Supplements SMOF in TPN for Liver Transplantation Recipients
Condition: Liver Transplantation; Total Parenteral Nutrition; End-stage Liver Disease
MeSH terms: Liver Diseases; End Stage Liver Disease
Study type: Observational

Summary: 
      Liver transplantation (LT) is one of the widely recognised and leading treatments for
      end-stage liver disease. Nutrition impacts its success. Total parenteral nutrition (TPN) is
      usually prescribed for patients recommended prolonged fasting after LT. The supplement of
      SMOFlipid (soybean oil, MCT oil, olive oil, and fish oil) is easily metabolised to produce
      energy, and it possesses anti-inflammatory effects; however, SMOFlipid emulsion use raises
      concerns regarding coagulopathy after LT. This study investigated the postoperative
      correlation between SMOFlipid and coagulation in LT.
    

Detailed description: 
      Liver failure is characterised by the loss of liver function and is complicated with hepatic
      encephalopathy and coagulopathy. Liver transplantation (LT) is one of the widely recognised
      and leading treatments for end-stage liver disease. Malnutrition is one of the common
      manifestations of this critical condition and is also an independent predictor of mortality.
      Several studies have shown that malnutrition is a poor prognostic factor for LT, which
      indicates that nutritional support may reduce LT complications and improve survival.

      Total parenteral nutrition (TPN) is usually prescribed for patients recommended prolonged
      fasting after LT. The supplement of SMOFlipid (soybean oil, MCT oil, olive oil, and fish oil)
      has the advantage of being easily metabolised to produce energy, and it has anti-inflammatory
      effects. The major therapeutic mechanism of fish oil is the attenuation of systematic
      inflammation, which may decrease the mortality risk in patients with severe injury and
      sepsis. SMOFlipid has been proven to be safe and well tolerated in a wide range of clinical
      conditions, and it is used as the standard lipid emulsion. Moreover, the short-term
      application of parenteral fish oil with soybean oil not only significantly reduces the
      parameters of liver damage in the postoperative period but also leads to a more balanced
      immune response, which may result in the faster resolution of inflammation and recovery.
      However, SMOFlipid emulsion use may be associated with coagulopathy after LT. Early studies
      have shown that the dietary intake of n-3 fatty acids, which is a component of fat, is
      associated with antithrombotic effects but increases the risk of bleeding. A detailed
      analysis is lacking, and these observations have yet to be proven; this concern persists.
      Hence, the investigators should pay attention to the bleeding tendency when using fish oil
      fat emulsion because it may aggravate the risk of bleeding. Therefore, the use of fish
      oil-containing fat emulsion and its related risks is a clinically important issue in early LT
      that should be investigated, because liver function is not restored immediately after
      transplantation, and there is a tendency of coagulopathy. Thus, classical haemostasis
      parameters such as activated partial thromboplastin time (aPTT) and platelet count are
      measured prior to surgery and before the start of TPN. However, many questions remain
      unanswered regarding nutritional assessment and support for these seriously ill,
      nutritionally, and metabolically complex patients. This study evaluated the effect of the
      SMOFlipid supplement in TPN in LT patients.
    

Intervention name(s): SMOFlipid
Intervention type(s): Dietary Supplement
Intervention MeSH terms: SMOFlipid
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        Adult patients who underwent LT at KCGMH between Jan 2012 and June 2015 were screened in
        this study. The medical records of patients were retrospectively reviewed to check if TPN
        was provided in the last 14 days in the peri-transplantation period. TPN and SMOFlipid
        support were indicated for patients who received NPO for more than 3 days, such as those
        with repeated laparotomy, staged biliary reconstruction, massive nasogastric (NG) drainage
        (>500 mL/day), ileus, diarrhoea, poor digestion (NG extraction >50 mL/time), and chylous
        ascites.
      
Keywords: Liver transplantation; SMOFlipid; fish oil