Structured triacylglycerol emulsion, containing both medium- and long-chain fatty acids, in long-term home parenteral nutrition: a double-blind randomized cross-over study

Parenteral n-3 polyunsaturated fatty acids supplementation improves postoperative recovery for patients with Crohn's disease after bowel resection: a randomized, unblinded controlled clinical trial

BACKGROUND

The postoperative inflammatory response is associated with postoperative recovery in surgery. n-3 (ω-3) polyunsaturated fatty acids have been reported to lower inflammation. The postoperative role of parenteral n-3 polyunsaturated fatty acids supplementation on outcomes in Crohn's disease after bowel resection is unclear.

OBJECTIVES

We aimed to investigate the effects of postoperative parenteral n-3 polyunsaturated fatty acids supplementation in Crohn's disease.

METHODS

A prospective randomized, unblinded controlled clinical trial was conducted for patients with Crohn's disease who underwent bowel resection between May 2019 and February 2022. Postoperative complications, complete blood count, serum biochemical values, and cytokine concentrations were compared in patients with and without parenteral n-3 polyunsaturated fatty acids supplementation for 5 d postoperatively.

RESULTS

There were 268 patients randomly assigned in the analysis, with 134 in the control group (a mix of long-chain and medium-chain fats at 1.0 g/kg/d) and 134 in the treatment group (long-chain, medium-chain, and n-3 polyunsaturated fats at 1.2 g/kg/d). Twenty-six did not complete the allocated treatment, and 8 patients were lost to follow-up. The intention-to-treat analysis and the per-protocol analysis showed that there were a significant reduction in overall complication rates (22.4% compared with 49.3%; P < 0.001 and 21.8% compared with 38.2%; P = 0.006) and postoperative stay (8.8 ± 4.5 d compared with 11.2 ± 6.8 d; P = 0.001 and 8.7 ± 4.0 d compared with 11.5 ± 7.3 d; P < 0.001) in patients with parenteral n-3 polyunsaturated fatty acids supplementation compared with patients in the control group. In the secondary outcomes, the mean ± standard deviation of interleukin (IL)-6 (17.11 ± 2.14 pg/mL compared with 30.50 ± 5.14 pg/mL; P = 0.014), IL-1β (2.01 ± 0.05 pg/mL compared with 2.24 ± 0.09 pg/mL; P = 0.019), tumor necrosis factor-α (2.09 ± 0.06 pg/mL compared with 2.29 ± 0.06 pg/mL; P = 0.029), and C-reactive protein concentrations (51.3 ± 4.2 mg/L compared with 64.4 ± 5.3 mg/L; P = 0.050) on postoperative day 5 in the treatment group were much lower than those in the control group.

CONCLUSIONS

Parenteral n-3 polyunsaturated fatty acids supplementation promotes postoperative recovery in patients with Crohn's disease following bowel resection, with fewer complications and reduced inflammatory cytokines. This trial was registered at clinicaltrials.gov as NCT03901937 at https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03901937?term=NCT03901937&cond=Crohn+Disease&draw=2&rank=1.

Assessing different oil sources efficacy in reducing environmental heat-stress effects via improving performance, digestive enzymes, antioxidant status, and meat quality

Adding oil to the feed of genetically improved broilers is necessary to provide energy requirements, in addition to enhancing metabolism, growth performance, immune response. This study aims to reveal the effect of adding different oil sources in the diets of broilers exposed to environmental heat stress on performance, digestibility, oxidative status, plasma lipids, fatty acids content, and meat quality. Six hundred twenty-five one-day-old broiler chicks were randomly distributed to five groups as follows: the first group fed a diet without oil (CON) as a control, while the second to the fifth group fed a diet containing soy oil (SO), corn oil (CO), olive oil (OO), and fish oil (FO), respectively. Results indicated a significant deterioration in growth performance, carcass traits, and oxidative state with a significant decrease in carcass quality in heat-stressed chickens fed the CON diet. Results showed increased growth, enhanced feed conversion ratio, and carcass dressing in broilers fed the oil-supplemented diet compared to the control diet, however, the digestive enzymes activity was not affected by receiving an oil-supplemented diet. The best performance was in chickens fed OO and SO, compared with FO and CO. Plasma aspartate aminotransferase (AST), and alanine aminotransferase (ALT) increased in broilers fed an oil-supplemented diet. Plasma high-density lipoprotein (HDL), and superoxide dismutase (SOD) remarkably increased in broilers fed OO, whereas the malondialdehyde (MDA) decreased compared to the other groups. Adding different dietary oil sources enhanced the breast muscle's fatty acid composition. Broiler diets supplemented with oils positively affected meat quality by enhancing color measurements, and TBA values, while the best were in chicken fed OO. It was concluded that adding dietary oil at 3% in the diets of broiler chicken exposed to environmental heat stress positively affected growth performance, enhanced oxidative status, and meat quality, best results were in broilers fed a diet that included olive oil.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Effects of Short- and Medium-Chain Fatty Acids on Production, Meat Quality, and Microbial Attributes-A Review

