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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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2
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Melendez M, Yeh DD. Exploring the long-term risk factors associated with intestinal failure-associated liver disease in pediatric and adult patients: The role of lipid injectable emulsions in the development of liver disease. Nutr Clin Pract 2022; 37:1142-1151. [PMID: 35148446 DOI: 10.1002/ncp.10824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite parenteral nutrition (PN) being life sustaining, one of the risk factors associated with its long-term use is intestinal failure-associated liver disease (IFALD), which increases the risk for morbidity and mortality. This review examines some of the risk factors associated with IFALD. METHODS A literature review using the databases PubMed, EMBASE, and CINAHL between 2010 and 2020 was performed using search terms, including long-term total PN and liver failure, serum plant sterols and liver failure, and complications and PN. Articles in English using both human and animal participants were included. RESULTS The pathophysiology associated with PN and liver disease is multifactorial and influenced by the remaining small-bowel length, presence of the ileal cecal valve, lack of enteral stimulation, type of lipid injectable emulsion (ILE), plant sterol content, and excessive calories. The type of ILE plays a major role because of the phytosterol (PS) content, affecting the microbiome composition and inhibiting key gut signals. The PS content is highest in soy oil (SO)-based ILE, which increases inflammation and impairs biliary flow. CONCLUSION Serum PS correlates with liver biomarker abnormalities and is highest in SO-based ILE use compared with mixed-oil emulsions. Selection of a low-PS content ILE is recommended to reduce the risk of biliary cholestasis. Stimulation of the gut, if possible, is recommended to maintain gut integrity and reduce bacterial overgrowth. Fish oil (FO) shows promise in IFALD reversal however, large randomized controlled trials are needed to further establish support for the use of FO in adults.
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Affiliation(s)
| | - Daniel Dante Yeh
- Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, Florida, USA.,DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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3
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Shafiekhani M, Nikoupour H, Mirjalili M. The experience and outcomes of multidisciplinary clinical pharmacist-led parenteral nutrition service for individuals with intestinal failure in a center without home parenteral nutrition. Eur J Clin Nutr 2022; 76:841-847. [PMID: 35031769 DOI: 10.1038/s41430-021-01048-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND/OBJECTIVES Intestinal Failure (IF) is a rare but serious form of organ failure, and patients with IF are dependent on Total Parenteral Nutrition (TPN) to maintain growth and development. This study aimed to describe the experiences of a multidisciplinary clinical pharmacist-led TPN service in the Intestinal Rehabilitation Unit of Shiraz Organ Transplant Center. SUBJECTS/METHODS This prospective study was conducted in Shiraz Organ Transplant Center, Iran from February 2018 to October 2020, including seven months with and 24 months without the clinical pharmacist involvement. Clinical and nutritional outcomes as well as the potential complications of TPN were compared in these two periods. RESULTS This study was conducted on 107 patients. The most important complication occurred among the patients receiving TPN were catheter infection (42.05%), sepsis, and catheter thrombosis (18.69%). Portal vein thrombosis (OR = 26.56) and length of Intensive Care Unit (ICU) stay (OR = 1.12) were significantly associated with the rate of parenteral nutrition-associated liver disease. The results also revealed an association between the rate of sepsis and history of malignancy, catheter thrombosis, length of the small bowel, length of PN, length of hospital stay, and length of ICU stay. Moreover, the results showed a significant difference regarding the patients' outcomes and TPN complications before and after the clinical pharmacist interventions (P < 0.05). CONCLUSION Working as a multidisciplinary team in Intestinal Rehabilitation Unit (IRU) has been suggested to improve patients' outcomes and reduce mortality and morbidity. Presence of a clinical pharmacist in this team can help improve the TPN service provided for individuals with IF.
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Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Nikoupour
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahtabalsadat Mirjalili
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.
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Fragkos KC, Picasso Bouroncle MC, Kumar S, Caselton L, Menys A, Bainbridge A, Taylor SA, Torrealdea F, Kumagai T, Di Caro S, Rahman F, Macnaughtan J, Chouhan MD, Mehta S. Serum Scoring and Quantitative Magnetic Resonance Imaging in Intestinal Failure-Associated Liver Disease: A Feasibility Study. Nutrients 2020; 12:E2151. [PMID: 32707726 PMCID: PMC7400956 DOI: 10.3390/nu12072151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 01/20/2023] Open
Abstract
(1) Background: Intestinal failure-associated liver disease (IFALD) in adults is characterized by steatosis with variable progression to fibrosis/cirrhosis. Reference standard liver biopsy is not feasible for all patients, but non-invasive serological and quantitative MRI markers for diagnosis/monitoring have not been previously validated. Here, we examine the potential of serum scores and feasibility of quantitative MRI used in non-IFALD liver diseases for the diagnosis of IFALD steatosis; (2) Methods: Clinical and biochemical parameters were used to calculate serum scores in patients on home parenteral nutrition (HPN) with/without IFALD steatosis. A sub-group underwent multiparameter quantitative MRI measurements of liver fat fraction, iron content, tissue T1, liver blood flow and small bowel motility; (3) Results: Compared to non-IFALD (n = 12), patients with IFALD steatosis (n = 8) demonstrated serum score elevations in Enhanced Liver Fibrosis (p = 0.032), Aspartate transaminase-to-Platelet Ratio Index (p < 0.001), Fibrosis-4 Index (p = 0.010), Forns Index (p = 0.001), Gamma-glutamyl transferase-to-Platelet Ratio Index (p = 0.002) and Fibrosis Index (p = 0.001). Quantitative MRI scanning was feasible in all 10 sub-group patients. Median liver fat fraction was higher in IFALD steatosis patients (10.9% vs 2.1%, p = 0.032); other parameter differences were non-significant; (4) Conclusion: Serum scores used for non-IFALD liver diseases may be useful in IFALD steatosis. Multiparameter MRI is feasible in patients on HPN.
