Quantitative Assessment of Trace-Element Contamination in Parenteral Nutrition Components

Manganese restriction in parenteral nutrition for preterm neonates: A pilot randomized controlled trial

BACKGROUND

Manganese (Mn) is present in many parenteral nutrition (PN) ingredients, presumably as a contaminant during ingredient manufacturing. Exposure to Mn in PN may have negative health consequences in preterm neonates. The purpose of this study was to test the feasibility and safety of not adding supplemental Mn to PN prepared for extremely preterm and very preterm neonates compared with standard Mn supplementation.

METHODS

Neonates <32 weeks' gestational age were randomized on postnatal day 1 to receive test PN prepared without adding Mn or standard PN prepared with Mn 5 mcg/kg/day using a commercially available neonatal multitrace element product. Randomization assignment was blinded to the clinical team. Whole blood Mn levels were measured at baseline, 2 weeks, and 8 weeks postnatal age. Growth parameters and nutrition intake were also collected.

RESULTS

Twenty-six participants were enrolled and nineteen completed the trial. The median duration of PN was 11 days in the no Mn group and 12 days in the standard Mn group. Whole blood Mn levels were not significantly different between the two groups at any time point. Growth and nutrition outcomes were also not significantly different between the two groups.

CONCLUSIONS

The provision of no-added-Mn PN in routine care was feasible and did not alter Mn blood levels or growth in the first 8 weeks of postnatal age compared with standard PN.

Rapid detection of microplastics/nanoplastics directly exposed to blood during intravenous injections via mie scattering spectra

Microplastics/nanoplastics (M/NPs) are pervasive in the environment, leading to inevitable human exposure through various pathways and raising significant public and scientific concern. Understanding the sources and levels of M/NPs in human blood is crucial for environmental health studies. This work examined the content, type, shape, and size of M/NPs released directly into the bloodstream from medical devices via saline solution during intravenous (IV) injection. The results of the Mie scattering spectra method show that the M/NPs content from infusion bags was 1.0 ± 0.7 μg/L, mainly fibers, polyethylene, and polypropylene, with fragments being predominant. During a IV process, the initial 12 mL of saline from infusion tubes contained 8.4 ± 3.6 μg/L of M/NPs, primarily polyvinyl chloride and fibers. These results suggest that M/NPs exposure during IV therapy mainly originates from infusion tubing, necessitating high concern for exposure risks. Recommendations include: 1) reducing non-essential IV treatments, 2) discarding the initial 12 mL of saline solution flowing through the tubing during essential IV therapy, and 3) expediting the development of legal requirements and detection standards by national authorities and the healthcare industry to mitigate the risk of M/NPs exposure in the bloodstream.

Investigation of parenteral nutrition-induced hepatotoxicity using human liver spheroid co-cultures

Parenteral nutrition (PN) is typically administered to individuals with gastrointestinal dysfunction, a contraindication for enteral feeding, and a need for nutritional therapy. When PN is the only energy source in patients, it is defined as total parenteral nutrition (TPN). TPN is a life-saving approach for different patient populations, both in infants and adults. However, despite numerous benefits, TPN can cause adverse effects, including metabolic disorders and liver injury. TPN-associated liver injury, known as intestinal failure-associated liver disease (IFALD), represents a significant problem affecting up to 90% of individuals receiving TPN. IFALD pathogenesis is complex, depending on the TPN components as well as on the patient's medical conditions. Despite numerous animal studies and clinical observations, the molecular mechanisms driving IFALD remain largely unknown. The present study was set up to elucidate the mechanisms underlying IFALD. For this purpose, human liver spheroid co-cultures were treated with a TPN mixture, followed by RNA sequencing analysis. Subsequently, following exposure to TPN and its single nutritional components, several key events of liver injury, including mitochondrial dysfunction, endoplasmic reticulum stress, oxidative stress, apoptosis, and lipid accumulation (steatosis), were studied using various techniques. It was found that prolonged exposure to TPN substantially changes the transcriptome profile of liver spheroids and affects multiple metabolic and signaling pathways contributing to liver injury. Moreover, TPN and its main components, especially lipid emulsion, induce changes in all key events measured and trigger steatosis.

