Principles and Strategies for Monitoring Home Parenteral Nutrition

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Energy Guidance Using Indirect Calorimetry for Intestinal Failure Patients with Home Parenteral Nutrition: The Right Bag Right at the Start

Intestinal failure is defined as the inability to absorb the minimum of macro and micronutrients, minerals and vitamins due to a reduction in gut function. In a subpopulation of patients with a dysfunctional gastrointestinal system, treatment with total or supplemental parenteral nutrition is required. The golden standard for the determination of energy expenditure is indirect calorimetry. This method enables an individualized nutritional treatment based on measurements instead of equations or body weight calculations. The possible use and advantages of this technology in a home PN setting need critical evaluation. For this narrative review, a bibliographic search is performed in PubMed and Web of Science using the following terms: 'indirect calorimetry', 'home parenteral nutrition', 'intestinal failure', 'parenteral nutrition', 'resting energy expenditure', 'energy expenditure' and 'science implementation'. The use of IC is widely embedded in the hospital setting but more research is necessary to investigate the role of IC in a home setting and especially in IF patients. It is important that scientific output is generated in order to improve patients' outcome and develop nutritional care paths.

Adaptation of the medical-nutrition therapy for patients with intestinal failure in a developing country: A modified Delphi survey

BACKGROUND & AIMS

Intestinal Failure (IF) is a complex disease with huge impacts on our society due to complications. Therefore, in a developing country like Mexico without specialized IF clinics, health care professionals must provide evidence-based interventions for the IF patient. This study aims to achieve consensus on how to adapt the existing guidelines for IF to the local practices considering the available resources and local practices.

METHODS

A three-round modified Delphi process was used to build consensus on the most important interventions for our IF patients. For each round, data was collected and consensus was defined as ≥80% of agreement for each item. Descriptive statistics were used to determine whether a consensus was achieved.

RESULTS

Ten content experts completed the three-round modified Delphi survey. Consensus was achieved for 98% of the items related to the hospitalized patient, ambulatory care management, and drug therapy. Some of these items are not included in the ESPEN guidelines for IF, but we considered that they are relevant in our clinical practice, like the calculation of fluids for patients with very low body weight, screening for refeeding syndrome and the use of some conventional drugs to promote intestinal rehabilitation.

CONCLUSIONS

Using a three-round modified Delphi process, consensus was achieved for nearly all items. This represents a starting point for the improvement of our local practices towards this complex disease, leading to better outcomes and the implementation of evidence-based protocolized interventions which can have an important impact due to the lack of access to some of the most novel pharmacological therapies like the glucagon-like-peptide (GLP-2) analog.

Monitoring Response to Home Parenteral Nutrition in Adult Cancer Patients

Current guidelines recommend home parenteral nutrition (HPN) for cancer patients with chronic deficiencies of dietary intake or absorption when enteral nutrition is not adequate or feasible in suitable patients. HPN has been shown to slow down progressive weight loss and improve nutritional status, but limited information is available on the monitoring practice of cancer patients on HPN. Clinical management of these patients based only on nutritional status is incomplete. Moreover, some commonly used clinical parameters to monitor patients (weight loss, body weight, body mass index, and oral food intake) do not accurately reflect patient’s body composition, while bioelectrical impedance analysis (BIA) is a validated tool to properly assess nutritional status on a regular basis. Therefore, patient’s monitoring should rely on other affordable indicators such as Karnofsky Performance Status (KPS) and modified Glasgow Prognostic Score (mGPS) to also assess patient’s functional status and prognosis. Finally, catheter-related complications and quality of life represent crucial issues to be monitored over time. The purpose of this narrative review is to describe the role and relevance of monitoring cancer patients on HPN, regardless of whether they are receiving anticancer treatments. These practical tips may be clinically useful to better guide healthcare providers in the nutritional care of these patients.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

BACKGROUND

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective.

METHODS

In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests.

RESULTS

Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002).

CONCLUSIONS

A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Iron Deficiency in Long-Term Parenteral Nutrition Therapy

BACKGROUND

Iron is not routinely added to parenteral nutrition (PN) formulations in the United States because of the risk of anaphylaxis and concerns about incompatibilities. Studies have shown that iron dextran in non-lipid-containing PN solutions is safe. Data are limited on iron status, prevalence of iron deficiency anemia (IDA), and efficacy of intravenous iron infusion in long-term home PN (HPN). We aimed to determine the incidence of IDA and to examine the effectiveness of parenteral iron replacement in patients receiving HPN.

METHODS

Medical records of patients receiving HPN at the Mayo Clinic from 1977 to 2010 were reviewed. Diagnoses, time to IDA development, and hemoglobin, ferritin, and mean corpuscular volume (MCV) values were extracted. Response of iron indices to intravenous iron replacement was investigated.

RESULTS

Of 185 patients (122 women), 60 (32.4%) were iron deficient. Five patients were iron deficient, and 18 had unknown iron status before HPN. Of 93 patients who had sufficient iron storage, 37 had IDA development after a mean of 27.2 months (range, 2-149 months) of therapy. Iron was replaced by adding maintenance iron dextran to PN or by therapeutic iron infusion. Patients with both replacement methods had significant improvement in iron status. With intravenous iron replacement, mean ferritin increased from 10.9 to 107.6 mcg/L (P < .0001); mean hemoglobin increased from 11.0 to 12.5 g/dL (P = .0001); and mean MCV increased from 84.5 to 89.0 fL (P = .007).

CONCLUSIONS

Patients receiving HPN are susceptible to IDA. Iron supplementation should be addressed for patients who rely on PN.

