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Clinical Nutrition (Edinburgh, Scotland) Mar 2021Patients who have chronic intestinal failure require home parenteral nutrition (HPN) support. Intravenous lipid emulsions (IVLEs) are a vital part of HPN. The...
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.
BACKGROUND & AIMS
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.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
Topics: Adult; Dietary Fats; Fat Emulsions, Intravenous; Fatty Acids; Female; Fish Oils; Humans; Intestinal Diseases; Male; Middle Aged; Nutritional Status; Olive Oil; Parenteral Nutrition, Home; Randomized Controlled Trials as Topic; Soybean Oil; Treatment Outcome
PubMed: 32758383
DOI: 10.1016/j.clnu.2020.07.014 -
The American Journal of Clinical... Oct 2021Parenteral nutrition (PN) is an available option for nutritional therapy and is often required in the hospital setting to overcome malnutrition. (Meta-Analysis)
Meta-Analysis
Mortality and overall and specific infection complication rates in patients who receive parenteral nutrition: systematic review and meta-analysis with trial sequential analysis.
BACKGROUND
Parenteral nutrition (PN) is an available option for nutritional therapy and is often required in the hospital setting to overcome malnutrition.
OBJECTIVES
The aim of this study was to assess whether PN is associated with an increased risk of mortality or infectious complications in all groups of hospitalized patients compared with those receiving other nutritional support strategies.
METHODS
For this systematic review and meta-analysis MEDLINE, Embase, Cochrane Central, Scopus, clinicaltrials.gov, and Web of Science were searched for randomized controlled trials (RCTs) and observational studies with parallel groups that explored the effect of PN on mortality and infectious complications, published until March 2021. Two independent reviewers extracted the data and assessed the risk of bias. Fixed-effects meta-analysis was performed to compare the groups from RCTs. Trial sequential analysis (TSA) was used to identify whether the results were sufficient to reach definitive conclusions.
RESULTS
Of the 83 included studies that compared patients receiving PN with those receiving other strategies, 67 RCTs were included in the meta-analysis. PN was not associated with a higher risk of mortality (RR: 1.01; 95% CI: 0.95, 1.07). On the other hand, PN was associated with a higher risk of infectious events (RR: 1.23; 95% CI: 1.12, 1.36). PN was specifically associated with abdominal infection and catheter infection. The TSA showed that there were sufficient data to make numerical conclusions about mortality, any infectious event, and abdominal infectious complications.
CONCLUSIONS
This study suggests that although PN is not associated with greater mortality in hospitalized patients, it is associated with infectious complications. Through TSA, definite conclusions about survival and infection rates could be made.This review was registered at www.crd.york.ac.uk/prospero/ as CRD42018075599.
Topics: Bacterial Infections; Catheter-Related Infections; Humans; Mortality; Parenteral Nutrition; Risk Factors
PubMed: 34258612
DOI: 10.1093/ajcn/nqab218 -
Clinical Nutrition (Edinburgh, Scotland) Feb 2015Acute pancreatitis is a systemic immunoinflammatory response to auto-digestion of the pancrease and peri-pancreatic organs. Patients with acute pancreatitis can rapidly... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND & AIMS
Acute pancreatitis is a systemic immunoinflammatory response to auto-digestion of the pancrease and peri-pancreatic organs. Patients with acute pancreatitis can rapidly develop nutritional deficiency; hence nutritional support is important and critical. Sometimes parenteral nutrition (PN) is inevitable in acute pancreatitis. Due to immunosuppressive and inflammatory nature of the disease, it seems that immunonutrients like glutamine and omega-3 fatty acids (ω-3 FAs) added to parenteral formulas may improve the conditions. We conducted a meta-analysis to evaluate the effects of parenteral immunonutrition on clinical outcomes (infectious complications, length of hospital stay (LOS) and mortality) in patients with acute pancreatitis.
METHODS
A computerized literature search on four databases (PubMed, Cochrane, ISI Web of Science, and Iran Medex) was performed to find all the randomized controlled trials (RCTs) assessed the effects of parenteral immunonutrition in acute pancreatitis. Necessary data were extracted and quality assessment of RCTs was performed with consensus in the study team. Fixed effects model was used to conduct the meta-analysis.
