Intradialytic Parenteral Nutrition Research Articles

Tackling PEW-associated muscle wasting in patients on haemodialysis: Going beyond the basics with intradialytic parenteral nutrition

Tackling PEW-associated muscle wasting in patients on haemodialysis: Going beyond the basics with intradialytic parenteral nutrition

Efficacy and Safety of Intradialytic Parenteral Nutrition Using ENEFLUID in Malnourished Patients Receiving Maintenance Hemodialysis: A Multicenter, Randomized, Open-Label Study

Efficacy and Safety of Intradialytic Parenteral Nutrition Using ENEFLUID in Malnourished Patients Receiving Maintenance Hemodialysis: A Multicenter, Randomized, Open-Label Study

Evaluation of Intradialytic Parenteral Nutrition Indication: Mirage or Reality?

Evaluation of Intradialytic Parenteral Nutrition Indication: Mirage or Reality?

#1530 Studying parenteral nutrition in patients with dialysis stage chronic kidney disease

Abstract Background and Aims Hemodialysis is associated with high rates of morbidity and mortality, as well as poor quality of life. Changes in nutritional status and loss of protein and energy are important indicators of these risks. Maintaining optimal nutritional status in hemodialysis patients is an important but sometimes overlooked aspect of treatment. In some cases, intradialytic parenteral nutrition is possible, but lack of knowledge about the practical aspects of administration is rarely discussed. The purpose of our study was to study the age-related characteristics of the nutritional status in patients with CKD of the dialysis stages who are on parenteral nutrition. Method The study included 40 patients with stage C5 CKD. Glomerular filtration rate (eGFR) was estimated using the CKD-EPI formula (2011) [11]. Anthropometric data were studied: height, weight, body mass index (BMI), mid-thigh circumference and mid-upper arm circumference, as well as laboratory data: urea, creatinine, electrolytes, albumin, total protein, hemoglobin. All patients underwent instrumental research methods: ECG, EchoCG. The patients were divided into 2 groups – with and without PEM. Statistical data processing was carried out according to standard methods using a computer program package. Results Total body water (TBW) (P = 0.026) and triceps skinfold thickness (P < 0.05) were higher in the hemodialysis group. BMI and other anthropometric parameters showed no significant differences between the two groups. Total caloric intake (P < 0.05) and total cholesterol (P < 0.05) were higher in patients with PEM. Intake of other nutrients, including proteins, lipids, microelements and vitamins, did not show significant differences between the two groups. Only 24% of patients were malnourished. Triglyceride levels were higher in non-malnourished patients, but HDL levels were higher in malnourished patients. Some anthropometric indicators were significantly higher in patients not suffering from PEM. It is worth noting that malnourished patients consumed more calories and nutrients, including proteins, plant lipids, animal lipids and carbohydrates. Conclusion Compared with malnutrition patients and non-malnutrition patients, several anthropometric parameters, including subiliac skinfold thickness and MAC, were significantly lower in the malnutrition group. These values can be measured using simple methods and are used as a useful method for assessing malnutrition. Interestingly, patients with malnutrition and lower BMI albumin actually consumed more calories and nutrients from food. This means that malnutrition in dialysis patients is not simply caused by low food intake.

Intradialytic parenteral nutrition in malnourished patients with chronic kidney disease: a systematic review

Introduction: Malnutrition is a prevalent condition among patients with chronic kidney disease (CKD). Objective: To answer the question of the effect of intradialytic parenteral nutrition (IPN) on malnourished CKD patients undergoing dialysis, a systematic review of clinical trials was performed. Methods: The systematic review was performed according with PRISMA. The review was carried out between September and October 2022. The search strategy included PubMed, Web of Science and LILACS databases. The selection of articles was carried out using the Rayyan platform and to assess the chance of bias, the Rob2 instrument recommended by Cochrane was employed. Results and Conclusions: From 762 article retrieved in the initial strategy only 4 articles were included in the review. In a general view, the use of IPN increased the levels of prealbumin and albumin in the participants. Studies evaluating this topic are sparse. More studies are needed to recommend the use of IPN universally in the context of malnourished patients with CKD.

How Can We Improve the Appetite of Older Patients on Dialysis in Japan?

