1
|
Aljohar HI, Nawawi RA, Albanyan NS, Aljarboa S, Orfali RS. An Assessment of aluminum contamination in neonatal parenteral nutrition solutions based on measured versus labeled content. Saudi Pharm J 2024; 32:101941. [PMID: 38292404 PMCID: PMC10825339 DOI: 10.1016/j.jsps.2023.101941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024] Open
Abstract
Aluminum can potentially cause toxicity in pediatrics and neonates receiving parenteral nutrition. Some PN solutions and ingredients in Saudi Arabia do not comply with US FDA regulations regarding aluminum exposure. This study aims to determine the aluminum concentration in samples of PN solutions and ingredients used to feed infants in Saudi Arabia. The aluminum in the samples was determined using inductively coupled plasma mass spectrometry. The concentration of metal contaminants in each sample was determined in triplicate. The aluminum content of 38 samples was investigated, 15 of which originated from components included in the prepared PN solutions. Among the 15 samples, the least measurable aluminum content was detected in potassium chloride solutions (0.81 mcg/L). In contrast, the greatest amount of aluminum was detected in potassium phosphate and calcium gluconate (141,64 mcg/L and 462.7 mcg/L), respectively. The results showed that the final PN solution (PNS) product contained more aluminum levels than the content ingredients; in addition, the study found a statistically significant relationship among 18 pediatric patients at KFMC who had intestinal failure and needed long-term parenteral nutrition. Specifically, their high aluminum levels, exceeding the normal range of 0.6 ng/ml, indicate that the current use of PN solutions will likely cause toxicity due to aluminum contamination in additives. Hence, reducing aluminum in PN solutions is imperative to ensure patient safety.
Collapse
Affiliation(s)
- Haya I. Aljohar
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Rania A. Nawawi
- Pharmacy Services Administration, King Fahad Medical City, P.O. Box 59046, Riyadh 11525, Saudi Arabia
| | - Nora S. Albanyan
- Clinical Pharmacy Department, Pharmacy Services Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Suliman Aljarboa
- Central Laboratory, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Razan S. Orfali
- Clinical Research Groups Department, Research Centre, King Fahad Medical City, Riyadh, 12231, Saudi Arabia
| |
Collapse
|
2
|
Schönenberger KA, Saxer C, Neyer PJ, Huwiler VV, Reber E, Hammerer-Lercher A, Stanga Z, Mühlebach S. Aluminum and other chemical elements in parenteral nutrition components and all-in-one admixtures. Clin Nutr 2023; 42:2475-2483. [PMID: 38411019 DOI: 10.1016/j.clnu.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/04/2023] [Accepted: 10/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN) can lead to high or even toxic exposure to aluminum (Al). We aimed to quantify concentrations of Al and other chemical elements of all-in-one (AIO) PN admixtures for adults prepared from commercial multichamber bags (Olimel® 5.7%, Omegaflex® special, SmofKabiven®, all with and without electrolytes) and vitamin and trace element additives over a 48-h period. Secondly, we determined the level of Al contamination resulting from admixing and infusion set use. METHODS We used dynamic reaction cell and kinetic energy discrimination inductively coupled plasma mass spectrometry (ICP-MS) to quantify Al, arsenic (As), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), molybdenum (Mo), nickel (Ni), antimony (Sb), selenium (Se), tin (Sn), vanadium (V), and zinc (Zn) in AIO PN admixtures. We extracted samples for analysis via the bag injection ports and infusion sets over a 48-h period after admixing. We compared the measured Al concentrations of AIO PN admixtures with calculated values based on the measured concentrations of individual chamber contents and additives. RESULTS Mean (standard deviation) baseline Al concentrations in AIO PN admixtures ranged from 10.5 (0.5) to 59.3 (11.4) μg/L and decreased slightly over the 48 h (estimate [standard error] -0.09 [0.02] μg/L/hour, p <0.001). Thus, certain products exceeded the widely accepted limit of 25 μg/L. There was no significant difference in Al concentrations between samples extracted via the bag injection ports or infusion sets (p = 0.33), nor between measured and calculated Al concentrations of AIO PN admixtures (p = 0.91). CONCLUSION Because certain commercially available PN admixtures for adults proved to contain excessively high levels of Al in our study, regulations and corresponding quality requirements at the authority level (e.g., Pharmacopoeia and regulatory authorities) are urgently required. Our results showed that the PN handling process (admixing and supplementing additives) or the materials of the infusion set did not lead to additional Al contamination to any extent. Moreover, calculated Al concentrations of AIO PN admixtures derived from individual chamber contents and additives are valid.
