Essential Amino Acid Profile in Parenteral Nutrition Mixtures: Does It Meet Needs?

A scoping review of parenteral requirements (macronutrients, fluid, electrolytes and micronutrients) in adults with chronic intestinal failure receiving home parenteral nutrition

INTRODUCTION

Home parenteral nutrition (HPN) prescriptions should be individualised in adults with chronic intestinal failure (IF). The aims of the review were to explore HPN requirements and available guidelines and to determine whether adults (≥ 18 years) receive recommended parenteral nutrient doses.

METHODS

Online databases searches identified empirical evidence (excluding case-reports), reviews and guidelines (Published 2006-2024 in English language). Additional reference lists were hand-searched. Older studies, cited in national guidelines were highlighted to map evidence source. Two reviewers screened 1660 articles independently, with 98 full articles assessed and 78 articles included (of which 35 were clinical studies). Citation tracking identified 12 older studies.

RESULTS

A lack of evidence was found assessing parenteral macronutrient (amounts and ratios to meet energy needs), fluid and electrolyte requirements. For micronutrients, 20 case series reported serum levels as biomarkers of adequacy (36 individual micronutrient levels reported). Studies reported levels below (27 out of 33) and above (24 out of 26) reference ranges for single micronutrients, with associated factors explored in 11 studies. Guidelines stated recommended parenteral dosages. Twenty-four studies reported variable proportions of participants receiving HPN dosages outside of guideline recommendations. When associated factors were assessed, two studies showed nutrient variation with type of HPN administered (multichamber or individually compounded bags). Five studies considered pathophysiological IF classification, with patients with short bowel more likely to require individualised HPN and more fluid and sodium.

CONCLUSIONS

This review highlights substantial evidence gaps in our understanding of the parenteral nutritional requirements of adult receiving HPN. The conclusions drawn were limited by temporal bias, small samples sizes, and poor reporting of confounders and dose. Optimal HPN nutrient dose still need to be determined to aid clinical decision-making and further research should explore characteristics influencing HPN prescribing to refine dosing recommendations.

Comprehensive Evaluation of Clinical Application of Balanced Compound Amino Acid Injection

Background

To provide a reference for hospital drug selection and rational clinical drug selection based on the evaluation of the safety, nutritional quality, and economy of 27 manufacturers of five varieties (18AA, 18AA-I, 18AA-II, 18AA-IV, 18AA-V) of balanced compound amino acids for injection and (18AA-II_{original research}).

Methods

The safety of compound amino acids for injection was evaluated by comparing the antioxidant sulfite contents. Based on the amino acid scoring standard mode and the whole egg protein mode as proposed by the Food and Agriculture Organization of the United Nations/World Health Organization (FAO/WHO) in 1973, we compared the formula. The first limiting amino acid content and the comprehensive quality of the total essential amino acid (EAA) contents of the six formulations were studied. The price/content ratio was used to evaluate their economy.

Results

Similar variety produced by different manufacturers have the same formula and contents of balanced compound amino acids for injection. Safety: 18AA-II_{original research} and 18AA-II had the lowest sulfite content. Compared with 18AA-II_{original research}, the sulfite content of 18AA-I, 18AA, 18AA-V, and 18AA-IV were higher (10 times, 16.67 times, 16.67 times, and 33.33 times, respectively). The lower the sulfite content, the safer the product. Nutritional quality: The proportions of amino acids in the five varieties of compound amino acid injection were all suitable. The order of the first limiting amino acids for the formulations was 18AA-II_{original research} = 18AA-II>18AA >18AA-I = 18AA-IV>18AA-V. The order of the EAA values for the formulations was 18AA-II_{original research} = 18AA-II>18AA>18AA-I > 18AA-IV > 18AA-V. The overall effectiveness order was 18AA-II_{original research} = 18AA-II>18AA > 18AA-I>18AA-IV>18AA-V. Economy: Among the 27 manufacturers, 12 manufacturers had a price/content ratio higher than that of 18AA-II original research manufacturers, and 15 manufacturers had a price/content ratio lower than original research manufacturers.

Conclusion

Through its security, effectiveness, and economy of the comprehensive research, we recommended 18AA-II and 18AA-IIoriginal research with high safety, efficacy, and reasonable price as the first choice. 18AA and 18AA-I with better safety and reasonable price, secondary recommendation. 18AA-IV or 18AA-V with poor safety, efficacy, and economy are not recommended.

Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome

Introduction

In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.

Macronutrients in Parenteral Nutrition: Amino Acids

The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.

Impact on Isoleucine and Valine Supplementation When Decreasing Use of Medical Food in the Nutritional Management of Methylmalonic Acidemia

BACKGROUND

Methylmalonic acidemia (MMA) is an autosomal recessive disorder treated with precursor-free medical food while limiting natural protein. This retrospective chart review was to determine if there was a relationship between medical food, valine (VAL) and/or isoleucine (ILE) supplementation, total protein intake, and plasma amino acid profiles. Methods: A chart review, of patients aged 31 days or older with MMA treated with dietary intervention and supplementation of VAL and/or ILE and followed at the Children's Hospital Colorado Inherited Metabolic Diseases Clinic. Dietary prescriptions and plasma amino acid concentrations were obtained at multiple time points.

RESULTS

Baseline mean total protein intake for five patients was 198% of Recommended Dietary Allowance (RDA) with 107% natural protein and 91% medical food. Following intervention, total protein intake (p = 0.0357), protein from medical food (p = 0.0142), and leucine (LEU) from medical food (p = 0.0276) were lower, with no significant change in natural protein intake (p = 0.2036). At baseline, 80% of patients received VAL supplementation and 100% received ILE supplementation. After intervention, only one of the cohort remained on supplementation. There was no statistically significant difference in plasma propiogenic amino acid concentrations.

CONCLUSIONS

Decreased intake of LEU from medical food allowed for discontinuation of amino acid supplementation, while meeting the RDA for protein.