MINIMIZING THE RISK OF HYPERGLYCAEMIA INDUCED BY

INTRADIALYTIC PARENTERAL NUTRITION

J Calder, JA Eastwood, C Gardiner, E Greaves, J Silcock, MJ Wright

Leeds General Infirmary

PROBLEM. Malnutrition is prevalent in the haemodialysis population and is known to have an adverse effect on dialysis outcomes. Methods of nutritional support include; dietary counseling and modification, nasogastric or gastrostomy feeding. If enteral tube feeding is clinically inappropriate or the patient refuses to have a feeding tube placed, intradialytic parenteral nutrition (IDPN) can be considered. The limitations of providing an IDPN solution with increased nutritional density are; the stability of the solution in 1000mls, the safety of delivering the infusion over a 4 hour period, the risk of hyperglycaemia and the need for a low electrolyte / electrolyte free solution.

PURPOSE. To provide maximal nutrition while reducing the risk of hyperglycaemia in a small group of patients that require IDPN.

DESIGN. Three IDPN formulas (Bag A, B and C) were each used for a 2 week period on 2 patients. The study population consisted of one female diabetic and one male non-diabetic patient.

Blood sugars were recorded pre, during and 30 minutes post IDPN infusion.

10mmol/l was considered to be the maximum acceptable blood glucose.

FINDINGS. One Way Analysis Of Variance (ANOVA) showed that the choice of IDPN formula was significant in influencing the change in blood glucose levels (P = <0.005).

Formula A had the least effect on blood glucose with no readings greater than 10mmol/l. Formula B had the greatest effect on blood glucose with more than 50% of readings during infusions greater than 10mmol/l. Formula C increased blood glucose levels, but the majority of readings were less than 10mmol/l. The three readings that exceeded 10mmol/l occurred on the same day and were preceded by high pre-dialysis readings. There was no statistically significant difference between the results of the diabetic and non-diabetic patient.

CONCLUSION. Bag A had no adverse effect on blood glucose but it had limited nutritional value so it would not be ideal. Bag B caused the largest increase in blood glucose. Using this formulation would require insulin infusion which would increase the risk of rebound hypoglycaemia. Bag C provided the maximal nutrition in 1000mls. The rise in the blood glucose associated with its use would not require insulin treatment. Further trials of bag C are needed in more patients to assess its tolerability and efficacy.

As part of the overall review of the use of IDPN within Leeds, clear criteria for patient selection, a monitoring tool and discontinuation criteria have been developed.

RELEVANCE. IDPN is not a therapy to be considered as the first line of nutritional support. However it does represent a useful form of nutritional support in the malnourished haemodialysis patient who cannot meet their nutritional requirements by oral supplementation and who has a contra-indication to either nasogastric or gastrostomy feeding. Further studies are needed with more patients to ensure that Bag C is tolerated and to monitor the nutritional status of patients during treatment.