CHAPTER 4


(PNALD) include those with a primary gastrointestinal disorder, pre- existing liver disease, malnutrition, or sepsis.51 Short-term use of PN is unlikely to result in permanent liver dys-


function. Abnormal liver test results are often seen within 4 weeks of PN initiation but are typically benign and transient.52


The challenge for the


clinician is to determine the etiology of and appropriate treatment for abnormal liver test results, which can be due not only to PN but to lack of enteral stimulation, over-the-counter supplements, prescription medica- tions, small intestinal bacterial overgrowth, infections including sepsis or hepatitis, or other hepatic complications.49


fat globules in hepatocytes without inflammation) is the most common cause of elevated liver function tests in adults receiving PN therapy, whereas cholestasis is more prevalent in pediatric patients.4,51


The eti-


ology of PNALD is not clear but may be a result of overfeeding energy, excess individual macronutrients, or deficiencies of choline, L-carnitine, and glutamine. Appropriate management of PN is important to reduce risk of PNALD


and to prevent further damage that could lead to irreversible liver fail- ure. Refer to Box 4.7 for ways to prevent or minimize the effect of PN on hepatic function.4,5,49,51-53


BOX 4.7 Ways to Minimize the Effect of Parenteral Nutrition on Hepatic Function4,5,49,51-53


Avoid providing excess kilocalories, especially in patients who are critically ill.


Provide a balanced mixture of macronutrients (50%–60% carbohydrate, 10%–20% protein, and 20%–40% lipids).


Avoid excess carbohydrate (greater than 5 mg/ kg/ min). Limit lipids to 1 g/ kg/ d or lower. Use mixed-oil lipids.


Use cyclic parenteral nutrition (PN) infusion (over 10–16 hours). Note that cyclic PN may not be well tolerated in patients who are critically ill because of fluid status, hyperglycemia, and organ dysfunction, nor in other patient populations with significant volume sensitivities or blood glucose abnormalities.


Provide oral or enteral nutrition along with PN if possible.


Therapies still under investigation include choline, L-carnitine, and glutamine supplementation.


68


Steatosis (the accumulation of


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