Long-term Parenteral Nutrition Research Articles

The vitamin and trace element status of intestinal failure patients receiving long-term home parenteral nutrition and home parenteral fluids

The vitamin and trace element status of intestinal failure patients receiving long-term home parenteral nutrition and home parenteral fluids

Cholecystitis following the initiation of glucagon-like peptide-2 analogue for short bowel syndrome: A case report.

Patients with short bowel syndrome (SBS) have a risk for cholelithiasis and cholecystitis, particularly those who have received long-term parenteral nutrition (PN). Teduglutide (Revestive), a glucagon-like peptide-2 (GLP-2) analogue, is the first effective therapy approved for treating patients with SBS via self-subcutaneous injection. It also pharmacologically inhibits gallbladder contraction, which may increase the risks for cholelithiasis and cholecystitis. Here, we report a case of cholecystitis occurring after the introduction of a GLP-2 analogue in a patient with SBS and cholelithiasis. A 16-year-old girl, with a residual intestinal anatomy of 5 cm jejunum and left colon, was referred to our hospital for further treatment of SBS. She underwent jejunocolic anastomosis 2 months later. After that, she received PN for 2.5 years. Teduglutide treatment was initiated to reduce PN dependence. Several asymptomatic gallbladder stones were found during a routine ultrasound examination before drug initiation. On day 31 of teduglutide treatment, right subcostal pain with fever occurred, and the patient was diagnosed with acute cholecystitis. GLP-2 analogue treatment was temporarily discontinued. The patient underwent gallbladder drainage followed by cholecystectomy 3 weeks later. Histopathological findings illustrated mucosal hyperplasia of the gallbladder. Her postoperative course was uneventful, and teduglutide was restarted 2 weeks postoperatively. GLP-2 analogues promote gallbladder refilling and epithelial hyperplasia, which may be a risk factor for cholecystitis in patients with cholelithiasis, as observed in our patient. Based on our experience, patients with SBS and established asymptomatic cholelithiasis may be considered for prophylactic cholecystectomy before the administration of GLP-2 analogues.

Nutritional Outcomes of Bowel Lengthening Procedure in Patients with Short Bowel Syndrome.

Although parenteral nutrition (PN) significantly improves mortality rates in pediatric short bowel syndrome (SBS), long-term PN has many possible complications and impacts quality of life. Bowel lengthening procedures (BLPs) increase the contact surface of food and the intestinal mucosa and enable the better absorption of nutrients and liquids, possibly leading to a PN decrease. We retrospectively reviewed the data of patients with short bowel syndrome who underwent BLPs in the period from January 2016 to January 2022. Overall, eight patients, four male, five born prematurely, underwent BLPs. There was a significant decrease in the percentage of total caloric intake provided via PN and PN volume after the BLPs. The more evident results were seen 6 months after the procedure and at the last follow-up, which was, on average, 31 months after the procedure. Two patients were weaned off PN after their BLPs. Patients remained well nourished during the follow-up. The BLP led to a significant decrease in PN needs and an increase in the food intake; however, significant changes happened more than 6 months after the procedure.

Optimizing Intravenous Access for Long-Term Parenteral Nutrition.

Securing safe and effective intravenous (IV) access is of utmost importance for administering parenteral nutrition (PN). Sustaining this access can indeed pose challenges, especially when dealing with the risk of complications associated with long-term PN. This review emphasizes best practices to optimize intravenous access and reviews the current evidence-based recommendations and consensus guidelines. An individualized approach when selecting central venous catheters (CVC) is recommended, considering the estimated duration of need for IV access and the number of lumens needed. Established and novel approaches to minimize complications, including infection and thrombosis, are recognized. These include placement and positioning of the catheter tip under sonographic guidance and the use of antimicrobial lock therapies. Moreover, when possible, salvaging CVCs can reduce the risk of vascular access loss. CVC selection for patients requiring PN depends on several factors. Carefully reviewing an individual patient's clinical characteristics and discussing options is important. Given the increased infection risk, CVC lumens should be minimized. For long-term PN beyond 6months, using CVCs with skin barriers and larger diameters should be considered.

