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Original Article


Randomized, Controlled, Trial on Effect of Intradialytic Parentral Nutrition (IDPN)

on Malnourished Dialysis Dependent Patients.

1Dr Anita Saxena, 2Dr RK Sharma, 2Dr Amit Gupta

1Additional Professor, 2Professor Department of Nephrology SGPGIMS Lucknow 226014


Key words: Intra Dialytic Parenteral Nutrition, maintenance hemodialysis, amino acids, body composition


P

P

oor nutritional status and muscle wasting , common in Indian patients with ESRD, is associated with increased morbidity and mortality. Intradialytic parenteral nutrition (IDPN) is a widely used nutritional support for correcting hypercatabolic state leading to protein-energy wasting in hemodialysis patients. A number of reports have emphasized the effectiveness of intradialytic parenteral nutrition (IDPN).

Objectives: i) To provide intradialytic parenteral amino acid supplementation to malnourished ESRD patients on maintenance hemodialysis (MHD), ii) to observe changes in biochemical parameters indicating nutritional status, iii) to observe changes in protein and muscle mass as depicted by bioelectrical impedance analysis (BIA), iv) to observe changes in nutritional status and body composition as depicted by BIA, v) to observe effect of nutritional status on post transplant wound healing.

Material and methods: Twelve patients were recruited. Patients were given aminoacid infusion twice weekly (50 g protein calories 200 kcal in 500 ml of aminoacid infusion) for a period of 3 months. For, biochemical tests 8.0 ml of venous blood was taken four times: at baseline, month 1, 2 and 3. Tests included hemoglobin, ESR, C-reactive protein (CRP), homocystein, serum cholesterol, HDL cholesterol, LDL cholesterol, VLDL cholesterol, serum triglycerides, serum transferring, blood sugar fasting, blood urea, serum creatinine, protein creatinine ratio, serum albumin, serum pre-albumin. Nutritional status was assessed with malnutrition inflammation score (MIS), body mass index (BMI) and four skinfolds: biceps, triceps, subscapular and suprailliac and mid upper arm circumference. Changes in body composition were measured with bioimpedance analyzer.

Results: Based on MIS one patient was mildly malnourished,

4 were moderately malnourished and 6 were severely malnourished. There was significant difference in the actual body weight and dry weight of the patients at baseline (p 0.000) and at 3 months (p 0.000). There was an increase

in gross values of GFR from baseline to month 3, although increase was not statistically significant. Paired t test between baseline and month 3 showed that there was significant difference in biceps skin fold (p 0. 000), triceps (p 0.001), subscapular (0.010), suprailliac (p 0.023) MUAC (P 0.042) BMI (p 0.003) andphase angle (p 0.028). Therewas significant difference in baseline and month 3 fat free mass and fat mass. Although TBW remained constant during three months of intervention, there was significant decrease in ICW, plasma fluid and interstitial fluid. Phase angle increased significantly (p 0.003) from baseline 3.67± 1.37 to 4.80± 1.81at month

  1. All the patients were anemic,had high ESR, CRP and homocysteine levels. Lipid profile of the patients was normal. Significant increase in serum albumin (3.61± 0.85 to 4.14± 0.13 g/dL) and prealbumin (25.2± 8.23 to 31.07± 3.21 g/dl) was observed from baseline to month 3 as positive effect of amino acid infusion.

    Conclusion: IDPN is a convenient and safe therapeutic interventionthatprovidesnutritionduringtheHDprocedure. It can help in rehabilitating a severely malnourished patient and improve post transplant outcomes.

    Introduction: Uremic anorexia, along with factors like inflammation, cytokines, metabolic acidosis, imbalance between anabolic and catabolic hormones, is the most common cause of protein-energy wasting in chronic kidney disease. Poor nutritional status and muscle wasting is common in Indian patients with ESRD and is associated with increased morbidity and mortality1-3 . Hemodialysis (HD) procedure is associated with loss of peptides, amino acids (AA) andvitamins inthedialysate andwhich causes decreased plasma aminoacid (AA) concentrations, accelerated rates of whole-body and skeletal muscle proteolysis, and increased energy expenditure, resulting in net negative intradialytic protein and energy balance4, 5

    Intradialytic parenteral nutrition (IDPN) is a widely used nutritional support for correcting hypercatabolic state leading to protein-energy wasting in hemodialysis patients.

