Amino acids are an essential part of parenteral nutrition. This study aimed to determine the serum profile of amino acids and their loss in urine in patients with long-term home parenteral nutrition (HPN) during 12 h of infusion in comparison with similar parameters in the remaining 12 h as well as in healthy participants. We enrolled forty-five patients with long-term HPN for 6–75 (median, 33) months. The indication for HPN was short bowel syndrome secondary to radical resection of the small intestine following complications of Crohn’s disease. HPN was administered via two-chamber all-in-one bags prepared in a hospital pharmacy overnight for 12 h each day. The average dose of amino acids, carbohydrates and fats administered was 1·5, 3·4 and 0·68 g/kg per d, respectively, at an infusion rate of 0·11, 0·28 and 0·06 g/kg per h, respectively. The levels of essential amino acids in the serum of the patients were not significantly different from those in healthy individuals; however, of the non-essential amino acids, cystine and glutamine levels were lower and glycine and ornithine levels were higher in the patients (P < 0·05). Excretion of amino acids in the urine during 12 h of infusion at an infusion rate of 0·11 g/kg per h was 301 mg, while it was 104 mg during the remaining 12 h (P < 0·0001). Our patients on long-term HPN had a normal serum profile of essential amino acids. The total urinary excretion of amino acids during 12 h of infusion accounted for only 0·34 % (0·23–0·46) of the administered dose.

The major complication of end jejunostomy is excessive fluid and electrolyte loss through the stoma, leading to hypovolaemia and dyselectrolytaemia within days and malnutrition within weeks. The aim was to compare the results of two nutritional approaches: unrestricted and restricted oral intake in patients with end jejunostomy commencing home parenteral nutrition (HPN) in terms of liver and renal biochemical markers and time to reconstructive bowel surgery with correlation to stoma output. Twenty patients with stabilised high output end-jejunostomy were divided into two groups. Group A consisted of ten patients with oral intake restricted to keep stomal output under 1000 ml. Group B consisted of ten patients with unrestricted oral intake. The following parameters were evaluated over 6 months: stomal output, self-estimation of general condition, body weight gain, plasma bilirubin and creatinine, number of hospitalisations prior to reconstructive surgery, the frequency of ostomy bag emptying, feelings of hunger and thirst in the daytime, and the time to reconstructive surgery. Stoma losses were compensated by parenteral supply. In group B, lower quality of life was observed, reflected by weakness, permanent feelings of hunger and thirst and the need for night-time emptying of the stoma bag. Patients in group B developed more complications and required more time to prepare for surgery. One death occurred in group B due to renal insufficiency followed by septic complications. Restricted oral intake seems to be more effective for prevention of HPN-related complications and shortening of time to surgery. Unrestricted oral intake appears to provoke uncontrolled losses of energy and protein, inhibiting weight gain.

Pharmacological, surgical and technological advances have resulted in children now surviving through adolescence into adulthood with conditions that were previously unseen by adult services. Arranging transition for young people on home parenteral nutrition (HPN) to the adult sector is one of greatest challenges for health services that care for young people. Transition is not only a key quality issue for health services, but is a multidimensional process covering psychosocial, educational and vocational aspects. Poorly-planned transition may result in difficulties when young people access adult specialist services. As a consequence, there may be increased risk of non-adherence or lack of follow-up, which carries dangers of morbidity and mortality as well as poor social and educational outcomes. Transition does not end at the exit from the paediatric clinic, but continues into the adult sector, which needs to provide developmentally-appropriate clinical care. Recent Department of Health initiatives are aimed at ensuring that young people do not miss out on healthcare during the transfer between paediatric and adult services. Transfer can be a major, often daunting, event for young people. Parents may also fear transfer and need to learn to ‘let go’ of some control, which may be particularly difficult with a young person on HPN.

Home parenteral nutrition is required by patients with intestinal disease such that they are unable to maintain nutritional status or fluid volume without this treatment. A Managed Clinical Network has been established in Scotland. The aims of this multi-professional group are to ensure equity of access and that patients are managed according to nationally-agreed evidence-based procedures and protocols. The Clinical Standards Board for Scotland has provided support in preparing a quality-assurance framework to which the network must adhere.

Parenteral nutrition is life saving in patients with intestinal failure but liver dysfunction is commonly encountered, especially in neonates. Although abnormal liver function tests associated with short-term parenteral nutrition are usually benign and transient, liver dysfunction in both children and adults receiving long-term parenteral nutrition can progress to end-stage liver disease and liver failure. The aetiology of parenteral nutrition-associated liver disease is complex and multifactorial, with a range of patient, disease and nutrition-related factors implicated. Sepsis is of particular importance, as is the lack of enteral nutrition and overfeeding with intravenous glucose and/or lipid. Deficiencies of a number of amino acids including choline and taurine have also been implicated. Management of hepatic dysfunction in parenteral nutrition should initially focus on preventing its occurrence. Sepsis should be managed appropriately, enteral nutrition should be encouraged and maximised where possible and parenteral overfeeding should be avoided. Provision of parenteral lipid should be optimised to prevent the adverse effects of both deficiency and excess, and cyclical rather than continuous parenteral feeding should be administered. There is some evidence of benefit in neonates from oral antibiotics to prevent intestinal bacterial overgrowth and from oral ursodeoxycholic acid, but less to support their use in adults. Similarly, data to support widespread use of parenteral choline or taurine supplementation are lacking at present. Ultimately, severe parenteral nutrition-associated liver disease may necessitate referral for small intestine and/or liver transplantation.

