Update to A.S.P.E.N. Position Paper

Vanek, Vincent W.; Seidner, Douglas L.; Allen, Penny; Bistrian, Bruce R.; Collier, Sharon; Gura, Kathleen M.; Miles, John M.; Valentine, Christina J.

doi:10.1177/0884533614555235

Cited by 12 publications

(7 citation statements)

References 3 publications

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“…Because side effects of PN on liver function were ascribed to the specific properties of soybean oil, research focused on reducing the excess of ω -6 LC-PUFAs and phytosterols in lipid emulsions by admixing alternative oils (MCT and olive) and most recently fish oil providing ω -3 LC-PUFAs to counterbalance proinflammatory ω -6 effects 4. In this regard, SMOFLE is the most recent development and was shown to improve the supply with the crucial ω -3 LC-PUFA docosahexaenoic acid (DHA) while lowering soybean oil exposure by 70% and phytosterol exposure by roughly 50% 10. Also, the higher supply with vitamin E compared with soybean oil-based lipid emulsion may prevent PNAC as recently shown in preterm piglets 32.…”

Section: Discussionmentioning

confidence: 99%

“…Most recently, a mixed lipid emulsion composed of soybean oil, medium chain triglycerides (MCTs), olive oil, and fish oil (SMOF-LE) has become available, and is licensed for pediatric use in the European Union, but not the US because of insufficient data to date on adequate supply with essential fatty acids (EFA). Because of its mixed nature, SMOF-LE contains less ω -6 LC-PUFA4,9 and phytosterols10 but more ω -3 LC-PUFA and also more alpha-tocopherol4,9 compared with soybean oil-based lipid emulsion. Parenteral nutrition using SMOF-LE may, therefore, prevent PNAC compared with the current standard soybean oil-based lipid emulsion.…”

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confidence: 99%

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A Mixed Lipid Emulsion for Prevention of Parenteral Nutrition Associated Cholestasis in Extremely Low Birth Weight Infants: A Randomized Clinical Trial

Repa

Binder

Thanhaeuser

et al. 2018

The Journal of Pediatrics

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ObjectivesTo examine whether a mixed lipid emulsion reduces the incidence of parenteral nutrition associated cholestasis (PNAC) in extremely low birth weight (ELBW, <1000 g) infants.Study designThis double-blind randomized trial of 230 ELBW infants (June 2012-October 2015) was performed at a single level IV neonatal intensive care unit. Patients received either a mixed lipid emulsion composed of soybean oil, medium chain triglycerides, olive oil, and fish oil-(intervention) or a soybean oil-based lipid emulsion (control) for parenteral nutrition. The primary outcome measure was PNAC (conjugated bilirubin >1.5 mg/dL [25 μmol/L] at 2 consecutive measurements). The study was powered to detect a reduction of PNAC from 25% to 10%.ResultsReasons for noneligibility of 274 infants screened were refusal to participate (n = 16), death (n = 10), withdrawal of treatment (n = 5), higher order multiples (n = 9), and parents not available for consent (n = 4). Intention to treat analysis was carried out in 223 infants (7 infants excluded after randomization). Parenteral nutrition associated cholestasis was 11 of 110 (10.1%) in the intervention and 18 of 113 (15.9%) in the control group (P = .20). Multivariable analyses showed no statistically significant difference in the intention to treat (aOR 0.428, 95% CI 0.155-1.187; P = .10) or per protocol population (aOR 0.457, 95% CI 0.155-1.347; P = .16). There was no statistically significant effect on any other neonatal morbidity.ConclusionsThe incidence of parenteral nutrition associated cholestasis was not significantly reduced using a mixed lipid emulsion in ELBW infants.Trial RegistrationClinicalTrials.gov NCT01585935.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

A Mixed Lipid Emulsion for Prevention of Parenteral Nutrition Associated Cholestasis in Extremely Low Birth Weight Infants: A Randomized Clinical Trial