RESULTS
One hundred and ninety four references were found via our search in which 7 articles matched our criteria for enrolling the meta-analysis. Parenteral immunonutrition significantly reduced the risk of infectious complications (RR = 0.59; 95% CI, 0.39-0.88; p ≤ 0.05) and mortality (RR = 0.26; 95% CI, 0.11-0.59; p ≤ 0.001). LOS was also shorter in patients who received immunonutrition (MD = -2.93 days; 95% CI, -4.70 to -1.15; p ≤ 0.001).
CONCLUSION
Immunonutrients like glutamine and ω-3 FAs added to parenteral formulas can improve prognoses in patients with acute pancreatitis.
Topics: Acute Disease; Fatty Acids, Omega-3; Glutamine; Humans; Infections; Length of Stay; Nutritional Support; Pancreatitis; Parenteral Nutrition; Prognosis; Randomized Controlled Trials as Topic
PubMed: 24931755
DOI: 10.1016/j.clnu.2014.05.008 -
European Journal of Clinical Nutrition Oct 2016The precise role of fish oil-based lipid emulsions (FBL=any lipid emulsion containing any amount of fish oil) and soy oil-based lipid emulsions (SBL=any lipid emulsion... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/OBJECTIVES
The precise role of fish oil-based lipid emulsions (FBL=any lipid emulsion containing any amount of fish oil) and soy oil-based lipid emulsions (SBL=any lipid emulsion not containing fish oil or containing at least 50% soy oil) in neonatal parenteral nutrition (PN) needs to be explored.
SUBJECTS/METHODS
The PubMed, MedLine and Google Scholar databases were searched for randomised control trials in which PN with FBL and SBL was the only difference between intervention and control groups. Methodological quality was assessed based on the Cochrane handbook for systemic reviews and Jadad's score. Revman 5.2 software was used for meta-analysis.
RESULTS
Of 420 trials, 25 met the inclusion criteria. The aggregate results showed that both FBLs and SBLs are beneficial. FBLs were associated with significantly lower incidences of cholestasis (relative risk (RR)=0.50; 95% confidence interval (CI)=0.27-0.92, P=0.03) compared with SBLs. FBLs also had a tendency to improve the rates of weight gain, increase in head circumference and the time to regain birth weight (mean difference (MD)=0.24; 95% CI=-0.63-0.15). SBLs were associated with reduced duration of respiratory support (MD=2.22, 95% CI=0.35-4.09, P=0.02) and mortality rate in the first 28 days (RR=1.24, 95% CI=-0.72-2.13).
CONCLUSIONS
Both FBLs and SBLs are beneficial for neonatal PN. FBLs reduce cholestasis, and SBLs reduce the duration of respiratory support.
Topics: Emulsions; Fish Oils; Humans; Infant Food; Infant Nutritional Physiological Phenomena; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Parenteral Nutrition; Soybean Oil
PubMed: 27142348
DOI: 10.1038/ejcn.2016.69 -
The British Journal of Nutrition Dec 2014In patients with severe acute pancreatitis (AP), enteral nutrition is delivered by nasojejunal (NJ) tube to minimise pancreatic stimulation. Nasogastric (NG) feeding... (Meta-Analysis)
Meta-Analysis Review
In patients with severe acute pancreatitis (AP), enteral nutrition is delivered by nasojejunal (NJ) tube to minimise pancreatic stimulation. Nasogastric (NG) feeding represents an alternative route. The primary objective of this systematic review and meta-analysis was to evaluate the efficacy of NG feeding. Secondary objectives were to compare the NG and NJ routes and assess the side effects of the former. The primary endpoint was exclusive NG feeding with delivery of 75% of nutritional targets. Additional outcomes included change to total parenteral nutrition (TPN), increased pain or disease severity, vomiting, diarrhoea, delivery rate reduction and tube displacement. Among the retrieved studies, six were found to be eligible for the qualitative review and four for the meta-analysis. NG nutrition was received by 147 patients; exclusive NG feeding was achieved in 90% (133/147). Of the 147 patients, 129 (87%) received 75% of the target energy. In studies where all subjects received exclusive NG nutrition, 82% (seventy-four of the ninety patients) received >75% of the intended energy. Compared with NJ nutrition, there was no significant difference in the delivery of 75% of nutritional targets (pooled risk ratio (RR) 1.02; 95% CI 0.75, 1.38.) or no increased risk of change to TPN (pooled RR 1.05; 95% CI 0.45, 2.48), diarrhoea (pooled RR 1.28; 95% CI 0.62, 2.66), exacerbation of pain (pooled RR 1.10; 95% CI 0.47, 2.61) or tube displacement (pooled RR 0.44; 95% CI 0.11, 1.73). Vomiting and diarrhoea were the most common side effects of NG feeding (13.3 and 12.9%, respectively). With respect to the delivery of nutrition, 11.2% of the patients required delivery rate reduction and 3.4% dislodged the tube. Other side effects included elevated levels of aspirates (9.1%), abdominal distension (1.5%), pain exacerbation (7.5%) and increased disease severity (1.6%). In conclusion, NG feeding is efficacious in 90% of patients. Further research is required to optimise the delivery of NG nutrition and examine 'gut-rousing' approaches to nutrition in patients with severe AP.
