Dejavniki zamaščenosti jeter pri bolnikih s kronično odpovedjo prebavil ; Factors associated with liver steatosis in patients with chronic intestinal failure

Uvod Pri odraslih bolnikih s kronično odpovedjo prebavil (tip 3) je praviloma potrebna trajna terapija z parenteralnim vnosom tekočin in/ali hranil. Zamaščenost jeter je opisana kot pogost in resen zaplet parenteralne prehrane (PP). Zamaščenost jeter, ki se razvije ob odpovedi prebavil (IFALD - intestinal failure associated liver disease) se razlikuje od nealkoholne jetrne bolezni (NAFLD – non-alcoholic fatty liver disease) glede na etiopatogenezo in dejavnike tveganja. Glede na starejše podatke iz literature se IFALD pojavlja pri 15-40% odraslih bolnikov s kronično odpovedjo prebavil. Novejši podatki o pogostosti IFALD in zamaščenosti jeter pa opisujejo nižjo prevalenco jetrne okvare pri bolnikih s kronično odpovedjo prebavil, na kar kaže tudi klinična praksa. Velika razlika v opredelitvi IFALD in prisotnosti zamaščenosti jeter ne nakazuje le morebitne neenotnosti pri uporabi diagnostičnih kriterijev, v veliki meri je tudi odraz kompleksnosti in slabega prepoznavanja etioloških dejavnikov, ki prispevajo k razvoju jetrne okvare. Med radiološkimi slikovno preiskovalnimi metodami je najbolj uveljavljena magnetno resonančna (MR) preiskava, s katero natančno prikažemo kvalitativno in kvantitativno oceno maščobne infiltracije jeter. Cilji Namen raziskave je bil oceniti pogostost zamaščenosti jeter pri bolnikih s kronično odpovedjo prebavil ter poiskati možne nove dejavnike, ki bi jih lahko povezali z zamaščenostjo jeter pri bolnikih s kronično odpovedjo prebavil na terapiji s PP na domu. Z raziskovalnim delom smo zˇeleli dokazati povezanost uravnotežene parenteralne prehrane, vitamina D in kroničnega vnetnega stanja z zamaščenostjo jeter pri bolnikih s kronično odpovedjo prebavil. Namen raziskovalnega dela je bil tudi opredelitev povezanosti med stanjem prehranjenosti in oceno presnovnega stanja z razvojem zamaščenosti jeter. Metode V prospektivno prečno raziskavo smo vključili 63 bolnikov z diagnozo kronične odpovedi prebavil, na terapiji s PP na domu, ki so se vodili na Enoti za klinično prehrano, Onkološki inštitut Ljubljana v obdobju med januarjem 2017 in decembrom 2018. Klinične in laboratorijske podatke ter podatke o telesni sestavi smo zbirali v namensko ustvarjeno bazo podatkov. Vsi zbrani podatki spadajo med rutinske preiskave, ki so priporočene za spremljanje bolnikov s parenteralno prehrano na domu. Kvalitativno in kvantitativno zamaščenost jeter smo ugotavljali z uporabo 3 Tesla MR aparata. Povezave med različnimi dejavniki tveganja in zamaščenostjo jeter smo izračunali z uni- in multivariatno logistično regresijo. Rezultati Srednje trajanje terapije s PP na domu je bilo 70 tednov (interkvartilni razpon, 22 – 203 tednov). Zamaščenost jeter je bila ugotovljena pri 28,6% bolnikov, od tega je bila le pri 1 bolniku izrazita zamaščenost jeter, pri 3 bolnikih zmerna zamaščenost jeter ter pri 14 bolnikih blaga zamaščenost jeter. Nivo holesterola v serumu in indeks puste telesne mase (FFMI) sta bila statistično značilno povezana s povišanim deležem maščobe v jetrih (p = 0,01, p = 0,046). Trajanje terapije s PP na domu ni bilo statistično značilno povezano z zamaščenostjo jeter (p = 0,219). Med ostalimi proučevanimi dejavniki in zamaščenostjo jeter prav tako ni bilo statistično značilne povezanosti. Zaključek Bolniki s kronično odpovedjo prebavil na terapiji s PP na domu, ki se držijo dobro nadzorovanega režima zdravljenja, imajo razmeroma majhno tveganje za zamaščenost jeter. Trajanje terapije s PP na domu pri bolnikih s kronično odpovedjo prebavil ni povezano z zamaščenostjo jeter. Poleg že znanih dejavnikov tveganja za zamaščenost jeter smo ugotovili na novo opisano povezavo med FFMI in zamaščenostjo jeter. ; Background In adult patients with chronic intestinal failure (CIF) a long-term therapy with parenteral fluids and/or nutrients is required. Liver steatosis has been described as a common and serious complication of parenteral nutrition (PN). Liver steatosis associated with intestinal failure-associated liver disease (IFALD) differs from nonalcoholic fatty liver disease (NAFLD) in terms of etiopathogenesis and risk factors. According to earlier literature, IFALD occurs in 15-40% of adult CIF patients. However, more recent data on the incidence of IFALD and liver steatosis describe a lower prevalence of liver steatosis in patients with CIF, which is also indicated by clinical practice. The large differences in the definition of IFALD and the presence of liver steatosis not only indicates a possible discrepancy in the diagnostic criteria but it also largely reflects the complexity and poor recognition of the etiological factors that contribute to the development of the liver disease. Magnetic resonance imaging (MRI) is the most reliable noninvasive method for qualitative and quantitative assessment of liver fat infiltration. Objectives Our study aimed to assess the prevalence of liver steatosis among CIF patients treated in our center and find possible new factors that could be connected to liver steatosis in CIF patients on home parenteral nutrition (HPN) therapy. We looked for a correlation between balanced parenteral nutrition, vitamin D status and chronic inflammatory state and liver steatosis in patients with CIF. The purpose of our research was also to determine the association between nutritional and metabolic status and liver steatosis. Methods We enrolled 63 patients diagnosed with CIF and undergoing long-term HPN therapy in Department for clinical nutrition, Oncologic institute Ljubljana between January 2017 and December 2018 in a prospective cross-sectional study. Clinical, laboratory and body composition data were collected from their medical records. All of the data collected were part of the routine examination recommended for monitoring patients on HPN therapy. Liver steatosis was diagnosed using a 3 Tesla MRI scanner. The associations between various risk factors and liver steatosis were calculated using uni- and multivariate logistic regression. Results The median HPN therapy duration was 70 weeks (IQR 22 – 203 weeks). The prevalence of liver steatosis was 28,6%, only 1 patient had severe steatosis, 3 patients moderate and 14 patients mild liver steatosis. Serum cholesterol level and FFMI were statistically significantly associated with liver steatosis (p = 0,01, p = 0,046). The duration of HPN therapy was not statistically significantly associated with liver steatosis (p = 0,219). There were also no statistically significant associations between the other factors studied and the liver steatosis. Conclusion The results of our study indicate that CIF patients on HPN therapy experience a relatively low risk of liver disease if they adhere to a well-controlled treatment regime. Our results showed that parenteral nutrition is not associated with liver steatosis in CIF patients on long-term HPN therapy. With respect to already known risk factors for liver steatosis, we did find a newly described association between FFMI and liver steatosis.