It is necessary to ensure adequate energy and protein intake in dialysis patients. However, in addition to the decline in dietary intake in older dialysis patients due to aging, the rate of anorexia is high in dialysis patients, which increases the risk of protein–energy wasting (PEW), sarcopenia, and frailty. There are many causes of anorexia in dialysis patients, including older dialysis patients, and approaches to improve the appetite of such patients have been reported; however, there has been no established approach to improve appetite adequately. Therefore, a key practical goal is to identify anorexia early and implement timely interventions before weight loss occurs. Appetite assessment tools and weight loss assessments are helpful for the screening and early identification of anorectic signs. Nutritional interventions include reducing dietary restrictions, using oral nutritional supplements, and intradialytic parenteral nutrition, as well as replenishing energy, protein, and zinc to prevent the development of nutritional disorders among older dialysis patients. Appetite assessments, early intervention, and dietary and nutritional counseling are key to improving appetite in these patients. The aging rate of dialysis patients in Japan is unprecedented globally, and I believe that this is a situation that will eventually occur in other countries as well. I discuss the factors that contribute to anorexia, especially in older dialysis patients, and Japan’s efforts to address this problem, such as the relaxation of dietary restrictions and the use of oral nutritional supplements.

The Administration of Intradialytic Parenteral Nutrition Does Not Affect the Anemia Status of Chronic Kidney Disease Patients Undergoing Hemodialysis

Background: Hemodialysis (HD) patients are susceptible to malnutrition, and there is a close relationship between malnutrition and the incidence of anemia. Parenteral nutrition plays a role in treating malnutrition. Objective: This study aims to determine the effect of parenteral nutrition on anemia in HD patients. Methods: Quasi-experimental research which is part of the nutritional research tree at the Hemodialysis Unit of RSUP Dr. Soetomo Surabaya for 3 months. A total of 45 malnourished CKD patients (SGA B & C) undergoing routine HD were included in this study (n=26 received regular diet & education, n=17 received regular diet, education and intradialytic parenteral nutrition, and n=2 dropped out of school due to blood transfusion). Measurements of body mass index (BMI), hemoglobin (Hb), serum iron (SI), and total iron binding capacity (TIBC) were carried out before and 8 weeks after therapy. Between groups used the Mann-Whitney test, while pre and post used the Wilcoxon matched-pairs sign rank test. Results: The treatment group was older than the control group. There was no difference in duration of HD between groups. Intradialytic parenteral nutrition had no effect on BMI (24.71±3.939 vs 24.71±4.026; p=0.3802), Hb (9.746±1.309 vs 9.162±1.960; p= 0.3525), SI (62.33±34.74 vs. 53.78±24.89; p=0.3594), and TIBC (242.8±119.0 vs. 197.3±43, 65; p=0.4258). Conclusion: In HD patients, intradialytic parenteral nutrition for 8 weeks did not affect Hb, SI and TIBC levels. Long-term observations with larger samples are needed to confirm these findings.

Providing Intradialytic Parenteral Nutrition Therapy Does Not Improve Anthropometric Status in Hemodialysis Patients with Malnutrition

Background: Malnutrition is prevalent in hemodialysis patients and significantly impacts prognosis. It can result from reduced food intake and protein loss during hemodialysis. Nutritional status is determined through anthropometric examinations, which include upper arm circumference (UAC), body mass index (BMI), hand grip strength, bicep, and tricep fold thickness. Laboratory examinations like total cholesterol and Malnutrition Inflammation Score (MIS) or Subjective Global Assessment (SGA) are also used. Intradialytic Parenteral Nutrition (IDPN) is expected to maintain or improve the nutritional status of hemodialysis patients. Objective: This research examines the impact of parenteral nutrition therapy on the anthropometric status of malnourished hemodialysis patients. Methods: This cross-sectional study, a sub-analysis of a larger nutritional therapy study, involved 24 hemodialysis patients experiencing malnutrition based on SGA B and C criteria with 1-10 years of hemodialysis. IDPN therapy was provided, and anthropometric measurements and total cholesterol were taken at baseline and three months after nutritional therapy. Data processing used comparative statistical analysis. Results: The mean age was 45.33 years, with 14 males and 10 females. After 3 months, there were no significant differences in UAC (mean difference = 0.13; p = 0.69), BMI (mean difference = 0.13; p = 0.50), hand grip strength (mean difference = -0.96; p = 0.282), biceps skinfold thickness (mean difference = 0.13; p = 0.69) and triceps (mean difference = 0.59; p = 0.134) or total cholesterol (mean difference = -1.5; p = 0.71). Conclusion: IDPN therapy for 3 months did not improve the anthropometric status of hemodialysis patients with malnutrition.

