Composition and Functionality of Lipid Emulsions in Parenteral Nutrition: Examining Evidence in Clinical Applications

Advancements in Sustainable Plant-Based Alternatives: Exploring Proteins, Fats, and Manufacturing Challenges in Alternative Meat Production

The rise in plant-based food consumption is propelled by concerns for sustainability, personal beliefs, and a focus on healthy dietary habits. This trend, particularly in alternative meat, has attracted attention from specialized brands and eco-friendly food companies, leading to increased interest in plant-based alternatives. The dominant plant-based proteins, derived mainly from legumes, include soy protein isolates, which significantly impact sensory factors. In the realm of plant-based fats, substitutes are categorized into fat substitutes based on fats and fat mimetics based on proteins and carbohydrates. The production of these fats, utilizing gums, emulsions, gels, and additives, explores characteristics influencing the appearance, texture, flavor, and storage stability of final plant-based products. Analysis of plant-based proteins and fats in hamburger patties provides insights into manufacturing methods and raw materials used by leading alternative meat companies. However, challenges persist, such as replicating meat's marbling characteristic and addressing safety considerations in terms of potential allergy induction and nutritional supplementation. To enhance functionality and develop customized plant-based foods, it is essential to explore optimal combinations of various raw materials and develop new plant-based proteins and fat separation.

Nutrition in chronic inflammatory conditions: Bypassing the mucosal block for micronutrients

Nutritional Immunity is one of the most ancient innate immune responses, during which the body can restrict nutrients availability to pathogens and restricts their uptake by the gut mucosa (mucosal block). Though this can be a beneficial strategy during infection, it also is associated with non-communicable diseases-where the pathogen is missing; leading to increased morbidity and mortality as micronutritional uptake and distribution in the body is hindered. Here, we discuss the acute immune response in respect to nutrients, the opposing nutritional demands of regulatory and inflammatory cells and particularly focus on some nutrients linked with inflammation such as iron, vitamins A, Bs, C, and other antioxidants. We propose that while the absorption of certain micronutrients is hindered during inflammation, the dietary lymph path remains available. As such, several clinical trials investigated the role of the lymphatic system during protein absorption, following a ketogenic diet and an increased intake of antioxidants, vitamins, and minerals, in reducing inflammation and ameliorating disease.

A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life

"End of life" is a stage defined by the existence of an irreversible prognosis that ends with a person's death. One of the aspects of interest regarding end of life focuses on parenteral nutrition, which is usually administered in order to avoid malnutrition and associated complications. However, parenteral nutrition can be adapted to specific circumstances and evolve in its functionality through supplementation with certain nutrients that can have a beneficial effect. This narrative review aims to carry out a situation analysis of the role that could be adopted by supplemental parenteral nutrition in attenuating alterations typical of end of life and potential improvement in quality of life.

Intravenous lipid emulsion therapy in 2 dogs and 2 cats with vitamin D toxicosis

Vitamin D toxicosis can lead to severe and prolonged hypercalcemia resulting in multi-organ damage and even death. Current treatment often involves prolonged hospitalization and may require medications with potential for adverse effects. The objective of this case series was to describe reductions in serum ionized calcium concentrations following intravenous lipid emulsion therapy in vitamin D toxicosis. Two dogs and 2 cats with vitamin D toxicosis were treated with intravenous lipid emulsion therapy in addition to standard treatment regimens. Ionized hypercalcemia was lower following intravenous lipid emulsion therapy despite a more than 24-hour delay in initiating treatment in 3 of the 4 patients, and no adverse reactions were observed. Additionally, 2 of the 4 animals in this case series had long-term monitoring of 25-hydroxyvitamin D concentrations that revealed persistent elevations at 6 d in a dog and 5 mo in a cat, despite earlier resolution of their ionized hypercalcemia. Key clinical message: This is the first documented serial report of reduction of serum ionized calcium concentrations after administration of intravenous lipid emulsion, in addition to other standard therapies, in 2 dogs and 2 cats with vitamin D toxicosis. Furthermore, a chronically elevated plasma 25-hydroxyvitamin D concentration was documented in 2 of the 4 patients, including the first report in a cat. In these 2 cases, ionized calcium concentrations normalized despite persistently elevated 25-hydroxyvitamin D concentrations.