Life on the line - Incidence and management of central venous catheter complications in intestinal failure

Background & AimsLoss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. MethodsFor this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDT) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/ port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDT were compared. ResultsOverall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 “CVC-days”). Broviac type “B” was found to be significantly superior to type “A” regarding occlusion, CRI, and material defects (log-rank test: p=0.05; p=0.026; p=0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 388.5 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. ConclusionsDifferent complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.

Avoiding the use of long-term parenteral support in patients without Intestinal Failure: a position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction

The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with – the use of long-term parenteral support in patients without IF.Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient’s primary underlying condition.

Evaluation of Arsenic and Cobalt Levels in Pediatric Patients Receiving Long-Term Parenteral Nutrition.

This study continues the research in which we determined the concentration of aluminum in children receiving long-term parenteral nutrition (LPN). Since our results were interesting, we decided to assay arsenic (As) and cobalt (Co) in the collected material, which, like aluminum, constitute contamination in the mixtures used in parenteral nutrition. Excesses of these trace elements in the human body are highly toxic, and deficiencies, particularly in the case of Co, can lead to various complications. The aim of this study was to determine the impact of LPN in children on their serum levels of As and Co, as well as the excretion of these elements in urine, and to compare them with a control group of healthy children. The study group consisted of 83 children receiving home parenteral nutrition from two Polish centers, while the control group included 121 healthy children. In both groups, the levels of As and Co in serum and urine were measured. The elemental compositions of the samples were determined using inductively coupled plasma mass spectrometry (ICP-MS). It was demonstrated that the children receiving LPN did not have increased As exposure compared to the controls. Greater exposure compared to the control group was shown for Co. In conclusion, children receiving LPN are not exposed to As, and even though the concentrations of Co in serum and urine were higher in the LPN group than in the healthy controls, neither trace element poses a health threat to children requiring LPN.

The Anxiety Burden in Patients with Chronic Intestinal Failure on Long-Term Parenteral Nutrition and in Their Caregivers.

Background and aims: Home parenteral nutrition (HPN) is a life-saving treatment for patients affected by chronic intestinal failure (CIF). Both this clinical condition and its therapy require radical lifestyle modifications, affecting life quality and psychological balance in patients as well as family members. Patient psychological burden has rarely been taken into consideration, not to mention that of caregivers. This study aims to evaluate the levels of anxiety in CIF patients on HPN, and their caregivers, consequently determining their impact on the psychological and physical aspects. Methods: After a brief introductory interview, adult patients on HPN for CIF and their caregivers were asked to fill in the HAMA-A questionnaire. Results: Fifty patients and their respective caregivers were enrolled. Mean HAMA-A scores were similar in patients and caregivers and testified the presence of a mild to severe impact of CIF and HPN in both groups, with a significantly higher impact on female patients and caregivers. After adjusting age, education level, duration of CIF and HPN dependence, and degree of kinship, no differences were revealed in the scores. Conclusions: The study confirms that CIF patients on HPN and their caregivers have a significant anxiety burden independently from the duration of the disease, therefore needing appropriate support.

Catheter salvage or removal in catheter-related bloodstream infections with Staphylococcus aureus in children with chronic intestinal failure receiving home parenteral nutrition and the use of prophylactic taurolidine catheter lock solution: A descriptive cohort study.

Children with chronic IF require long-term home parenteral nutrition (HPN), administered through a central venous catheter. Catheter-related bloodstream infection (CRBSI) with Staphylococcus aureus is known to be a serious infection with a high mortality rate and risk of complications. A standardized protocol on the management of S aureus CRBSIs in children receiving HPN is lacking. The aim of this study is to evaluate the effectiveness and safety of the current management in an HPN expertise center in the Netherlands. We performed a retrospective descriptive cohort study between 2013 and 2022 on children 0-18 years of age with chronic IF requiring long-term HPN. Our primary outcomes were the incidence of S aureus CRBSI per 1000 catheter days, catheter salvage attempt rate, and successful catheter salvage rate. Our secondary outcomes included complications and mortality. A total of 74 patients (39 male; 53%) were included, covering 327.8 catheter years. Twenty-eight patients (38%) had a total of 52 S aureus CRBSIs, with an incidence rate of 0.4 per 1000 catheter days. The catheter salvage attempt rate was 44% (23/52). The successful catheter salvage rate was 100%. No relapse occurred, and no removal was needed after catheter salvage. All complications that occurred were already present at admission before the decision to remove the catheter or not. No patients died because of an S aureus CRBSI. Catheter salvage in S aureus CRBSIs in children receiving HPN can be attempted after careful consideration by a multidisciplinary team in an HPN expertise center.

