Liver injury and cholestasis due to concomitant use of alanyl glutamine injection and fat emulsion, amino acids(17) and glucose(11%) injection

An 86-year-old male patient received parenteral nutrition therapy [IV infusions of alanyl glutamine injection 100 ml once daily and fat emulsion, amino acids (17) and glucose (11%) injection 1 440 ml once daily] for hypovolemic shock and malnutrition. His liver function was normal before medication. On day 23 after medication, the patient developed mild yellowish skin. Laboratory tests showed alanine aminotransferase (ALT) 342 U/L, aspartate aminotransferase (AST) 236 U/L, γ-glutamyl transpeptidase (γ-GT) 322 U/L, alkaline phosphatase (ALP) 308 U/L, and total bilirubin (TBil) 116.2 μmol/L. On day 25 after medication, the yellowish skin was aggravated. The above treatments were continued because of less food intake and hepatoprotective drugs were given at the same time. On day 32 after medication, laboratory tests showed ALT 186 U/L, AST 113 U/L, γ-GT 237 U/L, ALP 220 U/L, and TBil 139.7 μmol/L. The parenteral nutrition therapy was stopped and the liver protection therapy was continued. On day 44 after the drugs withdrawal, the patient′s jaundice disappeared, ALT 12 U/L, AST 14 U/L, γ-GT 37 U/L, ALP 72 U/L, and TBil 27 μmol/L. Key words: Parenteral nutrition; Chemical and drug induced liver injury; Cholestasis; Fat emulsions, intravenous