    A number of reports have emphasized the effectiveness of intradialytic parenteral nutrition (IDPN)6 But some have not been able to show benefits because of i) varied durations for which it was used and ii) lack of a prospective randomized trials7,8 With this background we conducted a study to see the effect of IDPN on severely malnourished patients who were awaiting renal transplant. The study was based on hypothesis that administration of intradialytic parenteral nutrition would compensate whole body and skeletal muscle protein derangements as a result of the HD procedure, resulting in net protein anabolism and improvement in nutritional status. Specific objectives were i) to provide intradialytic parenteral amino acid supplementation to patients with ESRD with malnutrition on maintenance hemodialysis (MHD), ii) to observe changes in biochemical parameters indicating nutritional status, iii) to observe changes in protein and muscle mass as depicted by bioelectrical impedance analysis (BIA), iv) to observe changes in nutritional status and body composition as depicted by BIA, v) to observe effect of nutritional status on post transplant wound healing.

    Material And Methods: This was a prospective randomized trail which was approved by the institute’s Ethics committee. The duration of the study was 1 year. Patients were given intradialytic parenteral nutrition along with dietary recommendations of 1.2g/kg/d of protein and 30-35 kcal/ kg/d of energy. Twelve patients were recruited (2 females and 10 males). Patients in group 1 were given aminoacid twice weekly (50 g protein calories 200 kcal in 500 ml of aminoacid infusion) for a period of 3 months. However out of 12 patients, 9 patients completed the study while 3 were drop outs: one patient was transplanted after 1 month of recruitment and the second patient expired after completing 14 weeks because of multiple organ failure and 3rd patient was a cased of autosomal dominant polycystic kidney disease. Patient did not continue HD as she died after nephrectomy. Death was not related to study drug. Patients (N=7) in group 2, controls, were not given IDPN. They were advised to take 1.2g/kg b.w/d of protein and 35 kcal/day.

    Inclusion criteria were i) male or female patient above the age of 18 years who were dialysis dependent end-stage-renal disease patients ii) patients having transplant prospects on twice weekly HD programme, at dialysis unit, of our department, iii). Patients with signs of deranged nutritional status as defined below (National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) nutritional Guidelines): serum albumin <4g/dl, serum prealbumin

    <30 mg/dl, serum cholesterol <150 mg/dl, serum transferin

    <150mg/dl before enrollment, and iv) patients willing to give written informed consent. Exclusion criteria were i) patients with active infectious disease, ii) hospitalization within last two months and iii) patients on immunosuppressive medication, iv) patients with malignancy, v) patient with significant mental illness, vii) HIV and HbsAg positive

    viii) patients with chronic liver disease. Written informed consent was taken from the patient.

    Physical examination included anemia dyspnea cyanosis

    jaundice edema exanthem lymph nodes head and neck chest abdomen, cardiovascular system (CVS), central nervous system (CNS), any abnormality in skin. For biochemical tests 8.0 ml of venous blood was taken four times: at baseline, month 1, 2 and 3. Tests included hemoglobin, ESR, C-reactive protein (CRP), homocystein, serum cholesterol, HDL cholesterol, LDL cholesterol, VLDL cholesterol, serum triglycerides, serum transferring, blood sugar fasting, blood urea, serum creatinine, protein creatinine ratio, serum albumin, serum pre-albumin. Nutritional status was assessed with malnutrition inflammation score (MIS)9, body mass index (BMI) and four skinfolds: biceps, triceps, subscapular and suprailliac and mid upper arm circumference using standard herpenden skinfold calipers and non stretchable tape. Anthropometric measurements included height in centimeters and body weight in kilograms. Body mass index (BMI) was calculated as weight (kg)/height in meter square.