The non-therapeutic use of antimicrobials in poultry production contributes to the spread of drug-resistant pathogens in both birds and humans. Antibiotics are known to enhance feed efficiency and promote the growth and weight gain of poultry. New regulatory requirements and consumer preferences have led to a reduced use of antibiotics in poultry production and to the discovery of natural alternatives to antibiotic growth promoters. This interest is not only focused on the direct removal or inhibition of causative microorganisms but also on the prevention of diseases caused by enteric pathogens using a range of feed additives. A group of promising feed additives is composed of short- and medium-chain fatty acids (SCFAs and MCFAs) and their derivatives. MCFAs possess antibacterial, anticoccidial, and antiviral effects. In addition, it has been proven that these acids act in synergy if they are used together with organic acids, essential oils, or probiotics. These fatty acids also benefit intestinal health integrity and homeostasis in broilers. Other effects have been documented as well, such as an increase in intestinal angiogenesis and the gene expression of tight junctions. The aim of this review is to provide an overview of SCFAs and MCFAs as alternatives to antibiotic growth promoters and to summarize the current findings in the literature to show their possible benefits on production, meat quality, and gut health in poultry.

Acute Oral Toxicity and Genotoxicity Test and Evaluation of Cinnamomum camphora Seed Kernel Oil

Cinnamomum camphora seed kernel oil (CCSKO) is one of the important natural medium chain triglycerides (MCT) resources, with more than 95.00% of medium chain fatty acids found in the world, and has various physiological effects. However, CCSKO has not been generally recognized as a safe oil or new food resource yet. The acute oral toxicity test and a standard battery of genotoxicity tests (mammalian erythrocyte micronucleus test, Ames test, and in vitro mammalian cell TK gene mutation test) of CCSKO as a new edible plant oil were used in the study. The results of the acute oral toxicity test showed that CCSKO was preliminary non-toxic, with an LD50 value higher than 21.5 g/kg body weight. In the mammalian erythrocyte micronucleus test, there was no concentration-response relationship between the dose of CCSKO and micronucleus value in polychromatic erythrocytes compared to the negative control group. No genotoxicity was observed in the Ames test in the presence or absence of S9 at 5000 μg/mL. In vitro mammalian cell TK gene mutation test showed that CCSKO did not induce in vitro mammalian cell TK gene mutation in the presence or absence of S9 at 5000 μg/mL. These results indicated that CCSKO is a non-toxic natural medium-chain oil.

The effects of different parenteral nutrition lipid formulations on clinical and laboratory endpoints in patients receiving home parenteral nutrition: A systematic review

BACKGROUND

Home parenteral nutrition (HPN) is a life-sustaining therapy for individuals with intestinal failure in a community setting. It refers to the intravenous infusion of macronutrients, micronutrients, fluids and electrolytes. Routinely used HPN solutions contain different quantities of these components. Consequently, each HPN solution may have different impacts on metabolism, inflammation and oxidative stress. Long-term use of HPN can lead to a number of adverse health outcomes including the development of metabolic bone disease, intestinal failure associated liver disease and poor quality of life but whether, and how, the composition of HPN solutions contributes to these health sequelae is poorly understood. The aim of this study is to systematically review and evaluate the evidence for the differential effects of HPN solutions and to understand what features are associated with differences in clinical endpoints.

METHODS

A systematic literature search was conducted between September and December 2020, and updated in July 2021 using the MEDLINE (Ovid), EMBASE, Scopus, and Web of Science databases. Studies were selected according to the following criteria (a) adult participants (>18 years old) dependent on HPN; (b) randomised controlled trials, prospective cohort and cross-sectional study designs; (c) primary research comparing two or more HPN solutions and (d) published in English language. Data were extracted and study quality assessed using Cochrane Collaboration's tools: Risk of Bias for Randomised Controlled Trials (RCTs); Risk of Bias in Non-Randomised Studies of Interventions; and the Newcastle Ottawa Scale for cross-sectional studies.

RESULTS

Of the 5148 articles identified, seven RCTs, two prospective cohort and one cross-sectional study were included with a total of 295 participants. Studies varied in terms of duration (one to 60 months) and sample size (n = 5 to 88). Ten studies compared lipid emulsions (LE) and one study also compared LE with lipid-free HPN. No studies were found that compared the amino acid, vitamin, trace element or electrolyte components of HPN. In general, LE were well tolerated with no significant adverse effects. LE containing olive +/or fish oil were associated with a lower ω-6:ω-3 fatty acid ratio, positive reductions in markers of liver function, and changes in blood and cell fatty acid profiles.

CONCLUSIONS

Despite the increasing use of HPN, there is surprisingly little evidence available to guide the provision of macro and micronutrients in the adult population requiring this therapy. Although LE containing olive +/or fish oil show promise with regards to liver function and blood and cell fatty acid profiles, further studies are needed before drawing definitive conclusions on the clinical value of these emulsions. It is likely that one type of HPN solution alone cannot be uniformly applied to patient care, and each patient should be assessed on an individual basis.

Synthesis of middle-long-middle structured intralipids by biological catalysis and the evaluation of intralipids' protective effect on liver injury rats

Intralipids are widely used to provide energy and necessary fatty acids for the patients. The structure of lipids may affect their function. We developed a bio-catalyzed route to prepare various intralipids and investigated the protective effect of intralipids against α-naphthylisothiocyanate (ANIT) induced liver injury rats, further discussing the structure-function relationship. The middle-long-middle (MLM) structural intralipid was synthesized through alcoholysis-esterification, and the influence factors were investigated. ANIT treatment caused liver injury, further making hepatocyte damage, and increasing related biochemical indexes, like aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), and total bilirubin (TBIL). Especially, MLM-based and structoglyceride (STG) intralipids worked better in the early stage, to reduce the AST, ALT, and TBIL (p < .05). MLM showed a comparative advantage over other intralipids to accelerate the reduction of ALT (1st day) and AST (3rd day). MLM intralipid might be a promising next-generation intralipid than the current STG intralipid liver-injury patients. The biological catalysis MLM-based intralipids can make the maximum utilization of fatty acids for the liver regeneration, where middle-chain fatty acid (MCFA) in sn-1,3 position can be metabolized directly to provide energy and long-chain fatty acid (LCFA) in sn-2 position can be delivered effectively for cell membrane repairing.

