Fish Oil-based Emulsion Research Articles

High inner phase emulsion of fish oil stabilized with rutin-grass carp (Ctenopharyngodon idella) myofibrillar protein: Application as a fat substitute in surimi gel

This study investigated the effect of rutin-grass carp myofibrillar protein (R-GMP) co-stable fish oil high internal phase emulsion on the quality of surimi gel compared with the direct addition of soybean oil. Combined with the stability, microstructure and rheological properties, R-GMP (GMP: 3.0%, rutin: 12%,/GMP, w/w) could form a stable O/W type high internal phase Pickering emulsion with an oil-water ratio of 0.75. The L*, a*, and b* values and whiteness of silver carp surimi gel were increased significantly (P < 0.05) after fish oil-based high internal phase emulsion was added as oil. Meanwhile, compared with the direct addition of soybean oil, the hardness, chewiness, gel strength and water-holding capacity of surimi gel were significantly enhanced (P < 0.05) after the addition of R-GMP high internal phase emulsion, and more free water was bound to the gel network. The microstructure showed that the R-GMP high internal phase emulsion could be evenly distributed in the dense and ordered protein network gel in the form of small oil droplets, while the direct addition of soybean oil would produce an aggregation of oil droplets and destroy the network structure of the gel. In conclusion, R-GMP stabilized fish oil high internal phase emulsion optimizes the gel quality of oil-enhanced surimi gel, providing new ideas for healthy fat replacement and the development of functional emulsified surimi products.

Exclusive Fish Oil Lipid Emulsion Rescue Strategy Improves Cholestasis in Neonates on Partially Fish Oil-Based Lipid Emulsion: A Pilot Study.

Resolution of parenteral nutrition-associated liver disease has been identified in infants receiving SMOFlipid™ or a 100% fish oil lipid emulsion (FOLE). However, the effect of FOLE is unknown when the previous emulsion received is a mixed lipid emulsion containing fish oil. This observational pilot study reports data regarding the use of Omegaven™ after the diagnosis of cholestasis while receiving SMOFlipid™. We conducted a retrospective review of medical charts of neonates in which a partially fish oil-based lipid emulsion was replaced by a fish oil lipid emulsion at 1 g/kg/day due to cholestasis. Thirty-eight infants (92.1% preterm, being 44.7% born below 28 weeks' gestation), received FOLE. Birth weight was 1390 (743.0; 2298) grams. The age that cholestasis diagnosed was 15.0 (10.0; 24.8) days. The fish oil emulsion was administered for 38.5 (11.2; 51.8) days. In 73.7% (28/38) of the neonates, the cholestasis was resolved. In 34.2% (13/38), resolution happened before FOLE discontinuation. In addition, in the rest of the neonates (15) in whom cholestasis resolved, resolution occurred after FOLE discontinuation. Nine of the neonates died. In conclusion, the use of a 100% fish oil-based emulsion in neonates afflicted with cholestasis developed while on a partially fish oil-based emulsion is associated with a bilirubin decrease.

Lipid emulsions prevent postoperative abdominal adhesions

IntroductionAdhesions are the most common cause of long-term morbidity after abdominal surgery and most often cause various forms of intestinal passage disorders ranging from partial obstruction to complete, life-threatening intestinal obstruction. The aim of the present study was to evaluate the protective effect of intraperitoneally administered lipid emulsions on the formation of adhesions in larger animal model, as the lubricating effect of phospholipids and the mechanical barrier of the lipid component are combined with the anti-inflammatory effect of fish oil. MethodsThirty-one female domestic pigs were randomly divided into three groups. At the end of the surgical procedure, a lipid emulsion or saline solution was applied intraperitoneally. After 14 days, an independent macroscopic, histological and immunohistochemical evaluation of the adhesions were performed. ResultsIntraperitoneal administration of lipid emulsions significantly reduced the incidence of intra-abdominal adhesions. Microscopic examination demonstrated a significant reduction in the number of inflammatory elements and the amount of collagen in the adhesions, especially after administration of the fish oil-based emulsion. A simultaneous decrease in neovascularization was observed in the adhesions. Evaluation of the intestinal anastomosis did not reveal significant differences in healing between the groups. ConclusionIntraperitoneal administration of lipid emulsions can reduce the development of postoperative intra-abdominal adhesions by the combined action of phospholipids as important lubricants and lipids as a mechanical barrier. Their effect is caused by a reduction in proinflammatory and profibrotic mediators. At the same time, intraperitoneal administration of lipid emulsions does not impair healing of the anastomosis in larger animal model.

