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Parenteral nutrition: fish oil reverses liver damage


Damage could be reversed by 6 months of fish oil in 75% of patients

Children needing artificial intravenous feeding (parenteral feeding) who have developed liver damage may be treated by switching to a fish oil based formula. This week a small study from UCLA estimated that in 7 out of 10 patients, 24 weeks of feeding a fish oil formula reversed the liver damage reducing need for expensive liver transplants. The study is reported in <em abp="5522">Journal of Parenteral and Enteral Nutrition.

For forty years or so the standard oil used in parenteral nutrition has been soyabean oil. Long term parenteral feeding using the standard formulation however results in 40-60% of patients developing life threatening liver disease that can progress to liver failure requiring transplants of liver and intestines. The liver damage begins as cholestasis, and can progress to fatty liver, fibrosis and cirrhosis (1). Evidence has accumulated that soyabean oil may be to blame and a few years ago researchers began trying alternatives.

In 2010 researchers began reporting that fish oil was safe to use in infants with liver damage from parenteral feeding and by 2012 researchers were finding that fish oil alone and several combinations of fish oil with other oils such as olive, coconut, and soyabean could help dramatically reverse it (2-5). &nbsp;Doing these studies in critically ill children is difficult so as yet all the studies have been quite small.

The UCLA team&rsquo;s study sought to examine if replacing soyabean oil with fish oil (1g/kg/day) worked and what duration of treatment was needed. The patients were aged 2 weeks to 18 years, 10 in the fish oil group and 20 controls. The team observed decreases in the fish oil group&rsquo;s serum direct bilirubin at 8 weeks of treatment onwards, indicating that the liver damage was reversing. They estimated that 75% of patients would experience reversal by 24 weeks compared to just 6% of controls continuing with soyabean oil. &nbsp;There were no signs of essential fatty acid deficiencies or increased bleeding risk with this treatment.

Adults could also benefit from these new formulations of parenteral feeding solutions. This year two cases have been reported where the formulation of fish oil alone was used successfully in adults with the same liver disease. (6,7)

The UCLA team is now concentrating on finding out the mechanisms behind the healing of the liver. They plan to look at the effect of the treatment on proteins and gene expression in the liver and blood according to Dr Kara Calkins, the lead author.

The problem with soyabean oil in parenteral feeds may be that it supplies too much linoleic acid which promotes inflammation. Fish oil is known to have anti-inflammatory properties. A &nbsp;recent study in mouse neutrophils &nbsp;appears to back this hypothesis as it suggests that a formula &nbsp;of 10% fish oil&nbsp; with 10% soyabean oil &nbsp;delays apoptosis and prevents synthesis of pro-inflammatory eicosanoids (8) compared to 20% soybean oil formulas. &nbsp;A recent review however, suggests the effect of the switch in formulations on the damaged livers is more to do with the reduction in plant derived phytosterols in the blood from not using soyabean oil rather than a beneficial effect of fish oils themselves (9).

Fish oil based parenteral nutrition is not yet approved in the USA&nbsp; and it is not covered by insurance there because its more costly according to Dr Calkins.&nbsp; More research evidence is needed. The UCLA group plan to do a five year follow up so see if transplant rates are reduced long term by the 6 month treatment. If so, many expensive transplants with low chances of success may be avoided.


Kara L. Calkins, James C. Y. Dunn, Stephen B. Shew, Laurie Reyen, Douglas G. Farmer, Sherin U. Devaskar, and Robert S. Venick Pediatric Intestinal Failure&ndash;Associated Liver Disease Is Reversed With 6 Months of Intravenous Fish Oil <cite abp="5533">JPEN J Parenter Enteral Nutr</cite><em abp="5534"> July 26, 2013

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