Lyn Gillanders

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.)

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.

Is manganese an essential supplement for parenteral nutrition

Purpose of reviewTo summarize the role of the essential trace element, manganese, its potential toxicity, monitoring methods and dosage recommendations for nutrition support. Recent findingsParenteral nutrition usually contains manganese as part of a fixed concentration multiple trace element supplement. Recent literature identifies potential problems in this approach and reports toxic symptoms resulting from hypermanganesaemia in paediatric and long-term home patients. Elimination by the hepatobiliary system is frequently impaired, and parenteral administration bypasses the regulatory mechanisms of homeostasis. Together with occasional oral intake and product contamination, this can lead to brain accumulation and neurotoxicity, with individual responses to supplementation difficult to predict. Regular monitoring is recommended, but plasma and serum analyses are poor indicators of body stores. Whole blood concentrations are more accurate and correlate with signal intensity of MRI. We have identified a need for individual trace element additives to be more widely available and for multitrace element products to be reformulated. There is now a persuasive argument for not routinely adding manganese to parenteral nutrition admixtures. SummaryHigh intravenous doses of manganese can lead to neurotoxicity. Current dosage guidelines and trace element formulations need revision. Frequent monitoring to identify tissue accumulation is recommended for paediatric and long-term home parenteral nutrition patients.

A prospective study of catheter-related complications in HPN patients.

BACKGROUND & AIMS Central venous access device (CVAD)-related complications such as catheter-related sepsis, occlusion and breakage contribute to both mortality and morbidity in home parenteral nutrition (HPN) patients. Prospectively collected data in these patients are scarce. METHODS Data on all CVAD-related complications in four tertiary referral centres in Australia and New Zealand were prospectively collected between 01/01/2009 and 31/12/2009 together with costs of each episode that required admission. RESULTS Of 53 patients (42 adults and 11 children), 27 suffered a total of 49 episodes of CVAD-associated complications (line infection 36, catheter blockage 5, line fracture 1, line migration 7), giving an incidence of 3.6 per 1000 CVAD days (11.6 per 1000 in patients with a multi-use CVAD). Thirty seven episodes resulted in hospital admission for a median duration of 8 days (range 1-29). Responsible microbes were mainly enteric with klebsiella being the most commonly isolated organism (10 episodes). The average cost of care per episode of CVAD-associated complication requiring inpatient admission was

AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand

A9,710 (€6480 approximately). CONCLUSION CVAD complications, in particular line infection are still a major source of potentially avoidable HPN morbidity and mortality with a high cost to the healthcare system. The predominance of enteric organisms in our series raises the possibility of bacterial translocation as a significant component of the pathogenesis of line sepsis in HPN patients.

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

OBJECTIVE Evidence based guidelines for home parenteral nutrition (HPN) were commissioned by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and developed by a multidisciplinary group. The guidelines make recommendations in four domains: patient selection, patient training, formulation and monitoring regimens, and preventing and managing complications. METHODS The Appraisal of Guidelines Research and Evaluation guideline process was used to focus questions and identify evidence by systematic literature reviews of meta-analyses and randomized control trials in the Cochrane Library, Medline, Embase, and Cinahl to mid-2007. Where no randomized control trial evidence was found, the search was broadened to observational studies and expert opinion from related national and international guidelines as assessed by a validated appraisal process. RESULTS Selection of patients must assess individual risk/benefit and medical ethics. Patient training should be undertaken within a structured framework. Access devices should be selected for lowest risk of complications, including occlusion, sepsis, and breakage and be managed by early diagnosis and treatment. HPN should be formulated according to individual patient requirements by professionals with relevant skills and training. Pumps and ancillary products should conform to quality standards. Other intravenous medications may be prescribed provided these are reviewed for compatibility and effects on metabolic status. CONCLUSION Overall there is a lack of randomized control trials to provide high-quality evidence-based guidance but graded recommendations can be made. Multidisciplinary teams in centers with HPN management expertise are required for optimal care. This guideline should improve outcomes and quality of life for HPN patients in Australia and New Zealand.

Australasian Society for Parenteral and Enteral Nutrition guidelines for supplementation of trace elements during parenteral nutrition

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)

Corrigendum to “ESPEN guidelines on chronic intestinal failure in adults” [Clin Nutr 35 (2) (2016) 247–307]

BACKGROUND This work represents the first part of a progressive review of AuSPENs 1999 Guidelines for Provision of Micronutrient Supplementation in Adult Patients receiving Parenteral Nutrition, in recognition of the developments in the literature on this topic since that time. METHODS A systematic literature review was undertaken and recommendations were made based on the available evidence and with consideration to specific elements of the Australian and New Zealand practice environment. The strength of evidence underpinning each recommendation was assessed. External reviewers provided feedback on the guidelines using the AGREE II tool. RESULTS Reduced doses of manganese, copper, chromium and molybdenum, and an increased dose of selenium are recommended when compared with the 1999 guidelines. Currently the composition of available multi-trace element formulations is recognised as an obstacle to aligning these guidelines with practice. A paucity of available literature and limitations with currently available methods of monitoring trace element status are acknowledged. The currently unknown clinical impact of changes to trace element contamination of parenteral solutions with contemporary practices highlights need for research and clinical vigilance in this area of nutrition support practice. CONCLUSIONS Trace elements are essential and should be provided daily to patients receiving parenteral nutrition. Monitoring is generally only required in longer term parenteral nutrition, however should be determined on an individual basis. Industry is encouraged to modify existing multi-trace element solutions available in Australia and New Zealand to reflect changes in the literature outlined in these guidelines. Areas requiring research are highlighted.

Australasian society for parenteral and enteral nutrition (AuSPEN) adult vitamin guidelines for parenteral nutrition.

To the authors regret, there is a mistake in Table 9 (recommended daily doses of trace elements for parenteral nutrition) regarding the conversion of the doses for copper and selenium to mcmols. Replace 4.7–9.6 by 4.7–7.9 mcmol (0.3–0.5 mg) for copper and 0.2–0.8 by 0.8–1.3 mcmol (60–100 mcg) for selenium, respectively. We apologise for any inconvenience caused.

Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study

BACKGROUND AND OBJECTIVES This work represents the second part of a progressive review of AuSPENs 1999 Guidelines for Provision of Micronutrient Supplementation in adult patients receiving parenteral nutrition. METHODS AND STUDY DESIGN A systematic literature review was undertaken and recommendations made based on the available evidence and with consideration to specific elements of the Australian and New Zealand (NZ) practice environment. The strength of evidence underpinning each recommendation was assessed. A multidisciplinary steering committee and external reviewers provided feedback on the guidelines. RESULTS On review of the available literature it appears that the parenteral multivitamin preparations presently available in Australia and NZ are to sufficient avoid deficiency without causing toxicity in most clinical situations for adults receiving PN when provided regularly as part of the PN prescription. Vitamin D is the most vulnerable vitamin for the Australian and NZ PN population. CONCLUSIONS Vitamins are an essential component of PN and should be provided from commencement for all patients receiving PN. With the exception of vitamin D, which is recommended to be monitored annually, routine monitoring of vitamin levels is unlikely to be necessary in patients receiving regular parenteral multivitamin preparations. Clinical judgement is an important element when assessing, prescribing and monitoring patients receiving PN. Areas requiring further research have been identified.