In PN patients with cholestasis, how should manganese be adjusted?

• A. Increase Mn
• B. Switch to zinc instead
• C. Decrease Mn
• D. No change

Answer: (C)

In cholestasis, bile flow is impaired, and manganese is eliminated primarily through the bile. When this excretion pathway is compromised, manganese can accumulate in the liver and brain, leading to neurotoxicity such as movement disorders and other neurologic signs. Because of this, manganese should be reduced in parenteral nutrition for patients with cholestasis to minimize the risk of toxicity. The idea is to lower the trace element dose rather than increase it or keep it the same. Switching to zinc doesn’t address the manganese accumulation, and not changing the dose would allow ongoing risk.