Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US

Alternative sources of bioactive omega-3 fatty acids: what are the options?

PURPOSE OF REVIEW

The very-long chain (VLC) omega-3 polyunsaturated fatty acids (PUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) promote optimal development, physiological function and healthy ageing and help to manage disease. EPA and DHA are sourced mainly from fish, which is not sustainable. This review explores alternative sustainable sources.

RECENT FINDINGS

Recent research confirms that higher intake and status of EPA and DHA are associated with health benefits including lower risk of incident type-2 diabetes and cardiovascular disease mortality. Meta-analyses confirm benefits of intravenous EPA and DHA in hospitalized adults. Algal oils and seed oils from some genetically modified (GM) plants are sources of EPA and DHA. An oil from GM camelina showed equivalence with fish oil in human trials. Ahiflower oil, a source of stearidonic acid, had biological effects in experimental studies that might translate into health benefits. An intravenous lipid emulsion based on Ahiflower oil has been tested in experimental research. Pine nut oil (PNO) is a source of pinolenic acid, which is not an omega-3 PUFA but has similar actions.

SUMMARY

Algal oils, oils from GM seed crops, Ahiflower oil and other sources of stearidonic acid, and nonomega-3 oils including PNO, are plant-sourced sustainable alternatives to fish-sourced VLC omega-3 PUFAs.

Metabolic impact of high lipid low dextrose parenteral nutrition

BACKGROUND

Parenteral nutrition (PN) containing 100% soybean oil lipids and high amounts of dextrose may lead to liver dysfunction and hyperglycemia. Mixed lipids have less pro-inflammatory components, so higher doses may be given to decrease the amount of dextrose provided. The purpose of this study is to provide a descriptive analysis of patients who received PN with high mixed lipid and low dextrose content versus PN with lower 100% soybean oil lipid and high dextrose content.

METHODS

We retrospectively reviewed 62 patients aged ≥18 years receiving PN ≥ 7 days from 2016 to 2021 in an acute care hospital. Participants were divided into two groups: high lipid low dextrose (HLLD) containing a four-oil lipid (>30% kcal or ≥1 g/kg) vs adequate lipid high dextrose (ALHD) containing a 100% soybean oil lipid (<30% kcal or <1 g/kg SO-ILE).

RESULTS

Patients in the HLLD group (n = 31) had 64.1% lower incidence of blood glucose levels >180 mg/dL, decreased insulin requirements, 52.7% lower alkaline phosphatase levels, 40.6% higher prealbumin levels, and 42.6% lower c-reactive protein levels while maintaining similar calorie targets compared to the ALHD group (n = 31).

CONCLUSION

Changing from 100% soybean oil to a mixed lipid in PN is helpful to reduce soybean oil intake. However, it is also important to increase the mixed lipid dose to decrease the amount of dextrose provided. PNs containing higher amounts of mixed lipids (40-45% kcal) with lower amounts of dextrose (20-30% kcal) may have clinical benefits that warrant further exploration.

High lipid, low dextrose parenteral nutrition allows patient to achieve nutritional autonomy: A case report

INTRODUCTION

Prolonged use of parenteral nutrition can eventually lead to liver abnormalities. Causative factors include decreased enteral stimulation, high intakes of intravenous dextrose, proinflammatory 100 % soybean oil-based lipids, and increased burden on liver through 24-h infusions. We present a case report of a patient who received parenteral nutrition modifications to address liver dysfunction.

PRESENTATION OF CASE

Our patient was a 37-year-old African American male with a past medical history including refractory Crohn's disease complicated by multiple small bowel obstructions, several bowel surgeries, left lower quadrant colostomy placement, short bowel syndrome, severe protein calorie malnutrition, parenteral nutrition dependence, and elevated liver function tests. He was admitted for nutritional optimization before a planned takedown of multiple chronic enterocutaneous and perianal fistulas. His home parenteral nutrition order contained high amounts of dextrose (69 % kcal), and low amounts of 100 % soybean oil (11 % kcal).

DISCUSSION

Due to an elevated alkaline phosphatase level at baseline (1746 U/L), the Registered Dietitian maximized protein, decreased the dextrose by 62.5 %, and changed to SMOFlipid (a fish-oil containing lipid) at >1 g/kg/day to address liver abnormalities. Within 1.5 months of changing parenteral nutrition to high SMOFlipid (>30 % kcal) with low dextrose (<30 % kcal) content, alkaline phosphatase levels declined by 62 %, prealbumin levels increased by 56 %, and c-reactive protein levels decreased by 62 %.

