Home Parenteral Nutrition Therapy Research Articles

Assessment of clinical outcome after sudden alteration of home parenteral nutrition program from customised to commercially premixed admixtures. Experience with short bowel syndrome treatment

Background & AimsDisruptions in the home parenteral nutrition (HPN) process may lead to failure to achieve the intended treatment purposes. This study aimed to evaluate the mid-term clinical outcome in a group of patients with short bowel syndrome (SBS) after a sudden change in the type of home parenteral nutrition programs from customized to commercially premixed admixtures. MethodsThe study conducted in 2020 identified 51 patients with SBS: 27 (53%) women and 24 (47%) men. The SBS were classified as SBS with end jejunostomy 23 (45%) patients, with jejuno-colon anastomosis 23 (45%) patients, with jejuno-ileo anastomosis and total colon in continuity 5 (10%) patients. The following therapeutic program-related data were analysed: changes in nutritional status, body mass index (BMI), Controlling Nutritional Status (CONUT) score, and biochemical assessment. For statistical analysis, the Wilcoxon rank-sum and signed-rank paired tests with continuity corrections were used to compare the results. A p-value of <0.001 was considered statistically significant. ResultsThere was no statistically significant difference between the analysed groups in total energy, amino acid concentrations, and intravenous volume supplementation. BMI and CONUT assessments of nutritional status and selected biochemical parameters were stable during the study period. ConclusionsThe study demonstrated that a sudden change in the HPN therapy program from parenteral admixtures, tailored to meet individual patients’ needs, to commercially premixed admixtures had no significant impact on the mid-term clinical condition of patients with SBS.

Rhoads Research Lecture-Reflections from a clinician scientist: The power of patient voice.

Qualitative research is a scientific method that systematically examines a phenomenon with the purpose of understanding and describing human experiences, exploring meanings and patterns, and illuminating the patient's lived experience. The Rhoads Research Lecture will highlight the power of patient voice and its importance to clinicians and researchers in addressing key clinical needs that are most relevant to patients receiving nutrition support. The subjective experience of patients who are dependent on home parenteral nutrition (HPN) will be shared, including how patients view HPN, define their quality of life (QOL), and describe the meaning of food in the context of being intravenously fed. As a result of these exploratory studies, the HPN patient-reported outcome questionnaire (HPN-PROQ) was developed and validated. Incorporating the HPN-PROQ in practice empowers patients to identify and communicate QOL and HPN therapy goals and clinicians to delve deeper in the provision of holistic and empathetic care.

Impact of nationwide essential trace element shortages: A before-after, single-center analysis of hospitalized adults receiving home parenteral nutrition therapy.

Recent data on the prevalence of essential trace element (ETE) deficiencies in home parenteral nutrition (HPN) patients are scarce. We investigated whether ETE deficiencies are still an important issue for HPN patients and whether the prevalence of such deficiencies may be influenced by nationwide drug shortages. We conducted a single-institution, retrospective analysis from 2006 to 2015 of hospitalized HPN patients who continued PN during and in between hospitalizations. In subgroup analysis, patients were dichotomized as those with HPN duration <1 vs ≥1 year. Zinc (Zn), copper (Cu), and selenium (Se) levels were abstracted for patients over the study period. Prevalence of ETE deficiency was compared using chi-squared test for patients hospitalized during nonshortage vs shortage (2011-2014) periods. Ninety-six patients were included in the analysis. Prevalence of ETE deficiency during nonshortage vs shortage periods was 48% vs 54% (Zn), 15% vs 21% (Cu), and 24% vs 48% (Se; P = .01), respectively. When comparing patients who received HPN <1 year vs ≥1 year, the prevalence of Se deficiency doubled during shortage in both subgroups (24% to 42% vs 26% to 49%); and Cu deficiency tripled during shortage period in the group receiving HPN ≥1 year (5% to 16%). ETE deficiency is prevalent in hospitalized HPN patients and was exacerbated during nationwide shortages of parenteral supplements. Statistical significance may be limited by small sample size. Future studies are needed to determine optimal ETE supplementation strategies for minimizing the impacts of nationwide drug shortages on HPN patients.

