- Email: [email protected]
Workshop on nutritional support in dialysis with a focus on the role of intradialytic parenteral nutrition
WORKSHOP PROCEEDINGS
Workshop on Nutritional Support in Dialysis With a Focus on the Role of Intradialytic Parenteral Nutrition Sponsored by the Renal Physicians Association in conjunction with the American Society of Nephrology, the American Society of Pediatric Nephrology, the American Society of Enteral and Parenteral Nutrition, and the National Kidney Foundation
Introduction
P
ROTEIN-CALORIE malnutrition is a frequent complication of end-stage renal disease (ESRD). The incidence of protein-calorie malnutrition in the ESRD population is 18% to 56%. Approximately 33% of the patients have clinically recognizable mild to moderate malnutrition, and 6% have severe malnutrition. It is increasingly evident that protein-calorie malnutrition is a significant cause of morbidity and mortality in the ESRD population. For example, malnutrition is associated with an increased frequency of hospitalizations, number of admissions per patient year, length of stay, and a threefold increase in hospital costs. Malnutrition can result in more difficult dialysis treatments and an increased number of missed dialysis sessions. If the serum albumin concentration is used as a surrogate of the patient’s nutritional status, there is an 18-fold increase in mortality associated with hypoalbuminemia. Despite its obvious deleterious impact on patients’ clinical outcomes, and the costs of treating malnutrition or its associated comorbid conditions, there is inadequate knowledge regarding the pathobiology and optimal nutritional interventions for malnutrition in the ESRD population. Fundamental issues that remain unresolved include identifica-
From the Division of Nephrology, The New York Hospital Medical Center of Queens, Department of Medicine, Flushing, NY; Cornell University College of Medicine, New York, NY; and the Division of Nephrology, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, MA. Received and accepted as submitted September 14, 1998. Address reprint requests to William F. Owen, Jr, MD, Renal Division, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail: [email protected]. edu
娀 1999 by the National Kidney Foundation, Inc. 0272-6386/99/3301-0028$3.00/0 170
tion of the predictors of malnutrition, surrogates to monitor patients’ nutritional state, and the appropriateness of various strategies to augment the protein-caloric intake and substrate utilization. The latter intellectual deficiency is compounded by mercantile considerations and restrictive reimbursement policies. On December 3, 1997, the Renal Physicians Association, in conjunction with the American Society of Nephrology, the American Society of Pediatric Nephrology, the American Society of Enteral and Parenteral Nutrition, and the National Kidney Foundation, sponsored a workshop on ‘‘Nutritional Support in Dialysis with a Focus on the Role of Intradialytic Parenteral Nutrition (IDPN).’’ The goals of the workshop were to (1) review and update the current state of knowledge regarding the pathobiology of malnutrition in patients with ESRD, (2) elucidate the benefits of the range of nutritional supports available for these patients with an emphasis on IDPN, (3) establish a framework for future research into the prevention and treatment of malnutrition in ESRD patients, and (4) offer a paradigm for collaborative scientific, regulatory, and fiscal evaluations of emerging clinical technologies. As illustrated by the accompanying papers, the presenters successfully addressed the issues raised to them. Their scholarly presentations underscore the immediate and pressing need for a prospective, multicenter intervention trial(s) to clarify the efficacy of nutritional interventions for malnutrition in the ESRD population. It is also evident that the complexity and cost of such an intellectual endeavor will require collaboration between the scientific, industrial, and payer communities. In the current era of rapid technological advances, the provider community is continually
American Journal of Kidney Diseases, Vol 33, No 1 (January), 1999: pp 170-171
WORKSHOP PROCEEDINGS
faced with novel tools and interventions that need improved definition of their clinical benefit, appropriate application, and cost-effectiveness. Despite the attempt to inject scientific rigor into all aspects of clinical medicine, much of our discipline is based on empirical observations. Therefore, arguably, it is unjust to deny patients the benefit of novel approaches that are supported by sound chains of logic and accompanied by reasonable clinical evidence. This is true even if the scientific evidence is not yet mature. However, fiscal responsibility mandates accountable behavior by providers to minimize abuse or misuse of such emerging technologies; and there must be collaborative support between the scientific/medical and the regulatory/payer communi-
171
ties. IDPN offers an excellent paradigm of these issues. A telling exchange from the question-andanswer period was, ‘‘Because of the rate and timing of nutrient administration, IDPN is an unphysiologic therapy.’’The panelist replied, ‘‘So is dialysis unphysiologic, but it works!’’ —Chaim Charytan, MD The New York Hospital Medical Center of Queens Cornell University College of Medicine New York, NY —William F. Owen, Jr, MD Brigham and Women’s Hospital Harvard Medical School Boston, MA