Potential of liposomes and lipid membranes for the separation of β-blockers by capillary electromigration and liquid chromatographic techniques

β-Blockers belong to a frequently used class of drugs primarily used to treat heart and circulatory conditions. Here we describe the use of lipid vesicles and liposomes as cell membrane biomimicking models in capillary electromigration (CE) and liquid chromatography (LC) techniques for the investigation of interactions between lipid membranes and β-blockers. In addition to liposomes, the use of commercial intravenous lipid emulsions, and their interactions with β-blockers are also discussed. Different CE and LC instrumental techniques designed for these purposes are introduced. Other methodologies for studying interactions between β-blockers and lipid membranes are also briefly discussed, and the different methodologies are compared. The aim is to give the reader a good overview on the status of the use of liposomes and lipids in CE and LC for studying β-blocker interactions.

n-3 Polyunsaturated Fatty Acid Supplementation Affects Oxidative Stress Marker Levels in Patients with Type II Intestinal Failure: A Randomized Double Blind Trial

Type II intestinal failure (IF-II) is a condition in which the gastrointestinal tract is compromised. Liver complications may occur because of the pathology and/or prolonged use of parenteral nutrition (PN); oxidative stress has been implicated as one of the causes. Lipid emulsions containing n-3 polyunsaturated fatty acids (PUFAs) have been proposed for the treatment. We aimed to evaluate the effect of 7-day n-3 PUFA supplementation on oxidative stress in IF-II patients receiving PN. This was a randomized, controlled, double-blinded, pilot trial of adult patients with IF-II, receiving either conventional PN (control) or PN enriched with n-3 PUFAs (intervention). Twenty patients were included (14 men, 49 ± 16.9 years), with the ANCOVA analysis the glucose (p = 0.003), and direct bilirubin (p = 0.001) levels reduced; whereas the high-density lipoprotein cholesterol (HDL-C) increased (p = 0.017). In the random-effect linear regression analysis, a reduction (p < 0.0001) in the malondialdehyde (MDA) level was found in the intervention group when the covariables age, HDL-C level, and alanine aminotransferase activity were considered. After 1 week of PN supplementation with n-3 PUFAs, the marker levels of some oxidative stress, blood lipids, and hepatic biomarkers improved in patients with IF-II.

Clinical impact of lipid injectable emulsion in internal medicine inpatients exclusively receiving parenteral nutrition: a propensity score matching analysis from a Japanese medical claims database

BACKGROUND

Although guidelines recommend lipid injectable emulsions (ILEs) be used as a part of parenteral nutrition, many patients in Japan receive lipid-free parenteral nutrition. Furthermore, little is known about the effect of ILEs on clinical outcomes in medical inpatients managed with parenteral nutrition. The aim of this study was to investigate the clinical impact of ILEs on internal medicine inpatients receiving parenteral nutrition.

METHODS

A propensity score matching (PSM) analysis was performed using a medical claims database covering 451 hospitals in Japan. Participants included the following internal medicine inpatients, ages ≥ 18 years, fasting > 10 days, and receiving exclusively parenteral nutrition, between 2011 and 2020. Participants were divided into 2 groups: those who did and did not receive ILEs. The primary endpoint was in-hospital mortality. The secondary endpoints included intravenous catheter infection, activities of daily living (ADL), hospital length of stay (LOS), and total medical costs. To adjust for energy doses, logistic or multiple regression analyses were performed using energy dose as an additional explanatory variable.

RESULTS

After PSM, 19,602 matched pairs were formed out of 61,437 patients. The ILE group had significantly lower incidences than the non-ILE group of in-hospital mortality (20.3% vs. 26.9%; odds ratio [OR], 0.69; 95% confidence interval [CI], 0.66-0.72; p < 0.001), deteriorated ADL (10.8% vs. 12.5%; OR, 0.85; 95% CI, 0.79-0.92; p < 0.001), and shorter LOS (regression coefficient, - 0.8; 95% CI, - 1.6-0.0; p = 0.045). After adjusting for energy dose, these ORs or regression coefficients demonstrated the same tendencies and statistical significance. The mean total medical costs were $21,009 in the ILE group and $21,402 in the non-ILE group (p = 0.08), and the adjusted regression coefficient for the ILE vs. the non-ILE group was - $860 (95% CI, - $1252 to - $47).