Topics: Enteral Nutrition; Female; Humans; Intubation, Gastrointestinal; Male; Nutritional Status; Pancreatitis; Parenteral Nutrition, Total; Treatment Outcome
PubMed: 25333639
DOI: 10.1017/S0007114514002566 -
The Journal of Nutrition Dec 2013Significant efforts have been made to improve the nutritional support of preterm infants in neonatal intensive care units (NICUs) to avoid cumulative nutritional... (Review)
Review
Significant efforts have been made to improve the nutritional support of preterm infants in neonatal intensive care units (NICUs) to avoid cumulative nutritional deficits, reduce postnatal growth restriction, and promote optimal long-term development. The objective of this systematic review was to compare the characteristics and results of all surveys published in the past 10 y (2002-2012) that used a questionnaire to survey at least 2 NICUs receiving preterm infants with an intention to treat with parenteral nutrition (PN) and that reported information on at least 1 macronutrient. A total of 6 surveys were identified, which were conducted in the United States (n = 2) or Europe (n = 4). There was wide variability in the response rate (23-100%), with a higher response rate in the smaller studies (81-100%; 8-64 respondents) compared with the larger studies (23-58%; 296-809 respondents). Large differences were observed in the nutritional protocols both among the NICUs in the individual surveys and between surveys. PN was initiated on the first day of life (DOL) by only 24-54% of respondents (4 surveys) and within the second DOL by 67-94% of respondents (5 surveys). Lipids were initiated before the third DOL for 46-96% of respondents (3 surveys). The results of this systematic review suggest that continuous education is needed and that greater efforts are required to disseminate and implement guidelines. Repeated surveys are needed to highlight trends in clinical practices and level of compliance of NICUs with existing guidelines.
Topics: Europe; Guideline Adherence; Humans; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Lipids; Parenteral Nutrition; Practice Guidelines as Topic; United States
PubMed: 24108136
DOI: 10.3945/jn.113.176982 -
Gastroenterology Nov 2009Micronutrient requirements are not fully understood. Parenteral nutrition (PN) usually contains the trace element (TE) manganese (Mn) from fixed-concentration TE... (Review)
Review
Micronutrient requirements are not fully understood. Parenteral nutrition (PN) usually contains the trace element (TE) manganese (Mn) from fixed-concentration TE supplements. Multiple TE formulations may not be optimal in pediatric and home PN. Moreover, most PN products contain Mn as a ubiquitous contaminant. Excessive Mn can lead to Parkinson-like symptoms resulting from hypermanganesemia. A survey of 40 Australasian hospitals that contributed data on 108 patients to the annual home PN register and a systematic review of the literature were conducted to establish the scope of the potential problem of Mn toxicity in PN patients. Exposure to Mn doses 5-6 times current daily requirements, together with the TE contamination that is reported in PN products, can lead to neurotoxicity. Whole-blood levels are more accurate for monitoring and correlate well with signal intensity of magnetic resonance imaging. Current TE formulations restrict prescribing options. The regulatory mechanisms of Mn homeostasis are bypassed via the parenteral route so elimination via the hepatobiliary system is impaired, resulting in tissue or brain accumulation. Published dosage recommendations may be excessive and official guidelines require revision. Variability in clinical practices necessitates that individual TE additives are more widely available and multiple TE products reformulated. More frequent monitoring for any brain accumulation is recommended. The scarcity of PN-associated Mn deficiency, plus the growing evidence for Mn toxicity, leads to the conclusion that it is unnecessary for Mn to be prescribed routinely for pediatric or long-term PN patients.