CONCLUSION

Parenteral nutrition modifications led to reversal of chronic liver dysfunction. This patient ultimately underwent a successful high-risk fistula takedown procedure, allowing for complete weaning of parenteral nutrition and achievement of sustained nutritional autonomy.

Comparing mixed oil to soybean oil lipid emulsion in patients on home parenteral nutrition: a pilot prospective double-blind, crossover, randomized trial

BACKGROUND

Home parenteral nutrition (HPN) can be associated with increased liver enzymes, catheter-related bloodstream infections (CRBSI), and hospitalizations. Mixed oil (MO) versus soybean oil (SO) lipid emulsion reduces risks in hospitalized patients, but there are no randomized double-blinded controlled trials in HPN. Therefore, the primary objective was to test the study's feasibility such as recruitment and retention in the HPN population and the secondary objective was to assess changes in liver enzymes between MO and SO as well as other clinical and biochemical outcomes.

METHODS

This 13-month prospective double-blind crossover randomized pilot trial took place in Toronto, Canada. Participants were HPN patients who were a part of the HPN program at Toronto General Hospital. We recruited patients from the HPN program. HPN patients receiving SO were randomized to either MO or SO, and the study duration was 6 months in each arm (MO or SO) with a 1-month washout period resuming SO. As this is a crossover trial design, the patient is his/her own control. The main outcome measures were descriptions of study feasibility, namely the study recruitment and retention. We also collected biochemical parameters, CRSBI, hospitalization rate, antibiotic use, and mortality. Demographic, nutritional, clinical, and laboratory data were collected at baseline, 3 and 6 months of each arm. The primary analysis population was defined as the per-protocol population who completed the trial including all lipid measurements.

RESULTS

A total of 65 HPN patients were assessed, and 60 met the inclusion criteria for the study. Thirty-five percent (21/60) were randomized using a computer-generated random number sequence generator: 10 participants were randomized to receive SO first while 11 were randomized to receive MO first. At 13 months, 3/10 who received SO first completed the study, whereas 9/11 who received MO first completed the study. This did not meet our a priori criteria for success in recruitment and retention. Between types of lipid emulsions, there were no significant differences in changes in liver enzymes or biochemical and clinical outcomes, despite significant changes in plasma free fatty acid composition reflecting MO or SO.

CONCLUSIONS

Overall, this pilot trial demonstrated that the use of a prospective double-blind, crossover, randomized trial design was not feasible to conduct in the HPN population because of difficulties in recruiting and retaining patients. In addition, there was no significant impact of MO versus SO lipid emulsion on liver enzymes or most parameters. The lack of significance may be attributed to low sample size from low recruitment and high drop-out rate, short study duration (6 months/arm), and complex care. In a future definitive trial, a multicenter study of longer duration and a larger sample size is recommended, and drop-outs may be reduced by using a parallel study design.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02796833. Registered on 13 June 2016-retrospectively registered.

Chronic Critical Illness and PICS Nutritional Strategies

The nutritional hallmark of chronic critical illness (CCI) after sepsis is persistent inflammation, immunosuppression, and catabolism syndrome (PICS), which results in global resistance to the anabolic effect of nutritional supplements. This ultimately leaves these patients in a downward phenotypic spiral characterized by cachexia with profound weakness, decreased capacity for rehabilitation, and immunosuppression with the propensity for sepsis recidivism. The persistent catabolism is driven by a pathologic low-grade inflammation with the inability to return to homeostasis and by ongoing increased energy expenditure. Better critical care support systems and advances in technology have led to increased intensive care unit (ICU) survival, but CCI due to PICS with poor long-term outcomes has emerged as a frequent phenotype among ICU sepsis survivors. Unfortunately, therapies to mitigate or reverse PICS-CCI are limited, and recent evidence supports that these patients fail to respond to early ICU evidence-based nutrition protocols. A lack of randomized controlled trials has limited strong recommendations for nutrition adjuncts in these patients. However, based on experience in other conditions characterized by a similar phenotype, immunonutrients aimed at counteracting inflammation, immunosuppression, and catabolism may be important for improving outcomes in PICS-CCI patients. This manuscript intends to review several immunonutrients as adjunctive therapies in treating PICS-CCI.