Utilizing selenious acid to reverse selenium deficiency in total parenteral nutrition patients

Impact of nationwide essential trace element shortages: A before-after, single-center analysis of hospitalized adults receiving home parenteral nutrition therapy

BACKGROUND

Recent data on the prevalence of essential trace element (ETE) deficiencies in home parenteral nutrition (HPN) patients are scarce. We investigated whether ETE deficiencies are still an important issue for HPN patients and whether the prevalence of such deficiencies may be influenced by nationwide drug shortages.

METHODS

We conducted a single-institution, retrospective analysis from 2006 to 2015 of hospitalized HPN patients who continued PN during and in between hospitalizations. In subgroup analysis, patients were dichotomized as those with HPN duration <1 vs ≥1 year. Zinc (Zn), copper (Cu), and selenium (Se) levels were abstracted for patients over the study period. Prevalence of ETE deficiency was compared using chi-squared test for patients hospitalized during nonshortage vs shortage (2011-2014) periods.

RESULTS

Ninety-six patients were included in the analysis. Prevalence of ETE deficiency during nonshortage vs shortage periods was 48% vs 54% (Zn), 15% vs 21% (Cu), and 24% vs 48% (Se; P = .01), respectively. When comparing patients who received HPN <1 year vs ≥1 year, the prevalence of Se deficiency doubled during shortage in both subgroups (24% to 42% vs 26% to 49%); and Cu deficiency tripled during shortage period in the group receiving HPN ≥1 year (5% to 16%).

CONCLUSION

ETE deficiency is prevalent in hospitalized HPN patients and was exacerbated during nationwide shortages of parenteral supplements. Statistical significance may be limited by small sample size. Future studies are needed to determine optimal ETE supplementation strategies for minimizing the impacts of nationwide drug shortages on HPN patients.

Influence of selenium deficiency on vital functions in rats

To clarify the relationship between selenium (Se) deficiency and functional disorders, the authors determined the Se concentration, anti-oxidant enzyme activity, and other parameters in rats fed a Se-deficient diet. Rats fed the Se-deficient diet showed a decrease in Se concentration and glutathione peroxidase (GSH-Px) activity in plasma, erythrocytes, heart, liver, and skeletal muscle from the first week after the initiation of the diet, an increase in heart lipid peroxide concentration from the second week, and an increase in liver glutathione S-transferase activity from the fourth week. From the twelfth week, a decrease in the growth rate in the rats fed the Se-deficient diet was observed. In spite of this growth impairment, no changes in electrocardiogram, muscle tone, degree of hemolysis, plasma biochemistry, or hematological values were detected. In summary, the authors found that a reduction of body Se is easily induced, but that the appearance of functional disorders following Se deficiency is difficult to detect in rats.

Effect of dietary selenium and vitamin E on the biomechanical properties of rabbit bones

It is generally agreed that combined deficiency of selenium and vitamin E leads to several abnormalities including Kashin-Beck disease which is an endemic and chronic degenerative osteoarthrosis. The abnormalities can be reversed by the administration of various forms of selenium and vitamin E. The present study was designed to investigate the effects of dietary selenium and vitamin E on bone tissue and on the biomechanical properties of bone. Young rabbits of both sexes were fed with either a selenium- and vitamin E-adequate diet (control group), or a selenium- and vitamin E-deficient diet or a selenium-excess diet. The selenium-deficient diet resulted in a significant decrease in plasma selenium level and the selenium-excess diet resulted in a significant increase in the plasma selenium level with respect to the corresponding control values (p < 0.05). The diets did not affect the blood cell counts considerably but erythrocyte glutathione peroxidase activity increased (decreased) relatively when the plasma selenium level increased (decreased) (p < 0.05). The light microscopic investigations of the bone tissues of the two experimental groups indicate that the findings of the present work are compatible with osteomalacia. The biomechanical properties of the bones from the three groups were determined experimentally with bending tests. Both the Se- and vitamin E-deficient diet and the Se-excess diet decreased the biomechanical strength of the bones significantly while the bones belonging to the control group always had the largest modulus of elasticity (p < 0.05).