Brain manganese deposition: potential effects of long-term parenteral nutrition

Brain manganese deposition: potential effects of long-term parenteral nutrition

Inflammation drives pathogenesis of early intestinal failure-associated liver disease

Patients with intestinal failure who receive long-term parenteral nutrition (PN) often develop intestinal failure-associated liver disease (IFALD). Although there are identified risk factors, the early pathogenesis is poorly understood and treatment options are limited. Here, we perform a transcriptomic analysis of liver tissue in a large animal IFALD model to generate mechanistic insights and identify therapeutic targets. Preterm Yorkshire piglets were provided PN or bottle-fed with sow-milk replacer for 14 days. Compared to bottle-fed controls, piglets receiving PN developed biochemical cholestasis by day of life 15 (total bilirubin 0.2 vs. 2.9 mg/dL, P = 0.01). RNA-Seq of liver tissue was performed. Ingenuity Pathway Analysis identified 747 differentially expressed genes (343 upregulated and 404 downregulated) with an adjusted P < 0.05 and a fold-change of > |1|. Enriched canonical pathways were identified, demonstrating broad activation of inflammatory pathways and inhibition of cell cycle progression. Potential therapeutics including infliximab, glucocorticoids, statins, and obeticholic acid were identified as predicted upstream master regulators that may reverse the PN-induced gene dysregulation. The early driver of IFALD in neonates may be inflammation with an immature liver; identified therapeutics that target the inflammatory response in the liver should be investigated as potential treatments.

Iodine status in children with intestinal failure.

Children on long-term parenteral nutrition (PN) are at high risk of iodine deficiency (ID). However, most available information comes from cross-sectional studies. We investigated the iodine status, associated factors, and prevalence of hypothyroidism in children with intestinal failure (IF) who were followed up longitudinally. This was a cohort study of children with IF monitored for urine iodine concentration (UIC), iodine intake, serum selenium concentration, and thyroid function in an intestinal rehabilitation program. The outcome variable ID was defined as a UIC value < 100 μg/L. Adjusted generalized estimating equations were used to assess the effects of the exposure variables on the UIC. Twenty-four patients aged 62.7 (39.1; 79.7) months who received PN for 46.5 (21.5) months were included. The average energy supply was 81.2 kcal/kg/day, 77.6% of which was provided by PN. An average of 5.2 UIC measurements per patient were performed. ID prevalence decreased from baseline (83.3%) to the last assessment (45.8%). Three patients had hypothyroidism secondary to iodine and selenium combined severe deficiency. Iodine intake from enteral or oral nutritional formulas was positively associated with UIC (β = 0.71 [0.35, 1.07]; p < 0.001). Meeting approximately 80% of the estimated average requirement for iodine from nutritional formulas resulted in a greater probability of normal UIC values. ID is highly prevalent in children with IF who receive long-term PN and its frequency decreases with iodine intake from nutritional formulas. Severe combined iodine and selenium deficiencies are associated with the development of hypothyroidism in these patients.

Lack of clinical benefit from preoperative short-term parenteral nutrition on the clinical prognosis of patients treated with radical gastrectomy for gastric cancer: a two-center retrospective study based on propensity score matching analysis.