Medium chain triglyceride and medium-and long chain triglyceride: metabolism, production, health impacts and its applications - a review

Structured lipid is a type of modified form of lipid that is "fabricated" with the purpose to improve the nutritional and functional properties of conventional fats and oils derived from animal and plant sources. Such healthier choice of lipid received escalating attention from the public for its capability to manage the rising prevalence of metabolic syndrome. Of which, medium-chain triacylglycerol (MCT) and medium-and long-chain triacylglycerol (MLCT) are the few examples of the "new generation" custom-made healthful lipids which are mainly composed of medium chain fatty acid (MCFA). MCT is made up exclusively of MCFA whereas MLCT contains a mixture of MCFA and long chain fatty acid (LCFA), respectively. Attributed by the unique metabolism of MCFA which is rapidly metabolized by the body, MCFA and MCT showed to acquire multiple physiological and functional properties in managing and reversing certain health disorders. Several chemically or enzymatically oils and fats modification processes catalyzed by a biological or chemical catalyst such as acidolysis, interesterification and esterification are adopted to synthesis MCT and MLCT. With their purported health benefits, MCT and MLCT are widely being used as nutraceutical in food and pharmaceutical sectors. This article aims to provide a comprehensive review on MCT and MLCT, with an emphasis on the basic understanding of its structures, properties, unique metabolism; the current status of the touted health benefits; latest routes of production; its up-to-date applications in the different food systems; relevant patents filed and its drawbacks.

Lipase catalysis of α-linolenic acid-rich medium- and long-chain triacylglycerols from perilla oil and medium-chain triacylglycerols with reduced by-products

BACKGROUND

Medium- and long- chain triacylglycerols (MLCTs) are functional structural lipids that can provide the human body with essential fatty acids and a faster energy supply. This study aimed to prepare MLCTs rich in α-linolenic by enzymatic interesterification of perilla oil and medium-chain triacylglycerols (MCTs), catalyzed by Lipozyme RM IM, Lipozyme TL IM, Lipozyme 435, and Novozyme 435 respectively.

RESULTS

The effects of lipase loading, concentration of MCTs, reaction temperature, and reaction time on the yield of MLCTs were investigated. It was found that the reaction achieved more than a 70% yield of MLCTs in triacylglycerols under the conditions of 400 g kg^-1 MCTs and 60 g kg^-1 lipase loading after equilibrium. A novel two-stage deodorization was also applied to purify the interesterification products. The triacylglycerols reach over 97% purity in the products with significant removal (P < 0.05) of the free fatty acids, and the trans fatty acids were strictly controlled at below 1%. There was more than 40% α-linolenic in the purified products, with long-chain fatty acids mostly occupying the desired sn-2 position in acylglycerols, which are more active in hydrolysis.

CONCLUSION

A series of novel α-linolenic acid-rich medium- and long-chain triacylglycerols was prepared. Under appropriate reaction conditions, the yield of MLCTs in triacylglycerols was above 70%. A novel two-stage deodorization can be used to promote the elimination of free fatty acids and limit the generation of trans fatty acids. © 2020 Society of Chemical Industry.

Influence of different intravenous lipid emulsions on fatty acid status and laboratory and clinical outcomes in adult patients receiving home parenteral nutrition: A systematic review

BACKGROUND & AIMS

Patients who have chronic intestinal failure require home parenteral nutrition (HPN) support. Intravenous lipid emulsions (IVLEs) are a vital part of HPN. The conventional IVLE is based on pure soybean oil, which contains a high concentration of omega-6 fatty acids. Alternative IVLEs are commercially available. These contain various oil blends and have different fatty acid compositions from soybean oil that could provide benefit to patients on HPN. The aim of this systematic review is to assess the effects of different IVLEs in adult patients requiring HPN.

METHODS

A systematic literature search was conducted up to October 2019 using relevant search terms in the Medline, EMBASE and CINAHL databases. Only randomised controlled trials (RCTs) in adults on HPN that compared two or more IVLEs were included. Data were extracted and the Cochrane Collaboration's tool for assessing risk of bias was used.

RESULTS

Six articles were identified for inclusion in this systematic review. Studies differed according to sample size, duration and the IVLEs compared. Four studies found no increased risk of adverse effects related to the different IVLEs, whilst one study found a higher frequency of serious adverse events with soybean oil. One study found higher serum α-tocopherol with the blend of soybean oil, medium chain triglycerides, olive oil and fish oil. Inflammatory markers were not affected by different IVLEs in three studies. Differences in liver function tests were minimal, but one study found slight abnormalities in patients receiving soybean oil. IVLEs containing olive oil or fish oil modified the blood fatty acid profile. No studies reported essential fatty acid deficiency.

