Liver Disease in Patients on Total Parenteral Nutrition

Parenteral Nutrition-Induced Liver Function Complications: Incidence, Risk Factors, and Prognosis

Background/Objectives: Parenteral Nutrition-Associated Liver Disease (PNALD) is a significant complication in patients undergoing parenteral nutrition (PN). This study aims to explore the incidence, risk factors, and outcomes associated with PNALD, including abnormal liver function tests, in patients receiving parenteral nutrition, even in short-term PN recipients. Methods: A retrospective analysis of 500 patients receiving PN for at least 3 days at a tertiary medical center was conducted. Liver enzyme levels were monitored for 28 days, and PN duration, comorbidities, and metabolic factors were analyzed to identify independent risk factors of abnormal liver function tests and PNALD. Results: This study reported a 24.4% incidence of abnormal liver function tests and an 8.2% incidence of PNALD. Risk factors for abnormal liver function tests included liver disease (OR 2.064, 95% CI 1.224-3.479), infection (OR 1.654, 95% CI 1.075-2.546), PN duration (OR 1.035, 95% CI 1.014-1.056), and PN calories (OR 1.001, 95% CI 1.000-1.002). Significant PNALD risk factors comprised liver disease (OR 3.623, 95% CI 1.670-7.858), lung disease (OR 3.648, 95% CI 1.615-8.240), recent surgery (OR 3.719, 95% CI 1.645-8.407), PN duration (OR 1.041, 95% CI 1.016-1.068), total cholesterol (OR 1.005, 95% CI 1.000-1.010), and HDL-cholesterol (OR 1.012, 95% CI 1.001-1.023). The majority of PNALD cases (85.3%) showed improvement with PN modification or cessation. Conclusions: This study underscores that abnormal liver function tests and PNALD risks can emerge with short-term PN use. Identifying and addressing patient-specific risk factors is vital for predicting and preventing PNALD onset.

Early oral feeding following intestinal anastomosis surgery in infants: a multicenter real world study

Background

To prevent postoperative complications, delayed oral feeding (DOF) remains a common model of care following pediatric intestinal anastomosis surgery; however, early oral feeding (EOF) has been shown to be safe and effective in reducing the incidence of complications and fast recovery after pediatric surgery. Unfortunately, the evidence in support of EOF after intestinal anastomosis (IA) in infants is insufficient. Therefore, this study was primarily designed to evaluate the safety and efficacy of EOF. In addition, the current status of EOF application and associated factors that favor or deter EOF implementation were also assessed.

Methods

A total of 898 infants were divided into two groups (EOF group, n = 182; DOF group, n = 716), and the clinical characteristics were collected to identify the factors associated with EOF in infants. Complications and recovery were also compared to define the safety and efficacy after balancing the baseline data by propensity score matching (PSM) (EOF group, n = 179; DOF group, n = 319).

Results

The total EOF rate in infants with IA was 20.3%. Multivariate logistic regression revealed significant differences in the EOF rates based on IA site and weight at the time of surgery (OR = 0.652, 95% CI: 0.542-0.784, p < 0.001) and (OR = 1.188, 95% CI: 1.036-1.362, p = 0.013), respectively. The duration of total parenteral nutrition (TPN), parenteral nutrition (PN), and postoperative hospital stay were significantly shorter in the EOF group than the DOF group [2.0 (1.0, 2.0) d vs. 5.0 (3.0, 6.0) d; 6.0 (5.0, 8.0) d vs. 8.0 (6.0, 11.0) d; 10.0 (7.0, 14.0) d vs. 12.0 (9.0, 15.0) d, all p < 0.001]. The rates of abdominal distension and vomiting in the EOF group were significantly higher than the DOF group (17.9% vs. 7.2%, p < 0.001; 7.8% vs. 2.5%, p = 0.006); however, no differences were found in failure to initial OF, diarrhea, hematochezia, and anastomotic leakage between the two groups (p > 0.05).

Conclusion

The overall rate of EOF in infants following IA was low, and the sites of anastomosis and weight at surgery were two factors associated with EOF. Nevertheless, performing EOF in infants after IA was safe and effective, reduced PN usage, shortened the hospital stay, and did not increase the rate of severe complications.Clinical Trial Registration: ClinicalTrails.gov, identifier NCT04464057.

