Prevalence of Liver Disease and Contributing Factors in Patients Receiving Home Parenteral Nutrition for Permanent Intestinal Failure

  1. Maryan Cavicchi, MD;
  2. Philippe Beau, MD;
  3. Pascal Crenn, MD;
  4. Claude Degott, MD; and
  5. Bernard Messing, MD
  1. From Hôpital Lariboisière-St. Lazare, Paris; Centre Hospitalier Universitaire La Milétrie, Poitiers; and Hôpital Beaujon, Clichy, France.

    Abstract

    Background: Liver cholestasis can be a life-threatening complication during home parenteral nutrition and may lead to combined liver-intestinal transplantation.

    Objective: To assess the prevalence of home parenteral nutrition-related liver disease and its contributing factors in patients with permanent intestinal failure.

    Design: Prospective cohort study.

    Setting: Two approved home parenteral nutrition centers.

    Patients: 90 patients with permanent intestinal failure who were receiving home parenteral nutrition were enrolled from 1985 to 1996.

    Intervention: Clinical, biological, endoscopic, and ultrasonographic follow-up. Histologic examination of the liver was done in 57 patients (112 liver biopsies).

    Measurements: The Kaplan-Meier method was used to determine the actuarial occurrence of chronic cholestasis and complicated home parenteral nutrition-related liver disease (bilirubin level ≥ 60 µmol/L [3.5 mg/dL], factor V level ≤ 50%, portal hypertension, encephalopathy, ascites, gastrointestinal bleeding, or histologically proven extensive fibrosis or cirrhosis). Contributing factors were assessed by using univariate and multivariate (Cox model) analysis.

    Results: 58 patients (65%) developed chronic cholestasis after a median of 6 months (range, 3 to 132 months), and 37 (41.5%) developed complicated home parenteral nutrition-related liver disease after a median of 17 months (range, 2 to 155 months). Of these patients, 17 showed extensive fibrosis after 26 months (range, 2 to 148 months) and 5 had cirrhosis after 37 months (range, 26 to 77 months). The prevalence of complicated home parenteral nutrition-related liver disease was 26% ± 9% at 2 years and 50% ± 13% at 6 years. Six patients died of liver disease (22% of all deaths). In multivariate analysis, chronic cholestasis was significantly associated with a parenteral nutrition-independent risk for liver disease, a bowel remnant shorter than 50 cm in length, and a parenteral lipid intake of 1 g/kg of body weight per day or more (ω-6-rich long-chain triglycerides), whereas complicated home parenteral nutrition-related liver disease was significantly associated with chronic cholestasis and lipid parenteral intake of 1 g/kg per day or more.

    Conclusion: The prevalence of complicated home parenteral nutrition-related liver disease increased with longer duration of parenteral nutrition. This condition was one of the main causes of death in patients with permanent intestinal failure. Parenteral intake of ω-6-rich long-chain triglycerides lipid emulsion consisting of less than 1 g/kg per day is recommended in these patients.

    Article and Author Information

    • Acknowledgments: The authors thank Ms. M. Beliah for her helpful assistance and Mr. Jeffrey Arsham for critical reading of the manuscript.

    • Requests for Single Reprints: Bernard Messing, MD, Service de Gastroentérologie et d'Assistance Nutritive, Hôpital Lariboisière-St. Lazare, 2 rue Ambroise Paré, 75475 Paris Cedex 10, France; e-mail, bernard.messing{at}lrb.ap-hop-paris.fr.

    • Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.

    • Current Author Addresses: Dr. Cavicchi: Service d'Hépato-Gastroentérologie, Hôpital Henri Mondor, 51 avenue du Mal de Lattre de Tassigny, 94010 Créteil, France.

    • Dr. Beau: Service d'Hépato-Gastroentérologie et de Nutrition, Centre Hospitalier Universitaire La Milétrie, 89000 Poitiers, France.

    • Dr. Crenn: Service d'Hépato-Gastroentérologie et de Nutrition, Hôpital Bichat-C. Bernard, 46 rue Henri Huchard, 75877 Paris Cedex 18, France.

    • Dr. Degott: Service d'Anatomo-Pathologie, Hôpital Beaujon, 100 boulevard du Général Leclerc, 92110 Clichy, France.

    • Dr. Messing: Service de Gastroentérologie et d'Assistance Nutritive, Hôpital Lariboisière-St. Lazare, 2 rue Ambroise Paré, 75475 Paris Cedex 10, France.

    • Author Contributions: Conception and design: M. Cavicchi, P. Beau, B. Messing.

    • Analysis and interpretation of the data: M. Cavicchi, P. Crenn, C. Degott, B. Messing.

    • Drafting of the article: M. Cavicchi, B. Messing.

    • Critical revision of the article for important intellectual content: M. Cavicchi, P. Beau, C. Degott, B. Messing.

    • Final approval of the article: M. Cavicchi, P. Beau, P. Crenn, C. Degott, B. Messing.

    • Provision of study materials or patients: P. Beau, B. Messing.

    • Statistical expertise: M. Cavicchi, P. Crenn, B. Messing.

    • Administrative, technical, or logistic support: M. Cavicchi, B. Messing.

    • Collection and assembly of data: M. Cavicchi, P. Beau.

    Summary for Patients

    • Summaries for Patients:Liver Disease in Patients Receiving Home Intravenous Feeding Ann Intern Med April 4, 2000 132:525
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    1. Ann Intern Med April 4, 2000 vol. 132 no. 7 525-532
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