CONCLUSIONS

There may be benefits of using alternative IVLEs to soybean oil-based emulsions in adults requiring HPN, although there is currently insufficient evidence to determine superiority of one formulation over another. More and larger RCTs are required in this area.

The Effects of Different Oil Sources on Performance, Digestive Enzymes, Carcass Traits, Biochemical, Immunological, Antioxidant, and Morphometric Responses of Broiler Chicks

This research evaluate the influence of different oil sources, namely fish oil (FO), coconut oil (CocO), canola oil (CanO), or a mixture of the three oils (MTO)—included at 1.5% in broiler diets—compared to a no oil-supplemented diet. Hence, 250 unsexed, 1-day-old Cobb chicks were weighed and randomly allocated into five dietary treatment groups of 50 chicks each and five replicates per group. Oil-supplemented diets significantly increased the growth, improved the feed conversion ratio (FCR), and decreased the abdominal fat percentage compared to the control diet. Amylase was significantly elevated due to feeding the FO- or CocO-supplemented-diet compared to the control diet, whereas lipase increased due to offering CocO- and CanO-enriched diet; chymotrypsin increased due to different oil sources. High-density lipoprotein cholesterol (HDL-C) increased markedly due to offering an oil-supplemented diet, but low-density lipoprotein cholesterol (LDL-C), the LDL-C:HDL-C ratio, and malondialdehyde (MDA) decreased. Blood plasma immunoglobulin (Ig) G and IgM significantly increased due to feeding CocO, CanO, or MTO compared to the control group, whereas FO increased IgG only. FO- and CanO-containing diets resulted in the highest increase in α2-globulin and γ-globulin. The antibody titer to avian influenza (HIAI) and Newcastle disease (HIND) were significantly elevated due to CocO supplementation compared to the control group. The bursa follicle length and width and thymus cortex depth were increased considerably due to the FO-supplemented diet compared to the control, but the follicle length:width ratio decreased. The villus height:depth ratio was significantly elevated due to both the CanO and MTO diets. The antioxidant status improved considerably due to the addition of CocO and CanO. Both CanO and MTO similarly increased plasma T3, T4, and the T3:T4 ratio. In conclusion, oil supplementations at 1.5% enhanced growth performance and immune status, improved the blood lipid profile and antioxidants status, and the effect of the oil sources depends on the criteria of response.

Valorization of Glycerol through the Enzymatic Synthesis of Acylglycerides with High Nutritional Value

The production of specific acylglycerides from the selective esterification of glycerol is an attractive alternative for the valorization of this by-product of the biodiesel industry. In this way, products with high added value are generated, increasing the profitability of the overall process and reducing an associated environmental threat. In this work, nutritional and medically interesting glycerides were obtained by enzymatic esterification through a two-stage process. In the first stage, 1,3-dicaprin was obtained by the regioselective esterification of glycerol and capric acid mediated by the commercial biocatalyst Lipozyme RM IM. Under optimal reaction conditions, 73% conversion of fatty acids and 76% selectivity to 1,3-dicaprin was achieved. A new model to explain the participation of lipase in the acyl migration reaction is presented. It evaluates the conditions in the microenvironment of the active site of the enzyme during the formation of the tetrahedral intermediate. In the second stage, the esterification of the sn-2 position of 1,3-dicaprin with palmitic acid was performed using the lipase from Burkholderia cepacia immobilized on chitosan as the biocatalyst. A biocatalyst containing 3 wt % of lipase showed good activity to esterify the sn-2 position of 1,3-dicaprin. A mixture of acylglycerides consisting mainly of capric acid esterified at sn-1 and sn-3, and of palmitic acid at the sn-2 position was obtained as the reaction product. The influence of the biocatalyst mass, the reaction temperature, and the molar ratio of substrates were evaluated for this reaction using a factorial design. Simple models were used to adjust the consumption of reagents and the generation of different products. The reaction product contained between 76% and 90% of acylglycerides with high nutritional value, depending on the reaction conditions.

Home parenteral nutrition with an omega-3-fatty-acid-enriched MCT/LCT lipid emulsion in patients with chronic intestinal failure (the HOME study): study protocol for a randomized, controlled, multicenter, international clinical trial

BACKGROUND

Home parenteral nutrition (HPN) is a life-preserving therapy for patients with chronic intestinal failure (CIF) indicated for patients who cannot achieve their nutritional requirements by enteral intake. Intravenously administered lipid emulsions (ILEs) are an essential component of HPN, providing energy and essential fatty acids, but can become a risk factor for intestinal-failure-associated liver disease (IFALD). In HPN patients, major effort is taken in the prevention of IFALD. Novel ILEs containing a proportion of omega-3 polyunsaturated fatty acids (n-3 PUFA) could be of benefit, but the data on the use of n-3 PUFA in HPN patients are still limited.

METHODS/DESIGN

The HOME study is a prospective, randomized, controlled, double-blind, multicenter, international clinical trial conducted in European hospitals that treat HPN patients. A total of 160 patients (80 per group) will be randomly assigned to receive the n-3 PUFA-enriched medium/long-chain triglyceride (MCT/LCT) ILE (Lipidem/Lipoplus® 200 mg/ml, B. Braun Melsungen AG) or the MCT/LCT ILE (Lipofundin® MCT/LCT/Medialipide® 20%, B. Braun Melsungen AG) for a projected period of 8 weeks. The primary endpoint is the combined change of liver function parameters (total bilirubin, aspartate transaminase and alanine transaminase) from baseline to final visit. Secondary objectives are the further evaluation of the safety and tolerability as well as the efficacy of the ILEs.

