omega 3 in Total Parenteral Nutrtion

[bizzarro]

I'd like to know if anyone use omega3 (fish oil OMEGAVEN) in total parenteral nutrition in case of very immature newborns at risk of Parenteral nutrition-Associated Cholestasis.
Thanks

[Omer]

The lipid source of the standard Parenteral Nutrition is Soybean fat emulsions or the Safflower oil emulsion. The intralipids content of these plant origin fat is rich in Omega-6 Poly Unsaturated Fatty Acids (Omega -6 PUFAS) which is believed to have a role in TPN mediated hepatic injury.On the other hand, fish -oil derived Lipids(Omegaven) contain Omega 3 polyunsaturated fatty acids(Omega -3 PUFAS) which Had a hepatoprotective action in situation where there is parenteral nutrition associated hepatic injury .
We use Omegaven in chronic cholestasis resulting from chronic TPN use in intestinal failure resulting from short bowel syndrome with the hope of halting the ongoing hepatic injury when patient are listed for transplantation. Iam not aware of any published randomized control trials on its use in TPN cholestais in preterm babies and we only use Intralipids 20% or 30%.
Omer Hamud
Toronto.

[bizzarro]

Thank you for your replay,
This is my next question: I'd like to know how do you treat severe cholestasis complicated by ascites in very immature preterm, resistent to ursodessossicolic acid and affected by persistent feeding difficulties?

[Omer]

Dear bizzarro;
I think you need to elaborate more on the history and course of the disease in this baby(??candidate for Virtual NICU). People will need to know the patient gestational age, Bwt , duration of TPN, feeding issues, NEC , liver enzymes and NICU course etc. You need to have a complete work up for this degree of hepatic injury. If the ascites is related to cholestasis in this baby; then the injury is severe and you may be dealing with possible hepatic fibrosis and portal hypertension. I don't remember seeing ascitis due to TPN cholestasis. The most common reason for ascitis in a preterm baby is NEC.
Rule other causes e.g. Biliary Atresia, viral hepatitis (specially CMV), alpha 1 anti-trypsin, metabolic etc. You will need ultrasound of the liver to rule out structural liver disease and delineate the portal , and biliary systems.You might even think of HIDA scan. A consult with gastro-enterology would be helpful.
Let us hear other ideas from the forum.
Omer Hamud
Toronto.

[fcardona]

Regarding your first question on omega3: I guess the scientific basis for use is amongst others this article by Gupa et al. http://www.ncbi.nlm.nih.gov/pubmed/18310188
There are a couple of ongoing trials in neonatal and pediatric patients and preliminary data look very promising http://www.clinicaltrials.gov/ct2/results?term=omegaven
Another option being contemplated is clinoleic based on olive emulsion which seems to be beneficial as well. If I may make a bold prediction I believe soy-based emulsions will be almost gone within the next 10-15 years. I would say the way to go is to join big randomized trials and see if the short term promises can be upheld in good large trials.

[fcardona]

I agree with Omer. Before blaming long-time parenteral nutrition I would try to find out if there is any underlying disease responsible for liver failure.
Are there any anatomical intestinal or hepatic problems? - Do ultrasound of the liver (-> you definitely want to exclude biliary atresia), try barium enemas and contrast studies to see if intestines are patent
Is there an underlying metabolic disease? - Do workup for aminoacidopathies, organic acidopathies, metabolic screen, carnitine pathway
Infectious screen? - bacterial, fungal or viral
Any medications you are giving that may cause liver failure?
if all is negative look for more severe diseases (admittingly the list is endless..)
Ascites would make me worried in any case..

Gastroenterology consult is definitely indicated
If you still cant figure it out - I would suggest explorative laparotomy

[fcardona]

Might be an interesting poll to see who uses alternatives to soy based lipid emulsions: omegaven, clinoleic etc.