Influence of selenium deficiency on the acute cardiotoxicity of adriamycin in rats

The influence of selenium (Se) deficiency on the acute cardiotoxicity induced by the anticancer drug adriamycin (ADR) has been studied in rats by electrocardiography. Two categories were formed by feeding groups of rats a Se-supplemented and a Se-deficient diet. The supplemented animals were taken as normals. The two categories were treated with iv injections of saline solution containing ADR at doses of 0, 7.5, and 15 mg/kg body wt. The cardiac Se concentration and glutathione peroxidase (GSH-Px) activity in the Se-deficient groups were < 2% lower than in the normals. The normal groups showed significant widening of the SaT and QaT durations when given 15 mg/kg ADR. The Se-deficient groups exhibited a dose-dependent widening of the SaT and QaT duration at 7.5 and 15 mg/kg and narrowing of the PQ duration at 15 mg/kg ADR. No heart rate or QRS duration changes were detected in both categories. Our results suggest that an imbalance of the antioxidant system is associated with Se deficiency and that Se plays a role in preventing the cardiac functional disorder attributable to oxygen free radical formation induced by ADR.

Selenium administration to a ten-year-old patient receiving long-term total parenteral nutrition (TPN)--changes in selenium concentration in the blood and hair

Muscle pain in the lower limbs occurred in a child with short bowel syndrome who has been receiving longterm total parenteral nutrition (TPN). Biochemical parameters revealed that the plasma and erythrocyte selenium concentrations were below the normal range for children and intravenous injection of selenium prepared from selenious acid was started at a dose of 100 micrograms per day. Muscle pain in the lower limbs disappeared one month afterwards. At this point in time, the elevation of the plasma selenium concentration was noted but the erythrocyte selenium concentration remained low. When administration was suspended due to catheter-induced fever five months later, the whole blood selenium concentration decreased again and the symptoms recurred. Accordingly, the dose of selenium was increased to 200 micrograms/day. Subsequently, the blood selenium concentration recovered to the normal range for children. After the dose increase to 200 micrograms/day, concentrations in hair samples collected at every centimeter distance from the root end were determined. The selenium concentration at the root end was found to be higher than the normal range for children, indicating that this was an excessive dose case. Although the dose was decreased from 200 micrograms/day to 120 micrograms/day, the plasma and erythrocyte selenium levels did not go down. Furthermore, the selenium level in the hair reached a plateau, and no recurrence of symptoms was observed. The above results indicate the usefulness of monitoring the selenium concentration in hair in addition to determining the blood selenium level and GSH-Px activity in administering selenium to children undergoing TPN.

Four cases of selenium deficiency in postoperative long-term enteral nutrition

Because selenium is seldom added to formulations for enteral nutrition (EN), postoperative patients who are supported with EN are at risk for selenium deficiency. This report describes four cases of suspected selenium deficiency in long-term EN. Two patients underwent pancreaticoduodenectomy, one underwent total gastro-pancreatectomy, and one underwent esophageal resection and reconstruction with jejunal autotransplantation. They all developed malabsorption syndrome within 2 yr after operation. Enteral nutritional support with an elemental diet was provided continuously for 7-11 yr. Over the past 1-2 yr they experienced increasing bilateral muscular pain and weakness in the legs, gait disturbance, palpitation, and shortness of breath. Investigation for possible trace element deficiency revealed very low levels of selenium in the blood. After 10-20 d of supplementation with daily intravenous administration of selenious acid 0.16 mg/d (100 micrograms/d of selenium), their blood levels of selenium rose and their symptoms resolved. They were then continued on a maintenance regimen of oral sodium selenite 0.13 mg/d (60 micrograms/d of selenium).

Trace elements in clinical nutrition

Although the nearly 20 essential trace elements in humans constitute a small fraction of total body weight (less than 4%), the effect of their presence on well-being is enormous. Enteral nutrition, whether oral or by tube, is fraught with problems that influence nutrient absorption, distribution, metabolism, and ultimately, excretion. Parenteral nutrition, although delivered to the intravascular milieu, carries with it no guarantee that the trace mineral will indeed reach the target site for action. With the questionable nature of dietary histories and their unavailability in the setting of relatively emergent nutrition therapy, it behooves the clinician to begin complete nutrition and to include recommended trace elements early on. The clinician must also be ever vigilant about delivering sufficient full-strength commercially available enteral formula to provide the recommended dietary allowances of trace minerals.

