Intradialytic parenteral nutrition in malnourished children treated with hemodialysis

Efficacy of intradialytic amino acids on nutritional status in children with stage 5 chronic kidney disease

BACKGROUND

Protein energy wasting (PEW) is a common cause of morbidity and mortality in patients with stage 5 chronic kidney disease (CKD 5). Intradialytic parenteral nutrition (IDPN) has been used as a therapy for preventing and treating PEW in children with CKD 5 when other conventional modalities fail. However, not enough data is available to define its effectiveness in treating malnutrition in children. This study aims to investigate potential benefits of IDPN in Egyptian children with CKD 5.

METHODS

In this prospective, placebo-controlled, parallel-group single blinded study, we enrolled 50 CKD 5 patients; 25 patients (intervention group) received intravenous amino acids (KIDIMN), while 25 patients (control group) received normal saline as placebo, each given during regular dialysis 3 times a week for 9 months. Patients were subjected to nutritional assessment at baseline and 3-, 6-, and 9-month follow-up using height Z-score, hand grip strength (HGS) for muscle power assessment, body composition monitor (BCM) for assessing lean tissue mass (LTM) and adipose tissue mass (ATM), and biochemical measures including serum albumin, serum triglyceride, and serum cholesterol.

RESULTS

When comparing baseline and 9-month follow-up values, significant improvement was recorded in height Z-score, LTM, and serum albumin in the intervention group unlike the control group where no significant changes were recorded.

CONCLUSION

IDPN is proposed to be an effective method for preventing and treating malnutrition in children with CKD 5. However, further multi-centric studies with larger sample size and longer duration of follow-up are still recommended.

Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

Intradialytic Parenteral Nutrition in Pediatrics

Children with end-stage renal disease (ESRD) on hemodialysis are at increased risk for malnutrition. Aggressive nutrition intervention such as intradialytic parenteral nutrition (IDPN) should be considered to prevent further co-morbidities and mortality associated with malnutrition when other interventions fail. IDPN is a non-invasive method of providing nutrition to malnourished hemodialysis (HD) patients via the HD access throughout the HD treatment. Although the evidence on the long-term benefits of IDPN is scant in pediatrics, there is evidence that it improves metabolic parameters and nutritional status. In this paper, therapy with IDPN including indications, goals of therapy, and elements to monitor will be described. In addition, a practice guideline for prescribing IDPN is provided.

Children tolerate intradialytic oral nutrition

BACKGROUND

People undergoing haemodialysis (HD) often have poor nutrition, which in turn can contribute to worse outcomes. Inadequate nutrition has a particularly deleterious effect on growth and neurocognitive development, as well as mortality, in children and adolescents. Nutritional supplementation can improve outcomes but can be difficult to administer.

OBJECTIVE

Determine the tolerability of intradialytic oral nutrition in children and adolescents.

DESIGN

A cross-sectional quality improvement study in an outpatient paediatric HD unit. Intervention was intradialytic oral nutritional supplementation provided as protein bars and/or meals.

SUBJECTS

Children and adolescents undergoing outpatient HD who were able to participate in surveys and eat by mouth.

MEASUREMENTS

Adverse effects and symptoms on nurse- and patient-reported surveys, respectively. Relationships between the predictor variables and the outcomes were assessed using generalised estimating equations.

RESULTS

The majority of children felt better after eating on dialysis (72%) with no adverse effects (80%). On unadjusted analyses and confirmed with generalised estimating equation modelling, children who reported being hungry felt better after eating on dialysis, despite being more likely to have adverse effects.

CONCLUSION

The study demonstrates that our children and adolescents feel better after eating on HD with minimal adverse effects. The finding that hungry patients are more likely to feel better despite having a higher likelihood of an adverse effect demonstrates the tolerability of eating on HD. Intradialytic oral nutrition could be a safe and well-tolerated opportunity to provide supplemental nutrition to paediatric HD patients and improve outcomes.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

The Effect of Intradialytic Intralipid Therapy in Pediatric Hemodialysis Patients

OBJECTIVE

Growth of children on maintenance hemodialysis is poor. Oral nutritional supplements are the preferred way to augment nutrition; however, many children have difficulties adhering to prescribed oral supplements. In our unit, we have been utilizing intralipid (IL) therapy as nutritional supplement during hemodialysis sessions. The aim of this study was to assess the safety, efficacy, and benefits of intradialytic IL therapy.

DESIGN

A retrospective chart review.

