Tolerance to starvation in children on long-term total parenteral nutrition

To evaluate the consequences of long-term cyclic total parenteral nutrition (TPN) on metabolic pathways which contribute to energy metabolism, adaptation to starvation was studied in a group of seven children 2-7 years old, on long-term cyclic TPN. In addition to clinical monitoring, the following biological parameters were measured: blood levels of glucose, free fatty acids, ketone bodies and carnitine, and urinary excretion of dicarboxylic acids. Five of the seven children had good clinical tolerance up to 30 h of fasting. This indicated that metabolic changes arising from prolonged cyclic TPN are easily reversed when such children are fasting. The other two children had to be refed after 22 and 24 h, respectively. Both had metabolic signs of impaired hepatic fatty acid oxidation or ketogenesis. These metabolic changes might reflect the liver failure caused by TPN in these children, and stresses the fact that prolonged starvation has to be carefully monitored in patients with liver dysfunction secondary to TPN.     

Total body potassium, fat and water during total parenteral nutrition in Crohn's disease

The body composition was studied by measurement of body weight (BW) and total body potassium (TBK), fat and water in 13 patients with Crohn's disease (CD), who were given altogether 18 courses of total parenteral nutrition (TPN) with nil by mouth each lasting at least 3 weeks. At the start of TPN, one group of steroid-free patients displayed intracellular potassium depletion, as reflected by the ratio TBK/lean body mass (LBM) (group 1). Another group of steroid-free patients showed no depletion of intracellular potassium (group 2). The patients given prednisolone all showed intracellular potassium depletion and were assigned to a separate group (group 3). During the initial 19-44 days of TPN, TBK, LBM and BW increased in group 1. All patients with intracellular potassium depletion (groups 1 + 3) showed an increase in TBK and TBK/LBM during the initial 19-51 days of TPN. For steroid-free patients (groups 1 + 2) there were linear relationships between the rate of energy supply per kg LBM and the 24 h change in BW during the third and fourth weeks of TPN (r = 0.79) and between the 24 h change inBW and LBM during the first 19-44 days of TPN (r = 0.59). A steady state in BW was found on administering 53 kcal/kg LBM/24 h. It is concluded that CD patients with intracellular potassium depletion are likely to be improved in terms of TBK and TBK/LBM by at least 3 weeks of TPN as given in the present study. Steroid-free CD patients with intracellular potassium depletion are, moreover, likely to show an improvement in LBM by at least 3 weeks of TPN, and an increase in their BW during the initial 3-6 weeks of TPN will probably reflect an increase in LBM. The pre-TPN TBK/LBM ratio may be a predictor of the repletion rate of the LBM compartment during TPN of steroid-free wasted CD patients.     

Availability of insulin from total parenteral nutrition solutions

Insulin is frequently required in total parenteral nutrition (TPN) solutions to control hyperglycemia. The purpose of this study was to evaluate the recovery of human insulin from standard TPN solutions with and without lipids and from TPN solutions with specialized amino acid formulations and to compare it to the insulin recovery from normal saline. All solutions were mixed in currently utilized PVC-free bags (ethylene vinyl acetate) and drained through PVC-containing tubing. Human insulin (Humulin-R) was spiked with 125I-labeled insulin and then added in concentrations of 10, 25, and 50 units to 1-liter bags containing 39-g amino acids (10% Freamine-III; or 6.9% Freamine HBC; or 8% Hepatamine), 257-g dextrose, electrolytes (Hyperlyte-R), 1000 units of heparin, MVI-12, and MTE-5 Concentrate. Alternate sets of bags contained 125 ml of 20% Intralipid and an appropriate amount of sterile water to keep the final volume at 1 liter. Actual clinical conditions of preparation, storage, and administration were simulated in this in vitro experiment. Multiple samples were collected during the 8-hr infusion period directly in gamma counter vials. All experiments and assays were done in triplicate. Our findings indicate that human insulin availability in TPN solutions is much higher (90%-95%) than the 50% suggested in the literature. Insulin recovery was not appreciably altered by adding lipids or by using Freamine HBC. Insulin recovery from TPN solutions was significantly reduced if they contained Hepatamine (87% and 88%, p less than 0.05) as compared to Freamine (90% and 94%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of separate insulin infusions with total parenteral nutrition

