Depletion of phytosterols from intravenous lipid emulsions: to be or not to be

Long-term total parenteral nutrition (TPN) results in the development of intestinal failure-associated liver disease (IFALD). Fligor et al. have depleted phytosterols from soy-based intravenous lipid emulsions in an attempt to prevent IFALD. Animal studies describe the mechanism of hepatotoxicity of phytosterols, while studies in patients associate high phytosterols with the severity of liver disease. Yet, there are unanswered questions on how much IFALD could be attributed to phytosterols. Challenges to using a phytosterol-depleted ILE include the possibility of the development of oxidation by-products in the lipid, higher cost in the face of as yet unknown clinical benefit from phytosterol depletion and challenges in performing randomised controlled trials to validate the efficacy of newer ILEs.