Chapter 45 - Intradialytic parenteral nutrition, intraperitoneal nutrition, and nutritional hemodialysis

Abstract

A frequent disorder encountered by patients with end-stage renal disease who are undergoing maintenance hemodialysis (MHD) or chronic peritoneal dialysis (CPD) is protein-energy wasting (PEW). This is one of the strongest risk factors for adverse clinical outcomes, including death, in these patients. Nutritional interventions, such as dietary counseling, oral nutritional supplements, or enteral tube feeding, may improve nutritional status and outcomes, although PEW may be the result of disorders that are not purely caused by inadequate nutritional intake. But for many patients, these treatments are not palatable or acceptable, and some patients are physically unable to receive sufficient nutrients through their gastrointestinal tract to meet their daily requirements by these techniques. Intradialytic parenteral nutrition (IDPN) offers an alternative method for providing additional nutrients to MHD patients. Both nonrandomized and randomized studies suggest that IDPN may improve the protein–energy status of many MHD patients with PEW. The studies that examine the effectiveness of IDPN have limitations, such as inadequately powered sample sizes, less than robust scientific design, and insufficient follow-up. Thus although IDPN is a promising treatment, more research is necessary before definitive conclusions can be made concerning its clinical benefits. For CPD patients who have PEW, experimental evidence suggests that intraperitoneal nutrition may have beneficial effects on their protein–energy status. Finally, supplemental amino acids and carbohydrates provided through the hemodialysate solution also may be provided to MHD patients with or at high risk for developing PEW.