早产儿胃肠外营养相关性胆汁淤积症临床研究

目的 探讨生后早期使用静脉营养的早产儿胆汁淤积症的临床特点,分析胃肠外营养相关性胆汁淤积症(parenteral nutrition associated cholestasis,PNAC)的相关因素及防治措施.方法 回顾性分析2011年1月至2016年4月出生并在盛京医院住院治疗的早产儿,生后均早期使用静脉营养2周,后出现胆汁淤积,共89例,分为两组,PNAC组即符合PNAC诊断(未发现其他导致胆汁淤积原因)41例,多病因组(除胃肠外营养因素还有其他病因)48例.通过病例对照研究分析其临床特点.结果 早产儿胆汁淤积症的男女比例为2.18:1,平均胎龄(31.05 ±2.15)周,平均出生体重(1360.55±421.14)g,静脉营养平均使用时间为(26.22±9.78)d.PNAC组根据丙氨酸氨基转移酶是否升高又分为肝炎组与非肝炎组,两组在胎龄、静脉营养开始时间、生后黄疸出现时间、开奶时间、氨基酸起始剂量及脂肪乳最大剂量方面的差异均有统计学意义,(P＜0.05);根据胃肠外营养时间分为长期组(≥20d)与短期组(＜20 d),长期组的谷丙转氨酶、谷草转氨酶、总胆红素、直接胆红素及胆汁酸水平均高于短期组,但P均≥0.05.多病因组患儿多合并感染,依次为细菌感染(75.0％)、真菌感染(20.83％)、巨细胞病毒感染(8.33％)和梅毒感染(2.08％)等.PNAC组和多病因组其他并发疾病的发生率差异无统计学意义.在预后方面,两组患儿经过保肝治疗后肝功能均较前明显好转,PNAC组的各项指标较多病因组降低更为显著(P＜0.05).结论 PNAC是早产儿胆汁淤积症发生的主要因素,PNAC早产儿肝损伤程度与胃肠外营养开始时间、使用时间、肠内喂养时间、氨基酸起始剂量及脂肪乳最大剂量有关.经保肝对症治疗后肝功能可以明显恢复,且效果优于多病因所致的胆汁淤积症.

Clinical analysis of preterm infants parenteral nutrition associated cholestasis

Objective To discuss the clinical feature of cholestasis preterm infants who have used parenteral nutrition early after birth,and analyze the relative factors and preventive meatures of parenteral nutrition associated cholestasis (PNAC).Methods We retrospectively analyzed the preterm infants who were born and hospitalized at Shengjing Hospital of China Medical University from January,2011 to April,2016.There were 89 cases in total that used at least 2 weeks of parenteral nutrition in the early stage after birth and were developed to cholestasis afterwards.We divided 89 cases into PNAC group and multifactor group:the former was corresponded to PNAC diagnosis standards,accounting for41 cases (46.07％);the latter with other etiology in addition to parenteral nutrition accounts for 48 cases.The clinical characteristics were studied and analyzed using case-control method.Results The sex ratio of premature cholestasis was 2.18:1,the mean gestational age was (31.05 ±2.15) weeks,the mean birth weight was (1360.55 ±421.14) g,and the mean using-time of parenteral nutrition was (26.22 ± 9.78) d.Futhermore,PNAC group was divided into hepatitis group and non-hepatitis group according to the alanine aminotransferase level,and they both had statistical significance in gestational age,starting time of parenteral nutrition,appearance time of jaundice,enteral feeding time,starting dose of amino acid,maximum dose of fat emulsion (P ＜ 0.05).We divided them into long-term group (≥20 d) and short-term group (＜ 20 d) according to the using time of parenteral nutrition.The level of alanine aminotransferase,glutamic oxalacetic transaminase,total bilirubin,direct bilirubin and bile acid of longterm group was higher than those of short-term group,but with P≥0.05.The multifactor group was mostly accompanied with multiple infections in the order of bacterial infection (75.0％),fungal infection (20.83％),cytomegalovirus infection (8.33％) and syphilis infection (2.08％),etc.The other complication's incidence rate of PNAC group and multifactor group had no statistical significance.In terms of prognosis,the liver function of two group improved remarkably than before,with PNAC group having more significance (P ＜0.05).Conclusion PNAC is the major factor of preterm cholestasis,and the degree of liver damage of PNAC preterm was related to starting time of parenteral nutrition,using time of parenteral nutrition,enteral feeding time,starting dose of amino acid and maximum dose of fat emulsion.The liver function of PNAC group is recovered obviously through regulatory treatment,and it possesses a better prognosis than multifactorgroup.