Mariacristina Guidetti

Assessment of Quality of Life on Home Parenteral Nutrition and After Intestinal Transplantation Using Treatment‐Specific Questionnaires

In order to investigate the quality of life on home parenteral nutrition and after intestinal transplantation using comparable questionnaires, the treatment‐specific quality of life questionnaire for adult patients on home parenteral nutrition was adapted for intestinal transplant recipients. Both instruments were composed of 8 functional scales, 9 symptom scales, 3 global health status/quality of life scales and 2 single items. A preliminary cross‐sectional study enrolling all the patients currently cared at the same hospital was carried out. Exclusion criteria were age ≥ 60 years and hospitalization at time of assessment. Thirty‐three home parenteral nutrition patients (100% answered) and 22 intestinal transplant recipients (82% answered) were enrolled. Intestinal transplant recipients showed a better score in following scales: ability to holiday/travel (p < 0.001), fatigue (p = 0.022), gastrointestinal symptoms (p < 0.001), stoma management/bowel movements (p = 0.001) and global health status/quality of life (p = 0.012). A better score for ability to eat/drink (p = 0.070) and a worse score for sleep pattern (p = 0.100) after intestinal transplantation were also observed. The results of this preliminary study with specific instruments were consistent with the main expected improvement of the quality of life related to intestinal transplantation. Further studies in larger patient cohorts are required to confirm these data.

Peroxidation potential of lipid emulsions after compounding in all-in-one solutions.

OBJECTIVES We investigated the peroxidation potential of fat emulsions in all-in-one solutions (AIOs). METHODS Three 20% emulsions were compared: soybean oil (SO; 60% polyunsaturated fatty acids [PUFAs], alpha-tocopherol:PUFAs = 0.44), soybean plus medium-chain triacylglycerol (SO-MCT; 31% PUFAs, alpha-tocopherol:PUFAs = 0.35), and olive oil (OO; 21% PUFAs, alpha-tocopherol:PUFAs = 1.42). For each emulsion, six AIO solutions were prepared by adding 250 mL of emulsion to a lipid-free solution. Lipid peroxide (LPX) and malondialdehyde (MDA) concentrations were evaluated in fat emulsions, lipid-free solutions, and AIOs immediately (T0) and 24 h (T24) after lipid addition. Statistical analysis was done with analysis of variance. RESULTS Fat emulsion LPX in SO-MCT was lower than that in SO (P = 0.015) and OO (P = 0.024); LPX in SO was greater than that in OO (P = 0.013); MDA in SO was greater than that in SO-MCT (P = 0.001) and OO (P = 0.013); and MDA in SO-MCT was greater than that in OO (P = 0.001). In comparison with MDA at AIO-T0, MDA at AIO-T24 increased in SO (P = 0.005) and SO-MCT (P < 0.001) and decreased in OO (P = 0.003); at AIO-T24, LPX was greater in SO, but not significantly. CONCLUSIONS In AIO bags, LPX occurred within 24 h after the addition of the lipid emulsion and seemed to be directly related to the PUFA content and inversely related to the alpha-tocopherol:PUFA ratio of the emulsion.

Renal function in patients on long-term home parenteral nutrition and in intestinal transplant recipients

OBJECTIVE A decrease of renal function was described in patients on long-term home parenteral nutrition (HPN) for benign intestinal failure. The risk for chronic renal failure (CRF) due to frequent episodes of dehydration despite optimal HPN, is an indication for intestinal transplantation (ITx). ITx is the solid organ transplant at highest risk for developing CRF. The aim of this study was to compare the prevalence and the probability of CRF occurring in adults on HPN and after ITx. METHODS A cross-sectional and retrospective follow-up study was carried out in 2011. Renal function was evaluated at cross-sectional and at time of starting HPN or ITx, by serum creatinine concentration (mg/dL) and estimated glomerular filtration rate (eGFR), according to the Modification of Diet in Renal Disease equation (mL·min·1.73 m2). CRF was defined as eGFR <60. Duration of follow up was from time of starting treatment to time of cross-sectional. RESULTS We enrolled 33 patients on HPN and 22 who had undergone ITx. The frequency of CRF was 6% in the HPN group and 9% in the ITx group (P = 0.67) at start of treatment, and 21% and 54%, respectively (P = 0.01) at the time of the cross-sectional evaluation. During the follow-up, the annual decline of eGFR was 2.8% and 14.5%, respectively (P = 0.02). The 5-y probability of maintaining an eGFR ≥60 was 84% in the HPN group and 44% in the ITx group (P < 0.001). CONCLUSIONS The decrease of renal function and the risk for developing CRF are greater after ITx than during HPN. The risk for CRF on HPN, as a criterion for ITx, should be revised.

