Research On Influence Factors For Parenteral Nutrition Associated Liver Disease In Elderly Patients

BackgroundOur country has entered an aging society,and gradually to speed up the aging process.Sixth census of China shows that the population of 65 years and older in China is about 120 million,accounting for 8.87%of the totol population.Compared with the results in 2000,the proportion of population increased 1.91%.With the increasing number of elderly population,elderly inpatients get more and more attention,and the complexity and the particularity of senile diseases makes its related research has special significance.The study found that elderly hospitalized patients are more likely to be malnutrition,and nutritional support is an important means of solving this problem.Parenteral nutrition-associated liver disease(PNALD)is the most devastating complication of long-term parenteral nutrition therapy.The etiology is varied,including gastrointestinal basic diseases,enterohepatic circulation dysfunction of bile acid,sepsis,dysbacteriosis and so on,but its pathogenesis is not very clear,at the point of concentration is where the lipid effects,intestinal injury and nutritional imbalance.The preventive treatment of PNALD,in view of its possible pathogenesis and etiology,is concentrated on reducing lipid effect,regulating intestinal flora,protecting intestinal barrier,reducing sepsis,dredging bile circulation,etc.Bifidobacterium is one of the dominent bacteria of human intestinal normal flora species,which has positive significance to protect the intestinal barrier,such as reducing bacteria ectopic and sepsis.Its effect about the protection of liver function has been paid more and more attention.Studies have found that bifidobacterium played a useful role in the prevention and treatment of PNALD,but its effect on PNALD in adults and the elderly is lack of related research.Ursodesoxycholic acid(UDCA)can increase the secretion of bile acid,promote bile discharge and reduce bilirubin.UDCA have evident clinic efficacy on cholestasis in infants who had received long-term PN,but its research is still rare in PNALD of adults and the elderly.Objective1.To investigate the situation of parenteral nutrition support in patients with senile hospitalized,to compare the change of the evaluation index of liver function before and after nutritional support,and to analyse the situation of parenteral nutrition support of elderly hospitalized patients and the incidence of PNALD.2.To analyze the effect of the related influence factors(age,gender,primary disease,nutritional support,time,total heat energy,the heat energy of non-protein)to PNALD,and to explore more reasonable nutrition support scheme.3.To discuss the effects of nutritional support with bifidobacterium and the incidence of PNALD,and to provide reference for clinical medication.4.To discuss the effects of nutritional support with UDCA and the incidence of’ PNALD,and to provide reference for clinical medication.MethodsRetrospectively analyzed to171 patients with parenteral nutrition support file records in Geriatrics department of Qilu Hospital of Shandong University from May 2012 to October 2016.1.The object of study:Age 65 or higher,parenteral nutrition support 7 d or more,at least two times of the liver function index including the results before and after nutritional support,and no obvious abnormal liver function index before nutrition support,a total of 171 cases.2.Data collection:Collecting and statistics of the research object of general situation,nutritional support,the liver function before and after nutritional support(the recently results before and after nutritional support),UDCA or bifidobacterium application situation.3.Study design:(1).Analysis of general situation and nutritional support of research object,comparing the different incidence of PNALD with two ways of nutritional support;(2).The research object is divided into PNALD group and control group whose liver function is normal.comparing and analyzing the difference of the related factors between different groups including age.gender,the way of nutrition support,the time of nutrition support,to explore the effect of related factors to PNALD;(3).The research object is divided into bifidobacterium group,UDCA group and control group without bifidobacterium or UDCA,comparing and 8nalyzing the changes of liver function index between different groups before and after nutritional support,comparing the incidence of PNALD,discussing the effectiveness of the drug for the prevention of PNALD.4.Statistical methods:Use Excel 2007,SPSS 21.0 and GraphPad Prism 5 to do statistical analysis and graphing.Measurement data with mean +/-standard deviation(x ±s)said,the data accord with normal distribution using analysis of variance and t test to compare differences between groups,the data accord with abnormal distribution was calculated by the nonparametric test to get P value.Counting datas use cases and percent to show,with chi-square analysis;Groups of cases less than 5 data with Fisher’s exact probability test.Multivariate statistical analysis on the influence factor of PNALD used logistic multivariate regression analysis method.As α=0.05 for testing standard,when P<0.05,said the difference was statistically significant.Results1.The object of study basic informationA total of 171 cases of elderly hospitalized patients were included in this study,the average age was(79.45±7.44),including 114 cases of male,mean age(80.06±7.36)years of age,female in 57 cases,average age(78.23±7.51).The age and the gastrointestinal disease of the patients with different gender and major diagnostic difference has no statistical significance(p>0.05),as shown in table 1.2.Parenteral