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stones• metabolic bone disease• trace element and /or
vitamins deficiencies• manganese toxicity• renal function impairment
B Messing. Approved centre for Intestinal failure. Paris1 title, 6 sub titles, 25 materials + 4 additional
HPN-long term ComplicationsHPN-long term Complications
• Renal function impairment
* in SBS : avoid hyperoxaluria and oxalate-Ca renal stone Up to 25% of patients if steatorrhea and colon. Prevention : oral Ca and food with low oxalate content
Serious Renal Impairment Is Associated With Long-Term Parenteral Nutrition
- 33 (13M, 20 W) adult 51 (21-79) yr old - on Long-term HPN : 8.3±4.4 yrs- Protein load : 1.28± 0.32 g.Kg.d- Nephrotoxic drug : 3.4±4.0% of all HPN days- Bacteriemia/fungemia : 2.3 (0.5±0.5 / yr) episode - Cr clearance (CrCl) decline was 3.5±6.3% per year
- age + 3 above factors : 50% change in CrCl- age + infection factor : idem- excessive urinary phosphate excretion (? aciduria)- but no association with amino acid content of TPN - this decline in renal function is largely unexplained
From L.-A. Buchman; A. Moukarzel, M.-E. Ament et al. JPEN 1993;17: 438-444
Buchman JPEN 1993; 17: 438-44
HPN - ComplicationsHPN - Complications
• deficiencies of trace elements • manganese toxicity • deficiencies of vitamins
Healing of Zn deficiency after a few days of IV supplements BM 0094
Vitamin deficiency during (H)PNDeficiency Presentation
Vitamin A Night blindness, xerophammia,dark field adaptation, defective bone mineralization
Vitamin E In vitro plateled hyper-aggregation and H2O2 - induced RBC hemolysis.
Signs and symptoms suggestive of subacute combined degeneration (postero-lateral columns) in the presence of normal B12,ophthalmoplegia
Vitamin D Osteomalacia
Vitamin K Bleeding tendencies,defective II,VII,IX,XII
Bone mineralization (Gla proteins)
Vitamin C Scurvy, bleeding sore gums,
peri joint and bone hemorrhages
BM 0096
HPN-LD ComplicationsHPN-LD Complications
• Multifactorial metabolic bone disease
Contributing factors of *Metabolic bone disease associated with HPN
Contributing factors of *Metabolic bone disease associated with HPN
- PN dependent - Patient ’s dependentContinuous > cyclic SteroidsAl in hydrolysates (past) ImmobilisationAl in additives Inflammation / sepsisToo much Ca Age of disease occurrence
Inappropriate vitamine DVitamin K deficit Vitamin K antagonistsVitamin A deficit
Decreased BMI or LBM Mg deficiency Physical inactivityP deficiency Tobacco use
better ≥ 21 yr oldFemoral (cortical) NS change NS change
Cohen-Solal M et al JBMR 2003; Pironi L et al Clin Nutr 2002 & 2004
0 2 4 6 8 10
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-1.5
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-0.5
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ar
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ore
15y
35y
55y
21y
0 2 4 6 8 10
-2.5
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Figure 2 : Mean change of lumbar spine Z-Score during long term HPN among 56 patients with or without osteoporosis according to the age at IF onset.
To illustrate the results, we chose 3 ages equally spaced within the age-range of our patients, and we calculated the evolution, using the regression equation. As the duration of treatment decreased linearly with age, we did not extrapolate the evolution above the duration of follow-up. The negative evolution under HPN in young patients became positive with aging, and the change was reversed when the patients reached the age of 21. Similar evolutions were observed among patients with osteoporosis. However their Z-Scores were much lower (all values were reduced by 1.1 SD).
With osteoporosisWithout osteoporosis
Duration of HPN (years) Duration of HPN (years)
Cohen-Solql M et al JBMR 2003
Haderslev KV et al AJCN 2002; 76: 482-8.IV Pamidronate (1500 mg/3mo) vs placebo in 20 HPN patients with a T score < 1.
Metabolic bone disease & LT-HPN• Osteomalacia :
- Check vit D metabolites & Ca, P and Mg balances• Low remodeling bone :
- ibid & reinforces Ca, Mg, Vit D metabolites orally- Avoid too much N & Ca IV (calciuria & lower PTH)- Check Al in Blood & in All-in-One (& in renal risk patients ++)
- Check DEXA & BMD at PN start & annually- Check bone markers : osteocalcin & cross laps / deoxypyridinoline
• Specific treatments of osteoporosis :- Biphoshonates ° : positive moderate results at lumbar site,be careful with Ca & vit D status before treatment to avoid deficits
- Near future : trophic factors (GLP2*) or rH-PTH** * Haderslev KV Scand J Gastroenterol 2002; ° Haderslev KV et al Am J Clin Nutr 2002, D ’aoust L et al Clin Nutr 2002 (A)** Khosla S. N Eng J Med. 2003 (editorial)