Parenteral nutrition, sepsis, acute heart failure and hepatotoxic drugs are related to liver test disturbances in critically ill patients

Abstract

Abstract Background and aims: In a clinical intensive care setting, parenteral nutrition (PN) is often associated with liver dysfunction although other contributing factors such as sepsis, acute heart failure (AHF) and hepatotoxic drugs can be present. This retrospective study aimed to identify the impact of these factors on liver test dysfunction with focus on PN. Methods: Adult ICU patients admitted for ≥3 days and treated with PN for ≥ 3days were included. Liver test disturbances were recorded at day 1 of PN based on elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT) or alkalic phosphatase (AP). The presence of AHF, sepsis and 5 previously selected hepatotoxic drugs was recorded. Volume of PN, calorie abundance, amount of proteins, lipids and carbohydrates were monitored. A linear mixed-effect model was used to assess the contribution of PN, sepsis, AHF and drugs to liver test abnormalities. Nutritional adequacy was defined as the caloric, protein, lipid and carbohydrate intake compared to theoretical needs. Results: Liver test abnormalities, presence of sepsis and AHF were the main confounders in predicting liver parameters in 224 ICU patients treated with at least 3 days PN. Presence of sepsis caused an average increase of 43% ± 7% for total bilirubin (TB), 36% ± 14% for gamma-glutamyltransferase (GGT) and 32% ± 8% for AP. Secondly, presence of AHF caused an increase of 29 ± 13% % for ALT and 75% ± 14% for AST. Volume of PN administrated caused an increase of 10% ± 5% for ALT and 14% ± 1% for AST. Carbohydrate intake exceeded nutritional recommendations and protein and lipid intake was not sufficient. Conclusion: Liver test disturbances in critically ill patients on PN for at least 3 days have multifactorial associations with sepsis and AHF being the main confounders. Volume of PN and hepatotoxic drugs had a smaller impact. Feeding adequacy revealed opportunity for improvement by reducing carbohydrate and increasing lipid and protein content.