    For evaluating body composition,single-frequency BIA measurements were taken on the right side of the body (which was not connected to hemodialysis machine), with a standard tetrapolar whole-body (hand–foot) bioelectrical impedance analyzer Maltron BIOSCAN analyzer 915/916. BIA was standardized on patients with chronic kidney disease, patients on dialysis and patients who had undergone renal transplantation. Parameters evaluated were total body water (TBW), extracellular water (ECW), ECW percent intracellular water (ICW), ICW percent, plasma, interstitial fluid (Ints.), extracellular solids (ECS), extracellular fluid (ECF), fatmass, fatfree mass (FFM), FFM percent GFR, total body protein, calcium (Ca), glycogen (Glyc), mineral, muscle mass, dry weight, resting metabolic rate (RMR), and phase angle. Water compartments are reported in liters, fat and FFM in kilograms. Protein and minerals in grams.

    IDPN infusion was given twice weekly for 3 months, It was started 30 minutesafter initiation of HDvia thevenous portof the bubble trap on the HD tubing and continued throughout the entire HD procedure (total of 4.0 hours of IDPN infusion). Duration on HD treatment was 4 hours but since IDPN was infused at slow rate, it was completed 30 minutes after dialysis was terminated. The solution was given at a rate of 100 ml/h and consisted of 500 ml of AAs at a concentration of 10%. AA solution (Celemin, ClarisLifesciences Ltd India) consisted of essential AAs (lysine,0.700 g; leucine, 0.890 g; phenylalanine 0.510 g; valine, 0.480 mg; histidine, 0.520 mg;

    isoleucine, 0.510 mg; methionine, 0.380 mg; threonine, 0.410 mg; thryptophan, 0.140 mg) and nonessential AAs (alanine,

    1.370 g; arginine,0.920 g; glycine, 0.790 g; proline,0.890 mg; glutamate, 0.460 mg; serine, 0.240 mg; aspartate, 0.130 mg; tyrosine,0.30 mg; acetyltyrosine 0.123; asparagines 0.372, cysteine 0.073g ornithine 0.320g). Concentration of electrolytes was sodium 45mmol/l, potassium 25 mmol/l, magnesium 2.50 mmol/l; acetate 59 mmol/l; chloride 62 mmol/l malate7.50 mmol/l. This solution provided 50g of amino acids, total nitrogen 8 g, non protein energy 200 kcalories, EAA: NEEAA ratio 0.345 osmolarity 520 mOsmol. The extra volume, as well as electrolytes, that IDPN provided to the patients was accounted for and removed during HD.

    BIA was repeated after HD session was terminated. Patients were observed closely for side effects of IDPN like, vomiting, burning sensation, cramps, and headache,

    Statistical analysis was done using SPSS version 15.0 (SPSS Inc. Chicago,lL.). Mean, standard deviation, correlation and paired t test were used for analyzing data to see if there was any difference between baseline and month 3 parameters.


    Results:

    Mean age of the patients was 43.17± 13.91 years and mean height was 166.4± 10.10 cm. Based on MIS score nutritional status of the patients is given in Table 1. One patient was mildly malnourished, 4 were moderately malnourished and 6 were severely malnourished. In control group 5 were severely malnourished and 2 were moderately malnourished

    MIS statistically correlated with phase angle at 2 months (p

    -0.016 r 0.929), fat mass at baseline (p 0.001, r 0.994), fat mass

    Table 1 Malnutrition Inflammation Score


    Group

    Mildly Malnourished

    Moderately Malnourished

    Severely Malnourished

    IDPN

    1(MIS 14)

    4 (MIS 15-19)

    6 (MIS 22-30)

    CONTROL

    -

    2

    5


    percent at 1 month (p 0.006 r 0.974), ECW at 1 month (p

    0.005, r 0,977), FFM baseline (p 0.002, r 00.2), ECW percent

    at 2 months (p 0.018, r 919); ICW percent 2 months (p

    0.046, r 0.789), ECW/ICW ratio (p 0.016 r 0.926) creatinine clearance at 1 month (p 0.046, r 808), negatively with triceps skinfold (p-0.018 r 0.779). The body composition parameters of controls and IDPN groups at baseline and at month 3 are given in Table 2a-2f. Table 3 gives parameters which were statistically different (student’s t test) between IDPN and Control Groups. There was ignificant difference in the water compartments of patients and controls.


