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Development of Amino Acid as
Parenteral Nutrition
fibrin and casein. Positive nitrogen balance was
achieved, thus demonstrating the role of intravenous
protein hydrolysates as possible alternative to dietary
protein in animals.
arenteral nutrition (PN) is a relatively new
therapeutic tool used in the clinical management
of patients. Arguably, the era of modern clinical
nutrition can be said to have dawned around 35 years
ago when Dudrick and colleagues reported their work
on the successful administration of long-term PN in an
infant.
It was only after 1937, when Elman published his
pioneering studies on the intravenous infusion of
protein hydrolysates in man that investigations of
complete intravenous nutrition (i.e. the intravenous
administration of carbohydrate, protein, and lipids
concurrently) were initiated worldwide. Due to
serious complications such as high concentration of
di- and tri-peptides resulting from incomplete
hydrolysis, poor utilization of nitrogen, and
hyperammonemia, the use of protein hydrolysates in
PN has now been superseded by the more flexible
crystalline amino acids. Today, various parenteral
amino acid preparations and also amino acid without
electrolytes for specific clinical states have been
developed and marketed for patients with liver
dysfunction, neonates and infants and patients with
renal impairment.
P
Parenteral nutrition is a mode of providing nutritional
supplement that involves the administration of
nutrients through the intravenous route (viz. par
enteral). It is also widely known as total parenteral
nutrition (TPN) or intravenous nutrition or artificial
nutrition. It is only indicated when the oral, or enteral
route of nutrition cannot be established, or is
insufficient for the maintenance of the patient's
nutritional requirements in relation to his/her clinical
status. Partial parenteral nutrition (PPN) is the
concurrent intravenous administration of nutrients
together with oral or enteral nutrition for the same
therapeutic objective.
The dietary components of a standard PN regimen are
the macronutrients (protein or amino acids,
carbohydrate, and lipids or fats), electrolytes, the
micronutrients (vitamins and minerals) and water.
Carbohydrate in the form of glucose or dextrose,
protein in the form of amino acid and lipids are used
as the major energy providers.
It is a vast subject and here we will concentrate only
on amino acid as parenteral nutrition as the subject is
relatively new in our country and getting popularity
day by day.
History of Intravenous Administration of Proteins
Ever since the 19th century, protein has been seen to
have an important role in the growth and development
of human. The special nature of protein and its
metabolism made it a challenge to find suitable ways
of administering it intravenously. The first study in the
intravenous administration of proteins was made in
goats in the form of protein hydrolysates by Herriques
and Andersen in 1913. These hydrolysates were
products of the naturally occurring proteins such as
Complete Intravenous Provision of Nutrients
from a Single Bag
Originally, PN administration constituted the use of
separate glass bottles. A two in one method was
adopted where the amino acids solution and glucose
were admixed together with the other components of
the PN regimen. Lipid emulsion was administered
from a separate bottle. This system, which is still
being adopted in some hospitals, requires two sets of
intravenous tubings and infusion pumps leading to
high cost, and problems of sepsis, vein patency and
line management.
In the Seventies, the All-in-One (AIO) system was
introduced by Solassol and colleagues to allow for the
direct administration of PN in the ambulatory patient.
This system involved the mixing of the main
components of a PN regimen (the amino acids,
glucose and lipid emulsion and other nutrient
components - the AIO admixture) in a single silicone
rubber bag. They showed that this admixture was
stable and safe to be administered to patients leading
to a more cost-effective and simple approach to PN
administration. This method has now been widely
accepted and is used worldwide although the type of
bags used has changed considerably.
PARENTERAL NUTRITION
Parenteral nutrition has now been accepted as part of
the overall therapeutic management of the
hospitalized patients when indicated. It is not only
limited to preventing starvation or correcting
deficiencies. In more advanced countries, the
instigation or cessation of PN therapy is subject to the
same legal and moral constraints as apply to other
recognized therapies. Refinement and sophistication
of techniques have made optimal nutrition possible in
virtually all patients regardless of the status of their
gastrointestinal tract, or the presence of complicating
metabolic disorders. Today, these advances have also
made home parenteral nutrition possible in stabilized
patients who require this mode of nutritional support
for a longer period of time.
