Patients Receiving Home Parenteral Nutrition Research Articles

Sleep patterns of patients receiving home parenteral nutrition: A home-based observational study.

Patients supported with home parenteral nutrition (HPN) often report poor sleep; however, limited research has been conducted to objectively measure sleep patterns of HPN-dependent patients. We aimed to characterize the sleep patterns of patients receiving HPN through 7-day actigraphy in a home-based observational study. Sleep measures of clinical importance were derived from actigraphy, including sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset. Participants also completed validated sleep surveys. Twenty participants completed all study procedures (mean [SD]: age = 51.6 [13.9] years, body mass index = 21.4 [4.6], and 80% female). The population median (IQR) for sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset was 6.9 (1.1) h, 83.3% (7.8%), 11.8 (7.1) min, and 57.2 (39.9) min, respectively, and 55%, 60%, 35%, and 100% of participants did not meet the recommendations for these measures from the National Sleep Foundation. Sixty-five percent of participants reported napping at least once during the 7-day period. Based on the Insomnia Severity Index, 70% of participants were classified as having subthreshold or more severe insomnia. Based on the Pittsburgh Sleep Quality Index, 85% were classified as having significant sleep disturbance. Most HPN-dependent patients likely have disrupted sleep largely driven by difficulty maintaining sleep. The extent to which HPN contributed to poor sleep cannot be elucidated from this observational study. Addressing known factors that contribute to sleep disruption and considering sleep interventions may improve the overall quality of life of patients receiving HPN.

Impact of infusion frequency on quality of life in patients receiving home parenteral nutrition.

Home parenteral nutrition (HPN) may be needed as a long-term therapy for patients with chronic intestinal failure whose clinical condition does not allow complete weaning of the parenteral nutrition (PN) solution. HPN is a time-consuming and clinically complex therapy and can negatively affect quality of life (QOL). The level of dependency on HPN, specifically, infusion frequency, has been proposed as a factor that may have an effect on QOL in patients receiving HPN. The primary aim of this qualitative review is to identify the impact of HPN frequency (days per week of HPN infusion) on QOL measurements in adult patients receiving HPN. A comprehensive literature search was completed in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Primary clinical research studies were included if they were conducted in adult patients receiving HPN and included the assessment of the associations between the frequency of HPN infusion and QOL measurements. Six articles ultimately met the criteria for this review. There was variability among the studies, including use of different tools to measure QOL. However, all six studies suggest that a reduction in HPN frequency may be associated with an improvement in QOL. Whenever patients' clinical situation allows, a reduction in HPN frequency should be considered to improve QOL in patients receiving HPN.

How Broad Should Gram-Negative Coverage Be for Febrile Parenteral Nutrition Dependent Short Bowel Syndrome Patients?

Broader spectrum Gram-negative antibiotics are commonly utilized empirically for central line-associated bloodstream infections (CLABSI) in febrile short bowel syndrome (SBS) patients receiving home parenteral nutrition compared to those used empirically for inpatient-acquired CLABSI. This analysis reports 57 CLABSI in 22 patients with SBS admitted from the community and 78 inpatient-acquired CLABSI in 76 patients over a 5-year period. Proportional Gram-negative CLABSI was similar between the SBS and inpatient-acquired cohorts (43.8% vs42.3%, respectively, P = 0.78). 1.8% and 10.3% (P = 0.125) of Gram-negative CLABSI were non-susceptible to ceftriaxone and 0% and 3.8% (P = 0.52) were non-susceptible to ceftazidime in the SBS and inpatient-acquired cohorts, respectively. In the SBS cohort, home ethanol lock therapy and prior culture results impacted Gramnegative pathogen distribution. Broader empiric Gram-negative coverage for CLABSI among SBS patients compared to inpatients is unnecessary. Third-generation cephalosporins represent appropriate empiric Gramnegative agents for febrile SBS patients presenting from the community to our institution.

