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Current Nutrition Reports
Published in: Current Nutrition Reports 3/2017

01-09-2017 | Gastroenterology, Critical Care, and Lifestyle Medicine (SA McClave, Section Editor)

Nutritional Risk Factors in the Pathogenesis of Parenteral Nutrition-Associated Liver Disease

Authors: Berkeley N. Limketkai, Monica Choe, Shruti Patel, Neha D. Shah, Valentina Medici

Published in: Current Nutrition Reports | Issue 3/2017

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Abstract

Purpose of Review

Parenteral nutrition has been a lifesaving therapy for individuals who cannot sustain adequate oral or enteral nutrient intake to maintain fluid, electrolyte, and nutrient balance. Nonetheless, parenteral nutrition can lead to an increased risk of complications, such as parenteral nutrition-associated liver disease (PNALD). The pathogenesis of PNALD has been associated with multiple risk factors, such as longer duration, reduced small bowel length, decreased enteral intake, and bacterial infections. Nutritional risk factors also play an important role in the development of PNALD. This review presents several nutrient deficiencies and excesses that have been associated with PNALD.

Recent Findings

Deficiencies in certain nutrients (amino acids, essential fatty acids, enteral intake), excesses of certain nutrients (calories, carbohydrates, lipids), types of lipid emulsions, and mineral toxicities (aluminum, copper, manganese) have been associated with PNALD. Strategies to address PNALD require correction of these risk factors. The use of newer mixed lipid emulsions (including soybean, medium-chain triglycerides, olive oil, and fish oil) may also have less hepatotoxicity than traditional soybean oil-based lipid emulsions.