DISCUSSION

Currently, there are only very few randomized controlled trials (RCTs) investigating the use of ILEs in HPN, and there are very few data at all on the use of n-3 PUFAs. The working hypothesis is that n-3 PUFA-enriched ILE is safe and well-tolerated especially with regard to liver function in patients requiring HPN. The expected outcome is to provide reliable data to support this thesis thanks to a considerable number of CIF patients, consequently to broaden the present evidence on the use of ILEs in HPN.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03282955. Registered on 14 September 2017.

Dietary Cold Pressed Watercress and Coconut Oil Mixture Enhances Growth Performance, Intestinal Microbiota, Antioxidant Status, and Immunity of Growing Rabbits

The present study assessed the effect of dietary supplementation with coconut oil (CNO), watercress oil (WCO), and their mixture as promoters of growth, antioxidant status, immunity, and intestinal microbiota in growing rabbits. A total of 120 rabbits were distributed into six groups (20 rabbits/group) receiving a basal diet without supplementation (G1) or diet supplemented with 2 g CNO (G2), 2 g WCO (G3), 0.5 g CNO plus 1.5 g WCO (G4), 1 g CNO plus 1 g WCO (G5), or 1.5 g CNO plus 0.5 g WCO/kg (G6). Live body weight and feed conversion ratio were significantly higher in the G4 and G5 groups than in the other groups. Superoxide dismutase activity and reduced glutathione concentration were significantly improved in the CNO or WCO diets. Supplemental CNO plus WCO at all tested levels produced the best lysozyme and complement 3 activities. Cecal lactobacilli, coliform, Enterobacteriaceae, and Clostridium spp. populations were lower in the group who received the 1 g CNO + 1 g WCO/kg diet than that in the control group. Dietary supplementation of 1 g CNO + 1 g WCO or 0.5 g CNO + 1.5 g WCO/kg had the potential to improve growth, feed utilization, antioxidant status, and immunity, and reduce cecal pathogenic bacteria in rabbits.

Use of

Structured lipids (SLs) were produced from the free fatty acids of Echium oil and tricaprylin by enzymatic acidolysis reactions. Lipozyme® RM IM, immobilized sn-1,3 specific lipase was used in the enzymatic reactions. In order to optimize the incorporation of stearidonic acid (SDA), three factors were chosen [Reaction temperature (50-60 ºC), reaction time (6-12 hour) and substrate molar ratio (3-6 mol/mol (total free fatty acids/tricaprylin)] for the application of response surface methodology (RSM) using a central composite circumscribed design (CCC) with five levels. The optimum temperature, time and substrate molar ratio obtained from the models were 60 ºC; 6 h, 6 mol/mol, respectively. Furthermore, SLs with 6.2% SDA content at sn-2 position were produced by scaling up the process. SL was obtained with nearly 78-79% of long-chain fatty acids at the sn-2 position. According to the melting profile analysis, the melting peaks of tricaprylin and Echium oil were sharper and narrower while the SL had more broadened peaks.

Structured Triglyceride Emulsions in Parenteral Nutrition

Over the past 3 decades, various concepts for IV fat emulsions (IVFE) have been developed. A randomized, structured-lipid emulsion based on an old technology has recently become available. This structured-lipid emulsion is produced by mixing medium-chain triglycerides and long-chain triglycerides, then allowing hydrolysis to form free fatty acids, followed by random transesterification of the fatty acids into mixed triglyceride molecules. Studies in animals have shown an improvement in nitrogen balance with the use of these lipid emulsions. Only 8 human clinical studies with these products have been performed. The results of these human clinical studies have been less promising than the animal studies; however, an improvement in nitrogen balance and lipid metabolism exceeds results associated with infusion of long-chain triglycerides (LCT) or a physical mixture of long-chain triglycerides and medium-chain triglycerides (LCT-MCT). Structured-lipid emulsion seems to induce less elevation in serum liver function values compared with standard IVFEs. In addition, structured-lipid emulsions have no detrimental effect on the reticuloendothelial system. Further studies are necessary in order to recommend the use of structured-lipid emulsions. The clinical community hopes that chemically defined structured triglycerides will make it possible to determine the distribution of specific fatty acids on a specific position on the glycerol core and therefore obtain specific activity for a specific clinical situation.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation

Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.

Nutrition Therapy for Mitochondrial Neurogastrointestinal Encephalopathy with Homozygous Mutation of the TYMP Gene

Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is characterized by significant gastrointestinal dysmotility. Early and long-term nutritional therapy is highly recommended. We report a case of MNGIE in a patient who was undergoing long-term nutrition therapy. The patient was diagnosed with a serious symptom of fatty liver and hyperlipidemia complications, along with homozygous mutation of the thymidine phosphorylase (TYMP) gene (c.217G > A). To our knowledge, this is the first report of such a case. Herein, we describe preventive measures for the aforementioned complications and mitochondrial disease-specific nutritional therapy.