Nutritional profile and risk assessment of inorganic elements in enteral and parenteral nutrition formulas

The contents of essential (Ca, Fe, K, Na, P, and Zn) and potentially toxic inorganic elements (As, Al, Cd, Cr, Cu, Mn, and Pb) in enteral and parenteral nutrition formulas were evaluated by inductively coupled plasma optical emission spectrometry (ICP OES) and graphite furnace atomic absorption spectrometry (GFAAS). A total of 30 enteral formulas, 23 parenteral solution components, and 3 parenteral solutions were analyzed. The elements Ca and K presented the higher contents (72-2918 mg L-1 and 235-2760 mg L-1) while the lowest concentration levels were found for As and Cd (<0.68 µg L-1 and <0.01-0.62 µg L-1) in the studied samples. The validated analytical methods presented an accuracy of 75-116% and RSD values lower than 9.8%. Calcium gluconate and magnesium sulfate, which are used as raw materials in parenteral solution, are potential sources of Al and Mn contamination. A Hazard Quotient (HQ) >1 was obtained for Al (27 ± 1 µg L-1) in one of the parenteral samples, whereas the established limit is 25 µg L-1. Enteral samples were considered safe for consumption regarding the Al, As, and Cd levels. One healing-specific and pediatric formula contained Pb at levels above 0.25 µg kg-day-1, too high for safe consumption. The enteral formulas (pediatric, diabetes-specific, renal-specific, healing-specific, and standard formula with addition of fiber) presented risks in relation to the consumption of Cr and Mn (>250 µg day-1 and >11 mg day-1). The results indicate the need for strict monitoring, considering that these formulations are often the single patient's food source.

Parenteral nutrition-associated liver injury: clinical relevance and mechanistic insights

Intestinal failure-associated liver disease (IFALD) is a relatively common complication in individuals receiving parenteral nutrition (PN). IFALD can be manifested as different types of liver injury, including steatosis, cholestasis, and fibrosis, and could result in liver failure in some cases. The onset and progression of IFALD are highly dependent on various patient and PN-related risk factors. Despite still being under investigation, several mechanisms have been proposed. Liver injury can originate due to caloric overload, nutrient deficiency, and toxicity, as well as phytosterol content, and omega-6 to omega-3 fatty acids ratio contained in lipid emulsions. Additional mechanisms include immature or defective bile acid metabolism, acute heart failure, infections, and sepsis exerting negative effects via Toll-like receptor 4 and nuclear factor κB inflammatory signaling. Furthermore, lack of enteral feeding, gut dysbiosis, and altered enterohepatic circulation that affect the farnesoid x receptor-fibroblast growth factor 19 axis can also contribute to IFALD. Various best practices can be adopted to minimize the risk of developing IFALD, such as prevention and management of central line infections and sepsis, preservation of intestine's length, a switch to oral and enteral feeding, cyclic PN, avoidance of overfeeding and soybean oil-based lipid formulations, and avoiding hepatotoxic substances. The present review thus provides a comprehensive overview of all relevant aspects inherent to IFALD. Further research focused on clinical observations, translational models, and advanced toxicological knowledge frameworks is needed to gain more insight into the molecular pathogenesis of hepatotoxicity, reduce IFALD incidence, and encourage the safe use of PN.

Direct entry of micro(nano)plastics into human blood circulatory system by intravenous infusion

Understanding the pathways of human exposure to micro(nano)plastics (MNPs) is crucial for assessing their health impacts. Intravenous infusion can induce MNPs direct entry into the human blood, posing serious risks on human health, but remains unclear. Herein, we developed comprehensive analytical methods to detect polyvinyl chloride (PVC) MNPs down to 20 nm, and found about 0.52 μg equal to 105-1011 particles of PVC-MNPs released from intravenous infusion products (IVIPs) during each intravenous infusion of 250 mL injection. The released amounts of MNPs from IVIPs were dependent on the plastic materials, and the injection volume and composition. These findings indicated that the released MNPs should be directly introduced into the human blood circulatory system, causing serious impacts on human health. Our study reveals a previously ignored but important pathway of human exposure to MNPs, and calls for further research on the potential risks of these MNPs on human health.