Summary

Knowledge of nutritional risk factors for PNALD will help the clinician in the systematic evaluation and treatment of these specific risk factors. Moreover, an understanding of their effects guides the balance between addressing the patient’s nutritional needs and reducing the risk of PNALD.
Literature
1.
Dudrick SJ, Wilmore DW, Vars HM, Rhoads JE. Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery. 1968;64(1):134–42.PubMed
2.
Crispin A, Thul P, Arnold D, Schild S, Weimann A. Central venous catheter complications during home parenteral nutrition: a prospective pilot study of 481 patients with more than 30,000 catheter days. Onkologie. 2008;31(11):605–9.
3.
Dibb M, Teubner A, Theis V, Shaffer J, Lal S. Review article: the management of long-term parenteral nutrition. Aliment Pharmacol Ther. 2013;37(6):587–603.CrossRefPubMed
4.
Shike M, Harrison JE, Sturtridge WC, et al. Metabolic bone disease in patients receiving long-term total parenteral nutrition. Ann Intern Med. 1980;92(3):343–50.CrossRefPubMed
5.
Kelly DA. Intestinal failure-associated liver disease: what do we know today? Gastroenterology. 2006;130(2 Suppl 1):S70–7.CrossRefPubMed
6.
Lauriti G, Zani A, Aufieri R, et al. Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. JPEN J Parenter Enteral Nutr. 2014;38(1):70–85.CrossRef
7.
Cavicchi M, Beau P, Crenn P, Degott C, Messing B. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. 2000;132(7):525–32.CrossRef
8.
Luman W, Shaffer JL. Prevalence, outcome and associated factors of deranged liver function tests in patients on home parenteral nutrition. Clin Nutr. 2002;21(4):337–43.CrossRefPubMed
9.
Buchman AL, Ament ME, Sohel M, et al. Choline deficiency causes reversible hepatic abnormalities in patients receiving parenteral nutrition: proof of a human choline requirement: a placebo-controlled trial. JPEN J Parenter Enteral Nutr. 2001;25(5):260–8.CrossRefPubMed
10.
Fell JM, Reynolds AP, Meadows N, et al. Manganese toxicity in children receiving long-term parenteral nutrition. Lancet. 1996;347(9010):1218–21.CrossRefPubMed
11.
Peng YZ, Yuan ZQ, Xiao GX. Effects of early enteral feeding on the prevention of enterogenic infection in severely burned patients. Burns. 2001;27(2):145–9.CrossRefPubMed
12.
El Kasmi KC, Anderson AL, Devereaux MW, et al. Toll-like receptor 4-dependent Kupffer cell activation and liver injury in a novel mouse model of parenteral nutrition and intestinal injury. Hepatology. 2012;55(5):1518–28.CrossRefPubMedPubMedCentral
13.
Chipponi JX, Bleier JC, Santi MT, Rudman D. Deficiencies of essential and conditionally essential nutrients. Am J Clin Nutr. 1982;35(5 Suppl):1112–6.PubMed
14.
Hoffer LJ. Human protein and amino acid requirements. JPEN J Parenter Enteral Nutr. 2016;40(4):460–74.CrossRefPubMed
15.
Hoffer LJ. Parenteral nutrition: amino acids. Nutrients. 2017;9(3).
16.
Lands WE. Discriminations among unsaturated fatty acids. Prog Clin Biol Res. 1988;282:11–28.PubMed
17.
Buchman AL, Moukarzel A, Jenden DJ, Roch M, Rice K, Ament ME. Low plasma free choline is prevalent in patients receiving long term parenteral nutrition and is associated with hepatic aminotransferase abnormalities. Clin Nutr. 1993;12(1):33–7.CrossRefPubMed
18.
Karpati G, Carpenter S, Engel AG, et al. The syndrome of systemic carnitine deficiency. Clinical, morphologic, biochemical, and pathophysiologic features. Neurology. 1975;25(1):16–24.CrossRefPubMed
19.
Palombo JD, Schnure F, Bistrian BR, Buchanan LM, Blackburn GL. Improvement of liver function tests by administration of L-carnitine to a carnitine-deficient patient receiving home parenteral nutrition: a case report. JPEN J Parenter Enteral Nutr. 1987;11(1):88–92.CrossRefPubMed
20.
Buchman AL, Dubin MD, Moukarzel AA, et al. Choline deficiency: a cause of hepatic steatosis during parenteral nutrition that can be reversed with intravenous choline supplementation. Hepatology. 1995;22(5):1399–403.PubMed
21.
Miyazaki T, Matsuzaki Y. Taurine and liver diseases: a focus on the heterogeneous protective properties of taurine. Amino Acids. 2014;46(1):101–10.CrossRefPubMed
22.
Tanphaichitr V, Leelahagul P. Carnitine metabolism and human carnitine deficiency. Nutrition. 1993;9(3):246–54.PubMed
23.
Schmidt-Sommerfeld E, Werner D, Penn D. Carnitine plasma concentrations in 353 metabolically healthy children. Eur J Pediatr. 1988;147(4):356–60.CrossRefPubMed
24.
