Introduction Parenteral nutrition associated liver disease (PNALD) is a life-threatening complication of long-term 1. PNALD can manifest as steatosis, cholestasis (each of which can lead to fibrosis and cirrhosis) and biliary complications. PN patients who develop cirrhosis have a very poor prognosis nutrition parenteral1, yet there are few studies and no guidelines on how to monitor or risk stratify in order to intervene before advanced fibrosis has developed.
Method We describe the burden of PNALD in our cohort of home PN patients and identify risk factors for developing PNALD. We present preliminary data using non-invasive markers (Fib-4 score2 and Fibroscan3) to estimate stage of fibrosis, comparing them to histological staging in patients who went on to have liver biopsies, in order to evaluate their potential for monitoring progression of PNALD in clinical practice.
Results 73 HPN patients were included (excluding palliative patients with metastatic malignancy and those on PN <12 months); mean age 51.2+/-16 years, median duration of PN 34 months. 69 patients had Fib-4 score calculated, 19 had Fibroscans and 7 had liver biopsies. 16.4% had cholestasis (2 of ALP/GGT/bil>1.5x ULN for 6 months), 43.8% had a Fib-4 score indicating intermediate to high risk of fibrosis (>1.3 in under 65 or >2 in over 65 year olds2). At liver biopsy, the majority (6) had advanced fibrotic liver disease, including (2) with cirrhosis. Raised Fib-4 score was associated with ESPEN classification of intestinal failure (IF)1 and short bowel (<50 cm) (see table). There was a significant correlation between fib-4 score and liver stiffness on Fibroscan (R=0.88). Patients with advanced fibrosis on histology had a liver stiffness >13 kPa and Fib-4 score >1.3/2. Fibroscan tended to overestimate fibrosis compared to histology, particularly in the presence of cholestasis.
Conclusion PNALD is a significant problem in patients on HPN, and is related to classification of IF and length of small bowel. Non-invasive scores may be useful to identify and monitor those at highest risk of advanced liver disease. However, further study is required to validate non-invasive scores against histology in this cohort if they are to be incorporated into clinical practice.
. ESPEN guidelines on chronic intestinal failure in adults. Pironi, et al. Clin Nutr. (2016)
. Age as a Confounding Factor for the Accurate Non-Invasive Diagnosis of Advanced NAFLD Fibrosis. McPherson, et al. Am J of Gastro. Oct 2016
. Non-invasive evaluation of liver fibrosis using transient elastography. Castera, et al. J Hepatol2008
Disclosure of Interest None Declared
- Liver Fibrosis
- non-invasive marker
- Parenteral Nutrition