Howard L, Ashley C, Lyon D, Shenkin A. Autopsy tissue trace elements in 8 long-term parenteral nutrition patients who received the current U.S. Food and Drug Administration formulation. J Parenter Enteral Nutr. 2007;31:388—396.

The aim of the study was to provide more information about parenteral trace element requirements in long-term parenteral nutrition (PN) patients. Autopsy tissue studies were completed in 8 long- term PN patients with short bowel syndrome. Samples were taken of heart, skeletal muscle, liver and kidney. Iron, zinc, copper, chromium, selenium and manganese levels were measured. All patients received multiple trace element 5 concentrate plus extra zinc to replace ostomy losses (3-5 mg/L of gastrointestinal losses).
Duration of PN ranged from 2-21 years (average 14 years). Age ranged from 29-78 years old. Two patients who had liver disease had copper and manganese removed when the bilirubin was elevated.
Comparisons were made to 45 controls done at same lab who did not have any gastrointestinal disease. Results were as follows:
- iron was present in normal concentrations in all organs studied.
- zinc was normal in heart and occasionally elevated in the kidney and frequently elevated in the liver.
- copper was normal in the heart and skeletal muscle but very elevated in the liver and kidney especially in the two patients that died of liver failure.
- manganese was elevated in the liver and kidney especially in patients with liver or kidney disease.
- chromium was 10-100 fold higher concentrations in all tissues studied.
- selenium was present at normal concentrations in all tissues measured.
The authors recommend the Food and Drug Administration approve a reformulation of the current commercially available multi trace element products in the United States. Specifically, their recommendations are zinc 3-6 mg/d plus extra for enteral losses, copper 0.3-0.5 mg/d and it should be removed as soon as liver associated enzymes, alkaline phosphatase and aminotransferases, are more than two times above their normal value and before bilirubin begins to rise. Manganese should be provided at 30-60 micrograms (mcg) daily and should also be removed when liver associated enzymes are two times greater than normal. Possibly manganese should not be routinely added at all due to the high contamination of PN additives with manganese. Chromium should be 5-10 mcg/d and selenium should be 60-120 mcg/d. Younger adults may require more selenium.


Speerhas RA, Seidner DL. Measured versus estimated aluminum content of parenteral nutrient solutions. Am J Health-Syst Pharm. 2007;64:740-746.

In January of 2000 the Food and Drug Administration mandated that the aluminum concentration of injectables used to compound parenteral nutrition (PN) solutions be placed on product labels. The regulation became effective on July 26, 2004. The populations at risk of aluminum toxicity are patients with renal impairment such as, patients with renal disease and neonates and patients who receive PN for longer than 3 weeks.
The calculated aluminum content that appears on the manufacturers label is the amount that the product contains at expiration. The aim of this study is to directly measure the aluminum concentration in a select number of PN solutions and to compare the value with the calculated dose using the concentrations reported by the manufacturer on the label. Samples were obtained from adult and pediatric/neonatal PN bags. Samples that were thought to be at greatest risk for aluminum contamination because of the large amounts of calcium, phosphate and acetate salts they contained were specifically chosen. Samples were sent to two different laboratories. Eighteen samples were available for analysis (some were lost and some were destroyed in shipping). The results showed that only two of the adult PN solutions had a measured aluminum level that exceeded the FDA threshold of 4-5 µ/kg/d. All of the pediatric/neonatal PN solutions had actual aluminum concentrations that were >4-5 µ/kg/d but the actual value was lower than what had been estimated using the labeled aluminum concentration at expiry. In fact, the estimated aluminum exposure was 7-10 times greater than the measured exposure.
The authors conclude that the PN solutions expected to have a high concentration of aluminum based on their ingredients actually had a measured amount that was far less than the amount that would be estimated by calculation using the labeled concentrations of aluminum on each of the ingredient labels.

Home Parenteral Nutrition Support in Adults: Experience of a Medical Center in Asia
Wang MW, Wu MH, Hsieh DY, Lin LJ, Le PH, Chen WJ, Lin MT. J Parenter Enteral Nutr. 2007; 31(4):306-310.

This is a study conducted at one hospital in Taiwan evaluating the use of home parenteral nutrition (HPN) for adult patients emphasizing disease patterns and indications. Thirty one patients received parenteral nutrition (PN) for at least 30 days during the retrospective review which took place from 1989-2002. The average length of PN was 19 months (range 1-115 months). The most common reason for PN was obstruction followed by short bowel syndrome, fistula and one case of malabsorption due to tropical sprue. There were 51 episodes of catheter related blood stream infection which correlated to 2.78 episodes per 1000 catheter days. Twenty four patients died during the study; 6 (25%) were related to catheter infection. The median survival was 4 months in patients with incurable malignant diseases and 53 months in patients with non malignant disease.


Telehealth Videoconferencing: Improving Home Parenteral Nutrition Patient Care to Rural Areas on Ontario, Canada. Saqui O, Chang A, McGonigle S, Purdy B, Fairholm L, Baun M, Yeung M, Rossos P, Allard J. J Parenter Enteral Nutr. 2007;31(3):234-239.

The aim of this study was to examine the management outcomes of home parenteral nutrition patients (HPN) patients when followed by telehealth as an alternative modality of care. Specifically, the study looked at catheter sepsis, time and cost savings and patient and family satisfaction of HPN care delivery using telehealth. Patients were referred to telehealth videoconferencing when they were unable to travel due to cost, weather or distance. There were 21 patients of a total 49 patients in the HPN program that participated in telehealth conferencing sessions and 13 completed a satisfaction survey. Each member of the multidisciplinary team (physician, dietitian, nurse and pharmacist) was present and interacted with the patient and family during the session. The average catheter sepsis rate for 13 patients was 0.89/1000 catheter days. All patients were generally satisfied with videoconferencing. Travel time and cost savings for patients were significantly less.


