Is Kabiven (parenteral nutrition) suitable for cancer patients requiring nutritional support?

Kabiven for Cancer Patients: Evidence-Based Recommendations

Direct Answer

Kabiven (parenteral nutrition) is NOT routinely recommended for cancer patients, but is appropriate in highly selected cases where intestinal failure exists, oral/enteral nutrition is impossible, and the patient has reasonable performance status with expected survival exceeding the time they would die from starvation. 1

Patient Selection Criteria

Appropriate Candidates for Parenteral Nutrition

Cancer patients suitable for PN (including Kabiven) must meet ALL of the following criteria:

• Intestinal failure present: Complete or partial GI obstruction, severe mucositis, or severe radiation enteritis preventing enteral intake 1
• Inadequate intake: Less than 60% of estimated energy expenditure for more than 10 days, or existing malnutrition with anticipated inadequate intake for >7 days 1, 2
• Enteral route not feasible: Oral or tube feeding is contraindicated, not tolerated, or insufficient 1
• Reasonable performance status: Karnofsky-Burchenal index >50 1
• Expected to die from starvation rather than tumor progression: This is the critical decision point 1
• Relatively normal function of other vital organs 1
• No severe, uncontrolled symptoms 1

Specific Clinical Scenarios Where PN Is Indicated

• Perioperative nutrition: Only in malnourished patients undergoing surgery when enteral nutrition is not feasible 1
• Acute GI toxicity: Severe mucositis or radiation enteritis from chemotherapy/radiotherapy preventing enteral intake 1
• Hematopoietic stem cell transplantation: Benefit has been demonstrated in this population 1
• Home parenteral nutrition (HPN): Incurable patients with peritoneal carcinomatosis, slow-growing tumors (ovarian, retroperitoneal), or intra-abdominal recurrences causing obstruction, if survival expected >3 months 1

Contraindications: When NOT to Use Parenteral Nutrition

PN is ineffective and probably harmful in the following situations:

• Well-nourished patients: No benefit demonstrated, increased morbidity documented 1
• Adequate oral/enteral intake possible: If patient can consume >60% of energy needs orally or enterally 1, 2
• Routine use during chemotherapy/radiotherapy: No benefit, possible harm including increased infections and fewer tumor responses 1, 3
• Patients dying imminently from tumor progression: PN will not alter outcome 1
• Non-aphagic patients without GI reason for intestinal failure: Documented harm in this population 1

Nutritional Regimen Specifications

Energy Requirements

• Bedridden patients: 20-25 kcal/kg/day using actual body weight 1, 2, 4
• Ambulatory patients: 25-30 kcal/kg/day 1, 2, 4

Macronutrient Composition

• Standard short-term PN: No special formulation needed for most patients 1
• Cachectic patients requiring prolonged PN: Higher fat-to-glucose ratio (50% of non-protein energy as lipid) is beneficial 1, 4
• Protein: Minimum 1.0 g/kg/day, optimal range 1.2-1.5 g/kg/day 2, 4

Fluid and Electrolyte Considerations

• Total fluid: Should not exceed 30 ml/kg/day in cancer patients 1
• Sodium: Should not exceed 1 mmol/kg/day 1
• Rationale: Cancer patients have expanded extracellular fluid volume from cachexia; combined water and sodium loads can precipitate ascites in peritoneal carcinomatosis 1

Critical Safety Concern: Refeeding Syndrome

Cachectic cancer patients with >20% weight loss over 3 months are at high risk for refeeding syndrome. 4

Prevention Protocol

• Start PN at no more than 25% of calculated energy requirements 4
• Prophylactically supplement phosphate before and during initial PN 4
• Monitor electrolytes closely during initiation 4

Home Parenteral Nutrition (HPN) Considerations

Survival Expectations

• Median survival in cancer patients on HPN ranges from 53-120 days, heavily dependent on selection criteria 1
• Quality of life remains stable and fairly acceptable in patients surviving >3 months 1

Decision-Making Framework

1. Estimate life expectancy: Do not commence if patient will succumb from disease rather than malnutrition 1
2. Communicate realistic expectations: Balance patient/family expectations with realistic outcomes 1
3. Define withdrawal criteria: Establish upfront when to stop if no benefit 1

Typical HPN Candidates

• Peritoneal carcinomatosis 1
• Slow-growing tumors: ovarian carcinoma, retroperitoneal cancers 1
• Intra-abdominal recurrences causing obstruction 1
• Little or no oral intake due to partial/complete GI obstruction 1

Essential Team-Based Approach

All cancer patients receiving PN should have coordinated care from a nutrition support team (NST). 1

Core NST Composition

• Physician (gastroenterologist, GI surgeon, or clinical biochemist) 1
• Nutrition nurse specialist 1
• Senior dietician 1
• Senior clinical pharmacist 1

NST Responsibilities

• Minimize complications through adherence to management protocols 1
• Provide catheter care protocols 1
• Manage and audit complications including catheter sepsis 1
• Provide physical and psychological support 1
• Train patients/carers for home administration 1

Common Pitfalls to Avoid

• Do not use PN routinely: The evidence shows no benefit and possible harm when used indiscriminately 1, 3
• Do not fear tumor feeding: While nutrients may be utilized by cancer cells, there is no evidence this translates into clinically relevant harm 5
• Do not use restrictive diets: Ketogenic or fasting diets lack evidence and may worsen malnutrition 2, 6
• Do not exceed calcium supplementation: Limit to <1200 mg/day 2, 6
• Do not provide PN in dying patients: Normal energy amounts may induce metabolic distress during terminal hypometabolism 6

Monitoring and Reassessment

• Assess nutritional status at every visit from tumor diagnosis onward 2
• Reassess every 8-12 weeks based on clinical status 6
• Discontinue if no benefit: Stop PN if no symptomatic improvement or if performance status deteriorates 6
• Monitor for complications: Catheter-related infections, metabolic derangements, mechanical problems 1, 5