Fig: Basic chemical structure of amino acid
Parenteral Amino Acid in
Clinical Setting
Protein is the most abundant nitrogen-containing
compound in the diet and in the human body. It is one
of the complex bio-molecules present in cells and
tissues. All amino acids (AAs) have a similar chemical
structure-each contains an amino group (NH2), an acid
group (COOH), a hydrogen atom (H), and a distinctive
side group (R) that makes proteins more complex than
either carbohydrates or lipids. All AAs are attached to a
central carbon atom (C).
The distinctive side group identifies each AA and
gives it characteristics that attract it to, or repel it
from, the surrounding fluids and other AA. Some AA
side groups carry electrical charges that are attracted
to water molecules (hydrophilic), while others are
neutral and are repelled by water (hydrophobic). Sidegroup characteristics (shape, size, composition,
electrical charge, and pH) work together to determine
each protein's specific function. Proteins are the
workhorses in cells and organs and their building
blocks are the AAs, which are joined together
according to a sequence directed by the base sequence
of the DNA, and so they serve as the currency of
protein nutrition and metabolism.
• Storage of protein: In adult/elderly people, protein
breakdown exceeds protein synthesis; proteins
cannot be stored when nitrogen equilibrium is
established. But they can be stored in
active/growing age, when protein synthesis exceeds
protein breakdown.
• Essential AAs: There are some AAs, which cannot
be synthesized in the body, but are essential for
growth and maintenance of life.
• Other synthesis process: AAs help in synthesis of
bile acids, plasma proteins, hemoglobin, hormones,
enzymes, milk proteins in lactating mothers,
glutathione and cytochrome, purine and pyrimidine,
melanin and antibodies. They help formation of
rhodopsin and urea. When the above functions are
served by the AAs intact form, the surplus amounts
of AAs break down and undergo the following next
group of functions.
Table: The AAs of Nutritional Significance in Human
Indispensable
Conditionally
indispensable
Dispensable
Valine
Glycine
Glutamic acid (?)
Isoleucine
Arginine
Alanine
Leucine
Glutamine
Serine
Lysine
Proline
Aspartic acid
Functions Served by Intact AA
• Synthesis of cell protoplasm: AAs are necessary to
build up living cells, since proteins are main and
essential constituents of them.
Methionine
Cystine
Asparagine
Phenylalanine
Tyrosine
Threonine
(Taurine)a
Tryptophan
(Ornithine)a
• Taking up wear and tear: AAs repair the damaged
parts when tissue proteins break down during
metabolism.
Histidine
(Citrulline)a
2
a.Nonproteinogenic AAs, which have nutritional value in special cases.
PARENTERAL NUTRITION
Multiple Functions of AA
• Substrate of protein synthesis (codons: CAA, CAG)
• Anabolic/trophic substance for muscle; intestine
("competence factor")
• Controls acid-base balance (renal ammoniagenesis)
• Substrate for hepatic ureagenesis
• Substrate for hepatic/renal gluconeogenesis
• Fuel for intestinal enterocytes
• Fuel and nucleic acid precursors and important for
generation
of
cytotoxic
products
in
immunocompetent cells
• Ammonia scavenger
• Substrate for citrulline and arginine synthesis
• Nitrogen donor
coenzymes)
(nucleotides,
amino
sugars,
• Nitrogen transport (1/3 circulating N) (muscle, lung)
• Precursor of GABA (via glutamate)
• Shuttle for glutamate (CNS)
• Preferential substrate for GSH production?
• Osmotic signaling mechanism in regulation of
protein synthesis?
• Stimulates glycogen synthesis
• L-Arginine NO metabolism
• Taste factor
CNS, central nervous system; GABA, aminobutyric acid; GSH,
growth stimulating hormone; NO, nitric oxide.