Selenium depletion in patients on home parenteral nutrition. The effect of selenium supplementation

Severe selenium (Se) depletion was found in nine patients receiving long-term home parenteral nutrition because of short bowel syndrome. Plasma Se ranged from 0-0.51 (median 0.21 mumol/L), and erythrocyte Se ranged from 0.7-2.6 (median 1.8 mumol/gHgb), which was significantly lower than in the controls. Glutathione peroxidase (GSHPx) in plasma and erythrocytes was also decreased. After bolus injections with 200 micrograms Se/d in the form of sodium selenite for 4 mo, followed by 100 micrograms/d for 8 mo, plasma Se increased to values slightly but significantly higher than in the controls. Erythrocyte Se reached normal levels in most of the patients after 4 mo substitution, but it remained lower than in the controls. Following Se supplementation, plasma and erythrocyte GSHPx did not differ between patients and controls. These data suggest that all patients receiving long-term parenteral nutrition because of short bowel syndrome should receive at least 100 micrograms sodium selenite/d when given as bolus injections to avoid Se depletion.

Parenteral nutrition: hospital to home

Parenteral nutrition support is the provision of essential nutrients intravenously, bypassing the intestinal tract. It is used in a variety of clinical settings and medical conditions. Parenteral nutrition is a complex technology that requires the input of many professionals, including dietitians. The role of the dietitian in parenteral nutrition support involves direct patient care, consultative services, education, program development, and research. Even though this field of practice is still developing, some common practices can be described. Nutrition assessment determination of macronutrient and micronutrient requirements, and monitoring are vital aspects of the provision of parenteral nutrition support that benefit from the knowledge and experience of a dietitian. The future of parenteral nutrition includes identification of preferred fuels for specific disease states, development of new lipid emulsions, and identification of conditionally essential nutrients.

Selenium deficiency in long-term total parenteral nutrition

Although selenium is an essential trace element, it is often not routinely added to total parenteral nutrition (TPN) formulations. When selenium is not added, patients are at risk for selenium deficiency. This report describes such a patient. He had several operations for colon cancer, including a massive resection of the small bowel that resulted in a short bowel and a fistula. TPN was started after his last operation. After he was discharged, he had a normal, active lifestyle, except that he limited oral intake to water and an occasional soft drink. After 3 years of almost exclusive nourishment by TPN, he developed whitened nail beds. Investigation for possible trace element deficiency resulted in a finding that he had very low levels of selenium in his blood. He did not have any of the cardiac or skeletal muscle abnormalities that have been associated with selenium deficiency. After supplementation with selenium, his blood levels of selenium rose and the nail bed changes were reversed.

Physiological and nutritional importance of selenium

The essential trace element selenium has recently attracted attention because of its potentialities in the maintenance of human health. Selenium forms part of the active site of the peroxide-destroying enzyme glutathione peroxidase, and it also has other functions, for example in biotransformation, detoxification and the immune response. Functional and clinical consequences of selenium deficiency states have been described, and the selenium requirement, which is influenced by the usual selenium exposure, has been discussed. Wide variations have been found in selenium status in different parts of the world, and populations or groups of patients exposed to marginal deficiency are more numerous than was previously thought. Current research activities in the field of human medicine and nutrition are devoted to the possibilities of using selenium for the prevention or treatment of degenerative or free radical diseases such as neurological disorders, inflammatory diseases or cancer. Pharmacological selenium doses are also recommended as an adjuvant in some treatments.

Selenium status prior to and during one month total parenteral nutrition in gastroenterological patients: A randomised study of two dosages of Se supplementation

13 consecutive adult gastroenterological patients with non-malignant disease who were candidates for total parenteral nutrition (TPN), and who had mild protein-energy malnutrition (82 +/- 3% of ideal body weight, serum albumin 32 +/- 2 g/l, mean +/- SEM) were found to have, prior to TPN, a Selenium level 50% less than controls (p < 0.001) as assayed by Se and glutathione peroxidase (GSHPx) in plasma and erythrocytes. Compared with other trace metals and minerals, eg, Mn, Zn and Cu, depletion of Selenium was the most marked in this population. Patients were randomised to be supplemented with either 100 or 200 microg/d of sodium-selenite, equal to 32 microg (0.4 micromol) or 64 microg (0.8 micromol) of selenium, in two cross-over periods of TPN, each of two weeks. In this short term study, significant increases in the four measurements of Se status (p < 0.05) were seen in all patients, but there was no difference between those receiving the high or low dose of the element. GSHPx in plasma was normalised within 1 month whereas the increase seen in the erythrocyte pool was consistent with a 4-month half-life. Pooled Se values for patients and controls showed logarithmic correlations between Se and GSHPx in erythrocytes (p < 0.001) and plasma (p < 0.01). Changes in GSHPx provided further evidence of Se depletion in our patients. This study suggests that malnourished gastroenterological patients receiving TPN require Se supplements and that 100 microg (0.4 micromol)/d of sodium-selenite is adequate for most patients since there was no additional benefit from the higher dose of 200 microg (0.8 micromol).

