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Title: High rates of resolution of cholestasis in parenteral nutrition-associated liver disease with fish oil-based lipid emulsion monotherapy

Author
item PREMKUMAR, MURALIDHAR - Baylor College Of Medicine
item CARTER, BETH - Baylor College Of Medicine
item HAWTHORNE, KELI - Children'S Nutrition Research Center (CNRC)
item KING, KRISTI - Baylor College Of Medicine
item ABRAMS, STEVEN - Children'S Nutrition Research Center (CNRC)

Submitted to: Journal of Pediatrics
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 10/5/2012
Publication Date: 4/1/2013
Citation: Premkumar, M.H., Carter, B.A., Hawthorne, K.M., King, K., Abrams, S.A. 2013. High rates of resolution of cholestasis in parenteral nutrition-associated liver disease with fish oil-based lipid emulsion monotherapy. Journal of Pediatrics. 162(4):793-798.

Interpretive Summary: Infants who require intravenous nutrition (TPN - total parenteral nutrition) treatments frequently sustain liver damage. Our study was designed to determine what factors would cause improvement in this liver damage. We studied 57 infants younger than 6 months of age who were treated with a fish-oil-based fat source given intravenously. We found that the median number of days to resolution of liver disease was 35 (range 7-129). Unfortunately, ten infants (17.5%) died. We also found that the length of time it took for liver improvement was correlated inversely with gestational age at birth (how premature) and directly with time until they were able to receive all of their calories by mouth. We concluded that using this fish-oil-based therapy was effective in treating TPN-related liver disease.

Technical Abstract: Our research was conducted to determine factors leading to resolution of cholestasis in patients with parenteral nutrition-associated liver disease treated with fish-oil-based lipid emulsion (FOLE). We used a prospective observational study of 57 infants <6 months of age with parenteral nutrition-associated liver disease who received parenteral FOLE as monotherapy. Median gestational age of subjects at birth was 28 weeks (range 22.7-39.5). Median conjugated bilirubin level at initiation of therapy with FOLE was 7.5 mg/dL (range 2.1-25). Resolution of hyperbilirubinemia (conjugated bilirubin <2.0 mg/dL) and survival to hospital discharge occurred in 47 (82.5%) infants. Median number of days to resolution of cholestasis was 35 (range 7-129). Ten infants (17.5%) died. Non-survivors showed a trend towards being more premature than survivors at birth (25.9 vs 29.1 weeks, P = .056). Infants with higher conjugated bilirubin at initiation of therapy (>10.0 compared with <5.0 mg/dL) had longer times to resolution (98 vs 56 days, P < .005). Time to resolution correlated inversely with gestational age at birth (r2 = 0.14, P = .02) and directly with time to receive 100% calories enterally (r2 = 0.12, P = .03). Younger gestational age infants demonstrated higher degree of cholestasis, longer time to resolution of cholestasis, and increased mortality. Higher levels of cholestasis were associated with longer time to resolution. FOLE monotherapy led to resolution of cholestasis in all surviving infants.