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

Abstract

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.

Dietary protein and muscle wasting in chronic kidney disease: new insights

“…In a recent randomized controlled trial between February 2020 and December 2020, 38 hemodialysis patients were divided into two groups as IDPN plus standard dietary counseling (IDPN group) and standard nutritional counseling (control group). The study showed that 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and malnutrition inflammation score [52]. However, there are not enough studies yet to reach such a conclusion.…”

Nutrition Management in Geriatric Patients with CKD

“…Studies suggest that the combination of IDPN with oral nutritional supplements can improve markers of nutritional status, including dry body weight, skinfold measurements, and mid-arm muscle circumference, as well as serum albumin and prealbumin, in patients who cannot reach nutritional goals with oral supplements alone. 28,36,37 Earlier studies showed that IDPN can be safely used in the geriatric population. In a study including 78 elderly patients older than 70 years, IDPN was found to improve serum albumin and transferrin after 3 months and body anthropometric measurements after 6 months of treatment.…”

“…The mean age was 67.6610.8 years, and two patients with manageable hyperglycemia were observed in the IDPN group. 37 While IDPN is valuable in the management of patients who cannot tolerate adequate oral supplementation, it is unlikely to provide additional nutritional benefit when sufficient oral supplementation can be maintained. A randomized trial including 186 patients with a mean age of 68.869.9 years showed that adding IDPN to a regimen of oral supplementation that contained 500 kcal/d and 25 g/d protein did not offer nutritional or survival benefits in a follow-up period of 2 years.…”

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

“…According to the guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN), the first week should be started at no more than 8 mL/kg/IDPN (500 mL at 60 kg) and up to 16 mL/kg/IDPN at the maximum, and then, the dosage per dialysis should not exceed 1000 mL [ 82 ]. In a recent RCT on patients with HD, IDPN was administered to a group of patients who had adequate dietary intake (energy ≥ 20 kcal/kg/day, protein ≥ 0.8 g/kg/day) but were unable to continue ONS due to digestive symptoms [ 83 ], while the control group only received weekly nutritional counseling. At three months, serum albumin increased from 3.6 to 3.8 g/dL, and energy intake and body weight increased in the IDPN group (total energy: 1100 kcal, water: 986 mL, continuous administration over 4 h on dialysis) compared to the control group.…”