Practical Aspects of Providing Intradialytic Parenteral Nutrition for Hemodialysis Patients in Indonesia

This paper conducts a comprehensive literature review on the administration of intradialytic parenteral nutrition (IDPN) for patients undergoing hemodialysis (HD) in Indonesia. The objective is to assess the current status and challenges associated with IDPN in the country and propose potential strategies for enhancement. The review, encompassing articles published between 2013 and 2023 from databases such as PubMed, Scopus, and Google Scholar, exposes significant risks and the prevalence of malnutrition, particularly protein-energy wasting (PEW), among patients undergoing HD. This patient cohort often necessitates nutritional therapy, and IDPN emerges as a viable option for both prevention and definitive treatment. However, detailed data on malnutrition among HD patients in Indonesia are limited. Challenges include a shortage of nutrition experts in kidney care, low patient adherence to dietary advice, and the inability of Indonesian hospitals to provide IDPN to malnourished hemodialysis patients. The non-uniform cost coverage by the National Health Insurance further complicates matters, despite consumable costs for HD being uniform across all hospitals. The payment system by BPJS does not accommodate the provision of parenteral IDPN with varying prices, as listed in the e-catalog by the national public procurement agency. To offer IDPN to patients, hospitals must achieve cost-efficiency within their HD units, or they risk financial losses. Currently, IDPN is exclusively administered to HD patients with acute conditions in an inpatient setting. A recommendation for policymakers is to explore the adoption of distinct tariffs for HD patients undergoing outpatient care, particularly those managing complex conditions such as PEW. This approach can contribute to improved nutritional support for hemodialysis patients in Indonesia.

Simply adding oral nutritional supplementation to haemodialysis patients may not be enough: a real-life prospective interventional study.

Protein-energy wasting (PEW) is a common and serious co-morbidity in haemodialysis (HD) patients. Its importance as a prognostic factor has been increasingly recognised during the past decades. Much effort has been invested in the improvement of nutritional status and amelioration of consequences through different therapeutic approaches, either intradialytic parenteral nutrition or more commonly oral nutritional supplementation. In the article, we present the results of a prospective study in HD patients after 12 months of therapeutic intervention with oral nutritional supplements (ONS). A total of 92 HD adult patients were enrolled in the study after 3 months of wash-out period. Baseline nutritional status was assessed using composite scores, laboratory markers, bioelectrical impedance analysis, and hand-grip strength test. Patients recognised as undernourished or at high risk for undernutrition received renal-specific commercially available ONS on HD day in addition to their regular diet. After 12 months, the effect of ONS on surrogate markers of undernutrition, serum albumin level, phase angle, and hand-grip strength was analysed in 71 surviving patients. After 12 months, data for 71 patients, 39 (54.9%) men, 62.4 ± 12.9 years, and median haemodialysis vintage 53.3 (IQR 27.5-92.8) months, were available. Patients were divided into three groups: group A patients were with normal nutritional status at baseline not necessitating ONS; group B patients received ONS; and group C patients were entitled to receive but refused to take ONS. The baseline results showed statistically significant differences between the groups in serum albumin levels and phase angle but not hand-grip strength. Differences between the groups remained statistically significant at month 12; we did not find any statistically significant positive changes within the groups, indicating no positive effect of intervention with ONS. In a prospectively designed interventional single-centre study, we did not find a statistically significant change in surrogate markers of PEW in our cohort of HD patients, receiving ONS for 12 months. Since PEW is an independent risk factor influencing the survival of HD patients, efforts should be directed towards a timely and comprehensive nutritional approach, including intensive, personalised dietary counselling, increase in protein and energy intake and advocating tight control of nutritional status during HD treatment, possibly providing psychological support and motivation.

Frailty in hemodialysis patients: results of a screening program and multidisciplinary interventions.