Reply to Abenavoli et al. Comment on "Clayton-Chubb et al. Understanding NAFLD: From Case Identification to Interventions, Outcomes, and Future Perspectives. Nutrients 2023, 15, 687"

Thank you for your interesting comment [...].

Molecular Oxygen Levels and Percentages of DNA Damage in TPN Patients

Total parenteral nutrition (TPN) is a life-saving therapy for patients with intestinal failure, but it carries the risk of complications, including an increase in liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) after long-term use. Patients receiving chronic TPN are also exposed to metabolic stress from both the underlying disease and parenteral nutrition. The aim of this study was to compare the concentration of liver transaminases AST and ALT in relation to the rate of oxygen consumption in platelet mitochondria in patients receiving long-term TPN with the degree of oxidative stress induced by lipid emulsions, and to explain their role in cellular energy metabolism and changes in the liver based on the percentage of genomic DNA damage. The study group consisted of 86 TPN patients, while the control group consisted of 86 healthy volunteers who were fed only orally. The results of the study showed that the percentage of molecular oxygen depended on the type of lipid emulsion supplied. Analyzing time on TPN as a factor, we observed a decrease in percentage genomic DNA damage and an increase in percentage molecular oxygen in cells. It remains unclear whether TPN has a direct effect on genomic DNA damage and the level of molecular oxygen in cells during the course of treatment. In conclusion, this study provides important insights into the potential effects of TPN on liver enzymes and cellular metabolism. Further research is needed to better understand the underlying mechanisms and to develop strategies to minimize the risk of complications associated with TPN.

Understanding NAFLD: From Case Identification to Interventions, Outcomes, and Future Perspectives

While non-alcoholic fatty liver disease (NAFLD) is a prevalent and frequent cause of liver-related morbidity and mortality, it is also strongly associated with cardiovascular disease-related morbidity and mortality, likely driven by its associations with insulin resistance and other manifestations of metabolic dysregulation. However, few satisfactory pharmacological treatments are available for NAFLD due in part to its complex pathophysiology, and challenges remain in stratifying individual patient's risk for liver and cardiovascular disease related outcomes. In this review, we describe the development and progression of NAFLD, including its pathophysiology and outcomes. We also describe different tools for identifying patients with NAFLD who are most at risk of liver-related and cardiovascular-related complications, as well as current and emerging treatment options, and future directions for research.

Histopathological liver steatosis linked with high parenteral glucose and amino acid supply in infants with short bowel syndrome

BACKGROUND

Steatosis is a common feature of intestinal failure-associated liver disease (IFALD) in adult and older pediatric patients receiving long-term parenteral nutrition (PN). There are limited clinical data concerning steatosis in infants with short bowel syndrome (SBS). We investigated early histopathological steatosis and its association to PN.

METHODS

In this retrospective study, 31 patients with SBS had a diagnostic liver biopsy taken at the median age of 5 (IQR 3-8) months. Follow-up biopsy was available for 24 patients at the median age of 29 (IQR 14-52) months. We evaluated the biopsies for steatosis and other histopathological signs of IFALD and compared results with patient characteristics, PN composition, and liver biochemistry.

RESULTS

Diagnostic biopsies revealed steatosis in 8 (26%) patients. At the age of 3 months, patients with steatosis had received higher amounts of parenteral glucose: median 15.1 (IQR 12.4-17.2) vs 12.3 (8.7-14.4) g/kg/d (P = 0.04), amino acids: 2.9 (2.5-3.4) vs 2.2 (1.6-2.7) g/kg/d (P = 0.03), and energy: 87 (80-98) vs 73 (54-79) kcal/kg/d (P = 0.01) than those without steatosis. We detected no significant differences in parenteral lipid intake between the groups. Steatosis also associated with increased serum bile acid (P = 0.02), alanine aminotransferase (P = 0.0002), and aspartate aminotransferase (P = 0.001) levels.

