Total parenteral nutrition-related gastroenterological complications.

Total parenteral nutrition is a life saving therapy for patients with chronic gastrointestinal failure, being an effective method for supplying energy and nutrients when oral or enteral feeding is impossible or contraindicated. Clinical epidemiological data indicate that total parenteral nutrition may be associated with a variety of problems. Herein we reviewed data on the gastroenterological tract regarding: (i) total parenteral nutrition-related hepatobiliary complications; and (ii) total parenteral nutrition-related intestinal complications. In the first group, complications may vary from mildly elevated liver enzyme values to steatosis, steatohepatitis, cholestasis, fibrosis and cirrhosis. In particular, total parenteral nutrition is considered to be an absolute risk factor for the development of biliary sludge and gallstones and is often associated with hepatic steatosis and intrahepatic cholestasis. In general, the incidence of total parenteral nutrition-related hepatobiliary complications has been reported to be very high, ranging from 20 to 75% in adults. All these hepatobiliary complications are more likely to occur after long-term total parenteral nutrition, but they seem to be less frequent, and/or less severe in patients who are also receiving oral feeding. In addition, end-stage liver disease has been described in approximately 15-20% of patients receiving prolonged total parenteral nutrition. Total parenteral nutrition-related intestinal complications have not yet been adequately defined and described. Epidemiological studies intended to define the incidence of these complications, are still ongoing. Recent papers confirm that in both animals and humans, total parenteral nutrition-related intestinal complications are induced by the lack of enteral stimulation and are characterised by changes in the structure and function of the gut. Preventive suggestions and therapies for both these gastroenterological complications are reviewed and reported in the present review.

[The metabolic role of glutamine]. / Ruolo metabolico della glutamina.

Glutamine is a non essential amino acid. Nevertheless it has to be considered a "conditionally essential" amino acid for several metabolic reactions in which it is involved. Glutamine is the most abundant amino acid in human plasma and muscle. Because glutamine is highly unsteady, it was never used for enteral and parenteral nutrition in the past. It appears to be a unique amino acid for rapidly proliferating cells serving as a preferred fuel compared to glucose. It seems to be essential for cellular replication such as a "nitrogen carrier" between the tissues. A deficiency state of glutamine causes morphology and functional changing and negative nitrogen metabolism. The need for glutamine is particularly high when metabolism is increased as in the critically ill (surgical stress, sepsis, inflammatory states, fasten, burns) especially in the tissues with a rapid cell turn-over. In these conditions the body requirements of glutamine appear to exceed the individual's muscle deposits (muscle is the most important place of synthesis and storage), causing an increased synthesis with a high energy waste and loss of muscle mass. Glutamine is essential for bowel mucosa trophism and its deficiency in all the catabolic states allows bacterial translocation. In these cases feeding is not sufficient to restore basal conditions. At present enteral or parenteral glutamine supplementations are of high interest for the feeding of critically ill patients.

Hepatotoxicity of intravenous cyclosporin A in patients with acute ulcerative colitis on total parenteral nutrition.

A group of 24 patients underwent a 7-14-day course of continuously infused Cyclosporin A (2 mg.kg-1.day-1) to treat a severe attack of ulcerative colitis. In 19 of them, including eight treated with total parenteral nutrition, we retrospectively analyzed the serum aminotransferase (AST/ALT) levels at the beginning and at the end of Cyclosporin infusion. The baseline levels of AST/ALT in the group were 19.9 +/- 3.2 and 31.4 +/- 6.4; on stopping Cyclosporin infusion, they were 43 +/- 15.8 and 119 +/- 56, respectively. Six patients showed an ALT change above 1.5 times the upper limit of reference. They included five of the eight patients treated with total parenteral nutrition (62.5%). In one of six, ALT rose to 1000 U/l and was accompanied by full-blown febrile cholangitis (proven by liver biopsy). This episode was preceded by excessive accumulation of Cyclosporin in blood. The development of liver toxicity was independent of the length of Cyclosporin treatment, nor did it impair drug efficacy. Thus, in these patients total parenteral nutrition and Cyclosporin were synergistic, causing twice the frequency of liver damage (62.5%) reported for ulcerative colitis patients on total parenteral nutrition alone (37%). Total parenteral nutrition should not be used to support patients needing Cyclosporin for autoimmune disease. However, too high a dose of Cyclosporin may cause liver disease per se.

[Total parenteral nutrition in critical patients. The metabolic-nutritional aspects and effects on immune function of 2 different isocaloric-isonitrogenous regimens]. / Nutrizione parenterale totale (NPT) in pazienti critici. Aspetti metabolico-nutrizionali ed effetti sulla funzione immunitaria di due differenti apporti isocalorici-isoazotati.

