Current practices in lipid emulsion utilization in the prevention and treatment of intestinal failure-associated liver disease: a survey of pediatric intestinal rehabilitation and transplant centers

BACKGROUND

Newer intravenous lipid emulsions (ILEs), such as fish oil-based intravenous lipid emulsions (FO-ILEs) and soybean oil, medium-chain triglycerides, olive oil, and fish oil-based intravenous lipid emulsions (SMOF-ILEs), provide alternatives to soybean oil-based intravenous lipid emulsions (SO-ILEs). We explored current ILE use practice patterns among intestinal rehabilitation and transplant centers.

METHODS

A survey was developed addressing ILE availability, ILE preference in clinical scenarios, and factors influencing ILE choice. This survey was reviewed locally and by the NASPGHAN Intestinal Rehabilitation Special Interest Group, the IRTA scientific committee, and the ASPEN pediatric intestinal failure section research committee. We recruited providers nationally and internationally from centers with and without intestinal transplant programs.

RESULTS

Of 34 complete responses included, 29 respondents were from the US. Center volume varied with 5 centers following <10 patients and 12 centers following >50. Sixteen centers performed intestinal transplants. All centers had access to SMOF-ILEs, 85% had access to FO-ILEs, and 91% had access to SO-ILEs. In new patients, 85% use SMOF-ILEs as the first choice ILE. In those with new intestinal failure-associated liver disease (IFALD), FO-ILE was preferred to SMOF-ILE (56% vs 38%). In those developing IFALD on SMOF-ILE, 65% switch to FO-ILE while 24% remain on SMOF-ILE. Half of respondents reported liver histology to be "Useful but not available" routinely.

CONCLUSIONS

Centers have routine access to alternative ILEs, and these are quickly replacing SO-ILEs in all circumstances. Future work should focus on how this shift in practice affects outcomes to provide decision support in specific clinical scenarios. This article is protected by copyright. All rights reserved.

Methods for Eliciting Informative Prior Distributions: A Critical Review

Eliciting informative prior distributions for Bayesian inference can often be complex and challenging. Although popular methods rely on asking experts probability-based questions to quantify uncertainty, these methods are not without their drawbacks, and many alternative elicitation methods exist. This paper explores methods for eliciting informative priors categorized by type and briefly discusses their strengths and limitations. Most of the review literature in this field focuses on a particular type of elicitation approach. The primary aim of this work, however, is to provide a more complete yet macro view of the state of the art by highlighting new (and old) approaches in one clear easy-to-read article. Two representative applications are used throughout to explore the suitability, or lack thereof, of the existing methods, one of which highlights a challenge that has not been addressed in the literature yet. We identify some of the gaps in the present work and discuss directions for future research.

Proposal for a Five-Step Method to Elicit Expert Judgment

Elicitation is a commonly used tool to extract viable information from experts. The information that is held by the expert is extracted and a probabilistic representation of this knowledge is constructed. A promising avenue in psychological research is to incorporated experts’ prior knowledge in the statistical analysis. Systematic reviews on elicitation literature however suggest that it might be inappropriate to directly obtain distributional representations from experts. The literature qualifies experts’ performance on estimating elements of a distribution as unsatisfactory, thus reliably specifying the essential elements of the parameters of interest in one elicitation step seems implausible. Providing feedback within the elicitation process can enhance the quality of the elicitation and interactive software can be used to facilitate the feedback. Therefore, we propose to decompose the elicitation procedure into smaller steps with adjustable outcomes. We represent the tacit knowledge of experts as a location parameter and their uncertainty concerning this knowledge by a scale and shape parameter. Using a feedback procedure, experts can accept the representation of their beliefs or adjust their input. We propose a Five-Step Method which consists of (1) Eliciting the location parameter using the trial roulette method. (2) Provide feedback on the location parameter and ask for confirmation or adjustment. (3) Elicit the scale and shape parameter. (4) Provide feedback on the scale and shape parameter and ask for confirmation or adjustment. (5) Use the elicited and calibrated probability distribution in a statistical analysis and update it with data or to compute a prior-data conflict within a Bayesian framework. User feasibility and internal validity for the Five-Step Method are investigated using three elicitation studies.

Intestinal failure following necrotizing enterocolitis: A clinical approach

Intestinal failure is a recognized complication of surgically-managed necrotizing enterocolitis (NEC). Functional adaptation of remaining bowel means that many children are eventually able to achieve enteral autonomy. Integrated multidisciplinary care in the early post-operative phase is key to long-term success. The objective of this review is to outline a clinical approach to management of intestinal and nutritional complications experienced by children following intestinal resection for NEC.

Preventing the Progression of Intestinal Failure-Associated Liver Disease in Infants Using a Composite Lipid Emulsion: A Pilot Randomized Controlled Trial of SMOFlipid

BACKGROUND

To examine whether SMOFlipid prevents progression of intestinal failure-associated liver disease (IFALD) in parenteral nutrition (PN)-dependent infants with early IFALD (conjugated bilirubin 17-50 µmol/L, 1-3 mg/dL).

STUDY DESIGN

Pilot multicenter blinded randomized controlled trial comparing SMOFlipid with Intralipid. Patients received the trial lipid for up to 12 weeks, unless they achieved full enteral tolerance sooner. The primary clinical outcome was the serum conjugated bilirubin.

RESULTS

Twenty-four infants (mean age, 6 weeks) participated in the trial (13 Intralipid and 11 SMOFlipid). At the time of trial enrollment, patients in both groups were receiving 90% of their calories by PN. Mean duration on trial was 8 weeks and did not differ according to treatment ( P = .99). At trial conclusion, patients who received SMOFlipid had a lower conjugated bilirubin than those who received Intralipid (mean difference, -59 µmol/L; P = .03). Patients receiving SMOFlipid were also more likely to have a decrease in serum conjugated bilirubin to 0 µmol/L than those in the Intralipid group over the entire observation period (hazard ratio, 10.6; 95%; P = .03). The time to achievement of full enteral tolerance did not differ statistically (hazard ratio, 1.3; P = .59) between the groups. There was no significant difference in safety outcomes between the groups.

CONCLUSIONS

Compared with Intralipid, SMOFlipid reduces the risk of progressive IFALD in children with intestinal failure. This trial was registered at clinicaltrials.gov as NCT00793195.