CONCLUSIONS

In this cohort, high parenteral glucose, amino acid, and energy provision associated with liver steatosis in infants with SBS. We recommend monitoring of bile acid and transaminase levels while aiming for PN with balanced macronutrient supply according to current recommendations to protect the liver from steatosis.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

Effects of phytosterols' intake on systemic and tissue-specific lipid metabolism in C57BL/6J mice

This study aimed to investigate the long-term effects of phytosterols (PS) intake on systemic and tissue-specific lipid metabolism in C57BL/6J mice. Healthy male C57BL/6J mice were randomly divided into control diet group (CS) and PS diet group (2% PS). After 28 weeks of continuous feeding, serums, livers, and lungs were collected for targeted free sterols quantification, biochemical tests, lipid profile detection, and RNA-seq analysis. Compared with the CS group, 2% PS supplementation significantly increased campesterol concentrations and its ratio to cholesterol in the serum, liver, and lung of mice, with cholestanol concentrations and its ratio to cholesterol decreased. Total cholesterol (TC) levels were reduced in the serum of the PS group (p < 0.05), with the triglyceride (TG) levels unchanged. In response to the decreased circulating cholesterol concentration, the expression of endogenous cholesterol synthesis genes was upregulated in the liver, but caused no obvious lipid accumulation and inflammatory cell infiltration. However, for peripheral tissues, long-term PS-fed mice exhibited diminished cholesterol synthesis, fatty acid transport, and oxidation in the lung. The results provided clear indication that 2% PS diet effectively reduced circulating TC levels in the healthy mice, with tissue-specific lipid metabolic regulation in the liver and the lung.

Gallstones in patients with severe motor and intellectual disability

BACKGROUND

Asymptomatic gallbladder stones may be detected with ultrasound; some gallstones produce symptomatic diseases, such as cholecystitis, cholangitis, or pancreatitis. Identifying the clinical features of symptomatic gallstones may help prevent severe complications by providing intervention for asymptomatic gallstones. We aimed to investigate risk factors associated with developing symptomatic disease in pediatric patients with severe motor and intellectual disabilities (SMID).

METHODS

This retrospective study enrolled 30 patients with SMID who were treated at the Nara Medical University between March 2016 and March 2019. We examined the prevalence of gallstones, and the rate at which associated symptoms of gallstones were observed in patients. Furthermore, we compared the clinical features of patients with and without gallstones.

RESULTS

Among 30 patients with SMID, 7 (23%) had gallstones, with 6 (86%) of them being symptomatic: 3 patients had acute pancreatitis and 3 had cholecystitis or cholangitis. Among 23 patients without gallstones, 2 had acute pancreatitis and 2 had biliary sludge. Patients with gallstones had significantly lower daily calorie intake than those without gallstones (P = 0.042). Furthermore, the incidence of gallstones was higher in patients who received total parenteral nutrition than in those who did not (P = 0.031). Comparative analysis between symptomatic and asymptomatic patients was not performed because almost all cases were symptomatic.

CONCLUSION

Gallstones were detected in 23% of patients with SMID. The gallstones were symptomatic at a very high rate. Considering this fact, patients with SMID should be surveyed for gallstones; careful management may be needed in such patients.

Drugs and liver injury: a not to be overlooked binomial in COVID-19

SARS-CoV-2 infection (COVID-19) results predominantly in pulmonary involvement but a direct, virus-induced liver damage may also occur, whose mechanisms are being actively investigated. Accordingly, it appears of utmost importance to monitor liver function and carefully evaluate hepatic safety of the various drugs administered during COVID-19. In this respect, many drugs, biological agents and novel molecules, whose efficacy in COVID-19 is under scrutiny, have also been shown to potentially cause or worsen liver damage. In this article, we review safety data of established as well as promising agents for COVID-19.

New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature

Intestinal failure-associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.

What was First, Obesity or Inflammatory Bowel Disease? What Does the Gut Microbiota Have to Do with It?

A sedentary lifestyle and inadequate nutrition often leads to disturbances in intestinal homeostasis, which may predispose people to excess body weight and metabolic syndrome. Obesity is frequently observed in patients with inflammatory bowel diseases (IBD), similar to the general population. Obesity may exert a negative effect on the course of IBD as well as reduce the response to treatment. Moreover, it may also be an additional risk factor for vein thromboembolism during the flare. In both obesity and IBD, it is of great importance to implement proper dietary ingredients that exert desirable effect on gut microbiota. The key to reducing body mass index (BMI) and alleviating the course of IBD is preserving healthy intestinal microflora.