The efficacy, safety, and cost effectiveness of treating total parenteral nutrition (TPN)-induced hyperglycemia with a continuous insulin infusion, separate from the actual TPN bottle, was evaluated. A patient was included in the study if his serum glucose was greater than 200 mg/dl at a TPN infusion rate of less than 75% of the calculated caloric goal. The insulin infusion was run into the central line with the TPN via a Y-connector. At the patient's caloric goal, the infusion was stopped and the insulin was added to the TPN bottle, after the glucose was in the 100-200 mg/dl range for 24 hr. Sixteen patients including five known diabetics were studied, with data gathered retrospectively through chart review. It was estimated that 7.3 liters of TPN per patient were saved, compared to the amount used when insulin was added to newly prepared bottles of TPN each time a dosage change was required. In our institution, this amounts to a savings of $395.00 per patient (including charges for materials and an infusion pump for the insulin infusion). We conclude that separate insulin infusion is a reasonable and cost-effective alternative when treating glucose intolerance in patients receiving TPN.     

Visual function in patients undergoing long-term total parenteral nutrition

To evaluate the effects of long-term total parenteral nutrition (TPN) on eye function, 27 adults and 12 children in the UCLA Home TPN Clinic underwent ophthalmoscopic examination and visual-function testing. Direct inspection of the fundus showed a marked granularity of the retinal pigmented epithelium in some patients. About one-half of the children and one-third of the adults tested had at least one and usually two abnormalities in their electroretinogram. Determination of blood nutrients thought to affect vision revealed that zinc and vitamin E were within normal range. Vitamin A concentrations were above normal in 10 of 19 adults and selenium concentrations were below normal in 10 of 10 children and 17 of 21 adults tested. Linoleic and linolenic acid concentrations were low; plasma, platelet, and urine taurine concentrations were significantly lower than normal. Despite these diffuse nutrient abnormalities, only zinc and vitamin E concentrations correlated significantly with any index of visual function.     

Progressive bone loss during long-term home total parenteral nutrition

Metabolic bone disease occurs in patients receiving prolonged home total parenteral nutrition (HTPN). We studied bone-mass status in 10 patients (seven males, three females, age 19-66 years) who had been receiving HTPN for 0 to 67 months (mean 24 months), mostly for short-bowel syndrome. Four patients had spinal osteoporosis on radiograms. The density of various bone components at the wrist was measured noninvasively using a novel technique based on Compton scattering effect. The density of the cancellous and cortical bone was decreased in nine and six patients, respectively. During a follow-up period of up to 19 months, a further significant decrease in the density of both bone components was found. We conclude that prolonged HTPN is associated with an ongoing bone diminution, affecting mainly the cancellous bone.     

Taurine supplementation in infants receiving long-term total parenteral nutrition

Twenty-one children and 23 adults receiving long-term total parenteral nutrition (TPN) for 27 +/- 23 (SD) months were investigated to determine if they were taurine-deficient because the TPN solutions were taurine-free. The fasting plasma taurine level was reduced in the children to 26 + 13 mumol/liter vs the control 57 +/- 16 mumol/liter (P greater than 0.001). The plasma taurine level was significantly reduced in those adults who absorbed less than 25% of their nutritional needs from their diet. Electroretinograms were abnormal in each of eight children who were examined; isolated cone and rod implicit times were both significantly delayed. Electroretinograms were not abnormal in those adults with low plasma taurine levels. Taurine was added to the TPN solutions of four children, and the plasma taurine level became normal in each of them. Electroretinograms of three of these children became normal. One year after discontinuing intervenous taurine supplementation, the plasma taurine level became abnormal in two of three children. These observations indicate that children, and possibly adults, receiving long-term TPN have a nutritional requirement for taurine.     

Taurine supplementation in infants receiving long-term total parenteral nutrition.

Twenty-one children and 23 adults receiving long-term total parenteral nutrition (TPN) for 27 +/? 23 (SD) months were investigated to determine if they were taurine-deficient because the TPN solutions were taurine-free. The fasting plasma taurine level was reduced in the children to 26 + 13 mumol/liter vs the control 57 +/? 16 mumol/liter (P greater than 0.001). The plasma taurine level was significantly reduced in those adults who absorbed less than 25% of their nutritional needs from their diet. Electroretinograms were abnormal in each of eight children who were examined; isolated cone and rod implicit times were both significantly delayed. Electroretinograms were not abnormal in those adults with low plasma taurine levels. Taurine was added to the TPN solutions of four children, and the plasma taurine level became normal in each of them. Electroretinograms of three of these children became normal. One year after discontinuing intervenous taurine supplementation, the plasma taurine level became abnormal in two of three children. These observations indicate that children, and possibly adults, receiving long-term TPN have a nutritional requirement for taurine.     

