Parenteral fish oil improves outcomes in patients with parenteral nutrition-associated liver injury

• Published in: Annals of surgery Vol. 250; no. 3; p. 395
• Main Authors: Puder, Mark, Valim, Clarissa, Meisel, Jonathan A, Le, Hau D, de Meijer, Vincent E, Robinson, Elizabeth M, Zhou, Jing, Duggan, Christopher, Gura, Kathleen M
• Format: Journal Article
• Language: English
• Published: United States 01.09.2009
• Subjects: Cholestasis - etiology; Cholestasis - therapy; Data Interpretation, Statistical; Fat Emulsions, Intravenous - adverse effects; Fat Emulsions, Intravenous - therapeutic use; Female; Fish Oils - adverse effects; Fish Oils - therapeutic use; Humans; Infant; Liver Function Tests; Liver Transplantation - statistics & numerical data; Male; Parenteral Nutrition - adverse effects; Parenteral Nutrition - methods; Prospective Studies; Short Bowel Syndrome - complications; Short Bowel Syndrome - therapy; Soybean Oil - adverse effects; Survival Rate; Treatment Outcome
• DOI: 10.1097/SLA.0b013e3181b36657

The objective was to determine the safety and efficacy of a fish oil-based intravenous lipid emulsion (ILE) in the treatment of parenteral nutrition-associated liver disease (PNALD). PNALD can be a lethal complication in children with short bowel syndrome (SBS). ILE based on soybean oil administered with parenteral nutrition (PN) may contribute to its etiology. We performed an open-labeled trial of a fish oil-based ILE in 42 infants with SBS who developed cholestasis (serum direct bilirubin >2 mg/dL) while receiving soybean oil-based ILE. Safety and efficacy outcomes were compared with those from a contemporary cohort of 49 infants with SBS and cholestasis whose PN course included soybean ILE only. The primary efficacy end-point was time to reversal of cholestasis (direct bilirubin <=2 mg/dL). Three deaths and 1 liver transplantation occurred in the fish oil cohort, compared with 12 deaths and 6 transplants in the soybean oil cohort (P = 0.005). Among survivors not transplanted during PN, cholestasis reversed while receiving PN in 19 of 38 patients in the fish oil cohort versus 2 of 36 patients in the soybean oil cohort. Based on Cox models, subjects receiving fish oil-based ILE experienced reversal of cholestasis 6 times faster (95% CI: 2.0-37.3) than those receiving soybean oil-based ILE. The provision of fish oil-based ILE was not associated with hypertriglyceridemia, coagulopathy, or essential fatty acid deficiency. Moreover, hypertriglyceridemic events and abnormal international normalized ratio levels were more common among controls. Fish oil-based ILE is safe, may be effective in treating PNALD, and may reduce mortality and organ transplantation rates in children with SBS.