Vitamin D deficiency in patients with chronic intestinal failure on home parenteral nutrition.

Vitamin D deficiency is an important complication of chronic intestinal failure (CIF). Liver steatosis is a known late complication of long-term home parenteral nutrition (HPN) therapy in patients with CIF, which can progress to intestinal failure-associated liver disease (IFALD). The aim of this study was to determine the prevalence of vitamin D deficiency among Slovene HPN patients and determine any potential correlation between serum vitamin D levels and liver steatosis associated with IFALD in adult patients with CIF on HPN therapy. Adult patients, diagnosed with CIF, receiving long term HPN therapy, were included in a cross-sectional study. Vitamin D status was determined by measuring serum levels of 25-hydroxyvitamin D. The presence of liver steatosis was diagnosed using 3TS MRI scanner. The association between serum vitamin D levels and liver steatosis was calculated using univariate logistic regression. We included 63 adult patients with CIF on HPN therapy in the study. The median duration of HPN therapy was 70 weeks. The average serum concentration of 25-hydroxyvitamin D was 41.3nmol/l. Insufficient vitamin D levels were found in 45 (73%) patients. Liver steatosis was present in 18 (28.6%) patients. No statistically significant association between serum vitamin D levels and liver steatosis in the study population was found. The results of this study have shown a high prevalence of vitamin D deficiency in adult patients with CIF on HPN. We failed to demonstrate an association between serum vitamin D levels and the prevalence of liver steatosis.

Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy.

Even with significant advances in surgical techniques and treatment, salvage chemotherapy remains the major treatment strategy for patients with unresectable or metastatic gastric cancer (GC). Practical and technical advances have simplified safe and convenient use of supplemental home parenteral nutrition (HPN). We aimed to clarify the role of HPN in patients with incurable GC undergoing salvage chemotherapy. We enrolled 25 patients with GC with a nutritional risk index (NRI) of ≦ 97.5 undergoing HPN. Their nutritional status, laboratory data, and quality of life (QoL) were analyzed using the Research and Treatment of Cancer quality of life questionnaire-C30 before and after HPN administration at 0.5, 1, 2, and 3 months. We enrolled 25 patients with an NRI of > 97.5 not undergoing HPN as the control group. Total protein (P = 0.008), prealbumin (P < 0.001), and total cholesterol (P = 0.023) levels improved significantly after 0.5 months of HPN administration. The study group also demonstrated a marked improvement in nitrogen balance (P = 0.004) and prealbumin levels (P < 0.012) after 1 month. Gains in body weight after 1 month and body mass index after 2 months of HPN administration remained comparable with those of the control group. Global QoL scores were maintained and comparable with those of the control group. Supplemental HPN therapy for malnourished patients with unresectable or metastatic GC undergoing salvage chemotherapy is feasible and revealed marked improvement in nutritional status. Early HPN intervention should be considered an important part of palliative treatment for advanced GC.

Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study.

A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.

SUN-PO100: Home Parenteral Nutrition Therapy for Malnourished Unresectable/Metastatic Gastric Cancer with Salvage Chemotherapy

SUN-PO100: Home Parenteral Nutrition Therapy for Malnourished Unresectable/Metastatic Gastric Cancer with Salvage Chemotherapy

Liver steatosis in adult patients on home parenteral nutrition.

