Use of Mixed‐Oil Fat Emulsion to Improve Intestinal Failure–Associated Liver Disease in Long‐Term Home Parenteral Nutrition: A Case Report

Kuchkuntla

Salonen

et al. 2019

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Background: Although home parenteral nutrition (HPN) is lifesaving for patients with chronic intestinal failure (IF), long‐term use can be associated with complications such as infections, metabolic abnormalities, and IF–associated liver disease (IFALD). The key to treatment of many of these complications is prevention. Guidelines recommend avoidance of overfeeding, use of oral/enteral nutrition if possible, cyclic PN, and maintaining dose of soybean oil (SO) intravenous lipid emulsion (ILE) <1 g/kg/day as preventive strategies for IFALD. Additionally, with development of IFALD, ω‐6/ω‐3 polyunsaturated fatty acid ratio should be decreased in ILE. The newly available mixed‐oil (MO) ILE offers such an opportunity; however, there is a paucity of long‐term data available. Methods: The current study reports our long‐term experience with MO ILE use in HPN patients. Results: Seventeen patients (8 female and 9 male) with an average age of 47 ± 12 years and median HPN duration of 4.6 years (1.1–32.1 years) have utilized MO ILE for >12 months after being transitioned from SO ILE because of intolerance. Use of MO ILE allowed an increase in ILE energy from 8% ± 8% to 22% ± 8% while reducing dextrose energy from 66% ± 8% to 54% ± 5%, maintaining stability in alkaline phosphatase and triglyceride levels, and achieving improvement in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and α‐tocopherol levels. Conclusion: In this HPN cohort with SO ILE intolerance, MO ILE was well tolerated and allowed an improvement in macronutrient composition while improving some liver parameters over a 12‐month period.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Long‐Term Use of Mixed‐Oil Lipid Emulsion in Soybean Oil–Intolerant Home Parenteral Nutrition Patients

Kuchkuntla

Salonen

et al. 2019

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“…After MO ILE was available in the United States, we were able to add to his PN as a 3:1 admixture utilizing the same pump, and the patient was slowly transitioned up to a dose of 70 g/d, 7 d/wk. With this increase, his weight rebounded and his total bilirubin decreased from 2.4 to 0.8 mg/dL after the first month, and his AST and ALT levels normalized …”

Section: Clinical Datamentioning

confidence: 98%

“…However, as the ILE component of PN is reduced, a higher percentage of non‐protein energy is derived from dextrose, a strategy that can have its own detrimental effects. This dilemma is highlighted nicely by the recently published case of a 32‐year‐old male with CIF owing to a history of intestinal dysmotility and pseudo‐obstruction, who subsequently developed IFALD . Initially, after development of IFALD, his SO ILE was reduced from 50 g provided 3 times per week to 50 g once every 2 weeks.…”

Section: Intestinal Failure Associated Liver Diseasementioning

confidence: 99%

“…Instead of starting with adult patients who are newer to HPN, another beneficial approach has been to use MO ILE in patients who may have developed intolerance to SO ILE, such as those with liver abnormalities . This was the approach taken in the case study of a patient with IFALD, as discussed previously . After development of IFALD, reduction in ILE dose and corresponding increase in dextrose dose was complicated by development of pancreatitis.…”

Section: Clinical Datamentioning

confidence: 99%

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Use of Lipids in Adult Patients Requiring Parenteral Nutrition in the Home Setting

Kłęk²,

Martindale

2020

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It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non‐protein energy, as well as supplying essential fatty acids. However, the long‐term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long‐term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω‐6:ω‐3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium‐chain triglycerides, and fish oil) to reduce the soybean‐oil content of ILE, which tends to be high in ω‐6 PUFA and phytosterols. Although additional long‐term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.

Management of long‐term home parenteral nutrition: Historical perspective, common complications, and patient education and training

Elfadil

Hurt

et al. 2022

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Intestinal failure (IF) is a rare disease that requires ongoing intravenous supplementation to sustain growth and health. Advancements in parenteral nutrition (PN) and central venous access in the 1960s and 1970s transformed a life-limiting disease to a chronic one in which patients are able to administer hydration, electrolytes, micronutrients, and macronutrients in the comfort of their home. However, despite ongoing advancements in the field of home PN (HPN), complications-whether related to central venous catheters or PN itself-remain common and can be associated with significant morbidity and mortality. Central venous access can be associated with thrombosis, central line-associated bloodstream infection, or damage and can result in loss of access over time. PN can be associated with IF-associated liver disease or hyperglycemia. The key to preserving central venous access and quality of life and maintaining health for patients with chronic IF (CIF) is education focused on prevention and prompt management of CIF complications as they arise. This education typically takes place at the time of initiation of HPN, either in the hospital setting or in the patient's home. The present manuscript describes the historical progression of HPN, prevalence and characteristics of CIF, and an in-depth discussion of the most common catheter-related and PN-related complications and their management, along with a discussion of our education and training process.