Worthley LI, Fishlock RC, Snoswell AM. Carnitine deficiency with hyperbilirubinemia, generalized skeletal muscle weakness and reactive hypoglycemia in a patient on long-term total parenteral nutrition: treatment with intravenous L-carnitine. JPEN J Parenter Enteral Nutr. 1983;7(2):176–80.CrossRef
25.
Bowyer BA, Miles JM, Haymond MW, Fleming CR. L-carnitine therapy in home parenteral nutrition patients with abnormal liver tests and low plasma carnitine concentrations. Gastroenterology. 1988;94(2):434–8.CrossRefPubMed
26.
Noga AA, Zhao Y, Vance DE. An unexpected requirement for phosphatidylethanolamine N-methyltransferase in the secretion of very low density lipoproteins. J Biol Chem. 2002;277(44):42,358–65.CrossRef
27.
28.
Buchman AL, Dubin M, Jenden D, et al. Lecithin increases plasma free choline and decreases hepatic steatosis in long-term total parenteral nutrition patients. Gastroenterology. 1992;102(4 Pt 1):1363–70.CrossRefPubMed
29.
Stapleton PP, Charles RP, Redmond HP, Bouchier-Hayes DJ. Taurine and human nutrition. Clin Nutr. 1997;16(3):103–8.CrossRefPubMed
30.
31.
Burr GO, Burr MM. Nutrition classics from the Journal of Biological Chemistry 82:345-67, 1929. A new deficiency disease produced by the rigid exclusion of fat from the diet. Nutr Rev. 1973;31(8):248–9.PubMed
32.
Oshita M, Takehara H, Yamaguchi M, et al. Significance of administration of fat emulsion: hepatic changes in infant rats receiving total parenteral nutrition with and without fat. Clin Nutr. 2004;23(5):1060–8.CrossRef
33.
Fukazawa T, Privett OS, Takahashi Y. Effect of EFA deficiency on lipid transport from liver. Lipids. 1971;6(6):388–93.CrossRefPubMed
34.
Huang MT, Williams MA. Essential fatty acid deficiency and plasma triglyceride turnover in rats. Am J Phys. 1980;238(5):E499–505.
35.
Williams MA, Tinoco J, Yang YT, Bird MI, Hincenbergs I. Feeding pure docosahexaenoate or arachidonate decreases plasma triacylglycerol secretion in rats. Lipids. 1989;24(9):753–8.CrossRefPubMed
36.
Levy E, Thibault L, Garofalo C, et al. Combined (n-3 and n-6) essential fatty deficiency is a potent modulator of plasma lipids, lipoprotein composition, and lipolytic enzymes. J Lipid Res. 1990;31(11):2009–17.PubMed
37.
Nilsson A, Hjelte L, Nilsson-Ehle P, Strandvik B. Adaptive regulation of lipoprotein lipase and salt-resistant lipase activities in essential fatty acid deficiency: an experimental study in the rat. Metabolism. 1990;39(12):1305–8.CrossRefPubMed
38.
Holman RT. The ratio of trienoic: tetraenoic acids in tissue lipids as a measure of essential fatty acid requirement. J Nutr. 1960;70:405–10.PubMed
39.
Holman RT, Smythe L, Johnson S. Effect of sex and age on fatty acid composition of human serum lipids. Am J Clin Nutr. 1979;32(12):2390–9.PubMed
40.
Bistrian BR. Clinical aspects of essential fatty acid metabolism: Jonathan Rhoads Lecture. JPEN J Parenter Enteral Nutr. 2003;27(3):168–75.CrossRefPubMed
41.
Press M, Hartop PJ, Prottey C. Correction of essential fatty-acid deficiency in man by the cutaneous application of sunflower-seed oil. Lancet. 1974;1(7858):597–8.CrossRefPubMed
42.
Friedman Z, Shochat SJ, Maisels MJ, Marks KH, Lamberth EL Jr. Correction of essential fatty acid deficiency in newborn infants by cutaneous application of sunflower-seed oil. Pediatrics. 1976;58(5):650–4.PubMed
43.
Miller DG, Williams SK, Palombo JD, Griffin RE, Bistrian BR, Blackburn GL. Cutaneous application of safflower oil in preventing essential fatty acid deficiency in patients on home parenteral nutrition. Am J Clin Nutr. 1987;46(3):419–23.PubMed
44.
Touloukian RJ, Seashore JH. Hepatic secretory obstruction with total parenteral nutrition in the infant. J Pediatr Surg. 1975;10(3):353–60.CrossRefPubMed
45.
Slagle TA, Gross SJ. Effect of early low-volume enteral substrate on subsequent feeding tolerance in very low birth weight infants. J Pediatr. 1988;113(3):526–31.CrossRefPubMed
46.
Rangel SJ, Calkins CM, Cowles RA, et al. Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2012;47(1):225–40.CrossRefPubMed
47.
Greenberg GR, Wolman SL, Christofides ND, Bloom SR, Jeejeebhoy KN. Effect of total parenteral nutrition on gut hormone release in humans. Gastroenterology. 1981;80(5 pt 1):988–93.PubMed
48.
Lucas A, Bloom SR, Aynsley-Green A. Metabolic and endocrine consequences of depriving preterm infants of enteral nutrition. Acta Paediatr Scand. 1983;72(2):245–9.CrossRefPubMed
49.
