Ultra-short bowel is an independent risk factor for liver fibrosis in adults with home parenteral nutrition

Background & AimsIntestinal failure-associated liver disease is rare in adults and risk factors are unclear. The aim of this study was to determine risk factors of liver fibrosis in adults receiving home parenteral nutrition for intestinal failure and its impact on survival. MethodsWe retrospectively analysed patients with irreversible intestinal failure who underwent a liver biopsy between 2000 and 2013. Significant liver fibrosis was defined as F2 according to NASH-CRN score. ResultsThirty-two patients (46years [29-60]) underwent liver biopsy 55months (9-201) after beginning parenteral nutrition. Twenty-six patients (81%) had a short bowel (gut<200cm), including 12 (37%) with an ultra-short bowel (gut<20cm). Eighteen patients (56%) had liver fibrosis (4F2, 10F3, 4F4), associated with steatohepatitis (72%) and/or cholestasis (17%). Factors associated with occurrence of liver fibrosis included ultra-short bowel (83% vs 13% at 60months; P<.001), alcohol consumption (73% vs 33% at 60months; P<.001) and diabetes (80% vs 34% at 60months; P=.01). Home parenteral nutrition composition, quantity, or duration, episodes of sepsis, abandoned bowel segment were not associated with fibrosis. Ultra-short bowel [risk ratio 12.4, P<.001] and alcohol consumption [risk ratio 7.4, P=.009] independently predicted the development of liver fibrosis on multivariate analysis. After a median follow-up of 118months (72-155), survival was poorer in patients who developed liver fibrosis than in those without (59% vs 92% at 120months; P=.02). ConclusionAn ultra-short bowel and alcohol consumption are independent risk factors for liver fibrosis in adults requiring HPN. See Editorial on Page 35