Journal of Pediatric Surgery ( IF 2.4 ) Pub Date : 2021-09-20 , DOI: 10.1016/j.jpedsurg.2021.09.018 Gregory Keefe 1 , Katherine Culbreath 1 , Jamie Knell 1 , Priyanka V Chugh 2 , Steven J Staffa 2 , Tom Jaksic 1 , Biren P Modi 1
Purpose
This study aimed to characterize the relationship between hepatoprotective parenteral nutrition (PN) dependence and long-term serum liver tests in children with intestinal failure (IF).
Methods
A retrospective review was performed of children with severe IF (> 90 consecutive days of PN) who were followed from 2012 to 2019 at a multidisciplinary intestinal rehabilitation program. Patients were stratified into three groups based on level of PN dependence at most recent follow up: EN (achieved enteral autonomy), mixed (parenteral and enteral nutrition), and PN (> 75% of caloric intake from PN). PN at any point for this cohort was hepatoprotective, defined as soy-based lipids < 1.5 g/kg/day, combination (soy, medium chain fatty acid, olive and fish oil) lipid emulsion, or fish oil-based lipid emulsion. Kaplan-Meier analysis and a generalized estimating equation (GEE) model were utilized to estimate time to normalization and trends, respectively, of two serum markers of liver health: direct bilirubin (DB) and alanine aminotransferase (ALT).
Results
The study included 123 patients (67 EN, 32 mixed, 24 PN). Median follow up time was 4 years. Based on the Kaplan Meier curve, 100% of EN and mixed group patients achieved normal DB levels by 3 years, while 32% of the PN group had elevated DB levels (Fig. 1). At 5 years, 16% of EN patients had elevated ALT levels compared to 73% of PN patients (p < 0.001, Fig. 2). The PN group's ALT levels were 1.76-fold above normal at 3 years (95%CI 1.48–2.03) and 1.65-fold above normal at 5 years (95%CI 1.33–1.97, Fig. 3).
Conclusions
While serum bilirubin levels tend to normalize, long-term PN dependence in the era of hepatoprotective PN is associated with a persistent transaminase elevation in an overwhelming majority of patients. These data support continued vigilant monitoring of liver health in children with intestinal failure.
Level of evidence
III
中文翻译:
保肝肠外营养时代小儿肠功能衰竭患者胆红素和转氨酶趋势的长期评估
目的
本研究旨在描述肠功能衰竭 (IF) 儿童的肝保护性肠外营养 (PN) 依赖与长期血清肝功能检查之间的关系。
方法
对 2012 年至 2019 年在多学科肠道康复计划中接受随访的重度 IF(PN 连续 > 90 天)儿童进行了回顾性研究。根据最近随访时的 PN 依赖程度将患者分为三组:EN(实现肠内自主)、混合(肠外和肠内营养)和 PN(> 75% 的 PN 热量摄入)。该队列的任何时间点的 PN 均具有保肝作用,定义为大豆基脂质 < 1.5 g/kg/天、组合(大豆、中链脂肪酸、橄榄油和鱼油)脂质乳剂或鱼油基脂质乳剂。Kaplan-Meier 分析和广义估计方程 (GEE) 模型分别用于估计两种肝脏健康血清标志物的正常化时间和趋势:
结果
该研究包括 123 名患者(67 名 EN,32 名混合,24 名 PN)。中位随访时间为 4 年。根据 Kaplan Meier 曲线,100% 的 EN 和混合组患者在 3 年内达到正常 DB 水平,而 32% 的 PN 组患者 DB 水平升高(图 1)。5 年时,16% 的 EN 患者 ALT 水平升高,而 PN 患者为 73%(p < 0.001,图 2)。PN 组的 ALT 水平在 3 年时比正常值高 1.76 倍(95%CI 1.48-2.03),在 5 年时比正常值高 1.65 倍(95%CI 1.33-1.97,图 3)。
结论
虽然血清胆红素水平趋于正常化,但在保肝 PN 时代,长期 PN 依赖与绝大多数患者的持续转氨酶升高有关。这些数据支持对肠衰竭儿童肝脏健康的持续警惕监测。
证据级别
三