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Liver dysfunction associated with artificial nutrition in critically ill patients.

Grau T, Bonet A, Rubio M, Mateo D, Farré M, Acosta JA, Blesa A, Montejo JC, de Lorenzo AG, Mesejo A, Working Group on Nutrition and Metabolism of the Spanish Society of Critical Ca - Crit Care (2007)

Bottom Line: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN).In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

View Article: PubMed Central - HTML - PubMed

Affiliation: Intensive Care Unit, Hospital Severo Ochoa, Madrid, Spain. tgrau.hdoc@salud.madrid.org

ABSTRACT

Introduction: Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients.

Methods: We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l.

Results: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).

Conclusion: TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

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Time free of liver dysfunction in surgical patients treated with Enteral Nutrition or Total Parenteral Nutrition. EN, enteral nutrition; TPN, total parenteral nutrition; AN days, days on artifical nutrition
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Figure 1: Time free of liver dysfunction in surgical patients treated with Enteral Nutrition or Total Parenteral Nutrition. EN, enteral nutrition; TPN, total parenteral nutrition; AN days, days on artifical nutrition

Mentions: In the univariate analysis, 91 patients treated with TPN developed some form of LD but only 75 in the EN group did (odds ratio [OR] 1.7, 95% CI 1.3 to 2.2) (Table 6). Surgical patients (31% versus 16%; OR 1.8, 95% CI 1.02 to 3.1) and trauma patients (52% versus 23%; OR 2.1, 95% CI 1.1 to 4) treated with TPN had more LD. This association was maintained for all types of LD: cholestasis (OR 1.7, 95% CI 1.04 to 2.9), liver necrosis (OR 1.95, 95% CI 1.1 to 3.42), and mixed pattern (OR 1.8, 95% CI 1.3 to 2.6). The patients with sepsis and TPN showed a higher incidence of LD than the group treated with EN (39% versus 24%; OR 1.6, 95% CI 1.02 to 2.4), although no type of LD was greater in either group. When looking at the time free of LD, EN increased the time free of disease in surgical patients only in the Kaplan-Meyer survival test (Figure 1). Only three patients were diagnosed with acalculous cholecystitis.


Liver dysfunction associated with artificial nutrition in critically ill patients.

Grau T, Bonet A, Rubio M, Mateo D, Farré M, Acosta JA, Blesa A, Montejo JC, de Lorenzo AG, Mesejo A, Working Group on Nutrition and Metabolism of the Spanish Society of Critical Ca - Crit Care (2007)

Time free of liver dysfunction in surgical patients treated with Enteral Nutrition or Total Parenteral Nutrition. EN, enteral nutrition; TPN, total parenteral nutrition; AN days, days on artifical nutrition
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2147066&req=5

Figure 1: Time free of liver dysfunction in surgical patients treated with Enteral Nutrition or Total Parenteral Nutrition. EN, enteral nutrition; TPN, total parenteral nutrition; AN days, days on artifical nutrition
Mentions: In the univariate analysis, 91 patients treated with TPN developed some form of LD but only 75 in the EN group did (odds ratio [OR] 1.7, 95% CI 1.3 to 2.2) (Table 6). Surgical patients (31% versus 16%; OR 1.8, 95% CI 1.02 to 3.1) and trauma patients (52% versus 23%; OR 2.1, 95% CI 1.1 to 4) treated with TPN had more LD. This association was maintained for all types of LD: cholestasis (OR 1.7, 95% CI 1.04 to 2.9), liver necrosis (OR 1.95, 95% CI 1.1 to 3.42), and mixed pattern (OR 1.8, 95% CI 1.3 to 2.6). The patients with sepsis and TPN showed a higher incidence of LD than the group treated with EN (39% versus 24%; OR 1.6, 95% CI 1.02 to 2.4), although no type of LD was greater in either group. When looking at the time free of LD, EN increased the time free of disease in surgical patients only in the Kaplan-Meyer survival test (Figure 1). Only three patients were diagnosed with acalculous cholecystitis.

Bottom Line: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN).In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

View Article: PubMed Central - HTML - PubMed

Affiliation: Intensive Care Unit, Hospital Severo Ochoa, Madrid, Spain. tgrau.hdoc@salud.madrid.org

ABSTRACT

Introduction: Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients.

Methods: We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l.

Results: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).

Conclusion: TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Show MeSH
Related in: MedlinePlus