Evaluation of the long-term use of soybean oil, medium-chain triglyceride, olive oil and fish oil in patients requiring home parenteral nutrition

Abstract

Background: Intestinal Failure is a rare form of organ failure which necessitates life sustaining intravenous parenteral nutrition. Lipid emulsions are an important component of parenteral nutrition and include essential fatty acids. Abnormal liver function is common in those receiving long-term parenteral nutrition and can be associated with sustained abnormalities including chronic cholestasis, which can lead to extensive fibrosis and cirrhosis. The causes of Intestinal Failure Associated Liver Disease (IFALD) are multifactorial and include parenteral lipid emulsions. IFALD is both treatable and potentially reversible. A wide variety of parenteral nutrition lipid emulsion formulae are available, though there is a dearth in long-term studies comparing effectiveness in adults. Aims: To determine the effectiveness of treatment strategies for IFALD in adults. To determine whether the fourth generation soybean oil, medium-chain triglyceride, olive oil and fish oil intravenous lipid emulsion (SMOFlipid®) in home parenteral nutrition is associated with more effective clinical outcomes compared to alternative lipids in adults with Intestinal Failure. Methods: A systematic review was undertaken to evaluate the effectiveness of strategies to treat IFALD in adults. Studies published between 1970 and 2018 were identified from six bibliographic database platforms: AMED, British Nursing Index, CINAHL, EMBASE, Medline, Web of Science. The Joanna Briggs Institute Critical Appraisal tools were used to assess quality of methodology and potential bias. A single-centre, retrospective cohort study was completed on a sample of adults with Intestinal Failure who received home parenteral nutrition between 1st April 2011 to 31st March 2015. A database of all individuals who received home parenteral nutrition was reviewed. SMOFlipid® was compared with a comparator lipid consisting of either soybean oil, or olive oil combined with soybean oil. Individuals were stratified into two groups based on lipid received over 12 consecutive months. Statistical analysis was completed on SPSS (IBM version 23). Outcomes sought included liver dysfunction, risk of chronic cholestasis, tolerability and clinical signs of essential fatty acid deficiency. Results: Nine studies, comprising of six case reviews and three intervention studies, were included in the systematic review which found very low quality evidence associating second, third and fourth generation lipid formulae with improved outcomes in adults with IFALD. The studies in the systematic review did not clearly define the clinical parameters which demarcate IFALD. A total of 179 individuals were included in the retrospective cohort study. Gender distribution was 104 (58.1%):75 (41.9%) females to males. Mean admission age 54.58 years (SD 15.21). Only 99 individuals received the same lipid over 12 consecutive months and there were no differences at baseline in gender, admission age, initial primary diagnosis, classification of Intestinal Failure, chronic cholestasis or liver function between in the SMOFlipid® group (n=37) and the comparator lipid group (n=62). At 12 months, those in the SMOFlipid® group did not differ from those receiving comparator lipids in terms of chronic cholestasis prevalence and incidence (p=0.466; p>0.999), liver function (ALP p=0.912, GGT p=0.953, bilirubin p=0.916, ALT p=0.141), mean change in liver function (ALP p=0.273, GGT p=0.373, bilirubin p=0.280, ALT p=0.273), line sepsis (p=0.195) and change in body mass index (p=0.971). There was no difference in group effect for the presence of chronic cholestasis or liver dysfunction after adjusting for confounding variables. SMOFlipid® was tolerated and no clinical signs of essential fatty acid deficiency were observed in either lipid group over the four-year study period; median duration of receiving SMOFlipid® was 238 days (range 1-1044, IQR 112- 460.8). Conclusion: The systematic review found there are limited data to support the use of

Date of Award	1 Aug 2019
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Sorrel Burden (Supervisor) & Sarah Tyson (Supervisor)