Predicting fatigue in patients using home parenteral nutrition: a longitudinal study

Background

Home parenteral nutrition (HPN) is a life-saving therapy for patients with diseases that preclude adequate oral or enteral food intake. HPN has a large impact on daily life. Many patients suffer from fatigue and depression, and they experience limits in social activities. This all contributes to a lower quality of life.

Purpose

Fatigue is the most frequently mentioned problem in Dutch HPN patients. Therefore, we studied the prevalence, course and predictors of fatigue in these patients.

Methods

Patients completed questionnaires at baseline and follow-up (12 months later). Measurements included fatigue, depression, functional impairment, social support, self-efficacy, coping, anxiety and acceptance. Laboratory measures, including total bilirubin, creatinine, albumin and haemoglobin levels, were obtained from the medical records. Descriptive statistics, correlations and linear regression analysis were performed.

Results

The response rate was 71% (n = 75). Sixty-five per cent of the patients were severely fatigued (n = 49). Eighty-nine per cent experienced persistent fatigue. Baseline fatigue predicted 57% of the variance of fatigue at follow-up, and avoidance was responsible for 3% of the variance. No significant correlations between fatigue and laboratory measures were found. A cross-sectional analysis showed that 46% of the variance of fatigue was explained by functional impairment, self-efficacy and depression.

Conclusion

Severe fatigue is a persistent problem for HPN patients. Baseline fatigue was the strongest predictor of fatigue at follow-up. Functional impairment, self-efficacy and depression are strongly related to fatigue. Early recognition and treatment of fatigue are important.

Vitamin D deficiency in patients receiving home parenteral nutrition

BACKGROUND

In addition to its role in bone metabolism, vitamin D has important immunomodulatory and antineoplastic effects. Patients on home parenteral nutrition (HPN) receive most of their vitamin D from intravenous (IV) supplementation. Vitamin D deficiency is common in the general population, and the adequacy of vitamin D supplementation in HPN patients is unclear. The purpose of this study is to determine the vitamin D status of patients on HPN.

METHODS

Consecutive patients seen in a regional home nutrition program had their oral and IV vitamin D intakes determined. Plasma 25-hydroxyvitamin D levels were measured in all patients. Intake of calcium, magnesium, and phosphate were also determined.

RESULTS

The mean 25-hydroxyvitamin D level in 22 patients receiving HPN for a mean of 33.5 months (range, 1-177) was 42 nmol/L. Vitamin D deficiency was present in 15 (68%) patients and vitamin D insufficiency in 6 (27%) patients. The mean dietary vitamin D intake was 79.5 IU per day, while the mean IV supplementation was 166 IU per day.

CONCLUSIONS

In this study of a regional Canadian HPN program, there was a high prevalence of vitamin D deficiency/insufficiency affecting virtually all patients. All patients receiving HPN should be supplemented with vitamin D and have their 25-hydroxyvitamin D levels monitored. Further studies are required to determine optimal methods and dosing of vitamin D replacement using oral supplements or ultraviolet light therapy.

Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience

BACKGROUND

Catheter-related bloodstream infections (CRBSI) cause morbidity and mortality in patients with intestinal failure dependent on parenteral nutrition. Ethanol lock of central venous catheters may decrease CRBSI, but limited pediatric data are available.

METHODS

Home parenteral nutrition patients with at least one previous CRBSI were initiated on a 70% ethanol lock protocol for a minimum of 4 hours. Infection rates (per 1000 catheter days) before and after initiation of ethanol locks were compared using a paired t test.

RESULTS

Ten patients (4 girls; median age, 44 months [range, 31-129 months]) began ethanol lock therapy after a total of 91 CRBSIs (37 gram-positive, 30 gram-negative, and 24 fungal) with a mean of 10.2 ± 6.2 per 1000 catheter days. Patients received ethanol lock for an average of 227 ± 64 days with only 3 CRBSI occurring (CRBSI rate of 0.9 ± 1.8 per 1000 catheter days [P = .005]). Central venous catheter replacements decreased from 5.6 per 1000 days to 0.3 per 1000 days posttherapy (P = .038). Ethanol lock was discontinued in 2 of 10 patients because of catheter thrombosis.

CONCLUSION

Preliminary results demonstrate a significant decrease in CRBSI with a 70% ethanol lock protocol. Catheter thrombosis may be a limitation that needs to be addressed. With such a dramatic therapeutic effect, a randomized trial is feasible and should be performed.

Hair loss in long-term or home parenteral nutrition: are micronutrient deficiencies to blame?

PURPOSE OF REVIEW

To review the key nutritional factors associated with hair loss in long-term parenteral nutrition patients.

RECENT FINDINGS

The phenomenon of unexplained hair loss is multifactorial, and nonstandard definitions are applied. Deficiencies of essential fatty acids resulting in alopecia and other symptoms appear to have been eliminated by regular use of lipid-containing parenteral nutrition. Zinc is the most frequently suspected deficiency with rapid clinical responses reported from zinc therapy. Alopecia in some infants on parenteral nutrition has been relieved in a few weeks by selenium supplementation as selenite. There may be a relationship between iron depletion and diffuse hair loss in home parenteral nutrition patients at higher risk of anaemia. A serum ferritin level of 70 μg/l should be targeted when hair loss is unexplained. However, there is limited data correlating cessation of hair loss with iron therapy and insufficient evidence to recommend iron supplementation in patients without anaemia. Parenteral nutrition-associated biotin deficiency has not been reported since the vitamin has been routinely added to parenteral nutrition. However, marginal biotin status, associated with diffuse hair loss, could still be prevalent.

SUMMARY

Micronutrient status is infrequently monitored and current recommendations for supplementation are nonspecific for hair loss in long-term parenteral nutrition. Studies are required to determine the incidence of marginal zinc, selenium, iron or biotin deficiencies that could manifest as hair loss.