Can parenteral (intravenous) nutrition be given to patients undergoing dialysis?

Parenteral Nutrition During Dialysis: Indications and Implementation

Yes, parenteral nutrition can be given during dialysis through a specific modality called Intradialytic Parenteral Nutrition (IDPN), which is administered through the venous line of the dialysis circuit during hemodialysis sessions. 1

What is IDPN?

• IDPN is a specialized form of parenteral nutrition administered through the extracorporeal circuit of hemodialysis, typically given three times a week for 3-4 hours during dialysis sessions 1
• It involves the administration of macro- and micronutrients (amino acids, glucose, lipids, electrolytes, vitamins, and trace elements) directly into the venous line of the dialysis circuit 1
• IDPN is cyclic by nature, as it can only be given during the dialysis treatment period 1

Indications for IDPN

• IDPN should be used in malnourished patients on hemodialysis who have failed to respond to or cannot tolerate oral nutritional supplements (ONS) or enteral nutrition (EN) 1
• Specific indications include:
  • Patients with chronic kidney disease (CKD) and kidney failure (KF) on hemodialysis with protein-energy wasting 1
  • Patients at risk of malnutrition who cannot achieve adequate nutritional intake through oral or enteral routes 1
  • Patients who need to prevent nutritional deterioration when other methods of nutrition therapy have proved insufficient 1

Clinical Evidence and Benefits

• Multiple studies, including several randomized controlled trials, have shown nutritional improvements with IDPN in dialysis patients with protein-energy wasting 1
• IDPN has been demonstrated to:
  • Improve visceral protein synthesis (increasing serum albumin, prealbumin, and cholinesterase) 2
  • Enhance immunocompetence by improving skin test reactivity and raising total lymphocyte count 2
  • Promote increased whole-body protein synthesis and decreased proteolysis 3
  • Change the patient from a catabolic state to a positive protein balance in both whole-body and forearm muscle compartments 3

Implementation Algorithm

1. First-line approach: Always attempt oral nutritional optimization with dietary counseling and oral nutritional supplements before considering IDPN 1
2. Assessment: Evaluate for malnutrition or risk of malnutrition in dialysis patients 1
3. IDPN initiation: Implement IDPN when:
   • Patient is malnourished or at risk of malnutrition 1
   • AND patient has failed to respond to oral nutritional supplements 1
   • OR patient cannot tolerate oral or enteral nutrition 1
4. Administration: Deliver through the venous line of the dialysis circuit during hemodialysis sessions 1
5. Monitoring: Regularly assess nutritional parameters, electrolytes, and metabolic response 1, 2

Important Considerations and Cautions

• IDPN is not superior to ONS when both are tolerated, so it should not be used as first-line therapy before trying counseling and ONS 1
• IDPN has time limitations (typically only 4 hours, three times weekly during dialysis), which may limit its overall nutritional impact 1
• Potential complications include:
  • Disorders of glucose homeostasis 4
  • Acid-base and fluid-electrolyte disturbances 4
  • Metabolic bone disease 4
• Most complications are avoidable with proper monitoring and adjustment of the IDPN formula 4

Nutritional Requirements for Dialysis Patients

• Protein requirements: 1.2-1.3 g/kg/day for patients with chronic renal failure 5
• Energy requirements: 30-35 kcal/kg/day 5
• IDPN formulations should be adapted to the specific metabolic alterations of uremia 2
• Careful monitoring of electrolytes, particularly phosphate, potassium, and magnesium, is essential 6

IDPN represents a valuable nutritional intervention for malnourished dialysis patients when other nutritional approaches have failed, but should be part of a comprehensive nutritional strategy rather than used in isolation.