Erythrocyte fatty acid membrane composition in children on long-term parenteral nutrition enriched with ω-3 fatty acids

Composite lipid emulsions containing soybean oil (30%), medium-chain triglycerides (30%), olive oil (25%), and fish oil (15%) (SMOF) are now widely used. We aimed to evaluate the tolerance, the efficiency, and the erythrocyte fatty acid (FA) profile for children on long-term home parenteral nutrition (HPN) receiving a composite fish oil-based emulsion (FOLE). At baseline, children (n=46) with severe intestinal failure highly dependent on parenteral nutrition (PN) for ≥1 y were included in the study when they had received the composite FOLE for >6 mo. Out of this baseline group, only 25 children remained highly PN-dependent (SMOF1, n=25) and could be assessed a second time, 2.4 y later (SMOF2, n=25). An independent control group ("weaned off PN" group; n=24) included children who had been weaned off PN for >2 y (median: 4 y). RBC-FA composition was established by GC-MS. Growth parameters, plasma citrulline, conjugated bilirubin, FA profiles, and the Holman ratio (20:3ω-9/20:4ω-6) were compared between groups. No difference for growth parameters, citrulline, and bilirubin was observed between the SMOF groups after 2.4 y (0.2<P<0.8). The weaned-off group did not differ from the SMOF groups for growth parameters (0.2<P<0.4) but citrulline was higher (P<0.0001) and conjugated bilirubin lower (P<0.01). The composite FOLE induced higher proportions of EPA (20:5n-3) (8.4%±2.9%) and DHA (22:6n-3) (11.7%±2.2%) than what was observed in weaned-off children (0.8%±0.4% and 6.6%±2.3%, respectively) but lower proportions of arachidonic acid (20:4n-6). However, the Holman ratio did not vary between groups (P=0.9), whereas the PUFA concentrations varied widely. Long-term use of the composite FOLE was well tolerated in HPN-dependent children. The RBC-FA profile alterations were consistent with the ω-3 PUFA-enriched composition of this emulsion without evidence of essential FA deficiency.

Does the use of fish oil-based lipid emulsion in the clinical setting of total parenteral nutrition and lipid rescue therapy interfere with common laboratory analytes on Roche Cobas 6000?

Lipaemic interference on automated analysers has been widely studied using soy-based emulsion such as Intralipid. Due to the greater adoption of fish oil-based lipid emulsion for total parenteral nutrition in view of improved clinical outcomes, we seek to characterize the optical properties of SMOFlipid 20% (Fresenius Kabi, Bad Homburg, Germany), a fish oil-based emulsion, on the Roche Cobas 6000 chemistry analyser (Roche Diagnostic, Basel, Switzerland). Various amounts of SMOFlipid were spiked into pooled serums. We plotted Roche Cobas Serum Index Gen.2 Lipaemia Index (L-index) against the amount of SMOFlipid added. We then studied the interference thresholds for aspartate aminotransferase, alanine aminotransferase, albumin and renal panel analytes using SMOFlipid. We subjected five levels of spiked lipaemia to high-speed centrifugation and analysed the specimens pre- and post-centrifugation. To postulate whether fish oil-based lipid emulsion interferes with laboratory results in the clinical setting, we calculated concentrations of SMOFlipid post-lipid rescue therapy and steady-state concentration of a typical total parenteral nutrition regime using pharmacokinetic principles. SMOFlipid optical behaviour is similar to Intralipid using the Serum Index Gen.2 L-index, with 1 mg/dL of SMOFlipid representing 1 unit of L-index. Manufacturer-stated interference thresholds are accurate for alanine aminotransferase, aspartate aminotransferase, albumin, urea and creatinine. High-speed centrifugation at 60 min 21,100g facilitates the removal of fish oil-based SMOFlipid. Based on the interference thresholds we verified and pharmacokinetics parameters provided by SMOFlipid manufacturer, total parenteral nutrition may not interfere with chemistry analytes given sufficient clearance, but lipid rescue therapy will interfere. Further studies assessing lipaemic interference on immunoassays are needed.

