Wednesday, March 2, 2011

The info from the dietitian nagged at me today, so I went back to the literature and restricted my search to peer-reviewed medical journal articles and one book chapter. I know how difficult it is to make suggestions to doctors, but given the critical nature of Bill's weight loss, it might be worth asking whether he can try Intradialytic Parenteral Nutrition (IDPN)--if he's not on it already.

IDPN is a form of intra-venous feeding that occurs at the same time as dialysis. The journal articles imply that it is used in addition to the stomach tube feeding that Bill already gets. It's helpful in cases of severe malnourishment that are caused by the body's response to dialysis. Several literature reviews (all sources are listed below) say IDPN causes statistically significant improvement in kidney patients across all measures of body nourishment. Unfortunately, this improvement takes two months on average, but that's better than two months without IDPN. They recommend that it be used when tube feeding is inadequate by itself for weight gain.

Sources:
www.ncbi.nlm.nih.gov/pmc/articles/PMC2795369/?tool=pmcentrez  - "Parenteral nutrition in patients with renal failure - Guidelines on Parenteral Nutrition"
www.ncbi.nlm.nih.gov/pubmed/9915908 - "Pathophysiology of protein-energy wasting in chronic renal failure"
www.ncbi.nlm.nih.gov/pubmed/18336518 - "Use of intradialytic parenteral nutrition in acutely ill haemodialysed patients"
www.ncbi.nlm.nih.gov/pubmed/14535227 - "Use of intradialytic parenteral nutrition to treat malnutrition"
www.ncbi.nlm.nih.gov/pubmed/9915288 - "Therapeutic approaches to malnourishment in chronic dialysis patients"

A couple other items emerged while I was reading about IDPN: 1) Standard parenteral nutrition in patients with kidney failure should be 20-30 calories a day for each kilogram of ideal body weight. For example, if Bill's ideal weight was 170 pounds, that would be 77 kg, and 30 calories x 77 = 2310 calories a day. So the number that he is receiving seems close to the number that medical scientists recommend during dialysis, if my guess of his ideal weight is correct. The 5000 calories I mentioned in a previous post is for people with extreme weight loss but not necessarily in kidney failure or dialysis, which changes the situation more than I realized at that time. 2) Severe malnutrition occurs in 5-10% of dialysis patients; light to moderate malnutrition occurs in 30% of dialysis patients. This is partly caused by "protein energy malnutrition" in which the body undergoing dialysis does not use its calories in the same way a normal body would. This sounds like what the dietitian was describing to Abby.

If possible, it might be worthwhile to ask Bill's best doctor whether intravenous feeding during dialysis would help him if he's not already on it. Just an idea; you all know best! Hope you are all riding the emotional roller coaster as well as you can.      Janet 

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