The metabolism of [75Se]selenite in patients with short bowel syndrome

Band 3/anion exchanger 1/solute carrier family 4 member 1 expression as determinant of cellular sensitivity to selenite exposure

Selenium is a chalcogen element that is essential in animals, but is highly toxic when ingested above the nutritional requirement. Selenite is used as a supplement in patients receiving total parenteral nutrition. However, the therapeutic and toxic doses of selenite are separated by a narrow range. This ambivalent character of selenite implies the presence of cellular mechanisms that precisely control selenite homeostasis. Here, we investigated mechanisms that determine cellular susceptibility to selenite exposure. The resistance to selenite exposure was significantly different among cell lines. We determined the expression levels of TPMT (thiopurine S-methyltransferase) and SLC4A1 (solute carrier family 4 member 1), which encode selenium methyltransferase and selenite transporter, respectively. We also examined the effect of inhibition of Band 3 protein activity, which is encoded by SLC4A1, on the cellular sensitivity to selenite. The data suggest that the expression level of SLC4A1 is the determinant of cellular sensitivity to selenite.

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TPMT expression level was not correlated with susceptibility to selenite.

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SLC4A1 expression level was correlated with sensitivity to selenite.

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Inhibition of SLC4A1 protein improved cellular survival after selenite exposure.

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Incorporation, but not methylation, was important for cell-specific selenite sensitivity.

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.

Effect of selenium-free parenteral nutrition on serum selenium of neonates and infants maintained on long-term parenteral nutrition

BACKGROUND

The risk of selenium deficiency increases for infants receiving long-term parenteral nutrition (PN). This study analyzed selenium deficiency in neonates and infants requiring long-term PN and evaluated the effect of intravenous (IV) selenium provision.

METHODS

This study was a retrospective study of neonates and infants who were admitted to a neonatal intensive care unit from January 2010 to December 2019, received PN for ≥2 weeks, and had their serum selenium concentration measured. Patients were divided into two groups, depending on their serum selenium concentration, a deficient group (n = 55) and a nondeficient group (n = 47).

RESULTS

Of the study participants, 53.9% (55 of 102) were deficient in selenium. No difference in demographic and clinical characteristics existed except bronchopulmonary dysplasia. A subgroup analysis was performed for patients (n = 29). The average dose of IV selenium administered to patients was 2.7 ± 1.0 mcg/kg/day. The average initial serum selenium concentration was 36.5 ± 18.0 mcg/L, and the serum concentration significantly increased to 52.5 ± 19.1 mcg/L after IV selenium administration (P < .001). The correlation between the average IV selenium dose and the change in serum selenium concentrations was statistically significant (r = .423; P = .022).

CONCLUSION

Selenium deficiency is common in neonates and infants receiving long-term PN. Serum selenium concentration increased proportionally as the IV selenium dose increased. Therefore, it is recommended to supply a proper dose of IV selenium depending on the degree of selenium deficiency.

Selenium and selenoproteins in inflammatory bowel diseases and experimental colitis

Inadequate dietary intake of the essential trace element selenium (Se) is thought to be a risk factor for several chronic diseases associated with oxidative stress and inflammation. Biological actions of Se occur through low-molecular weight metabolites and through selenoproteins. Several key selenoproteins including glutathione peroxidases; selenoproteins M, P, and S; and selenium-binding protein 1 have been detected in the intestine. Interestingly, Se and antioxidant selenoproteins are known to modulate differentiation and function of immune cells and contribute to avoid excessive immune responses. This review discusses the role of Se and intestinal selenoproteins in inflammatory bowel diseases, based on data from human, animal, and in vitro studies. In humans, Se deficiency is commonly observed in patients with Crohn's disease. In animal models of experimental colitis, the Se status was negatively correlated with the severity of the disease. While the cause-effect relationship of these observations remains to be clarified, the beneficial outcome of dietary Se supplementation and an optimization of selenoprotein biosynthesis in murine inflammatory bowel disease models have led to investigations of targets and actions of Se in the gastrointestinal tract. The Se status affects gene expression, signaling pathways, and cellular functions in the small and large intestine as well as the gut microbiome composition. This data, particularly from animal experiments, hold promise that adequate dietary Se supply may counteract chronic intestinal inflammation in humans.

Intestinal selenoprotein P in epithelial cells and in plasma cells

The micronutrient selenium and selenium-containing selenoproteins are involved in prevention of inflammation and carcinogenesis in the gut. Selenoprotein P (Sepp1), the plasma selenium transport protein, is secreted primarily from hepatocytes, but Sepp1 mRNA is also abundant in the intestine. By immunofluorescence analysis, we show that Sepp1 levels in epithelial cells of the rat jejunum increase along the crypt-to-villus axis. A different Sepp1 distribution pattern was observed in the rat colon, where the epithelial cells located at the base and at the top of the crypts were similarly positive for Sepp1. In addition, we found pronounced Sepp1 immunoreactivity in CD138-positive plasma cells scattered within the lamina propria of the colon. This hitherto unrecognized presence in terminally differentiated B-cells was corroborated by detection of Sepp1 in plasma cells residing in the rat spleen. Following supplementation with dietary selenium compounds, polarized intestinal epithelial Caco-2 cells secreted Sepp1 into the culture medium across the basolateral membrane. Our data suggest that Sepp1 secreted from epithelial cells may support the intestinal immune system by providing immune cells (including plasma cells) with selenium for the biosynthesis of endogenous selenoproteins.

Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US

BACKGROUND

The purpose of this analysis was to provide a concise report of the literature on the burden of intestinal failure associated with short bowel syndrome (SBS-IF) in adults, focused on clinical and humanistic issues important to clinicians and payers.

SCOPE

A literature search was performed using the National Library of Medicine PubMed database ( http://www.ncbi.nlm.nih.gov/pubmed ) with the search term 'short bowel syndrome' limited to adult populations and English-language reports published from January 1, 1965, to January 18, 2013. Citations were assessed for relevance and excluded articles focused on single case studies, colon fermentation, absorption of medications with PN/IV, surgical technique, mesenteric artery complications/surgery, and transplantation focus. Additional hand searches were performed using the terms 'short bowel syndrome' AND 'cost', and 'home parenteral nutrition' AND 'cost', along with the exclusion criteria described above.

FINDINGS

Despite advances in management in recent decades, SBS-IF continues to carry a high burden of morbidity and mortality. In the absence of sufficient intestinal adaptation following resection, many patients remain dependent on long-term parenteral nutrition and/or intravenous fluids (PN/IV). Although potentially life saving, PN/IV is costly, invasive, and associated with numerous complications and deleterious effects on health and quality of life. Surgical interventions, especially intestinal transplantation, are costly and are associated with substantial morbidity and high mortality. New therapies, which show promise in promoting intestinal rehabilitation and reducing dependence on PN/IV therapy, are the subject of active research.

CONCLUSIONS

Overall, the available literature suggests that although SBS-IF affects a relatively small population, the clinical and humanistic burden is significant, and there is an unmet need for effective therapeutic options that target the underlying problem of inadequate absorptive capacity of the remaining intestine. Consequently, many patients with SBS-IF remain dependent on long-term PN/IV support, adding to the burden imposed by the underlying disorder.

Role of trace elements in parenteral nutrition support of the surgical neonate

BACKGROUND

Parenteral nutrition (PN) has transformed the outcome for neonates with surgical problems in the intensive care unit. Trace element supplementation in PN is a standard practice in many neonatal intensive care units. However, many of these elements are contaminants in PN solutions, and contamination levels may, in themselves, be sufficient for normal metabolic needs. Additional supplementation may actually lead to toxicity in neonates whose requirements are small.

METHODS

An electronic search of the MEDLINE, Cochrane Collaboration, and SCOPUS English language medical databases was performed for the key words "trace elements," "micro-nutrients," and "parenteral nutrition additives." Studies were categorized based on levels of evidence offered, with randomized controlled trials and meta-analyses accorded the greatest importance at the apex of the data pool and case reports and animal experiments the least importance. Articles were reviewed with the primary goal of developing uniform recommendations for trace element supplementation in the surgical neonate. The secondary goals were to review the physiologic role, metabolic demands, requirements, losses, deficiency syndromes, and toxicity symptoms associated with zinc, copper, chromium, selenium, manganese, and molybdenum supplementation in PN.

RESULTS

Zinc supplementation must begin at initiation of PN. All other trace elements can be added to PN 2 to 4 weeks after initiation. Copper and manganese need to be withheld if the neonate develops PN-associated liver disease. The status of chromium supplementation is currently being actively debated, with contaminant levels in PN being sufficient in most cases to meet neonatal requirements. Selenium is an important component of antioxidant enzymes with a role in the pathogenesis of neonatal surgical conditions such as necrotizing enterocolitis and bronchopulmonary dysplasia. Premature infants are often selenium deficient, and early supplementation has shown a reduction in sepsis events in this age group.

CONCLUSION

Appropriate supplementation of trace elements in surgical infants is important, and levels should be monitored. In certain settings, it may be more appropriate to individualize trace element supplementation based on the predetermined physiologic need rather than using bundled packages of trace elements as is the current norm. Balance studies of trace element requirements should be performed to better establish clinical recommendations for optimal trace element dosing in the neonatal surgical population.

Dosing and monitoring of trace elements in long-term home parenteral nutrition patients

BACKGROUND

Trace elements (TEs) dosing and monitoring in home parenteral nutrition (PN) patients vary with their underlying conditions.

METHODS

This retrospective observational study evaluated parenteral TE dosing, serum TE concentrations and monitoring, and dose-concentration relationships between TE doses and serum TE concentrations in 26 adult and adolescent home PN patients.

