Nutrition therapy for patients on chronic dialysis
Among patients undergoing chronic hemodialysis, approximately 20-30% show symptoms of malnutrition. 5-10% of patients already present with severe malnutrition, especially protein energy malnutrition. These effects are results from a number of underlying causes, first but not exclusively through decreased oral dietary intake due to diet restrictions and nausea and vomiting. However, also specific metabolic changes such as dialysis-induced catabolism, peripheral insulin resistance, hyperparathyroidism and metabolic acidosis may lead to malnutrition. Malnutrition can increase morbidity and mortality and can significantly reduce the quality of life. Nutritional support directly during the dialysis procedure achieves additional therapeutic benefits without additional time expenditures.
Guidelines recommend the use of intradialytic parenteral nutrition for patients with malnutrition if a significant improvement in nutritional status is not achievable through oral or enteral nutrition and a number of additional criteria is met. Screening tools such as the “Subjective Global Assessment” (SGA) are available to structure decision making.
Patients in need of chronic hemodialysis typically have an arterio-venous shunt to enable appropriate blood flow. Alternatively, catheters for dialysis such as Shaldon’s are applied. Nutritional support given during dialysis can be added into the venous part of the catheter system.
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The preparation largely depends on the choice of the nutritional regime whether a ready-to-mix product or a compounded regime shall be used. The additional injection of vitamins and trace elements might be indicated. Goes without saying: thorough disinfection of devices and correct priming of the giving set is crucial.
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Optimally, intradialytic nutrition is given via a volumetric infusion pump, such as Infusomat® Space, connected by a luer lock device to the venous access of the dialyzer.
Nutritional support for patients requiring chronic dialysis is optimally not limited to parenteral nutrition during the hemodialysis sessions but rather completed by enteral nutrition support between sessions, such as motivation and guidance for patients with regards to balanced and valuable nutrition. This might also include the use of sip feeds.