The number of frail patients of advanced age with end-stage kidney disease (ESKD) undergoing hemodialysis is increasing globally. Here we evaluated a frailty screening program of ESKD patients starting hemodialysis, and subsequent multidisciplinary interventions. This was a prospective observational study of ESKD patients in a hemodialysis program. Patients were evaluated for frailty (Fried frail phenotype) before and after a 12-month period. Patients followed standard clinical practice at our hospital, which included assessment and multidisciplinary interventions for nutritional (malnutrition-inflammation score, protein-energy wasting), physical [short physical performance battery (SPPB)] and psychological status. A total of 167 patients (mean±standard deviation age 67.8±15.4 years) were screened for frailty, and 108 completed the program. At screening, 27.9% of the patients were frail, 40.0% pre-frail and 32.1% non-frail. Nutritional interventions (enrichment, oral nutritional supplements, intradialytic parenteral nutrition) resulted in stable nutritional status for most frail and pre-frail patients after 12 months. Patients following recommendations for intradialytic, home-based or combined physical exercise presented improved or stable in SPPB scores after 12 months, compared with those that did not follow recommendations, especially in the frail and pre-frail population (P=.025). A rate of 0.05 falls/patient/year was observed. More than 60% of frail patients presented high scores of sadness and anxiety. Frailty screening, together with coordinated interventions by nutritionists, physiotherapists, psychologists and nurses, preserved the health status of ESKD patients starting hemodialysis. Frailty assessment helped in advising patients on individual nutritional, physical or psychological needs.

Recent Advances in the Nutritional Screening, Assessment, and Treatment of Japanese Patients on Hemodialysis

Patients on hemodialysis (HD) have a higher rate of protein-energy wasting (PEW) due to lower dietary intake of energy and protein (particularly on dialysis days) and greater loss of many nutrients in the dialysate effluent than other patients. The most well-known method of nutritional screening is the subjective global assessment. Moreover, the Global Leadership Initiative on MalnutIrition has developed the first internationally standardized method for diagnosing malnutrition; however, its use in patients on HD has not been established. In contrast, the nutritional risk index for Japanese patients on HD has recently been developed as a screening tool for malnutrition in patients on HD, based on the modified PEW criteria. These tools are beneficial for screening nutritional disorders, enabling registered dietitians to assess patients' dietary intake on dialysis and non-dialysis days and provide advice on dietary intake, especially immediately after dialysis cessation. Oral supplementation with enteral nutrients containing whey protein may also be administered when needed. In patients that experience adverse effects from oral supplementation, intradialytic parenteral nutrition (IDPN) should be combined with moderate dietary intake because IDPN alone cannot provide sufficient nutrition.

Effect of Intra-Dialytic Parenteral Nutrition (IDPN) on malnourished maintenance haemodialysis patients - Case Series.

Ceylon Medical Journal (CMJ) is a peer-reviewed, open access journal published quarterly by the Sri Lanka Medical Association in the last week of March, June, September and December each year. The mission of the CMJ is to promote the science and art of medicine and betterment of public health. The Journal publishes original papers and commentaries which have relevance to medicine and allied sciences. The CMJ is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on ’Access to pharmacist and dietitian at HD units’ (2.65 ± 0.21) and ’Access to continuous medical education on managing PEW patients on HD’ (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

Intradialytic parenteral nutrition using a standard amino acid solution not for renal failure in maintenance hemodialysis patients with malnutrition: a multicenter pilot study

