How does long-term parenteral nutrition impact the bone mineral status of children with intestinal failure?

Abstract

Patients on long-term parenteral nutrition (PN) are at significantly increased risk for the development of metabolic bone disease (MBD); this condition is characterized by incomplete mineralization of osteoid with consequent disturbances ranging from osteopenia to severe bone disease with fractures. The aim of the study was: (1) to evaluate the prevalence of MBD, (2) to identify the PN- or intestinal failure (IF)-related factors and (3) to assess annual changes of bone mineral status. Since September 2005 all patients affected by IF and treated with PN started a BMD evaluation program using dual-energy X-ray absorptiometry (DXA). Twenty-four IF patients were included [15 with short bowel syndrome (SBS), 5 with severe protracted diarrhea and 4 with chronic intestinal pseudostruction]. The bone mineral density (BMD) Z-score was significantly lower in patients than in the control group. In our series SBS patients showed a BMD Z-score significantly higher in comparison with the medical causes of IF. No significant correlations were found between bone mineral status and PN duration and nutrient intake. Nine IF patients were submitted to a second DXA evaluation after 1 year from the baseline. All bone mineral variables were significantly increased at the second DXA evaluation. The high prevalence of MBD in IF patients undergoing long-term treatment with PN requires that these patients undergo careful and periodic monitoring of their bone mineral status; patients with congenital gut dysfunctions, such as epithelium defects and motility anomalies, are at major risk of developing this complication, probably due to the association with extra-intestinal causes of bone loss.

Pediatric intestinal failure: Predictors of metabolic bone disease

“…Of note, while we failed to show a correlation between underlying cause of IF and severity of MBD, a prior study with a higher proportion of non-SBS patients did show that children with SBS demonstrated milder MBD compared to those with mucosal and motility abnormalities as the cause of IF [9]. This series by Diamanti et al [9] found no significant correlation between PN duration and bone mineral status, in contrast to our results.…”

“…This rate was somewhat lower than that of prior studies where MBD has been reported in 70-83% of pediatric patients with IF [9,27]. By contrast, Ubesie et al found a lower (12.5%) MBD prevalence, though a more strict threshold of a BMD Z-score less than or equal to − 2 was used [14].…”

“…BMD Z-score has been used by prior investigators as a measure of bone mineralization in children [20,27]. MBD was defined as a BMD Z-score of less than −1.0 [9].…”

“…Among other complications such as sepsis and cholestasis [3,5], patients on PN are at significantly increased risk of developing metabolic bone disease (MBD) [6,7]. This complication, which may manifest as bone pain or pathologic fractures [8], has been shown to disproportionally affect children with IF relative to matched controls [9][10][11].…”

Risk of Metabolic Bone Disease is Increased Both during and after Weaning off Parenteral Nutrition in Pediatric Intestinal Failure

“…Osteoporosis [defined as a BMD T-score <-2.5 in adults (measured with dual-energy X-ray absorptiometry, DXA) according to the WHO] is reported in 32-67% of adults on long-term PN [13,14,15,16]. Low bone mineral content has been described in children with short bowel syndrome during [17] and after weaning off PN [18,19]. Also, other chronic intestinal disorders, such as inflammatory bowel disease, have a negative effect on bone mineralization in children [20,21].…”