Parenteral nutrition supplementation in biliary atresia patients listed for liver transplantation

Abstract

The objective of this study was to determine the impact of parenteral nutrition (PN) on the outcomes of biliary atresia (BA) patients listed for liver transplantation (LT). We retrospectively reviewed the charts of all BA patients at our institution who underwent hepatoportoenterostomy and were listed for LT before the age of 36 months between 1990 and 2010. The initiation of PN was based on clinical indications. Twenty-five PN subjects and 22 non-PN subjects (74% female) were studied. The median PN initiation age was 7.7 months, the mean duration was 86 days, and the mean amount of energy supplied by PN was 77 kcal/kg/day. Before PN, the triceps skinfold thickness (TSF) and the mid-arm circumference (MAC) z scores were decreasing. After PN, TSF (P < 0.001) and MAC (P < 0.001) improved significantly. The PN group had lower MAC and TSF scores than the non-PN group at the time of LT listing. Between listing and LT, MAC and TSF improved in the PN group and worsened in the non-PN groups; as a result, the 2 groups had the same z scores at LT. The PN group had a higher incidence of gastrointestinal bleeding and ascites before LT, but there were no differences in the rates of pre-LT bacteremia, days in the intensive care unit after LT, or patient or graft survival. In conclusion, PN improves the nutritional status of malnourished BA patients awaiting LT, and this is associated with post-LT outcomes comparable to those of patients not requiring PN.

Figure 1

Energy Intake in PN vs. Non-PN Groups. Total energy intake was similar between PN and Non-PN groups at time of HPE, time of transplant listing, and time of clinical endpoint. There was a significant difference in energy delivered by parenteral route in the PN group at the time of clinical endpoint compared with the Non-PN group at the clinical endpoint (*p=0.002). PN=parenteral nutrition, HPE = hepatoportoenterostomy, Clinical Endpoint = liver transplant, death, or removal from transplant waiting list.

Figure 2

Comparison of MAC and TSF Thickness between PN and Non-PN Groups. MAC and TSF thickness were similar in PN and Non-PN groups at the time of HPE. However, by the time of listing for transplantation MAC and TSF were significantly lower in the PN group compared to the Non-PN group (*p=0.01 and **p=0.001). At the time of clinical endpoint, because both MAC and TSF had improved in the PN group, there was no difference in MAC and TSF between the PN and Non-PN groups. MAC=mid-arm circumference, TSF=triceps skin fold, PN=parenteral nutrition, Clinical Endpoint=transplant, death, or removal from transplant waiting list.

Figure 3

Post-transplant Patient and Graft Survival in PN vs. Non-PN Groups. Patient (log rank test p=0.37) and graft (log rank test p=0.52) survival was similar in both PN and Non-PN groups following liver transplantation (log rank test p=0.37).