BackgroundStandard amino acid solutions have recently been removed from the contraindications for use in dialysis patients in Japan. However, the details of their safety and efficacy in these patients are still not known. In this study, we investigated the safety and efficacy of intradialytic parenteral nutrition (IDPN) using ENEFLUID® injection containing standard amino acids, glucose, electrolytes, fats, and water-soluble vitamins in maintenance hemodialysis patients with malnutrition.MethodsThis clinical trial was designed as a multicenter, prospective, non-randomized, open-label, single-arm, observational pilot study. The participants were patients on maintenance hemodialysis who were in the nutritional high-risk group according to the Nutritional Risk Index for Japanese Hemodialysis Patients. One bag of ENEFLUID® injection was administered during every hemodialysis session for 12 weeks. The primary endpoint was change in serum transthyretin levels between before and after the 12-week period. As safety endpoints, we evaluated changes in body fluid volume and blood biochemical tests, including blood urea nitrogen and electrolytes, as well as blood glucose variability using flash glucose monitoring (FGM).ResultsThe mean age and body mass index of the 13 participants were 79.0 ± 10.7 years and 18.0 ± 1.7 kg/m2, respectively. No significant changes were observed in nutritional parameters, including serum transthyretin, between before and after the start of the study. After IDPN initiation, there was no obvious fluid overload or significant changes in blood biochemical tests, including electrolytes, and the treatment could be safely continued for 12 weeks. In the FGM analysis, asymptomatic hypoglycemia during hemodialysis was observed at the beginning of the study, but there was a trend toward improvement after 12 weeks (area over the curve < 70 mg/dl per dialysis session: 747.5 ± 1333.9 to 21.6 ± 54.3, P = 0.09).ConclusionsIDPN using ENEFLUID® injection can be safely continued, although it does not significantly improve markers of nutritional status. It also showed the potential to ameliorate asymptomatic hypoglycemia during hemodialysis sessions. More detailed studies of the improvement in nutritional indicators are needed.Trial registration: This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) on May 9, 2021 (registration ID, UMIN000044051).

Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom?

Hemodialysis is associated with high morbidity and mortality rates as well as low quality of life. Altered nutritional status and protein-energy wasting are important indicators of these risks. Maintaining optimal nutritional status in patients with hemodialysis is a critical but sometimes overlooked aspect of care. Nutritional support strategies usually begin with dietary counseling and oral nutritional supplements. Patients may not comply with this advice or oral nutritional supplements, however , or compliance may be affected by other complications of progressive chronic kidney disease. Intradialytic parenteral nutrition (IDPN) may be a possibility in these cases, but lack of knowledge on practical aspects of IDPN delivery are seldom discussed and may represent a barrier. In this review, we, as a consensus panel of clinicians experienced with IDPN, survey existing literature and summarize our views on when to use IDPN, which patients may be best suited for IDPN, and how to effectively deliver and monitor this strategy for nutritional support.

Amino acid availability enhanced through glucose coadministration of amino acid supplementation during hemodiafiltration: two case reports

BackgroundIntravenous administration of amino acid (AA) formulation (IVAA) as intradialytic parenteral nutrition is widely used for malnourished patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) or hemodiafiltration (HDF). Although various therapy recipes such as AA compositions or simultaneous administration of glucose and/or lipids have been attempted, the specific effects of each recipe on AA behaviors and metabolic consequences have not been well investigated. To clarify the effect of simultaneous glucose administration with IVAA, we investigated the behavior of AAs, insulin as a metabolic hormone, and energy-related metabolites during an HDF session in two patients.Case presentationWe aimed to determine the effect of IVAA with or without simultaneous glucose administration. The plasma levels of AAs, branched-chain AAs (leucine, isoleucine, and valine), major nonessential AAs (alanine and glutamine with glutamate), insulin, glucose, and ketone bodies were measured before HDF and at the second hour (prior to the meal in the HDF session). Lost AAs in the spent dialysate were also measured for the first two hours during the HDF session.ConclusionIn the absence of glucose administration, plasma AA levels and the loss of AAs in the dialysate increased owing to IVAA, with the increase in plasma levels in ketone bodies occurring because of scarce secretion of plasma insulin. In the presence of glucose administration, plasma levels and the loss of AA decreased even when the same amount of AAs was injected, possibly because of the profound secretion of insulin with a decrease in ketone bodies. The present findings suggest that the metabolic effects of simultaneous glucose administration on IVAAs enhanced AA uptake into the body during HDF sessions, which might increase the effectiveness of IVAAs.