In patients with chronic intestinal failure (CIF) and long-term home parenteral nutrition (HPN), liver steatosis is a known late complication, which can progress to intestinal failure-associated liver disease (IFALD). Magnetic resonance imaging (MRI) provides a qualitative and quantitative assessment of liver steatosis. The aim of our study was to assess the prevalence of liver steatosis and find possible new factors that could be connected to liver steatosis in CIF patients on HPN therapy. Patients diagnosed with CIF and undergoing long-term HPN therapy were enrolled in a prospective cohort study. Clinical, laboratory and body composition data were collected from their medical records between January 2017 and November 2018. Liver steatosis was diagnosed using 3 Tesla Siemens MRI scanner. The associations between various risk factors and liver steatosis were calculated using uni- and multivariate logistic regression. In our study, we included 63 adult patients with CIF on HPN therapy. The median HPN therapy duration was 70 weeks (IQR 22-203). The prevalence of liver steatosis was 28.6%. Serum cholesterol level, CRP and FFMI were statistically significantly associated with liver steatosis. The results of our study indicate that CIF patients on HPN therapy experience a low risk of liver disease if they adhere to a well-controlled treatment regime. We found that MRI is an appropriate diagnostic tool for monitoring liver steatosis in patients on long-term PN. With respect to already known risk factors for liver steatosis, we did find a newly described association between FFMI and liver steatosis.

Home parenteral nutrition provision modalities for chronic intestinal failure in adult patients: An international survey

The safety and effectiveness of a home parenteral nutrition (HPN) program depends both on the expertise and the management approach of the HPN center. We aimed to evaluate both the approaches of different international HPN-centers in their provision of HPN and the types of intravenous supplementation (IVS)-admixtures prescribed to patients with chronic intestinal failure (CIF). In March 2015, 65 centers from 22 countries enrolled 3239 patients (benign disease 90.1%, malignant disease 9.9%), recording the patient, CIF and HPN characteristics in a structured database. The HPN-provider was categorized as health care system local pharmacy (LP) or independent home care company (HCC). The IVS-admixture was categorized as fluids and electrolytes alone (FE) or parenteral nutrition, either commercially premixed (PA) or customized to the individual patient (CA), alone or plus extra FE (PAFE or CAFE). Doctors of HPN centers were responsible for the IVS prescriptions. HCC (66%) was the most common HPN provider, with no difference noted between benign-CIF and malignant-CIF. LP was the main modality in 11 countries; HCC prevailed in 4 European countries: Israel, USA, South America and Oceania (p<0.001). IVS-admixture comprised: FE 10%, PA 17%, PAFE 17%, CA 38%, CAFE 18%. PA and PAFE prevailed in malignant-CIF while CA and CAFE use was greater in benign-CIF (p<0.001). PA+PAFE prevailed in those countries where LP was the main HPN-provider and CA+CAFE prevailed where the main HPN-provider was HCC (p<0.001). This is the first study to demonstrate that HPN provision and the IVS-admixture differ greatly among countries, among HPN centers and between benign-CIF and cancer-CIF. As both HPN provider and IVS-admixture types may play a role in the safety and effectiveness of HPN therapy, criteria to homogenize HPN programs are needed so that patients can have equal access to optimal CIF care.

Home Parenteral Nutrition in Patients with Intestinal Failure: Possible Undetected Complications.

Background: Septic pulmonary embolism (SPE) may be a frequently undetected complication of central venous catheter (CVC)-related bloodstream infections (CRBSIs). Materials and Methods: The incidence of SPE was evaluated in a cohort of non-oncological patients on home parenteral nutrition (HPN) who were hospitalized for a CRBSI from January 2013 to December 2017. The main clinical, microbiological, and radiological features and the therapeutic approach were also described. Results: Twenty-three infections over 51,563 days of HPN therapy were observed, corresponding to an infection rate of 0.45/1000. In 10 out of the 23 cases (43.5%), pulmonary lesions compatible with SPE were identified. Conclusion: Our results demonstrated that a CRBSI can produce asymptomatic SPE with lung infiltrates in 43.5% of the cases, suggesting the need to check for secondary lung infections to choose the most appropriate antimicrobial therapy.

Challenges and Obstacles of Long-Term Home Parenteral Nutrition.

