cholestasis and fibrosis, collectively known as parenteral nutrition-associated liver disease (PNALD). To date, the pathogenesis of PNALD is poorly understood and therapeutic options are limited. Impaired bile salt homeostasis has been proposed to contribute PNALD. The objective of this study was to establish a PNALD model in rats and to evaluate the effects of continuous parenteral nutrition (PN) on bile salt homeostasis. METHODS Rats received either PN via the jugular vein or received normal diet for 3, 7 or 14 days. Serum biochemistry, hepatic triglycerides, circulating bile salts and C4, IL-6 and TNF-alpha, and lipogenic and bile salt homeostatic gene expression in liver and ileum were assessed. RESULTS PN increased hepatic triglycerides already after 3 days of administration, and resulted in conjugated bilirubin elevation after 7 or more days. This indicates PN-induced steatosis and impaired canalicular secretion of bilirubin, the latter which is in line with reduced hepatic expression of Mrp2 mRNA. There was no histological evidence for liver inflammation after PN administration, and circulating levels of pro-inflammatory cytokines IL-6 and TNF-α, were comparable in all groups. Hepatic expression of Fxr mRNA was decreased after 7 days of PN, without apparent effect on expression of Fxr targets Bsep and Shp. Nonetheless, Cyp7a1 expression was reduced after 7 days of PN, indicative for lowered bile salt synthesis. Circulating levels of C4 (marker of bile salt synthesis) were also decreased after 3, 7 and 14 days of PN. Levels of circulating bile salts were not affected by PN. CONCLUSIONS This study showed that PN in rats caused early mild steatosis and cholestasis, while hepatic and systemic inflammation were not present. The onset of these abnormalities was associated with alterations in bile salt synthesis and transport. This animal model serves as an experimental model to further investigate the pathogenesis of PNALD inflicted by steatosis and cholestasis.
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Affiliation(s)
- Kiran V K Koelfat
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Frank G Schaap
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Caroline M J M Hodin
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Ruben G J Visschers
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Björn I Svavarsson
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Martin Lenicek
- Department of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ronit Shiri-Sverdlov
- Department of Molecular Genetics, Maastricht University and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Kaatje Lenaerts
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands; Institute for Liver and Digestive Health, University College London, London, United Kingdom.
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Kim AY, Lim RK, Han YM, Park KH, Byun SY. Parenteral Nutrition-Associated Cholestasis in Very Low Birth Weight Infants: A Single Center Experience. Pediatr Gastroenterol Hepatol Nutr 2016; 19:61-70. [PMID: 27066450 PMCID: PMC4821984 DOI: 10.5223/pghn.2016.19.1.61] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Parenteral nutrition (PN)-associated cholestasis (PNAC) is one of the most common complications in very low birth weight infants (VLBWIs). The aim of this study is to evaluate the risk factors of PNAC in VBLWIs. METHODS We retrospectively reviewed the medical records of 322 VLBWIs admitted to the neonatal intensive care unit of our hospital from July 1, 2009 to December 31, 2013. We excluded 72 dead infants; 6 infants were transferred to another hospital, and 57 infants were transferred to our hospital at 2 weeks after birth. The infants were divided into the cholestasis and the non-cholestasis groups. PNAC was defined as a direct bilirubin level of ≥2.0 mg/dL in infants administered with PN for ≥2 weeks. RESULTS A total of 187 VLBWI were enrolled in this study; of these, 46 infants developed PNAC. Multivariate logistic regression analysis showed that the risk factors of PNAC in VLBWI were longer duration of antimicrobial use (odds ratio [OR] 4.49, 95% confidence interval [95% CI] 4.42-4.58), longer duration of PN (OR 2.68, 95% CI 2.41-3.00), long-term lack of enteral nutrition (OR 2.89, 95% CI 2.43-3.37), occurrence of necrotizing enterocolitis (OR 2.40, 95% CI 2.16-2.83), and gastrointestinal operation (OR 2.19, 95% CI 2.03-2.58). CONCLUSION The results of this study suggest that shorter PN, aggressive enteral nutrition, and appropriate antimicrobial use are important strategies in preventing PNAC.
