Mean Duration Of Home Parenteral Nutrition Research Articles

Long term clinical outcomes of home parenteral nutrition in Singapore.

Home parenteral nutrition (HPN) is a life sustaining therapy for patients with chronic intestinal failure. Reported outcomes for Asian HPN patients are scarce. We aim to review the clinical outcomes of adult and paediatric HPN patients in our cohort which caters for 95% of Singaporean HPN patients. This is a retrospective review of HPN patients from an adult (2002-2017) and paediatric cohort (2011-2017) from the largest tertiary PN centres in Singapore. Patient demographics and clinical outcomes were reviewed. There were 41 adult and 8 paediatric HPN patients. Mean age was 53.0(±15.1) (adults) and 8(±1.8) years-old (paediatrics). Mean duration of HPN was 2.6(±3.5) and 3.5(±2.5) years. Leading indications for adult HPN were short bowel syndrome (SBS) (n=19,46.3%), mechanical obstruction (n=9,22.0%), and gastrointestinal dysmotility disorders (GID) (n=5,12.2%). Thirteen adult (31.7%) patients had underlying malignancy, with seven (17.3%) receiving palliative HPN. Indications for HPN amongst paediatric patients was GID (n=5,62.5%) and SBS (n=3,37.5%). Central line-associated bloodstream infection (CLABSI)/1000catheter-days was 1.0(±2.1) and 1.8(±1.3). Catheter associated venous thrombosis (CAVT)/1000catheter-days was 0.1(±0.4) and 0.7(±0.8). Biochemical Intestinal Failure Associated Liver Disease (IFALD) was found in 21.9% and 87.5%. For adults, median overall survival was 90-months (4.3,175.7,95%CI), with actuarial survival of 70.7%(1-year) and 39.0%(5-years). Median survival for adult patients with malignancy was 6-months (4.2,7.7,95%CI), actuarial survival of 85.7%(3-months) and 30.7%(1-year). One adult patient died from PN related complications. No paediatric deaths were noted. Whilst patient numbers were modest, we report comparable complication and survival rates to other international centres in both our adult and paediatric cohorts.

Home parenteral nutrition and the older adult: Experience from a national intestinal failure unit

The population in developed countries is getting older and with advancing age comes increasing co-morbidity and demand on health care services. The use of home parenteral nutrition (HPN) is also increasing in the UK and elsewhere. Age and co-morbidity need to be taken into consideration when HPN is contemplated because of the significant associated economic burden and clinical risk. However, there are minimal data on HPN outcomes specific to the elderly. We performed an observational study of a prospectively maintained database of patients dependent on HPN managed at a national U.K. referral centre. Data were collected on the 31st March 2018. Charlson index was used to assess co-morbidity. Data included demographics, HPN requirements, underlying disease aetiology, mechanism of intestinal failure, and whether the patient, carer or home care nurses administered the PN. The main outcome was the occurrence of at least one catheter-related blood stream infection (CRBSI) during HPN, with putative predictors of CRBSI assessed by uni- and multi-variable logistic regression. Two hundred and seventy-seven patients were included in this study, 62% were female and the overall mean age of the entire cohort was 58 years (range 20-93). The mean duration of HPN was 1778 days (range 45-12,832). One hundred patients were aged 65 years or older. Patients aged 65 years or older had a higher Charlson index (1.8 vs 1.1, p=<0.0001), were more likely to require a home care nurse to administer PN (p=0.01), and had the lowest risk of CRBSI (25% vs 39%; p=0.01). Home care nurse administration was associated with the lowest risk of CRBSI, followed by carer and self-administration (P=0.001). In multivariable analysis, duration of HPN and CVC care provider were the only independent predictors of CRBSI occurrence. There was no significant difference in unplanned intestinal failure-related hospital admissions between those under or above 65 years of age (p=0.08). HPN can be safely used in patients over the age of 65, even with increased co-morbidity. In this large cohort study, increasing age was found to be protective against CRBSI. CVC care provider was an independent predictor of CRBSI, while age and co-morbidity were not, suggesting that the use of home care nurses for PN administration is the principal reason for the low CRBSI rate in the elderly. Hence, older age should not be seen as a contra-indication for HPN, but increased healthcare resource may be required as those aged over 65 are more likely to require nursing assistance for CVC care.