Jawaheer G, Pierro A, Lloyd DA, Shaw NJ. Gall bladder contractility in neonates: effects of parenteral and enteral feeding. Arch Dis Child Fetal Neonatal Ed. 1995;72(3):F200–2.CrossRefPubMedPubMedCentral
50.
Fedorowski T, Salen G, Tint GS, Mosbach E. Transformation of chenodeoxycholic acid and ursodeoxycholic acid by human intestinal bacteria. Gastroenterology. 1979;77(5):1068–73.
51.
Miyai K, Price VM, Fisher MM. Bile acid metabolism in mammals. Ultrastructural studies on the intrahepatic cholestasis induced by lithocholic and chenodeoxycholic acids in the rat. Lab Investig. 1971;24(4):292–302.
52.
Hoang V, Sills J, Chandler M, Busalani E, Clifton-Koeppel R, Modanlou HD. Percutaneously inserted central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower extremity insertion. Pediatrics. 2008;121(5):e1152–9.CrossRef
53.
Capron JP, Gineston JL, Herve MA, Braillon A. Metronidazole in prevention of cholestasis associated with total parenteral nutrition. Lancet. 1983;1(8322):446–7.CrossRefPubMed
54.
55.
Meguid MM, Chen TY, Yang ZJ, Campos AC, Hitch DC, Gleason JR. Effects of continuous graded total parenteral nutrition on feeding indexes and metabolic concomitants in rats. Am J Phys. 1991;260(1 Pt 1):E126–40.
56.
Nussbaum MS, Li S, Bower RH, McFadden DW, Dayal R, Fischer JE. Addition of lipid to total parenteral nutrition prevents hepatic steatosis in rats by lowering the portal venous insulin/glucagon ratio. JPEN J Parenter Enteral Nutr. 1992;16(2):106–9.CrossRefPubMed
57.
Girard J, Perdereau D, Foufelle F, Prip-Buus C, Ferre P. Regulation of lipogenic enzyme gene expression by nutrients and hormones. FASEB J. 1994;8(1):36–42.PubMed
58.
Crill CM, Gura KM. Parenteral Nutrition. In: Corkins M, ed. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2015:596.
59.
• Ayers P, Holcomb B, Plogsted S, Guenter P. A.S.P.E.N. Parenteral Nutrition Handbook. 2nd ed: American Society for Parenteral and Enteral Nutrition; 2014. Comprehensive guidance on the prescription and use of parenteral nutrition.
60.
Antebi H, Mansoor O, Ferrier C, et al. Liver function and plasma antioxidant status in intensive care unit patients requiring total parenteral nutrition: comparison of 2 fat emulsions. JPEN J Parenter Enteral Nutr. 2004;28(3):142–8.CrossRefPubMed
61.
• Klek S, Chambrier C, Singer P, et al. Four-week parenteral nutrition using a third generation lipid emulsion (SMOFlipid)—a double-blind, randomised, multicentre study in adults. Clin Nutr. 2013;32(2):224–31. Randomized trial demonstrating the safety and improvement in fatty acid profile with use of the recently FDA-approved mixed lipids (soybean oil, medium-chain triglycerides, olive oil, fish oil) emulsion. CrossRefPubMed
62.
Puder M, Valim C, Meisel JA, et al. Parenteral fish oil improves outcomes in patients with parenteral nutrition-associated liver injury. Ann Surg. 2009;250(3):395–402.PubMedPubMedCentral
63.
Gura KM, Duggan CP, Collier SB, et al. Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management. Pediatrics. 2006;118(1):e197–201.CrossRefPubMed
64.
• Nandivada P, Chang MI, Potemkin AK, et al. The natural history of cirrhosis from parenteral nutrition-associated liver disease after resolution of cholestasis with parenteral fish oil therapy. Ann Surg. 2015;261(1):172–9. Prospective study that evaluated the response of PNALD to fish oil-based lipid emulsion. CrossRefPubMedPubMedCentral
65.
Strang BJ, Reddix BA, Wolk RA. Improvement in parenteral nutrition-associated cholestasis with the use of Omegaven in an infant with short bowel syndrome. Nutr Clin Pract. 2016;31(5):647–53.CrossRefPubMed
66.
Park HW, Lee NM, Kim JH, Kim KS, Kim SN. Parenteral fish oil-containing lipid emulsions may reverse parenteral nutrition-associated cholestasis in neonates: a systematic review and meta-analysis. J Nutr. 2015;145(2):277–83.CrossRefPubMed
67.
Vanek VW, Seidner DL, Allen P, et al. Update to A.S.P.E.N. position paper: clinical role for alternative intravenous fat emulsions. Nutr Clin Pract. 2014;29(6):841.CrossRefPubMed
68.
Clayton PT, Whitfield P, Iyer K. The role of phytosterols in the pathogenesis of liver complications of pediatric parenteral nutrition. Nutrition. 1998;14(1):158–64.CrossRefPubMed
69.
Llop JM, Virgili N, Moreno-Villares JM, et al. Phytosterolemia in parenteral nutrition patients: implications for liver disease development. Nutrition. 2008;24(11–12):1145–52.CrossRefPubMed
70.