A Case of Bacteremia Caused by Pantoea ananatis in a Patient Receiving Home Parenteral Nutrition

A Case of Bacteremia Caused by <i>Pantoea ananatis</i> in a Patient Receiving Home Parenteral Nutrition

Activity of aminotransferases as a marker of liver injury in home parenteral nutrition patients.

Aim of the studyParenteral nutrition associated liver disease (PNALD) is a frequently reported complication of long-term parenteral nutrition. Early diagnosis and treatment of PNALD can help prevent end-stage liver disease. The aim of the study was to evaluate the activity of aminotransferases as a marker of liver dysfunction in patients receiving home parenteral nutrition under the care of a reference center.Material and methodsA comprehensive analysis of patients’ medical records from a 9-year period (December 2012 – December 2021) was conducted and the following parameters were evaluated: parenteral nutrition mixture composition, total plasma bilirubin, activity of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST), standardized time factor prothrombin (international normalized ratio [INR] factor) and serum albumin. The analysis covered 630,537 days of parenteral nutrition. The study included 251 patients (140 women and 111 men) included in the Home Parenteral Nutrition Program.ResultsPNALD was diagnosed in 11 parenteral fed patients, which gives the frequency of 8.3%/9 years of treatment. Two deaths were classified as cause of death related to liver disease but not related to PNALD. None of the patients included in the analysis developed end-stage liver failure.ConclusionsThe above analysis shows that individual selection of the composition of the mixture for intravenous nutrition significantly reduces the risk of PNALD and may prevent liver failure in this context.

The effects of different parenteral nutrition lipid formulations on clinical and laboratory endpoints in patients receiving home parenteral nutrition: A systematic review

Home parenteral nutrition (HPN) is a life-sustaining therapy for individuals with intestinal failure in a community setting. It refers to the intravenous infusion of macronutrients, micronutrients, fluids and electrolytes. Routinely used HPN solutions contain different quantities of these components. Consequently, each HPN solution may have different impacts on metabolism, inflammation and oxidative stress. Long-term use of HPN can lead to a number of adverse health outcomes including the development of metabolic bone disease, intestinal failure associated liver disease and poor quality of life but whether, and how, the composition of HPN solutions contributes to these health sequelae is poorly understood. The aim of this study is to systematically review and evaluate the evidence for the differential effects of HPN solutions and to understand what features are associated with differences in clinical endpoints. A systematic literature search was conducted between September and December 2020, and updated in July 2021 using the MEDLINE (Ovid), EMBASE, Scopus, and Web of Science databases. Studies were selected according to the following criteria (a) adult participants (>18 years old) dependent on HPN; (b) randomised controlled trials, prospective cohort and cross-sectional study designs; (c) primary research comparing two or more HPN solutions and (d) published in English language. Data were extracted and study quality assessed using Cochrane Collaboration's tools: Risk of Bias for Randomised Controlled Trials (RCTs); Risk of Bias in Non-Randomised Studies of Interventions; and the Newcastle Ottawa Scale for cross-sectional studies. Of the 5148 articles identified, seven RCTs, two prospective cohort and one cross-sectional study were included with a total of 295 participants. Studies varied in terms of duration (one to 60 months) and sample size (n=5 to 88). Ten studies compared lipid emulsions (LE) and one study also compared LE with lipid-free HPN. No studies were found that compared the amino acid, vitamin, trace element or electrolyte components of HPN. In general, LE were well tolerated with no significant adverse effects. LE containing olive+/or fish oil were associated with a lower ω-6:ω-3 fatty acid ratio, positive reductions in markers of liver function, and changes in blood and cell fatty acid profiles. Despite the increasing use of HPN, there is surprisingly little evidence available to guide the provision of macro and micronutrients in the adult population requiring this therapy. Although LE containing olive+/or fish oil show promise with regards to liver function and blood and cell fatty acid profiles, further studies are needed before drawing definitive conclusions on the clinical value of these emulsions. It is likely that one type of HPN solution alone cannot be uniformly applied to patient care, and each patient should be assessed on an individual basis.

