Nutrizione parenterale intradialitica in pazienti con malnutrizione moderata-severa: studio prospettico osservazionale multicentrico

Dialysis patients have a wide range of pathologies that contribute to their frailty. Maintaining a good nutritional status is useful to prevent and treat the so-called Protein-Energy Wasting (PEW), a complex clinical-laboratory condition in which a protein-energy depletion occurs. Adherence to a proper nutritional therapy in CKD requires considerable effort from both patients and health personnel (doctors and nurses). In order to slow down the effects of malnutrition and the disasters that complicate PEW, nephrologists can use supplementation products. In our observational, prospective, multicentre study, we administered an intradialytic parenteral nutrition of a three-compartment emulsion for intravenous infusion through an infusion pump connected to the venous line. After 12 weeks of treatment, subjects with severe malnutrition were reduced from 61.1% to 33.3%, serum creatinine increased by 16% (from 6.00 ± 1.48 mg/dL to 6.98 ± 2.46 mg/dL; P < 0.001), total protein and albumin levels respectively by 13% (from 5.46 ± 0.63 g/dL to 6.19 ± 0.66 g/dL; P < 0.001) and 19% (from 2.70 ± 0.48 g/dL to 3.20 ± 0.57 g/dL; P < 0.001), body weight by 3% (from 55.7 ± 13.2 kg to 57.6 ± 13.0 kg; P < 0.001).

Uremic Sarcopenia and Its Possible Nutritional Approach

Uremic sarcopenia is a frequent condition present in chronic kidney disease (CKD) patients and is characterized by reduced muscle mass, muscle strength and physical performance. Uremic sarcopenia is related to an increased risk of hospitalization and all-causes mortality. This pathological condition is caused not only by advanced age but also by others factors typical of CKD patients such as metabolic acidosis, hemodialysis therapy, low-grade inflammatory status and inadequate protein-energy intake. Currently, treatments available to ameliorate uremic sarcopenia include nutritional therapy (oral nutritional supplement, inter/intradialytic parenteral nutrition, enteral nutrition, high protein and fiber diet and percutaneous endoscopic gastrectomy) and a personalized program of physical activity. The aim of this review is to analyze the possible benefits induced by nutritional therapy alone or in combination with a personalized program of physical activity, on onset and/or progression of uremic sarcopenia.

SO047HEMODIAFILTRATION DECREASES RISE OF LEPTIN AND RESISTIN IN PROTEIN ENERGY WASTING (PEW) WITHOUT HARMFULL EFFECT ON ALBUMIN CONCENTRATION

Background and Aims The role of adipocytokines (ADCK), and particularly of anorectic leptin and of resistin in the mortality of PEW is strongly suspected. Convective techniques (ol-HDF) decrease leptin concentrations but induce a concomitant albumin loss which could be potentially harmful in malnourished patients. The aim of the prospective multicentric randomized study performed in France by the NUTRIPEPA GROUP is to compare one year evolution of 4 ADCK and seric albumin using HDF or HD and membranes with different cut-off. Method 47 patients responding to both criteria of albumin &lt;35 g/l (mean of 3 dosages) and prognostic inflammatory and nutritional index (PINI)≥ 1 were randomized to be treated using either polyester polyarylate (PEPA Nikkiso Japan) or polysufone, polyethersulfone dialyser (control) and followed for one year. Treatment consists in 3*4 hours HD session or in 3 HDF sessions with more than 20 liters reinjection/session. 24 patients were treated with HDF (HDF gr) : 11 with PEPA, 13 with control, and 23 with HD (HD gr) : 13 with PEPA, 10 with control. Oral nutritional supplementation was systematic, eventually completed by intradialytic parenteral nutrition. Albumin, leptin, adiponectin, ghrelin and resistin concentrations were determined at M0, M6, M9, M12. Delta concentration M0-M12 of albumin and of the 4 ADCK were compared with Wilcoxon test. Results At 12 months, decrease of leptin and of resistin was significantly higher in HDF group compare to HD group. There was no significant variation of adiponectin, ghrelin and albumin concentrations regardless of the technic or of dialyser cut-off. Conclusion In PEW, on a one year practice and regardless of the cut-off of the dialyser, HDF decreases both the anorexigenic adipokine leptin and resistin, adipokine implicated in insulin resistance, without harmfull incidence on seric albumin concentration. The decrease of concentrations of leptin and resistin obtained using ol-HDF could explain, at least in part, the reduction of one year mortality that we reported last year in preliminary results of NUTRIPEPA study.

Intradialytic parenteral nutrition improves nutritional status in a complex cystic fibrosis patient with redo double lung transplant and end-stage renal disease

This case study reports on the use of intradialytic parenteral nutrition (IDPN) to address severe malnutrition in a 38-year-old woman, redo double lung transplant recipient with a complex medical history including cystic fibrosis and end-stage renal disease (ESRD) on haemodialysis. Gastroparesis and severe postprandial abdominal pain limited oral/enteral nutrition input. The addition of IDPN resulted in a dry weight increase of 13.6% over a 12-month period and an improvement in the patient’s malnutrition status from severe (Patient-Generated Subjective Global Assessment (PG SGA) C24) to moderate (PG SGA B7). The patient stated she would recommend IDPN to others in a similar situation. Management of patients with coexisting cystic fibrosis and ESRD with or without haemodialysis requires patient engagement in treatment planning and a multidisciplinary team approach for clinical judgement in the absence of guidelines. As advances in medical care see more patients with these coexisting conditions, IDPN may provide an increasingly useful adjunct therapy.