Selenium: clinical significance and analytical concepts

Selenium is an essential trace element in humans and animals. Its only established function in humans is the antioxidant activity of glutathione peroxidase, a selenoenzyme. Severe prolonged deficiency may cause a fatal cardiomyopathy. Iatrogenic causes of selenium deficiency include parenteral and enteral nutrition. Low plasma selenium is also found in malabsorption, cystic fibrosis, rheumatoid arthritis, neoplasia, and other varied clinical disorders. Death has resulted from a single massive ingestion of selenium, while chronic excessive intake causes skin, nail, and hair pathology. Extreme geographical variation in population blood and urine selenium levels and a marked age-specific variation in population reference intervals are important factors in understanding selenium nutrition. Nutritional requirements, biological availability, and metabolism are discussed in relation to geographical, age, and method variability. Sampling, processing procedures, and methods for selenium quantitation are reviewed. Selenium content in different biological matrices and reference values for pediatric, adult, and obstetric populations are provided.

Kinetics of a single administration of 74Se-selenite by oral and intravenous routes in adult humans

The purpose of this study was to explore the fate of a single dose of labeled selenium as determined by its route of administration. Thus, the appearance of a stable isotope of selenium, administered as 74-Se-selenite, was measured in plasma, urine, and feces, with neutron activation analysis, following a 81.7 micrograms dose of 74Se-selenite given either intravenously or orally in two groups (n = 4) of healthy, young adult men, who were otherwise maintained on a diet providing a constant and adequate selenium intake. From these isotopic data, measurable parameters of urine excretion, total body retention and selenite-exchangeable metabolic pool (Se-EMP) were defined to provide a quantitative assessment of selenium metabolism in these subjects. The initial 24-hr urine excretion of the label was higher for the intravenously administered label (18.2 +/- 2.1% of dose) compared to the oral dose (11.7 +/- 2.6% absorbed dose). Thereafter, the excretion of isotope was the same for both groups. For equivalent entry of Se into the body, measured total body retention and Se-EMP were the same for both groups. These initial kinetic data suggest that the overall utilization of selenium from a single administration of selenite is comparable for the two routes of intake and that the host's selenium requirement can probably be met adequately via the intravenous administration of selenite.

The effect of income on selenium intake and status in Utah County, Utah

Foodstuffs produced and/or purchased locally were analyzed for Se. The effect of income and gender on Se intake and status of Utah County residents was evaluated by measurement of the following indicators: erythrocyte (RBC) and plasma Se concentration, and activity of Se-glutathione peroxidase (Se-GSH-Px) (EC 1.11.1.9) in RBCs, platelets, and plasma. A Random Digit Dialing procedure was employed to stratify subjects according to gender and annual family income (less than +10,000, +10,000-20,000, greater than +20,000) in a 2 x 3 factorial design, seven subjects per cell. The weekly consumption of 44 foods shown to contribute over 90% of the Se intake of U.S. subjects was recorded for each study participant. The estimated minimum daily intake for this sample was 76.0 +/- 4.5 micrograms Se/day (mean +/- SEM). Available grain products are not produced locally, and their Se content is lower than average values reported by the U.S.D.A. Locally produced meat and dairy products had higher than average Se contents. In spite of lower grain Se and higher meat Se concentrations, subjects in this study derived more Se from grain and dairy products, and less from meat products than did subjects in a nationwide sample. The Se status of Utah County residents is similar to several other populations in the United States. There were no significant differences in Se status or intake due to gender or income. The results suggest that consumption of other foods produced in a "high Se" area can maintain Se intake and status in spite of reduced consumption of meat products generally viewed as more reliable sources of dietary Se.

Selenium in total parenteral nutrition

In clinical practice, selenium deficiency may arise under conditions of chronic malnutrition and especially after long-term total parenteral nutrition (TPN). In infants receiving long-term TPN, we observed plasma selenium levels as low as those previously reported in Chinese children with Keshan disease. Low plasma selenium levels were also usually associated with very low activities of glutathione peroxidase. Although clinical symptoms of selenium deficiency did not occur in our patients, several cases have been described in the literature, indicating the need for supplementation in TPN. In order to derive at the appropriate dosage, it is proposed to correlate it with the total protein supply. According to our present knowledge, .5-1.0 micrograms selenium/g of protein appears to be adequate to keep patients in Se balance. For Se repletion of body stores, this dosage has been increased up to 3 micrograms of Se/g of protein. Advantages and disadvantages of selenite and of selenomethionine as possible supplemental forms of Se for TPN solutions are discussed.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.

