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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2015, Vol. 11 ›› Issue (05): 559 -563. doi: 10.3877/cma.j.issn.1673-5250.2015.05.002

Special Issue: ；

Original Article

Clinical analysis of risk factors of parenteral nutrition-associated cholestasis in very low birthweight infants

Jun Yang1, Shuixia Li1, Lina Chen2()   

  1. 1. Department of Neonatology, Dujiangyan People's Hospital, Dujiangyan 611830, Sichuan Province, China
    2. Department of Pediatrics, West China Second University Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2015-07-12 Revised:2015-08-30 Published:2015-10-01
  • Corresponding author: Lina Chen
  • About author:
    Corresponding author: Chen Lina, Email:
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Objective

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

Methods

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.

Results

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).

Conclusions

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.

Key words: Parenteral nutrition-associated cholestasis, Risk factors, Birth weight, Very low birth weight, Infant, newborn
表1 可能导致PNAC的临床观察项目(27项)相关影响因素的单因素分析结果比较[例数(%)]
影响因素 PNAC组(n＝29) 非PNAC组(n＝143) t值/χ2值 P值
产前应用糖皮质激素 21(74.4) 98(68.5) 0.171 0.157
母胆汁淤积症 8(27.6) 54(37.8) 1.083 0.102
胎龄(周，±s) 30.1±2.0 31.7±2.3 －1.524 0.762
出生体质量(g，±s) 1 228±219 1 240±231 －3.306 0.043
AGA儿 7(24.1) 35(26.6) 0.002 0.187
SGA儿 20(69.0) 68(47.6) 4.424 0.016
性别(男/女) 16/13 81/62 0.021 0.162
Apgar评分(分，±s) 8.5±1.5 9.0±1.0 0.987 0.715
分娩方式(自然分娩/剖宫产) 17/12 91/52 0.260 0.158
代谢性酸中毒 12(41.4) 69(48.3) 0.457 0.129
低氧血症 16(55.2) 71(49.7) 0.294 0.143
高碳酸血症 8(27.6) 56(39.2) 1.383 0.091
NRDS 11(37.9) 49(34.3) 0.143 0.156
新生儿吸入综合征 8(27.6) 57(39.9) 1.545 0.792
动脉导管未闭 4(13.8) 25(17.5) 0.045 0.214
贫血 3(10.3) 23(16.1) 0.252 0.178
呼吸衰竭 3(10.3) 19(13.3) 0.016 0.226
颅内出血 5(17.2) 22(15.4) 0.001 0.209
感染性肺炎 14(48.3) 40(28.0) 4.615 0.022
败血症 7(24.1) 13(9.1) 3.949 0.018
感染性休克 6(20.7) 10(5.6) 3.861 0.016
NEC 5(17.2) 7(4.9) 3.920 0.032
使用抗菌药物 15(51.7) 89(62.2) 1.115 0.091
吸氧 18(62.1) 91(63.6) 0.026 0.156
机械通气 15(51.7) 82(57.3) 0.310 0.096
口服益生菌 13(44.8) 97(67.8) 5.535 0.014
母乳喂养 9(31.0) 79(55.2) 5.656 0.012
表2 可能导致PNAC的营养因素项目(19项)相关影响因素的单因素分析结果比较(±s)
影响因素 PNAC组(n＝29) 非PNAC组(n＝143) t值 P值
PN起始时间(d) 3.1±2.3 4.1±2.9 0.301 0.691
PN持续时间(d) 30.1±15.9 25.6±10.9 1.790 0.041
葡萄糖累计用量(g) 369±142 299±128 0.710 0.052
氨基酸累计用量(g) 123±31 82±41 2.163 0.106
脂肪乳累计用量(g) 102±59 86±45 1.529 0.847
氨基酸每日最高用量[g/(kg·d)] 3.0±0.4 2.5±1.0 0.563 0.514
脂肪乳每日最高用量[g/(kg·d)] 3.0±0.5 2.6±0.9 0.582 0.570
禁食时间(d) 6.2±2.8 3.1±1.5 1.231 0.023
奶累积量(mL) 4 350±3 156 5 214±4 056 2.712 0.205
总热卡(kcal) 6 159±2 810 7 510±2 912 1.580 0.406
糖热卡比(%) 30.5±18.3 22.1±11.2 2.013 0.209
氨基酸热卡比(%) 8.2±3.8 5.1±2.5 3.193 0.037
脂肪乳热卡比(%) 19.0±7.3 12.1±4.5 2.815 0.012
奶热卡比(%) 42.5±26.3 64.8±18.1 2.519 0.023
住院天数(d) 42.1±19.5 39.4±17.3 0.873 0.127
每天总热卡[kcal/(kg·d)] 98.7±35.6 103.2±35.3 3.256 0.219
静脉每天热卡[kcal/(kg·d)] 45.6±23.8 46.2±19.7 1.592 0.501
PN持续第14天的静脉热卡(kcal/kg) 62±23 50±26 0.492 0.127
PN持续第14天的热氮比(kcal/kg) 142±57 153±59 3.139 0.212
表3 可能导致PNAC的影响因素的非条件多因素logistic回归分析结果比较
变量 偏回归系数 偏回归系数标准误 Wald P值 OR值 95%CI
新生儿感染 1.026 0.236 15.439 0.021 8.785 3.603～25.236
SGA儿 0.734 0.228 8.179 0.003 3.851 1.526～8.932
出生体质量 0.861 0.215 10.348 0.002 7.134 2.534～19.651
禁食时间 2.298 0.824 3.473 0.043 4.728 1.473～15.326
PN持续时间 1.356 0.361 14.527 0.021 6.746 1.219～12.471
氨基酸热卡比 16.289 0.927 9.266 0.002 7.113 3.124～19.358
脂肪乳热卡比 1.157 0.433 8.026 0.010 3.765 3.230～26.246
奶热卡比 1.972 0.316 8.017 0.031 0.016 0.027～0.679
母乳喂养 1.337 0.219 19.117 0.015 0.204 0.076～0.531
口服益生菌 0.679 0.139 26.132 0.043 0.078 0.013～0.169
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