Intradialytic parenteral nutrition (IDPN) is a non-invasive infusion of amino acids, dextrose, and sometimes lipids given to hemodialysis patients. It is designed specifically to boost patient’s nutrition without increasing patient burden by using the dialysis access site during the patient’s regular dialysis session. The goal of IDPN is to combat malnutrition and protein energy wasting. Objectively we use albumin, prealbumin, nPCR, and weight and/or BMI to assess response to IDPN. Subjectively, patients report improved appetite, energy, and overall better quality of life after starting IDPN.
Although many clinicians currently using IDPN therapy are familiar with the related successful outcomes, other members of the healthcare team can be curious about what to expect from the therapy. We joined our team of experts including dietitians and other healthcare professionals to hear about their first-hand experience with IDPN for their hemodialysis patients:
Describe the typical appropriate IDPN patient.
Chelsea Moore, RD, LDN shared her experience as a dialysis dietitian, “An appropriate patient is one that meets any of the standard requirements for applying the patient to IDPN: weight loss, consecutive low albumin labs, and low BMI. When I was working in the clinics, I kept a list of patients who I felt would benefit from the therapy before they hit the criteria (i.e. autoimmune, cancer, GI surgery). I would keep these patients at the top of my list to review, so as soon as one hit criteria for weight loss or low albumin, I would refer them for IDPN therapy before health continued to weaken.”
With years of experience as a Nutrition Therapy Consultant, Mike Romeo reminds us, “Patients can start on IDPN even though their Albumins levels are over 3.5. By having a BMI below 20 they would still qualify, as well as by having a 5% weight loss over 3 months. IDPN can build back lean muscle mass.”
What is something you wish all clinicians knew about IDPN?
Kim Bloomer RD, CDN gave her take, “In my clinical experience, the earlier I intervened, I saw the albumin increase more quickly. I wish I would have started my patients on IDPN as soon as they qualified for therapy rather than waiting until the patient levels became extremely low.”
Sarah Voegtle, MS, RD, CSSD, LDN added “I wish that all clinicians understood that IDPN is really just like feeding their patients, but in a different way. It also has no long-term side effects, where other medications do.”
Lissett Cruz, a longtime Nutrition Therapy Consultant with PCA, adds her take, “IDPN is a tool, just like protein bars, shakes, appetite stimulants that, when used TOGETHER, can achieve great outcomes for malnourished dialysis patients. You can’t build a house with ONLY a hammer, so why would you rely solely on one option when treating malnutrition?”
How do you address some of the mixed messaging or negative perceptions of IDPN?
Kathleen Meyer, RD, LD has a lot of experience to reflect on and shared, “Just as malnutrition occurs over time with patients, so does repletion. In speaking with RDs who have used our therapies and seen success with their patients, many of them have commented that ‘we have to be patient and give the therapy time to make an impact.’ Even if we do not see a big change in albumin levels right away, we often see other signs of progress such as improved strength, appetite, and wound healing, which may also improve the patient’s quality of life.”
Another clinician with a long history in dialysis and working with IDPN, Scott Kimner, MPH, RD, LD adds his take, “Every patient is different, and every patient is dealing with multiple co-morbidities. Since the half-life of albumin is ~3 weeks, any missed IDPN therapy or improper titration or rate could have a possible impact since the patient is only getting dialysis and thus IDPN therapy 3 times per week; unless they are doing home hemodialysis or peritoneal dialysis.”
Can you share a patient IDPN success story?
Kim Bloomer, RD, CDN started off with, “I had a patient on IDPN who always came into dialysis in a wheelchair. His appetite was poor, and he was very weak. His albumin remained stable on therapy but while on therapy his appetite improved dramatically and one day, I noticed he came to his treatment in a walker, and then not to long after that with a cane! He was getting stronger while on IDPN. It was very exciting to watch.”
Scott Kimner, MPH, RD, LD, provided an honest take from before he understood the full benefit of IDPN, “I had a patient who maxed out on amino acids in their IDPN and albumin was at BEST a 3.5. I held the therapy because I didn’t think it was working. Albumin tanked from 3.4 to 3.0 to 2.8. Restarted IDPN and it came back up and hovered between 3.3-3.5. Sometimes preventing decline is just as important as the upward trend in albumin because every patient is dealing with something differently. An albumin of 3.4 will always be better than an albumin of 2.8.”
Sarah Voegtle, MS, RD, CSSD, LDN shares, “My greatest success was a little man who had a great albumin but his BMI was 15. We started him on IDPN 2 years ago at which point he only ate zone bars and Boost supplements. His wife couldn’t get him to eat any other foods. Last month I checked in with his current RD, he hit a BMI of 21 and is eating home cooked meals so he’s been able to graduate off of IDPN. The patient feels good, has more energy and a wonderfully improved quality of life.”
Kathleen Meyer, RD, LD concluded with, “I’ve seen several success stories from patients who’ve received our therapies! The biggest success is when I see patients meet and maintain their nutrition goals to where they are able to discharge from our therapies!”
The best evidence for IDPN therapy results is obtained when seeing your patient feel better by feeling healthier and stronger. Often times, the clinical team will use Patient Care America’s unique NutriTrak reporting system to measure the patient’s monthly progress via a quarterly report, by tracking their serum albumin and dry weight.
IDPN Nutrition Therapy can result in a significant and relevant increase in nutrition and strength for your patient, whether referred due to low albumin, unwanted weight loss, or low BMI; the therapy can improve their outcomes and quality of life. Stacey Armstrong probably said it best when she concluded, “IDPN can’t hurt, it can only potentially help your patients; so, when first lines of nutrition intervention aren’t cutting it, which is the case for 5-15% of patients, why wouldn’t you give IDPN a shot?”
If you would like to learn more about Patient Care America and our IDPN and IPN therapies, please contact us at [email protected].