The aim of this investigation was to compare, in a randomized short-term study the effects on some parameters evaluating lipid metabolism, nutritional status and immune function of two different patients. Particularly, the influence of the intravenous (i.v.) infusion of a fat emulsion on above-mentioned parameters was evaluated. The two regimens (G and GL) were isocaloric (about 30 kcal.kg-1.d-1 non protein energy) and isonitrogenous (about 0.27 g.kg-1.d-1 nitrogen); the only difference was the source of non-protein calories administered. Regimen G consisted of glucose-based TPN (100% of non-protein energy as glucose) whereas, in regimen GL (glucose-lipid-based TPN), the 55% of non-protein caloric supply was given as glucose and 45% as lipids. 9 of the patients were randomly assigned to receive regimen GL (group GL) and 8 to receive regimen G (group G). TPN was delivered through a central vein catheter for 8 days; during this period no hepatic or metabolic complications have been observed. Clinical and laboratory tests were performed at day 0 (enrollment), at day 4 (after 4 days of TPN) and at day 8 (at the end of TPN). Both regimens of TPN were able to induce an improvement of the nutritional status and serum prealbumin (TBPA) significantly increased in all patients (p < 0.05). The results of the immune measurements showed that no significant change in immune function during the administration of either regimen occurred. However, in group GL, we observed a slight, non significant change in the percentage numbers of T-cells subpopulations that resulted in a decrease in the ratio of helper to suppressor T-cells (H:S). Serum lipids and lipoprotein profile didn't change significantly in group GL. On the contrary, in group G, we observed a significant decrease in serum concentrations of HDL cholesterol (p < 0.05), LDL cholesterol and apo A1 (p < 0.01) while total cholesterol remained unchanged; a non significant rise in serum triglyceride also occurred, These results show that the two regimens had a similar impact on nutritional status in both groups. The i.v. infusion of the fat emulsion didn't alter lipid profile and was not associated with an impairment of some aspects of the immune function. In conclusion, our results confirm that fat emulsions represent an important component of i.v. nutritional support regimens and should continue to be used when and where indicated in short-term TPN. However, long-term effects of i.v. infusion of fat emulsions on the immune systems should be further investigated, in a more substantial number of patients.

[Possibilities and limitations of nutritional support in Crohn disease]. / Possibilità e limiti del supporto nutrizionale nella malattia di Crohn.

Crohn's disease involves a great risk of malnutrition. Malabsorption, bacterial contamination, frequent abdominal surgery, meal-related pain, protein loss through the damaged mucosa contribute to creating nutritional problems. Malnutrition can worsen the outcome, both in medical and surgical patients, and deteriorate an often already altered immune response. Weight loss, low levels of blood protein, electrolytes, micronutrients and vitamins are usually related to the extension of the mucosal damage. Nutritional assessment can be difficult due to oedema and bleeding, who interfere with both clinical and laboratory evaluation. The exact amount of nitrogen, lipids, minerals stool loss can be useful. It is widely accepted the use of nutritional support in Crohn's disease, but many Authors do not agree concerning the route (enteral or parenteral) and the kind of nutrient to be used. Still controversial is the role of nutrition: just support or real therapy? Most recent hypothesis concerning the pathogenesis of Crohn's disease indicate food and/or bacterial antigens as involved in determining the pathology. The "bowel rest", considered for many years as a fasting period necessarily supported by parenteral nutrition, can also be obtained by the temporarily reduction or stop in presenting those antigens to the bowel mucosa. This new concept can be achieved not only by parenteral nutrition, but with an enteral elemental diet as well. The elemental diet contains all nutrients in the simplest way and thus succeeds in lowering or eliminating the antigenic power. The reported results seem to indicate an equivalence of enteral and parenteral nutrition; anyway enteral is advisable when feasible, being more physiological and less expensive and involving a lower risk of serious complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of nutritional support and physical exercise in the dyslipidemia of renal transplantation]. / Ruolo dell'apporto nutrizionale e dell'esercizio fisico nella dislipidemia del trapianto di rene.

The purpose of the study is to evaluate the effect of diet and physical exercise on the dyslipemia of renal transplant (RT) patients 52 pts, transplanted between 12/85 and 4/87, subdivided into 2 groups (A and B), were studied. Characteristics of the diet adopted in patients in group A are: low carbohydrates, moderate animal protein, unsaturated and polyunsaturated fat in high rate. The second group had a lower animal protein and more fiber rich diet than the first one and a program of PE. By comparing A and B1 we noticed and increase in body weight, more slight in the group B, at the 24 months (56 +/- 8 59 +/- 10 vs 59 +/- 10 61 +/- 10). The study of lipid behaviour has showed a trend to normalization of triglycerides at 24 months in A (189 +/- 88 106 +/- 33) and in B1 (173 +/- 81 103 +/- 40), more evident normalization of cholesterol in group B1 (195 +/- 72 185 +/- 42), and increase of CT-HDL in A (42 +/- 12 63 +/- 17) and in B1 (44 +/- 10 61 +/- 14, p less than 0.05). It should be noted that CT-LDL increase in A (100 +/- 34 131 +/- 40) but not in B1 (103 +/- 35 111 +/- 33). With the aim of this program we obtained a positive effect on DL with a slight increase in body weight, a significant increase in CT-HDL without variation of total CT and CT-LDL levels.

[Nutritional support in non-Hodgkin's lymphoma treated with polychemotherapy MACOP-B cycle]. / Supporto nutrizionale nel linfoma non-Hodgkin in trattamento con ciclo polichemioterapico MACOP-B.

The collateral effects of antineoplastic therapy often lead to a deterioration of the cachectic condition induced by the presence of the tumour itself. This study analysed the effects of a programme of dietary surveillance/support in patients with non-Hodgkin's lymphoma undergoing a cycle of MACOP-B polychemotherapy. During the entire course of therapy patients were followed weekly by a nutritional specialist and a dietician in order to assess and if necessary modify food intake, also in relation to the onset of collateral effects. Using this programme it was observed that a satisfactory nutritional state was maintained during the entire cycle, with an increased food intake compared to the start of the cycle and to conditions of good health.