Effects of Dietary Coconut Oil as a Medium-chain Fatty Acid Source on Performance, Carcass Composition and Serum Lipids in Male Broilers

This study was conducted to investigate the effects of dietary coconut oil as a medium-chain fatty acid (MCFA) source on performance, carcass composition and serum lipids in male broilers. A total of 540, one-day-old, male Arbor Acres broilers were randomly allotted to 1 of 5 treatments with each treatment being applied to 6 replicates of 18 chicks. The basal diet (i.e., R0) was based on corn and soybean meal and was supplemented with 1.5% soybean oil during the starter phase (d 0 to 21) and 3.0% soybean oil during the grower phase (d 22 to 42). Four experimental diets were formulated by replacing 25%, 50%, 75%, or 100% of the soybean oil with coconut oil (i.e., R25, R50, R75, and R100). Soybean oil and coconut oil were used as sources of long-chain fatty acid and MCFA, respectively. The feeding trial showed that dietary coconut oil had no effect on weight gain, feed intake or feed conversion. On d 42, serum levels of total cholesterol, low-density lipoprotein cholesterol, and low-density lipoprotein/high-density lipoprotein cholesterol were linearly decreased as the coconut oil level increased (p<0.01). Lipoprotein lipase, hepatic lipase, and total lipase activities were linearly increased as the coconut oil level increased (p<0.01). Abdominal fat weight/eviscerated weight (p = 0.05), intermuscular fat width (p<0.01) and subcutaneous fat thickness (p<0.01) showed a significant quadratic relationship, with the lowest value at R75. These results indicated that replacement of 75% of the soybean oil in diets with coconut oil is the optimum level to reduce fat deposition and favorably affect lipid profiles without impairing performance in broilers.

The peroxisomal enzyme L-PBE is required to prevent the dietary toxicity of medium-chain fatty acids

Specific metabolic pathways are activated by different nutrients to adapt the organism to available resources. Although essential, these mechanisms are incompletely defined. Here, we report that medium-chain fatty acids contained in coconut oil, a major source of dietary fat, induce the liver ω-oxidation genes Cyp4a10 and Cyp4a14 to increase the production of dicarboxylic fatty acids. Furthermore, these activate all ω- and β-oxidation pathways through peroxisome proliferator activated receptor (PPAR) α and PPARγ, an activation loop normally kept under control by dicarboxylic fatty acid degradation by the peroxisomal enzyme L-PBE. Indeed, L-pbe(-/-) mice fed coconut oil overaccumulate dicarboxylic fatty acids, which activate all fatty acid oxidation pathways and lead to liver inflammation, fibrosis, and death. Thus, the correct homeostasis of dicarboxylic fatty acids is a means to regulate the efficient utilization of ingested medium-chain fatty acids, and its deregulation exemplifies the intricate relationship between impaired metabolism and inflammation.

Lipases as biocatalysts for the synthesis of structured lipids

Structured lipids (SL) are broadly referred to as modified or synthetic oils and fats or lipids with functional or pharmaceutical applications. Some structured lipids, such as triglycerides that contain both long-chain (mainly essential) fatty acids and medium- or short-chain fatty acids and also artificial products that mimic the structure of natural materials, namely human milk fat substitutes and cocoa butter equivalents, have been discussed. Further, other modified or synthetic lipids, such as structured phospholipids and synthetic phenolic lipids are also included in this chapter. For all the products described in this chapter, enzymatic production in industry has been already conducted in one way or another. Cocoa butter equivalents, healthy oil containing medium-chain fatty acids, phosphatidyl serine, and phenol lipids from enzyme technology have been reported for commercial operation. As the demand for better quality functional lipids is increasing, the production of structured lipids becomes an interesting area. Thus, in this chapter we have discussed latest developments as well as present industrial situation of all commercially important structured lipids.

State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications

OBJECTIVE

To review the current state of the science regarding intravenous fat emulsions (IVFEs), with an emphasis on their safety profile.

DATA SOURCES

Articles were identified via a search of the MEDLINE database, including publications from 1979 to December 2009, using a search string that included the terms parenteral nutrition, lipid emulsion, fat emulsion, IVFE, safety, adverse effect, neonate intralipid, and terms describing a range of specific adverse events (AEs) such as pancreatitis.

STUDY SELECTION AND DATA EXTRACTION

We selected articles that allowed us to compare the results of clinical trials involving delivery of medications via IVFEs with the historical use and effects of IVFEs in parenteral nutrition, with an emphasis on AEs. We focused on 2 drugs in current use that are administered intravenously in lipid emulsions: propofol and clevidipine.

DATA SYNTHESIS

Clearance of the fat particles in IVFEs is mediated by the enzyme lipoprotein lipase. AEs are more likely if the rate or duration of IVFE administration exceeds the enzyme's clearance capacity. AEs are also more likely after administration of a 10% IVFE formulation than a 20% formulation, because the higher concentration of free phospholipid in the 10% formulation interferes with lipoprotein lipase activity. AEs can be reduced by administering IVFEs at a dosage < or = 2.5 g/kg/day and at a rate < or = 0.11 g/kg/h. The anesthetic agent propofol, which is formulated in a 10% IVFE, has been used clinically for 25 years. Typical AEs associated with propofol use include infection, high plasma triglyceride concentrations, and pancreatitis. Recent clinical trials involving clevidipine, which is formulated in a 20% IVFE, have demonstrated a low rate of lipid-related AEs.

CONCLUSIONS

The results of this review demonstrate that IVFEs are well tolerated when administered in accordance with guideline recommendations.

Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6

The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (α-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25–40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7–1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.

ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients

Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.

