Choline total parenteral nutrition

Shronts EP. Essential nature of choline with implications for total parenteral nutrition. J Am Diet Assoc 1997 97(6) 639-46649. 

Equally, demonstrating that a compound has a physiological function as a coenzyme or hormone does not classify that compound as a vitamin. It is necessary to demonstrate that endogenous synthesis of the compound is inadequate to meet physiological requirements in the absence of a dietary source of the compound. Table 1.3 lists compounds that have clearly defined functions, but are not considered vitamins because they are not dietary essentials endogenous synthesis normally meets requirements. However, there is some evidence that premature infants and patients maintained on long-term total parenteral nutrition may be unable to meet their requirements for carnitine (Section 14.1.2), choline (Section 14.2.2), and taurine (Section 14.5.3) unless they are provided in the diet, and these are sometimes regarded as... 

In addition to the established vitamins, a number of organic compounds have clear metabolic functions they can be synthesized in the body, but it is possible that under some circumstances (as in premature infants and patients maintained on long-term total parenteral nutrition) endogenous synthesis may not be adequate to meet requirements. These compounds include biopterin (Section 10.4), carnitine (Section 14.1), choline (Section 14.2), creatine (Section 14.3), inositol (Section 14.4), molybdopterin (Section 10.5), taurine (Section 14.5), and ubiquinone (Section 14.6). 

In many animals, dietary deprivation of choline leads to liver dysfunction and growth retardation, and some patients maintained on choline-free total parenteral nutrition develop liver damage that resolves when choline is provided, suggesting that endogenous synthesis may be inadequate to meet requirements (Zeisel, 2000). There is inadequate information to permit the setting of reference intakes, but the Acceptable Intake for adults is 550 mg (for men) or 425 mg (for women) per day (Institute of Medicine, 1998). In experimental animals choline deficiency is exacerbated by deficiency of methionine, folic acid, or vitamin B12, which impairs the capacity for de novo synthesis. 

Choline, supplied as dietary PC or as free choline, is required in the diet by rats. Although it has not been established that choline is required by humans, it is probably an essential nutrient and may, in the future, be classified as an essential amine or vitamin, Its possible requirement is a concern to clinicians feeding patients by total parenteral nutrition (TpN), In this type of feeding, which may be used for a year or longer, the patient is sustained intravenously with an artificial, chemically defined diet. The choline in foods occurs mainly as PC rather than as free choline. PC is a more desirable dietary component because, when free choline is consumed in large amounts, it is degraded by the gut bacteria to produce trimethylamine, an odoriferous compound (Magil et ai, 1981). 

Amino acid-glucose solutions used in total parenteral nutrition of humans lack choline. The lipid emulsions that deliver extra calories and essential fatty acids during parenteral nutrition contain choline in the form of lecithin (20% emulsion contains 13.2 mmol 1 ). Humans treated with parenteral nutrition require 1-1.7 mmol of choline-containing phospholipid per day during the first week of parenteral nutrition therapy to maintain plasma choline levels. 

Buchman AL, Dubin M, Jenden D, Moukarzel A, Roch MH, Rice K, Gornbein J, Ament ME, and Eckhert CD (1992) Lecithin increases plasma free choline and decreases hepatic steatosis in long-term total parenteral nutrition patients. Gastroenterology 102 1363-1370. 

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