Kidney stones are common in patients with short-bowel syndrome receiving long-term parenteral nutrition: A predictive model for urolithiasis.

In short-bowel syndrome (SBS) treated with parenteral nutrition (PN), multiple complications can occur. The etiology of kidney stones may be linked to the underlying disease thrombosis, surgical complications, complications of therapy for cancer, Crohn's disease, metabolic abnormalities resulting from morphological and functional changes in the gastrointestinal tract, and to treatment used. We analyzed all these parameters in a large cohort of patients receiving home PN (HPN), to define the incidence of stones and groups of patients particularly at risk of stone formation. One of the objectiveswas to develop a predictive model of urolithiasis. This observational retrospective study included 459 patients with SBS recieving HPN in a single center. Patient records were evaluated for demographics, SBS etiology, and underlying disease, anatomy of the gastrointestinal tract, intestinal failure classification, nutrition regimen, and presence of urolithiasis. Kidney stones were diagnosed in 24% of patients. Nodifferences in incidence were noted between the various etiologic groups. The incidence in patients with a colon in continuity and those with an end stoma was similar. The length of residual small bowel did not play a role in stone formation. There were no differences between patients according to the severity of intestinal failure. In patients treated with PN and limited oral feeding, the risk of urolithiasis was twice as high as in patients receiving PN only. Patients developed urolithiasis with no relation to the SBS etiology. The risk of kidney stone formation was higher in patients recieving PN with oral feeding.

Home parenteral nutrition in older vs younger patients: Clinical characteristics and outcomes.

There is a demographic shift toward older patients receiving home parenteral nutrition (HPN), but data on clinical outcomes are limited. The objective of this study was to determine differences between older and younger HPN patients in regard to HPN indications, prescriptions, and outcomes over the first 2 years receiving HPN. This was a retrospective analysis of prospectively collected data from HPN adult patients entered in the Canadian HPN Registry. New HPN patients enrolled between 2003 and 2017 and receiving HPN for at least 2 years were selected. Data included demographics, PN prescriptions, catheter-related bloodstream infections (CRBSIs) over the past year, survival, and quality of life based on Karnofsky Performance Status (KPS). Four hundred two patients were included: 184 patients were ≥60 years old, and 219 patients were between 18 and 59 years old. There were no differences in the main indications for HPN, body mass index (BMI), and PN prescriptions at baseline. At 2 years, younger patients received more energy from PN than older patients (27.9 vs 19.6 kcal/kg; P < .001), but BMI remained comparable. There were fewer CRBSIs in the older group (20% vs 36%, P = .0023), but 78% of younger patients remained alive vs 69% in the older group (P = .0401). In those alive, the proportion of patients continuing to receive HPN was comparable and the proportion of patients with a KPS ≥60. Older HPN patients have similar clinical characteristics as younger patients but have fewer CRBSIs and higher 2-year mortality.

