Changing Patterns in the Use of Home Parenteral Nutrition in Crohnʼs Disease Patients

Abstract

Purpose: This is a descriptive study of the changing patterns of home parenteral nutrition (HPN) use in Crohn's Disease (CD) patients treated at the Cleveland Clinic from the years of 1986–2006. Methods: We identified subjects through a prospectively maintained electronic database of all patients receiving HPN through the Cleveland Clinic. Information was extracted from the HPN database for the years of 1986–2006. A separate CD-HPN database was created in Microsoft Access by adding data from the colorectal surgery database, the electronic chart, and paper charts of our subjects. The HPN episodes were categorized into 3 time frames: 1) 1970's and 1980's, 2) 1990's and 3) 2000's (N = 15, 26, and 101 respectively). To assess whether there were significant trends over time in factors such as duration of TPN and total energy amount, univariable cumulative logit models were created modeling decade as the outcome; Jonckheere-Terpstra tests were used for categorical factors. A P < 0.05 was considered statistically significant. Results: There were a total of 112 subjects and 142 episodes of HPN use in CD. Number of subjects starting HPN increased over time from 15 to 101 per decade. Months of HPN use decreased significantly from 88.6 months in the 1970's/1980's to 4.4 months in the 2000s (P < 0.0001). Indications for HPN changed from short bowel as the main indication in the early time period to post-op fistula in the 2000's. The duration of HPN was inversely associated with the year in which it was started for short bowel and post-op fistula (R = −0.74, P < 0.001; R = −0.40, P= 0.01 respectively). TPN composition changed significantly with increases in protein Kcal/day (243.5 to 368.1, P= 0.002), fat Kcal/day (74.7 to 133.1, P= 0.049), total Kcal/day (989.1 to 1644.4, P= 0.02) and number of infusion days (5.7 to 6.3, P= 0.009). It appeared that there was an increase in infections over time however our data on complications during the early time period was limited (P= 0.01). Conclusion: To our knowledge this is one of the largest and longest reports of HPN use in CD patients. Our experience shows that more patients are being placed on HPN than in the past. This is likely due to the trend to send patients with post-op fistula and prolonged ileus home whereas in the past they were observed in the hospital until these problems resolved. The increase in total kcal, protein kcal, fat kcal and number of infusion days reflects this increasing trend of discharging severe bowel dysfunction CD patients that require greater intakes rather than administering in-hospital TPN.Table: Changes in Indications, Duration and Composition of HPN in CD.