Parenteral Fish Oil Improves Outcomes in Patients with Parenteral Nutrition Associated Liver Injury
*Mark Puder, *Meisel A Meisel, *Valim Clarissa, *Hau D Le, *Elizabeth M Robinson, *Katherine B Novak, *Christopher Duggan, *Kathleen M Gura
Children's Hospital Boston, Boston, MA
Parenteral nutrition-associated liver disease (PNALD) can be a lethal complication in children with short bowel syndrome (SBS). Intravenous fat emulsions (IFE) based on soybean oil administered with parenteral nutrition (PN) may contribute to its etiology. The objective was to determine the safety and efficacy of a fish oil-based IFE in the treatment of PNALD.
We performed an open-labeled trial of a fish-oil IFE in 42 infants with SBS who developed cholestasis (serum direct bilirubin > 2 mg/dL) while receiving soybean IFE. Safety and efficacy outcomes were compared with those from a contemporary cohort of 49 infants with SBS and cholestasis whose PN course included soybean IFE only. The primary 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 to 12 deaths and 6 transplants in the controls (P=0.006). Among survivors not transplanted, cholestasis reversed while receiving PN in 19/38 patients in the fish oil cohort vs. 2/32 patients in the controls. Based on Cox models, subjects receiving fish oil-IFE experienced reversal of cholestasis 8.1 times faster (95% CI=1.9,35.5) than those receiving soybean IFE. The provision of fish oil IFE was not associated with hypertriglyceridemia, coagulopathy, essential fatty acid deficiency or growth delay. Moreover, hypertriglyceridemic events and abnormal INR levels were more common among controls.
Fish oil IFE is safe, may be effective in treating PNALD, and may reduce mortality and organ transplantation rates in children with SBS.