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

Abstract

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.

High Dose Intravenous Fish Oil Reduces Inflammation—A Retrospective Tale from Two Centers

“…Since IFALD can become a life-threatening complication, there is ongoing discussion about the type of ILE that is most beneficial in patients dependent on PN [ 26 , 27 , 28 , 29 , 30 ].…”

Summary of Proceedings and Expert Consensus Statements From the International Summit “Lipids in Parenteral Nutrition”

“…46 However, patients with intestinal failure who require long-term PN are at risk of developing intestinal failure associated liver disease (IFALD). The accompanying article by Mundi et al 47 examines factors that may contribute to IFALD and discusses lipid management strategies in adult patients at risk for IFALD. Consensus statements related to the provision of lipid emulsions to adults requiring home PN are presented in Table 1 (consensus statements [26][27][28].…”

“…48 Evidence from clinical trials suggests that the risk of liver complications may be reduced in adult home PN patients by using lipid emulsions containing fish oil. 47,50 Lipid emulsions containing fish oil offer several potential advantages compared with pure soybean oil emulsions, including reduced ω-6 PUFA and phytosterol content, increased ω-3 PUFA content, and increased amounts of α-tocopherol, an isoform of vitamin E that exhibits strong antioxidant effects. 11,51,52 Based on the reduced risk of hepatic injury, lipid emulsions containing fish oil are preferred over lipid emulsions derived exclusively from soybean oil in adult home PN patients at risk for liver complications (consensus statement 27, Table 1).…”

“…Evidence from clinical trials suggests that the risk of liver complications may be reduced in adult home PN patients by using lipid emulsions containing fish oil . Lipid emulsions containing fish oil offer several potential advantages compared with pure soybean oil emulsions, including reduced ω‐6 PUFA and phytosterol content, increased ω‐3 PUFA content, and increased amounts of α‐tocopherol, an isoform of vitamin E that exhibits strong antioxidant effects .…”

Lipids in Parenteral Nutrition: Introduction

“…Thereafter, other reviews have been included based on presentations at the summit, including additional information from the literature. These are: lipids in parenteral nutrition: biological aspects, lipid use in hospitalized adults requiring parenteral nutrition, the use of lipids in adult patients requiring parenteral nutrition in the home setting, use of lipids in neonates requiring parenteral nutrition, lipid emulsion use in pediatric patients requiring long‐term parenteral nutrition, pharmacoeconomics of parenteral nutrition with ω‐3 fatty acids in hospitalized adults, and the use of intravenous lipid emulsions with parenteral nutrition: practical handling aspects …”