SUBJECTS

Fifteen pediatric hemodialysis patients receiving intradialytic IL therapy for at least 3 months from July 2011 through July 2014.

MAIN OUTCOME MEASURE

For each patient, anthropometric measurements and laboratory nutritional parameters were compared prior to and at the end of IL therapy. Anthropometric measurements evaluated were dry weight, height, body mass index (BMI), and BMI corrected for height age. Laboratory nutritional parameters evaluated were albumin, normalized protein catabolic rate, predialysis blood urea nitrogen, transferrin, cholesterol, and triglyceride levels. Adverse events during therapy were also noted.

RESULTS

Significant improvement was noted in albumin levels, predialysis blood urea nitrogen, and normalized protein catabolic rate during therapy (P = .02; P = .03; P = .03, respectively). Six patients (37.5%) improved their weight standard deviation score, and eight patients (50%) improved their BMI standard deviation score though not statistically significant (P = .59; P = .9, respectively). No significant side effects were noted.

CONCLUSIONS

Administration of IL alone during hemodialysis is well tolerated with beneficial effects on nutritional parameters. The provision of IL alone is relatively cheap and does not require additional resources. In conjunction with other measures of nutritional support, it can help improve nutritional status of pediatric hemodialysis patients.

Renal consequences of parenteral nutrition

Parenteral nutrition (PN) can be described as the "Intravenous administration of nutrients necessary to sustain life in those who would otherwise have died or suffered serious disease". PN is indicated in children who cannot be fully fed by the oral or intestinal route, usually as a result of intestinal failure. Intradialytic parenteral nutrition (IDPN) is rarely indicated in children on dialysis and does not confer a benefit over enteral supplements in the compliant patient with adequate intestinal function. Renal and metabolic consequences of PN are potentially life-threatening and include disorders of glucose homeostasis, acid-base and fluid and electrolyte disturbances, nephrolithiasis, impaired renal function and metabolic bone disease. Many of these complications are avoidable. Adequate clinical and biochemical assessment and monitoring of children receiving PN by a multidisciplinary nutrition support team is recommended to mitigate against the risks of these complications.

Nutrition in children with CRF and on dialysis

The objectives of this study are: (1) to understand the importance of nutrition in normal growth; (2) to review the methods of assessing nutritional status; (3) to review the dietary requirements of normal children throughout childhood, including protein, energy, vitamins and minerals; (4) to review recommendations for the nutritional requirements of children with chronic renal failure (CRF) and on dialysis; (5) to review reports of spontaneous nutritional intake in children with CRF and on dialysis; (6) to review the epidemiology of nutritional disturbances in renal disease, including height, weight and body composition; (7) to review the pathological mechanisms underlying poor appetite, abnormal metabolic rate and endocrine disturbances in renal disease; (8) to review the evidence for the benefit of dietetic input, dietary supplementation, nasogastric and gastrostomy feeds and intradialytic nutrition; (9) to review the effect of dialysis adequacy on nutrition; (10) to review the effect of nutrition on outcome.

Advances in renal replacement therapy as a bridge to renal transplantation

While renal transplantation remains the most prevalent treatment for children with end-stage renal disease, the majority of children incident to ESRD receive dialytic therapy prior to receiving a renal allograft and 25% of children are still receiving dialytic therapy 36 months after achieving ESRD. The current review discusses the most recent advancements in both hemodialysis and PD therapies to provide optimal care for children as a bridge until renal transplantation. Areas covered include dialysis dose assessment, target dry weight assessment, vascular access and advancements in PD technology.

Malnutrition in Hemodialysis Patients: What Therapy?

Malnutrition is common in hemodialysis patients and is a powerful predictor of morbidity and mortality. Although much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients, as well as recognizing the link between malnutrition and morbidity and mortality, no consensus has been reached concerning its management. Along with such conventional interventions as nutritional counseling, oral nutritional supplements, and intradialytic parenteral nutrition, novel preventive and therapeutic strategies have been tested, such as appetite stimulants, growth hormone, androgenic anabolic steroids, and anti-inflammatory drugs, with contradictory and nonconclusive results. Malnutrition still remains a great challenge for nephrologists in the third millennium.