Patients receiving long-term home parenteral nutrition (HPN) and clinicians managing their care face complex challenges not fully addressed by existing clinical practice guidelines. This review aims to increase awareness of some of the challenges encountered when managing patients receiving HPN and provide strategies for management. The ability to optimally manage these patients starts with involvement of a qualified team of clinicians, which is sometimes difficult to find. There are unique challenges related to the parenteral nutrition (PN) prescribing and compounding process that are not typically encountered with inpatient use. Clear communication is required between the HPN prescriber/team and the home infusion pharmacist to prevent errors related to misinterpretation of the order and PN product shortages. Dependency on HPN and living with chronic disease create a number of psychosocial, financial, and other lifestyle restrictions that can negatively impact a patient's quality of life. HPN nonadherence is a challenge that complicates the clinician's ability to accurately assess and make appropriate adjustments to therapy. HPN adherence may be improved by incorporating a patient-centered approach to care that allows patients to prioritize those issues most meaningful and valuable to them. Patient-centered care also encourages self-care and relies on a high level of HPN education. Clinicians are encouraged to use an interactive interview style when engaging patients to prioritize goals of care and make self-motivated decisions for change. In spite of challenges, HPN therapy has allowed patients the ability to maintain adequate nutrition and thrive in the home setting when the oral/enteral route fails.

Home parenteral nutrition therapy (HPNT) panorama from Turkey (2009–2017)

Home parenteral nutrition therapy (HPNT) panorama from Turkey (2009–2017)

Nutrition Management of Home Parenteral Nutrition Among Patients With Enterocutaneous Fistula in the Sustain Registry.

Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications. This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ2 as appropriate. There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal-weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly. The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.

神経性食欲不振症患者への在宅中心静脈栄養法の導入の試み(摂食障害の治療の進歩,2012年,第53回日本心身医学会総会ならびに学術講演会(鹿児島))

神経性食欲不振症患者への在宅中心静脈栄養法の導入の試み(摂食障害の治療の進歩,2012年,第53回日本心身医学会総会ならびに学術講演会(鹿児島))

The Prevalence of Vitamin D Insufficiency and Deficiency and Their Relationship with Bone Mineral Density and Fracture Risk in Adults Receiving Long-Term Home Parenteral Nutrition.

It has been demonstrated that low bone mass and vitamin D deficiency occur in adult patients receiving home parenteral nutrition (HPN). The aim of this study is to determine the prevalence of vitamin D insufficiency and deficiency and its relationship with bone mineral density (BMD) and fracture risk in long-term HPN patients. Methods: A retrospective chart review of all 186 patients in the HPN registry followed by the Northern Alberta Home Parenteral Nutrition Program receiving HPN therapy >6 months with a 25 (OH) D level and BMD reported were studied. Results: The mean age at the initiation of HPN was 53.8 (20–79) years and 23 (37%) were male. The mean HPN duration was 56 (6–323) months and the most common diagnosis was short bowel syndrome. Based on a total of 186 patients, 62 patients were categorized based on serum vitamin D status as follows: 1 (24.2%) sufficient, 31 (50%) insufficient and 16 (25.8%) deficient. Despite an average of 1891 IU/day orally and 181 IU/day intravenously vitamin D, the mean vitamin D level was 25.6 ng/mL (insufficiency) and 26.2 ± 11.9 ng/mL in patients with the highest 10-year fracture risk. Conclusion: Suboptimal vitamin D levels are common among patients on long-term HPN despite nutrient intake that should meet requirements.

Management of Crohn's Disease in the New Era of Gut Rehabilitation and Intestinal Transplantation.

Despite recent therapeutic advances, patients with Crohn's disease (CD) continue to experience high recurrence with cumulative structural damage and ultimate loss of nutritional autonomy. With short bowel syndrome, strictures, and enteric fistulae being the underlying pathology, CD is the second common indication for home parenteral nutrition (HPN). With development of intestinal failure, nutritional management including HPN is required as a rescue therapy. Unfortunately, some patients do not escape the HPN-associated complications. Therefore, the concept of gut rehabilitation has evolved as part of the algorithmic management of these patients, with transplantation being the ultimate life-saving therapy. With type 2 intestinal failure, comprehensive rehabilitative measures including nutritional care, pharmacologic manipulation, autologous reconstruction, and bowel lengthening is often successful, particularly in patients with quiescent disease. With type 3 intestinal failure, transplantation is the only life-saving treatment for patients with HPN failure and intractable disease. With CD being the second common indication for transplantation in adults, survival outcome continues to improve because of surgical innovation, novel immunosuppression, and better postoperative care. Despite being a rescue therapy, the procedure has achieved survival rates similar to other solid organs, and comparable to those who continue to receive HPN therapy. With similar technical, immunologic, and infectious complications, survival is similar in the CD and non-CD recipients. Full nutritional autonomy is achievable in most survivors with better quality of life and long-term cost-effectiveness. CD recurrence is rare with no impact on graft function. Further progress is anticipated with new insights into the pathogenesis of CD and mechanisms of transplant tolerance.