Catheter-related infections in patients with acute type II intestinal failure admitted to a national centre: Incidence and outcomes

The management of intestinal failure (IF) requires safe and sustained delivery of parenteral nutrition (PN). The long-term maintenance of central venous catheter (CVC) access is therefore vital, with meticulous catheter care and salvage of infected CVCs being of prime importance. CVC-related infection and loss of intravenous access are important causes of morbidity and mortality in IF. Avoidance, prompt recognition and appropriate management of CVC-related infections are crucial components of IF care. However, there are few, if any, data on the occurrence of CVC-related infections in patients with acute, type 2, IF managed on a dedicated IF unit and no data on the salvage outcomes of infected CVCs in this group of patients. This is a retrospective observational study conducted between January 2011 and July 2017. All patients with acute, type 2 IF newly admitted to a national U.K. IF unit (IFU) during these dates were included. All patients admitted to the unit with a CVC in place underwent immediate 'screening' paired central and peripheral blood cultures on arrival before the CVC was used for any infusate. A prospectively maintained database was used to record all confirmed catheter-related blood stream infections (BSI)/colonisations, demographic and clinical data. Diagnosis of catheter-related BSI/colonisation was based on quantitative and qualitative analysis of paired central and peripheral blood cultures. A standardized 10-14-day catheter salvage treatment protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration was used to salvage any infected or colonised CVCs, as appropriate. The CVC was not used for PN until successful salvage had been confirmed by negative blood cultures drawn 48h after antibiotic completion. The development of a subsequent catheter-related BSI was recorded for all patients, both during the remaining in-patient stay on the IFU and after discharge home on PN. Of the 509 patients with type 2 IF admitted to the IFU during the study period, 341 (54% female; mean age 54.6 (range 16-86 years)) had an indwelling CVC that had been placed in the referring hospital. Surgical complications and mesenteric ischaemia were the most common underlying disease aetiologies. Sixty-five of 341 (19.1%) patients had an infected/colonised CVC on the initial screening set of blood cultures. A successful CVC salvage rate of 91% was achieved in this cohort after antibiotic therapy. The subsequent in-patient catheter-related BSI rate for those admitted with a CVC (n=341) on the IFU was 0.042 per 1000 catheter days, over a total of 23,548 in-patient catheter days. Two hundred and seventy nine of 341 patients were discharged on home PN (HPN); with a subsequent catheter-related BSI rate on HPN of 0.22 per 1000 catheter days (mean duration of HPN=778 catheter days (range:)) over a follow-up period of 216,944 out-patient catheter days. There was no increased risk of HPN-related catheter-related BSI (p=0.09) or mortality (p=0.4) in those admitted with an infected CVC. This is the first study to report catheter-related BSI/colonisation rates and salvage outcomes in patients with type 2 IF newly admitted to a dedicated IF Unit. We report that nearly one-fifth of all patients were referred with evidence of a catheter related BSI/colonisation; despite this, successful catheter salvage is possible and, with stringent CVC care, an extremely low subsequent catheter related BSI rates can be achieved and maintained during in-patient stay on a dedicated IF Unit and after discharge on HPN. These data provide novel evidence to support ESPEN recommendations that patients with type 2 IF are managed on a dedicated IF Unit.

Transient Elastography (FibroScan) Is Not Correlated With Liver Fibrosis but With Cholestasis in Patients With Long-Term Home Parenteral Nutrition.

Long-term home parenteral nutrition (HPN) may induce liver disorders. Transient elastography (TE) has been proposed as a noninvasive alternative to liver biopsy analysis for assessment of the progression of hepatic fibrosis to cirrhosis. The goal of this study was to compare values from TE measurements to biopsy-determined stages of histologic fibrosis in patients receiving HPN. In this multicenter prospective study, patients receiving long-term HPN (≥ 6 months) who required a liver biopsy for clinical reasons were included. TE (FibroScan) values for each patient were compared with the degree of hepatic fibrosis measured from biopsy specimens based on the Brunt classification. TE values were also correlated to biochemical and histologic cholestasis. Two noninvasive indices for predicting liver fibrosis (APRI and FIB-4) were also evaluated. Thirty patients were included in this study (mean age, 42.1 years; 63% male). The mean duration of HPN was 100.7 months; 25 patients had a short bowel and 13 had an intestinal stoma. Biochemical cholestasis was described in 22 patients. Liver histologic features varied among these patients. There was no correlation between the values of TE and the stages of histologic fibrosis, but TE values were significantly correlated to serum bilirubin level and the severity of histologic cholestasis as well as APRI and FIB-4 scores. In patients with long-term HPN, TE failed to assess the degree of hepatic fibrosis. This could be due to the heterogeneity of liver histologic features observed in these patients and the presence of chronic cholestasis.