Fish oil-based lipid emulsion in the treatment of parenteral nutrition-associated cholestasis

BackgroundParenteral nutrition-associated cholestasis (PNAC) is a serious complication in preterm infants receiving prolonged parenteral nutrition. Soybean lipid emulsion (SLE) seems to have a role in its pathogenesis, whereas fish oil-based emulsion (FOLE) seems to be able to reverse cholestasis. This study aimed to evaluate the effectiveness of a FOLE in reversing PNAC.MethodsThe effectiveness in reversing PNAC was evaluated in prospective cohort study of very preterm infants when compared to historical controls: twenty-six infants (27.0 ± 2.6 weeks GA; 724 ± 204 g) who developed cholestasis while receiving SLE were shifted to receive FOLE and were compared with 30 infants (27.3 ± 2.5 weeks GA¸ 838 ± 277 g) who continued to receive SLE at diagnosis of cholestasis.ResultsTime to reversal of cholestasis was the same in the two study groups (45 ± 21 vs 43 ± 32 days).ConclusionsFOLE does not seem to be superior to SLE in reversing cholestasis. Considering that definitive data on the actual efficacy of FOLE to reverse PNAC are lacking, larger randomized trials are required, mainly to asses if FOLE may have a role in PNAC prevention rather than PNAC treatment.

The Effect of Fish Oil-Based Versus Soybean Oil-Based Fat Emulsion in the Occurrence of Parenteral Nutrition-Associated Liver Disease in Premature Infants

The Effect of Fish Oil-Based Versus Soybean Oil-Based Fat Emulsion in the Occurrence of Parenteral Nutrition-Associated Liver Disease in Premature Infants

MON-P218: What is The Right Dosage of Refined Fish Oil-Based Emulsion in Neonates?

MON-P218: What is The Right Dosage of Refined Fish Oil-Based Emulsion in Neonates?

Fish Oil-Based Fat Emulsion Reduces Acute Kidney Injury and Inflammatory Response in Antibiotic-Treated Polymicrobial Septic Mice.

Acute kidney injury (AKI) is a common complication in sepsis. This study compared the effects of a fish oil-based with a mixed oil fat emulsion on remote renal injury in an antibiotic-treated septic murine model. Mice were randomly assigned to a normal control (NC) group and three septic groups. Sepsis was induced by cecal ligation and puncture (CLP). The antibiotic was injected intraperitoneally (IP) after CLP and then daily till the time of sacrifice. Three hours after antibiotic treatment, one of the septic groups was injected IP with a fish oil-based emulsion (FO), while the other two groups were given either a mixed oil emulsion (MO) or saline (SC). The septic groups were further divided into two separate time groups, with blood and kidneys samples collected at 24 h or 72 h post-CLP. The results showed that sepsis leads to the activation of neutrophils, T helper (Th)1/Th-2/Th-17 and Treg cells (p < 0.05). Plasma NGAL and mRNA expressions of renal MyD88 and TLR4 were also enhanced (p < 0.05). Compared to the SC group, the group given the fish oil-based emulsion had decreased plasma NGAL by 22% and Treg by 33%. Furthermore, renal gene expressions of MyD88 and TLR4 reduced by 46% and 62%, respectively, whereas heat shock protein 70 and peroxisome proliferator-activated receptor-γ increased by 158% and 69%, respectively (p < 0.05), at Day 3 after CLP. These results suggest that administration of a fish oil-based emulsion has favorable effects, maintaining blood T cell percentage, downregulating Treg expression, attenuating systemic and local inflammation and offering renal protection under conditions of antibiotic-treated polymicrobial sepsis.