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Affiliation(s)
- Konstantinos C. Fragkos
- Intestinal Failure Service, Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (K.C.F.); (M.C.P.B.); (S.D.C.); (F.R.)
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
| | - María Claudia Picasso Bouroncle
- Intestinal Failure Service, Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (K.C.F.); (M.C.P.B.); (S.D.C.); (F.R.)
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
| | - Shankar Kumar
- UCL Centre for Medical Imaging, University College London, London WC1E 6BT, UK; (S.K.); (L.C.); (A.M.); (S.A.T.)
| | - Lucy Caselton
- UCL Centre for Medical Imaging, University College London, London WC1E 6BT, UK; (S.K.); (L.C.); (A.M.); (S.A.T.)
| | - Alex Menys
- UCL Centre for Medical Imaging, University College London, London WC1E 6BT, UK; (S.K.); (L.C.); (A.M.); (S.A.T.)
| | - Alan Bainbridge
- Department of Medical Physics, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK; (A.B.); (F.T.)
| | - Stuart A. Taylor
- UCL Centre for Medical Imaging, University College London, London WC1E 6BT, UK; (S.K.); (L.C.); (A.M.); (S.A.T.)
| | - Francisco Torrealdea
- Department of Medical Physics, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK; (A.B.); (F.T.)
| | - Tomoko Kumagai
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
| | - Simona Di Caro
- Intestinal Failure Service, Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (K.C.F.); (M.C.P.B.); (S.D.C.); (F.R.)
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
| | - Farooq Rahman
- Intestinal Failure Service, Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (K.C.F.); (M.C.P.B.); (S.D.C.); (F.R.)
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
| | - Jane Macnaughtan
- UCL Institute for Liver and Digestive Health, University College London, London WC1E 6BT, UK;
| | - Manil D. Chouhan
- UCL Centre for Medical Imaging, University College London, London WC1E 6BT, UK; (S.K.); (L.C.); (A.M.); (S.A.T.)
| | - Shameer Mehta
- Intestinal Failure Service, Gastrointestinal Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; (K.C.F.); (M.C.P.B.); (S.D.C.); (F.R.)
- UCL Division of Medicine, University College London, London WC1E 6BT, UK;
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Morgan J, Bond A, Kullu C, Subramanian S, Dibb M, Smith PJ. Managing intestinal failure in inflammatory bowel disease - 'when the drugs don't work'. Frontline Gastroenterol 2020; 12:414-422. [PMID: 35401958 PMCID: PMC8989006 DOI: 10.1136/flgastro-2018-101058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/17/2020] [Accepted: 05/26/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- James Morgan
- Department of Gastroenterology, Arrowe Park Hospital, Wirral, UK
| | - Ashley Bond
- Department of Gastroenterology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Cecil Kullu
- Department of Psychiatry, Mersey Care NHS Trust, Liverpool, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Martyn Dibb
- Department of Gastroenterology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Philip J Smith
- Department of Gastroenterology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
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6
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Bathgate JR, Matarese L, Ziegler J, Touger-Decker R. Case Report: Transitioning to a Mixed-Oil Intravenous Lipid Emulsion in an Adult Patient Receiving Home Parenteral Nutrition. Nutr Clin Pract 2019; 35:871-884. [PMID: 31478264 DOI: 10.1002/ncp.10387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A potential risk of long-term parenteral nutrition (PN) is intestinal failure-associated liver disease (IFALD). One recommendation for mitigating risk is limiting the fat dose to reduce the harmful effects of the ω-6 fatty acids, which are the main ingredient in traditional fats. SMOFlipid (SMOF) (Kabi-Fresenius, Bad Homburg, Germany) is a combination of soybean oil, medium-chain triglycerides, olive oil, and fish oil emulsion. This fat source may alleviate the risk of IFALD and improve liver function tests. A patient with a long history of PN reliance and IFALD is presented in this case report. After 4 months on SMOF, total and direct bilirubin levels improved.
