Efficacy of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients

Nancy Cherry and Karen Shalansky

Disclosures

Am J Health Syst Pharm. 2002;59(18) 

In This Article

Abstract and Introduction

The efficacy of intradialytic parenteral nutrition (IDPN) in malnourished hemodialysis patients was studied.

All patients at a large tertiary care institution who received IDPN for one month or longer between June 1997 and December 2000 were included in the study. The IDPN formulation contained 10% amino acids 250 or 500 mL, 50% dextrose 250 mL, and 20% fat emulsion 250 mL. IDPN was administered during each thrice-weekly hemodialysis session. Patient data were collected 6 and 3 months before IDPN therapy began, at baseline, and 3, 6, 9, and 12 months after the therapy began. Therapeutic efficacy was assessed by the percent change from baseline in dry body weight and serum albumin concentration.

Twenty-six courses of IDPN in 24 patients met the study s inclusion criteria. The mean duration of treatment was 4.3 months. Dry body weights were significantly lower 6 and 3 months before the start of IDPN therapy than at baseline and significantly higher 6, 9, and 12 months after the start of therapy. Serum albumin levels were also significantly higher at 3 and 9 months than at baseline. The percentage of treatment courses in which patients had a serum albumin concentration of ≥34 g/L was 12% at baseline, 39% at 6 months, and 47% at 9 months. Adverse effects consisted primarily of excess fluid gain and hyperglycemia.

IDPN therapy significantly increased body weight and serum albumin levels in malnourished hemodialysis patients.

Malnutrition is a common problem in patients with end-stage renal disease (ESRD).[1] An estimated 10% of patients with ESRD are severely malnourished, and another 33% are moderately malnourished.[2] Causes may include inadequate dialysis, decreased protein and caloric intake due to loss of appetite, loss of amino acids in the dialysate, and catabolic factors, such as acidosis, hyperparathyroidism, and insulin resistance.[3] Comorbid conditions, including diabetes, cardiovascular disease, and peripheral vascular disease, also contribute to malnutrition in these patients. While many markers are used to evaluate the nutritional status of ESRD patients, serum albumin is of particular use to clinicians, as it has been directly correlated with an increased risk of morbidity and mortality.[4,5,6] Serum albumin concentrations of <35 g/L are associated with a mortality rate twice that of serum albumin concentrations of ≥40 g/L; severely depressed albumin levels (<25 g/L) are linked to a more than 10-fold increase in mortality.[4]

One widely used therapy for improving nutritional status in hemodialysis patients is intradialytic parenteral nutrition (IDPN).[5] IDPN therapy consists of administering a mixture of amino acids, dextrose, and lipid emulsion during each hemodialysis session and provides 1000-1200 kcal per treatment. IDPN is recommended for patients who cannot tolerate or have not responded to enteral supplements and who have clinical signs of malnutrition, such as a serum albumin concentration of <34 g/L, a >10% loss of ideal body weight, a dietary protein intake of <0.8 g/kg, and a dietary intake of <25 kcal/kg.[7] Goals of IDPN include increases in appetite, weight, and serum albumin.[8] Beneficial effects are expected to occur three to six months after the start of therapy, after which IDPN should be discontinued and nutrition maintained through oral supplementation.[7,9]

A handful of trials evaluating the efficacy of IDPN in malnourished patients have shown variable improvement in nutritional status.[10,11,12,13,14] Most of these trials were retrospective and nonrandomized and involved fewer than 20 subjects. The only prospective, randomized trial involved 12 patients who received IDPN for 12 weeks.[8] At the end of the study period, body weight and serum albumin were significantly higher in IDPN recipients than in 14 matched control patients. Evidence of malnutrition was not a requirement for study entry, and mean serum albumin concentration in both study groups was >36 g/L.

The purpose of our study was to evaluate the efficacy of IDPN therapy at a large tertiary care institution. Changes in body weight and serum albumin concentration were the primary endpoints. In contrast to previous studies, patient data were collected for up to six months before IDPN began, allowing the patients to serve as their own controls.

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