Treatment of Parenteral Nutrition-Associated Liver Disease: The Role of Lipid Emulsions

Abstract

Parenteral nutrition is a life-saving therapy for infants with intestinal failure. However, long-term parenteral nutrition carries the risk of progressive liver disease. Substantial data has implicated components of parenteral soybean oil in the pathogenesis of parenteral nutrition-associated liver disease (PNALD). Elevated serum concentrations of phytosterols, an abundance of omega-6 polyunsaturated fatty acids, and a relative paucity of α-tocopherol have been associated with the risk of cholestasis and hepatic injury observed in PNALD. Currently available treatment strategies include the reduction of the dose of administered parenteral soybean oil and/or the replacement of parenteral soybean oil with alternative parenteral lipid emulsions. The purpose of this review is to provide an overview of the pathogenetic mechanisms associated with the development of PNALD and the data evaluating currently available treatment strategies.

Supplemental Parenteral Vitamin E Into Conventional Soybean Lipid Emulsion Does Not Prevent Parenteral Nutrition–Associated Liver Disease in Full‐Term Neonatal Piglets

“…Parenteral lipid emulsions, specifically soy‐based emulsions, are now recognized as one of the major associated risk factors for PNALD 4 , 5 . Conventional soy‐based lipid emulsions are predominant in ω‐6 PUFAs, implicated for proinflammatory eicosanoid production 6 .…”

“…In the past decade, the use of soy‐based parenteral lipid emulsion has emerged as a major risk factor of cholestasis and hepatic injury. The long‐chain polyunsaturated fatty acids (PUFAs) in lipid emulsions can undergo peroxidation and produce free radical peroxides that are believed to contribute to the liver damage observed in PNALD 4 , 5 . Vitamin E is added to lipid emulsions to reduce the risk of such peroxidation and potentially can also provide increased antioxidant delivery, which may benefit the patient, protecting host cellular membranes from lipid peroxidation 6 .…”

Higher Doses of Fish Oil–Based Lipid Emulsions Used to Treat Inadequate Weight Gain and Rising Triene:Tetraene Ratio in a Severely Malnourished Infant With Intestinal Failure–Associated Liver Disease

“…Prolonged use of PN for infants with intestinal failure is essential for provision of life‐sustaining nutrition support when the enteral route cannot be utilized. There is a documented association between the use of SOLE and the development of IFALD, 5 and SOLE dose reduction is a well‐known management strategy for IFALD 16 . However, long‐term use of lipid minimization strategies may lead to EFAD in children, which can pose a risk to growth and development 17 .…”

Lipid Emulsion Use in Pediatric Patients Requiring Long‐Term Parenteral Nutrition

“…Pediatric patients at risk for developing IFALD should be identified early to prevent cholestasis, by promoting oral feeding, if possible, and limiting the risk of sepsis and small intestinal bacterial overgrowth . Because long‐term use of a pure soybean oil emulsion is a risk factor for cholestasis, both lipid restriction and the use of alternative lipid sources are potential preventative strategies . Studies evaluating the effect of lipid emulsions on the prevention of cholestasis in infants and children are shown in Table …”