A Descriptive Study of the Risk Factors Associated With Catheter-Related Bloodstream Infections in the Home Parenteral Nutrition Population.

Home parenteral nutrition (HPN) is increasingly used for nutrition support after patients are discharged from the hospital. Catheter-related bloodstream infections (CR-BSI) are a common and potentially fatal complication of HPN. The risk factors for development of CR-BSI in the outpatient setting are poorly understood. We conducted an observational, retrospective study of 225 patients discharged from Barnes-Jewish Hospital on HPN between January 1, 2007, and December 31, 2009. HPN complications were defined as any cause that led to either premature discontinuation of HPN therapy or catheter replacement. CR-BSI events were identified by provider documentation. We calculated the overall complication rate and the complication rate specifically due to CR-BSI. Backward stepwise Cox regression analyses were used to assess for independent predictors of catheter-related complications. In total, 111 of 225 patients (49%) developed complications while receiving HPN (incidence = 5.06 episodes/1000 catheter days). Sixty-eight of 225 patients (30%) required catheter removal for CR-BSI (incidence = 3.10 episodes/1000 catheter days). Independent predictors of line removal specifically due to infection included anticoagulant use, ulcer or open wound, and Medicare or Medicaid insurance. The following risk factors were associated with catheter-associated complications and/or CR-BSI: the presence of ulcers, the use of systemic anticoagulants, public insurance (Medicare or Medicaid), and patient age. Independent predictors of line removal for any complication included age and anticoagulant use. Catheter-related complications were extremely common in patients receiving HPN. Healthcare providers caring for individuals who require HPN should be aware of risk factors for complications.

Evaluating catheter complications and outcomes in patients receiving home parenteral nutrition.

We describe catheter complications and outcomes in patients who received home parenteral nutrition (HPN) therapy. Retrospective chart data were obtained from Boston Home Infusion agency that provided HPN therapy to 212 patients [International Classification of Diseases, 9th revision (ICD-9) codes: gastrointestinal (GI)-related disorders and oncology] between 1 January 2005 and 30 September 2011. Of the 163 patients who represented 19104 home-catheter days, 19 (11.7%) patients experienced 25 catheter complications (CCs; 12 occlusions, 11 central line-associated bloodstream infections, one thrombosis and one line dislodgment). The overall CC rate was 1.30 per 1000 peripherally inserted central catheter (PICC)-line days. The mean number of PICC-line days (278.7 ± 335.0 vs. 95.9 ± 154.0) and patients with at least one hospital admission were significantly higher for patients with one or more CCs compared with patients with no CCs (P<0.03). Patients who experienced CCs had more PICC-line days, more hospital admissions and had an ICD-9 code for GI-related disorders compared with patients with oncology-related diagnoses.

Home Parenteral Nutrition Program and Referral of Potential Candidates for Intestinal and Multivisceral Transplantation in a Single Brazilian Center

Intestinal failure is a multifaceted condition that may require high-complexity treatment and a multidisciplinary program, including home parenteral nutrition therapy (HPNT) and intestinal transplantation. In this article, we profile a Brazilian single-center experience with 128 cases of HTPN followed for the last 30 years and appraise the referral for potential intestinal and multivisceral transplantation.

Tu1279 Predictors of Catheter Related Hospitalizations in Patients Receiving Home Parenteral Nutrition Therapy: A Tertiary Care Experience

Tu1279 Predictors of Catheter Related Hospitalizations in Patients Receiving Home Parenteral Nutrition Therapy: A Tertiary Care Experience