Elsevier

Nutrition

Volume 31, Issue 9, September 2015, Pages 1109-1116
Nutrition

Applied nutritional investigation
Impact of intravenous lipid emulsions on liver function tests: Contribution of parenteral fish oil

https://doi.org/10.1016/j.nut.2015.04.005Get rights and content

Highlights

  • γ-Glutamyl transferase (GGT) and alkalin phosphatase (AP) increase, particularly in the second week of parenteral nutrition.

  • Intravenous fish oil is associated with a decrease in GGT and AP.

  • Vegetable oils have a tendency to increase GGT and AP.

  • Use of intravenous fish oil should be considered to reduce liver function test alterations.

Abstract

Objective

Lipids in parenteral nutrition (PN) have been linked to liver damage. The aim of this study is to 1) determine whether the incidence of alterations in liver function tests (LFTs) changes over time among hospitalized adult patients receiving PN; 2) evaluate whether the alteration in LFTs varies with the pattern of lipid administration; and 3) study the relationship between LFT alterations and fish oil (FO) emulsions.

Methods

Patients treated with PN over 4 y were included. Demographic, clinical, nutritional, and analytical variables were collected. LFTs (γ-glutamyl transferase [GGT], alkaline phosphatase [AP], alanine aminotransferase [ALT], and total bilirubin [BIL]) were collected during PN treatment. Differences in LFTs were studied with t tests for paired samples. To match the type of lipid with each of the LFTs studied, four multivariate statistical models were performed. Significance was reported with the 95% confidence interval (CI) at p < 0.05 (two-tailed).

Results

We studied 1555 patients. LFT alterations at baseline were high and increased during PN treatment except ALT. GGT and AP showed significant increases from baseline values. In the multivariate study, daily dose of FO (g·kg−1·d−1) was associated with a significant decrease in GGT (B = −11.189; 95% CI, −19.799 to −2.578) and in AP (B = −5.250; 95% CI, −10.263 to −0.237). Daily dose of vegetal oil (g/kg) had a tendency for a significant increase in GGT (B = 0.441; 95% CI, −0.107 to 1.039) and AP (B = 0.312; 95% CI, −0.023 to 0.648).

Conclusions

GGT and AP increased throughout the clinical course of PN administration. These alterations had a multifactorial component. The administration of FO was associated with a significant decrease in the levels of GGT and AP.

Introduction

In patients on parenteral nutrition (PN), alteration of liver function tests (LFTs) and subsequent liver complications are frequent and have a multifactorial component. After some days of PN therapy, LFTs begin to rise and liver complications occur in a variable percentage of patients, ranging from 30% to 100% [1], [2], [3].

One of the most important risk factors described is the amount and type of lipids administered [4], [5]. Thus, hepatic steatosis may occur with high amounts of intravenous lipid emulsions (ILE) [6], [7], [8]. The source of ILE may increase the risk for developing abnormal liver function [6], [7], [8], [9], [10] and, in recent years, the role of parenteral phytosterols in the onset of liver disorders has been shown, mainly in the pediatric population and in patients on long-term PN [8], [11]. Therefore, ILE should be used with caution in patients who are septic [8], [12], [13] and those with conditions that impair hepatic clearance of fatty acids [8], [13].

The use of fish oil (FO) ILEs and their influence on liver disorders has become an important area of study in pediatric patients [14]. Studies in hospitalized adult patients that show improved LFTs with FO administration are scarce [15]. Table 1 summarizes studies about lipid emulsions and liver function. In 2003, in a randomized trial, we studied the use of olive oil (OO) emulsions alone or with FO in a group of high-risk surgical patients undergoing elective, major abdominal surgery and a tendency toward liver improvement in those patients who had received both emulsions together was demonstrated [33].

In the current study, we carried out a 4-y review of all patients treated with PN to study the relationship between the type of ILE administered and LFT alterations. Our hypothesis is that patients who received FO emulsions had better liver parameter outcomes.

Hence, the aims of our study were to 1) determine whether the incidence of LFT alterations changes over time in hospitalized adult patients receiving PN; 2) evaluate whether the alteration of LFTs varies with the type and pattern of lipid administration; and 3) study the relationship between LFT alterations and FO emulsions.

Section snippets

Materials and methods

We conducted a 4-y data collection (2005–2008) of all patients treated with PN in a 600-bed, tertiary teaching hospital. Patients included in the study were those aged >17 y who had received any amount of lipids in PN during hospitalization. Table 2 depicts the ILE brands administered during the study.

The eight ILEs can be grouped into four types taking into account the lipid pattern:

  • 1.

    Emulsions with 80% of OO and 20% soy oil (SO) (Clinoleic [Baxter, Lessines, Belgium] and Oliclinomel [Baxter])

Results

During the 4 y studied, 1555 patients received PN treatment. Of these, 66% were men, aged 62.3 ± 14.9 y weighing 62.1 ± 12.5 kg. During PN treatment, 48.1% were admitted to the ICU and 12% died. Table 4 details diagnoses. Most of the patients were suffering from gastrointestinal (GI) diseases: 35.1% non-neoplastic and 34.4% neoplasms. The most prevalent diagnoses were 221 colorectal cancer, 153 gastroesophageal cancer, 121 pancreatic cancer, 104 trauma, 98 pancreatitis, and 61 inflammatory

Discussion

This study corroborates the high incidence of LFT alterations in patients receiving PN, seen mainly in GGT and AP that increased throughout the clinical course. At the end of treatment, the incidence of patients with GGT and AP above normal values represented almost 80%, approaching the high range of published data [1], [2], [3], [34], [35]. Meanwhile in contrast ALT, associated with hepatocellular damage, showed a significant decrease; whereas BIL, associated with cholestatic jaundice, did not

Conclusions

LFT alteration in PN-treated hospitalized adult patients is frequent. GGT and AP values increase throughout the clinical course of PN administration and these increases are maintained despite a reduced daily lipid supply (0.7 g/kg).

The multivariate adjusted model corroborated that these disorders have a multifactorial component. The inclusion of FO is associated with a significant decrease in the levels of GGT and AP in these patients. The use of Omegaven instead of the combinations of FO and

Acknowledgments

The authors acknowledge Maren White for editorial support in the preparation of this manuscript.

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. M.B.T. collected, assembled, and analyzed the data and drafted, corrected, and approved the manuscript. J.L.T. conceived and designed the study; generated, collected, and analyzed the data; and approved the manuscript. E.L.B. approved the final version of the manuscript. The authors had no

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