Vitamin A and vitamin E isoforms stability and peroxidation potential of all-in-one admixtures for parenteral nutrition.

BACKGROUND In all-in-one admixtures (AIOs), vitamins can be degraded and lipid can be peroxidized by light exposure, oxygen action, and multiple chemical interactions. AIM We investigated the impact of three commercial lipid emulsions and two multivitamin preparations on vitamin A and vitamin E chemical stability and lipid peroxidation potential of AIOs. METHODS A soybean oil (Soy), soybean/medium-chain triacylglycerol oil (MCT), and olive/soybean oil (Olive)-based emulsion (all 20%), and a lyophilized (Lyo) and emulsified (Emu) multivitamin compounds, were tested. Two AIOs for each lipid emulsion were prepared, the former with Lyo and the latter with Emu. The concentrations of retinol palmitate, alpha-gamma-delta-tocopherol, and malondialdehyde were analyzed in AIOs, immediately (T0) and 24 hours (T24) after compounding. RESULTS Retinol palmitate, and alpha- and gamma-tocopherol were more stable in MCT-AIOs than in both Soy-AIOs and Olive-AIOs (p < 0.013; p < 0.001 respectively). Furthermore alpha-tocopherol was more stable in Lyo-AIOs than in Emu-AIOs (p < 0.004). Malondialdehyde (MDA) increased differently among the admixtures; however the concentrations were similar in all AIOs at T24. CONCLUSIONS The differences in retinol palmitate stability were due both to lipid emulsions per se and to interaction between lipid emulsions and multivitamin preparations. The alpha-gamma-tocopherol stability depended on both lipid emulsions and multivitamin preparations. In tested AIOs there was a different degradation rate of fat-soluble vitamins to keep the same lipid peroxidation level, since MDA concentrations at T24 were similar among AIOs.

Functional lipidomics in patients on home parenteral nutrition: Effect of lipid emulsions