Topics: Cholestasis; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Contamination; Humans; Manganese; Parenteral Nutrition; Practice Guidelines as Topic; Trace Elements
PubMed: 19874947
DOI: 10.1053/j.gastro.2009.08.011 -
Health Technology Assessment... 1997The objective of this Review was to locate, appraise and summarise evidence from scientific studies on home parenteral nutrition (HPN) in order to answer specific... (Review)
Review
OBJECTIVES
The objective of this Review was to locate, appraise and summarise evidence from scientific studies on home parenteral nutrition (HPN) in order to answer specific research questions on the effectiveness of this technology. The following questions were asked. What patients have received HPN? What has been the experience of patients on HPN programmes? How have HPN programmes been organised, and what techniques and equipment have been used, and to what effect? What comparative information is available on effectiveness? What evidence exists for the cost-effectiveness of HPN? What questions about the provision of HPN could be answered with additional research, and what studies would be most suitable?
DATA SOURCES
A comprehensive list of studies was provided by an extensive search of electronic databases (including MEDLINE, Embase, Science Citation Index, Uncover, Cinahl, Caredata, Food Science and Technology Abstracts, NTIS, Pascal, Psychlit, and Economic Literature Index), relevant journals (including Journal of Parenteral and Enteral Nutrition, Clinical Nutrition, American Journal of Clinical Nutrition, Nutrition, Clinical Gastroenterology, Nutrition Reviews, Annals of Nutrition and Metabolism, Nutrition and Cancer, Nutrition and Health, and Journal of Paediatric Nutrition and Metabolism), and scanning of reference lists, as well as other search strategies outlined in the protocol.
STUDY SELECTION
Studies relevant to the questions were selected. The inclusion criteria were fairly broad because of the quality of the studies located.
DATA EXTRACTION
Data extraction forms were used to collect data from studies included in the review. The data was checked by a second researcher to reduce error.
DATA SYNTHESIS
Quantitative analysis was difficult owing to the type of studies located. The data is discussed in a qualitative manner. Where complication rates have been given, we have attempted to combine the results in a quantitative manner.
RESULTS
The age and sex of patients on HPN varies according to the underlying disease but, on the whole, patients are young (see Tables 4a and 4b). There are trends showing an increased use of the technology at the extremes of the age range. There are marked differences between countries on the underlying diseases for which HPN is indicated. For example, many more patients with an underlying malignancy are treated in Italy and the USA than in the UK (40-67% versus 8%). Morbidity rates for the majority of patients are acceptable (see Table 8), the complications tend to be related to the central venous catheter. It is fairly clear that a minority of patients are susceptible to recurrent problems and that many patients have very few complications. The mortality rate for HPN patients (see Table 10) was good for those patients with benign underlying disease (for example, 5% of Crohn's HPN patients die per year), and there are very few reports of patients dying from complications of the technology. The survival of those with malignant disease and AIDS is poor, almost all having died from the underlying disease at one year; despite this, most programme growth worldwide is due to an increase in the numbers of patients with these diagnoses (see Table 5). Quality of life is reasonable for patients with benign disease (see Table 9); no studies were found that examined the quality of life of HPN patients with malignant disease. Economic analysis shows that the cost of HPN treatment is cheaper than the alternative of in-patient care (see Table 18). There is a paucity of comparative studies examining different aspects of the technology, and this accounted for the majority of gaps in the evidence.