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Affiliation(s)
- Ah-Young Kim
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Ryoung-Kyoung Lim
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Young-Mi Han
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Kyung-Hee Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Shin-Yun Byun
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Vanwijngaerden YM, Langouche L, Brunner R, Debaveye Y, Gielen M, Casaer M, Liddle C, Coulter S, Wouters PJ, Wilmer A, Van den Berghe G, Mesotten D. Withholding parenteral nutrition during critical illness increases plasma bilirubin but lowers the incidence of biliary sludge. Hepatology 2014; 60:202-10. [PMID: 24213952 DOI: 10.1002/hep.26928] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 11/03/2013] [Indexed: 12/23/2022]
Abstract
UNLABELLED Cholestatic liver dysfunction (CLD) and biliary sludge often occur during critical illness and are allegedly aggravated by parenteral nutrition (PN). Delaying initiation of PN beyond day 7 in the intensive care unit (ICU) (late PN) accelerated recovery as compared with early initiation of PN (early PN). However, the impact of nutritional strategy on biliary sludge and CLD has not been fully characterized. This was a preplanned subanalysis of a large randomized controlled trial of early PN versus late PN (n = 4,640). In all patients plasma bilirubin (daily) and liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], gamma-glutamyl transpeptidase [GGT], alkaline phosphatase [ALP], twice weekly; n = 3,216) were quantified. In a random predefined subset of patients, plasma bile acids (BAs) were also quantified at baseline and on days 3, 5, and last ICU-day (n = 280). Biliary sludge was ultrasonographically evaluated on ICU-day 5 (n = 776). From day 1 after randomization until the end of the 7-day intervention window, bilirubin was higher in the late PN than in the early PN group (P < 0.001). In the late PN group, as soon as PN was started on day 8 bilirubin fell and the two groups became comparable. Maximum levels of GGT, ALP, and ALT were lower in the late PN group (P < 0.01). Glycine/taurine-conjugated primary BAs increased over time in ICU (P < 0.01), similarly for the two groups. Fewer patients in the late PN than in the early PN group developed biliary sludge on day 5 (37% versus 45%; P = 0.04). CONCLUSION Tolerating substantial caloric deficit by withholding PN until day 8 of critical illness increased plasma bilirubin but reduced the occurrence of biliary sludge and lowered GGT, ALP, and ALT. These results suggest that hyperbilirubinemia during critical illness does not necessarily reflect cholestasis and instead may be an adaptive response that is suppressed by early PN.
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Affiliation(s)
- Yoo-Mee Vanwijngaerden
- University Hospitals of the KU Leuven, Intensive Care Medicine and Department of Molecular and Cellular Medicine, Leuven, Belgium
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Arrieta F, Balsa JA, de la Puerta C, Botella JI, Zamarrón I, Elías E, Del Río JIP, Alonso P, Candela A, Blanco-Colio LM, Egido J, Navarro P, Vázquez C. Phase IV prospective clinical study to evaluate the effect of taurine on liver function in postsurgical adult patients requiring parenteral nutrition. Nutr Clin Pract 2014; 29:672-80. [PMID: 24829298 DOI: 10.1177/0884533614533610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Taurine's role in bile acid metabolism and anti-inflammatory activity could exert a protective effect on hepatobiliary complications associated with parenteral nutrition (PN). In this study, the effects of 2 amino acid solutions, with and without taurine, on liver function administered to nonacutely ill postsurgical patients as part of a short-term PN regimen were prospectively compared. METHODS Adult patients randomly received (double-blind) Tauramin 10% or a standard PN solution without taurine as the control (1.5 g amino acid/kg body weight [bw]/d; infusion rate of ≤4 mg glucose/kg bw/d) for a period of 5-30 days. γ-Glutamyl transpeptidase (GGT) and other indicators of liver function, glucose metabolism, lipid profile, inflammation markers, and treatment safety data were collected. RESULTS Thirty-five patients receiving taurine PN and 39 receiving control PN were enrolled (intention-to-treat [ITT] population). Most patients (n = 62) discontinued after day 7 of follow-up (per-protocol [PP] population: n = 24 and n = 27, respectively). ITT patients with high GGT values after 5 days of PN comprised 68.6% and 64.1%, respectively. The mean change in GGT values with respect to the baseline values was 167 ± 192 and 157 ± 185 IU/L, respectively. Low-density lipoprotein (LDL) cholesterol levels after 7 days of PN were significantly decreased in the taurine PN group of PP patients (-2.83 ± 30.9 vs 23.9 ± 27.0 mg/dL for control PN; P < .05). None of the adverse events reported (taurine PN: n = 6; control PN: n = 7) were treatment related. CONCLUSION PN solutions with and without taurine had similar effects on liver function parameters, except for an LDL reduction in PN with taurine, when administered to nonacutely ill postsurgical patients in the short term (5-7 days).