AIM To investigate the fatty acid-based functional lipidomics of patients on long-term home parenteral nutrition receiving different intravenous lipid emulsions. METHODS A cross-sectional comparative study was carried out on 3 groups of adults on home parenteral nutrition (HPN), receiving an HPN admixture containing an olive-soybean oil-based intravenous lipid emulsion (IVLE) (OO-IVLE; n = 15), a soybean- medium-chain triacylglycerol-olive-fish oil-based IVLE (SMOF-IVLE; n = 8) or HPN without IVLE (No-IVLE; n = 8) and 42 healthy controls (HCs). The inclusion criteria were: duration of HPN ≥ 3 mo, current HPN admixtures ≥ 2 mo and HPN infusions ≥ 2/wk. Blood samples were drawn 4-6 h after the discontinuation of the overnight HPN infusion. The functional lipidomics panel included: the red blood cell (RBC) fatty acid (FA) profile, molecular biomarkers [membrane fluidity: saturated/monounsaturated FA ratio = saturated fatty acid (SFA)/monounsaturated fatty acid (MUFA) index; inflammatory risk: n-6/n-3 polyunsaturated fatty acid (PUFA) ratio = n-6/n-3 index; cardiovascular risk: sum of n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) = n-3 index; free radical stress: sum of FA trans isomers = %trans index] and FA pathway enzyme activity estimate (delta-9-desaturase = D9D; delta-6-desaturase = D6D; delta-5-desaturase = D5D; elongase = ELO). Statistics were carried out using nonparametric tests. The amount of each FA was calculated as a percentage of the total FA content (relative%). RESULTS In the OO-IVLE group, the percentage of oleic acid in the RBCs was positively correlated with the weekly load of OO-IVLE (r = 0.540, P = 0.043). In the SMOF-IVLE cohort, the RBC membrane EPA and DHA were positively correlated with the daily amount of SMOF-IVLE (r = 0.751, P = 0.044) and the number of HPN infusions per week (r = 0.753; P = 0.046), respectively. The SMOF-IVLE group showed the highest EPA and DHA and the lowest arachidonic acid percentages (P < 0.001). The RBC membrane linoleic acid content was lower, and oleic and vaccenic acids were higher in all the HPN groups in comparison to the HCs. Vaccenic acid was positively correlated with the weekly HPN load of glucose in both the OO-IVLE (r = 0.716; P = 0.007) and the SMOF-IVLE (r = 0.732; P = 0.053) groups. The estimated activity of D9D was higher in all the HPN groups than in the HCs (P < 0.001). The estimated activity of D5D was lower in the SMOF-IVLE group than in the HCs (P = 0.013). The SFA/MUFA ratio was lower in all the HPN groups than in the HCs (P < 0.001). The n-6/n-3 index was lower and the n-3 index was higher in the SMOF-IVLE group in comparison to the HCs and to the other HPN groups (P < 0.001). The %trans index did not differ among the four groups. CONCLUSION The FA profile of IVLEs significantly influenced the cell membrane functional lipidomics. The amount of glucose in the HPN may play a relevant role, mediated by the insulin regulation of the FA pathway enzyme activities.

Intravenous Lipids in Home Parenteral Nutrition

Intravenous lipid emulsions (IVLEs) are an important component of the nutritional admixtures for patients on long-term home parenteral nutrition (HPN) for chronic intestinal failure (CIF). IVLEs are primarily used as a source of energy and essential fatty acids, and the content of polyunsaturated fatty acids (PUFAs) is the most important characteristic of IVLEs. IVLEs rich in n-6 PUFAs may have a pro-inflammatory effect, whereas those rich in n-3 PUFAs may exert an anti-inflammatory effect. Other components to be considered are the risk of lipid peroxidation and the contents of α-tocopherol and phytosterols. Published studies were reviewed to determine the effects of the commercially available IVLEs on essential fatty acid status, liver function tests, lipid peroxidation and inflammatory indices, and α-tocopherol status, as well as their clinical safety and efficacy in patients on HPN. Investigations on the efficacy of fish oil-based IVLEs, which are rich in n-3 PUFAs, in the treatment of parenteral nutrition-associated liver disease (PNALD) in adult patients on HPN for CIF were also analyzed. The current commercial IVLE formulations have similar clinical safety profiles and efficacies and can prevent the development of essential fatty acid deficiency in adults on HPN for CIF. IVLE with a low content of n-6 PUFAs and with or without increased n-3 PUFA content may reduce the risk of PNALD. Fish oil-based IVLE, which is rich in n-3 PUFAs, may be effective in reversing hepatic cholestasis due to PNALD.

Plasma citrulline after small bowel transplantation: effect of time from transplantation, acute cellular rejection, and renal failure.

Plasma citrulline concentration (CIT) depends on its synthesis by enterocytes and its catabolism by renal tubules. To evaluate CIT applicability as a marker of acute cellular rejection (ACR) after intestinal transplantation (ITx), CIT was investigated according to time from ITx, episodes of ACR, and creatinine clearance (CrCl).

Role of citrulline in rejection monitoring after bowel transplantation

Purpose of reviewCitrulline metabolism is primarily regulated by the small intestinal mucosa (synthesis) and kidney (catabolism). This review first analyzes knowledge on plasma citrulline as a marker of status of the small bowel mucosa and kidneys. It then considers data on citrulline as a marker of graft mucosal status in intestinal transplantation recipients, who may develop both intestinal and renal damage. Recent findingsCitrulline correlated well with small bowel remnant length in patients with a short bowel; it also correlated well with the degree of mucosal damage in patients with small bowel mucosal injury. In patients with renal failure citrulline appears to be a more reliable marker of uraemia than are the usual, classic markers. Intestinal transplantation recipients exhibited low citrulline levels during the earliest postoperative days, due to ischaemia/reperfusion mucosal damage, and in the presence of graft acute cellular rejection or viral enteropathy. A negative correlation with creatinine clearance was observed in recipients with renal failure. SummaryCurrent data indicate that plasma citrulline could be a reliable marker of post-transplant graft mucosal damage in intestinal transplant recipients. Further studies are required to improve interpretation of plasma citrulline in recipients with renal failure.