A240 HOME PARENTERAL NUTRITION IN OLDER VERSUS YOUNGER PATIENTS: CLINICAL CHARACTERISTICS AND OUTCOMES

Abstract Background There is a demographic shift toward older patients receiving home parenteral nutrition (HPN) but there is little data on their clinical characteristics and outcomes versus younger HPN patients. Aims The objective of this study was to determine if there are any differences between older (&amp;gt; 60 years) and younger (18–59 years) HPN patients in regard to HPN indications, prescriptions and outcomes over the first 2 years receiving HPN. Methods This was a retrospective analysis of prospectively collected data from HPN adult patients entered in the password protected web-based Canadian HPN Registry. New HPN patients enrolled between 2003 and 2017 and receiving HPN for 2 years were selected from 8 participating programs across Canada. Data included demographics, anthropometrics, PN prescriptions, line sepsis events, survival and quality of life based on the Karnofsky Performance Status (KPS). Results 402 patients met the inclusion criteria: 184 patients were 60 years old or above (older group) and 219 patients were between 18 and 59 years old (younger group). Around 64% of both groups were female. There were no significant differences in the main indications for HPN, body mass index (BMI), and PN prescriptions at baseline. At 2-years, younger patients received more calories from PN than older patients (27.88 vs 19.56 Kcal/kg respectively, p &amp;lt;0.001) but BMI remained comparable between groups. There were less line sepsis in the older group versus the younger group (20% vs 36%, p=0.0023) but 78% of younger patients remained alive versus 69 % in the older group (p=0.0401). In those alive, the proportion of patients remaining on HPN was comparable (older group: 77%; younger; group 81%, p=0.4709) and the proportion of patients with a reasonable quality of life (KPS &amp;gt; 60) was similar (older group: 58%; younger group: 63%, p=0.2156). Conclusions Older HPN patients have similar clinical characteristics as younger patients but with reduced line sepsis events and higher 2-year mortality. Funding Agencies Ontario Medical Supply, Takeda, Fresenius Kabi and Baxter Inc

Cost-effectiveness of taurolidine locks to prevent recurrent catheter-related blood stream infections in adult patients receiving home parenteral nutrition: a 2-year mirror-image study

The use of long-term taurolidine locks (LTTL) seems to be effective in preventing catheter-related blood stream infections (CRBSI), especially in patients on home parenteral nutrition (HPN). This work targets the cost-effectiveness of LTTL in a cohort of adult HPN patients. A monocentric mirror-image design study was conducted in our referral centre among long-term HPN patients experiencing recurrent CRBSI. From 7th January 2011, LTTL were started after the third CRBSI episode within 12 months. CRBSI data was prospectively collected until 7th January 2013, in the same way as it had retrospectively been done before initiating LTTL. A cost-effective analysis was conducted to estimate the incremental costs and effects on CRBSI with LTTL. The efficacy of LTTL on CRBSI rate was assessed over 1000 days of catheter use. A total of 31,100 catheter days were analysed in 37 patients (median [interquartile range (IQR)]) aged 58 [42-68] years. The mean±SD proven CRBSI rate was 3.18±3.51 per 1000 catheter days before the introduction of LTTL and 0.39±1.50 per 1000 catheter days after its introduction (p<0.0001). Considering both proven and probable CRBSI requiring hospital management, LTTL reduced by (mean [bootstrap CI 95%])-2.63 [-3.26 to-2.06] infections per patient (from 2.89 [2.31 to 3.49] before to 0.26 [0.13 to 0.41] after) as well as incremental costs by-7 258 [-10 450 to -4 016] € (from 11 176 [8 004 to 14 968] € before to 3 918 [2 390 to 5 445] € after). Implementing LTTL to prevent recurrent CRBSI is cost-effective by dramatically decreasing their incidence.

An International Survey of Clinicians' Experience Caring for Patients Receiving Home Parenteral Nutrition for Chronic Intestinal Failure During the COVID-19 Pandemic.

BackgroundThis survey of centers caring for patients receiving home parenteral nutrition (HPN) was conducted to assess the impact of the coronavirus disease 2019 (COVID‐19) crisis on the management of these patients regarding provision of care, monitoring, regular follow‐up, and any changes to service infrastructure.MethodsA survey was devised and publically published on the Research Electronic Data Capture database management system, with individual centers responding to a public link.ResultsA total of 78 adult and pediatric centers worldwide contributed to the survey, representing ≥3500 patients’ experiences. Centers reported infrastructure maintenance for Parenteral Nutrition (PN) bag deliveries to patients (60, 76.92%) or delivery of ancillary items (57, 73.08%), home delivery and HPN administration (65, 83.33%), and home care nurse shortages (25, 32.05%). Routine follow‐up of HPN patients changed to either all telemed or mixed with emergency clinic review (70, 89.74%). In 26 centers (33.33%), HPN for newly discharged patients with benign conditions was reduced or stopped. Based on clinical history, the centers reported psychological distress for patients (52, 66.67%), with anxiety, worry, concern, and apprehension reported most frequently (37 of 52, 71.15%) but also fear (10 of 52, 19.23%), depression (5 of 52, 9.62%), and issues related to isolation/confinement (12 of 52, 23.08%).ConclusionsThe COVID‐19 pandemic was reported by clinicians to have had a far‐reaching adverse impact on patients receiving HPN, especially their safety in terms of provision of personal protective equipment, PN bags, available nursing staff, and psychological well‐being. Healthcare systems responded to the challenge and presented new ways of working.

