Parenteral nutrition (PN) is generally given to provide adequate amounts of macronutrients and micronutrients to allow recovery after injury and illness. Maintenance of the skeleton is often neglected when one prepares a PN prescription. Although this may not be critical for the brief length of time that most patients receive PN, it becomes an important consideration in patients who need long-term PN, during which time metabolic bone disease (MBD) can develop. It is therefore important to have an understanding of the factors involved in normal bone metabolism and the impact that PN has on this process. This review describes some of the important factors that may play a role in the development of parenteral nutrition-associated metabolic bone disease (PN-MBD) and discusses a strategy for the diagnosis and treatment of this problem.
Get full access to this article
View all access options for this article.
References
1.
1. Marx SJ: Mineral and bone homeostasis. IN Cecil Textbook of Medicine, (20th ed.), Bennett JC, Plum F (Eds). W.B. Saunders, Philadelphia, 1996, pp 1351–1357
2.
2. Manolagas SC, Jilka RL: Bone marrow, cytokines, and bone remodeling. N Engl J Med332:305–311, 1995
3.
3. Ravn P, Hetland ML, Overgaard K, et al: Premenopausal and postmenopausal changes in bone mineral density of the proximal femur measured by dual-energy x-ray absorptiometry. J Bone Miner Res9:1975–1980, 1994
4.
4. Shike M, Harrison JE, Sturtridge WC, et al: Metabolic bone disease in patients receiving long-term TPN. Ann Intern Med92:343–350, 1980
5.
5. Klein GL, Ament ME, Bluestone R, et al: Bone disease associated with TPN. Lancet2:1041–1044, 1980
6.
6. Shike M, Shils ME, Heller A, et al: Bone disease in prolonged parenteral nutrition; Osteopenia without mineralization defect. Am J Clin Nutr44:89–98, 1986
7.
7. Howard L, Heaphey L, Fleming CR, et al: Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. JPEN15:384–393, 1991
8.
8. Abitbol V, Roux C, Chaussade S, et al: Metabolic bone assessment in patients with inflammatory bowel disease. Gastroenterology108:417–422, 1995
9.
9. Harvey HA: The management of hypercalcemia of malignancy. Supportive Care in Cancer3:123–129, 1995
10.
10. Chu RC, Barkowski SM, Buhac J: Small bowel resection associated urinary calcium loss in rats on long-term TPN. JPEN14:64–67, 1990
11.
11. Silvennoincn JA, Karttunen TJ, Niemela SE, et al: A controlled study of bone mineral density in patients with inflammatory bowel disease. Gut37:71–76, 1995
13. DeVernejoul MC, Messing B, Modrowski D, et al: Multifactorial low remodeling bone disease during cyclic TPN. J Clin Endocrinol Metab60:109–113, 1985
14.
14. Zemel MB, Schuette SA, Hegsted M, et al: Role of sulfur-containing amino acids in protein-induced hypcrcalciuria in men. J Nutr11:545–552, 1981
15.
15. DeFronzo RA, Cooke CR, Andes R, et al: The effect of insulin on renal handling of sodium, potassium, calcium and phosphorous in man. J Clin Invest55:845–855, 1975
16.
16. Bengoa JM, Sitrin MD, Wood RJ, et al: Amino acid induced hypcrcalciuria in patients on TPN. Am J Clin Nutr83:264–269, 1983
17.
17. Sloan GM, White DE, Brennan MF: Calcium and phosphorous metabolism during TPN. Ann Surg197:1–6, 1983
18.
18. Wood RJ, Sitrin MD, Cusson GJ, et al: Reduction of TPN induced urinary calcium loss by increasing the phosphorous in the TPN prescription. JPEN10:188–190, 1986
19.
19. Lau K, Goldfarb S, Goldberg M, et al: Effects of phosphate administration on tubular calcium transport. J Lab Clin Med99:317–324, 1982
20.
20. Cunningham J, Fraher LJ, Clemens TL, et al: Chronic acidosis in metabolic bone disease: Effective alkali on bone density and vitamin D metabolism. Am J Med73:199–204, 1982
21.
21. Karton MA, Rettmer R, Lipkin EW, et al: D-lactate and metabolic bone disease in patients receiving long-term parenteral nutrition. JPEN13:132–135,1989
22.
22. Wood RJ, Bengoa JM, Sitrin MD, et al: Calciuretic effect of cyclic versus continuous TPN. Am J Clin Nutr41:614–619, 1985
23.
23. Lipkin EW, Ott SM, Chestnut CH, et al: Mineral loss in parenteral nutrition patients. Am J Clin Nutr47:515–523, 1988
24.
24. Lipkin EW: A longitudinal study of calcium regulation in a nonhuman primate model of parenteral nutrition. Am J Clin Nutr67:246–254, 1988
25.
25. Ott SM, Maloney NA, Klein GL, et al: Aluminum is associated with low bone formation in patients receiving chronic parenteral nutrition. Ann Intern Med99:910–914, 1983
26.
26. Goodman WG, Henry DA, Horst R, et al: Parenteral aluminum administration in the dog: II. Induction of osteomalacia and effect on vitamin D metabolism. Kidney Int25:270–275, 1984
27.
27. Klein GL: Aluminum in parenteral products: Medical perspective on large and small volume parenterals. J Parenter Sci Technol43:120. 1989
28.
28. Koo WWK, Kaplan LA, Horn J, et al: Aluminum in parenteral nutrition solutions: Sources and possible alternatives. JPEN10:591–595, 1986
29.
29. Multivitamin preparations for parenteral use. A statement by the Nutrition Advisory Group. American Medical Association-Department of Foods and Nutrition, 1975. JPEN3:258–262, 1979
30.
30. Shike M, Sturtridge WC, Tarn CS, et al: A possible role of vitamin D in the genesis of parenteral nutrition induced metabolic bone disease. Ann Intern Med95:560–568, 1981
31.
31. Seligman JV, Basi SS, Deitcl M, et al: Metabolic bone disease in a patient on long-term TPN: A case report with review of literature. JPEN8:722–727, 1984
32.
32. Vieth R: The mechanisms of vitamin D toxicity. Bone Miner11:267–272, 1990
33.
33. Verhage, AH, Cheong WK, Allard JP, et al: Increase in lumbar spine bone mineral content in patients on long-term parenteral nutrition without Vitamin D supplementation. JPEN19:431, 1995
34.
34. Hurley DL, Khosla S: Update on primary osteoporosis. Mayo Clin Proc72:943–949, 1997
35.
35. Steiger ES, Seidner DL, McAdams MP, et al: Parenteral nutrition. IN The Cleveland Clinic Foundation: Nutrition Support Handbook, Matarese LM (Ed). The Cleveland Clinic Foundation, Cleveland, OH, 1997, pp 45–62
36.
36. Fleming CR, Georg L, Stoner GL, et al: The importance of urinary magnesium values in patients with gut failure. Mayo Clin Proc71:21–24, 1996
37.
37. Administration of parenteral nutrition solutions. IN Handbook of TPN (2nd ed, Grant JP, Ed). W.B. Saunders, Philadelphia, 1992, pp 171–202
38.
38. Eastell R: Drug therapy: Treatment of postmenopausal osteoporosis. N Engl J Med338:736–746, 1998
