Liver transplantation parenteral nutrition

Intestinal transplantation is combined with liver transplantation in 46% of cases, because of terminal liver failure (93). Of 78 patients who had received parenteral nutrition for more than 2 years n — 66) and/ or had short bowel syndrome and could not be weaned from parenteral nutrition (n = 12), 58 developed chronic cholestasis and 37 developed one or more severe liver complication (serum bilirubin concentration 60 pmol/l, factor V (proaccelerin) 50%, portal hypertension, encephalopathy, ascites, bleeding from the gastrointestinal tract, or histological findings consisting of extensive fibrosis and cirrhosis) after 6 (3-132) months and 17 (2-155) months respectively. Liver disease was responsible for deaths in 6.5% of the patients (22% of deaths). 

Cavicchi M, Crenn P, Beau P, Degott C, Boutron MC, Messing B. Severe liver complications associated with long-term parenteral nutrition are dependent on lipid parenteral input. Transplant Proc 1998 30(6) 2547. 

Kuse ER, et al. Hepatic reticuloendothehal function during parenteral nutrition including an MCT/LCT or LCT emulsion after liver transplantation—a double-bhnd study. Transpl Int 2002 15 272-277. 

The food and milk interactions are established, clinically important, and result in an increase in the bioavailability of ciclosporin. The situation should therefore be monitored if any changes are made to the diet of patients taking ciclosporin. Patients should be warned because increased ciclosporin levels are associated with increased nephrotoxicity. Lipid admixtures in parenteral nutrition do not appear to affect ciclosporin pharmacokinetics and it is speculated that they may protect against ciclosporin-induced nephrotoxicity. Close supervision and monitoring is required. There is insufficient evidence to allow extrapolation of the results to bone-marrow transplant recipients with risk factors such as dysli-pidaemia, liver, or renal impairment. ... 

Two infants with intestinal failure and parenteral nutrition-associated liver disease were given an intravenous fat emulsion containing primarily omega-3 fatty acids instead of the conventional emulsion [30 ]. Biochemical tests of liver function improved significantly. One child was removed from the liver transplantation list because of improved hepatic function, and the second child had complete resolution of cholestasis while solely on parenteral nutrition. 

A fish oil-based intravenous lipid emulsion in the treatment of liver disease associated with parenteral nutrition has been compared with soybean oil in an open study in 42 infants with short bowel syndrome who developed cholestasis [35 ]. There were three deaths and one liver transplantation in those who received the fish oil, compared with 12 deaths and 6 transplants in those who received soybean oil The fish oil was not associated with hypertriglyceridemia, coagulopathy, or deficiency of essential fatty acids. 

In contrast, in a retrospective analysis of 292 neonates who received parenteral nutrition with lipid emulsions containing omega-3 fatty acids for more than 1 day, 104 (36%) developed cholestasis after a mean of 22 days, with a conjugated bilirubin concentration over 34 pmol/l 31 had a serum conjugated bilirubin concentration over 100 pmoUl and 13 developed liver failure 4 underwent transplantation and 5 died of hepatic disease [385]. The authors suggested that in the absence of definitive evidence of efficacy, as well as increased costs, it is difficult to justify the routine use of lipid... 

Cober MP, Teitelbaum DH. Prevention of parenteral nutrition-associated liver disease lipid minimization. Curr Opin Organ Transplant 2010 15(3) 330-3. 

Biliary tract In a study of 66 infants with cholestasis associated with parenteral nutrition, there were 10 deaths and one referral for liver transplant in the first year of life, all of whom had at least one positive blood culture after the onset of cholestasis [70 ]. Maximum conjugated bilirubin in these 11 infants was 270 pmol/l, compared with 145 pmol/l in babies who recovered. A maximum conjugated bilirubin concentration over 170 pmol/l was a susceptibility factor for death or transplantation. 

In a case report, a 49-year-old female with short bowel syndrome who underwent multivisceral transplant due to total parenteral nutrition-related liver disease developed posterior reversible encephalopathy syndrome (PRES) which was thought to be due to sirolimus. PRES resolved after sirolimus was discontinued [48 ]. 

Plauth M, Merli M, Kondrup J, et al. European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines for nutrition in liver disease and transplantation. Clin Nutr 1997 16 43-55. 

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