Objectives: Malnutrition negatively affects the quality of life, survival, and clinical outcome of patients with cancer. Home artificial nutrition (HAN) is an appropriate nutritional therapy to prevent death from cachexia and to improve quality of life, and it can be integrated into a home palliative care program. The choice to start home enteral nutrition (HEN) or home parenteral nutrition (HPN) is based on patient-specific indications and contraindications. The aim of this observational study was to analyze the changes that occurred in the criteria for choosing the access route to artificial nutrition during 30 y of activity of a nutritional service team (NST) in a palliative home care setting, as well as to compare indications, clinical nutritional outcomes, and complications between HEN and HPN. Methods: The following parameters were analyzed and compared for HEN and HPN: tumor site and metastases; nutritional status (body mass index, weight loss in the past 6 mo); basal energy expenditure and oral food intake; Karnofsky performance status; access routes to HEN (feeding tubes) and HPN (central venous catheters); water and protein-calorie support; and survival and complications of HAN. Results: From 1990 to 2020, HAN was started in 1014 patients with cancer (592 men, 422 women; 65.6 +/- 12.7 y of age); HPN was started in 666 patients (66%); and HEN was started in 348 patients (34%). At the end of the study, 921 patients had died, 77 had suspended HAN for oral refeeding and 16 were in the progress of HAN. The oral caloric intake was <50% basal energy expenditure in all patients: 721 (71.1%) were unable to eat at all (HEN 270, HPN 451), whereas in 293 patients (28.9%), artificial nutrition was supplementary to oral intake. From 2010 to 2020, the number of central venous catheters for HPN, especially peripherally inserted central catheters, doubled compared with that in the previous 20 y, with a decrease of 71.6% in feeding tubes for HEN. At the beginning, patients on HEN and HPN had comparable nutrition and performance status, and there was no difference in nutritional outcome after 1 mo of HAN. In 215 patients who started supplemental parenteral nutrition to oral feeding, total protein-calorie intake allowed a significant increase in body mass index and Karnofsky performance status. The duration of HEN was longer than that of HPN but was similar to that of supplemental parenteral nutrition. Conclusions: Over 30 y of nutritional service team activity, the choice of central venous catheters as an access route to HAN increased progressively and significantly due to personalized patient decision-making choices. Nutritional efficacy was comparable between HEN and HPN. In patients who maintained food oral intake, supplemental par enteral nutrition improved weight, performance status, and survival better than other types of HAN. (c) 2021 Elsevier Inc. All rights reserved.

BACKGROUND AND AIMS:The prevalence of malnutrition is over 70% in advanced cancer patients and impacts negatively on survival and quality of life. Artificial nutrition can be integrated into a home palliative care program. This observational study aims to describe the criteria for identifying the cancer patients that could benefit from home artificial nutrition (HAN) and to evaluate its impact on survival and performance status.METHODS:The selection criteria for patient's eligibility to HAN were: Karnofsky Performance Status (KPS) ≥40, life expectancy ≥6 weeks, inadequate caloric intake ± malnutrition, suitable psycho-physical conditions and informed consent. The access route for nutritional therapy (home parenteral nutrition, HPN; home enteral nutrition, HEN) was chosen according to the ESPEN Guidelines. The parameters considered were: primary site of the tumor; oral food intake; nutritional status; stage of cachexia; fluid, energy and protein supplied by HAN; survival.RESULTS:From 1990 to 2019, 43,474 cancer patients were assisted at home in Bologna (Italy). HAN started in 969 patients (2.2% of total patients, 571 men and 398 women, mean age 65.7 ± 12.7 years): HPN in 629 patients (64.9%), with gastrointestinal obstruction as the main indication; HEN in 340 patients (35.1%), with dysphagia as the main indication. Considering the 890 deceased patients, the mean survival after the start of HAN was 18.3 weeks and 649 patients (72.9%) survived more than 6 weeks. The mean survival was higher in HEN (22.1 weeks) compared to HPN patients (16.1 weeks) (p < .001). After one month, KPS was unchanged in 649 (67.0%), increased in 232 (23.9%) and decreased in 88 patients (9.1%). The mean KPS increased in patients starting HAN in pre-cachexia and cachexia (p < .001). Cachexia and refractory cachexia at the entry were associated with a reduced survival [odds ratio: 1.5 and 2.3 respectively, p < .001 for both condition] respect to pre-cachexia.CONCLUSIONS:The selection criteria allow the identification of the patient who can take advantage of HAN. HAN can be effective in avoiding death from malnutrition in 73% of patients, and in maintaining or improving the KPS at one month in 90% of cases. The benefits provided by HAN on survival and performance status depend on the cachexia degree at the entry.