Hypomagnesemia associated with chondrocalcinosis: A cross‐sectional study

To determine an association between magnesium (Mg) depletion and chondrocalcinosis, which has been reported but not investigated in a cross-sectional study. Prevalence of chondrocalcinosis was investigated in 144 individuals: 72 patients receiving home parenteral nutrition (HPN) compared with 72 age- and sex-matched controls. Presence of chondrocalcinosis was assessed by knee radiographs. Blood serum and globular Mg levels and 24-hour urinary Mg content were compared. Mean +/- SD age for both patients and controls was 51 +/- 17 years, and 51% in both groups were women. Mean duration of HPN was 6.4 years. Prevalence of chondrocalcinosis was markedly higher in patients receiving HPN than controls (16.6% versus 2.7%; P = 0.006, odds ratio [OR] 7.0, 95% confidence interval [95% CI] 1.45-66.1). Mean +/- SD serum and globular Mg levels were significantly lower in patients than controls (serum: 0.75 +/- 0.09 mmoles/liter versus 0.81 +/- 0.08 mmoles/liter, P = 0.0006; globular Mg: 1.8 +/- 0.31 mmoles/liter versus 2.0 +/- 0.35 mmoles/liter, P = 0.0003). Twenty-four-hour urinary Mg level was lower in patients than controls (mean +/- SD 3.85 +/- 1.50 mmoles versus 5.37 +/- 3.71 mmoles; P = 0.001). Prevalence of chondrocalcinosis was significantly higher in patients with a low serum Mg level (OR 13.5, 95% CI 2.76-127.3, P < 0.0001), with a similarly high but not significant occurrence of chondrocalcinosis in patients with a low globular Mg level (OR 4.09, 95% CI 0.603-20.26, P = 0.08) and in patients with a low 24-hour urinary Mg level (OR 3.9, 95% CI 0.77-16.34, P = 0.05). Long-lasting Mg depletion is strongly associated with chondrocalcinosis.

Adult Home Parenteral Nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

To evaluate the current use of Home Parenteral Nutrition (HPN) in a Southern European region. A total of 159 (86 m, 73 f) HPN patients, mean age 60.1 +/- 14.2 years, BMI 18.8 +/- 3.3kg/m2, consecutively referred to the Artificial Nutrition outpatient Unit of the Federico II University Hospital in Naples (Italy), from January 2000 to December 2002 and treated for at least 4 weeks. Retrospective evaluation of baseline disease, indications and duration of HPN treatment, type of venous access, complications. In all, 140 (88%) were cancer and 19 (12%) noncancer patients. Main indications were carcinosis in 68 for total, and hypophagia/dysphagia in 62 patients for partial/integrative (to oral-enteral nutrition) HPN; mean duration of HPN was 81.45 +/- 110.86 days of treatment and infection rate 2.89% in the whole population and 2.66% in the 36 patients treated for more than 3 months. No other major complications have been observed. HPN is confirmed to be a safe and effective treatment when prescribed and administered by a trained team.

Prevalence of liver complications in pediatric patients on home parenteral nutrition: indications for intestinal or combined liver-intestinal transplantation

Parenteral nutrition (PN) is the only treatment for patients affected by chronic intestinal failure (CIF). Home parenteral nutrition (HPN) programs are started when patients need prolonged PN. Unfortunately, many patients on prolonged PN develop liver disease (LD). The aim of our study was to assess the prevalence of LD in our series of patients on HPN. We reviewed our records of patients discharged from the hospital on HPN for CIF. HPN was started when one parent was fully trained in the use of this treatment and if the social and familial home environment was reliable. All patients received total PN by a central venous catheter. All patients with abnormal AST, ALT, ALK, γGT, and bilirubin values for more than 3 months were considered affected by PN-related LD. Thirty-six patients (23 of whom were boys and 13 girls) were discharged on HPN. During the study period, for CIF, 16 were affected by short bowel syndrome (SBS), of whom 6 had ultra-short bowel; 16 with functional intestinal failure, and 4 with chronic intestinal pseudobstruction (CIPO). Mean duration of HPN was 2.1 years/patient. Nine of 36 patients (25%) on HPN for CIF showed LD. Seven of the 16 patients (43%) with LD were affected by SBS and 2 (12.5%) patients by functional intestinal failure. No patients with CIPO developed LD. In patients affected by SBS, the onset of LD was very earlier than in patients with ID.

Outcome of patients with radiation enteritis treated with home parenteral nutrition.