Effects of parenteral structured lipid emulsion on modulating the inflammatory response in rats undergoing a total gastrectomy

OBJECTIVES

Structured lipid emulsion improves the nitrogen balance and is rapidly cleared from the blood of moderately catabolic patients. However, the effects of structured lipids on inflammatory reactions during major surgery are not clear. This study investigated the effect of a parenteral structured triacylglycerol emulsion on leukocyte adhesion molecule expression and inflammatory mediator production in rats undergoing a total gastrectomy.

METHODS

Normal rats with internal jugular catheters were assigned to three experimental groups and received total parenteral nutrition. At the same time, a total gastrectomy was performed on the experimental groups. The total parenteral nutrition solutions were isonitrogenous and identical in nutrient compositions except for differences in the composition of the fat emulsion. Group 1 received a conventional fat emulsion with long-chain triacylglycerols (LCTs), group 2 received a physical mixture of medium-chain triacylglycerols (MCTs) and LCTs (MCT/LCT), and group 3 received structured lipids composed of MCTs and LCTs (STG). Half of the rats in each respective group were sacrificed 1 d and the other half 3 d after surgery to examine the analytical parameters.

RESULTS

Plasma cholesterol and free fatty acid levels in the STG group were lower than those in the other groups after surgery. The STG group had lower leukocyte CD11a/CD18 expressions than the MCT/LCT group 3 d after surgery, and CD11b/CD18 expressions in the STG group were lower than those in the LCT group on postoperative days. The STG group had higher monocyte chemotactic protein-1 and macrophage inflammatory protein-2 levels in peritoneal lavage fluid than did the other two groups.

CONCLUSION

These results suggest that, compared with the LCT and MCT/LCT groups, rats administered STG had lower plasma lipid concentrations and leukocyte integrin expressions. In addition, STG administration may cause increased recruiting of neutrophils and monocytes at the site of injury and enhance antipathogenicity in rats undergoing a total gastrectomy.

Parenteral nutrition related hepato-biliary disease in adults

Parenteral nutrition is a life-saving therapy in patients with intestinal failure. One of the major causes of morbidity and mortality in patients receiving long-term total parenteral nutrition (TPN) is liver disease. Early on, there is steatosis, which can evolve to steatohepatitis and eventually to cholestasis of varying severity. The etiology of parenteral nutrition related liver disease is multifactorial. Provision of excess calories in the TPN solution, along with lipids administered >1 g/kg are thought to increase the risk of parenteral nutrition related liver disease. Other factors such as nutrient deficiencies and nutrient toxicities may also play a role in the pathogenesis of liver disease, along with sepsis and the lack of enteral stimulation. Non-pharmacological management strategies for TPN-related liver disease include enteral stimulation, optimal TPN composition, and avoidance of excess carbohydrate and lipid calories. Pharmacological therapy with ursodeoxycholic acid and antibiotic therapy to reduce the risk of bacterial translocation and sepsis should be considered. Early referral for transplantation should be considered in patients with evidence of portal hypertension. This review focuses on the clinical aspects, pathogenesis, and management strategies of parenteral nutrition-related liver disease in adult patients.

Novel substrates

Enteral and parenteral feeds need at least to contain adequate amounts of water, energy, protein, electrolytes, vitamins and trace elements. Ready-manufactured parenteral feeds for example are incomplete because of shelf-life constraints and require the addition of vitamins (especially) and trace elements. Acute vitamin deficiencies, notably thiamine deficiency, can be precipitated if this is not adhered to. An increasing interest, however, exists in the use of feeds containing substrates, which are intended to improve patient outcome in particular clinical circumstances. The purpose of this article is to examine as to what is available and make recommendations on their use. It deals with artificial feeds only - disease-specific diets are outside our remit.

Lymphatic recovery of exogenous oleic acid in rats on long chain or specific structured triacylglycerol diets

Specific structured triacylglycerols, MLM (M = medium-chain fatty acid, L = long-chain fatty acid), rapidly deliver energy and long-chain fatty acids to the body and are used for longer periods in human enteral feeding. In the present study rats were fed diets of 10 wt% MLM or LLL (L = oleic acid [18:1 n-9], M = caprylic acid [8:01) for 2 wk. Then lymph was collected 24 h following administration of a single bolus of 13C-labeled MLM or LLL. The total lymphatic recovery of exogenous 18:1 n-9 24 h after administration of a single bolus of MLM or LLL was similar in rats on the LLL diet (43% and 45%, respectively). However, the recovery of exogenous 18:1 n-9 was higher after a single bolus of MLM compared with a bolus of LLL in rats on the MLM diet (40% and 24%, respectively, P = 0.009). The recovery of lymphatic 18:1 n-9 of the LLL bolus tended to depend on the diet triacylglycerol structure and composition (P= 0.07). This study demonstrated that with a diet containing specific structured triacylglycerol, the lymphatic recovery of 18:1 n-9 after a single bolus of fat was dependent on the triacylglycerol structure of the bolus. This indicates that the lymphatic recovery of long-chain fatty acids from a single meal depends on the overall long-chain fatty acid composition of the habitual diet. This could have implications for enteral feeding for longer periods.

