Intradialytic Parenteral Nutrition (IDPN)

Intradialytic parenteral nutrition is the infusion of an intravenous nutritional formula of hyperalimentation (artificial supplements of nutrients), like amino acids, glucose, and lipids, during dialysis to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure or end-stage renal disease (ESRD). The term “parenteral” refers to administration of medication or fluid other than through the digestive tract (intravenous or intramuscular).

Protein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25–40% of those undergoing dialysis and is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5 g/dL, and those with a serum albumin near the normal range have a mortality rate twice as high as those with albumin greater than 4.0 g/dL.

In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of equal to or greater than 1.2 g/kg in patients undergoing hemodialysis and equal to or greater than 1.3 g/kg in patients undergoing peritoneal dialysis. In hemodialysis, the intradialytic IDPN infusion is administered through the venous port of the dialysis tubing, typically, 30 minutes after dialysis has begun, and continued throughout the remainder of a dialysis session. In peritoneal dialysis, sometimes referred to as intraperitoneal parenteral nutrition (IPPN) or intraperitoneal nutrition (IP), parenteral nutrition is infused into the peritoneal cavity during peritoneal dialysis.

Patients with ESRD on chronic hemodialysis have a high incidence of protein-energy malnutrition (PEM). The reasons for this are multi-factorial and include: inadequate food intake, a catabolic response to systemic illness or chronic inflammation, loss of nutrients through the dialysis procedure, as well as systemic effects of the uremic milieu. IDPN has been supported for the management of malnutrition in hemodialysis patients. The rationale for its use is that patients are unable to increase oral intake to meet their nutritional needs or that the oral or enteral route is not effective in managing malnutrition in this group of patients. Nevertheless, numerous studies using IDPN have failed to demonstrate efficacy conclusively with this very costly mode of treatment.

So, this being said… Today I had the opportunity to witness and assist in the methodology regarding how the Clinical Manager at my rotation site approves or possibly denies a patient request for IDPN. Currently, the cost for this request would approximately be $7,000 per month for a patient to receive IDPN, which is three times per week. So, my job today was to determine if this patient is eligible for the hospital to provide IDPN and how to justify the approval/deny request to hospital administrators as well.

Below are the criteria that I researched which is currently being used for the approval/denial of IDPN:

Patient must demonstrate the following:
– Failed attempt to increase nutritional status with oral nutritional supplements
– Is not a candidate for tubefeeding (where nasogastric or gastronomy feeding is unsafe or impractical)
– Is able to meet greater than or equal to 50% of needs orally

Criteria for Initiation: Patient must meet any three of the following:
– Three month average serum albumin 10% of UBW –or- <90% of IBW
– SGA: score B or C indicating moderate to severe malnutrition
– Diet history showing decrease in:
o Protein <1.0g/kg/d
o Calories <25kcal/kg/d (≤30kcal/kg/d for those with higher kcal requirements)
– Documented diagnosis of a GI disorder (like gastroparesis, malabsorption syndromes, etc.)

Sample IDPN prescription
Initiated after 30 minutes into the dialysis session, through the venous port of the dialysis tubing and given for the duration of the hemodialysis procedure (3.5 hours) at a rate of 150 ml/hour.

1. Amino acids: 300 mL of a 15% solution of amino acids (15% Clinisol®; Baxter Healthcare Corp., Deerfield, Illinois, USA) consisted of nine essential AAs (lysine, 1.18 g; leucine, 1.04 g; phenylalanine, 1.04 g; valine, 960 mg; histidine, 894 mg; isoleucine, 749 mg; methionine, 749 mg; threonine, 749 mg; thryptophan, 250 mg) and eight nonessential AAs (alanine, 2.17 g; arginine, 1.47 g; glycine, 1.04 g; proline, 894 mg; glutamate, 749 mg; serine, 592 mg; aspartate, 434 mg; tyrosine, 39 mg).
2. Dextrose: 150 mL of dextrose at a concentration of 50%
3. Lipids: 150 mL of lipids at a concentration of 20% This solution provides 188 kcal/hour or 3.5 kcal/kg fat-free mass per hour for a total of: 45 g of protein and 735 total kcal in 600 mL.

Medicare Intermediary Criteria (2009) for Initiating IDPN in the Presence of a Functional Gastrointestinal Tract
1. Evidence of protein or energy malnutrition and inadequate dietary protein and/or energy intake (for instance: dietary history of decreased intake: protein <0.8 g/kg and/or calories <25 kcal/kg and subjective global assessment (SGA): “C” rating [severe malnutrition])
2. Weight loss greater than 10% of ideal body weight or 20% of usual body weight (no time constraints)
3. Serum albumin <3.4 g/dL (3 month rolling average)
4. Evidence of a comprehensive nutritional assessment and dietary counseling
5. Inability to administer or tolerate adequate oral nutrition, including food supplements or tube feeding
6. Evidence that patient was intolerant of enteral nutrition, or could not meet the individual’s nutritional needs or is not feasible (3 month trial)
7. Evidence that the individual has had the following conditions ruled out or previously addressed:
– Anorexia caused by the uremic state
– Altered taste sensation
– Intercurrent (limited) illness
– Emotional distress or illness
– Impaired ability to procure, prepare or mechanically ingest foods
– Unpalatable prescribed diets
– Catabolic response to a superimposed (limited) illness
– Inadequate dialysis/uremic state
– Gastroparesis
– Constipation