Iodine status in intestinal failure in adults.

Purpose of reviewThe aim of this work is to review the recent findings on iodine nutrition in adults with intestinal failure. Recent findingsPatients with intestinal failure who require long-term parenteral nutrition are potentially at risk for trace element deficiencies. It was considered that iodine deficiency was unlikely to occur in adults on parenteral nutrition, even if iodine is not added to parenteral nutrition, because of iodine absorption from iodine-containing antiseptics, to presence of iodine as contaminant in parenteral nutrition products and to absorption of dietary iodine, in patients eating and having a functioning duodenum. It is believed that thyroidal iodine could support thyroid function for several months during total parenteral nutrition. Clinical Nutrition Societies do not have uniform opinion about the need to supplement iodine routinely in parenteral nutrition in adults. Although very few studies have addressed this topic, inadequate iodine supply in long-term parenteral nutrition in young adults, and the increased risk of iodine deficiency in adults on long-term parenteral nutrition have recently been reported. SummaryThere is some evidence that adults with intestinal failure on long-term parenteral nutrition may be at risk of iodine deficiency. Studies carried out in large cohorts of patients are required to better define iodine requirements in long-term parenteral nutrition.

SUN-PP038: Lipidomics Profile of Red Blood Cell Membrane in Patients on Long-Term Home Parenteral Nutrition: Effect of Two Different Lipid Emulsions

Introduction: Lipidomics considers the structural and functional roles played by lipids and their in vivo changes due to metabolic or degradation pathways, as well as their biological consequences. We investigated the effects of two different intravenous lipid emulsions (LE) on red blood cell (RBC) membrane lipidomics of patients on home parenteral nutrition (HPN) for chronic intestinal failure. Methods: A cross sectional study was carried out on two groups of patients receiving a lipid-based HPN. Inclusion criteria: age> 18 years, no active cancer, duration of HPN > 3 months, use of the current HPN admixture > 2 months, HPN infusion > 2 / week, HPN admixture with an olive-oil based LE (OOLE) or a LE containing soy, MCT, olive and fish oils (mixed-LE). Fasting blood samples were drawn in the morning, 4–6 h after discontinuation the overnight HPN infusion. The RBC membrane fatty acid profile was analyzed by gas chromatography, according to the Lipinutragen® methodology. The single fatty acid concentrations were calculated as percentage of the total fatty acid content. The following indexes were calculated: membrane fluidity index, represented by the saturated/monounsaturated fatty acids ratio (SFA/MUFA; high value=low fluidity); inflammatory risk index, given by the omega-6/omega-3 fatty acids ratio (ω-6/ω-3, high value=high risk); the free radical stress index, represented by the % of trans isomers of fatty acids (%trans, high concentration=high radical stress); the ω-3 cardiovascular risk index, given by the sum of the ω-3 EPA and DHA content (ω-3-index, high value=low risk). Statistics. Median and Mann-Whitney U test. Results: Two groups of patients were enrolled: 15 receiving the OOLE and 8 receiving the mixed-LE. The two groups did not differ for age, BMI and the characteristics of HPN, other than the type of LE. The mixed-LE group showed a higher SMA/MUFA ratio (p= 0.017), a lower ω-6/ω-3 ratio (p<0.001) and a higher ω-3 index (p<0.001). The %TFA did not differ between the two groups. Conclusions: In comparison with an OO-LE, the mixed-LE containing fish oil was associated with a lower inflammatory risk index, a lower cardiovascular risk index and a lower cell membrane fluidity. 121