Comparison of the structures of triacylglycerols from native and transgenic medium-chain fatty acid-enriched rape seed oil by liquid chromatography--atmospheric pressure chemical ionization ion-trap mass spectrometry (LC-APCI-ITMS)

The sn position of fatty acids in seed oil lipids affects physiological function in pharmaceutical and dietary applications. In this study the composition of acyl-chain substituents in the sn positions of glycerol backbones in triacylglycerols (TAG) have been compared. TAG from native and transgenic medium-chain fatty acid-enriched rape seed oil were analyzed by reversed-phase high performance liquid chromatography coupled with online atmospheric-pressure chemical ionization ion-trap mass spectrometry. The transformation of summer rape with thioesterase and 3-ketoacyl-[ACP]-synthase genes of Cuphea lanceolata led to increased expression of 1.5% (w/w) caprylic acid (8:0), 6.7% (w/w) capric acid (10:0), 0.9% (w/w) lauric acid (12:0), and 0.2% (w/w) myristic acid (14:0). In contrast, linoleic (18:2n6) and alpha-linolenic acid (18:3n3) levels decreased compared with the original seed oil. The TAG sn position distribution of fatty acids was also modified. The original oil included eleven unique TAG species whereas the transgenic oil contained sixty. Twenty species were common to both oils. The transgenic oil included trioctadecenoyl-glycerol (18:1/18:1/18:1) and trioctadecatrienoyl-glycerol (18:3/18:3/18:3) whereas the native oil included only the latter. The transgenic TAG were dominated by combinations of caprylic, capric, lauric, myrisitic, palmitic (16:0), stearic (18:0), oleic (18:1n9), linoleic, arachidic (20:0), behenic (22:0), and lignoceric acids (24:0), which accounted for 52% of the total fat. In the original TAG palmitic, stearic, oleic, and linoleic acids accounted for 50% of the total fat. Medium-chain triacylglycerols with capric and lauric acids combined with stearic, oleic, linoleic, alpha-linolenic, arachidic, and gondoic acids (20:1n9) accounted for 25% of the transgenic oil. The medium-chain fatty acids were mainly integrated into the sn-1/3 position combined with the essential linoleic and alpha-linolenic acids at the sn-2 position. Eight species contained caprylic, capric, and lauric acids in the sn-2 position. The appearance of new TAG in the transgenic oil illustrates the extensive effect of genetic modification on fat metabolism by transformed plants and offers interesting possibilities for improved enteral applications.

Improvement of graft function and animal survival by fat emulsion in liver transplant rats

Nutritional supports are required for liver transplant patients. However, no systematical assessment has been made of the optimal composition of energy yielding substrates in these patients. This study is to evaluate whether mixed energy system consisting of carbohydrate and lipid emulsions is more advantageous over single energy source of glucose for nutritional support in liver transplant recipients and whether structured lipid emulsion (STG) is superior to medium-chain triglyceride/long-chain triglycerides (MCT/LCT) and long-chain triglycerides (LCT) using a total parenteral nutrition model. Liver transplant rats were randomly divided to four groups according to the energy source, i.e. glucose (GLU), MCT/LCT, STG and LCT groups. Sham operated rats served as control. Hepatic function and lipid profile were determined to investigate the roles of lipid emulsion in hepatic function and lipid metabolism. Morphological changes of liver were observed, and nitrogen balance was determined. The results showed that infusion of lipid emulsion was well tolerated. The 1-week survival rate in the lipid emulsion groups was significantly higher than in the GLU group (100% versus 50%, P<0.05); compared with the GLU group, hepatic function recovered quickly and returned to normal level, and morphological alterations were less severer in the lipid emulsion groups, especially in the STG group; the lipid emulsions groups had normal serum TG and TC levels, especially STG and MCT/LCT groups; the lipid emulsions groups achieved a positive nitrogen balance on day 7 compared with the GLU group, and the STG group had the highest nitrogen balance. In conclusion, lipid emulsion is beneficial in improving hepatic function and the recipients' survival and does not influence the lipid metabolism. Mixed energy system consisting of carbohydrate and lipid is more advantageous over single energy source of glucose after liver transplantation, and STG is superior to MCT/LCT and LCT.

Differences in the intramolecular structure of structured oils do not affect pancreatic lipase activity in vitro or the absorption by rats of (n-3) fatty acids

The fatty acid composition and intramolecular structure of dietary triacylglycerols (TAGs) influence their absorption. We compared the in vitro pancreatic lipase activity and the lymphatic transport in rats of fish oil and 2 enzymatically interesterified oils containing 10:0 and (n-3) PUFAs of marine origin to investigate whether the positional distribution of fatty acids influenced the overall bioavailability of (n-3) PUFAs in the body. The structured oils had the (n-3) PUFA either mainly at the sn-1,3 position (LML, M = medium-chain fatty acid, L = long-chain fatty acid) or mainly at the sn-2 position (MLM). Oils were administered to lymph-cannulated rats and lymph was collected for 24 h. The fatty acid composition as well as the lipid class distribution of lymph samples was determined. In vitro pancreatic lipase activity was greater when fish oil was the substrate than when the structured oils were the substrates (P < 0.001 at 40 min). This was consistent with a greater 8-h recovery of total fatty acids from fish oil compared with the 2 structured oils (P < 0.05). The absorption profiles of MLM and LML in rats and their in vitro rates of lipase activity did not differ. This indicates that the absorption rate is highly influenced by the lipase activity, which in turn is affected by the fatty acid composition and intramolecular structure. The lipid class distribution in lymph collected from the 3 groups of rats did not differ. In conclusion, the intramolecular structure did not affect the overall absorption of (n-3) PUFAs.