![]() A minimal amount of soybean lipid emulsion was maintained to avoid the possibility of essential fatty acid deficiency syndrome. A total amount of 2 g/kg/die of lipids was administered. Patients received fish-oil emulsions at 1.5 g/Kg/die and soybean-based emulsion (Intralipid, Fresenius Kabi, Italy) at 0.5 g/Kg/die. In the FOLE group, at the moment of diagnosis of PNAC, treatment with fish-oil–based emulsion (Omegaven, Fresenius Kabi, Italy) was started. At that time SLE was continued at the diagnosis of cholestasis (SLE group). The institutional review boards approved the study, and written informed consent was obtained from the parents of all subjects enrolled in the FOLE group.Ī historical cohort of infants, admitted to our unit between 20 with PNAC was used as comparison group. PNAC was defined as a concentration of direct bilirubin ≥2 mg/dL on 2 consecutive measurements in a patient receiving NP for ≥2 weeks, without other liver diseases (i.e., cystic fibrosis, inborn metabolic errors, and hepatitis). Infants in the SLE group continued to receive SLE at the diagnosis of cholestasis. These infants were prospectively studied (FOLE group) and compared with an historical cohort of infants, admitted to our unit between 20 (SLE group). In January 2010 we started to use FOLE in infants with PNAC who met the following criteria: birth weight 30 days.Īll infants with PNAC were switched from SLE to FOLE at the time of diagnosis. In this study we assessed the efficacy of a FOLE to reverse PNAC in a population of very low birth weight preterm infants who developed cholestasis while receiving SLE. On the contrary, fish-oil-based emulsions, rich in ω-3 fatty acid metabolites, including docosahexaenoic and eicosapentaenoic acids, can enhance anti-inflammatory pathways. Moreover soybean-derived lipid emulsions contain phytosterols, a group of plant steroid compounds that have been shown to decrease bile flow in animal models and that are believed to be hepatotoxic. They are rich in ω-6 fatty acids, which have pro-inflammatory metabolites that can contribute to impaired immunologic function. ![]() Soybean-based emulsions may be involved in the aetiology of PNAC for several reasons. Several reports and clinical studies have found reversal of PNAC when replacing standard soy-based parenteral lipid emulsion (SLE) with fish oil-based lipid emulsion (FOLE). Intravenous lipid emulsions seem to have a significant role in the pathogenesis of PNAC. Mortality rate in cholestatic infants with end stage liver disease almost reaches 100% within one year from the diagnosis, unless PN can be discontinued or liver/small bowel transplantation can be performed. ![]() ![]() The most effective treatment for PNAC is increasing enteral energy intake while weaning off PN but, in about 3–15% of patients, end-stage liver disease develops and liver/small bowel transplantation remains the only treatment option. A further risk factor is the occurrence of severe infections, due to the requirement for central line for infusion of PN, and bacterial overgrowth caused by enteral starvation and immature immune function. Risk factors for PNAC include low birth weight, prematurity, prolonged PN use, lack of enteral intake, enzyme deficiencies, genetic causes, anatomic factors, susceptibility to cholestatic injury, and factors relevant to the PN itself. The incidence of PNAC is variable, from 12 to 85%, being inversely proportional to gestational age. Its long-term use is associated with serious complications, such as PN-associated cholestasis (PNAC). Parenteral nutrition (PN) is a life-saving therapy, providing nutrients to preterm neonates who are unable to tolerate enteral nutrition. Considering that definitive data on the actual efficacy of FOLE to reverse PNAC are lacking, larger randomized trials are required, mainly to asses if FOLE may have a role in PNAC prevention rather than PNAC treatment. ConclusionsįOLE does not seem to be superior to SLE in reversing cholestasis. Time to reversal of cholestasis was the same in the two study groups (45 ± 21 vs 43 ± 32 days). The effectiveness in reversing PNAC was evaluated in prospective cohort study of very preterm infants when compared to historical controls: twenty-six infants (27.0 ± 2.6 weeks GA 724 ± 204 g) who developed cholestasis while receiving SLE were shifted to receive FOLE and were compared with 30 infants (27.3 ± 2.5 weeks GA¸ 838 ± 277 g) who continued to receive SLE at diagnosis of cholestasis. This study aimed to evaluate the effectiveness of a FOLE in reversing PNAC. Soybean lipid emulsion (SLE) seems to have a role in its pathogenesis, whereas fish oil-based emulsion (FOLE) seems to be able to reverse cholestasis. Parenteral nutrition-associated cholestasis (PNAC) is a serious complication in preterm infants receiving prolonged parenteral nutrition.
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