Intestinal failure requiring either surgery or home parenteral nutrition (HPN) develops in approximately 5% of patients treated with radiation. The aim of the study was to determine survival, duration of HPN, and complications associated with HPN in patients with intestinal failure after radiation therapy. Fifty-four patients with radiation enteritis who received HPN were studied (39 women and 15 men with a mean age of 57.9 yr). Retrospective data were collected from the patients' medical records dated between 1975 and 1999. The probability of survival was calculated by the Kaplan-Meier method. HPN was initiated a median of 20 months (range = 2-432) from the start of radiation therapy. The mean number of intestinal operations for radiation-related complications was 2.2/patient (range = 0-6). The causes of intestinal failure resulting from radiation therapy were intestinal obstruction (27 patients), short bowel (17), malabsorption (five), fistula (three), and dysmotility (two). The mean duration of HPN was 20.4 months (range = 2-108). At last follow-up, 37 patients (68%) were dead, most as a result of recurrent cancer. One patient died of catheter sepsis, and no other deaths were directly related to HPN. The overall estimated 5-yr probability of survival on HPN calculated by Kaplan-Meier analysis was 64%. HPN is a reasonable treatment option in patients with intestinal failure as a result of radiation enteritis. Survival and complications associated with HPN in patients with radiation enteritis seem to be similar to those in other HPN-treated groups.

Outcome of patients with radiation enteritis treated with home parenteral nutrition

OBJECTIVES: Intestinal failure requiring either surgery or home parenteral nutrition (HPN) develops in approximately 5% of patients treated with radiation. The aim of the study was to determine survival, duration of HPN, and complications associated with HPN in patients with intestinal failure after radiation therapy. METHODS: Fifty-four patients with radiation enteritis who received HPN were studied (39 women and 15 men with a mean age of 57.9 yr). Retrospective data were collected from the patients’ medical records dated between 1975 and 1999. The probability of survival was calculated by the Kaplan-Meier method. RESULTS: HPN was initiated a median of 20 months (range = 2–432) from the start of radiation therapy. The mean number of intestinal operations for radiation-related complications was 2.2/patient (range = 0–6). The causes of intestinal failure resulting from radiation therapy were intestinal obstruction (27 patients), short bowel (17), malabsorption (five), fistula (three), and dysmotility (two). The mean duration of HPN was 20.4 months (range = 2–108). At last follow-up, 37 patients (68%) were dead, most as a result of recurrent cancer. One patient died of catheter sepsis, and no other deaths were directly related to HPN. The overall estimated 5-yr probability of survival on HPN calculated by Kaplan-Meier analysis was 64%. CONCLUSIONS: HPN is a reasonable treatment option in patients with intestinal failure as a result of radiation enteritis. Survival and complications associated with HPN in patients with radiation enteritis seem to be similar to those in other HPN-treated groups.

Central venous catheter-related infections in children on long-term home parenteral nutrition: incidence and risk factors

Background and aims: This study aimed to assess the incidence and etiology of central venous catheter (CVC) infections in children on home parenteral nutrition (HPN). Methods: 207 CVC-years were studied retrospectively in 47 children on HPN, aged 8.1±5.0 years. Results: 125 CVC were used (means: 2.6 CVC/patient and 21 months utilization/CVC). Half of the hospitalizations (162) were due to proven CVC-related infections. The mean infection incidence was 2.1/1000 HPN days. The total population divided in two groups below and above this value: group one including 24 children, incidence ≤ 2.1 per 1000 days (mean: 0.83) and group two including 23 children, incidence >2.1 per 1000 days (mean: 4.3). No differences were found between the two groups in terms of underlying disease, presence of ostomies, age at the time of HPN onset, or micro-organisms responsible. The only differences (p<0.05) were the mean duration of HPN (longer in group one) and the delay between HPN onset and the first infection (longer in group one). Conclusions: This study does not highlight any risk factors for CVC infection. However, early CVC infections after HPN onset appear to predict a bad prognosis.

Risks and Benefits of Home Parenteral Nutrition in the Acquired Immunodeficiency Syndrome

The gastrointestinal tract is a major target of the human immunodeficiency virus. Many AIDS patients have weight loss and/or diarrhea. Parenteral nutrition can be used to treat malnutrition associated with malabsorption. We reviewed retrospectively the clinical course of 22 patients with AIDS and weight loss greater than 10% who received home parenteral nutrition (HPN) for 56.2 patient-months. Mean weight loss was 21.4%, mean duration of HPN 2.55 months, mean age 37.4 years. Fifteen patients gained weight, six stabilized and two continued to lose weight. Nine patients returned to previous activity. Five died. The rates of catheter-related sepsis, complications, and metabolic disturbances were 0.12, 0.25, and 0.12/100 catheter days, respectively, results identical to those reported in other patient populations where HPN is commonly applied. We found that HPN induced weight gain and clinical improvement in most patients without higher risks of sepsis than in patients with malignancies.