612

LETTERS Sean

TO

K C’herot

Liliana Clement Keith P West, Jr The

Mason

The

Johns

F Lord

Chronic

Hopkins

Baltimore,

MD

and

Nursing

Home

Institutions

1 16-20.

Group on Standards Solutions Report

for Aluminum or bone

efforts

ofthe

ofaluminum tions

ASCN/ASPEN

contamination renal

fluids

and

failure

from

members

although

not

antacids

ofthis

all

working

investigators

nutrient

renal

function.

support

regarding

contamination This

and the

the

bone

(PN)

additional calcium supplement with aluminum (8). A preliminary

soluwith

mulation

investigators, role

of alu-

apparently

normal

any

relationship

depressed potent

misinformation

between

aluminum

contamination of parenteral nutrients and the serious complications of long-term PN therapy such as bone and liver disease. The role of aluminum in causing tissue toxicity from PN in patients

with

normal

renal

receiving

PN

estimated

to be ‘-60

lysate

casein

is no longer

minum acid 1-2

with

function hydrolysate.

g

kg

I

in use

for

PN,

PN

solutions

in current

remains

.

d

ill defined.

the (4).

‘

and

aluminum

However, the

crystalline

area, an occurred

no significant between

patients had

patients

and serial

showed

opsy

despite

tient;

the third

biopsy.

continuing patient

report,

improved

biopsies

aluminum

of the

of these the

taming

a low

sequent

reports

contributed

gitudinal

data

in patients

aluminum A

changes

that issue

the toxic

use

in one 5 y after

low BFR

Group effect

PN

an

acid

formulation

sub-

information both

the

of

is that

the toxic effects However, more mation persisted contamination

of

early

reports

inconsistent

on

diagnostic

bone criteria

high-

and

low-

histomorphometric were

of aluminum and other causative recent data indicated that decreased despite PN solutions with minimal and

minimal

or no elevation

for-

over

a

histomorphometric PN solution,

the D, a

to increase

after

low-

to the

receiving aluminum ig - kg

studies,

d’.

The

term

infants

(bone)

study

to

However,

improved

with

elevated

to eliminate

nutrients,

obtain scientifically will limit aluminum

but

urine,

accumulation

determine bone

additional

aluminum, rather

its

of aluclinical

accumulation

and

of toxins

known and does not always the osteopenia in small preintake

taminated with aluminum (1 1). The role related liver disease remains speculative. This letter serves not to contradict the group

bone

serum,

are documented from an aluminum depending on the amount of mmtissue

further

to implicate

of PN-related

PN solutions, -

significance.

it is difficult

development

of minerals

con-

ofaluminum laudable

effort

a potential

as a plea

valid recommendations content in PN solutions.

for

in PN-

more

of the

toxin,

for legislation Winston Russell

from

studies

WK

to that Koo

i’V Chesnet’

College of Medicine Department of Pediatrics 853 Jefferson Avenue, Memphis, TN 38163

2nd

floor

References

on lon-

PN solutions.

criticism

acid

con-

Unfortunately,

additional received

absence

bone

are reported

such as lead and strontium is well result in tissue toxicity. In addition,

parenteral

not

an amino

of 1 ,25-dihydroxyvitamin

welldid

with

of aluminum

the high-aluminum

In the

solution

with

continued

of the above

solution.

pathological

pacon-

requires

showed

ofaluminum. who

aluminum

PN

concentration

hormone,

warrants

working

on subsequent

that

in PN

bi-

measurements in patients a 6-54-mo interval. Further,

patients

little

in one

ofaluminum.

same

use of an amino

concentration

Two

on subsequent infusion

to have

minum

patients

disease

that was heavily contaminated report on longitudinal follow-

long-term

received

In infants

erals

(BFR).

treated

as critical

amino

surfaces

three

rate

BFR

is an important

continued

were

hydrolysate

the Working

to clarify

resorbing

formation

significantly alter histomorphometric who had serial bone biopsies over bone

and There

bone

continued

with

studies

osteoid

subjects.

on casein

of nutrients

performed same

control data

significantly

We agree

tamination

in the

On the basis aluminum

of alu-

with aluminum and there was

successfully

concentrations

calciotropic

and tissue (bone) intake of2O-40

as in

were

ering of aluminum intake. However, these patients also simultaneously had a 60% decrease in phosphorus intake (10), an important regulator of serum 1,25-(OH)2D concentrations.

hydro-

intake as low of an increase

feature associated six of the 16 patients,

difference

(6)

who

abnormal in only

is

bone

aluminum

a low

(9). who serum

disease.

intake casein

concentration

containing

is as low as 16 zg/L, with daily aluminum tg- kg -d (5). The initial report (6)

osteoid toxicity.

