Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom?

Abstract

Hemodialysis is associated with high morbidity and mortality rates as well as low quality of life. Altered nutritional status and protein-energy wasting are important indicators of these risks. Maintaining optimal nutritional status in patients with hemodialysis is a critical but sometimes overlooked aspect of care. Nutritional support strategies usually begin with dietary counseling and oral nutritional supplements. Patients may not comply with this advice or oral nutritional supplements, however , or compliance may be affected by other complications of progressive chronic kidney disease. Intradialytic parenteral nutrition (IDPN) may be a possibility in these cases, but lack of knowledge on practical aspects of IDPN delivery are seldom discussed and may represent a barrier. In this review, we, as a consensus panel of clinicians experienced with IDPN, survey existing literature and summarize our views on when to use IDPN, which patients may be best suited for IDPN, and how to effectively deliver and monitor this strategy for nutritional support.

Keywords: chronic kidney disease; hemodialysis; parenteral nutrition; protein-energy malnutrition.

Graphical Abstract

FIGURE 1:

The effects of hemodialysis coupled with inadequate nutrient intake on muscle loss. Dialysis contributes to underlying factors that result in protein energy wasting. The dialysis process induces the activation of defense mechanisms, and the body reacts by increasing acute phase protein synthesis and initiating the inflammation cascade. In this setting, chronic undernutrition and amino acid (AA) losses into dialysate lead to low availability of circulating AA for protein synthesis. The body, in turn, increases muscle protein catabolism to promote AA release as a substrate for acute-phase proteins; this muscle catabolism activates cytokine production in the muscle, which tends to perpetuate this process in a vicious cycle.

FIGURE 2:

A streamlined decision tree for nutritional support based on clinical guidelines and panel consensus.

FIGURE 3:

Schematic review of a hemodialysis circuit. Adapted from: National Institute of Diabetes and Digestive and Kidney Diseases, https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis (December 3, 2021, date last accessed).