Physicochemical stability assessment of parenteral nutrition admixtures for pediatric patients compounded with different kinds of fish oil-based emulsion

Physicochemical stability assessment of parenteral nutrition admixtures for pediatric patients compounded with different kinds of fish oil-based emulsion

Characterization of the genomic responses in early Senegalese sole larvae fed diets with different dietary triacylglycerol and total lipids levels

The aim of this work was to evaluate the genomic responses of premetamorphic sole larvae (9days post-hatching, dph) fed diets with different lipid and triacylglycerol (TAG) content. For this purpose, two diets with high (rotifers enriched with a fish oil-based emulsion; referred to as HTAG) and low (rotifers enriched with a krill oil-based emulsion; LTAG) levels of total lipids and TAG were evaluated. Lipid class and fatty acid (FA) profiles, histological characterization of intestine, liver and pancreas and expression patterns using RNA-seq were determined. Discriminant analysis results showed that larvae could be clearly differentiated on the basis of their FA profile as a function of the diet supplied until 9dph although no difference in growth was observed. RNA-seq analysis showed that larvae fed HTAG activated coordinately the transcription of apolipoproteins (apob, apoa4, apoc2, apoe, and apobec2) and other related transcripts involved in chylomicron formation, likely to facilitate proper lipid absorption and delivery. In contrast, larvae fed LTAG showed higher mRNA levels of several pancreatic enzymes (try1a, try2, cela1, cela3, cela4, chym1, chym2, amy2a and pnlip) and appetite modulators (agrp1) and some intra- and extracellular lipases. Moreover, KEGG analysis also showed that several transcripts related to lipid metabolism and glycolysis were differentially expressed with a higher abundance in larvae fed LTAG diet. All these data suggest that early larvae were able to establish compensatory mechanisms for energy homeostasis regulating key molecules for FA and TAG biosynthesis, FA uptake and intracellular management of TAG and FA to warrant optimal growth rates.

Short-Term Intravenous Fish-Oil Emulsions in Pediatric Oncologic Patients—Effect on Liver Parameters

Pediatric oncologic patients often need parenteral nutrition (PN) during chemotherapy. Long-term use of soybean-based lipid emulsions is associated with progressive liver disease and cholestasis, whereas fish-oil based emulsions have anticholestatic effects. We studied the potentially hepato-protective effects of short-term use of SMOF lipids in children undergoing chemotherapy. Fifteen pediatric oncologic patients treated with SMOF lipids were retrospectively analyzed in respect to bilirubin and liver parameters and compared to matched-controls who had received soybean-based fat emulsions. For statistics the time-points baseline, Day 14 of PN (PN14), and post (Day+7) were chosen. None of the study patients developed cholestasis. Within the SMOF-lipid group there were no differences in the laboratory parameters between baseline, PN14, and post. In the control group, gamma glutamyltransferase (γGT) levels increased during PN (baseline vs. PN14, 26.43 vs. 63.00 U/l, P < 0.05). Lactate dehydrogenase (LDH) levels showed a significantly different behavior in the 2 groups: In the SMOF lipids group, LDH decreased whereas it increased in the controls (−32.75 U/l vs. + 29.57 U/l, P < 0.05). An advantage of fish oil-based fat emulsions can be shown even after short-term PN. In children undergoing chemotherapy the use of soybean-based fat emulsions but not SMOF lipids led to increased γGT levels.