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Affiliation(s)
- Francisco Arrieta
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - José Antonio Balsa
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - Cristina de la Puerta
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - José Ignacio Botella
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - Isabel Zamarrón
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
| | - Elena Elías
- Servicio de Anestesia, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Paloma Alonso
- Servicio de Anestesia, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Angel Candela
- Servicio de Anestesia, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Jesús Egido
- Laboratorio de Patología Vascular, Madrid, Spain CIBERDEM, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pilar Navarro
- Servicio de Farmacia, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Clotilde Vázquez
- Unidad de Nutrición y Dietética, Obesidad y Metabolismo, Hospital Universitario Ramón y Cajal, Ciber de Obesidad y Nutrición (CIBEROBN), Madrid, Spain
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Alemmari A, Miller GG, Arnold CJ, Zello GA. Parenteral aluminum induces liver injury in a newborn piglet model. J Pediatr Surg 2011; 46:883-7. [PMID: 21616246 DOI: 10.1016/j.jpedsurg.2011.02.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Parenteral nutrition-associated cholestasis remains a significant problem, especially for the surgical neonate. Aluminum is a toxic element known to contaminate parenteral nutrition. We hypothesize that parenterally administered aluminum causes liver injury similar to that seen in parenteral nutrition-associated cholestasis. METHODS Twenty 3- to 6-day-old domestic pigs were divided into 5 equal groups. A control group received daily intravenous 0.9% sodium chloride. Each subject in experimental groups received intravenous aluminum chloride at 1500 μg/kg per day for 1, 2, 3, or 4 weeks. At the end of the study, blood was sampled for direct bilirubin and total bile acid levels. Liver, bile, and urine were sampled for aluminum content. Liver tissue was imaged by transmission electron microscopy for ultrastructural changes. RESULTS Transmission electron microscopy revealed marked blunting of bile canaliculi microvilli in all experimental subjects but not the controls. Serum total bile acids correlated with the duration of aluminum exposure. The hepatic aluminum concentration correlated with the duration of aluminum exposure. CONCLUSIONS Parenterally infused aluminum resulted in liver injury as demonstrated by elevated bile acids and by blunting of the bile canaliculi microvilli. These findings are similar to those reported in early parenteral nutrition-associated liver disease.
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Affiliation(s)
- Abdulla Alemmari
- Division of Nutrition and Dietetics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada S7N 0W8
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Plasma Levels of Conjugated Bile Acids in Newborns After a Short Period of Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2010; 34:538-41. [DOI: 10.1177/0148607110374059] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hong L, Wang X, Wu J, Cai W. Mitochondria-initiated apoptosis triggered by oxidative injury play a role in total parenteral nutrition-associated liver dysfunction in infant rabbit model. J Pediatr Surg 2009; 44:1712-8. [PMID: 19735813 DOI: 10.1016/j.jpedsurg.2009.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 03/31/2009] [Accepted: 04/01/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of the study was to investigate oxidative injury and apoptosis as the mechanisms underlying total parenteral nutrition (TPN)-associated liver dysfunction. METHODS Twenty New Zealand rabbits (2 weeks old) were divided into 2 groups as follows: 10 in the control group (maternal feed) and 10 in the TPN group. The rabbits in the TPN group received continuous PN infusion through a silastic catheter inserted in the right jugular vein. RESULTS After 10 days of treatment, the serum levels of total bilirubin and bile acid were significantly higher in the TPN group than in the control group (P < .01, respectively). The light microscopic findings in the TPN rabbits included inflammatory cell infiltration and hepatic steatosis. Electron microscopy showed change in the cytosolic vacuoles and rare microvilli in the microbile duct. Moreover, 10 days of treatment resulted in an inhibition of the superoxide dismutase (SOD) activity in hepatocytes, an increase of the malondialdehyde level, a significant increase in cytochrome c release from the mitochondria, a significant increase in caspase 3 activity, and increased apoptosis (P < .01, individually). CONCLUSIONS Oxidative damage may be one of the essential mechanisms of TPN-associated liver dysfunction. Moreover, mitochondria-initiated apoptosis triggered by oxidative damage may play an important role in this process.