nutrition support and the incidence of PNALD171 cases of the object of study in 53 cases(30.99%)received total parenteral nutrition(TPN)treatment,the average time of nutrition support(]5.47±5.31)days,the average total calories(20.72±4.63)kcal/kg/day,on average than protein heat(16.20±4.42)kcal/kg/day;PN joint enteral nutrition(EN)therapy in 118 patients(69.01%),the average time of nutrition support(14.86±5.46)days,the average total calories(21.72±8.74)kcal/kg/day,average heat not protein(17.51±7.95)kcal/kg/day.The differences of the time,the average total quantity of heat,the average of the heat energy of non-protein with different way of nutritional support therapy had no statistical significance(p>0.05),as shown in table 2.There were 34 cases(19.88%)of PNALD in 171 cases of the research object,53 patients who received TPN occurred 16 patients(30.19%)of PNALD,118 patients who treated with PN joint EN occurred 18 cases(15.25%)of PNALD,the difference of the incidence of PNALD with different nutrition support therapy patients was statistically significant(p<0.05),are shown in table 3.3.The analysis of influence factors for PNALDThe research object is divided into PNALD group(n=34)and liver function is normal group(n=137).The basic situation and liver function indicators before treatment of two patients groups are shown in table 4.The age and gender between the two groups had no statistical difference(p>0.05),while liver function indexes in the normal range.The difference of nutritional support mode,time,total calories,non-protein calories between two groups had statistical significance(p<0.05),as shown in table 5.The logistics regression analysis of the factors which influence the results are shown in table 6.The partial regression coefficient of nutritional support way was 0.967,with statistical significance(p<0.05).The partial regression coefficient of time was 0.124,with statistical significance(p<0.05).The partial regression coefficient of total heat was 0.520,with statistical significance(p<0.05).The partial regression coefficient of non-protein heat was-0.459,with statistical significance(p<0.05).The partial regression coefficient of bifidobacterium was 1.838,with statistical significance(p<0.05).The partial regression coefficient of UDCA was 2.325,with statistical significance(p<0.05).We can see that the way of nutritional support,the heat of non-protein,bifidobacterium,UDCA were negatively correlated with occurrence of PNALD,the time of PN,total calories were positively correlated with the incidence of PNALD.In patients with TPN than with PN joint EN patients are more likely to occur with PNALD.The lower the total quantity of heat,the higher the non-protein quantity of heat,are more likely to happen with PNALD.The longer time of PN is easier to get PNALD.Application of bifidobacteria and application of UDCA in patients compared with those with no application of the two drugs,are less likely to occur with PNALD.4.The influence of drugs combined with nutritional support for PNALD and liver functionIn 171 cases of the research object,who combined with bifidobacterium were 39 cases,combined with UDCA were 27 cases,without bifidobacteria and UDCA were 105 cases,hence the research object is divided into bifidobacterium group(n=39),UDCA group(n=27)and the control group(n=105).Bifidobacterium group with PNALD were 4 cases,the incidence was 10.26%(4/39),combined with TPN was 1 case,the incidence was 16.67%(1/6),the combined with PN joint EN were 3 cases,the incidence was 9.09%(3/33);PNALD occurred in UDCA group were 2 cases,the incidence was 10.26%(2/27),combined with TPN were two cases,the incidence was 20%(2/10),combined with PN joint EN was 0 cases,the incidence was 0.00%(0/17);The control group in which got PNALD were 28 cases(26.67%),combined with TPN were 13 cases,the incidence was 35.14%(13/37),combined with PN joint EN were 15 cases,the incidence was 22.06%(15/68).Specific results are shown in table 7 and figure 2.The incidence of PNALD in bifidobacteria groups and in UDCA group were both lower than the control group.The proportion of PNALD in bifidobacterium group combined with PN joint EN and UDCA group combined with PN joint EN than the control group of pure TPN were significantly lower,the difference was statistically significant(p<0.05).The liver function index before nutritional support deducting the liver function index after nutrition support respectively,get new variable △ ALB,△ ALT,△ AST,△ AKP,△γ-GT,△ DBIL,△ TBIL,△TBA.Positive representative is reduced,negative on behalf of the rise,the bigger the absolute value on behalf of the variables.△ AKP of bifidobacterium group average(1.97±20.99),and the difference between control group was statistically significant(p<0.05),Ay-GT average(-3.56±14.39),but there was no statistically significant difference(p>0.05).△ AKP,△ DBIL,△ TBIL of UDCA group average(-0.48±42.85),(3.35±3.21),(3.35±4,45)respectively,and the difference between the control group had statistical significance(p<0.05),Ay-GT average(-11.70±39.28),but there was no statistically significant difference(p>0.05).Specific results are shown in table 8.Conclusion1.Different way of nutritional support has different effect on PNALD.The patients with TPN are more likely to get PNALD than the patients with PN joint EN.2.PNALD was associated with the way.the time,the total calories,the non-protein heat of nutritional support and the application of drugs.3.Bifidobacterium can reduce the bacteria ectopic to protece intestinal barrier.It may reduce the incidence of PNALD via reducing cholestasis to protect the liver function.4.UDCA can reduce cholestasis.reduce bilirubin to protect the liver function,and reduce the incidence of PNALD.