Is There a Role for Intradialytic Parenteral Nutrition? A Review of the Evidence

Ramanath Dukkipati,Kamyar Kalantar-Zadeh,Joel D Kopple

doi:10.1053/j.ajkd.2009.08.006

Abstract

Protein-energy wasting (PEW) is highly prevalent in people with stages 4 and 5 chronic kidney disease, particularly in maintenance dialysis patients, and many indicators of PEW correlate strongly with mortality. Consequently, the causes, prevention, and treatment of PEW are active areas of investigation. A major cause of PEW is insufficient intake of nutrients, especially protein and energy (calories). Standard methods for increasing nutritional intake in patients with chronic kidney disease with PEW include dietary counseling and use of food supplements. If nutrient intake does not increase sufficiently, tube feeding and total parenteral nutrition may be considered. For maintenance hemodialysis patients, intradialytic parenteral nutrition (IDPN), an intravenous infusion of essential nutrients during hemodialysis treatments, may be used. Many studies have evaluated the effectiveness and safety of IDPN and show that IDPN has a good safety profile and also may improve protein-energy status. However, most studies have limitations in experimental design, such as small numbers of patients, lack of adequate controls, inclusion of patients without PEW, uncontrolled or unmonitored oral intake, nonrandomized design, or short duration. Additionally, most studies used nutritional or inflammatory indicators, rather than the more important outcomes of morbidity, mortality, or quality of life. Thus, although IDPN may partially satisfy the nutritional needs of maintenance hemodialysis patients who have or are at risk of PEW and who have substantial, but not adequate, protein and/or energy intake, longer term randomized prospective clinical trials with appropriate control groups are necessary to more definitively evaluate the clinical effectiveness and indications for IDPN.

Highlights

There presently are ϳ400,000 people undergoing maintenance dialysis therapy in the United States and 1,000,000 people worldwide.[1]
Most nephrologists would agree that dietary counseling and food supplements should be the first approach for maintenance dialysis patients who are ingesting inadequate quantities of nutrients,[8,12] and it is important to ensure that inadequate food intake is not caused by the lack of ability to purchase, prepare, or ingest foods; that illnesses that might prevent the digestion, absorption, or assimilation of nutrients are not present; and there are not correctible psychogenic causes for inadequate intake.[13]
Six weeks after therapy with intradialytic parenteral nutrition (IDPN) alone, serum transferrin concentrations increased; there was no significant change in the protein equivalent of total nitrogen appearance (PNA), insulin-like growth factor 1, serum albumin, or anthropometric measurement values

Summary

Sample size too small to show benefits or lack of benefits

An oral nutritional supplement given to some patients ments generally was not controlled; hemodialysis treatments, including dialysis doses, were not standardized or were poorly described; and some studies were retrospective. There have been Ͼ 20 published nonrandomized observational studies of IDPN (Table 2) These trials described an increase in various nutritional measures in association with the inauguration of IDPN, with increases observed most commonly for body weight, serum albumin level, and/or transferrin level. Six weeks after therapy with IDPN alone, serum transferrin concentrations increased; there was no significant change in the protein equivalent of total nitrogen appearance (PNA), insulin-like growth factor 1, serum albumin, or anthropometric measurement values. IDPN was continued for another 6 weeks, with 5 mg of growth hormone given at each hemodialysis session, and this was associated with a significant increase in serum albumin levels.

Design

Findings

CONCLUSION