Parenteral nutrition admixtures for pediatric patients compounded with highly refined fish oil-based emulsion: Assessment of physicochemical stability

Fish oil-based emulsion is increasingly used in pediatric patients receiving Parenteral Nutrition (PN). However, its unique use in children on long-term PN is nutritionally debatable as some patients are better off with a mixture of long-chain (LCT) or long-chain+medium-chain (LCT+MCT) triglycerides along with Fish Oil (FO). Lipid emulsions are safely infused when particle diameter ranges between 0.4 and 1.0micron (like chylomicra), according to European guidelines. No data exist on Fish Oil stability when added to other PN components typically present in pediatric formulations such as other lipids or micronutrients. Our goal is to evaluate the stability of a highly refined FO-emulsion in PN admixtures containing LCT or LCT+MCT triglycerides and different calcium content. Stability studies were carried out on six PN admixtures having two levels of calcium concentration compounded with olive oil LCT+FO, LCT+MCT+FO emulsion and pure FO alone, respectively. The analyses were performed immediately at time 0 (t=0) and 24, 48, 72, 96 (t=96) hours after compounding. Particle diameters were determined by Light Scattering-Reverse Fourier Optics Technique by means of a Laser Granulometer. Every sample was stored at 4°C and triple tested. Statistical significance was verified by f-test. In all admixtures, physicochemical stability did not change between t=0 and t=96 and particle diameters were in the expected range of 0.4-1.0micron provided calcium concentration remained below 4.5mmol/L. When calcium exceeded that level, 12% of particle diameters was larger than 1.0micron and 2% exceeded 5.0micron immediately after compounding. In particular, admixtures compounded with olive oil LCT+FO emulsion or FO emulsion alone showed lower particle diameters compared to admixture with olive/soybean LCT alone, probably due to a different steric encumbrance of oleic acid and omega-3 fatty acid. In the PN admixtures tested, containing FO-emulsion alone or in combination with olive LCT or LCT+MCT, the fat emulsion appears to be stable and safe for infusion when calcium concentration is maintained below 4.5mmol/L. If calcium level exceeds 4.5mmol/L, as often required in premature patients, it is advisable to infuse FO emulsion alone through a second intravenous line.

Agglutination of Intravenously Administered Phosphatidylcholine‐Containing Lipid Emulsions With Serum C‐reactive Protein

C-reactive protein (CRP) is able to bind phospholipids in the presence of calcium. We wanted to investigate the reaction of CRP with various commercial fat emulsions and to explore the impact of CRP agglutination on serum CRP levels. Serum specimens were mixed with Intralipid 20% (soybean oil-based fat emulsion), Structolipid (structured oil-based fat emulsion), Omegaven (fish oil-based fat emulsion), or SMOFlipid (mixed soybean oil-, olive oil-, and fish oil-based emulsion) in Tris-calcium buffer (pH 7.5). After 30 minutes of incubation at 37°C, CRP-phospholipid complexes were turbidimetrically quantified and flow cytometric analysis was performed. Similarly, CRP complexes were monitored in vivo, following administration of fat emulsion. CRP was able to agglutinate phospholipid-containing lipid droplets present in the soybean oil-based fat emulsion and the structured oil-based fat emulsion. To a lesser extent, agglutination was observed for fish oil-containing fat emulsions, whereas no agglutination was noticed for the mixed soybean oil-, olive oil-, and fish oil-based emulsion. Results for propofol-containing emulsions were comparable. Agglutination correlated with phospholipid content of the emulsions. When in vivo agglutination occurred, plasma CRP values dropped due to consumption of CRP by phospholipid-induced agglutination. In this in vitro experiment, we demonstrated agglutination of CRP with phospholipids in various fat emulsions. Research studies are required in patients to determine which effects occur with various intravenous fat emulsions.

