Home Parenteral Nutrition Support Research Articles

Management of Short Bowel Syndrome With Chronic Intestinal Failure: A Single-Center Experience in Portugal.

Short bowel syndrome with chronic intestinal failure (SBS/CIF) is the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance due to a short bowel. Although SBS/CIF is rare, its clinical management is complex, challenging, expensive, and time-consuming. This study aimed to analyze a single center's experience with SBS/CIF in adult patients treated with home parenteral nutrition (HPN). A retrospective single-center analysis of all 13 consecutive adult patients with SBS/CIF was included in an HPN program between January 1994 and August 2023. Between 1992 and 2023, 13 patients were included in an HPN program. The primary underlying pathology was acute mesenteric ischemia. The median age of starting HPN was 44 years. Most were subjected to several surgeries of extensive intestinal resection with posterior intestinal reconstruction. Five of the 13 patients died while on HPN with a median duration of 42 months. The causes of death related to HPN were catheter sepsis, endocarditis with cardiac failure, or hepatic failure. One patient died due to underlying pathology: pelvic abscesses and bleeding related to radiotherapy. Eight patients remainalive, with a median time of HPN of 173 months. During the HPN support, the most frequent complications were venous catheter infection and venous territory thrombosis. None of the eight patients alive have hepatic failure. Two patients recently started teduglutide with good tolerance and need a reduction in HPN support. All eight patients have a satisfactory quality of life (parenteral support needs range between five and two nutrition bags per week). Conclusion: Home parenteral nutrition remains the gold standard of SBS/CIF treatment, although teduglutide may reduce HPN needs and complications and provide a better quality of life. Despite the small number of patients, the results shown in this study are not inferior to those in large-volume centers. The existence of the commitment and interest of professionals involved in SBS/CIF at Centro Hospitalar Universitário de Santo António, Portugal, was a fundamental key to achieving those results. A multidisciplinary healthcare group for HPN support can be essential to ensuring these patients' survival and quality of life.

Descriptive Analysis of Renal Function and Potential Renal Acid Load in Adult Patients with Long-term Home Parenteral Nutrition Support: A Retrospective Study

Descriptive Analysis of Renal Function and Potential Renal Acid Load in Adult Patients with Long-term Home Parenteral Nutrition Support: A Retrospective Study

United Kingdom artificial nutrition database: The changing landscape of adult home parenteral support.

The United Kingdom nutrition database monitors the changing landscape of adult home parenteral nutrition support (HPS) to inform clinicians and policy makers of the need for this life-saving treatment. The UK database is administered by the British Association for Parenteral and Enteral Nutrition. Data for home parenteral nutrition (HPN) has been collected since 2005 and home intravenous fluids (HIVFs) since 2011. During this study the reporting of data to the database by healthcare workers has been voluntary. Data were analyzed using linear regression. A threefold increase of new registrations for patients receiving HPS was noted on this 10-year period, with a notable increase in the number of patients with advanced malignancy supported with HPS. Crohn's disease and short bowel syndrome were the leading causes for both HPN and HIVF use in the UK. A statistically significant increase in older (P < 0.001) and less independent patients using HPS was noted. The prevalence of HPS is steadily increasing in size with the broadening of its acceptable performance status. The launch of the Intestinal Failure Registry and mandatory registration will increase accuracy in data reporting.

Randomized clinical trial: Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition

Staphylococcus aureus decolonization has proven successful in prevention of S.aureus infections and is a key strategy to maintain venous access and avoid hospitalization in patients receiving home parenteral nutrition (HPN). We aimed to determine the most effective and safe long-term S.aureus decolonization regimen. A randomized, open-label, multicenter clinical trial was conducted. Adult intestinal failure patients with HPN support and carrying S.aureus were randomly assigned to a 'continuous suppression' (CS) strategy, a repeated chronic topical antibiotic treatment or a 'search and destroy' (SD) strategy, a short and systemic antibiotic treatment. Primary outcome was the proportion of patients in whom S.aureus was totally eradicated during a 1-year period. Secondary outcomes included risk factors for decolonization failure and S.aureus infections, antimicrobial resistance, adverse events, patient compliance and cost-effectivity. 63 participants were included (CS 31; SD 32). The mean 1-year S.aureus decolonization rate was 61% (95% CI 44, 75) for the CS group and 39% (95% CI 25, 56) for the SD group with an OR of 2.38 (95% CI 0.92, 6.11, P=0.07). More adverse effects occurred in the SD group (P=0.01). Predictors for eradication failure were a S.aureus positive caregiver and presence of a (gastro)enterostomy. We did not demonstrate an increased efficacy of a short and systemic S.aureus decolonization strategy over a continuous topical suppression treatment. The latter may be the best option for HPN patients as it achieved a higher long-term decolonization rate and was well-tolerated (NCT03173053).

Management of catheter related bacteremia in patients on home parenteral nutrition: a systematic review and meta-analysis

Rationale: Catheter-related bacteremia (CRB) is regarded as a life-threatening complication of home parenteral nutrition (HPN) support. Therefore optimal CRB management, preferably with salvage of the catheter, is required to secure vascular access in the long term. The aim of this review was to systematically evaluate the currently available literature for CRB treatments in adult patients on HPN support.

ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients with Enterocutaneous Fistula

Background: the management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to surgeons, gastroenterologists, intensivists, wound/stoma care specialists, and nutrition support clinicians. Available guidelines for optimizing nutritional status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual or institutional experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing nutrients, and use of somatostatin analogs in the management of patients with ECF remain a challenge for the clinician. The purpose of this clinical guideline is to develop recommendations for the nutritional care of adult patients with ECF. Methods: a systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the A.S.P.E.N. and FELANPE Board of Directors. Questions: in adult patients with enterocutaneous fistula: 1) What factors best describe nutritional status? 2) What is the preferred route of nutritional therapy (oral diet, EN or PN)? 3) What protein and energy intake provide best clinical outcomes? 4) Is fistuloclysis associated with better outcomes than standard care? 5) Are immune-enhancing nutrients associated with better outcomes? 6) Does the use of somatostatin provide better outcomes than standard medical therapy? 7) When is home parenteral nutrition support indicated?

Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition: study protocol for a randomized multicenter trial

BackgroundPatients with long-term intestinal failure are usually treated by means of home parenteral nutrition (HPN) where they administer their nutritional formulation intravenously via a central venous access device (mostly a catheter). This implies that such patients are exposed to a lifelong risk of developing Staphylococcus aureus bacteremia (SAB). SAB poses a threat to both catheter and patient survival and may lead to frequent hospitalization and a permanent loss of vascular access. In other clinical settings, S. aureus carriage eradication has been proven effective in the prevention of S. aureus infections. Unfortunately, there is a complete lack of evidence in HPN support on the most effective and safe S. aureus decolonization strategy in S. aureus carriers. We hypothesized that long-term S. aureus decolonization in HPN patients can only be effective if it is aimed at the whole body (nasal and extra-nasal) and is given chronically or repeatedly on indication. Besides this, we believe that S. aureus carriage among caregivers, who are in close contact with the patient, are of great importance in the S. aureus transmission routes.Methods/designThe CARRIER trial is a randomized, open-label, multicenter clinical trial in Dutch and Danish hospitals that treat patients on HPN. A total of 138 adult HPN patients carrying S. aureus will be randomly assigned to a search and destroy (SD) strategy, a quick and short, systemic antibiotic treatment, or a continuous suppression (CS) strategy, a repeated chronic topical antibiotic treatment. The primary outcome measure is the proportion of patients in whom S. aureus is totally eradicated during a 1-year period. Secondary outcomes are time to successful eradication, long-term antimicrobial resistance, adverse events, patient compliance, incidence of (S. aureus) infections, catheter removals, mortality rates, S. aureus transmission routes, quality of life, and health care costs.DiscussionThe CARRIER trial is designed to identify the most safe and effective long-term S. aureus carriage decolonization strategy in HPN patients. This will eventually lead to a better understanding of long-term S. aureus decolonization treatments in general. The results of this study will have a great impact on our daily clinical practice, which eventually may result in less S. aureus-related infections.Trial registrationClinicalTrials.gov; NCT03173053. Registered on 1 June 2017.

ASPEN-FELANPE Clinical Guidelines.

The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF. A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE. In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

ESPEN guidelines on chronic intestinal failure in adults

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

PTH-208 Home parenteral nutrition (HPN) in palliative oncology patients – a UK single centre case series with survival analysis

Introduction HPN support should be a nutritional management strategy in patients who cannot meet their nutritional requirements by oral or enteral routes and those who are eligible to receive therapy outside an acute-care setting. 1 However, use of HPN in incurable patients who cannot eat remains controversial and is only accounted for by approximately 8% of the UK HPN population. 2 We therefore aimed to describe the HPN palliativeoncology cohort at University College London Hospital (UCLH) and identify what factors determine their survival rates and performance status. Method Data was collected retrospectively and prospectively for palliative oncologypatients receiving HPNthrough hospital computer systems and databases stored by members of the Nutrition team at UCLH between 01/01/2006 to 31/12/2014 (censor date). Survival time was expressed in weeks, Kaplan Meier curves were plotted and performance status was obtained using Karnofsky score (KPS). Results A cohort of n = 65 (n = 12 active at analysis) palliative oncology patients (male 36.9%, median age 56 years) recieved HPN at UCLH from 2006–2014. Cancers of the following aetiologies comprised most of the cohort: upper gastrointestinal (n = 13, 20%); lower gastrointestinal (n = 15, 23%); and gynaecological (n = 24, 36.9%). The main indicator for HPN was bowel obstruction (n = 44). Overall mean/median survival was 22.4 and 10 weeks (range: 0.4 to 193.3), respectively (Figure 1). Survival also differed by malignancy (mean/median survival-weeks: upper gastrointestinal 10.3/6.4; lower gastrointestinal 24.8/10.7), gynaecological 28.1/8.3). Overall median KPS was 50. The correlation between KPS and survival from discharge to death was r = 0.315 (P Abstract PTH-208 Figure 1 Survival of palliative oncology HPN patients (N = 65) Conclusion Our results show there is an indication for HPN in palliative oncology patients as it may increase survival period post hospital discharge however this may differ by underlying malignancy. In addition, HPN may improve performance status. Further research is required into patients’ quality of life to provide holistic as well as medical insights into HPN in this patient group. Disclosure of interest None Declared. References Staun M, et al . ESPEN guidelines on Parenteral nutrition: Home Parenteral Nutrtiion (HPN) in adult patients. Clin Nutr. 2009:467–479 BANS: Annual BANS Report, 2011; Artificial Nutrition Support in the UK 2000–2010. www.bapen.org.uk

