As I have mentioned in my previous posts, I am trying to become more confident with using IDPN (intra-dialytic parenteral nutrition) in my practice. Based on an article, Intradialytic parenteral nutrition in Europe: a survey among clinical practitioners, published in the Journal of Nephrology this summer, I am not alone.
In a survey of 208 practitioners in Europe, 34% reported having no experience with IDPN. The authors concluded that more education programs are needed to support the implementation and monitoring of IDPN.
One barrier the authors identified was the perceived lack of efficacy, which is definitely something I have seen in my own practice. This often comes up during our team rounds when we discuss IDPN, with team members expressing concern that it doesn’t really help or make a difference.
So, I was excited when my colleague sent me this article, published in Clinical Nutrition ESPEN. In this study, the authors looked at what happened to survival after the addition of IDPN.
What is IDPN?
IDPN stands for intra-dialytic parenteral nutrition. If you find yourself asking this question, refer back to my previous post here.
Why did the authors do the study?
The authors highlight that the evidence supporting IDPN remains inconclusive. Studies examining the potential survival benefits of IDPN have produced conflicting results. There have also been conflicting findings about whether IDPN improves albumin levels or Subjective Global Assessment (SGA) scores.
How was nutrition status monitored?
In this study, the authors tracked participants’ Integrative Clinical Nutrition Dialysis Score (ICNDS). I hadn’t heard of this score before, so I was interested in learning more about it.
The authors describe the ICNDS as a six-component score that considers:
- Albumin
- Creatinine
- Urea
- Cholesterol
- CRP
- Kt/V
- Change in end-of-dialysis dry weight compared with the previous month
Each component is scored between 1 and 5, with higher scores indicating better status and lower scores indicating poorer status.
The authors note that non-nutritional factors can influence measures such as CRP and Kt/V. Although the medical team may be better positioned to manage these measures, they can still serve as flags for potential malnutrition.
Who was studied?
The study specifically included people who remained at risk of malnutrition after three months of standard nutrition care from a registered dietitian.
How was the study conducted?
The study took place over a 10-year period.
During the first five years, the researchers divided patients into two groups: one received standard nutrition care alone, while the other received standard nutrition care plus IDPN.
During the second five years, the researchers offered all patients identified as malnourished both standard nutrition care and IDPN.
What was administered via IDPN?
IDPN was administered three times per week during the dialysis session and provided:
- 1000 mL total volume
- 1040 kcal
- 42.5 g protein
- 50 g lipids
- 125 g dextrose
The IDPN available in my practice has a different composition. For a 1000 mL volume, it provides:
- 950 kcal
- 76.9 g protein
- 35 g lipids
- 73 g dextrose
So, I will need to be a little cautious when interpreting these results. While the energy content is clinically similar, the macronutrient composition is quite different. How does the studied composition compare with what is available in your practice?
Does IDPN reduce mortality?
The authors reported a survival advantage for people who received IDPN compared with those who did not at 6 and 9 months. But by 12 months, there was no survival advantage between groups.
The results suggest that IDPN may provide a short-term mortality benefit, but the authors did not observe this benefit over the longer term.
What components of the ICNDS improved with IDPN?
Compared with baseline, those who received IDPN had higher albumin levels and appeared to halt or reverse post-dialytic weight loss.
There were no differences in creatinine, cholesterol, CRP, or Kt/V.
Key Takeaways
This paper provides some evidence that the use of IDPN in people at risk of malnutrition may reduce short-term mortality, although it may not reduce longer-term mortality.
For me, an important consideration is that the macronutrient composition of the IDPN used in this study differs substantially from the formulation available in my practice. This means I need to be cautious about assuming these results will translate directly to my patient population.
