Metabolic Complications of Long-Term Parenteral Nutrition


BOX 5.3 Micronutrients and Non-Nutrient Factors That Can Affect Risk of Developing Parenteral Nutrition–Associated Liver Disease1,7,10-12


Intestinal rehabilitation (may decrease risk)


Minimize PN dependency by optimizing nutrient absorption through pharmacology and dietary interventions to increase intestinal absorptive capacity.


Medications


Eliminate hepatotoxic medications. Other


Consider evaluating for non-PN etiologies, such as hepatitis, malignancy, alcohol use disorder, polysubstance use, and herbal supplement use.


Metabolic Bone Disease


PN-related bone disease is a reduction of bone mineralization related to low plasma vitamin D, calcium, and magnesium levels.14


Patients


receiving long-term PN therapy are at risk for developing abnormal bone metabolism or MBD, which can result in osteomalacia or osteoporosis. Patients may experience symptoms related to MBD, such as back or bone pain, joint pain, loss of height, or bone fractures, or they may be entirely asymptomatic. Pironi et al conducted a cross-sectional, multicenter study of 165 patients receiving home PN (HPN) for more than 6 months (average length of time receiving HPN was 5 years) and reported that 84% of the patients had MBD, 50% had severe disease, and 33% were symptomatic.15 The exact cause of MBD in long-term PN therapy is unknown, although


there are several recognized contributing factors (refer to Box 5.4 on page 78).7,9,14-18


: The clinician must be aware of all potential contributing factors


to determine interventions that will reduce the development and pro- gression of MBD. Potential interventions for MBD include the following9,18-20


ƒ promote weight-bearing activity; ƒ encourage smoking cessation;


ƒ provide adequate calcium, phosphorus, magnesium, vitamin D, and vitamin K;


ƒ minimize the aluminum content of PN without compromising the nutrient requirements of the patient;


ƒ optimize amino acid content (avoid excessive provision); 77


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