Collapse
Affiliation(s)
- Katja A Schönenberger
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland.
| | - Christoph Saxer
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Peter J Neyer
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Valentina V Huwiler
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | | | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland
| |
Collapse
|
3
|
Barbieri J, Cober MP. Select micronutrients for the preterm neonate. Nutr Clin Pract 2023; 38 Suppl 2:S66-S83. [PMID: 37721469 DOI: 10.1002/ncp.11054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 09/19/2023] Open
Abstract
If premature neonates are not provided with adequate nutrition, they will quickly become deficient because of increased requirements and a lack of nutrient stores to achieve adequate growth. The provision of many of the recommended micronutrients for pediatric and adult patients is challenging in premature neonates because of the limited data surrounding the true needs of premature neonates and the difficulty in assessing adequate serum levels of these nutrients in this patient population. Parenteral and enteral nutrition shortages further complicate providing adequate micronutrients to premature neonates. This review will discuss select micronutrients and their importance to the preterm neonate, with special emphasis on micronutrients with limited evidence and more challenging supplementation and repletion strategies.
Collapse
Affiliation(s)
- Jessica Barbieri
- Department of Nutritional Services, Akron Children's Hospital, Akron, Ohio, USA
| | - Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pharmacy Practice, Northeast Ohio Medical University, Rootstown, Ohio, USA
| |
Collapse
|
4
|
Yokel RA, Harris WR, Spilling CD, Abramov VP, Lone JM, Kuhn RJ. A Filtration System That Greatly Reduces Aluminum in Calcium Gluconate Injection, USP Used to Prepare Parenteral Nutrition Solutions. J Pediatr Pharmacol Ther 2014; 19:189-95. [PMID: 25309149 DOI: 10.5863/1551-6776-19.3.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The study objective was to reduce aluminum (Al) in Calcium Gluconate Injection, US Pharmacopeia (USP) used in the preparation of parenteral nutrition (PN) solutions. METHODS A flow-through filter containing an immobilized chelator that complexes Al from Calcium Gluconate Injection, USP as it flows through the filter was designed, refined by design modifications, and extensively tested. When a small-volume parenteral vial containing 100 mL of Calcium Gluconate Injection, USP is connected on the inlet side of the filter, and the outlet side is connected to an evacuated receiving vial, the filtered solution is drawn into the receiving vial. This constitutes a complete system to remove Al from Calcium Gluconate Injection, USP. RESULTS The extent of Al removal is flow rate dependent. At a flow rate of 1 mL/min approximately 85% of the Al was removed from calcium gluconate solution. PN solutions have been reported to deliver 15 to 23 mcg/kg/day Al to neonates. Given that Calcium Gluconate Injection, USP provides 85% of the Al in neonatal PN solutions, removal of 85% of the Al from this source was calculated to reduce Al delivered to most neonates to <5 mcg/kg/day. CONCLUSIONS A point-of-use, self-contained, single-use, disposable, Al-complexing filter has been created. It was calculated to reduce Al delivered in PN solutions by 72%, resulting in daily Al delivery below the level that results in Al accumulation associated with central nervous system and bone toxicity to all but the smallest (<1 kg) infants.