The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial

In hemodialysis (HD) patients, protein-energy wasting (PEW) is highly prevalent and firstly treated with oral nutritional supplements (ONS). The extent to which intradialytic parenteral nutrition (IDPN) contributes to improve PEW status in HD patients intolerable to ONS remains unclear. Maintenance PEW HD patients being unable to tolerate ONS adverse effects, and having spontaneous energy and protein intake of ≥ 20 kcal/kg/day and ≥ 0.8 g/kg/day, respectively were randomly assigned 1:1 into IDPN and control groups. In IDPN group, most concentrated 3-in-1, fish-oil based parenteral nutrition was infused during HD for 3 months. The control group received intensive dietary counselling once weekly for 3 months. Both groups were then followed for additional 3 months after intervention. A total of 38 patients were randomized (mean age 67.6 years). After 3 months, serum albumin was significantly higher in the IDPN (n = 18) compared with control group (from 3.5 ± 0.3 to 3.8 ± 0.2 vs from 3.6 ± 0.3 to 3.5 ± 0.3 g/dL, respectively, p = 0.01). Spontaneous dietary intake (p = 0.04), body weight (p = 0.01), and malnutrition inflammation score (MIS, p = 0.01) were improved in the IDPN, but not in the control group. Muscle mass, strength, serum prealbumin, interleukin-6, high sensitivity-c reactive protein, and acylated ghrelin were not significantly different but leptin levels increased in the control group after 3 months (p = 0.03). At 6 months, serum albumin in the IDPN group was persistently higher than baseline (p = 0.04). Neither volume overload nor uncontrolled hyperglycemia was found throughout the study. In conclusion, a 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and MIS; and appeared to be superior to continuing intensive dietary counselling among HD patients intolerable to ONS. The impacts of IDPN therapy on clinical outcomes may require larger scale with longer period of study.

POS-013 PROTEIN ENERGY WASTING IN ACUTE KIDNEY INJURY REQUIRING HEMODIALYSIS AND INTRADIALYTIC PARENTERAL NUTRITION

A 78-year-old female with a previous diagnosis of type 2 diabetes mellitus attended to the emergency room after presenting dyspnea of small efforts, chest pain and generalized edema of three days of evolution, as well as a history of decreased food intake from approximately 8 months related to depressive disorder. Upon admission on 12/30/2020, laboratories report serum creatinine 6.70mg/dL (glomerular filtration= 7.2mL/min/1.73m2 by CKD-EPI), urea106.30 mg/dL, potassium 8.01mmol/L, glucose 297 mg/dL; electrocardiographic findings of peaked T waves, widened QRS and supraventricular tachycardia. Admission weight= 44Kg, height= 1.52 m, BMI=19.04 Kg/m2. Nutritional risk was assessed through Malnutrition Universal Screening Tool (MUST) which scored 4 (high risk of malnutrition). The patient was admitted to the hospital with the following diagnoses: Uncontrolled type 2 diabetes mellitus, acute kidney injury KDIGO 3, severe hyperkalemia and protein energy wasting (PEW). Right jugular tunneled vascular access was placed and an urgent hemodialysis session was scheduled at the same day. After three hemodialysis sessions control laboratories were carried out: serum creatinine 3.34mg/dL, urea 53 mg/dL, albumin3.7 mg/dL, potassium4.69 mmol/L. As the patient showed improvement in clinical and biochemical parameters, she was discharged from hospital, and she continued treatment with outpatient hemodialysis two sessions per week. Nutritional counsel was given. During the follow-up, a tendency to decrease in weight prior to hemodialysis sessions was detected, the relatives reported that the patient persisted with low dietary intake (<10kcal /kg ideal weight/day) still related to depressive disorder, so that nutritional status was assessed again founding severe protein energy wasting thus, we decided to start with intradialytic parenteral nutrition (IDPN) on 01/29/2021 in order to increase caloric-protein intake and improve clinical prognosis. It was started with standard emulsion for infusion of 1100 Kcal/986 ml placed in a venous chamber with infusion pump, with good tolerance from the first occasion and continues to be administered during the following 8 sessions. During this period there were no episodes of catheter-related bacteremia, infections or complications associated with treatment; the infusion of parenteral emulsion did not interrupt or complicate the proper functioning of any hemodialysis session. The patient reported a constant increase in her dietary intake evidenced by a desirable increase in dry weight, which is why IDPN was suspended and dialysis doses were progressively decreased until her withdrawal. The patient continues to be followed up and by the last assessment (08/11/2021) her weight increased to 57 Kg without data of water overload, serum creatinine decreased to 1.07mg/dL, urea 47.60mg/dL, and BUN 22.2 mg/dL. The lessons learned from this case are:

The Beneficial Effects of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients: A Randomized Controlled Trial

The Beneficial Effects of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients: A Randomized Controlled Trial