Repa

Binder

Thanhaeuser

et al. 2018

The Journal of Pediatrics

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“…The amount and types of vitamin E homologs in commercially available lipid emulsions vary considerably, depending both on the oil source and on the amount of exogenously α-tocopherol added to the lipid emulsion. 43,48…”

Section: Vitamin E Deficiencymentioning

confidence: 99%

“…Considering the tendency for a disturbed (anti)oxidant balance in PN dependency and the pathogenic effect of lipid peroxidation in the development and/or progression of IFALD, vitamin E deficiency has been suggested as a potential cause for IFALD. The amount and types of vitamin E homologs in commercially available lipid emulsions vary considerably, depending both on the oil source and on the amount of exogenously α‐tocopherol added to the lipid emulsion …”

Section: Introductionmentioning

confidence: 99%

“…Accumulating scientific evidence suggests that liver disease is, at least partly, due to (high doses of) soybean oils present in fat emulsions, which contain high amounts of hepatotoxic phytosterols and pro‐inflammatory omega‐6 polyunsaturated fatty acids . To address this potential risk, newer lipid emulsions have been developed to contain lower levels of phytosterols and omega‐6 polyunsaturated fatty acids, such as coconut medium chain triglycerides, olive and fish oils, mixed in different proportions with soybean oil …”

Section: Introductionmentioning

confidence: 99%

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Review article: diagnosis and management of intestinal failure‐associated liver disease in adults

Bond

Huijbers

Pironi

et al. 2019

Aliment Pharmacol Ther

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Summary Background Hepatic disturbances in the context of intestinal failure and parenteral nutrition (PN) are frequently encountered and carry a significant burden of morbidity and sometimes mortality. The term intestinal failure‐associated liver disease (IFALD) refers to liver injury due to intestinal failure and associated PN, in the absence of another evident cause of liver disease, encompassing a spectrum of conditions from deranged liver enzymes, steatosis/ steatohepatitis, cholestasis as well as progressive fibrosis, cirrhosis and end‐stage liver disease. Aims To present an up to date perspective on the diagnosis/definition, aetiologies and subsequent management of IFALD and to explore future consideration for the condition, including pharmacological therapies Results In adults using long‐term PN for benign chronic intestinal failure, 1%‐4% of all deaths are attributed to IFALD. The aetiology of IFALD is multifactorial and can be broadly divided into nutritional factors (eg lipid emulsion type) and patient‐related factors (eg remaining bowel anatomy). Given its multifaceted aetiology, the management of IFALD requires clinicians to investigate a number of factors simultaneously. Patients with progressive liver disease should be considered for combined liver‐intestine transplantation, although multivisceral grafts have a worse prognosis. However, there is no established non‐invasive method to identify progressive IFALD such that liver biopsy, where appropriate, remains the gold standard. Conclusion A widely accepted definition of IFALD would aid in diagnosis, monitoring and subsequent management. Management can be complex with a number of factors to consider. In the future, dedicated pharmacological interventions may become more prominent in the management of IFALD.

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Change to Mixed-Lipid Emulsion From Soybean Oil–Based Lipid Emulsion in Pediatric Patients

Haines,

Ohnuma,

Hornik

et al. 2023

JAMA Netw Open

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ImportanceCritically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes.ObjectiveTo examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes.Design, Setting, and ParticipantsRetrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023.ExposureIn 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil–based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group).Main Outcomes and MeasuresClinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin).ResultsA total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant.Conclusions and RelevanceIn this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy–LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.

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Update to A.S.P.E.N. Position Paper

Cited by 12 publications

References 3 publications

A Mixed Lipid Emulsion for Prevention of Parenteral Nutrition Associated Cholestasis in Extremely Low Birth Weight Infants: A Randomized Clinical Trial

A Mixed Lipid Emulsion for Prevention of Parenteral Nutrition Associated Cholestasis in Extremely Low Birth Weight Infants: A Randomized Clinical Trial

Review article: diagnosis and management of intestinal failure‐associated liver disease in adults

Change to Mixed-Lipid Emulsion From Soybean Oil–Based Lipid Emulsion in Pediatric Patients

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