Nutrition, for dialysis patients, has a fundamental role in achieving a good degree of well-being. 40% of dialysis patients show signs of malnutrition, while 5-15% are significantly malnourished.
This nutritional imbalance can be caused by kidney disease itself or by inefficient absorption and utilization of nutrients.
The chronic state of kidney disease is called CKD, and is clinically defined by the significant reduction of renal function and/or the presence of markers of kidney damage (ex. albuminuria). This is considered a predictor of increased risk of mortality, and progression to a more advanced stage, i.e. to end-stage renal failure (ESKD). ESKD can be defined as the irreversible condition that chronic kidney disease can reach, and the patient, in that case, needs kidney transplantation or dialysis for survival. Statistically, 50 % undergo haemodialysis.
During CKD, the progressive reduction of the individual’s protein and energy assets can occur, a condition called caloric protein depletion (PEW). This severe state of malnutrition, which involves the loss of fat and muscle reserves, occurs in more than 45% of nephropathic patients, and is exacerbated in relation to the worsening of renal function: in 28 – 48% of patients, in the first 4 stages of CKD and up to 50-75% in subjects on chronic dialysis. The CKD condition is considered the most relevant morbidity factor in the nephropathic patient and even predictive of mortality, since it can lead to increased exposure to infections, cardiovascular diseases, frailty, depression, etc.
There are many pathogenetic factors that can affect the nutritional status of patients with CKD / ESKD, leading to PEW and multiple negative effects. The competing causes of PEW, therefore, can be varied and co-present, some of these are: advanced age, inadequate food intake, inadequate treatment of the syndrome itself, several acute / chronic comorbidities, complications / metabolic alterations related to it.
More specifically, the most common factors contributing to a considerable reduction in nutrients are anorexia (35 – 70%) and inappropriate dietary restrictions.
Therefore, a careful evaluation of the nutritional status of the dialysis patient, at risk of malnutrition, must take place, based both on anthropocentric and behavioral evaluations and on hematochemical parameters. To monitor clinically, several indicators can be used. The most significant are BMI and plasma albulimia, which however have numerous limitations, which makes them unreliable, as the only criteria, for a correct objective assessment.
In recent years, oral nutritional supplementation during dialysis, and/or in the interdialytic interval, associated with precise dietary counseling, has been evaluated as a simple low-cost approach, and particularly effective in the prevention and treatment of PEW.
A group of European nephrologists is producing a “position paper” (announced as available at the end of the current year) to define the guidelines to be followed, to provide an adequate clinical nutritional treatment to the dialysis patient. This document clearly contains recommendations and practical indications for health workers, engaged in the field in intra-dialysis parenteral nutrition.
Intra-dialysis parenteral nutrition (IDPN), i.e. the administration of nutrients directly into the dialysis circulation, is a treatment aimed at patients who cannot meet their nutritional needs through a special diet plan, or through supplemental oral nutrition (according to ESPEN guidelines).
In general, the aforementioned approach plays a fundamental role in the treatment of those who have a long-term condition, such as intestinal failure, cancer, patients in intensive care or undergoing surgery, while it is still underutilized in the field of hemodialysis.
This therapy ensures the right dose of essential macronutrients, providing patients with a balanced blend of amino acids, glucose and lipids during dialysis treatment.
Ready-to-use solutions for IDPN are efficient and cost-effective in use, reduce preparation time by 65%, lower the risk of mistakes by specialist doctors, reduce the risk of infection by 16%, and ensure immediate availability because the product is ready to use, and benefiting from a shelf-life of 24 months, refrigeration is not required.
In addition, clinical nutrition with IDPN optimizes the allocation of healthcare costs and improves health outcomes by reducing hospitalizations by 30% and decreasing the duration of hospitalizations before treatment by 40%.
In conclusion, this therapy, although it leads to numerous benefits in terms of health and economic, to date is scarcely widespread and underused by the community of nephrologists, probably due to dishabit or lack of knowledge of clinical data.
Therefore, there is a need to have greater awareness of the treatment options available to patients undergoing dialysis treatment, and it is hoped that thanks to the dissemination of the guidelines for the use of IDPN within the aforementioned document, available by the end of the year, this can begin to happen.