Cholestatic Liver Diseases: A Primer for Generalists and Subspecialists

Cholestasis describes impairment in bile formation or flow which can manifest clinically with fatigue, pruritus, and jaundice. The differential diagnosis of cholestatic liver diseases is broad, and the etiologies of cholestasis vary in the anatomical location of the defect and acuity of presentation. Cholestasis may occur in a variety of clinical scenarios. Therefore, it is important for a diverse audience with varied clinical practices to have a basic understanding of manifestations of cholestatic liver diseases.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Development of Novel Heparin/Protamine Nanoparticles Useful for Delivery of Exogenous Proteins In Vitro and In Vivo

We previously reported that heparin/protamine particles (LHPPs) produced as nanoparticles through simple mixing of raw materials exhibit sustained protein release and can be retained in cells. In the present study, we modified LHPPs without employing any organic synthetic approach. The resulting LHPPs were re-named as improved LHPPs (i-LHPPs) and have the ability to retain cell-penetrating peptides (GRKKRRQRRRPPQ) based on electrostatic interactions. We examined whether i-LHPPs can introduce exogenous proteins (i.e., lacZ protein encoding bacterial β-galactosidase) into cultured cells in vitro, or into murine hepatocytes in vivo through intravenous injection to anesthetized mice. We found an accumulation of the transferred protein in both in vitro cultured cells and in vivo hepatocytes. To the best of our knowledge, reports of successful in vivo delivery to hepatocytes are rare. The i-LHPP-based protein delivery technique will be useful for in vivo functional genetic modification of mouse hepatocytes using Cas9 protein-mediated genome editing targeting specific genes, leading to the creation of hepatic disease animal models for research that aims to treat liver diseases.

Review of parenteral nutrition-associated liver disease

Parenteral nutrition has been widely used in patients whose gastrointestinal tract is anatomically or physiologically unavailable for sufficient food intake. It has been considered lifesaving but is not without adverse effects. It has been proven to cause liver injury through different mechanisms. We present a review of parenteral nutrition-associated liver disease.

A Molecular Mechanism Underlying Genotype-Specific Intrahepatic Cholestasis Resulting From MYO5B Mutations

BACKGROUND AND AIMS

Progressive familial intrahepatic cholestasis (PFIC) 6 has been associated with missense but not biallelic nonsense or frameshift mutations in MYO5B, encoding the motor protein myosin Vb (myoVb). This genotype-phenotype correlation and the mechanism through which MYO5B mutations give rise to PFIC are not understood. The aim of this study was to determine whether the loss of myoVb or expression of patient-specific myoVb mutants can be causally related to defects in canalicular protein localization and, if so, through which mechanism.

APPROACH AND RESULTS

We demonstrate that the cholestasis-associated substitution of the proline at amino acid position 600 in the myoVb protein to a leucine (P660L) caused the intracellular accumulation of bile canalicular proteins in vesicular compartments. Remarkably, the knockout of MYO5B in vitro and in vivo produced no canalicular localization defects. In contrast, the expression of myoVb mutants consisting of only the tail domain phenocopied the effects of the Myo5b-P660L mutation. Using additional myoVb and rab11a mutants, we demonstrate that motor domain-deficient myoVb inhibited the formation of specialized apical recycling endosomes and that its disrupting effect on the localization of canalicular proteins was dependent on its interaction with active rab11a and occurred at the trans-Golgi Network/recycling endosome interface.

CONCLUSIONS

Our results reveal a mechanism through which MYO5B motor domain mutations can cause the mislocalization of canalicular proteins in hepatocytes which, unexpectedly, does not involve myoVb loss-of-function but, as we propose, a rab11a-mediated gain-of-toxic function. The results explain why biallelic MYO5B mutations that affect the motor domain but not those that eliminate myoVb expression are associated with PFIC6.

Development and validation of an ambulatory piglet model for short bowel syndrome with ileo-colonic anastomosis

IMPACT STATEMENT

Short bowel syndrome is associated with significant comorbidities and mortality. This study is important as unlike current systems, it provides a validated piglet model which mirrors anatomical, histological, and serological characteristics observed in human SBS. This model can be used to advance knowledge into mechanistic pathways and therapeutic modalities to improve outcomes for SBS patients. This study is novel in that in addition to significant reduction in the remnant bowel and noted liver disease, we also developed a method to emulate ileocecal valve resection and described gut adaptive responses which has important clinical implications in humans.

