探讨极低出生体质量儿(VLBWI)胃肠外营养相关性胆汁淤积(PNAC)发病的独立危险因素。

选择2008年5月至2014年5月在四川大学华西第二医院接受胃肠外营养(PN)持续时间≥14 d，符合本研究纳入与排除标准的VLBWI的临床病历资料为研究对象。采用回顾性分析方法，将其按照接受持维PN后是否发生PNAC，分为PNAC组和非PNAC组。首先根据临床经验，确定导致PNAC的影响因素，并对其进行单因素分析；再根据单因素分析结果及专业知识，进一步进行非条件多因素logistic回归分析，最终确定导致PNAC的独立危险因素。

①最终符合本研究纳入与排除标准的VLBWI共计172例，其中非PNAC组为143例，PNAC组为29例，PNAC发生率为16.9%。两组受试者性别构成比、胎龄及分娩方式等比较，差异均无统计学意义(P>0.05)。②根据临床经验，对可能导致PNAC的临床观察项目(27项)与营养因素项目(19项)相关影响因素的单因素分析结果显示：8项临床观察项目与5项营养因素项目为可能导致PNAC的影响因素，如出生体质量轻，小于胎龄(SGA)儿，PN持续时间及禁食时间长，氨基酸热卡及脂肪乳热卡高，奶热卡低，感染性肺炎、败血症、新生儿坏死性小肠结肠炎(NEC)及感染性休克率高，母乳喂养及口服益生菌均为可能导致PNAC发生的影响因素，差异均有统计学意义(t/χ²＝－3.306，4.424，1.790，1.231，3.193，2.815，2.519，4.615，3.949，3.920，3.861，5.656，5.535；P<0.05)。③对可能导致PNAC的影响因素的非条件多因素logistic回归分析结果显示：新生儿感染(感染性肺炎、败血症、NEC及感染性休克)，SGA儿，VLBWI，禁食时间长，PN持续时间长，氨基酸热卡比及脂肪乳热卡比高是导致PNAC的独立危险因素(OR＝8.785，3.851，7.134，4.728，6.746，7.113，3.765；95%CI：3.603～25.236，1.526～8.932，2.534～19.651，1.473～15.326，1.219～12.471，3.124～19.358，3.230～26.246；P<0.05)，奶热卡比高、母乳喂养及口服益生菌是PNAC的保护因素(OR＝0.016，0.204，0.078；95%CI：0.027～0.679，0.076～0.531，0.013～0.169；P<0.05)。

VLBWI的PNAC发生与新生儿感染、SGA儿、出生体质量轻、PN持续时间长、氨基酸热卡比及脂肪乳热卡比高、禁食时间长有关，奶热卡比高、母乳喂养及口服益生菌为保护因素。

To investigate the risk factors of parenteral nutrition-associated cholestasis (PNAC) in very low birth weight infants (VLBWI).

VLBWI who were accorded with inclusion and exclusion criteria of this study: treatment for parenteral nutrition (PN) for over 14 days in West China Second University Hospital of Sichuan University from May 2008 to May 2014 were chosen as study subjects. By retrospectively analyzed method, they were divided into PNAC group and non PNAC group according to whether suflered from PNAC or not. First of all, according to the clinical experience, the influence factors of PNAC were identified and carried on the single factor analysis, then comprehensively considered with statistically significant variables and professional knowledge, multiple factors unconditional logistic regression analysis method was used to further analyze the independent and risk factors of PNAC.

①A total of 172 cases of VLBWI were chosen as study subjects finally. According to whether suffered from PNAC or not, they were divided into PNAC group (n=29) and non PNAC group (n=143), and the incidence of PNAC was 16.9%. There were no significant differences between two groups among gender ratio, gestational age at delivery and mode of delivery, etc. (P>0.05). ②According to clinical experience, the single factor analysis results about 27 clinical observation items and 19 nutritional factors which may lead to PNAC showed that 8 clinical observation items and 5 nutritional factors were influence factors of PNAC, such as VLBWI, less than appropriate for gestational age (SGA), long fasting time and longer duration of PN, higher amino acid and fat emulsion calories, milk lower calories, higher neonatal infections, such as infectious pneumonia, sepsis, neonatal necrotizing enterocolitis (NEC) and septic shock rate, lower breastfeeding and oral probiotics rate, and all the differences were statistically significant (t/χ²=3.306, 3.306, 1.790, 1.231, 3.193, 2.815, 2.519, 4.615, 3.949, 3.920, 3.861, 5.656, 5.535; P<0.05). The unconditioned and multi-factor of logistic regression analysis results of influence factors may cause PNAC showed that neonatal infections, SGA, VLBWI, long fasting time, long duration of PN, higher amino acid and fat emulsion calories were the risk factors of PNAC (OR=8.785, 8.785, 8.785, 3.851, 6.746, 7.113, 3.765; 95%CI: 3.603-25.236, 1.526-8.932, 2.534-19.651, 1.473-15.326, 1.219-12.471, 3.124-19.358, 3.230-26.246; P<0.05), milk high calorie, breastfeeding and oral probiotics were protective factors of PNAC (OR=0.016, 0.016, 0.016; 95%CI: 0.027-0.679, 0.076-0.531, 0.013-0.169; P<0.05).

Neonatal infections, SGA, low birth weight, long duration of PN, higher amino acid and fat emulsion calorie, long fasting time are significant risk factors of PNAC in our study. Protective factors are high milk calorie, breastfeeding and oral probiotics.