Collapse
Affiliation(s)
- Robert A Yokel
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky ; ALKYMOS Inc, Lexington, Kentucky
| | - Wesley R Harris
- ALKYMOS Inc, Lexington, Kentucky ; Department of Chemistry and Biochemistry, University of Missouri, St Louis, Missouri
| | - Christopher D Spilling
- ALKYMOS Inc, Lexington, Kentucky ; Department of Chemistry and Biochemistry, University of Missouri, St Louis, Missouri
| | | | | | - Robert J Kuhn
- ALKYMOS Inc, Lexington, Kentucky ; Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
5
|
Poole RL, Pieroni KP, Gaskari S, Dixon T, Kerner JA. Aluminum exposure in neonatal patients using the least contaminated parenteral nutrition solution products. Nutrients 2012; 4:1566-74. [PMID: 23201834 PMCID: PMC3509507 DOI: 10.3390/nu4111566] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 10/16/2012] [Accepted: 10/23/2012] [Indexed: 11/23/2022] Open
Abstract
Aluminum (Al) is a contaminant in all parenteral nutrition (PN) solution component products. Manufacturers currently label these products with the maximum Al content at the time of expiry. We recently published data to establish the actual measured concentration of Al in PN solution products prior to being compounded in the clinical setting [1]. The investigation assessed quantitative Al content of all available products used in the formulation of PN solutions. The objective of this study was to assess the Al exposure in neonatal patients using the least contaminated PN solutions and determine if it is possible to meet the FDA “safe limit” of less than 5 μg/kg/day of Al. The measured concentrations from our previous study were analyzed and the least contaminated products were identified. These concentrations were entered into our PN software and the least possible Al exposure was determined. A significant decrease (41%–44%) in the Al exposure in neonatal patients can be achieved using the least contaminated products, but the FDA “safe limit” of less than 5 μg/kg/day of Al was not met. However, minimizing the Al exposure may decrease the likelihood of developing Al toxicity from PN.
Collapse
Affiliation(s)
- Robert L. Poole
- Department of Pharmacy, Lucile Packard Children’s Hospital at Stanford, 725 Welch Road, Palo Alto, CA 94304, USA; (S.G.); (T.D.)
| | - Kevin P. Pieroni
- Division of Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, Stanford University School of Medicine, 750 Welch Road, Suite 116, Palo Alto, CA 94304, USA; (K.P.P.); (J.A.K.)
| | - Shabnam Gaskari
- Department of Pharmacy, Lucile Packard Children’s Hospital at Stanford, 725 Welch Road, Palo Alto, CA 94304, USA; (S.G.); (T.D.)
| | - Tessa Dixon
- Department of Pharmacy, Lucile Packard Children’s Hospital at Stanford, 725 Welch Road, Palo Alto, CA 94304, USA; (S.G.); (T.D.)
| | - John A. Kerner
- Division of Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, Stanford University School of Medicine, 750 Welch Road, Suite 116, Palo Alto, CA 94304, USA; (K.P.P.); (J.A.K.)
| |
Collapse
|
6
|
Abstract
Intestinal failure-associated liver disease (IFALD), a serious complication occurring in infants, children, and adults exposed to long-term parenteral nutrition (PN), causes a wide-spectrum of disease, ranging from cholestasis and steatosis to fibrosis and eventually cirrhosis. Known host risk factors for IFALD include low birth weight, prematurity, short bowel syndrome, and recurrent sepsis. The literature suggests that components of PN may also play a part of the multifactorial pathophysiology. Because some intravenous lipid emulsions (ILEs) may contribute to inflammation and interfere with bile excretion, treatment with ILE minimization and/or ILEs composed primarily of omega-3 fatty acids can be helpful, but requires careful monitoring for growth failure and essential fatty acid deficiency (EFAD). Data from randomized controlled trials are awaited to support widespread use of these approaches. Other IFALD treatments include cycling PN, ursodeoxycholic acid, sepsis prevention, photoprotection, and polyvinylchloride-free tubing. Management and prevention of IFALD remains a clinical challenge.
Collapse
Affiliation(s)
- Bram P Raphael
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | |
Collapse
|