A Case of Macrocytic Anemia Due to Selenium Deficiency in a Bedridden Elderly Patient Receiving Home Parenteral Nutrition

目的：セレン欠乏症は筋痛や筋力低下などで発見される報告が多いが，大球性貧血をきたすこともある．しかしその症例報告は少ない．在宅中心静脈栄養を受けている高齢患者に生じたセレン欠乏症による大球性貧血の症例を報告する．方法/結果：20年来のパーキンソン病のため寝たきりの89歳女性で，6年間在宅中心静脈栄養を受けていた．発熱で入院時，Hb 7.5 g/dL，MCV 131 fLと大球性貧血を認め，全血セレン 3.2 μg/dLと低値だった．セレン製剤を院内調剤し，セレン 100 μg/日の補充を行ったところ3ヶ月後にHb 9.7 g/dL，MCV 104 fL，全血セレン 5.5 μg/dLに改善し，セレン欠乏症による大球性貧血と診断した．結論：寝たきり高齢患者や認知症患者では筋痛などの症状を訴えられないことがあり，医療者はセレン欠乏症のリスクと症状に注意し早期発見と治療に努めることが大切である．

Influence of different intravenous lipid emulsions on fatty acid status and laboratory and clinical outcomes in adult patients receiving home parenteral nutrition: A systematic review

Patients who have chronic intestinal failure require home parenteral nutrition (HPN) support. Intravenous lipid emulsions (IVLEs) are a vital part of HPN. The conventional IVLE is based on pure soybean oil, which contains a high concentration of omega-6 fatty acids. Alternative IVLEs are commercially available. These contain various oil blends and have different fatty acid compositions from soybean oil that could provide benefit to patients on HPN. The aim of this systematic review is to assess the effects of different IVLEs in adult patients requiring HPN. A systematic literature search was conducted up to October 2019 using relevant search terms in the Medline, EMBASE and CINAHL databases. Only randomised controlled trials (RCTs) in adults on HPN that compared two or more IVLEs were included. Data were extracted and the Cochrane Collaboration's tool for assessing risk of bias was used. Six articles were identified for inclusion in this systematic review. Studies differed according to sample size, duration and the IVLEs compared. Four studies found no increased risk of adverse effects related to the different IVLEs, whilst one study found a higher frequency of serious adverse events with soybean oil. One study found higher serum α-tocopherol with the blend of soybean oil, medium chain triglycerides, olive oil and fish oil. Inflammatory markers were not affected by different IVLEs in three studies. Differences in liver function tests were minimal, but one study found slight abnormalities in patients receiving soybean oil. IVLEs containing olive oil or fish oil modified the blood fatty acid profile. No studies reported essential fatty acid deficiency. There may be benefits of using alternative IVLEs to soybean oil-based emulsions in adults requiring HPN, although there is currently insufficient evidence to determine superiority of one formulation over another. More and larger RCTs are required in this area.

Bone mineral density and vitamin D in paediatric intestinal failure patients receiving home parenteral nutrition.

