Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Table 4 Symptoms, prophylactic supplementation, and therapy of frequent (critical) nutrient deficiencies in chronic intestinal failure

Nutrient	Symptoms of deficiency	Normal values (blood/serum)	Additional lab tests	Prophylaxis	Therapy in case of deficiency
Calcium	Neuromuscular hyperarousal, cardiovascular symptoms, osteopathy	2.1-2.7 mmol/L	↑Alkaline phosphatase; ↑intact PTH; ↓Bone mineral density	Calcium citrate, oral 1200–2000 mg/d	Bisphosphonate if T-Score < 2.5
Magnesium	Neuromuscular hyperarousal, osteopathy (PTH effect ↓)	0.75-1.15 mmol/L	↓Magnesium in urine	Magnesium citrate, oral 300 mg/d	10 – 15 mmol magnesium, e.g., in 1000 mL NaCl 0.9 %
Vitamin A	Night blindness, wound healing disorders	1.05-2.80 µmol/L	↓Plasma retinol; ↓Retinol binding protein	10000-50000 U/d, if liver function normal	No corneal changes: 10000–25000 IU/d oral for 1–2 wk; Corneal changes: 50000–100000 IU i.m. followed by 50000 IU/d i.m. for 2 wk
Vitamin D	Osteopathy, wound healing disorders, immune system disorders	< 20 µg/L: deficiency; 20-30 g/L: insufficiency; > 30 µg/L: sufficient supplies	↑Alkaline phosphatase; ↑intact PTH; ↓Bone mineral density	Oral vitamin D (400–800 U/d) [ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3)] or 100000 U/3–6 mo orally	50000–150000 IU oral 3-5 times a week; If required: calcitriol [1,25(OH)2D] oral
Vitamin K	Hemorrhagic diathesis	INR < 1.2	PIVKA	10 mg/wk	N/A
Vitamin B1	Polyneuritis (“dry form“), edema, tachycardia, Cardiac insufficiency (“wet form“); Wernicke encephalopathy, ataxia (“central form“)	10.64 µg/L	↓Thiamine pyrophosphate; ↓Erythrocyte transketolase activity	If vomiting, aggressive oral thiamine supplementation with 100 mg/d for 7–14 d	Treatment of Wernicke Encephalopathy: 500 mg i.v. 3 ×/d for 2-3 d; ≥ 250 mg/d i.v. for 5 d; 30 mg oral 2 ×/d
Vitamin B12	Megaloblastic anemia, glossitis, skin and mucous membrane pallor, paresthesia, polyneuropathy, funicular myelosis	156-675 pmol/L	↓Holo-TC; ↓MMA; ↑Homocysteine	Oral: 1000 μg/wk or 250–350 μg/d, i.m./s.c.: 1000 μg/mo or 3000 μg every 6 mo	1000 or 2000 μg/d oral or 1000 μg/wk i.m.
Zinc	Wound healing disorders, hair loss, taste disturbances, predisposition to infection	11-23 mol/L	↓Zinc in urine	In presence of fistula, diarrhea or stomata: 12 mg; Otherwise: 3-4 mg	30-45 mg (as zinc histidine), 220-440 mg (as zinc sulphate). For each 8–15 mg of elementary zinc, 1 mg copper should be substituted
Iron	Anemia, hair loss, cognitive disorders, predisposition to infection	CRP < 5 µg/L: > 30 µg/L; CRP ≥ 5 µg/L: ≥ 100 g/L	↓Transferrin saturation; ↑Soluble transferrin receptor; ↑Zinc protoporphyrin	Oral max: 100–150 mg iron	Parenteral, depending on iron status: Aim: normalization of Hb plus transferrin saturation 35%-50% (calculated according to Ganzoni)
Copper	Neutropenia, iron deficiency anemia, central venous development disorders	11-22 µmol/L	↓Copper/zinc superoxide dismutase	Copper gluconate, oxide or sulphate equivalent to 2 mg elementary copper; 1 mg copper for each 8-15 mg zinc	Copper sulphate equivalent to 2.4 mg elementary copper in 100 ml 0.9% NaCl i.v. administered one hour/d for 5 d. Subsequently, oral substitution as required

CRP: C-reactive protein; Holo-TC: Holo-transcobalamin; INR: International normalized ratio; MMA: Methylmalonic acid; PTH: Parathyroid hormone.