CONCLUSIONS

ILE use was associated with improved clinical outcomes, including lower in-hospital mortality, in internal medicine inpatients receiving parenteral nutrition.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

Setting impurity limits for endogenous substances: Recommendations for a harmonized procedure and an example using fatty acids

Endogenous substances, such as fatty, amino, and nucleic acids, are often purposefully used in parenterally pharmaceuticals, but may be present as impurities. Currently, no consensus guidance exists on setting impurity limits for these substances. Specific procedures are needed, as the amount and types of toxicity data available for endogenous substances are typically far less than those for other chemical impurities. Additionally, the parenteral route of administration of these substances is inherently non-physiological, resulting in potentially different or increased severity of toxicity. Risk Assessment Process Maps (RAPMAPs) are proposed as a model to facilitate the development of health-based exposure limits (HBELs) for endogenous substances. This yielded a framework that was applied to derive HBELs for several fatty acids commonly used in parenteral pharmaceuticals. This approach was used to derive HBELs with further vetting based on anticipated perturbations in physiological serum levels, impacts of dose-rate, and consideration of intermittent dosing. Parenteral HBELs of 100-500 mg/day were generated for several fatty acids, and a proposed class-based limit of 50 mg/day to be used in the absence of chemical-specific data. This default limit is consistent with the low toxicity of this chemical class and ICH Q3C value for Class 3 solvents.

Lipid-Enriched Parenteral Nutrition and Bloodstream Infections in Hospitalized Patients: Is It a Real Concern?

Today, few clinicians are still convinced that lipids are sepsis risk factors in patients receiving parenteral nutrition. This dogma is principally based on old literature. This review deals with the most recent literature search that provided up-to-date data over the past ten years. Systematic research was performed on Pubmed, MEDLINE, and Web of Science. The recent evidence does not justify the exclusion of lipid emulsions in patients receiving parenteral nutrition for fear of bloodstream infection risk. Moreover, lipids represent a substantial proportion of the energy source providing essential fatty acids, potentially improving clinical outcomes in patients often malnourished. Understanding the actual risk factors of sepsis during parenteral nutrition is necessary to optimize patient nutritional status and care and avoid essential fatty acid deficiency. There is an urgent need to make updated nutrition training available at all levels of medical education.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Therapeutic Properties and Use of Extra Virgin Olive Oil in Clinical Nutrition: A Narrative Review and Literature Update

Extra virgin olive oil (EVOO) is a cornerstone of the Mediterranean diet (MedD). In this narrative review, we synthesize and illustrate the various characteristics and clinical applications of EVOO and its components—such as oleic acid, hydroxytyrosol, and oleuropein—in the field of clinical nutrition and dietetics. The evidence is split into diet therapy, oleic acid-based enteral nutrition formulations and oral supplementation formulations, oleic acid-based parenteral nutrition, and nutraceutical supplementation of minor components of EVOO. EVOO has diverse beneficial health properties, and current evidence supports the use of whole EVOO in diet therapy and the supplementation of its minor components to improve cardiovascular health, lipoprotein metabolism, and diabetes mellitus in clinical nutrition. Nevertheless, more intervention studies in humans are needed to chisel specific recommendations for its therapeutic use through different formulations in other specific diseases and clinical populations.

A Stepwise Framework for the Systematic Development of Lipid Nanoparticles

A properly designed nanosystem aims to deliver an optimized concentration of the active pharmaceutical ingredient (API) at the site of action, resulting in a therapeutic response with reduced adverse effects. Due to the vast availability of lipids and surfactants, producing stable lipid dispersions is a double-edged sword: on the one hand, the versatility of composition allows for a refined design and tuning of properties; on the other hand, the complexity of the materials and their physical interactions often result in laborious and time-consuming pre-formulation studies. However, how can they be tailored, and which premises are required for a “right at first time” development? Here, a stepwise framework encompassing the sequential stages of nanoparticle production for disulfiram delivery is presented. Drug in lipid solubility analysis leads to the selection of the most suitable liquid lipids. As for the solid lipid, drug partitioning studies point out the lipids with increased capacity for solubilizing and entrapping disulfiram. The microscopical evaluation of the physical compatibility between liquid and solid lipids further indicates the most promising core compositions. The impact of the outer surfactant layer on the colloidal properties of the nanosystems is evaluated recurring to machine learning algorithms, in particular, hierarchical clustering, principal component analysis, and partial least squares regression. Overall, this work represents a comprehensive systematic approach to nanoparticle formulation studies that serves as a basis for selecting the most suitable excipients that comprise solid lipid nanoparticles and nanostructured lipid carriers.

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.