Background & aims: Intestinal failure associated liver disease (IFALD) has been defined using numerous criteria; however the clinical relevance of these criteria has never been compared. We therefore aimed to evaluate the prevalence, incidence, evolution of IFALD diagnosed by different criteria and to assess any clinical features that may be associated with its occurrence. Methods: A cross sectional (CS) and retrospective study were carried out on adults on home parenteral nutrition (HPN) for chronic intestinal failure (CIF) managed at a single center. Inclusion criteria at CS: age >= 18 years, benign disease. Collected data included: patient demographics, CIF and HPN characteristics, episodes of central venous catheter related bloodstream infection (CRBSI). IFALD was diagnosed by 9 criteria based on liver function tests and liver ultrasound (US) imaging. IFALD diagnoses were categorized as steatosis (2 criteria), cholestasis (3 criteria) or fibrosis (2 criteria) and unclassified (2 criteria). Prevalence was assessed at CS and at starting HPN (baseline, BS). Evolution was assessed as change of IFALD between BS and CS. Incidence was calculated as patients who developed IFALD from BS to CS. Results: A total of 113 patients were included. At CS, IFALD prevalence range in each diagnostic categories was: cholestasis 5-15%; steatosis 17-43%; fibrosis 10-20%; unclassified 7-38%. A 28.5% of patients did not have IFALD according to any criteria. Two cholestasis criteria and one fibrosis criterion were significantly (P < 0.05) associated with a short bowel syndrome as the pathophysiological mechanism of CIF, HPN requirement and the number of CRBSI episodes. At BS, IFALD prevalence range was: cholestasis 13-40%; steatosis 27-90%; fibrosis 2-5%; unclassified 8-75%. The incidence range of IFALD was: cholestasis 0-7%; steatosis 0-39%; fibrosis 7-18%; unclassified 4-9%. IFALD steatosis diagnosed by US was the most frequent diagnosis at both CS prevalence and incidence assessments. Notably, IFALD criteria normalized in various percentages (2-70%), depending on the diagnostic categories, between BS and CS. Conclusions: This is the first study to systematically demonstrate that the frequency of IFALD varies greatly depending on diagnostic criteria used, confirming the need for a consensus definition to be used between different national and international IF units. IFALD can be present at HPN initiation but may resolve thereafter; further work is required to evaluate the factors associated with improvement. (C) 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

OBJECTIVE:The aim of this study was to evaluate kidney function outcome in adults on home parenteral nutrition (HPN) for chronic intestinal failure using the newly recommended equations for estimated glomerular filtration rate (eGFR) assessment in clinical practice. METHODS:This was an observational study with 72 patients. Clinical and biochemical parameters were collected at initiation of HPN (retrospective baseline [BL]), at inclusion in the study (cross-sectional [CS]), and at the end of a 30-mo prospective follow-up (Fup). The eGFR (mL/min/1.73 m2 body surface) was calculated by the Chronic Kidney Disease Epidemiology Collaboration creatinine and categorized as normal, mildly decreased (MDKF), and chronic kidney disease (CKD) when ≥90, 60 to 89, and <60, respectively. RESULTS:An eGFR<90 was observed in 41.7% of patients at BL, 53.4% at CS, and 56.6% at Fup. A CKD was present in all of the patients at BL, 20.1% at CS, and 35.9% at Fup. The probability of maintaining an eGFR ≥60 was 98%, 82%, and 79% at 1, 5, and 10 y after BL, respectively (Kaplan-Meier analysis). The probability was lower in patients with MDKF at BL (P = 0.039). The development of a CKD was significantly associated with aging and urologic diseases and numerically associated with the episodes of venous-catheter sepsis, short bowel syndrome, and a low volume of HPN. CONCLUSIONS:In patients on HPN for chronic intestinal failure, decreased kidney function is a frequent finding, even at HPN commencement, demanding accurate monitoring during the treatment. Prevention of CKD primarily relies on the maintenance of fluid balance and the prevention of catheter-sepsis and urologic diseases.