Possible biotin deficiency in adults receiving long-term total parenteral nutrition

Two adult patients receiving total parenteral nutrition on a long-term home basis presented with severe loss of hair. Both patients had extensive gut resection, consumed no biotin orally and received no biotin parenterally. Supplementation with Berroca-C, one ampule containing 200 micrograms biotin per day resulted in gradual regrowth of healthy hair. The patients now receive a parenteral solution containing biotin and have shown no recurrence of alopecia. It is suggested that biotin deficiency can occur in the adult when no preformed biotin is provided to the body and the contribution of this vitamin from intestinal microbial biosynthesis is compromised.     

Carcass and organ composition of rats fed high fat total parenteral nutrition

Fat-based total parenteral nutrition (TPN) has been shown to maintain the host nutritionally equivalent to carbohydrate-based TPN in a rat model; however, data on body composition have not been obtained. This study compared the effects of a lipid-based TPN regimen to those of an isocaloric glucose-based regimen and an oral diet on the composition of the carcass and organs of tumor- and nontumor-bearing rats. Sprague-Dawley rats implanted with the Walker 256 carcinosarcoma were randomly assigned to either diet A, a glucose-based TPN regimen; B, a lipid-based TPN regimen; or C, a purified oral diet. Tumor-bearing rats infused with diet B had less protein and more fat in their carcasses than those in the other dietary groups. Organs of nontumor- and tumor-bearing rats fed diet B contained less protein and more fat and triglycerides than rats fed either diet A or C. Survival index and hematocrit values were lowest in rats infused with the parenteral lipid diet. These findings indicate an abnormal pathological response to a TPN diet formulated to deliver 67% of nonprotein kilocalories as lipid.     

Comparison of body protein metabolism during total parenteral nutrition using glucose or glucose and fat as the energy source

Direct measurement of body protein metabolism using L-(1-14C) leucine during total parenteral nutrition following cholecystectomy demonstrated no significant difference between isocaloric isonitrogenous regimens containing glucose alone (n = 5) or with a fat emulsion (n = 5) as the energy substrates. It would appear that providing the obligatory requirement for glucose is met (about 150g d(-1)), fat and carbohydrate calories are inter-changeable with regards to fueling protein metabolism in the early period following moderately severe trauma.     

Pancreatic exocrine response to parenteral nutrition

Animal experimental data concerning pancreatic exocrine secretory response to parenteral nutrition is contradictory. We have studied the pancreatic exocrine output in a patient with a pure pancreatic fistula. In this patient, parenteral nutrition with hypertonic glucose, amino acids and fat emulsion was not associated with increases in fistula volume or protein output. Enteral protein and fat in this patient caused rapid increases in both fistula volume and protein output. This study supports the use of parenteral nutrition as a means of maintaining the pancreas at rest.     

Small bowel resection-associated urinary calcium loss in rats on long-term total parenteral nutrition

This study was designed to study the effects of small bowel resection on daily urinary excretion patterns, plasma and bone levels of magnesium, phosphorus and calcium in rats on long-term total parenteral nutrition (TPN). Male Sprague-Dawley rats weighing 300 to 350 g were randomly divided into two groups with six rats in each group. Control consists of rats whose small intestines were transected but anastomosed. Resected rats had 70% of their small intestine removed. After intestinal resection and transection, rats were infused with a balanced TPN solution for 17 days. Resected rats excreted significantly more calcium than transected rats during the first 10 days of TPN infusion. Peak excretion occurred between day 3 and 4 followed by a trend toward a slightly higher than normal level of calcium excretion between days 10 and 17. Urinary losses of phosphorus and magnesium were not influenced by bowel resection. Plasma and tibia calcium, phosphorus and magnesium levels were not altered. The effects of small bowel resection on urinary calcium loss is specific and our data demonstrate the involvement of gut in regulating urinary calcium excretion and suggest that gut may play a significant role in TPN induced metabolic bone disease.     

Successful fibrinolytic therapy for superior vena cava thrombosis secondary to long-term total parenteral nutrition

Thrombosis of the superior vena cava and other major central veins is an unusual and infrequent complication of total parenteral nutrition. When it does occur, it may be life threatening and prompt therapy is indicated. A case of superior vena cava thrombosis secondary to an indwelling Broviac catheter for long-term parenteral nutrition is presented, which was successfully treated with Streptokinase with reestablishment of flow through the catheter and veins.     