Patients with intestinal failure (IF) are dependent on long-term home parenteral nutrition (HPN) to ensure growth and development. The primary aim of the present study was to assess bone mineral density (BMD) and vitamin D status in paediatric IF patients on HPN and a group of healthy children aged 2-18 years. Secondary aims were to assess growth, body composition, nutrient provision and physical activity. An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo, from January to September 2017. Dual energy x-ray absorptiometry (DXA; Lunar Prodigy in IF patients and Lunar iDXA in healthy subjects) was performed to assess BMD and body composition. BMD z-score (BMDz) was calculated for total body and lumbar spine L2-L4 based on the integrated reference population in the software. Weight and height were measured for growth assessment. Nutrient provision was assessed by a 4-day food record. Blood samples were analysed for 25-hydroxy-vitamin D (25(OH)D) and 1,25-dihydroxyvitamin D (1,25(OH)2D). Physical activity was reported by a questionnaire. Nineteen IF patients and 50 healthy children were included. The mean age of participants was 10.0 years. The aetiology of IF patients was paediatric intestinal pseudo-obstruction (58%), short bowel syndrome (26%), and intestinal enteropathy (16%). Lower median BMDz for total body (-0.4 vs 1.1, P<0.001) and lumbar spine L2-L4 (-0.9 vs 0.2, P=0.01) were found in the IF group compared with the healthy children. Vitamin D provision was significantly higher in IF patients (17μg/d vs 5.3μg/d, P<0.001). Both groups were sufficient in 25(OH)D (IF patients 71nmol/L vs healthy 81nmol/L). Nevertheless, IF patients had significantly lower 1,25(OH)2D than healthy children (71pmol/L vs 138pmol/L, P<0.001). The IF group was significantly shorter (height for age z-score-1,5 vs 0,1, P=0.001) and lighter (weight for age z-score-1,0 vs 0,1, P=0.009) compared with the healthy subjects. BMIz did not differ; however, body fat percentage was significantly higher in IF patients compared with healthy children (34% vs 25%, P=0.02). A lower frequency of physical activity was found in the IF group compared with the healthy group (P=0.001). Paediatric IF patients on HPN had lower BMD, impaired growth, and higher body fat percentage in comparison with the healthy children. Despite a higher total supply of vitamin D in the IF group, the levels of 25(OH)D did not differ. Nevertheless, a significantly lower level of 1,25(OH)2D was found in IF patients. The results raise questions regarding differences between oral and parenteral vitamin D provision and whether intestinal function is important for the metabolism of vitamin D. Clinical Trials AEV2017/1. 2016/391/REK sør-øst B REVISION NUMBER: CLNESP-D-20-00022.

Comparative Complication Rates of 854 Central Venous Access Devices for Home Parenteral Nutrition in Cancer Patients: A Prospective Study of Over 169,000 Catheter-Days.

Whether peripherally inserted central catheters (PICCs) are appropriate as safe and durable venous access devices (VADs) is still controversial. The aim of this 7-year, prospective cohort study was to compare the incidence rate differences of catheter-related complications (CRCs) among 4 types of central VADs in cancer patients receiving home parenteral nutrition (HPN). We enrolled all adult cancer outpatients who were candidates for HPN and who had a central VAD inserted during the study period, focusing on the incidence rate of CRCs. We evaluated 854 central VADs (401 PICCs, 137 nontunneled centrally inserted central catheters [CICCs], 118 tunneled-cuffed CICCs, and 198 ports) in 761 patients, for a total of 169,116 catheter-days. Overall, the rate of total CRCs was 1.08/1000 catheter-days. The incidence of catheter-related bloodstream infections was low (0.29/1000), particularly for PICCs (0.08/1000; P < .001 vs tunneled-cuffed CICCs) and for ports (0.21/1000; P < .019 vs tunneled-cuffed CICCs). The rates of mechanical complications (0.58/1000) and of catheter-related symptomatic thrombosis (0.09/1000) were low and similar for PICCs, tunneled-cuffed CICCs, and ports. In terms of duration and removal rate due to complications, PICCs were like tunneled-cuffed CICCs and ports. Altogether, PICCs had fewer total complications than tunneled-cuffed CICCs (P < .001), there was no difference in total complications between PICCs and ports. PICCs had significantly better outcomes than tunneled-cuffed CICCs and were safe and durable as ports. Our extensive, long-term study suggests that PICCs can be successfully used as safe and long-lasting VADs for HPN in cancer patients.