Data from the European Society for Parenteral and Enteral Nutrition Home Artificial Nutrition Survey suggest that the use of home parenteral nutrition (HPN) in patients with cancer as the primary diagnosis varies markedly between different countries in Europe, being highest in The Netherlands and low in the UK. This finding is difficult to explain on the basis of cancer incidence. The main indication for HPN remains malignant gastrointestinal tract obstruction, which occurs most frequently in gynaecological and colon cancers. The use of HPN should be planned in the light of the proposed cancer treatment and should be discussed beforehand with the patient. Before HPN is considered, a patient should typically require intravenous fluids to maintain hydration, be capable of self care, be able to control the treatment, have an expected survival of ≥3 months and have no other available route of feeding. The effect of HPN on quality of life remains controversial, but nutrition is only one of the factors that influence the quality of life in cancer patients. The differing rates of HPN in Europe are probably related to cultural attitudes to incurable cancer as much as to meeting the nutritional needs of the patient.

The paper discusses the case histories of three patients who have faced the emotional implications of being initiated onto long-term parenteral nutrition (PN). In each case the patient's personal and family history, relationship to their illness and the presence or relative absence of resentments and grievances have influenced their ability to tolerate the training and the transition to home PN (HPN). In addition, the emotional importance of food and feeding from a developmental and social perspective is explored, together with the numerous psychological and social ‘losses’ experienced by all patients on PN and the adaptations required within the family setting. The ‘meaning’ of PN to the individual and the need for both internal and external support are identified and, based on clinical experience, a number of features are described that may be indicative of the relative abilities of different patients to cope with HPN. Finally, the role of a dedicated Psychological Medicine Unit closely allied to a nutrition service is discussed.

The British Artificial Nutrition Survey 2001 recorded 507 home parenteral nutrition (HPN) patients (Crohn's disease 31.5%, vascular disease 19.7%, cancer 6.9%). Parenteral nutrition was administered via tunnelled central line (92%) and supplied by a commercial homecare company in 89% of cases. The majority of HPN patients live at home (95.5%) with an independent life (74%), normal activity (59.2%) and 92% survive 1 year. However, there is good evidence that the geographical distribution of HPN patients is uneven (prevalence no patients to thirty-six patients per million of the population) suggesting inequity of access. Patients are increasingly concerned about the distances travelled to main centres and variable standards of more local support. Funding issues continue to cause difficulties as commissioning of health care transfers from Health Authorities to Primary Care Trusts. The two nationally-funded intestinal failure units provide HPN services to 220 HPN patients. HPN-related readmissions have displaced those awaiting admission for intestinal failure treatment, for which the waiting list mortality in one unit has risen to 14%. The government has now recognised HPN as a specialised service distinct from intestinal failure and that existing medium-sized HPN units should be encouraged to take on HPN patients from intestinal failure units and smaller units. In Scotland a Managed Clinical HPN Network supported by the Scottish administration now cares for seventy-two patients under common protocols. The challenge for the future is how to provide high-quality care to all who need it in the rest of the UK.

Intravenous lipid emulsions (ILE) have demonstrated advantages including prevention of essential fatty acid (EFA) deficiency; however, too much EFA can down regulate fatty acid elongation leading to an imbalance of nutritional compounds in plasma and cell membranes. An olive oil-based ILE containing long-chain triacylglycerols (LCT) with a low content (20 %) of PUFA was administered for home parenteral nutrition (HPN) and compared with a conventional soyabean oil-based ILE (PUFA content, 60 %). Thirteen patients (26–92 years) with stable intestinal failure were randomised after a 1-month run-in period with a medium-chain triacylglycerols–LCT-based ILE, to receive 3 months of HPN with either olive oil- (n 6) or soyabean oil-based (n 7) ILE. The nutritional impact and safety of HPN, oral intakes and absorption rates, phospholipid fatty acids in plasma and lymphocyte cell membrane were assessed. The only clinical event reported was one case of pneumonia (soya group). In both groups, 20 : 3n-9:20:4n-6 ratios remained within normal ranges (0·03–0·07). There was a significant increase of γ-linolenic acid (γ-LA) in plasma and lymphocyte cell membrane (P=0·02) and of oleic acid in plasma (P<0·01) in the olive compared with the soya group. A significant correlation was found between γ-LA (day 90 – day 0) in plasma and PUFA parenteral intakes (P=0·02), but neither with fat intakes nor with fat absorption rates. In conclusion, plasma and lymphocyte EFA pattern remained in normal ranges without EFA deficiency with both lipid emulsions, despite a lower content of n-3 and n-6 series with the olive oil-based ILE.