Kerry McIlroy

Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: A randomized 12‐month trial

Patients with liver cirrhosis exhibit early onset of gluconeogenesis after short‐term fasting. This accelerated metabolic reaction to starvation may underlie their increased protein requirements and muscle depletion. A randomized controlled trial was conducted to test the hypothesis that provision of a late‐evening nutritional supplement over a 12‐month period would improve body protein stores in patients with cirrhosis. A total of 103 patients (68 male, 35 female; median age 51, range 28–74; Child‐Pugh grading: 52A, 31B, 20C) were randomized to receive either daytime (between 0900 and 1900 hours) or nighttime (between 2100 and 0700 hours) supplementary nutrition (710 kcal/day). Primary etiology of liver disease was chronic viral hepatitis (67), alcohol (15), cholestatic (6), and other (15). Total body protein (TBP) was measured by neutron activation analysis at baseline, 3, 6, and 12 months. Total daily energy and protein intakes were assessed at baseline and at 3 months by comprehensive dietary recall. As a percentage of values predicted when well, TBP at baseline was similar for the daytime (85 ± 2[standard error of the mean]%) and nighttime (84 ± 2%) groups. For the nighttime group, significant increases in TBP were measured at 3 (0.38 ± 0.10 kg, P = 0.0004), 6 (0.48 ± 0.13 kg, P = 0.0007), and 12 months (0.53 ± 0.17 kg, P = 0.003) compared to baseline. For the daytime group, no significant changes in TBP were seen. Daily energy and protein intakes at 3 months were higher than at baseline in both groups (P < 0.0001), and these changes did not differ between the groups. Conclusion: Provision of a nighttime feed to patients with cirrhosis results in body protein accretion equivalent to about 2 kg of lean tissue sustained over 12 months. This improved nutritional status may have important implications for the clinical course of these patients. (HEPATOLOGY 2008.)

Systematic review and meta‐analysis of enteral nutrition formulations in acute pancreatitis

Although the benefits of enteral nutrition in acute pancreatitis are well established, the optimal composition of enteral feeding is largely unknown. The aim of the study was to compare the tolerance and safety of enteral nutrition formulations in patients with acute pancreatitis.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery

Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double‐blind randomized trial.

Early nasogastric tube feeding versus nil per os in mild to moderate acute pancreatitis: A randomized controlled trial

BACKGROUND & AIMS Nasojejunal tube feeding is a standard of care in patients with predicted severe acute pancreatitis (AP) and several recent trials suggested that nasogastric tube feeding (NGT) is as safe and efficient as nasojejunal tube feeding in these patients. The aim was to investigate whether NGT presents any benefit to patients with mild to moderate AP. METHODS The study design was a randomized controlled trial. The patients in the intervention group received NGT within 24 h of hospital admission. The patients in the control group were on nil per os (NPO). The severity of acute pancreatitis was determined according to the new international multidisciplinary classification. RESULTS There were 17 patients randomly allocated to the NGT group and 18 to the NPO group. The visual analogue pain score decreased to a significantly greater extent in the NGT group (from median 9 (range 7-9) at baseline to 1 (0-3) at 72 h after randomization) compared with the NPO group (from 7 (5-9) to 3 (1-4) (p = 0.036). The number of patients not requiring opiates at 48 h after randomization was significantly different (p = 0.024) between NGT (9/17) and NPO (3/18). Oral food intolerance was observed in 1/17 patient in the NGT group and 9/18 patients in the NPO group (p = 0.004). The overall hospital stay in the NGT group was 9 (5-12) days as compared with 8.5 (6-13) days in the NPO group (p = 0.91). CONCLUSIONS NGT commenced within 24 h of hospital admission is well tolerated in patients with mild to moderate acute pancreatitis. Further, when compared with NPO, it significantly reduces the intensity and duration of abdominal pain, need for opiates, and risk of oral food intolerance, but not overall hospital stay.

Perioperative immunonutrition in patients undergoing liver transplantation: A randomized double‐blind trial

Preliminary work suggested that perioperative immunonutrition (IMN) enriched in n‐3 fatty acids, arginine, and nucleotides may improve preoperative nutritional status, enhance postoperative recovery, and reduce postoperative infectious complications in patients undergoing liver transplantation (LT). The current study examined these outcomes in a double‐blind, randomized, controlled trial. Patients wait‐listed for LT (n = 120) were randomized to either supplemental (0.6 L/d) oral IMN or an isocaloric control (CON). Enteral IMN or CON was resumed postoperatively and continued for at least 5 days. The change in total body protein (TBP) measured by neutron activation from study entry until immediately prior to LT was the primary endpoint and TBP measurements were repeated 10, 30, 90, 180, and 360 days after LT. Infectious complications were recorded for the first 30 postoperative days. Nineteen patients died or were delisted prior to LT. Fifty‐two IMN and 49 CON patients received supplemental nutrition for a median (range) 56 (0‐480) and 65 (0‐348) days, respectively. Preoperative changes in TBP were not significant (IMN: 0.06 ± 0.15 [SEM]; CON: 0.12 ± 0.10 kg). Compared to baseline, a 0.7 ± 0.2 kg loss of TBP was seen in both groups at 30 days after LT (P < 0.0001) and, at 360 days, TBP had not increased significantly (IMN: 0.08 ± 0.19 kg; CON: 0.26 ± 0.23 kg). Infectious complications occurred in 31 (60%) IMN and 28 (57%) CON patients (P = 0.84). The median (range) postoperative hospital stay was 10 (5‐105) days for IMN and 10 (6‐27) days for CON patients (P = 0.68). Conclusion: In patients undergoing LT, perioperative IMN did not provide significant benefits in terms of preoperative nutritional status or postoperative outcome. (Hepatology 2015;61:639‐647)

Prevalence, Outcomes, and Management of Enteral Tube Feeding Intolerance: A Retrospective Cohort Study in a Tertiary Center:

Background: Enteral tube feeding (ETF) is the most common form of artificial feeding in hospitalized patients, and the development of intolerance (ETFI) is the most common complication. This study aimed to determine the prevalence of ETFI, the clinical consequences, and the current management approach to ETFI in hospitalized adult patients. Materials and Methods: Adult patients receiving ETF were identified from a prospective database in the Nutrition Services at Auckland City Hospital. Further information was obtained by the review of clinical records for a 12-month period, up to December 2014. Results: The prevalence of ETFI was 33% among 754 patients. ETFI more frequently occurred in the intensive care unit (P < .05). Patients with ETFI were less likely to reach their feeding goal rate (P < .01). Multivariate analysis showed that younger age, certain specialties, and acute mesenteric ischemia were independent predictors of ETFI (P < .05). The management of ETFI was highly variable. Medication was the most common treatment, while changes in the feeding protocol such as reducing infusion rate and stopping and changing the route of ETF were also frequently attempted. Conclusion: ETFI is a frequent problem in adult hospitalized patients receiving ETF, and it is associated with poor clinical outcomes such as inadequate nutrition and complications of feeding. While the pathophysiology is poorly understood, there also appears to be no standard evidence-based treatment. Studies investigating the mechanisms and optimized management are therefore indicated.