Hepatic Cytolytic and Cholestatic Changes Related to a Change of Lipid Emulsions in Four Long‐Term Parenteral Nutrition Patients With Short Bowel

Abstract

Long-term parenteral nutrition hepatic-related impairment is commonly reported and diversely explained. However, with a low cyclic caloric intake (100% to 130% of basal metabolism calculated with the Harris-Benedict formula) consisting of two-thirds glucose, one-third lipid, and 0.20 to 0.25 g of nitrogen per kilogram per day, these complications were infrequent in a clinical practice of home long-term parenteral nutrition. Retrospectively, it was noticed that the switch from Intralipid 20% to Ivelip 20% at the same amount was followed within 2 months by four cases of jaundice in a population of four home long-term parenteral nutrition patients with short bowel disease. Hepatic disturbances were characterized by cytolysis and cholestasis and were reversible after switching from Ivelip 20% back to Intralipid 20%. Neither viral, nor biliary, nor septic etiologies were detected. The exact pathological mechanism remains unknown. The basal composition of both lipid emulsions seems to be identical: soy oil emulsion emulsified by egg phospholipids. However, some differences exist such as the size of particles, the presence of sodium oleate in Ivelip 20%, and the purification process of lecithin. These may explain the difference in hepatic tolerance during long-term parenteral nutrition.

Lipid globule size in total nutrient admixtures prepared in three-chamber plastic bags

“…15,16 In humans, there is evidence of hepatic injury from lipid emulsions laden with large-diameter fat globules in adults receiving home parenteral nutrition. 17 In critically ill neonates, hypertriglyceridemia from lipid infusions has been associated with hepatic dysfunction and growth retardation. 18 Most recently, the infusion of coarse lipid emulsions failing USP chapter 729 limits in critically ill premature infants produced hypertriglyceridemia compared with those receiving the same emulsion that formerly met these globule-size standards.…”

Liver function and plasma antioxidant status in intensive care unit patients requiring total parenteral nutrition: comparison of 2 fat emulsions

“…Because TPN-induced liver alterations have been partly attributed to phytosterol hepatotoxicity the above interpretation may be explained by the lower phytosterol content of SMOF. 13,[43][44][45][46] The antioxidant content of emulsions is also to be taken into account because various studies have addressed ␣-tocopherol protective effects against adverse consequences of the excess of lipids and oxidation by-products. [47][48][49] Indeed, TPN using fat emulsion containing high levels of non-␣tocopherol isomers, even ␣-tocopherol supplemented, does not improve ␣-tocopherol status.…”

Parenteral Nutrition‐Associated Liver Complications in Children

“…A report of patients who developed cholestasis and hepatic cytolysis after a change in lipid emulsion formula raised the hypothetical question whether liver dysfunction could be related to the size of lipid particles in that emulsion, lecithin purification process, or sodium oleate content. 161 Based on an in vitro study, lipid emulsions induce dose-dependent inhibition of cholesterol uptake by cultured hepatic cells. It thus is proposed that reduced cholesterol availability for bile formation by hepatocytes would result in decreased bile volume and reduced bile secretion and flow that lead to cholestasis.…”