Intradialytic Parenteral Nutrition Treatment and Biochemical Marker Assessment for Malnutrition in Adolescent Maintenance Hemodialysis Patients

Protein-energy malnutrition (PEM) is a significant cause of morbidity and mortality for patients receiving maintenance hemodialysis. Minimal study has evaluated therapeutic options for and biochemical marker assessment of pediatric patient PEM. In 2001, we expanded the indications for intradialytic parenteral nutrition (IDPN) treatment of PEM to all maintenance hemodialysis patients, regardless of etiology, who had a >10% weight loss and were at less than the 90th percentile of ideal body weight. Nine patients received thrice weekly IDPN from 3 to 22 months with minimal side effects. Six patients had weight and body mass index increase, 1 patient stopped losing weight, and 2 patients continued to lose weight during the initial 5 months of IDPN therapy. Cohort subanalysis showed that all patients with organic PEM responded to IDPN therapy, whereas patients with psychosocial causes of PEM did not. The normalized protein catabolic rate increased significantly for patients whose condition responded to IDPN therapy, whereas serum albumin did not change. The current study suggests that IDPN is effective treatment of organic causes of PEM in pediatric patients receiving maintenance hemodialysis and that normalized protein catabolic rate may be superior to serum albumin as a marker of nutrition status. The observation that IDPN was not sufficient to reverse PEM in patients with psychosocial PEM causes should direct caregivers to address the relevant underlying causes as well as to provide intensive nutrition therapy.

Outcomes research in nutrition and chronic kidney disease: perspectives, issues in practice, and processes for improvement

Despite greater access to health care and advances in medicine and technology, the morbidity and mortality among patients diagnosed with chronic kidney disease (CKD) remain unacceptably high. Discrepancies in patient care outcomes exist between the United States and other industrialized countries and are partly explained by variances reported in clinical practice. Outcomes research (OR) has been the primary methodology used to more fully explore the root causes for the practice variation and to uncover which indicators have the greatest impact. Research has established the relationships between early diagnosis and treatment, cardiovascular disease, quality of life, and malnutrition with morbidity and mortality rates among patients with kidney disease. Although nutrition parameters are predictive of mortality, they are complex to understand and even more difficult to improve, largely because of the effects of the inflammatory process and the lack of a direct measure that defines nutritional status. Future OR projects must focus on specific nutrition-related outcomes and the effectiveness of intervention, as these outcomes can establish clinical guidelines, lead to changes in practice, and create more controlled clinical trials that continue to search for answers to questions on the impact of nutrition and others.

Intradialytic amino acids supplementation in hemodialysis patients with malnutrition: results of a multicenter cohort study

OBJECTIVE

Prospective evaluation of the effect of 6-month-long intradialytic amino acids (AA) supplementation on selected nutritional variables in malnourished hemodialysis (HD) patients.

DESIGN

Multicenter, prospective, (nonrandomized, noncontrolled) observational study.

SETTING

Thirty-one HD units affiliated with academic centers and tertiary-care hospitals.

PATIENTS

Adult patients treated by HD for at least 6 months. Inclusion criteria were: serum albumin concentration < or =39 g/L and at least 4% loss of body weight during the last 6 months in otherwise stable HD patients. From a cohort of 133 patients who were enrolled, 97 (54 men and 43 women) were eligible for the analysis.

INTERVENTION

Intradialytic AA supplementation with 500 mL 10% solution per HD session for a period of 6 months.

MAIN OUTCOME MEASURES

Serum albumin concentration, modified Subjective Global Assessment (SGA) score, body mass index (BMI), mid-arm circumference (MAC), and total lymphocyte count. Measurements were recorded at baseline and after 3 and 6 months of AA supplementation.

RESULTS

Serum albumin concentration increased significantly from the mean 32.5 +/- 4.6g/L at baseline to 36.4 +/- 4.8 g/L at 3 months (P <.001) and 37.1 +/- 4.8 g/L at final observation (P <.001 versus baseline). Significant correlation was observed between frequency of AA supplementation and serum albumin increase (r = 0.41; P <.0001). Rate of improvement negatively correlated significantly with baseline concentration of serum albumin (r = - 0.42; P <.0001). SGA score significantly improved from median of 16 points at baseline to 12 points at 3 months (P <.01) and 11 points at 6 months (P <.01 versus baseline), and this improvement also correlated with the frequency of AA supplementation. Small yet significant increase of MAC was observed at 6 months (from baseline 24.1 +/- 4.3 to 24.8 +/- 4.8 cm; P <.01), whereas BMI remained unchanged.

CONCLUSION

Intradialytic AA supplementation improves selected nutritional parameters of HD patients with malnutrition. The improvement depends on the intensity of supplementation.