Functions of AA While Breaking Down
• Supply of energy: AAs liberate energy on break
down at the rate of 4.3 Calories per gram of protein.
• Dynamic action: AAs while breaking down, excrete
a specific stimulating action to the extent of about
30% on tissue metabolism.
• Deamination: During deamination under the
influence of certain enzymes, the AA losses its
radicle, into nitrogenous part and non-nitrogenous
part, each of which perform separate function. The
nitrogenous part, ammonia, a large part (80%) of it
is converted to urea, and the smaller part combines
with acids to form ammonium salts. It is also
utilized for the synthesis of simple AAs like glycine,
alanine, glutamic acid; and some nitrogenous
substances like creatinine, purine, uric acid,
pyrimidine, lecithin etc.
The non-nitrogenous residues are utilized as
carbohydrates, and some also get broken down as fatty
acids in the body. Its sulphur and phosphorus
components get converted into their compounds
before excretion.
Classification of Amino Acid
Amino acid have been divided into two general,
nutritional categories: indispensable (essential) and
dispensable (nonessential). This categorization
provided a convenient and generally useful way of
viewing AA nutrition, but, new studies are
increasingly
questioning
the
conventional
classification of indispensable and dispensable AA in
Table: The Earlier and Three Contemporary Suggested Patterns of AA Requirements in Healthy Adults
AA
United Nationsa 2002
University of Surreyb 1999
MITc 2000
IOMd 2002
Isoleucine
10e (13)f
18 (30)
23 (35)
(25)
Leucine
14 (19)
26 (44)
23 (65)
(55)
Lysine
12 (16)
19 (31)
30 (50)
(51)
Methionine and cystine
13 (17)
16 (27)
13 (25)
(25)
Phenylalanine and tyrosine
14 (19)
20 (33)
39 (65)
(47)
Threonine
7 (9)
16 (26)
15 (25)
(27)
Tryptophan
3.5 (5)
4 (6)
6 (10)
(7)
Valine
10 (13)
14 (23)
20 (35)
(32)
a FAO/WHO/UNU. Technical Report Series No. 724. Geneva: World Health Organization, 2002.
b Millward DJ. The nutritional value of plant-based diets in relation to human AA and protein requirements. Proc Nutr Soc 1999; 58:
249-260.
c Young VR, Borgonha S. Nitrogen and AA requirements: the Massachusetts Institute of Technology AA Requirement Pattern.
J Nutr 2000; 130: 1841S-1849S, reproduced with permission of the American Society of Nutrition.
d US National Academies of Science Institute of Medicine.
e Values expressed as mg/kg/d.
f Values expressed as mg AA/protein required for effectively meeting total protein and AA needs.
3
PARENTERAL NUTRITION
Table: AAP and A.S.P.E.N. Pediatric Parenteral Nutrition Guidelines
American Academy of Pediatrics (AAP)
American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.)
Weight
Daily Recommendation
Weight/Age
Daily Recommendation
Protein
10-20 kg
>20 kg
1-2.5 g/kg
0.8-2 g/kg
>10 kg or 1-10 yrs
11-17 yrs
1-2 g/kg
0.8 - 1.5 g/kg
Energy
10-20 kg
>20 kg
60-90 kcal/kg
30-75 kcal/kg
1-7 yrs
7-12 yrs
12-18 yrs
75 - 90 kcal/kg
50 - 75 kcal/kg
30-50 kcal/kg
Fluid
10-20 kg
>20 kg
1000 mL + 50mL/kg
1500 mL + 20mL/kg
10-20 kg
20 kg
1000 mL + 50mL/kg
1500 mL + 20mL/kg
Carbohydrates 10-20 kg
(Dextrose)
>20 kg
8-28 g/kg
5-20 g/kg
Carbohydrates should comprise
40% to 60% of the total caloric intake
Fat Emulsion
1-3 g/kg
The minimum fat requirement is
determined by essential fatty acid
need, and the daily maximum is 50%
to 60% of energy
>10 kg
Nonprotein
Calorie to
Nitrogen Ratio
clinical nutrition. Numerous data point out that some
of the so-called dispensable AAs are conditionally
indispensable in adults under certain medical
situations. The original definition of an Indispensable
AA is: One which cannot be synthesized by the animal
organism out of materials ordinarily available to the
cells at a speed commensurate with the demands for
normal growth.