Pediatric parenteral admixture compounding in a highly specialized university hospital

Introduction: The aim of this paper is to describe personalized pediatric parenteral admixture compounding in a specialized University Hospital. Materials and methods: Pediatric formulations require small volumes, high concentrations of nutrients and electrolyte micro-additions, thus they must be carefully evaluated by pharmacists and compounded by means of an automatic filling system in a “clean room”. Different kinds of lipid emulsions are used according to the patients’ needs: composite lipids or long and medium chain triglycerides with or without fish oil-based omega-3 fatty acid addition. Admixture stability is defined by determining particle diameter, which must be in the range of 0.4-1.0 µm, like chylomicra, for a safe infusion to patients. Analyses were carried out by means of a laser diffraction technique. Results: In the last 3 years 21,500 personalized pediatric admixtures were compounded (15,480 for children and 6,020 for neonates); the total number of treated patients was 1,700, including 550 neonates. Stability studies pointed out that, in all admixtures, the physicochemical stability did not change between t=0 and t=96 hours and particle diameter was in the expected range of 0.4-1.0 µm provided calcium concentration remained below 9 mEq/L. When calcium exceeded this level, as it is often required for neonates, in the admixtures containing fish oil-based emulsion, 12% of the particles had a diameter larger than 1.0 µm and 2% exceeded 5.0 µm immediately after compounding. Conclusions: Pediatric admixture compounding in a centralized service, and stability studies allowed to prepare any required formulation, providing patients with a safe and effective product. In particular, our analyses pointed out that admixtures containing fish oil-based emulsion and calcium concentrations higher than 9 mEq/L cannot be safely infused to pediatric patients; in these cases it is advisable to infuse the fish oil-based emulsion alone through a second intravenous line.

Influence of Lipid Type on Bis (2‐ethylhexyl)phthalate (DEHP) Leaching From Infusion Line Sets in Parenteral Nutrition

Bis(2-ethylhexyl)phthalate (or DEHP) is widely used in polyvinyl chloride (PVC) tubings for its good plasticizing properties. Because it is not covalently bound to the plastic matrix, it is able to escape from PVC during the infusion of the lipid emulsions used in parenteral nutrition (PN). This creates a vector through which it can enter into contact with the patient via the nutrition admixtures infused. This study was designed to assess the potential role of the type of lipids used in PN admixtures on the quantity of DEHP leached out from PVC-based tubings. PVC-based infusion lines, 6 commercially available lipid emulsions, and their oil base components were left in direct contact, and the amount of DEHP leached was measured by liquid chromatography. After a 24-hour exposure period, DEHP migration varied significantly (P = .0000152) according to lipid type. The olive oil-based emulsion Clinoleic leached the most DEHP (65.8 µg/mL intravenous fat emulsion), followed by the fish oil-based emulsion Omegaven (37.8 µg/mL). The soybean oil-based emulsions Intralipid, Medialipide, Lipidem, and Structolipid showed comparable performances, with DEHP leaching rates into the emulsion measured at 27.3, 27.8, 23.6, and 19.6 µg/mL, respectively. Results from the same experiments run on pure-form oils (soybean oil, olive oil, coconut oil, and cod liver oil) confirmed the influence of lipid type on DEHP leaching. The major DEHP leaching caused by olive oil-based emulsions raises cause for concern because DEHP presents distinctive toxic effects, including an increased risk of cholestasis.

Fish oil-based emulsion for the treatment of parenteral nutrition associated liver disease in an adult patient

Summary Background & aims Reversal of parenteral nutrition associated liver disease with fish oil emulsion (FO) has been reported in infants. We report a similar case in an adult patient. Methods A 58 year-old female on home parenteral nutrition for a short bowel syndrome due to Crohn’s disease, showed a progressive worsening of liver steatosis, and a persistent increase of the plasma liver function tests (LFTs). LFTs, serum alpha-tochopherol, red blood cell membrane fatty acids and liver histology were evaluated before and after an 8 month treatment with FO. Results The patient’s LFT’s improved. There was an increase of the n-3 and a decrease of the n-6 series of fatty acids in erythrocyte membrane. There was an approximate 30% increase in vitamin E status. Before FO, liver histology showed a non-alcoholic steatohepatitis with grade 2 steatosis and inflammation and stage 3 fibrosis. After the treatment, steatosis and inflammation were grade 1, whereas fibrosis remained at stage 3. Conclusions Infusion of FO was associated with consistent changes of cell membrane fatty acid structure and with mild improvement of vitamin E status. A potential role of FO in decreasing liver steatosis and inflammation with no change of liver fibrosis might be suggested.