Iodine nutrition in adults on long-term home parenteral nutrition

ObjectiveThe aim of this study was to evaluate iodine nutrition in adults on long-term home parenteral nutrition (HPN) and to compare it with iodine supplemented with PN, categorized as below or according to the European Society for Clinical Nutrition and Metabolism guidelines (ESPEN-GL) recommendation.MethodsIodine nutrition was evaluated retrospectively in 31 stable adults on long-term HPN. We analyzed urinary iodine concentration (UIC) and serum thyroid-stimulating hormone (TSH). A median UIC value ≥100 μg/L was considered indicative of adequate iodine intake, a value between 50 and 100 was indicative of moderate iodine deficiency, and a value <50 μg/L was indicative of overt iodine deficiency.ResultsPN iodine amount was according to ESPEN-GL in 26% of patients and lower in 19%; 55% did not receive iodine with PN. The median UIC was 63 μg/L (95% confidence interval [CI], 26–99 μg/L) in the whole group of patients, 56 μg/L (95% CI, 24–100) in the group including patients who did not receive any PN iodine supplementation and those who received PN iodine supply lower than the ESPEN-GL recommendation, and slightly higher (77 μg/L) in eight patients with PN iodine supply according to the ESPEN-GL (P = 0.42). TSH was normal in 74% of patients, increased in 23%, and reduced in 3%. Results did not change when patients with reduced glomerular filtration rate were excluded from the analysis.ConclusionsThe analyzed patients on long-term HPN had a low iodine intake as shown by low median UIC level, as did the group of patients who received PN iodine supplementation according to ESPEN-GL. A condition of subclinical hypothyroidism was observed in a small percentage of patients.     

Tumor cytokinetic response to total parenteral nutrition in patients with head and neck cancers

Refeeding of patients with malignant tumors may induce tumor-cell DNA synthesis. The present study was aimed at evaluating whether induction of altered cell-cycle kinetics could be induced by intravenous total parenteral nutrition (TPN) in tumor biopsies from head and neck cancers. Nine malnourished patients with squamous cell carcinoma in the head-and-neck area were investigated before and after 5-7 d of continuous TPN. Tumor biopsies were taken in both fasted and fed states for determination of 1) ornithine decarboxylase (ODC) activity, which is rate limiting for polyamine synthesis; 2) flow-cytometric-DNA-distribution measurements; and 3) the fraction of proliferating cells expressed as immunohistochemical reactivity with the monoclonal antibody Ki-67. The histopathological differentiation, the fraction of aneuploidic cells, ODC activity, and Ki-67 reactivity were not significantly related to each other, although the number of aneuploidic cells in replicative phases correlated with the number of cells expressing the Ki-67 antigen (r = 0.86, P less than 0.01). Tumor cytokinetics showed no evidence of being changed by TPN administration.     

Folic acid and total parenteral nutrition

The stability of folic acid in a variety of solutions used for parenteral nutrition has been determined over a 2-wk period. Provided that the acidity of the solution remains above pH 5.0 the folate, in the concentrations usually used for parenteral nutrition, will remain stable in solution, and all of the folate added to the solution will be delivered to the patient. The applicability of this in vitro work to a group of patients requiring parenteral nutrition was assessed, in order to determine a suitable dose. A dose of 0.2 mg of folic acid daily was inadequate to meet the requirements of these patients. In contrast a dose of 1.2 mg daily for 7 days was sufficient to cause an increase in the serum folate concentration.     

Thermogenic response to total parenteral nutrition in depleted patients with multiple organ failure

Nutrient-induced thermogenesis was studied in eight patients with severe nutritional depletion and multiple organ failure after abdominal surgery. Energy expenditure (EE) and RQ were recorded continuously over a period of 4 days. On each study day balanced total parenteral nutrition was administered during a period of approximately 16 h, followed by a period of low-energy glucose infusion. The total energy supply was in the order of 110% of the measured EE and the supply of glucose, fat and amino-acids was 2.6 +/- 0.4, 2.6 +/- 0.2 and 0.84 +/- 0.2 kJ x kg BW(-1) x h(-1) (mean +/- SD), respectively. The nutrient-induced thermogenesis, expressed as the rise in EE in percent of the energy content of the administered nutrients, was approximately 5%, which appears to be lower than previously observed in healthy individuals. A plateau in energy expenditure was reached after 6-8 h in response to parenteral nutrition. It is hypothesized that this plateau reflects the oxidative capacity and thus may be used as a guideline for nutritional therapy.