Workshop on Nutritional Support in Dialysis With a Focus on the Role of Intradialytic Parenteral Nutrition Sponsored by the Renal Physicians Association in conjunction with the American Society of Nephrology, the American Society of Pediatric Nephrology, the American Society of Enteral and Parenteral Nutrition, and the National Kidney Foundation
Introduction
P
ROTEIN-CALORIE malnutrition is a frequent complication of end-stage renal disease (ESRD). The incidence of protein-calorie malnutrition in the ESRD population is 18% to 56%. Approximately 33% of the patients have clinically recognizable mild to moderate malnutrition, and 6% have severe malnutrition. It is increasingly evident that protein-calorie malnutrition is a significant cause of morbidity and mortality in the ESRD population. For example, malnutrition is associated with an increased frequency of hospitalizations, number of admissions per patient year, length of stay, and a threefold increase in hospital costs. Malnutrition can result in more difficult dialysis treatments and an increased number of missed dialysis sessions. If the serum albumin concentration is used as a surrogate of the patient’s nutritional status, there is an 18-fold increase in mortality associated with hypoalbuminemia. Despite its obvious deleterious impact on patients’ clinical outcomes, and the costs of treating malnutrition or its associated comorbid conditions, there is inadequate knowledge regarding the pathobiology and optimal nutritional interventions for malnutrition in the ESRD population. Fundamental issues that remain unresolved include identifica-
From the Division of Nephrology, The New York Hospital Medical Center of Queens, Department of Medicine, Flushing, NY; Cornell University College of Medicine, New York, NY; and the Division of Nephrology, Brigham and Women’s Hospital, Department of Medicine, Harvard Medical School, Boston, MA. Received and accepted as submitted September 14, 1998. Address reprint requests to William F. Owen, Jr, MD, Renal Division, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail: [email protected]. edu
娀 1999 by the National Kidney Foundation, Inc. 0272-6386/99/3301-0028$3.00/0 170
tion of the predictors of malnutrition, surrogates to monitor patients’ nutritional state, and the appropriateness of various strategies to augment the protein-caloric intake and substrate utilization. The latter intellectual deficiency is compounded by mercantile considerations and restrictive reimbursement policies. On December 3, 1997, the Renal Physicians Association, in conjunction with the American Society of Nephrology, the American Society of Pediatric Nephrology, the American Society of Enteral and Parenteral Nutrition, and the National Kidney Foundation, sponsored a workshop on ‘‘Nutritional Support in Dialysis with a Focus on the Role of Intradialytic Parenteral Nutrition (IDPN).’’ The goals of the workshop were to (1) review and update the current state of knowledge regarding the pathobiology of malnutrition in patients with ESRD, (2) elucidate the benefits of the range of nutritional supports available for these patients with an emphasis on IDPN, (3) establish a framework for future research into the prevention and treatment of malnutrition in ESRD patients, and (4) offer a paradigm for collaborative scientific, regulatory, and fiscal evaluations of emerging clinical technologies. As illustrated by the accompanying papers, the presenters successfully addressed the issues raised to them. Their scholarly presentations underscore the immediate and pressing need for a prospective, multicenter intervention trial(s) to clarify the efficacy of nutritional interventions for malnutrition in the ESRD population. It is also evident that the complexity and cost of such an intellectual endeavor will require collaboration between the scientific, industrial, and payer communities. In the current era of rapid technological advances, the provider community is continually
American Journal of Kidney Diseases, Vol 33, No 1 (January), 1999: pp 170-171
WORKSHOP PROCEEDINGS
faced with novel tools and interventions that need improved definition of their clinical benefit, appropriate application, and cost-effectiveness. Despite the attempt to inject scientific rigor into all aspects of clinical medicine, much of our discipline is based on empirical observations. Therefore, arguably, it is unjust to deny patients the benefit of novel approaches that are supported by sound chains of logic and accompanied by reasonable clinical evidence. This is true even if the scientific evidence is not yet mature. However, fiscal responsibility mandates accountable behavior by providers to minimize abuse or misuse of such emerging technologies; and there must be collaborative support between the scientific/medical and the regulatory/payer communi-
171
ties. IDPN offers an excellent paradigm of these issues. A telling exchange from the question-andanswer period was, ‘‘Because of the rate and timing of nutrient administration, IDPN is an unphysiologic therapy.’’The panelist replied, ‘‘So is dialysis unphysiologic, but it works!’’ —Chaim Charytan, MD The New York Hospital Medical Center of Queens Cornell University College of Medicine New York, NY —William F. Owen, Jr, MD Brigham and Women’s Hospital Harvard Medical School Boston, MA