Impaired Gut-Systemic Signaling Drives Total Parenteral Nutrition-Associated Injury

BACKGROUND

Total parenteral nutrition (TPN) provides all nutritional needs intravenously. Although lifesaving, enthusiasm is significantly tempered due to side effects of liver and gut injury, as well as lack of mechanistic understanding into drivers of TPN injury. We hypothesized that the state of luminal nutritional deprivation with TPN drives alterations in gut-systemic signaling, contributing to injury, and tested this hypothesis using our ambulatory TPN model.

METHODS

A total of 16 one-week-old piglets were allocated randomly to TPN (n = 8) or enteral nutrition (EN, n = 8) for 3 weeks. Liver, gut, and serum were analyzed. All tests were two-sided, with a significance level of 0.05.

RESULTS

TPN resulted in significant hyperbilirubinemia and cholestatic liver injury, p = 0.034. Hepatic inflammation (cluster of differentiation 3 (CD3) immunohistochemistry) was higher with TPN (p = 0.021). No significant differences in alanine aminotransferase (ALT) or bile ductular proliferation were noted. TPN resulted in reduction of muscularis mucosa thickness and marked gut atrophy. Median and interquartile range for gut mass was 0.46 (0.30-0.58) g/cm in EN, and 0.19 (0.11-0.29) g/cm in TPN (p = 0.024). Key gut-systemic signaling regulators, liver farnesoid X receptor (FXR; p = 0.021), liver constitutive androstane receptor (CAR; p = 0.014), gut FXR (p = 0.028), G-coupled bile acid receptor (TGR5) (p = 0.003), epidermal growth factor (EGF; p = 0.016), organic anion transporter (OAT; p = 0.028), Mitogen-activated protein kinases-1 (MAPK1) (p = 0.037), and sodium uptake transporter sodium glucose-linked transporter (SGLT-1; p = 0.010) were significantly downregulated in TPN animals, whereas liver cholesterol 7 alpha-hydroxylase (CyP7A1) was substantially higher with TPN (p = 0.011).

CONCLUSION

We report significant alterations in key hepatobiliary receptors driving gut-systemic signaling in a TPN piglet model. This presents a major advancement to our understanding of TPN-associated injury and suggests opportunities for strategic targeting of the gut-systemic axis, specifically, FXR, TGR5, and EGF in developing ameliorative strategies.

Cohort Multicenter Study on the Role of Medications in Parenteral Nutrition-Related Alteration of Liver Function Tests in Adults

BACKGROUND

Our objective was to assess in non-critically-ill adult inpatients receiving parenteral nutrition (PN) the risk of developing liver function test (LFT) alterations when receiving concomitant possibly hepatotoxic medications or others reported to improve LFTs during PN.

METHODS

A multicenter retrospective analysis of prospectively collected data was performed on patients receiving PN. Two groups were recruited: group LALT (patients with any LFT alterations during PN), and group NOLALT (patients without such alterations). Exclusion criteria were previous sepsis, shock, renal failure, hyperglycemia, LFT alteration, or biliopancreatic surgical procedures. Medications were classified into 2 categories: medications reported to improve LFTs during PN (n = 8) and possibly hepatotoxic medications (n = 54), including a subgroup of possibly highly hepatotoxic medications (n = 30).

RESULTS

The study included 200 patients, 136 (68.0%) in the LALT group. The groups differed in the number of patients requiring surgical intervention ≤7 days before PN (LALT, 94 [69.1%]; NOLALT, 29 [45.3%]; P < .002) and those receiving possibly hepatotoxic medications (LALT, 126 [92.6%]; NOLALT, 45 [70.3%]; P < .001). Variables in the final Cox regression model were possibly hepatotoxic medications, odds ratio (OR) 3.310 (1.678-6.530); surgical intervention prior to PN, OR 1.861 (1.277-2.711); baseline triglyceridemia, OR 1.005 (1.001-1.009); and creatinine, OR 1.861 (1.043-3.323).

CONCLUSIONS

Patients who received PN and concomitantly possibly hepatotoxic medications had a 3-fold risk of developing LFT alterations. Medications reported to improve LFTs had no effect. The use of possibly hepatotoxic medications during PN was associated with LFT alterations.

Nutritional Management of Cholestasis

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-1-reading-abdel-send a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-1-interview-send the interview with the author Answer questions and earn https://www.wileyhealthlearning.com/Activity/7025317/disclaimerspopup.aspx.