Background & aim: Home parenteral nutrition (HPN) is the primary treatment for chronic intestinal failure (IF). Intestinal transplantation (ITx) is indicated when there is an increased risk of death due to HPN complications or to the underlying disease. Age, pathophysiologic conditions and underlying disease are known predictors of HPN dependency and overall survival. Although the cause of death on HPN is mostly related to underlying disease in these patients, the relationship between mortality and duration of HPN use remains unclear. The purpose of the present study is to describe factors associated with survival and HPN dependency as well as causes of death in adult patients requiring HPN for chronic intestinal failure during the first 5 years of treatment with HPN. Methods: A multicenter international (European and USA) questionnaire-based retrospective follow-up of a cohort of 472 IF patients who started HPN was conducted between June and December 2000. Study endpoint was either end of 5-year follow-up, weaned-off HPN, ITx, or death on HPN. Data were analyzed for HPN dependence and overall survival using Kaplan-Meier models and log rank tests. Results: The overall survival probability was 88%, 74% and 64% at 1, 3 and 5 years respectively. Survival was inversely related to age (p < .001) and higher in patients with Crohn's disease or chronic idiopathic pseudo-obstruction. A total of 169 (36.5%) patients were weaned-off HPN mainly (80%) within the first year and most frequently in patients with fistulae. Five of the 14 patients who underwent ITx died. By the end of the study, 104 (23%) of patients died on HPN; 65% of deaths occurred within the first 2.5 years of HPN. Conclusions: Younger ages at HPN initiation and underlying pathologies are significantly predictive of survival on HPN. Risk of death is greatest during the first 2 years of HPN. (C) 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Background & aims: The aim of the study was to evaluate the applicability of the ESPEN 16-category clinical classification of chronic intestinal failure, based on patients' intravenous supplementation (IVS) requirements for energy and fluids, and to evaluate factors associated with those requirements. Methods: ESPEN members were invited to participate through ESPEN Council representatives. Participating centers enrolled adult patients requiring home parenteral nutrition for chronic intestinal failure on March 1st 2015. The following patient data were recorded though a structured database: sex, age, body weight and height, intestinal failure mechanism, underlying disease, IVS volume and energy need. Results: Sixty-five centers from 22 countries enrolled 2919 patients with benign disease. One half of the patients were distributed in 3 categories of the ESPEN clinical classification. 9% of patients required only fluid and electrolyte supplementation. IVS requirement varied considerably according to the pathophysiological mechanism of intestinal failure. Notably, IVS volume requirement represented loss of intestinal function better than IVS energy requirement. A simplified 8 category classification of chronic intestinal failure was devised, based on two types of IVS (either fluid and electrolyte alone or parenteral nutrition admixture containing energy) and four categories of volume. Conclusions: Patients' IVS requirements varied widely, supporting the need for a tool to homogenize patient categorization. This study has devised a novel, simplified eight category IVS classification for chronic intestinal failure that will prove useful in both the clinical and research setting when applied together with the underlying pathophysiological mechanism of the patient's intestinal failure. (C) 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Introduction: The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for CIF in adults suggest that patients on home parenteral nutrition (HPN) with CVC-VT occluding ≥ 2 central veins be listed for a life-saving ITx on a case-by-case basis [1]. An individual CIF center retrospective survey was carried out to investigate the survival rate on HPN (SR) and the causes of death, in adult patients with CIF due to benign disease who developed a CVC-VT. Methods: The prospectively collected data of all the CIF patients treated with HPN between 1986 and 2015 were retrospectively reviewed on April 30th 2015. Patient, CIF and HPN characteristics as well as the episodes of CVC-VT (in internal jugular, subclavian, femoral and superior vena cava