Parenteral lipid emulsions in the preterm infant: current issues and controversies

Parenteral lipid emulsions are a necessary component of nutrition for extremely low gestational age newborns until adequate levels of enteral intake are established. Historically, Intralipid, a 100% soybean oil emulsion, has filled this role. Newer multicomponent lipid emulsions containing a mixture of other oils, including olive oil and fish oil, are now available as options, although the regulatory approval for use in neonates varies worldwide. When dosed at currently published recommendations, each of these lipid emulsions meets total fat and energy requirements without a risk of essential fatty acid deficiency. Thus, when choosing which lipid emulsion to provide, the answer must be based on the metabolic differences induced as a result of these fatty acid-rich emulsions and whether the emulsions provide a health advantage or pose a health risk. The questions of induced fatty acid profiles, health benefit and health risk are discussed sequentially for multicomponent lipid emulsions. Despite the growing acceptance of multicomponent lipid emulsions, there is concern regarding changes in blood fatty acid levels and potential health risk without strong evidence of benefit. There remains no ideal parenteral lipid emulsion option for the preterm infant. Standardising future animal and human studies in lipid delivery with the inclusion of lipid metabolism data will iteratively provide answers to inform the optimal lipid emulsion for the preterm infant.

Cold-Burst Method for Nanoparticle Formation with Natural Triglyceride Oils

The preparation of nanoemulsions of triglyceride oils in water usually requires high mechanical energy and sophisticated equipment. Recently, we showed that α-to-β (viz., gel-to-crystal) phase transition, observed with most lipid substances (triglycerides, diglycerides, phospholipids, alkanes, etc.), may cause spontaneous disintegration of microparticles of these lipids, dispersed in aqueous solutions of appropriate surfactants, into nanometer particles/drops using a simple cooling/heating cycle of the lipid dispersion (Cholakova et al. ACS Nano 2020, 14, 8594). In the current study, we show that this "cold-burst process" is observed also with natural oils of high practical interest, including coconut oil, palm kernel oil, and cocoa butter. Mean drop diameters of ca. 50-100 nm were achieved with some of the studied oils. From the results of dedicated model experiments, we conclude that intensive nanofragmentation is observed when the following requirements are met: (1) The three-phase contact angle at the solid lipid-water-air interface is below ca. 30 degrees. (2) The equilibrium surface tension of the surfactant solution is below ca. 30 mN/m, and the dynamic surface tension decreases rapidly. (3) The surfactant solution contains nonspherical surfactant micelles, e.g., ellipsoidal micelles or bigger supramolecular aggregates. (4) The three-phase contact angle measured at the contact line (frozen oil-surfactant solution-melted oil) is also relatively low. The mechanism(s) of the particle bursting process is revealed, and on this basis, the role of all of these factors is clarified and discussed. We explain all main effects observed experimentally and define guiding principles for optimization of the cold-burst process in various, practically relevant lipid-surfactant systems.

Effects of Dietary n-3 and n-6 Polyunsaturated Fatty Acids in Inflammation and Cancerogenesis

The dietary recommendation encourages reducing saturated fatty acids (SFA) in diet and replacing them with polyunsaturated fatty acids (PUFAs) n-3 (omega-3) and n-6 (omega-6) to decrease the risk of metabolic disturbances. Consequently, excessive n-6 PUFAs content and high n-6/n-3 ratio are found in Western-type diet. The importance of a dietary n-6/n-3 ratio to prevent chronic diseases is linked with anti-inflammatory functions of linolenic acid (ALA, 18:3n-3) and longer-chain n-3 PUFAs. Thus, this review provides an overview of the role of oxylipins derived from n-3 PUFAs and oxylipins formed from n-6 PUFAs on inflammation. Evidence of PUFAs' role in carcinogenesis was also discussed. In vitro studies, animal cancer models and epidemiological studies demonstrate that these two PUFA groups have different effects on the cell growth, proliferation and progression of neoplastic lesions.

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.

Intravenous Lipid Emulsions in the Prevention and Treatment of Liver Disease in Intestinal Failure

The development of intestinal failure-associated liver disease (IFALD) in pediatric and adult patients on parenteral nutrition is usually multifactorial in nature due to nutritional and non-nutritional causes. The role of lipid therapy as a contributing cause is well-established with the pathophysiological pathways now better understood. The review focuses on risk factors for IFALD development, biological effects of lipids, lipid emulsions and the mechanisms of lipid toxicity observed in laboratory animals followed by a synopsis of clinical studies in pediatric and adult patients. The introduction of fish oil-based lipid emulsions that provide partial or complete lipid replacement therapy has resulted in resolution of IFALD that had been associated with soybean oil-based therapy. Based on case reports and cohort studies in pediatric and adult patients who were at risk or developed overt liver disease, we now have more evidence that an early switch to partial or complete fish oil–based lipid therapy should be implemented in order to successfully halt and reverse IFALD.