Early downregulation of P-glycoprotein facilitates bacterial attachment to intestinal epithelial cells and thereby triggers barrier dysfunction in a rodent model of total parenteral nutrition

Intestinal barrier dysfunction is a major complication of total parenteral nutrition (TPN). Our preliminary study revealed that intestinal P-glycoprotein (P-gp) was significantly downregulated under TPN treatment followed by disruption of barrier function, and thus the significance of early downregulation of P-gp needs to be addressed. Herein, we report a pivotal role of P-gp in the development of intestinal barrier dysfunction under TPN. Functional suppression of P-gp may facilitate bacterial attachment to intestinal epithelial cells (IECs) and thereby induce degradation of tight junctions to trigger barrier dysfunction. By using a rat model of TPN, we found early downregulation of P-gp function in ileum after 3-day TPN, followed by disruption of barrier function after 7-day TPN. By using Escherichia coli (E. coli) k88 and DH5α as type strains, we found significantly increased bacterial attachment to IECs in TPN group compared to sham. By using Caco-2 cells as an IEC model in vitro, we found that functional suppression of P-gp remarkably facilitated bacterial attachment to Caco-2 cells, leading to subsequent disruption of intestinal barrier function. Of note, Occludin was significantly downregulated by bacterial attachment when P-gp was functionally suppressed. Mechanistically, changes on Occludin were attributed to enhanced protein degradation instead of suppressed protein translation. Despite the half-life of Occludin protein being unchanged by DH5α treatment alone, it was decreased by about 40% when P-gp was simultaneously suppressed. Taken together, our findings revealed that early downregulation of intestinal P-gp under TPN may be a potential therapeutic target to prevent the development of barrier dysfunction.

Evaluation of parenteral nutrition-associated liver disease in surgical infants for necrotizing enterocolitis

The purpose of this study was to determine the factors associated with parenteral nutrition-associated liver disease (PNALD) in infants who underwent surgery for necrotizing enterocolitis (NEC) and followed up the postoperative outcomes for long term parenteral nutrition (PN).This study included a retrospective review of 87 infants with NEC and managed surgically from July 2007 to May 2017 at the Children's Hospital, Chongqing Medical University. Clinical data and procedure information were collected and analyzed.Among the infants included, 16.1% of patients developed PNALD. Multivariable logistic regression analysis revealed progressive clinical deterioration (OR, 5.47; 95% CI, 1.10-26.96; P = .037) was independent risk factor for PNALD whereas congenital heart disease (OR, 0.068; 95% CI, 0.008-0.55; P = .012) presentation served as a protective factor.The current data suggested the distinct disease process for cardiac patients with NEC, which might help in the prevention and treatment of PNALD for patients with NEC.

Incidence and risk factors of parenteral nutrition-associated liver disease in hospitalized adults: A prospective cohort study

BACKGROUND AND AIMS

Parenteral nutrition-associated liver disease (PNALD) is a common complication in patients receiving parenteral nutrition (PN). Few studies have investigated the incidence and risk factors of PNALD in adult patients receiving PN with newer generation intravenous lipid emulsions. The aim of this study was to investigate the incidence and risk factors of PNALD in hospitalized adult patients.

METHODS

Patients expected to receive PN for more than 14 days and have normal liver tests at baseline during September 2016 to February 2017 were enrolled. All patients were followed until there were liver test abnormalities. Incidence, onset and characteristics of PNALD, calories intake, amount of fat and carbohydrate, types of fat, nutrition status, and incidence of infection were evaluated.

RESULTS

Forty-four adults were recruited. The incidence of PNALD was 59.1% (22.7% steatosis, 34.1% cholestasis, and 2.3% mixed type). Median onset of PNALD was 12.5 days (range: 4-42) and the onset was not significantly different between each subtype. In multiple regression analysis, severe malnutrition and amount of carbohydrate were independent risk factors for PNALD with an odds ratio of 13.25 (95% CI: 1.37-128.24; p = 0.026) and 21.61 (95% CI: 1.81-258.56; p = 0.015), respectively.

CONCLUSIONS

PNALD was common in this group of patients. In contrast to previous studies, cholestasis was more common than steatosis, and the median onset was not different between each subtype. In severely malnourished patients, physicians need to exercise caution and monitor for PNALD intensively, and overfeeding of carbohydrate should be avoided to prevent PNALD from occurring.