Preoperative nutritional support studies for patients undergoing gastrointestinal (GI) surgery mostly focused on enteral nutrition (EN) or long-term (≥7 days) parenteral nutrition (PN). Some studies also found that preoperative short-term PN could improve the postoperative short-term nutritional status of tumor patients. But whether short-term PN support (1-6 days) before surgery can improve the prognosis of patients undergoing surgery for gastric cancer (GC) remains unclear. Therefore, we focused on assessing the effect of preoperative short-term PN on the outcomes of patients undergoing radical surgery for GC. A retrospective analysis of 1,155 patients who underwent radical gastrectomy for GC between July 2014 and February 2019 was conducted. According to whether patients received short-term (1-6 days) PN support before surgery, patients were divided into non-PN group and PN group. After 1:1 propensity score matching (PSM), two groups of patients with similar baseline clinical characteristics were obtained. The incidence of various complications and overall survival (OS) rate were compared between the two groups, and logistic regression analysis for complications, Cox regression analysis for OS, and subgroup analysis were performed. Each group had 478 patients after PSM, and the clinical characteristics were balanced. There were no significant differences in overall postoperative complications (pre-PSM: P=0.495; post-PSM: P>0.99), postoperative length of stay (LOS; pre-PSM: P=0.092; post-PSM: P=0.460), or readmission rate within 30 days (pre-PSM: P=0.496; post-PSM: P=0.793) between the two groups before and after PSM. The OS of PN group before matching was lower than that of non-PN group (P=0.023), but this difference was not significant after matching (P=0.950), but the PN group's hospitalization expenses were substantially greater than those of the control group (post-PSM: P<0.001). Preoperative short-term PN support was not an independent factor in the incidence of postoperative complications (P>0.99) and OS (P=0.949). Subgroup analyses failed to identify those patients who might benefit from preoperative short-term PN support. Preoperative short-term PN support may have no significant benefit on short-term postoperative complications or the long-term OS of patients with GC but increase hospitalization costs. It thus should not be the first choice of treatment for these patients.

Outcomes of Premature Infants With Type C Esophageal Atresia

BackgroundTo review the outcomes of premature patients with type C esophageal atresia (EA). MethodsIn this retrospective cohort study, charts of patients of type C EA patients were reviewed from 1992 to 2022. Outcomes of premature patients were compared to term patients. Preterm patients were analyzed to compare outcomes of infants with very low birth weights (VLBW) to patients >1,500 g as well as primary versus delayed anastomosis. ResultsAmong 192 type C EA, 67 were premature. Median and interquartile range (IQR) gestational age and birth weight of preterm patients were 34 [33–36] weeks and 1965 [1740–2290] g. Delayed anastomosis was performed in 12 (18%) preterm vs. 3 (2%) term patients (p = 0.0003). Short-term postoperative outcomes were similar between preterm and term patients, except for recurrent fistula (16% vs. 6%, p = 0.01). Prematurity was associated with an increased need for long-term enteral tube feeding (56% vs. 10%, p = 0.0001) and parenteral nutrition (10 days vs. 0 days, p = 0.0004). The length of stay was 3 times longer when patients were premature (50 days vs. 17 days, p = 0.002). Delayed surgery in preterm patients was associated with post-operative leaks, strictures, recurrent fistula, prolonged enteral tube feeding, and gastrostomy insertion. Patients with very low birth weight (VLBW) were compared to other preterm patients and showed no difference in terms of rate of delayed surgery, and post-operative outcomes. ConclusionDespite increased prematurity-related comorbidities and low birth weight, premature infants with type C EA/TEF have similar post-operative outcomes to term patients though recurrent fistula was more frequent with prematurity. Type of StudyRetrospective cohort study. Level of EvidenceIII.

Shifting the paradigm of long-term total parenteral nutrition: Lessons from renal dialysis.

Shifting the paradigm of long-term total parenteral nutrition: Lessons from renal dialysis.

An Assessment of aluminum contamination in neonatal parenteral nutrition solutions based on measured versus labeled content

Aluminum can potentially cause toxicity in pediatrics and neonates receiving parenteral nutrition. Some PN solutions and ingredients in Saudi Arabia do not comply with US FDA regulations regarding aluminum exposure. This study aims to determine the aluminum concentration in samples of PN solutions and ingredients used to feed infants in Saudi Arabia. The aluminum in the samples was determined using inductively coupled plasma mass spectrometry. The concentration of metal contaminants in each sample was determined in triplicate. The aluminum content of 38 samples was investigated, 15 of which originated from components included in the prepared PN solutions. Among the 15 samples, the least measurable aluminum content was detected in potassium chloride solutions (0.81 mcg/L). In contrast, the greatest amount of aluminum was detected in potassium phosphate and calcium gluconate (141,64 mcg/L and 462.7 mcg/L), respectively. The results showed that the final PN solution (PNS) product contained more aluminum levels than the content ingredients; in addition, the study found a statistically significant relationship among 18 pediatric patients at KFMC who had intestinal failure and needed long-term parenteral nutrition. Specifically, their high aluminum levels, exceeding the normal range of 0.6 ng/ml, indicate that the current use of PN solutions will likely cause toxicity due to aluminum contamination in additives. Hence, reducing aluminum in PN solutions is imperative to ensure patient safety.