In adults

PN-related

of 2 y showed

deterioration In patients

or by quantitative

report,

receiving

interval

staining

In another

containing

mean

intake

with

increased

up in patients

reported

of aluminum

to minimize

a cause-and-effect

and

of dialysate

central

issue

in patients

is essential

on the role

in patients

other

(by histochemical (5).

is eloquently

group

minum in tissue pathology (3). It is also important to discuss from

toxicity contamination

aluminum

measurement) nutrition

potential

aluminum

aluminum-containing

by certain

Group

ofparenteral

( 1 , 2). The

are laudable

chronic

Working

Content

used

to define

factors (7). bone foraluminum

in plasma,

urine,

1 . ASCN/ASPEN Working Group on Standards for Aluminum Content of Parenteral Nutrition Solutions. Parenteral drug products containing aluminum as an ingredient or a contaminant: response to FDA notice of intent. Am J Clin Nutr 1991:53:399-402. 2. ASCN/ASPEN Working Group on Standards for Aluminum Content of Parenteral Nutrition Solutions. Parenteral drug products containing aluminum as an ingredient or a contaminant: response to Food and Drug Administration notice of intent and request for information. JPEN 199 1:15:194-8.

Downloaded from https://academic.oup.com/ajcn/article-abstract/54/3/612/4694401 by University of Glasgow user on 11 February 2019

Working Nutrition

Sir:

The

I . Cockram DB. Baumgartner RN. Evaluation of accuracy and reliability of calipers for measuring knee height in elderly people. Am J Clin Nutr 1990:52:397-400. 2. Chumlea WC, Roche AF, Steinbaugh ML. Estimating stature from knee height for persons 60-90 years ofage. J Am Geriatr Soc 1985:33:

21224

ASCN/ASPEN of Parenteral Dear

Hospital

Medical

EDITOR

References

Murphy

Elizabeth

THE

LETTERS 3. Quarles disease:

LD, Gitelman HJ, Drezner what’s in a name. J Bone

TO

MK. Aluminum-associated Miner Res 1986:2:389-90.

THE

in total

bone

7. Frame B, Marel G. Reflections on bone disease in total parenteral nutrition. In: Coburn JW, Klein GL, eds. Metabolic bone disease

equations

Benedict metabolic

rate

takes.

In our

rehabilitation

(RMR)

measurements

in determining requirements

in normal

clinical

setting,

a significant

part

therapy

is based

on measuring

RMR

calorimetry (ventilated hood) and multiplying activity factor to determine the energy needs Other and

centers must

tions used,

do not have

rely

routine

on published

in-

access

equations

for

exist in the literature (1-3). The when height and weight are the

indirect

Several

correct or best only measures

equa-

riety the

of techniques techniques

TABLE I Comparison

and used

several

were

ofmeasured

10-17

y, M

10-17 y. 18-29 y, 18-29 y, 30-59 y, 30-59y.F(n=

with

a

Total S

j

(n

=

and

Benedict,

individuals.

to that

me tabolic

used

by

rate (RMR)

Most

7)

=

5)

(n

= = = = =

4)

18) 14) 6) 7) 1)

62)

by indirect

of

(aged

from

the FA 0/WHO/UNU

RMR

7-33

y) using

two

RMR

108.5 ±

-

103.6

23.4 21.5 22.5

± 2.1

12.3

men (n

by

those

hood.

predicted

concluded

RMR

29) and

a ventilated

than

=

Hams

that

by

the

10% in

22.7

indirect

calorimeters.