The dispensable AA is one that can be synthesized de
novo from a non AA source of nitrogen (e.g.,
ammonium ion) and a carbon source (e.g., glucose).
Conditionally indispensable are those when the
physiological or patho-physiological condition of an
individual is stressed, out of balance, or diseased,
these AAs become essential and must get from food or
supplements.
Indications of Amino Acid as Parenteral Nutrition
Specialized nutritional support is often required for
patients who have chronic disease or for those
undergoing long-term rehabilitation that are at risk for
malnutrition.
Most of the nitrogen lost from the body in disease
arises from hydrolysis of skeletal-muscle protein,
whether it occurs in acute or chronic illness, severe
injury, minor fractures, or unstressed starvation.
Losses from other protein sources, such as liver or
bone matrix, may be locally and functionally
important, but they are quantitatively small. The
4
150:1 to 300:1 is most likely to achieve
positive nitrogen balance
object of parenteral feeding of AA is to maintain
nutrition even though the patient cannot eat, to
promote redeposit and resynthesis of muscle protein
for the maintenance of nitrogen homeostasis.
Parenteral amino acid is usually indicated in the
following situations:
• Critical care
♦
Post-surgical
Burn
Premature infants
Prolonged coma
• Complete bowel obstruction, or intestinal pseudoobstruction
♦
♦
♦
• Documented inability to absorb adequate nutrients
via the gastrointestinal (GI) tract such as:
♦
♦
♦
Massive small-bowel resection/short bowel
syndrome (at least initially)
Radiation enteritis
Untreatable steatorrhea/malabsorption (i.e.,
not due to pancreatic insufficiency, small
bowel bacterial overgrowth, or coeliac
disease)
• Severe catabolism with or without malnutrition when
GI tract is not useable within 5-7 days
• Inability to obtain enteral access
• Inability to provide sufficient nutrients/fluids
enterally
PARENTERAL NUTRITION
• Lengthy GI work-up requiring nothing per oral
(NPO) status for several days in a malnourished
patient
• Trauma requiring repeated surgical procedures
• Renal failure
• Intensive chemotherapy/severe mucositis
• Hepatic failure
Important Factors to Consider when Assessing a
Patient for Parenteral AA Nutrition:
• Anthropometric Data
♦ Recent weight changes
♦ Current height and weight
• Lab Values
♦ Comprehensive metabolic panel
♦ Serum magnesium level
♦ Serum phosphorus level
♦ Serum triglycerides level
• Medical/Surgical History
♦ Anatomy (resections)/ostomies
♦ Pre-existing conditions such as diabetes,
renal failure, liver disease, etc.
• Diet/Medication History
♦
♦
♦
♦
♦
Food/drug allergies
Diet intake prior to admission
Special diets
Herbal/supplement use
Home and current medications
Nitrogen balance:
Nitrogen balance is one of the classical approaches,
which has been widely used for determinations of
protein requirement. Most estimates of human protein
requirements have been obtained directly, or
indirectly, from measurements of nitrogen excretion
and balance (Nitrogen balance = Nitrogen intake Nitrogen excretion via urine, feces, skin, and other
minor routes of nitrogen loss). The basic concept is
that protein is the major nitrogen-containing substance
in the body, so that gain or loss of nitrogen from the
body can be regarded as synonymous with gain or loss
of protein. Second, in the healthy subject, body
nitrogen will be constant (in the adult) or increase
maximally (in the growing child) if the dietary intake
of the specific nutrient such as an indispensable amino
acid, is adequate. It follows from this if body nitrogen
is decreasing or is not increasing adequately, then the
diet is deficient.