Prevention of parenteral nutrition-associated liver disease: role of ω-3 fish oil

Parenteral nutrition-associated liver disease (PNALD) is the most severe complication of long-term parenteral nutrition. Its cause remains unclear, although recent studies suggest that the omega-6 polyunsaturated fatty acids in plant oil-based lipid emulsions and the associated phytosterols contribute to the development of hepatotoxicity. In contrast, fish oil-based lipid emulsions are composed mainly of omega-3 polyunsaturated fatty acids and are hypothesized to be hepatoprotective. This review will discuss fish oil-based lipid emulsions in the prevention of PNALD. In several animal models of PNALD, the use of an intravenous fish oil-based lipid emulsion improved parenteral nutrition-associated cholestasis without resultant essential fatty acid deficiency or growth impairment. Following these results and preliminary human data, an open trial for compassionate use was initiated, followed by a randomized controlled trial to evaluate the current management of pediatric PNALD. To date, at the author's institution, more than 130 children with PNALD have been treated with Omegaven, a fish oil-based emulsion, with improved liver function among most patients. PNALD remains the most severe complication of long-term parenteral nutrition with an unclear pathophysiology. However, the use of a fish oil-based emulsion appears efficacious and hepatoprotective.

Parenteral Fish Oil Monotherapy in the Management of Patients With Parenteral Nutrition–Associated Liver Disease

To update knowledge on the management of parenteral nutrition-associated liver disease (PNALD) and to review the clinical data on the use of parenteral fish oil for reversal of PNALD. A literature review was conducted by searching the MEDLINE database (May 1, 2009) using the keywords parenteral nutrition-associated liver disease, fish oil, omega-3, Omegaven, and lipid emulsion. All articles reporting clinical cases with the use of parenteral fish oil for management of PNALD. Three reviewers independently analyzed the epidemiological, clinical, and treatment data of the articles. Six case reports (10 patients) and 2 cohort studies (12 and 18 patients) were analyzed. Fish oil-derived emulsions have been demonstrated to reverse preexisting PNALD and to prevent and treat essential fatty acid deficiency. Its ability to prevent PNALD is currently under investigation. Although the mechanism has yet to be fully understood, the advantages of fish oil-based lipid emulsions over soybean oil-based lipid emulsions seen to date suggest that fish oil-based emulsions would be better suited for use in long-term parenteral nutrition.

Fish oil containing intravenous lipid emulsions in parenteral nutrition-associated cholestatic liver disease

Lipid emulsions containing fish oils have been proposed to improve parenteral nutrition associated cholestasis (PNAC), a very serious complication of prolonged parenteral nutrition occurring particularly in infants and children with intestinal failure. Here, we summarize current data. The cause of PNAC is multifactorial. Prevention is possible by appropriate management, surgical procedures, infection prevention, and optimal parenteral nutrition management. Plausible hypotheses and experimental data support potential benefits of fish oils for treatment and prevention of PNAC. Improvement of PNAC over weeks and months has been reported in observational case studies in part of the children who received parenteral lipids with fish oil, but similar improvements also occurred by withholding or reducing standard lipid emulsions. No controlled trials are available that would allow final conclusions on efficacy and safety of fish oil-based emulsions in PNAC. Concerns exist regarding possible untoward effects and an inadequate supply of n-6 fatty acids with parenteral fish oil only. First data from controlled trials with mixed lipid emulsions containing partly fish oil suggest safety in infants and children and some possible benefits for liver function. The observed improvement of PNAC on parenteral lipids with fish oil deserves further exploration. No controlled trials are available, nutritional adequacy and safety of 100% fish oil emulsions are not adequately documented, and currently their use cannot be considered standard care. First data on mixed lipid emulsions with some fish oil are encouraging, and their effects in PNAC should also be explored.