Home Parenteral Nutrition

Abstract

Since the first intravenous nutrition support attempt with olive oil in the 17th century, intravenous fat emulsions (IVFEs) have evolved to become an integral component in the management of patients receiving home parenteral nutrition (HPN). IVFEs serve as a calorie source and provide essential fatty acids (linoleic acid and α-linolenic acid) in patients unable to achieve adequate intake of these fatty acids through alternative means. However, IVFE use is also associated with multiple complications, including increased infection risk, liver disease, and systemic proinflammatory states. In the United States, most IVFEs are composed of 100% soybean oil; internationally multiple alternative IVFEs (using fish oil, olive oil, and long- and medium-chain triglycerides) are available or being developed. The hope is that these IVFEs will prevent, or decrease the risk of, some of the HPN-associated complications. The goal of this article is to review how IVFEs came into use, their composition and metabolism, options for IVFE delivery in HPN, benefits and risks of IVFE use, and strategies to minimize the risks associated with IVFE use in HPN patients.

Parenteral Nutrition and Lipids

“…In Europe in 1984, a second generation IVLE was introduced consisting of 50:50 physical mixtures of SOY and medium chain triglycerides (MCT) that was derived from the assumption that the newly recognized SOY-related complications (i.e., reticulo-endothelial system dysfunction exaggerated systemic inflammatory response in the critically ill, and liver dysfunction in acutely ill infants and in patients of any age requiring long-term PN) [16,17,18,19,20] were possibly attributed to its high ω-6 FA content [2]. A third generation IVLE was introduced in 1990 that consisted of 20% SOY and 80% olive oil.…”

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

“…2 Although rigorous training can assist in minimizing complications, PN-especially when administered long-term-can be associated with complications such as lipid abnormalities, catheter-related bloodstream infection, and IF-associated liver disease (IFALD). 3,4 Although, no standardized definition of IFALD exists, it is routinely defined as a liver injury that occurs because of multiple factors relating to IF, including sepsis, lack of enteral nutrition, and PN. 5 IFALD can have variable presentation, including hepatic steatosis, cholestasis, cholelithiasis, and hepatic fibrosis, and can be seen in as many as 30%-60% of children and 15%-40% of adults who require longterm PN.…”

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

“…9 Linoleic acid (18:2ω-6) and α-linolenic acid (18:3ω-3) cannot be synthesized by humans and play key roles, such as in cellular signaling and the structural stability of membranes. 12 In the era of ILE-free PN in the United States, a number of patients developed EFAD, which tended to present biochemically with elevations of mead acid (20:3ω-9), a triene/tetraene ratio >0.4, and a fall in linoleic and α-linolenic acid levels. The triene/tetraene ratio refers to the mead acid:arachidonic acid ratio.…”

“…Metabolism of ω-6 PUFA (linoleic acid) gives rise to arachidonic acid and inflammatory eicosanoids (2-series prostaglandins and thromboxanes as well as 4-series leukotrienes). 12 Metabolism of ω-3 PUFA, on the other hand, tends to generate eicosapentaenoic acid (EPA) and less inflammatory 3series prostaglandins and thromboxanes as well as 5-series leukotrienes. 12,26 Additionally, EPA and docosahexaenoic acid (DHA) may give rise to E-series and D-series resolvins that dampen acute leukocyte responses and facilitate resolution of inflammation.…”

“…12 Metabolism of ω-3 PUFA, on the other hand, tends to generate eicosapentaenoic acid (EPA) and less inflammatory 3series prostaglandins and thromboxanes as well as 5-series leukotrienes. 12,26 Additionally, EPA and docosahexaenoic acid (DHA) may give rise to E-series and D-series resolvins that dampen acute leukocyte responses and facilitate resolution of inflammation. 27,28 IFALD has also been linked with the relatively high phytosterol content of SO ILE.…”