Cholestasis associated with administration of L-amino acids and dextrose solutions

Infants of very low birth weight who require prolonged assisted ventilation are unable to tolerate oral feedings. To provide and maintain nutrition in these infants, a modified form of parenteral nutrition (dextrose 10% and crystalline L-amino acids, 1.7-3.4 g%) is used in our nursery. Intrahepatic cholestasis was diagnosed at autopsy in four infants who received modified peripheral alimentation and in a fifth infant who received total parenteral alimentation (dextrose 20%, L-amino acids 3.8 g%) via a central venous catheter. These infants weighed less than 1,250 g at birth (range 943-1,247 g) and were appropriate for gestational age. They required assisted ventilation for over 2 weeks. Three infants did not receive any oral feedings. L-Amino acids were given for a mean of 36.8 +/- 10 days (range, 22-76 days). The diagnosis of cholestasis was suspected clinically in only one infant, in whom persistent elevation of direct bilirubin was detected at 4 weeks of age. Pathologic findings in four infants included the presence of bile casts in bile canaliculi and, in one case, in ductules and canaliculi. Liver architecture was well preserved. Inflammatory infiltrate in the portal tract was either absent or minimal, consisting of lymphocytes, and only in one of five cases a few eosinophils. Cholestasis may be regarded as a possible complication of parenteral alimentation even if the fluids are modified and given peripherally. High direct bilirubinemia may be the earliest clinical manifestation.