Cystatin C as a marker of renal function in patients with chronic intestinal failure on long-term parenteral nutrition

Cystatin C as a marker of renal function in patients with chronic intestinal failure on long-term parenteral nutrition

Predictive value of serum fibroblast growth factor 19 and liver stiffness for intestinal failure associated liver disease-cholestasis

BackgroundIntestinal failure associated liver disease (IFALD)-cholestasis is a common complication of long-term parenteral nutrition (PN) in patients with intestinal failure (IF). The lack of effective early identification indicators often results in poor clinical outcomes. The objective of this study was to evaluate the predictive value of serum FGF19 and liver stiffness in IFALD-cholestasis. MethodsEligible adults diagnosed with IF were identified from Jinling Hospital in China. Diagnostic criteria for IFALD-cholestasis: total bilirubin >1 mg/dL and conjugated bilirubin >0.3 mg/dL for ≥6 months. Fasting blood specimens were prospectively collected and serum FGF19 concentrations were determined using ELISA and liver stiffness was measured by Two-dimensional shear wave elastography. Binary logistic regression analysis identified predictors of IFALD-cholestasis. Receiver operating characteristic (ROC) curves and areas under the ROC curves (AUROC) were used to evaluate the accuracy of serum FGF19 and liver stiffness in identifying IFALD-cholestasis. ResultsOf 203 study patients with IF, 70 (34.5%) were diagnosed with IFALD-cholestasis. The serum FGF19 levels in those with IFALD-cholestasis were significantly decreased compared with those in patients without, and liver stiffness was significantly increased (p<0.001). Multivariate logistic regression analyses suggested that intestinal discontinuity, dependence on PN, liver stiffness >6.5 kPa, and serum FGF19 ≤107 pg/mL were independent risk factors for IFALD-cholestasis. The AUROC for serum FGF19 and liver stiffness, which indicate the occurrence of IFALD-cholestasis, were 0.810 and 0.714, respectively. Serum FGF19 had a superior predictive performance than liver stiffness (p<0.05). ConclusionBoth low circulating serum FGF19 concentration and increased liver stiffness are excellent predictors of IFALD-cholestasis, but serum FGF19 is superior to increased liver stiffness in predicting IFALD-cholestasis.

About the Usage and Usability of Central Venous Catheters in Children with TPN: the Parents' Viewpoint.

Medical devices are important components of medical care. Therefore, they must be safe and useful for patients. This study aimed to analyze the situation of children with central venous catheters (CVCs) for long-term parenteral nutrition from the parents' perspective with respect to patient safety and usefulness. An online cross-sectional survey was conducted using a quantitative research approach, with a German patient support group for children with chronic intestinal failure. 61 responses were collected between November 202 and January 2021. Concerning the usability of the CVCs, the caregivers assessed overall satisfaction, patient safety, usability, learnability of handling, "self-explanatory ability, " and mental load. Furthermore, various suggestions for improvements have been documented. Although CVCs can cause a variety of complications in the context of long-term use, the usage for parents in everyday life is feasible. Insufficient fixation and protection outside of the body have been identified as unmet clinical needs. In addition to the underlying disease of chronic intestinal failure, the catheter adds an extra mental burden to families' lives. Furthermore, parents articulated the need for further information and training.

Descriptive Analysis of Renal Function and Potential Renal Acid Load in Adult Patients with Long-term Home Parenteral Nutrition Support: A Retrospective Study

Descriptive Analysis of Renal Function and Potential Renal Acid Load in Adult Patients with Long-term Home Parenteral Nutrition Support: A Retrospective Study