Plant-based sterols and stanols in health & disease: "Consequences of human development in a plant-based environment?"

Dietary plant sterols and stanols as present in our diet and in functional foods are well-known for their inhibitory effects on intestinal cholesterol absorption, which translates into lower low-density lipoprotein cholesterol concentrations. However, emerging evidence suggests that plant sterols and stanols have numerous additional health effects, which are largely unnoticed in the current scientific literature. Therefore, in this review we pose the intriguing question "What would have occurred if plant sterols and stanols had been discovered and embraced by disciplines such as immunology, hepatology, pulmonology or gastroenterology before being positioned as cholesterol-lowering molecules?" What would then have been the main benefits and fields of application of plant sterols and stanols today? We here discuss potential effects ranging from its presence and function intrauterine and in breast milk towards a potential role in the development of non-alcoholic steatohepatitis (NASH), cardiovascular disease (CVD), inflammatory bowel diseases (IBD) and allergic asthma. Interestingly, effects clearly depend on the route of entrance as observed in intestinal-failure associated liver disease (IFALD) during parenteral nutrition regimens. It is only until recently that effects beyond lowering of cholesterol concentrations are being explored systematically. Thus, there is a clear need to understand the full health effects of plant sterols and stanols.

Short bowel syndrome in children and adults: from rehabilitation to transplantation

Short bowel syndrome (SBS) is a dramatic clinical condition in both children and adults; the residual bowel length is not sufficient to avoid intestinal failure, with subsequent malnutrition and growth retardation, and intravenous support is required to provide the nutrients normally coming from the intestine. Apart from the primary disease, the medical status can be worsened by complications of intestinal failure: if there are irreversible, the prognosis is poor unless a successful intestinal rehabilitation is achieved. Areas covered: The rescue of the remnant small bowel requires a multidisciplinary expertise to achieve digestive autonomy. The use of intestinal trophic factors has shown encouraging results in improving the intestinal adaptation process. Whenever the residual bowel length is inadequate, in a well-selected population weaning parenteral nutrition (PN) off could be attempted by surgery through lengthening procedures. A further subset of patients, with total and irreversible intestinal failure and severe complications on PN, may have an indication to intestinal transplantation. This procedure is still affected by poor long-term results. Expert commentary: Novel approaches developed through a multidisciplinary team work, such as manipulation of microbiota or tissue bioengineering, should be added to current therapies to treat successfully SBS.

Risk factors of hepatic function alterations in hospitalized adult patients treated with short-term parenteral nutrition receiving the same lipid composition at the same dose

BACKGROUND

High doses and vegetable origin of lipid emulsions (LE) are prominent factors for liver test (LT) alterations in patients treated with parenteral nutrition (PN). This study aims to determine incidence of LT alterations, and risk factors related to these alterations in patients with short term PN with homogenous LE.

METHODS

Adult non-critically ill hospitalized patients, with normal LTs at the beginning of PN, receiving 0.8 g/kg/day of an olive/soybean LE were included. A paired Student t-test was applied to compare final with initial LT values. LT variation (end vs start of PN) according to type of surgery and infection was studied by means of an analysis of the variance. Univariate and multivariate analyses were constructed to relate the variations of each of the 4 LTs with the adjustment variables.

RESULTS

One hundred eighty one patients (66.57 ± 12.89 years; 72.4% men), 66.8% suffered from cancer. Final LT values increased from initial values for gamma-glutamyltransferase (GGT) 2.69 ± 2.49 μkat/L vs 0.55 ± 0.36 μkat/L, alkaline phosphatase (AP) 1.97 ± 1.49 μkat/L vs 1.04 ± 0.33 μkat/L, and alanine aminotransferase (ALT) 0.57 ± 0.92 μkat/L vs 0.32 ± 0.26 μkat/L. GGT and AP variations were associated with days of PN; GGT, AP and total bilirubin with surgical patients, AP variations with infection, and GGT with cancer. Multivariate analysis: elevation of GGT, AP and ALT was related to infection, days of PN and surgery.

CONCLUSIONS

Factors that increased the risk of LTs elevation during short term PN treatment were duration of PN, surgery, cancer, and infection associated with oxidative stress.