The effect of lipid restriction on the prevention of parenteral nutrition-associated cholestasis in surgical infants

Abstract

Purpose: Surgical infants requiring long-term parenteral nutrition (PN) are at risk for parenteral nutrition-associated liver disease (PNALD). The purpose of this study was to determine the effect of a lipid restricted PN regimen in preventing the development of PNALD in surgical infants.

Methods: In 2009, we implemented a lipid restricted strategy in surgical infants expected to be on long-term PN using a soy-based lipid emulsion at a goal provision of 1g/kg/day throughout a patient's entire PN course. An experimental cohort of surgical infants treated with lipid restriction from 2009 to 2011 (n=82) was retrospectively compared to a control cohort of infants from 2005 to 2008 receiving standard intravenous lipid dosing (n=132). A multivariable relative risk regression model was constructed analyzing the association between lipid restriction and PNALD.

Results: Patients admitted during the lipid restriction era had reduced daily lipid provisions compared to the control group (p<0.001). There were no significant differences in demographic or measured clinical characteristics between the two groups. A significant reduction in the incidence of PNALD was demonstrated in the lipid restricted group compared to the control group (22% vs. 43%, p=0.002). On multivariable relative risk regression, patients treated with standard lipid provisions were 1.77 times more likely to develop PNALD than patients who were lipid restricted (95% CI: 1.2-2.7; p=0.007).

Conclusion: Restriction of intravenous soy-based lipid in PN-fed surgical infants is associated with a reduction in the incidence of liver disease. Early lipid restriction should be considered in all surgical infants who require PN as a preventative measure against PNALD.

Fig. 1

Average daily lipid dose in control (2005–2008) and experimental (2009–2011) groups. The average daily lipid provision provided in PN was calculated for each subject. There was a significant difference in the intravenous lipid allotment between the standard and lipid restricted cohort in this study.

Fig. 2

Maximum conjugated bilirubin level in patients that developed cholestasis in the control (2005–2008) and experimental groups (2009–2011). Lipid restriction was associated with a reduction in the peak conjugated bilirubin level (p<0.0001) indicating that restriction of intravenous lipid may ameliorate the extent of liver disease in those patients who still develop PNALD.