Acute selenium poisoning of a 2-year-old child

After ingestion of an unknown amount of a gun blueing compound containing selenious acid (11 ml from the bottle fluid were missing, equivalent to 2.9 g Se) a 2-year-old girl suffered from continuous hyper-salivation, vomiting, diarrhoea, restlessness and muscle spasm. Blood pressure and pulse rate were increased. Symptomatic treatment was performed by parenteral fluid administration. The plasma Se concentration was increased to 20 times normal 5 h after ingestion. Erythrocyte Se exceeded plasma Se, 24 h after intoxication. Urinary Se excretion decreased parallel to the plasma Se concentration. Ten weeks later, the Se content of hair had risen to 10 times normal. The plasma glutathione peroxidase activity showed only a slight increase during the first 36 h, erythrocyte glutathione peroxidase, catalase and superoxide dismutase activities were not significantly altered. The child fully recovered.

The effect of selenium supplementation on selenium status of patients receiving chronic total parenteral nutrition

Patients receiving long-term total parenteral nutrition (TPN) are at risk for selenium deficiency. The purpose of this study was to determine the effect of parenteral selenium as selenious acid on the selenium status of seven long-term TPN patients. Patients received a dosage of zero, 80, or 160 micrograms Se/day for 1 month each. The measures of selenium status used were selenium levels in plasma and glutathione-peroxidase activities in erythrocytes and platelets. Urinary selenium excretion was measured. Control subjects were selected to match the sex, age, and weight of the patients. With increasing levels of parenteral selenium, there was increasing plasma selenium concentration as well as erythrocyte and platelet glutathione-peroxidase activity. There was no statistical difference between the patients during the time they received the 160 micrograms parenteral selenium treatment and the control subjects for platelet glutathione-peroxidase activity. At the 160 micrograms Se/day level, patient plasma selenium concentrations increased from 28% to 58% of the control levels. Four patients were studied after they returned to the 80 micrograms parenteral selenium/day from the 160-micrograms Se/day treatment. With decreasing parenteral selenium, three patients had decreasing platelet glutathione-peroxidase activity, while plasma selenium concentration decreased in two patients. These data suggest that some patients receiving long-term parenteral nutrition should receive parenteral selenium.

Selenium content of enteral formulas

Selenium content of several complete enteral formulas and modular enteral components was determined by neutron activation analysis. Formulas based on egg albumin provided the highest content of selenium. Most of the remaining formulas had selenium contents that would provide an amount less than the proposed safe and adequate range of intake. Selenium supplementation should be considered for these latter formulas.

Dietary selenium intake in Belgium for different population groups at risk for deficiency

An estimation of the dietary selenium intake in different population groups in Belgium has been carried out. 24 h duplicate meals and food consumption statistics combined with concentration levels in different foods, as determined by hydride generation atomic absorption spectrometry, are used. Dietary intake of selenium is low to very low, especially for vegetarians (12.7 +/- 9.1 micrograms) and patients on long-term total parenteral nutrition (1.2 +/- 0.8 microgram). The different intakes are discussed and compared with intakes published for other countries, while the importance of bioavailability of the selenium in food in the risk of deficiency is stressed.

Selenium deficiency

Selenium is undoubtedly an essential trace element: its involvement in GPx structure, the presence of deleterious effects of selenium deficiency in animals, and the recognition of deficiency states in man attest to its importance. However, if the consequences of selenium deficiency in man are now widely recognized, the mechanisms underlying these conditions are poorly understood. The definition of the exact role of selenium in human homeostasis has been hampered by the lack of a sensitive parameter, usable in routine investigation, to assess selenium status. Measurements of plasma and urinary levels, although useful in clinical practice, are inadequate indicators. The only true evidence of selenium deficiency lies in a positive response to selenium therapy. Deficiency states have been demonstrated for inhabitants of regions where selenium supply is limited, in protein-energy malnutrition, and in patients maintained on total parenteral nutrition without selenium supplementation. The benefit of selenium supplementation, together with other antioxidant drugs, in non-deficient subjects is still a matter of debate; its protective effect in neoplastic, cardiovascular and neurological degenerative diseases is not yet proven.