The Advent of Home Parenteral Nutrition Support

I review here some key developments of personal and professional interest, with special reference to total parenteral nutrition (TPN), an area in which I have been involved from 1937 until recently. As a result of basic and biomedical science advances achieved in university and industrial laboratories in numerous countries, many essential nutrients were identified, synthesized, produced, and provided to patients in safe and effective forms both enterally and parenterally. This period also saw important developments in analytic instrumentation. I have had the privilege of seeing major advances in nutrition during my lifetime, and it is my belief and my hope for the future that with the advent of bowel transplants and tissue growth from cells, TPN will be a temporary measure rather than a lifetime regimen.

Pneumoperitoneum without intestinal perforation in an adolescent girl

Pneumoperitoneum without intestinal perforation in an adolescent girl

Home Parenteral Nutrition Support in Adults: Experience of a Medical Center in Asia

Parenteral nutrition (PN) support is mandatory in patients with gut failure. Short bowel syndrome is a term used for symptoms and pathophysiological disorders brought about by the removal or malfunction of a large portion of the small bowel. Inflammatory bowel disease, vascular disease, and malignancy are the most common causes of short bowel syndrome in adults. There are many complications associated with chronic use of PN. Cholestasis, nutrient deficiency, small bowel bacterial overgrowth, and catheter-related infections were noted in these patients. Due to the various etiologies, we tried to find the optimal method to manage these patients. We reviewed all patients over 16 years old, from 1989 to 2002, who required home PN support for at least 30 days. Charts were reviewed to obtain information regarding demographics, nutrition management, outcome, and complications related to PN. Survival was estimated by using the Kaplan-Meier method. The association of survival with primary disease, length of small bowel, age, and gender was assessed by proportional hazard regression analysis. There were 31 patients who needed home PN support during this period, 14 male and 17 female. The average age was 55 (median age, 53; range, 28-88); the average period of PN administration was 19 months (median, 7; range, 1-115 months). The most common indications for home PN were alimentary tract obstruction and short bowel syndrome. Most deaths were related to their original diseases and catheter-related sepsis. Malignant diseases were a major indication for home PN (HPN). However, 20% of these patients with incurable diseases lived longer than 1 year. The disease patterns were different from those in western societies. Most patients had malignancies and vascular insults in our series. There was much less inflammatory bowel disease in our patients than in western countries; catheter-related infections were frequent and caused 25% of mortality. HPN is very important to patients with intestinal failure or who are waiting for recovery from temporal intestine insufficiency. Even in malignant diseases, a significant number of patients survived for >1 year with treatment of HPN. Most complications related to their underlying diseases and associated infections. Improving patient education and treatment might improve the prognosis of these patients and expand the application of this technique to help more patients with small intestine failure.

Home parenteral nutrition registry: A five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support

Objective Few data are currently reported on home parenteral nutrition (HPN) patient outcomes, which makes evaluating comparative outcomes in HPN difficult. This study describes outcomes of consecutive HPN patients collected retrospectively over a 5-y period by one HPN support provider. Methods Retrospective data from the HPN support provider was aggregated yearly from 1997 to 2001. Length of therapy, demographics, diagnosis, rehospitalizations, catheter infection rate, catheter occlusion rate, and mechanical complication rate data were reported. Results The mean age of HPN patients ranged from 42 y to 45 y. The average length of HPN therapy was 100 d. There were more female than male HPN patients. Nutritional deficiency and malabsorption were the most common International Classification of Diseases, Ninth Revision codes for HPN use and reflects a focus on nutritional diagnosis rather than on disease state as the criterion for HPN use. Catheter infection rates ranged from 0.44 to 0.84 per 1000 catheter days, a lower than anticipated number. Mean catheter occlusion rates were lower than 7% and mean mechanical complication rates were approximately 5%. Known termination of therapy was secondary to completion of therapy (50% to 56%) or death (17.3% to 22%). Conclusions Overall, time on HPN therapy in the United States has increased. Nutritional diagnoses are currently used to justify HPN. Catheter infection and occlusion rates, in general, are low. Termination of therapy and death are the most common reasons for HPN discontinuation. Standardization of HPN data collection is necessary to obtain a historical snapshot of the efficacy and safety of patients treated outside the hospital with nutritional support.