Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition".

BACKGROUND: The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). METHODS: The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. RESULTS: The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. CONCLUSIONS: This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

Lipid Emulsion Use in Pediatric Patients Requiring Long-Term Parenteral Nutrition.

The ability to deliver nutrients via parenteral nutrition (PN) has markedly improved the prognosis of infants and children with intestinal failure. Technical refinements and advances in knowledge have led to the development of highly sophisticated PN solutions that are tailored to meet the needs of pediatric patients. However, children who require long-term PN have an increased risk of complications such as catheter-related sepsis, liver disease, and bone disease. Although the pathogenesis of intestinal failure associated liver disease (IFALD) is multifactorial, studies have identified a possible link between the dose of lipid emulsions based on soybean oil and cholestasis, shown to occur with a significantly higher frequency in patients receiving >1 g lipids/kg/d. Potential contributing factors include oxidative stress, high ω-6 polyunsaturated fatty acid (PUFA) and phytosterol content, and relatively low α-tocopherol levels. Lipid emulsions containing fish oil offer potential advantages compared with traditional emulsions with a high soybean oil content, such as decreased ω-6 and increased ω-3 PUFA concentrations, high concentrations of α-tocopherol, and reduced phytosterol content. Studies in PN-dependent children at risk for IFALD have shown that lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with pure soybean oil emulsions. This review summarizes evidence regarding the role of lipid emulsions in the management of pediatric patients with intestinal failure requiring long-term PN, with a particular focus on the prevention and treatment of IFALD.

Intestinal failure-associated liver disease and the use of fish oil-based lipid emulsions.

Intestinal failure (IF) is caused by the critical reduction of functional gut mass below the minimal amount necessary for adequate digestion and absorption to satisfy body nutrient and fluid requirements for maintenance in adults and growth in children. The advent of parenteral nutrition (PN) resulted in a dramatic improvement in life expectancy of patients suffering IF, but it has its own complications, such as catheter related sepsis. In pediatric patients suffering IF, intraluminal intestinal bacterial overgrowth may cause bacterial translocation and subsequent cholestasis and liver fibrosis. With our current understanding of the genesis of intestinal failure associated liver disease (IFALD), it should be prevented or at least early recognized and treated especially in patients experiencing prematurity and/or sepsis. Targeting harmful cytokine responses can be expected to reduce the severity and frequency of IFALD. In that view, prevention of sepsis, appropriate management of enteral feeding, prevention and treatment of intestinal bacterial overgrowth and the effects of fish oil, as providing omega-3 fatty with anti-inflammatory effects, are promising in avoiding or reversing cholestasis. This chapter aims to review both IF and PN related factors of liver disease with special emphasize on inflammation as cause of liver injury and on the use of fish oil based lipid emulsions as a provision of both alpha-tocopherol (200 g/l of 20% emulsion), as anti-oxidant agent and long-chain PUFAs.

Estimate of specific energy expenditure of fat-free mass and fat mass in children receiving total parenteral nutrition.

OBJECTIVES: Simple methods for calculation of the energy expenditure may be useful for clinicians involved in the treatment of nutritional disorders in children. The aims of this study were to (1) estimate the specific energy expenditure (SEE) of fat mass (FM) and fat-free mass (FFM) and (2) determine a sensitive predictive indicator of resting energy expenditure (REE). METHODS: The REE of 26 children receiving longterm TPN, was measured by long-term indirect calorimetry. Body composition was estimated from the sum of four skinfold measurements. RESULTS: The following regression equations were derived: (1) REE (kcal/d) = 56.6 x FFM (kg) + 97.9 (r2 = 0.98, p < 0.001); (2) REE (kcal/d) = 45.6 x BW (kg) + 136 (r2 = 0.92, p < 0.001); (3) REE (kcal/d) = 68.9 x FFM (kg) + 3.3 x FM (kg) (r2 = 0.985, p < 0.001). The results obtained allowed the estimate of K1 and K2 with their respective SEE: K1 = 3.3 +/- 18.0 kcal/kg of FM, K2 = 68.9 +/- 3.1 kcal/kg of FFM. CONClUSIONS Anthropometrically measured FFM is an easily determined predictive factor of REE. The above equations may be used to estimate the REE in stable children receiving TPN.