RESULTS

There was a total of 40,493 PN days. Average parenteral zinc doses of 9.1 mg/d and 7.6 mg/d resulted in the majority of serum zinc concentrations (90%) within normal range in patients with and without short bowel syndrome (SBS), respectively. Selenium at about 70 mcg/d resulted in about 60% of serum selenium concentrations within normal range, with 38% of values below normal in patients with and without SBS alike. Copper at 1 mg/d resulted in 22.5% of serum copper concentrations above the normal range. The majority of serum manganese (94.6%) and chromium (96%) concentrations were elevated. Serum TE concentrations were infrequently monitored. Significant relationships existed between doses and serum concentrations for zinc (P < .0001), manganese (P = .012), and chromium (P < .0001) but not for selenium or copper.

CONCLUSIONS

TE doses in home PN should be individualized and adjusted based on regular monitoring of TE status. In long-term home PN patients, higher zinc and selenium doses may be necessary to maintain their normal serum concentrations. Lower copper doses and restrictions of manganese and chromium supplementation may be needed to avoid their accumulation. Relationships between TE doses and serum TE concentrations vary for each TE and underlying clinical conditions.

Enteral and parenteral nutrition in the care of patients with short-bowel syndrome

Short-bowel syndrome is a challenging entity for the gastroenterologist, requiring integration of medical, nutritional, surgical and psychological therapies. Treatment must be based on the patient's age, remaining gastrointestinal anatomy, baseline nutritional status and underlying general health as well as the numerous complications which may arise. This chapter reviews physiological alterations that occur with short-bowel syndrome and how therapies can be tailored to most adequately meet the needs of these patients. Emphasis on early stages of therapy to enhance intestinal adaptation is focused on as management during this time has a significant impact on the long-term outcome of these patients.

Management of patients with a short bowel

There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B₁₂. Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D (-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.

Micronutrient status and glutathione peroxidase in bedridden patients on tube feeding

Deficiency of micronutrients, especially selenium, is common in critically ill patients. We investigated the micronutrient status (selenium, zinc, copper and manganese) and glutathione peroxidase (GSH-Px) activity in 30 tube-fed patients and 21 hospitalized non-tube-fed control patients. Serum levels of selenium, copper and manganese in tube-fed patients were significantly lower than in control patients (selenium: 4.85+/-1.38 microg/dl versus 8.67+/-1.45 pg/dl; copper: 44.7+/-36.9 microg/dl versus 92.1+/-21.2 microg/dl; manganese 0.59+/-0.41 microg/dl versus 1.52+/-0.59 microg/dl). However, zinc and log GSH-Px in the serum were similar in the two groups. Serum selenium concentration correlated with the daily intake of selenium in tube-fed patients, but zinc, copper and manganese concentrations did not correlate with the daily intake of the respective trace elements in tube-fed patients. Blood GSH-Px activity correlated positively with serum selenium concentrations in the control patients, but not in tube-fed patients. These results demonstrate that selenium content of enteral feed appears to be insufficient to maintain normal serum levels in elderly bedridden patients. Our findings emphasize the importance of monitoring micronutrient status in patients on enteral feeding to avoid trace element deficiencies.

Selenium absorption and retention from a selenite- or selenate-fortified milk-based formula in men measured by a stable-isotope technique

The present study was designed to determine the apparent absorption and retention of the inorganic Se compounds SeO3(2-) and SeO4(2-), which are commonly used for Se fortification of clinical nutrition products and infant formulas. Ten healthy men were fed a milk-based formula labelled with 40 microg Se as 74SeO3(2-) or 76SeO4(2-) on two consecutive days using a randomised crossover design. Se stable-isotope analysis of 9 d complete collections of urine and faeces was used to calculate apparent Se absorption and retention. Se retention from 74SeO3(2-) (41.0 (SD 8.4) %) and from 76SeO4(2-) (46.0 (SD 7.9) %) was not significantly different (P > 0.05). However, Se absorption was significantly higher from SeO4(2-) than from SeO3(2-) (91.3 (SD 1.4) % v. 50.2 (SD 7.8) %, P < 0.05). Urinary excretion of the administered dose was 9.2 (SD 1.8) % for 74SeO3(2-) and 45.3 (SD 8.2) % for 76SeO4(2-) (P < 0.05). Urinary Se excretion kinetics differed significantly for the two Se compounds; 90 % of the total urinary Se was excreted after 121 h for 74SeO32- and after 40 h for 76SeO42- These results suggest that although Se absorption and urinary excretion differ for SeO3(2-) and SeO4(2-), both Se compounds are equally well retained when administered at a relatively low dose (40 microg Se). The nutritional impact of Se fortification of foods would thus be expected to be similar when SeO4(2-) or SeO3(2-) are used.

Home parenteral nutrition. 25 years later

After 25 years, there is enough clinical outcome experience to determine appropriate use of home parenteral nutrition in different disease states and age groups. Information regarding how to avoid complications and how patients and families can find necessary psychosocial support is provided in this article. Currently, small bowel transplantation is not a safer choice, unless there is severe liver disease caused by home parenteral nutrition or lack of central intervenous access.