veins) were recorded. Exclusion criteria: age < 18 years and presence of cancer at time of study. Statistic: Kaplan–Meier method and non parametric tests. Results: A cohort of 271 patients was analyzed for a total 1429 CVC-years. Fifty-two patients had 83 episodes of CVC-VT (incidence: 0.058 per CVC-year). In the total cohort, the SR was 98%, 88%, 71% and 58% at 1, 5, 10 and 20 years, respectively; the SR was negatively associated with the decade of age at starting HPN (<18, 18–50, >50 year; p=0.001). In the 244 patients who started HPN at age ≥18 years, the SR did not differ between the 45 who had (VT) and the 198 who didn’t have (no-VT) a CVC-VT (p=0.982). The VT group had a longer duration of HPN and a greater number of inserted CVC and of episodes of CVC-related infections (all p<0.001). The HPN-related causes of death were 32% and 38% of total deaths in the VT and the no-VT groups, respectively (p=0.635). Two deaths were due to CVC-VT (5.7% of death in the adult patient groups). In the VT, the SR after the first episode of CVC-VT did not differ on the basis of the number of occluded veins (≤2, n.28; >2, n.17; P=0.277). Conclusion: In adult patients on HPN for CIF due to benign disease, the development of a CVC-VT is not associated with either an increased risk of death or an increased risk of HPN-related death. These results confirm the ESPEN guidelines for CIF in adults: patients with multiple CVC-VT should be listed for a life-saving ITx only on a case-by-case basis. References: 1. Pironi L. et al. Clin Nutr. 2016; 35: 247–207

AIM:To investigate the fatty acid-based functional lipidomics of patients on long-term home parenteral nutrition receiving different intravenous lipid emulsions.METHODS:A cross-sectional comparative study was carried out on 3 groups of adults on home parenteral nutrition (HPN), receiving an HPN admixture containing an olive-soybean oil-based intravenous lipid emulsion (IVLE) (OO-IVLE; n = 15), a soybean- medium-chain triacylglycerol-olive-fish oil-based IVLE (SMOF-IVLE; n = 8) or HPN without IVLE (No-IVLE; n = 8) and 42 healthy controls (HCs). The inclusion criteria were: duration of HPN ≥ 3 mo, current HPN admixtures ≥ 2 mo and HPN infusions ≥ 2/wk. Blood samples were drawn 4-6 h after the discontinuation of the overnight HPN infusion. The functional lipidomics panel included: the red blood cell (RBC) fatty acid (FA) profile, molecular biomarkers [membrane fluidity: saturated/monounsaturated FA ratio = saturated fatty acid (SFA)/monounsaturated fatty acid (MUFA) index; inflammatory risk: n-6/n-3 polyunsaturated fatty acid (PUFA) ratio = n-6/n-3 index; cardiovascular risk: sum of n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) = n-3 index; free radical stress: sum of FA trans isomers = %trans index] and FA pathway enzyme activity estimate (delta-9-desaturase = D9D; delta-6-desaturase = D6D; delta-5-desaturase = D5D; elongase = ELO). Statistics were carried out using nonparametric tests. The amount of each FA was calculated as a percentage of the total FA content (relative%).RESULTS:In the OO-IVLE group, the percentage of oleic acid in the RBCs was positively correlated with the weekly load of OO-IVLE (r = 0.540, P = 0.043). In the SMOF-IVLE cohort, the RBC membrane EPA and DHA were positively correlated with the daily amount of SMOF-IVLE (r = 0.751, P = 0.044) and the number of HPN infusions per week (r = 0.753; P = 0.046), respectively. The SMOF-IVLE group showed the highest EPA and DHA and the lowest arachidonic acid percentages (P < 0.001). The RBC membrane linoleic acid content was lower, and oleic and vaccenic acids were higher in all the HPN groups in comparison to the HCs. Vaccenic acid was positively correlated with the weekly HPN load of glucose in both the OO-IVLE (r = 0.716; P = 0.007) and the SMOF-IVLE (r = 0.732; P = 0.053) groups. The estimated activity of D9D was higher in all the HPN groups than in the HCs (P < 0.001). The estimated activity of D5D was lower in the SMOF-IVLE group than in the HCs (P = 0.013). The SFA/MUFA ratio was lower in all the HPN groups than in the HCs (P < 0.001). The n-6/n-3 index was lower and the n-3 index was higher in the SMOF-IVLE group in comparison to the HCs and to the other HPN groups (P < 0.001). The %trans index did not differ among the four groups.CONCLUSION:The FA profile of IVLEs significantly influenced the cell membrane functional lipidomics. The amount of glucose in the HPN may play a relevant role, mediated by the insulin regulation of the FA pathway enzyme activities.