CONCLUSIONS
The use of HPN for benign intestinal failure is supported by evidence from the scientific studies located. There are, however, large gaps in the evidence, particularly relating to the use of HPN in malignant disease and AIDS. A programme of research is suggested at the end of this review.
Topics: Cost-Benefit Analysis; Female; Humans; Male; Parenteral Nutrition, Home; Research Design; United Kingdom
PubMed: 9414540
DOI: No ID Found -
Nutrition Reviews Dec 2019Very preterm neonates (VPNs) are unable to digest breast milk and therefore rely on parenteral nutrition (PN) formulations. This systematic review was prepared following...
CONTEXT
Very preterm neonates (VPNs) are unable to digest breast milk and therefore rely on parenteral nutrition (PN) formulations. This systematic review was prepared following PRISMA-P 2015 guidelines. For the purpose of this review, desirable mean plasma arginine concentration is defined as ≥80 micromoles/L.
OBJECTIVE
The review was performed to answer the following research question: "In VPNs, are high amounts of arginine in PN, compared with low amounts of arginine, associated with appropriate circulating concentrations of arginine?" Therefore, the aims were to 1) quantify the relationship between parenteral arginine intakes and plasma arginine concentrations in PN-dependent VPNs; 2) identify any features of study design that affect this relationship; and 3) estimate the target parenteral arginine dose to achieve desirable preterm plasma arginine concentrations.
DATA SOURCES
The PubMed, Scopus, Web of Science, and Cochrane databases were searched regardless of study design; review articles were not included.
DATA EXTRACTION
Only articles that discussed amino acid (AA) intake and measured plasma AA profile post PN in VPNs were included. Data were obtained using a data extraction checklist that was devised for the purpose of this review.
DATA ANALYSIS
Twelve articles met the inclusion criteria. The dose-concentration relationship of arginine content (%) and absolute arginine intake (mg/(kg × d)) with plasma arginine concentrations showed a significant positive correlation (P < 0.001).
CONCLUSION
Future studies using AA solutions with arginine content of 17%-20% and protein intakes of 3.5-4.0 g/kg per day may be needed to achieve higher plasma arginine concentrations.
Topics: Arginine; Dose-Response Relationship, Drug; Humans; Infant, Newborn; Infant, Premature; Parenteral Nutrition
PubMed: 31504841
DOI: 10.1093/nutrit/nuz049 -
Fundamental & Clinical Pharmacology Feb 2024While ursodeoxycholic acid is used in treating parenteral nutrition-associated cholestasis (PNAC) in neonates, its role in prevention is unclear. (Review)
Review
BACKGROUND
While ursodeoxycholic acid is used in treating parenteral nutrition-associated cholestasis (PNAC) in neonates, its role in prevention is unclear.
OBJECTIVES
In this systematic review and meta-analysis, we attempted to determine the role of ursodeoxycholic acid in preventing PNAC in neonates.
METHODS
PubMed, Embase, Cochrane Library, Scopus, and CINAHL databases were searched on September 16, 2023, for interventional studies comparing ursodeoxycholic acid with placebo.
RESULTS
Of the 6180 unique records identified, five studies were eligible for inclusion (three randomised and two nonrandomised). Evidence from randomised trials showed that ursodeoxycholic acid prophylaxis did not reduce cholestasis, mortality, sepsis, and necrotising enterocolitis. Ursodeoxycholic acid prophylaxis reduced feed intolerance (RR 0.23 (0.09, 0.64); 1 RCT, 102 neonates), peak conjugated bilirubin levels (MD -0.13 (-0.22, -0.04) mg/dL; 1 RCT, 102 neonates), and time to full enteral feeds (MD -2.7 (-5.09, -0.31) days; 2 RCTs, 76 neonates). There was no decrease in hospital stay and parenteral nutrition duration. Data from nonrandomised studies did not show benefit in any of the outcomes. The certainty of the evidence was low to very low.
CONCLUSION
Because of the very low-quality evidence and lack of evidence on critical outcomes, definitive conclusions could not be made on using ursodeoxycholic acid to prevent parenteral nutrition-associated cholestasis in neonates.
PubMed: 38342497
DOI: 10.1111/fcp.12993