Table :Condition/Disease Wise Dose Recommendation of Parenteral Amino Acid
Condition/Disease
• Critical care
- Post-surgical
- Burn
- Premature Infants
- Low birth weight (LBW) infants
(> 2500 gm)
- Very low birth weight (VLBW) infants
(> 1500 gm)
- Extremely low birth weight (ELBW) infants
(> 1000 gm)
- Micropremies (<750 gm)
• Severe catabolic state (prolonged stress response)
• Normal renal and hepatic function
• Renal failure
- Acute renal failure
- Dialysis
- Renal failure when a patient is not yet dialyzed
and has rising blood urea nitrogen concentrations
- Acute renal failure in patients not on renal-replacement
therapy
- Renal failure in patients on renal-replacement therapy
• Hepatic failure
- Hepatic failure (cholestasis)
- Encephalopathy
Recommended amount g/kg/day
1.2-2
1.2- 2
PN
Enteral
PN
Enteral
PN
Enteral
PN
Enteral
3.2
3.6
3.4
3.9
3.5
4.0
3.5
4.0
as high as
2-2.5
1.2-1.5
1.5-1.6
1.2 - 2
0.8
0.6-1.0 (based on renal function)
1.2-1.5
0.6-1.2 (based on estimated function)
0.6 (may be temporarily discontinued)
5
PARENTERAL NUTRITION
However, as no more direct method for assessing
adequacy in relation to health has been devised,
nitrogen balance has remained an important, and until
now the major, method for assessing protein and
amino acid requirements. Moreover, there can be little
doubt that maintenance or gain of body protein
(Nitrogen) is a prerequisite for health in adults or in
children, respectively.
Parenteral Amino Acid in Some
Common Disease Condition
Critical Care
Burn: Burn injury results in profound metabolic
abnormalities perpetuated by an exaggerated stress
response to injury. Immediate attention to the
metabolic response to a severe burn significantly
decreases complications and improves outcome.
Protein loss across the burn wounds is considerable
and is the greatest during the first three post burn days.
Early protein loss across full thickness burns is greater
than that in partial thickness burns. A formula that
estimates daily protein loss (grams) across the burn
wound can be deviced:
1.2×body surface area (m2)×TBSA (Total body
surface area) burned (%).
Protein loss across the burn wound during the second
post burn week occurs at approximately half of this
rate. The administration of supplemental AAs
specially leucine to burn patients should reduce
protein catabolism in skeletal muscle and increase
protein synthesis.
Premature Infants: Infants in the neonatal intensive
care unit (NICU) often require nutrition support.
Parenteral nutrition is often used in the first days of
life to maximize caloric intake while oral feedings or
enteral feedings (e.g., nasogastric), or a combination
of the two methods are not possible. In situations
where adequate nutrition support cannot be achieved
and fat and glycogen stores have been exhausted,
infants begin to catabolize protein stores for energy.
Parenteral nutrition should be initiated if an infant can
not receive enteral feedings for two to three days. The
majority of cases in the NICU requiring PN support
are due to either gastrointestinal malformations or
necrotizing enterocolitis (NEC). Gastrointestinal
malformations include omphalocele, intestinal atresia,
volvulus, and Hirschsprung's disease.
6
Severe Catabolic State (prolonged stress response)
Parenteral nutrition in malnourished cancer patients
may increase body weight, visceral protein levels,
immunocompetence, and the capacity to tolerate
antineoplastic treatment. However, exogenous
nutrient adminstration may also influence tumor
metabolism due to a complex relationship between
nutritional status, tumor growth and host metabolism.
Forced feeding has been shown to stimulate tumor
metabolism and stimulation of tumor growth and this
has traditionally been regarded as a potential adverse
effect of nutritional support in the cancer patient.
