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Total parenteral nutrition-associated intrahepatic cholestasis in infants: 25 years' experience
1Department of Surgery II, Kinki University School of Medicine, Osaka, Japan.
Insights
Incidence of total parenteral nutrition-associated intrahepatic cholestasis (TPNAC) in infants has decreased significantly over 25 years. However, TPN still presents challenges for neonates requiring long-term nutritional support.
Area of Science:
- Neonatal Medicine
- Pediatric Surgery
- Gastroenterology
Background:
- Total parenteral nutrition (TPN) is crucial for neonates unable to receive enteral feeding.
- TPN-associated intrahepatic cholestasis (TPNAC) is a significant complication in infants.
- Long-term chronological reviews on TPNAC incidence are scarce.
Purpose of the Study:
- To review the incidence of TPN-associated intrahepatic cholestasis (TPNAC) in surgical neonates over a 25-year period.
- To evaluate current challenges and outcomes associated with TPN in infants.
- To identify trends in TPNAC and associated mortality.
Main Methods:
- A retrospective review of 273 surgical neonates receiving TPN for over 2 weeks.
- Patients were divided into three chronological groups: 1971-1982 (n=77), 1983-1987 (n=72), and 1992-1996 (n=124).
- TPNAC was defined as a direct bilirubin level > 2.0 mg/dL during the neonatal period.
Main Results:
- TPNAC incidence decreased significantly from 57% (Group A) to 31% (Group B) and 25% (Group C) (P < .01).
- TPN-associated mortality rates also decreased from 13% (Group A) to 3% (Groups B and C) (P < .05).
- In the last 5 years, 16% of patients developed severe TPNAC, with mortality linked to sepsis, hepatic failure, or underlying conditions like hypoganglionosis.
Conclusions:
- TPNAC incidence and TPN-associated mortality in surgical neonates have shown significant reductions.
- Despite improvements, a 3% mortality rate persists, highlighting ongoing challenges with long-term TPN.
- Conditions like hypoganglionosis, requiring TPN dependence, underscore the need for further research and potential interventions such as small bowel transplantation.
Background/Purpose:
There are few long-term chronological reviews examining the incidence of total parenteral nutrition (TPN)-associated intrahepatic cholestasis (TPNAC) in infants. The authors therefore reviewed TPNAC in their 25-year series, and also looked at the current problems associated with TPN in infants.
Methods:
Two hundred seventy-three surgical neonates who received TPN for more than 2 weeks were divided into 3 groups chronologically: group A (1971 through 1982, n = 77), group B (1983 through 1987, n = 72), and group C (1992 through 1996, n = 124). TPNAC was defined as serum direct bilirubin (DB) level greater than 2.0 mg/dL during the neonatal period.
Results:
The incidence of TPNAC in groups A, B and C was 57%, 31%, and 25% (P< .01), respectively, and the mortality rate from TPN-associated complications was 13%, 3%, and 3% (P< .05), respectively. Over the last 5 years, severe TPNAC developed in 20 patients (16%). Four of 20 died of TPN-associated sepsis with hepatic failure; 2 had hypoganglionosis with intractable stagnant enteritis and subsequent sepsis, and 2 had fatal respiratory or cardiac disease.
Conclusions:
The incidence of TPNAC in surgical neonates and TPN-associated mortality rates have decreased significantly. The mortality rate, however, still remains at 3%. Two of 4 fatal cases had hypoganglionosis, which were totally dependent on TPN. In patients who require long-term TPN, TPN still has unsolved problems, and small bowel transplantation may be indicated.