Trace Elements' Contamination of Pediatric Parenteral Nutrition Solutions in Canada: A Cause for Concern.

Trace elements' (TEs) contamination of parenteral nutrition (PN) solutions is an ongoing concern. The aims of this study were 1) to measure actual TE concentrations in PN admixtures compared with ordered concentrations and 2) compare TE intake with current recommendations. PN admixtures from discarded bags were collected from patients receiving home PN and on inpatient wards. Samples were collected from 72 patients (39 inpatients, 33 receiving home PN). Age, percentage energy intake from PN, and PN orders were collected from patients' charts. PN samples were analyzed for TEs, including chromium (Cr) and manganese (Mn), and concentration measurements compared with ordered concentrations and current recommendations. Measured Cr and Mn concentrations were higher than ordered concentrations: 5.3 ± 1.7 vs 2.8 ± 1.5 µg/L; P < 0.0001 and 11.9 ± 5.9 vs 0.00 µg/L; P < 0.0001, respectively. Chromium contamination alone accounted for over 100% of current recommendations for patients 0-12 months and between 63% and 92% for children >1 year. Contamination of Mn provided all the measured Mn in PN admixtures, since Mn is excluded from PN orders at our institution. Between 70% and 120% of current Mn recommendations were met from contamination. Cr should be excluded from PN admixtures for children 0-12 months and only one-fourth the current recommendation should be added for pediatric patients >1 year. Manganese should also be excluded from PN admixture for pediatric patients but plasms monitoring 2-3 times per year is recommended for those on long-term PN.

Micronutrients in paediatric Intestinal Failure Patients receiving home parenteral nutrition.

Children with intestinal failure (IF) receive parental nutrition to ensure adequate growth and development. The aim of this study was to assess micronutrient status in paediatric IF patients receiving home parenteral nutrition (HPN) in comparison to a group of healthy children. An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo from January to September 2017. All children with IF, aged two to 18 years, were invited to participate. A reference group of healthy children was recruited through social media advertisement. Dietary intake was assessed by a four-day food record, and enteral and parenteral provision was recorded. Blood samples were analysed for vitamins, minerals and haematology to assess iron status. Two spot urine samples from each subject were analysed for iodine concentration (UIC) and creatinine. Nineteen children with IF and 50 healthy children were included. The mean age of the participants was 10.0 years. IF-patients received a median of 76% of their estimated energy requirements from parenteral nutrition (PN). Recommended intake (RI) for iodine from the diet was reached by 16% of IF patients and 28% of healthy children. In the IF group there was a significant positive correlation between UIC and the percentage of iodine intake from oral diet and enteral nutrition support (r=0.57, p=0.03). Although the IF patients had a median parenteral iodine supply of more than twice the ESPGHAN recommendation, the median UIC was 89μg/L indicating insufficient iodine status. This may suggest that the ESPGHAN recommendation for iodine in paediatric parenteral nutrition is too low. The healthy children had sufficient iodine status according to the median UIC (133μg/L). IF patients had significantly lower total provision of iron compared to the healthy children, 4,9 vs 8,4mg/day (p=0.01) with 21% of IF patients and 28% of healthy children reaching RI for iron. The prevalence of anaemia was higher in IF patients than in the healthy children (40 vs.10%, p=0.016). The study indicates an insufficient iodine and iron status among paediatric IF patients. Iodine status was associated with enteral provision and patients had insufficient status even if they received the ESPGHAN recommendation of iodine. Clinical Trials AEV2017/1. 2016/391/REK sør-øst B.

Antimicrobial Locks in Patients Receiving Home Parenteral Nutrition.