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Affiliation(s)
- Li Hong
- Department of Pediatric Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
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Wiles A, Woodward JM. Recent advances in the management of intestinal failure-associated liver disease. Curr Opin Clin Nutr Metab Care 2009; 12:265-72. [PMID: 19339882 DOI: 10.1097/mco.0b013e328329e4ef] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize the current management of intestinal failure-associated liver disease (IFALD) by reviewing recent advances in our understanding of the condition and the effects of different therapeutic approaches. RECENT FINDINGS The importance of gastrointestinal length and continuity in the aetiology and treatment of IFALD has been demonstrated in both retrospective and interventional cohorts. A mechanism for the cholestatic effect of soy-based lipid has been described, and the clinical use of alternative lipid sources has demonstrated benefit. Prevention of IFALD has been shown with the use of erythromycin in neonates, and reversal of established IFALD has been demonstrated with isolated intestinal transplantation. SUMMARY A greater understanding of the mechanisms of IFALD has led to promising interventions to prevent and treat the condition. Other possible therapeutic targets require more formal evaluation, and further work is required to develop noninvasive tools for the assessment and prognosis of IFALD that will guide treatment and help in the selection of patients and timing of transplantation.
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Affiliation(s)
- Alan Wiles
- Department of Gastroenterology and Clinical Nutrition, Addenbrookes Hospital, Cambridge, UK
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Abstract
Intestinal failure (IF) occurs when the body is unable to sustain its energy and fluid requirements without support, due to loss of functional small bowel. Prolonged IF is seen after large intestinal resection and described as short bowel syndrome (SBS). The hallmark of the management is parental nutrition (PN), which is costly and may be associated with the well-recognized problems of parental nutrition associated liver disease (PNALD) and line related sepsis. Cessation of PN at the earliest possible stage is desirable but for this enteral autonomy has to be achieved first. Intestinal adaptation occurs when the remaining gut goes through morphological changes increasing its absorptive capacity. Factors such as intraluminal nutrients, gastrointestinal secretions and hormones facilitate adaptation. Enteral feeds are a potent stimulant to adaptation and should be started as soon as the clinical situation permits. Some drugs are thought to increase intestinal adaptation. These include glutamine, growth hormone and glucagon like peptide- 2, but there is a paucity of pediatric data to guide their use. In some cases surgical bowel lengthening procedures can be performed to increase the absorptive surface area. An isolated liver transplantation may be required if the liver has sustained irreversible damage but intestinal autonomy seems achievable. When prolonged PN is either unsustainable or associated with unacceptable side effects, small bowel transplantation should be considered as a treatment option.
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Affiliation(s)
- K Soondrum
- Department of Child Health, King's College Hospital, London, United Kingdom
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Preservation of liver function in intestinal failure patients treated with long-term total parenteral nutrition. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000227841.29452.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Choi JS, Bae YJ, Lee YA. Comparison of total parenteral nutrition-associated cholestasis according to amino acid mixtures in very low birth weight infants. KOREAN JOURNAL OF PEDIATRICS 2006. [DOI: 10.3345/kjp.2006.49.9.972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jin-Sung Choi
- Department of Pediatrics, College of Medicine, Dong-A University, Busan, Korea
| | - Yun-Jin Bae
- Department of Pediatrics, College of Medicine, Dong-A University, Busan, Korea
| | - Young Ah Lee
- Department of Pediatrics, College of Medicine, Dong-A University, Busan, Korea
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