Liver Disease
The prevalence of malnutrition in patients with liver
disease varies from 10% to 100%. Protein-calorie
malnutrition (PCM) can be observed in all clinical
stages but is more frequently seen in advanced stages
of liver disease. The alterations in amino acid
metabolism associated with liver disease are
characterized by low levels of circulating branched
chain amino acid (BCAAs) (leucine, isoleucine and
valine), elevated levels of circulating aromatic amino
acids (phenylalanine, tryptophan and tyrosine), and
methionine. Protein restrictions have been
recommended for patients with hepatic failure but
may be contraindicated in association with catabolism
or critical illness. The appropriate protein intake
depends on the stage of encephalopathy and the
proposed medical treatment. Formulations that
contain 35% of amino acids as branched chains have
been used to supplement protein intake for hepatic
failure patients.
Acute and Chronic Renal Disease
Renal failure results when the kidneys cannot
adequately excrete nitrogenous and metabolic wastes,
either acutely, as a part of a clinical illness, or
chronically over years of declining renal function.
Patients with renal failure who show marked
metabolic derangements and changes in nutritional
requirements require the use of specifically adapted
nutrient solutions.
Parenteral nutrition may be necessary in renal failure
in the following patient groups:
• Patients with acute or chronic renal failure (ARF or
CRF) and additional acute diseases but without
extracorporeal renal replacement therapy.
• Patients with ARF or CRF with additional acute
diseases on extracorporeal renal replacement
therapy, hemodialysis therapy (HD), peritoneal
dialysis (PD) or continuous renal replacement
therapy (CRRT).
PARENTERAL NUTRITION
Available Amino Acid Solutions by Local Companies
Composition: Each 100 ml Contains 5% Composite Amino Acid IV Infusion with D-Sorbitol and Electrolytes
Essential Amino Acids
L-Isoleucine
L-Leucine
L-Lysine Hydrochloride
L-Methionine
L-Phenylalanine
L-Threonine
L-Tryptophan
L-Valine
L-Histidine
L-Tyrosine
Specification
USP
USP
USP
USP
USP
USP
USP
USP
USP
USP
Quantity
0.352 gm
0.490 gm
0.430 gm
0.225 gm
0.533 gm
0.250 gm
0.090 gm
0.360 gm
0.250 gm
0.025 gm
Non Essential Amino Acids
L-Arginine
L-Aspartic Acid
L-Glutamic Acid
L-Alanine
L-Cystine
Glycine(Aminoacetic Acid)
L-Proline
L-Serine
USP
USP
BP
USP
BP
USP
USP
USP
0.500
0.250
0.075
0.200
0.010
0.760
0.100
0.100
Carbohydrate
D-Sorbitol
BP
5.00 gm
Electrolytes
Sodium(Na+)
Potassium(K+)
Magnesium(Mg++)
Chloride(Cl-)
Acetate(CH3COO-)
gm
gm
gm
gm
gm
gm
gm
gm
40.78 mmol/L
25 mmol/L
2.5 mmol/L
53.54 mmol/L
25 mmol/L
Nitrogen content: 7.7 gm/L
Composition: Each 100 ml Contains 7% Composite Amino Acid IV Infusion with 10% Glucose and Electrolytes
Essential Amino Acids:
Active ingredients
L-Isoleucine
L-Leucine
L-Lysine Hydrochloride
L-Methionine
L-Phenylalanine
L-Threonine
L-Tryptophan
L-Valine
L-Histidine
L-Tyrosine
Specification
USP
USP
USP
USP
USP
USP
USP
USP
USP
USP
Quantity
0.390 gm
0.530 gm
0.390 gm
0.190 gm
0.550 gm
0.300 gm
0.100 gm
0.430 gm
0.240 gm
0.050 gm
Non Essential Amino Acids:
Active ingredients
L-Arginine
L-Aspartic Acid
L-Glutamic Acid
L-Alanine
L-Cystine
Glycine(Aminoacetic Acid)
L-Proline
L-Serine
USP
USP
BP
USP
BP
USP
USP
USP
0.330
0.410
0.900
0.300
0.140
0.210
0.810
0.750
Carbohydrate:
Active ingredients
Anhydrous Glucose
BP
10.00 gm
Electrolytes:
Active ingredients
Sodium(Na+)
Potassium(K+)
Calcium(Ca++)
Magnesium(Mg++)
Chloride(Cl-)
gm
gm
gm
gm
gm
gm
gm
gm
50.00 gm
20.00 gm
2.5 gm
1.5 gm
44.00 gm
7
PARENTERAL NUTRITION
• Patients on HD therapy with intradialytic Parenteral
nutrition.