Parenteral Nutrition

Prematurity and other complications at birth are nutritional emergencies. Parenteral nutrition is a bridge to enteral nutrition for a few days or months, and sometimes the sole source of nutrition for life. Parenteral nutrition regimens are constructed to provide adequate and balanced energy, macronutrients, and micronutrients to support growth and prevent deficiencies. Neonatal parenteral nutrition regimens are complicated by periodic shortages of essential products, compatibility challenges, and contaminants. Newborns benefit from serial growth assessments, monitoring of biochemical status, nutrition-focused physical examinations, and management by a multidisciplinary team to ensure adequacy of parenteral nutrition and promote best outcomes.

Advances in Trace Element Supplementation for Parenteral Nutrition

Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT^® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.

Sources of unintentional manganese delivery in neonatal parenteral nutrition

BACKGROUND

Manganese (Mn) neurotoxicity is a concern in neonates receiving parenteral nutrition (PN). Prior studies have identified Mn contamination of PN ingredients as a source of daily Mn exposure from PN. This study was conducted to determine which neonatal PN ingredients are sources of this unintentional Mn delivery.

METHODS

Mn concentration was measured in different lot numbers of individual PN ingredients using inductively coupled plasma mass spectrometry (ICP-MS). PN admixtures were then prepared using standard doses of the tested individual ingredients and admixture Mn concentration was measured.

RESULTS

Magnesium sulfate and calcium gluconate are the major contributors to hidden unintentional Mn exposure in neonatal PN. Maximum measured Mn concentrations in these two ingredients were 443 and 46.8 mcg/L, respectively. Sodium and potassium phosphate were the next highest at 40 and 24 mcg/L, respectively. Other ingredients contained a trivial or no measurable quantity of Mn. PN admixture Mn content was 16-30% higher than predicted values based on individual ingredient Mn content. If infused at 150 mL/kg/day, a standard neonatal PN admixture with no added Mn is capable of unintentionally delivering up to 0.9 mcg/kg/day of Mn.

CONCLUSION

Neonatal PN without any added Mn provides close to the ASPEN recommended 1 mcg/kg/day dosage of Mn. This supports the potential utility of a Mn-omission approach to trace element provision in neonatal PN. Further studies are needed to test such an approach, and to evaluate the clinical significance of unintended Mn delivery in neonates receiving PN. This article is protected by copyright. All rights reserved.

Parenteral nutrition compatibility and stability: A comprehensive review

Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Evaluating the risk of manganese-induced neurotoxicity of parenteral nutrition: review of the current literature

INTRODUCTION

Several diseases and clinical conditions can affect enteral nutrition and adequate gastrointestinal uptake. In this respect, parenteral nutrition (PN) is necessary for the provision of deficient trace elements. However, some essential elements, such as manganese (Mn) may be toxic to children and adults when parenterally administered in excess, leading to toxic, especially neurotoxic effects.

AREAS COVERED

Here, we briefly provide an overview on Mn, addressing its sources of exposure, the role of Mn in the etiology of neurodegenerative diseases, and focusing on potential mechanisms associated with Mn-induced neurotoxicity. In addition, we discuss the potential consequences of overexposure to Mn inherent to PN.

EXPERT OPINION

In this critical review, we suggest that additional research is required to safely set Mn levels in PN, and that eliminating Mn as an additive should be considered by physicians and nutritionists on a case by case basis in the meantime to avoid the greater risk of neurotoxicity by its presence. There is a need to better define clinical biomarkers for Mn toxicity by PN, as well as identify new effective agents to treat Mn-neurotoxicity. Moreover, we highlight the importance of the development of new guidelines and practice safeguards to protect patients from excessive Mn exposure and neurotoxicity upon PN administration.

Significant Published Articles for Pharmacy Nutrition Support Practice in 2019

The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2019 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 111 articles were identified; 6 from the primary literature were voted by the group to be of high importance. An additional 9 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.