16 Institute for Biomedicine of Aging, Friedrich-Alexander-Universit€ at Erlangen-N€ urnberg, N€ urnberg, Germany 17 The Gilad Geriatric Center, Ramat-Gan, Israel Nutrition and Dietetics, Flinders University, Adelaide, Australia Rehabilitation Studies Unit, University of Sydney, Australia Unit of Primary Health Care, Helsinki University Central Hospital, Department of General Practice, Helsinki, Finland 21 The S. H. Ho Center for Gerontology and Geriatrics, The Chinese University of Hong Kong, Hong Kong SAR, China; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Department of Public Health, Experimental and Forensic Medicine, Section of Human Nutrition, Endocrinology and Nutrition Unit, University of Pavia, Pavia, Italy 25 Faculty of Health Sciences, University of Link€ oping, Link€ oping, Sweden 26 Section of Dietetics, Department of Agriculture and Food Sciences, University of Applied Sciences, Neubrandenburg, Germany Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala Science Park, Uppsala, Sweden Department of Medical Sciences, University of Ferrara, Ferrara, Italy Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong

BACKGROUND: The aim of the paper was to analyze the first results of a medical and nursing team dedicated to the treatment of pressure ulcers (Pu) in advanced cancer patients, assisted at home by the ANT Foundation (Bologna, Italy). METHODS: Patients' clinical and nutritional characteristics were evaluated at their admission to the study (T-0). Nursing parameters were weekly measured at time T-0-T-7-T-14-T-n, including description of the number, site, stage and typology of the PU, photo of the lesion, type and frequency of medication according to the specific ANT protocol. RESULTS: From April 2013 to March 2014 twenty patients were evaluable (7 M, 13 F, mean age 80 +/- 9 years), for a total of 26 Pus. the stage of the lesion was: II in 17 Pus, III in 6 and IV in 3. At the end of the survey, 11 Pus were completely healed, 12 had improved with significant reduction of stage and dimensions, 2 were stable and 1 had worsened. The median survival is significantly longer in patients with healed PUs than in those with improved, stable or worsened PUs. CONCLUSIONS: The significant improvement, including complete healing, in 23/26 patients after just 6 weeks of treatment with medications justifies the creation of a team dedicated to prevention and treatment at home of the PUs in advanced cancer patients. the end of life and the state of malnutrition are negative prognostic factors to have tissue repair.

Intravenous lipid emulsions (IVLEs) are an important component of the nutritional admixtures for patients on long-term home parenteral nutrition (HPN) for chronic intestinal failure (CIF). IVLEs are primarily used as a source of energy and essential fatty acids, and the content of polyunsaturated fatty acids (PUFAs) is the most important characteristic of IVLEs. IVLEs rich in n-6 PUFAs may have a pro-inflammatory effect, whereas those rich in n-3 PUFAs may exert an anti-inflammatory effect. Other components to be considered are the risk of lipid peroxidation and the contents of α-tocopherol and phytosterols. Published studies were reviewed to determine the effects of the commercially available IVLEs on essential fatty acid status, liver function tests, lipid peroxidation and inflammatory indices, and α-tocopherol status, as well as their clinical safety and efficacy in patients on HPN. Investigations on the efficacy of fish oil-based IVLEs, which are rich in n-3 PUFAs, in the treatment of parenteral nutrition-associated liver disease (PNALD) in adult patients on HPN for CIF were also analyzed. The current commercial IVLE formulations have similar clinical safety profiles and efficacies and can prevent the development of essential fatty acid deficiency in adults on HPN for CIF. IVLE with a low content of n-6 PUFAs and with or without increased n-3 PUFA content may reduce the risk of PNALD. Fish oil-based IVLE, which is rich in n-3 PUFAs, may be effective in reversing hepatic cholestasis due to PNALD.