Publication: Arias-Guillén M, González JC, Betancourt L, Coll E, Collado S, Romano-Andrioni B, Lupiañez-Barbero A, Garro J, Duarte V, Soler-Majoral J, Calabia J. Intradialytic Parenteral Nutrition in Patients on Hemodialysis: A Multicenter Retrospective Study. Nutrients. 2024 Nov 24;16(23):4018. doi: 10.3390/nu16234018. PMID: 39683411; PMCID: PMC11643966.
Reviewer: Liran Barda, MD, CNSC
Why is This Paper Important: Patients with chronic kidney disease (CKD) are prone to develop an imbalance between dietary intake and nutritional requirements leading to protein energy malnutrition, or protein energy wasting (PEW). PEW is a response to poor nutrition and chronic inflammation, both conditions common among patients with CKD especially those undergoing maintenance dialysis therapy, and is associated with increased morbidity and mortality.
Dietary counseling and education are the first steps to bridge this gap, followed by provision of oral nutritional supplements (ONS). Although feeding through the gastrointestinal route is always preferable, TPN can be conveniently administered during hemodialysis (HD) via dialysis tubing eliminating the need for an additional permanent venous catheter placement. This type of TPN administration is called intradialytic parenteral nutrition (IDPN).
When considering amino acids and energy losses with each HD session, no >3000 kcal of energy and 150 g of amino acids will be provided with thrice weekly IDPN. Hence the potential of IDPN to meet target 30-35kcal/kg/d and 1.2 g/kg/d depends on the actual dietary intakes including ONS.
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) practice guideline 2020 update was developed with the Academy of Nutrition and Dietetics and suggests a trial of IDPN if the difference between dietary intake and requirements can be met by the IDPN regimen.
ESPEN 2024 guidelines recommend IDPN be applied in malnourished, non-critically ill, hospitalized patients with CKD on hemodialysis, or if at risk of malnutrition and fail to respond or do not tolerate ONS or EN (Grade A, strong consensus 100%).
ASPEN did not recommend IDPN because of lack of adequate supporting data, nonetheless those guidelines were last updated 2010.
Summary: This is an observational study with no control group. A retrospective analysis (for a “routinely collected data bank” in a multicenter cohort) was conducted on consecutive malnourished or at-risk of malnutrition patients with CKD on HD who underwent IDPN for a period ≥ 2 weeks in one of eight Catalan hospitals.
The sample size required to detect a difference of 2 units in the mean malnutrition inflammation score (MIS), at a significance level of 0.05, with a power of 90% and assuming a standard deviation of 4.5 units was determined in advance.
Inclusion criteria included age ≥ 18 years; CKD stage 5 and ≥90 days on HD; malnutrition or at risk of malnutrition; MIS ≥ 8; ability to give written informed consent; availability, willingness, and sufficient cognitive awareness to comply with interventions.
Patients with life expectancy < 12 months; clinically significant infection; pregnant (or not taking contraceptive measures) or nursing women; or those who received treatment with IDPN within 3 months prior to the baseline visit were excluded from this study.
Patients received a 3-in-1 parenteral nutrition formula (OlimelN9®, Baxter Healthcare Corporation Deerfield, IL 60015 USA) consisting of glucose, essential and non-essential AAs, and lipid emulsion. The IDPN formula met the following conditions: proteins (0.8–1.2 g/kg weight); non-protein energy (1000–1200 Kcal); carbohydrates (150–175 g); lipids (40–50 g); vitamins; and trace elements. IDPN was infused at a constant rate during 4 h but not exceeding 250 mL/h via a venous drip chamber of the HD machine using an infusion pump.
Fifty-six patients were included. The mean age was 72.4 ± 12.0 years, 24 (42.9%) were women and 46.4% had DM.
In the overall study sample, MIS significantly decreased from 16.4 (95%CI: 15.3–17.65) at baseline to 14.3 (95%CI: 12.8–15.8) at the last follow-up visit on IDPN (p = 0.0019). Fifteen (26.8%) patients achieved a MIS reduction ≥ 5 points after IDPN. As compared to baseline, IDPN significantly reduced the proportion of patients with PEW (89.3% versus 66.1%, respectively, p = 0.0023). Regarding analytical parameters, serum albumin (p = 0.0003) and total proteins (p = 0.0024) significantly increased after IDPN administration. Throughout the study’s follow-up period, 45 (80.4%) patients reported experiencing some type of adverse event, none of them in relation to the administration of IDPN.
Commentary: The nutritional support provided by IDPN is limited (as detailed); pending on patient’s specific requirements, as adjusted per kg, and actual oral intake, IDPN might be able to balance or counter further catabolism. As IDPN was shown to be safe with low complication rate, it is worth consideration in the management of malnourished or at risk of malnutrition HD patients. IDPN cost will vary based on insurance coverage; Medicare part D has covered IDPN under “drug therapies” since 2006 allowing to obtain coverage once medical necessity is demonstrated.
Nonetheless, it is worth emphasizing that for patients with PEW whose oral intake is much lower than the amount able to be compensated by IDPN to reach nutritional goals, or those with malfunctioning gastrointestinal tract, more extensive and alternative means of nutritional support ought to be considered.
The original differences in recommendations between the different societies stems from lack of high-grade clinical evidence, but as evidence evolves throughout the years, new studies, including few RCTs, show nutritional improvements with the use of IDPN.
As IDPN enriches the nutrition support clinician’s armamentarium, the need for clinical judgment in determining which patient may benefit from IDPN is paramount to the success of treatment and adequate nutrition provision. Further randomized controlled studies of larger scale and longer period interventions are warranted.
References:
- Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Fouque D, Friedman AN, Ghaddar S, Goldstein-Fuchs DJ, Kaysen GA, Kopple JD, Teta D, Yee-Moon Wang A, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107. doi: 10.1053/j.ajkd.2020.05.006. Erratum in: Am J Kidney Dis. 2021 Feb;77(2):308. doi: 10.1053/j.ajkd.2020.11.004. PMID: 32829751.
- Sarav M, Friedman AN. Use of Intradialytic Parenteral Nutrition in Patients Undergoing Hemodialysis. Nutr Clin Pract. 2018 Dec;33(6):767-771. doi: 10.1002/ncp.10190. Epub 2018 Sep 12. PMID: 30207411.
- Sabatino A, Fiaccadori E, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Cuerda C, Bischoff SC. ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr. 2024 Sep;43(9):2238-2254. doi: 10.1016/j.clnu.2024.08.002. Epub 2024 Aug 20. Erratum in: Clin Nutr. 2024 Oct;43(10):2394-2398. doi: 10.1016/j.clnu.2024.09.019. PMID: 39178492.
- Brown RO, Compher C; American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010 Jul-Aug;34(4):366-77. doi: 10.1177/0148607110374577. PMID: 20631382.
- Kittiskulnam P, Banjongjit A, Metta K, Tiranathanagul K, Avihingsanon Y, Praditpornsilpa K, Tungsanga K, Eiam-Ong S. The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial. Sci Rep. 2022 Mar 16;12(1):4529. doi: 10.1038/s41598-022-08726-8. PMID: 35296793; PMCID: PMC8927103.
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