I would like to take your opinion about a stomach cancer case who came from the states recently with home ketogenic TPN formula. We are not familiar with such cases so we would like to share it with you. A 60 years old female her weight is 39-40kg.
TPN formula is :
Amino acids 10% (450ml)
Lipids 20% (500ml)
Total volume is 1500ml/day
Total calories 1300
The patient is feeling very weak with no energy we don’t know whether it’s from the cancer or the energy requirement is low. Her family noticed she has lost some weight. Her hospital in the USA suggested that even if there will be an increase in calories it will feed the cancer so they recommended this plan. We noticed that the BUN is elevating (13mmol) with normal creatinine level. ascites drain ~1000ml daily , urine output is normal. liver enzymes are high AST and ALT both ~200.
Do we need to increase protein/calories !?
Since the patient is draining 1000 ml BUN is going up does the volume need to be adjusted ?
Your input will be greatly appreciated.
To my knowledge, ketogenic nutrition support terminology either parenteral nutrition or enteral feedings concept is applied to patients with intractable seizure and some cases in inborn error of metabolism like carbohydrate disorder metabolism and characterized by high fat, low carbohydrate, and maintenance protein contents.
The goal of nutrition support in cancer patients is to minimize wasting but not for ideally nutrition repletion and gaining weight.
Also, The goal of nutrition support in patient with cancer (adult) maintenance support which is between 23- 25 KCla/kg/day. not anabolic support as theoretically high calories providing may feed cancer cells as stated in some studies.
I advise you to monitor other parameters like prealbumin or transferrin with CRP (if patient is not under any kind of stress) if you don’t see increasing in patient weight in order to if the patient got benefit from PN
With limited patient history provided, I won’t recommend increasing calories further. Current intake of 1300 (~32 Kcal/kg) is considered high for this kind of patient. I don’t think weight gain is an objective for this patient. You are already observing adverse effects in terms of deranged LFTs. You also need to look at lipid profile as patient is receiving ~75% calories from lipids. Ketogenic diet for patients with cancer is new concept that’s is still under investigation. Theoretically, lack of carbohydrate supply creates oxidative stress in cancer cells and sensitize cancer cells to standard radiation and chemotherapy. Not much literature is available. I don’t know If stomach cancer is also involving the remaining gut. If remaining gut is accessible and functional, you should also look at the possibility of tube feeding (e.g., Jejunostomy Tube)
1000ml drain on daily basis is a lot and definitely need to be replaced. You need to look at fluid status and calculate/estimate fluid balance and make up the difference with extra fluids.
Below are my thoughts.
1- The idea behind ketogenic diets is relatively simple. If glucose is the primary fuel for cancer, then lower carbohydrate intake and replace carbohydrates with other sources of fuel, such as fats, in order to push the body’s metabolism into ketosis.
2- Preclinical and case report studies indicated that the restricted ketogenic diet can be an effective “metabolic therapy” for managing malignant cancer in children and adults.
3- From the provided macronutrient information your patient typically on balanced ketogenic formula (lipid 75-85 % remaining from Amino acid and dextrose). However, because of elevated liver enzyme I would recommend reducing Lipid dose and change PN to cyclic over 12-14 hours.
4- Drainage must be replaced. Yet, for such cases the fluid replacement and total fluid intake must be discussed with primary physician.
5- Addition of Carnitine should be considered along with a high-fat or ketogenic PN solution. Carnitine is a nonessential amino acid that facilitates the transport of fatty acids from long-chain fats into the mitochondria. It is also essential in certain conditions, such as liver disease, trauma, sepsis, and organ failure, and is advised when the major source of calories are derived from fat.
6- Selenium is an essential trace mineral that is generally included in PN solutions when used longer than 4 weeks.
I hope this will help.
I do not think this will be of benefit for the immediate case between your hands, but if you want more information about the benefits of intermittent fasting and ketosis in cancer patients you can check the work of Dr. Dominic D’Agostino, he is one of the pioneer researchers in the field of ketosis and its military and medical applications especially in cancer patients.
He is an assistant professor in the Department of Molecular Pharmacology and Physiology at the University of South Florida Morsani College of Medicine, and a senior research scientist at the Institute for Human and Machine Cognition (IHMC).
This is his official website: http://www.ketonutrition.org/ or you can just Google his name.
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