Carter BA, Taylor OA, Prendergast DR, et al. Stigmasterol, a soy lipid-derived phytosterol, is an antagonist of the bile acid nuclear receptor FXR. Pediatr Res. 2007;62(3):301–6.CrossRefPubMed
71.
Cober MP, Killu G, Brattain A, Welch KB, Kunisaki SM, Teitelbaum DH. Intravenous fat emulsions reduction for patients with parenteral nutrition-associated liver disease. J Pediatr. 2012;160(3):421–7.CrossRef
72.
Sanchez SE, Braun LP, Mercer LD, Sherrill M, Stevens J, Javid PJ. The effect of lipid restriction on the prevention of parenteral nutrition-associated cholestasis in surgical infants. J Pediatr Surg. 2013;48(3):573–8.CrossRefPubMed
73.
Pluhator-Murton MM, Fedorak RN, Audette RJ, Marriage BJ, Yatscoff RW, Gramlich LM. Trace element contamination of total parenteral nutrition. 1. Contribution of component solutions. JPEN J Parenter Enteral Nutr. 1999;23(4):222–7.CrossRefPubMed
74.
Bohrer D, do Nascimento PC, Binotto R, Becker E, Pomblum S. Contribution of the raw material to the aluminum contamination in parenterals. JPEN J Parenter Enteral Nutr. 2002;26(6):382–8.CrossRefPubMed
75.
Hernandez-Sanchez A, Tejada-Gonzalez P, Arteta-Jimenez M. Aluminium in parenteral nutrition: a systematic review. Eur J Clin Nutr. 2013;67(3):230–8.CrossRefPubMed
76.
Arnold CJ, Miller GG, Zello GA. Parenteral nutrition-associated cholestasis in neonates: the role of aluminum. Nutr Rev. 2003;61(9):306–10.CrossRefPubMed
77.
Alemmari A, Miller GG, Arnold CJ, Zello GA. Parenteral aluminum induces liver injury in a newborn piglet model. J Pediatr Surg. 2011;46(5):883–7.CrossRefPubMed
78.
Alemmari A, Miller GG, Bertolo RF, et al. Reduced aluminum contamination decreases parenteral nutrition associated liver injury. J Pediatr Surg. 2012;47(5):889–94.CrossRefPubMed
79.
Klein GL. Aluminum contamination of parenteral nutrition solutions and its impact on the pediatric patient. Nutr Clin Pract. 2003;18(4):302–7.CrossRef
80.
Bishop NJ, Morley R, Day JP, Lucas A. Aluminum neurotoxicity in preterm infants receiving intravenous-feeding solutions. N Engl J Med. 1997;336(22):1557–61.CrossRefPubMed
81.
Cope-Yokoyama S, Finegold MJ, Sturniolo GC, et al. Wilson disease: histopathological correlations with treatment on follow-up liver biopsies. World J Gastroenterol. 2010;16(12):1487–94.CrossRefPubMedCentral
82.
Fessler TA. Trace elements in parenteral nutrition: a practical guide for dosage and monitoring for adult patients. Nutr Clin Pract. 2013;28(6):722–9.CrossRefPubMed
83.
Spiegel JE, Willenbucher RF. Rapid development of severe copper deficiency in a patient with Crohn’s disease receiving parenteral nutrition. JPEN J Parenter Enteral Nutr. 1999;23(3):169–72.CrossRef
84.
Fuhrman MP, Herrmann V, Masidonski P, Eby C. Pancytopenia after removal of copper from total parenteral nutrition. JPEN J Parenter Enteral Nutr. 2000;24(6):361–6.CrossRefPubMed
85.
Medici V. The evolving scenario of copper and fatty liver. Metab Syndr Relat Disord. 2013;11(1):4–6.CrossRef
86.
Papavasiliou PS, Miller ST, Cotzias GC. Role of liver in regulating distribution and excretion of manganese. Am J Phys. 1966;211(1):211–6.
87.
Bertinchamps AJ, Miller ST, Cotzias GC. Interdependence of routes excreting manganese. Am J Phys. 1966;211(1):217–24.
88.
Hauser RA, Zesiewicz TA, Rosemurgy AS, Martinez C, Olanow CW. Manganese intoxication and chronic liver failure. Ann Neurol. 1994;36(6):871–5.CrossRefPubMed
89.
Kelly DA. Liver complications of pediatric parenteral nutrition—epidemiology. Nutrition. 1998;14(1):153–7.CrossRefPubMed
90.
Baker B, Ali A, Isenring L. Recommendations for manganese supplementation to adult patients receiving long-term home parenteral nutrition: an analysis of the supporting evidence. Nutr Clin Pract. 2016;31(2):180–5.CrossRefPubMed
91.
Vanek VW, Borum P, Buchman A, et al. A.S.P.E.N. position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products. Nutr Clin Pract. 2012;27(4):440–91.CrossRefPubMed
92.
Huston RK, Heisel CF, Vermillion BR, Christensen JM, Minc L. Aluminum content of neonatal parenteral nutrition solutions. Nutr Clin Pract. 2017;32(2):266–70.CrossRefPubMed
Metadata
Title
Nutritional Risk Factors in the Pathogenesis of Parenteral Nutrition-Associated Liver Disease
Authors
Berkeley N. Limketkai
Monica Choe
Shruti Patel
Neha D. Shah
Valentina Medici
Publication date
01-09-2017
Publisher
Springer US
Published in
Current Nutrition Reports / Issue 3/2017
Electronic ISSN: 2161-3311
DOI
https://doi.org/10.1007/s13668-017-0217-7

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