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Affiliation(s)
- Jennifer R Bathgate
- Rutgers School of Health Professions, Newark, New Jersey, USA.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Laura Matarese
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Jane Ziegler
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, New Jersey, USA
| | - Riva Touger-Decker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, New Jersey, USA
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7
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Abstract
PURPOSE OF REVIEW The aim of this review is to give up-to-date information on intestinal failure-associated liver disease (IFALD) and how its investigation and management has evolved. Despite advances in treatment for patients with intestinal failure, IFALD remains a significant cause of mortality. RECENT FINDINGS Liver biopsy remains as the gold standard for the diagnosis of IFALD, but its invasive nature has prompted assessment of noninvasive techniques. Risk factors for IFALD are both nonnutritional (e.g. sepsis) and nutritional. Strict protocols for the prevention of central venous catheter infections in patients with intestinal failure are well established, as is the optimization of the constituents of parenteral nutrition. Further research comparing the available lipid emulsions has become available. Novel approaches at maximizing intestinal absorption are discussed including glucagon-like peptide-2 analogues, as well as surgical approaches. SUMMARY Although there are data on the novel investigative and therapeutic strategies for managing IFALD, further study is required to identify a suitable noninvasive technique for earlier diagnosis and then monitoring of IFALD. Further data are also required on the impact of novel therapies aimed at improving absorption and reducing parenteral nutrition load on IFALD occurrence and progression.
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Affiliation(s)
- James Morgan
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD
- Gastroenterology Department, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Martyn Dibb
- Gastroenterology Department, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD
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8
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Zhang YZ, Yao JN, Zhang LF, Wang CF, Zhang XX, Gao B. Effect of NLRC5 on activation and reversion of hepatic stellate cells by regulating the nuclear factor-κB signaling pathway. World J Gastroenterol 2019; 25:3044-3055. [PMID: 31293340 PMCID: PMC6603813 DOI: 10.3748/wjg.v25.i24.3044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/27/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The formation of liver fibrosis is mainly caused by the activation of hepatic stellate cells (HSCs) and the imbalance of extracellular matrix (ECM) production and degradation. The treatment of liver fibrosis mainly includes removing the cause, inhibiting the activation of HSCs, and inhibiting inflammation. NOD-like receptor (NLR) family, caspase activation and recruitment domain (CARD) domain containing 5/NOD27/CLR16.1 (NLRC5) is a highly conserved member of the NLR family and is involved in inflammation and immune responses by regulating various signaling pathways such as nuclear factor-κB (NF-κB) signaling. It has been found that NLRC5 plays an important role in liver fibrosis, but its specific effect and possible mechanism remain to be fully elucidated.
AIM To investigate the role of NLRC5 in the activation and reversion of HSCs induced with transforming growth factor-β (TGF-β) and MDI, and to explore its relationship with liver fibrosis.
METHODS A total of 24 male C57BL/6 mice were randomly divided into three groups, including normal, fibrosis, and recovery groups. Twenty-four hours after a liver fibrosis and spontaneous reversion model was established, the mice were sacrificed and pathological examination of liver tissue was performed to observe the degree of liver fibrosis in each group. LX-2 cells were cultured in vitro and treated with TGF-β1 and MDI. Real-time quantitative PCR (qPCR) and Western blot were used to analyze the expression levels of NLRC5, α-smooth muscle actin (α-SMA), and collagen type I alpha1 (Col1a1) in each group. The activity of NF-κB in each group of cells transfected with NLRC5-siRNA was detected.
RESULTS Compared with the normal mice, the expression level of NLRC5 increased significantly (P < 0.01) in the fibrosis group, but decreased significantly in the recovery group (P < 0.01). In in vitro experiments, the content of NLRC5 was enhanced after TGF-β1 stimulation and decreased to a lower level when treated with MDI (P < 0.01). The expression of α-SMA and Col1a1 proteins and mRNAs in TGF-β1-mediated cells was suppressed by transfection with NLRC5-siRNA (P < 0.01). Western blot analysis showed that the expression of NF-κB p65 protein and phosphorylated IκBα (p-IκBα) was increased in the liver of mice in the fibrosis group but decreased in the recovery group (P < 0.01), and the protein level of nuclear p65 and p-IκBα was significantly increased after treatment with NLRC5-siRNA (P < 0.01).
CONCLUSION NLRC5 may play a key role in the development and reversal of hepatic fibrosis through the NF-κB signaling pathway, and it is expected to be one of the clinical therapeutic targets.
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Affiliation(s)
- Yan-Zhen Zhang
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jian-Ning Yao
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Lian-Feng Zhang
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Chun-Feng Wang
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Xue-Xiu Zhang
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Bing Gao
- Department of Second Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
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9
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Abstract
PURPOSE OF REVIEW The goal of this review is to provide updates on the causes, manifestations and therapies IFALD in adults with an emphasis on recent discoveries on pathways of pathogenesis and interventions to reduce the incidence of IFALD. RECENT FINDINGS IFALD is a multifactorial complication of long-term home parenteral therapy. Although exact pathways are unknown, altered bile acid metabolism, microbiome dysbiosis impact on the gut-liver axis and soybean-based lipid formulations are major drivers of IFALD development. SUMMARY IFALD contributes to morbidity and mortality in patients on parenteral nutrition. Proactive management by a multidisciplinary team has led to improved outcomes in at-risk patients. Attention to early treatment and prevention of sepsis, introduction of nonsoybean based lipid formulations, surgical procedures such as step enteroplasties and, potentially, microbiome dysbiosis are considerations in IFLAD management.
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