± ±

3.0 1.7

±

±

RMR

portable

(W)*

±

1 1.7 5.8

5.4

108.8 ±

5.4

7.4

103.6

7.5

101.1 94.6

±

±

103.2 ± 10.3

103.3 101.3

102.8 103.1

± ±

4.6 8.1

103.7

2.3

one

103.3 ± 10.4

21.9

-

±

They

NAIl NA

-

95.2

using

(W. H)t

5.2

13.6

-

report

equations5

-

-

and,

men.

jects

BMIt

-

l980s

are overestimated.

used

for RMR

overestimate

by

the FAO/

an earlier

in young

that

equations.

equations

-

±

to

prewith

FAO/WHO/UNU

men

calorimetry

8.2

88.5 ±

(4) and

young

the

determined when

in the early

current

the RMR

gave lower values

87.2 97.2

the

similar

98.2 ± 13.4 ±

of RMR

met

ofnormal

FAO/WHO/UNU young

that

(2) agree

Our past experience using the ventilated-hood technique (5) does not corroborate Clark and Hoffers’ lower RMR estimate. In addition to that work, we measured RMR of62 normal sub-

and

and pr edicted

the

that

(4) measured

FAO/WHO/UNU

puba va-

Hams

and

Both techniques

RMR

were from

originally

respirometer

surprising

not prevalent

of the database. by Clark and Hoffer

(2) for RMR

and Hoffer

one to be available,

WFHt

=

F(n M (n F(n M (n

available,

thousand

similar

resting

Age, sex 3-9 y, M (n 3-9 y, F (n

literature

height, and/or weight are derived from data

committee

Clark

normal

energy

Estimates were

estimates

extensively

the

Benedict. technique

et al (3) suggest

from

reviewed

& Schwarzenberg,

by FAO/WHO/UNU

by Owen

has been a subject of intense debate. In 1985 the expert FAO/ WHO/UNU committee on protein and energy requirements (2) equations based on sex, age, lished. These RMR equations

and

thus, were not part The recent report

calorimetry

RMR.

of Harris

WHO/UNU

the result by an of an individual.

to indirect

derived

the ventilated-hood

of nutritional with

equations

those

the equations to be used and, thus, for energy in-

( 1), so it is not

(respirometer)

dictive Resting

Urban

for

Sir:

dividuals are important as guidelines for energy

Baltimore:

103.6

±

± ±

13.2 8.3

103.2

8.7

102.7

±

9.2

SD.

t Percent

weight

for height

t Body mass index (kg/m2) § RMR values are expressed and height

used for ages 3- 17 y.

used for ages 18-59 as measured RMR (W, H) and for weight (W) alone.

II Not applicable.

y. (ventilated

hood)

as a percent

ofthe

values

predicted

by FAO/WHO/UNU

equations

for weight

Downloaded from https://academic.oup.com/ajcn/article-abstract/54/3/612/4694401 by University of Glasgow user on 11 February 2019

6. Ott SM, Maloney NA, Klein GL, et al. Aluminum is associated with low bone formation in patients receiving chronic parenteral nutrition. Ann Intern Med 1983:98:910-4.

Dear

nutrition.

8. LidorC, Schwartz I, Freund U. Gazit D. Successful high-dose calcium treatment of aluminum-induced metabolic bone disease in longterm home parenteral nutrition. JPEN 199 1:15:202-6. 9. Saitta JC, Lipkin EW, Ott SM, et al. Longitudinal measurements of bone histomorphology and bone density in parenteral nutrition with solutions low in aluminum and vitamin D2. JPEN 199 1; I 5(suppl):20S(abstr). 10. Klein GL, Horst RL, Alfrey AC, et al. Serum levels of 1.25 dihydroxyvitamin D in children receiving parenteral nutrition with reduced aluminum content. J Pediatr Gastroenterol Nutr 1985:4: 93-6. 1 1. Koo WWK, Tsang RC. Mineral requirements of low birth weight infants. J Am CoIl Nutr (in press).

MB, Klein GL, Wong A, et al. Aluminum does not acin teenagers and adults on prolonged parenteral nutrition free amino acids. JPEN 1986:10:86-7.

Are the FAO/WHO/UNU predictive resting metabolic rate accurate?

parenteral

1985:3- 15.

4. Klein GL. Metabolic bone disease of total parenteral nutrition. In: Favus Mi, ed. Primer on the metabolic bone diseases and disorders ofmineral metabolism. Kelseyville, CA: American Society for Bone and Mineral Research, 1990:197-200. 5. Heyman cumulate containing

613

EDITOR