Recommended protein intake in renal disease varies
according to the stage of renal failure and the type of
treatment. With peritoneal dialysis 1.2 to 1.5 g of
protein/Kg of ideal body weight/day is recommended
for maintenance or repletion. For hemodialysis, 1.1 to
1.4 g/Kg of ideal body weight/day is recommended
for maintenance or repletion.
Currently continuous renal replacement therapy,
especially continuous venovenous hemofiltration
(CVVH), is usually used in intensive care patients.
The continuous therapy mode and the usually high
filtration rates result in significant influences on
electrolyte and nutrient balance, especially when
losses are not sufficiently replaced. The loss of amino
acids is approximately 0.2 g per litre of filtrate. It has
been shown that various amino acids (like alanine,
glycine, taurine and particularly, arginine) have a
protective effect on the kidneys, or prevent ARF or
may delay the progression of CRF.
Complications of Parenteral Nutrition
Short-term potential adverse effects of PN
• Infection
• Hyperglycemia
• Electrolyte abnormalities
• Disturbance of acid-base balance
• Hypertriglyceridemia
• Bacterial translocation and compromised gut
integrity
Long-term PN support adverse effects
• Infection
• Hepatic complications include liver dysfunction,
painful hepatomegaly, and hyperammonemia. They
can develop at any age but are most common among
infants, particularly premature ones (whose liver is
immature)
• Metabolic bone disease, or bone demineralization
(osteoporosis or osteomalacia), develops in some
patients given TPN for >3 months. disturbance of
acid-base balance, osteopenia
• Gallbladder complications include cholelithiasis,
gallbladder sludge, and cholecystitis
• Risk of vitamin/mineral deficiency or toxicity
• Continued risk of bacterial translocation
Conclusion
In the recent beginning of the post-genome era it will
be more critical for physicians to understand the
physiology of human protein metabolism at its various
levels of biological complexity (cell, organ, and whole
body) and its nutritional corollaries. There are certain
areas of research in protein nutrition where more
knowledge will equip nutritionists to make the best
use of parenteral amino acid. The influence of the ratio
of total essential AAs to total nitrogen and AA
requirements for different physiological states as well
as the need for a functional definition of protein
requirements for maximum resistance to disease and
enhanced physical performance are some of the major
challenges nutritionists will face in the future.
References
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2.
3.
4.
5.
6.
7.
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9.
10.
11.
12.
13.
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15.
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Introduction to Human Nutrition, Second Edition
Practical Gastroenterology, July 2006
https://www. medicalcardsystem.com/NR/
rdonlyres/790F2E5F.../TPN.pdf. May, 2010
https://www.clinimix.com; Parenteral Nutrition
Guidelines for Pediatric Patients
N engl j med 361; 11, september 10, 2009
Clinics in Perinatology, Volume 29, Issue 2,
Pages 225-244 June 2002
h t t p s : / / w w w. N u t r i t i o n D i m e n s i o n . c o m ;
December 2009
Guidelines on Parenteral Nutrition, Chapter 4.
GMS Ger Med Sci. 2009; 7:Doc24.
Report of a Joint WHO/FAO/UNU Expert
Consultation on Protein and Amino Acid
Requirements in Human Nutrition 2002
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