Catheter-related bloodstream infection (CRBSI) is one of the most common and potentially fatal complications in patients receiving home parenteral nutrition (HPN). In order to prevent permanent venous access loss, catheter locking with an antimicrobial solution has received significant interest and is often a favored approach as part of the treatment of CRBSI, but mainly for its prevention. Several agents have been used for treating and preventing CRBSI, for instance antibiotics, antiseptics (ethanol, taurolidine) and, historically, anticoagulants such as heparin. Nonetheless, current guidelines do not provide clear guidance on the use of catheter locks. Therefore, this review aims to provide a better understanding of the current use of antimicrobial locking in patients on HPN as well as reviewing the available data on novel compounds. Despite the fact that our current knowledge on catheter locking is still hampered by several gaps, taurolidine and ethanol solutions seem promising for prevention and potentially, but not proven, treatment of CRBSI. Additional studies are warranted to further characterize the efficacy and safety of these agents.

Use of Catheter Lock Solutions in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Individual-Patient Data Meta-Analysis.

BackgroundUse of catheter lock solutions (CLSs) as a strategy to prevent catheter‐related bloodstream infections (CRBSIs) has been evaluated in recent clinical trials. Our aim was to identify the most effective CLS formulation in patients receiving home parenteral nutrition (HPN).MethodsWe conducted a systematic review and individual‐patient data meta‐analysis (IPDMA). Prospective randomized clinical trials in adult HPN patients using CLS were identified from PubMed, EMBASE, Web of Science, CINAHL, Cochrane library, and ClinicalTrials.gov. Primary outcome was the number of CRBSIs per 1000 catheter days for each CLS. Other outcomes included time to CRBSI and identification of patients with a higher risk for CRBSIs.ResultsIn total, 1107 studies were screened for eligibility, of which three studies comprising 162 HPN patients and 45,695 catheter days were included in the IPDMA. CRBSI rates were significantly decreased in patients using taurolidine (rate 0.13; 95% confidence interval [CI], 0.05–0.32) when compared with saline (rate 0.74; 95% CI, 0.31–1.74; P = .002) or heparin (rate 2.01; 95% CI, 1.03–3.91; P < .001). The cumulative proportion of CRBSI‐free patients using taurolidine, saline, and heparin after 1 year was 88%, 56%, and 14%, respectively. Three risk factors for CRBSIs were identified: type of CLS, intestinal dysmotility as underlying condition, and use of central venous catheters.ConclusionsTaurolidine was the most effective CLS formulation in HPN patients for the prevention of CRBSIs. We suggest discussing with patients the benefits and risks when starting taurolidine, especially in patients who are considered to have a higher risk for CRBSIs.

Absence of colon as the predominant risk factor for liver fibrosis in adults requiring home parenteral nutrition

Liver fibrosis is a well-known complication of long-term use of parenteral nutrition in patients with intestinal failure associated to the nutrient composition in parenteral nutrition. This study investigates the prevalence of significant liver fibrosis and identifies risk factors for liver fibrosis. This was a retrospective study of 35 parenteral nutrition-dependent patients with intestinal failure and 54 patients with intestinal insufficiency and oral nutrition only with a valid liver stiffness measurement obtained with transient elastography from November 2016 to August 2018. Clinical and demographic parameters including age, fat mass index and fat-free mass index, intact colon or colectomy, and nutritional management were analyzed for their association with liver stiffness. A prevalence for liver fibrosis (liver stiffness >7.0 kPa) was established at 37.1% in parenteral nutrition-dependent patients and at 22.2% in patients on oral nutrition. Several factors were significantly and independently associated with liver fibrosis including lipids in home parenteral nutrition (OR 10.66, p= 0.010) and colectomies (OR 3.24, p= 0.036). More than a third of patients receiving home parenteral nutrition have liver fibrosis. Several risk factors were demonstrated such as the amount of lipids and performed colectomies despite current international guidelines for lipids are followed. Our findings emphasize suggest a new perspective to prevent significant hepatic complications: colectomies.