Salvino R, Ghanta R, Seidner DL, Mascha E, Xu Y, Steiger E. Liver Failure is Uncommon in Adults Receiving Long- Term Parenteral Nutrition. J Parenter Enteral Nutr. 2006;30(2):202-208.

This is a historic cohort study which investigated the prevalence of abnormal liver tests and end stage liver disease in a large home parenteral nutrition population. All patients on PN for at least 6 months from July 1991 to June 2002 were included in the study. Exclusions were active malignancy, underlying liver disease, exposure to a hepatotoxin, alcohol abuse or graft versus host disease. Patients were categorized as having: (1) normal liver laboratory values; (2) patients with abnormal liver laboratory values; and (3) patients with severe liver dysfunction. 162 patients constituted the study group. The average duration of PN was 2 years. Of the 162 patients, 92 (57%) had chronically abnormal liver associated enzymes, 161 (99%) had abnormal liver function tests and 1 patient (0.7%) had normal liver tests. Only one of the seven patients with severe liver dysfunction could be attributed solely to the use of PN. Female gender was associated with the development of worse liver function. There was a trend toward a greater amount of total calories, dextrose calories and duration of PN exposure leading to the development of severe liver dysfunction. On average, patients received a PN formula with 24.7 kcal/kg, 1.45 g/kg/d of amino acid and enough lipid emulsion to meet the essential fatty acid requirement. The authors conclude that when a modest amount of total energy and a minimal amount of lipid emulsion is provided, abnormal liver enzymes are common but severe liver dysfunction is unusual.

Quality of Life on Home Parenteral Nutrition or After Intestinal Transplantation. Pironi L, Paganelli F. Lauro A, Spinucchi G, Guidetti M, Pinna AD. Transplant Proc. 2006;38:1673-1675.

The aim of this study was to compare the health related quality of life (HRQOL) of stable patients on home parenteral nutrition (HPN) to patients who underwent successful intestinal transplantation (ITx). Inclusion criteria were age >18 years, duration of HPN or time after ITx greater than 9 months and optimal rehabilitation status. Patients completed the short form 36 questionnaire (SF-36). There were 18 patients in the HPN group and 12 patients in the ITx group. The ITx group was significantly younger, more likely to be taking a free diet, taking more drugs per day and 3 patients were taking IVF 3-6 days/week. There was no difference in primary intestinal disease, cause of intestinal failure, presence of a stoma, body mass index or employment or marital status. A statistically significant difference was found between groups for the body pain domain of the questionnaire. The values of the physical components of the SF-36 (physical functioning, role functioning physical and body pain) was lower in all areas in the HPN patients and lower in the physical functioning area only in the ITx group. The mental health components were normal in both groups.
The authors conclude that successful transplant showed a better subjective physical health feeling than in stable HPN patients.

Epidemiology of Bloodstream Infections in Patients Receiving Long Term Total Parenteral Nutrition. J Clin Gastroenterol. 2007;41(1):19-28.

The objective was to describe the epidemiology and microbiologic characteristics of blood stream infections in patients receiving long term parenteral nutrition (PN). Long term PN was described as greater than 6 months. Forty seven patients receiving PN from 1981 to 2005 were evaluated. Thirty eight patients (80.9%) developed 243 blood stream infections; 0.83 per catheter year. 78.9% of patients developed more than one blood stream infection. The most common complication among patients with a blood stream infection was central venous thrombosis. The most common pathogen overall was coagulase negative staphylococci and 23.2% of episodes were polymicrobial. Four of the 11 deaths were related to infection. The authors state there was a high incidence of blood stream infections in their long term PN population.

Therese Austin MS, RD, CNSD, Nutrition Support Clinician, Cleveland Clinic Foundation

Hyperglycemia is a common metabolic complication of the home nutrition support (HNS) patient on either tubefeedings or parenteral nutrition (PN). Adequate glucose control in this patient population is important to prevent complications for the same reasons cited for all patients. For example, the short term consequences of poor blood glucose control are infectious complications and delayed wound healing (1). Long term consequences of poor blood glucose control include nephropathy, retinopathy, neuropathy and vascular disease (2).

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First, I want to applaud the decision to deal with this very difficult subject. As noted in the editorial comment, it is not an easy subject to address, especially for HPEN patients who routinely struggle to maintain their good health. Yet, it is a subject worthy of being addressed, since when circumstances force one to address the issue, it is usually the absolute worst time to have to make these types of decisions. The short version of my story is that despite my wife’s long history as a TPN patient, we never contemplated what would happen if she became terminally ill. When that happened this Spring, at age 50, my immediate reaction was that it was important to continue TPN, as she had relied on TPN for nutrition for 25 years. I ultimately came to the realization that my first instincts in this difficult situation were probably not the best ones.

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Lyn Howard, MB, FRCP, FACP, Medical & Research Director, The Oley Foundation

Editorial Comment: From time to time we receive requests for our thoughts on the subject of death, dying and the termination of nutritional support. In response to one such request, we asked Dr. Lyn Howard, who has spent a long and distinguished career caring for patients on nutritional support, to write about her experience with this issue. We at Oley have avoided publishing information on this most difficult topic for obvious reasons. Even people in good health avoid it, and we in the HomePEN community who expend extraordinary effort to survive have more reason for not wanting to dwell on death and its particulars. Recognizing this is a difficult and controversial issue, we sent this article to a number of longterm consumers for review and comment before going to press. We thank everyone involved for sharing their opinions freely. Oley does not intend to take a position on this subject, but will remain a neutral conduit for the exchange of information. If this exchange is to produce meaningful results we must hear from you, our readers, on our handling of this topic as well as comments on the paper itself. We hope you find the article helpful.

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