    Table 2a Body Composition Parameters of Controls and Treatment Group at Baseline


    Weight

    Phase angel

    BMI

    RMR

    FFM

    (kg)

    FFM%

    Fat (kg)

    Fat %

    TBW (Lt)

    ECF (Lt)

    IDPN

    60.4±

    19.9

    3.6± 1.3

    21.5±

    5.8

    1424.1±

    144.6

    47.6±

    8.5

    81.7±

    11.1

    12.7±

    14.4

    18.1± 11.1

    35.7± 9.17

    22.3± 9.8

    CONTROL

    47.1±

    6.4

    6.7± 5.0

    17.5±

    1.1

    1378.6±

    219.6

    40.5±

    7.1

    85.2±

    7.2

    6.3± 3.3

    13.3± 6.1

    28.4± 4.3

    13.8± 4.2


    Table 2 b Body Composition Parameters of Controls and Treatment Group at Baseline


    TBW%

    ECW (Lt)

    ECW%

    ICW (Lt)

    ICW%

    ECW/ ICW

    BCM

    (kg)

    ECM

    (kg)

    ECS

    Plasma (Lt)

    Ints. (Lt)

    IDPN

    60.4±

    8.1

    21.4±

    9.2

    59.4± 16.7

    14.4±

    7.9

    40.4±

    16.7

    2.5±

    3.0

    22.9± 6.7

    24.6± 6.0

    4.6±

    1.2

    4.4± 1.9

    15.9± 1.3

    CONTROL

    60.4±

    5.7

    12.5±

    4.2

    43.5± 11.8

    16.4±

    3.9

    55.1±

    10.6

    .87± .4

    20.5± 3.3

    19.7± 5.0

    3.9±

    .90

    2.7±

    0.82

    9.3± -94


    Table 2 c Body Composition Parameters of Controls and Treatment Group at Baseline


    Group

    Creat Clear

    GFR ml/ min

    Protein (kg)

    Mineral (kg)

    Muscle (kg)

    Potassium (g)

    Calcium (g)

    Glycogen (g)

    Dry Weight (kg)

    IDPN

    15.0± 11.0

    6.4± 9.2

    8.5± 2.7

    3.1± .88

    20.7± 5.3

    138.9±

    143.2

    857.9± 249.3

    429.1± 74.9

    54.3± 22

    CONTROL

    11.6± 2.0

    3.6± 1.8

    8.3± 2.8

    3.1± .84

    18.7± 4.2

    96.2± 18.8

    822.1± 124.2

    370.6± 67.3

    45.1± 6.87


    Table 2 d Body Composition Parameters of Controls and Treatment Group at 3 Months


    Weight (kg)

    Phase angel

    BMI

    RMR

    FFM

    (kg)

    FFM%

    Fat (kg)

    Fat %

    TBW (Lt)

    TBW%

    IDPN

    61.1±

    21.1

    4.7± 1.8

    22.3± 6.6

    1413.5±

    152.7

    46.9±

    8.3

    77.0±

    16.5

    14.9±

    17.2

    20.2±

    13.6

    35.5±

    8.4

    58.9± 7.4

    CONTROL

    48.5± 5.8

    6.8± 5.4

    18.4± 1.4

    1379.0±

    201.2

    41.0±

    6.3

    84.9±

    7.31

    5.9± 2.8

    13.2± 6.0

    29.3±

    3.7

    60.0± 4.7

    Table 2e Body Composition Parameters of Controls and Treatment Group at 3 Months


    ECW (Lt)

    ECW%

    ICW (Lt)

    ICW%

    ECW/ ICW

    BCM

    (kg)

    ECM

    (kg)

    ECS

    ECF (Lt)

    Plasma (Lt)

    Ints Fluid (Lt)

    IDPN

    19.5± 10.5

    47.5± 14.0

    19.5±

    8.7

    47.8±

    15.6

    1.97±

    4.0

    24.9±

    6.0

    22.3±

    6.0

    4.92±

    1.13

    17.8±

    5.9

    3.6±

    1.18

    12.9±

    4.3

    CONTROL

    13.1± 3.6

    44.0± 10.3

    17.4±

    3.9

    56.6± 9.6

    .84±

    0.46

    19.0±

    3.6

    16.9±

    5.2

    3.43±

    0.79

    13.6±

    3.4

    2.5±

    0.57

    9.6± 2.7


    Table 2f Body Composition Parameters of Controls and Treatment Group at 3 Months


    Group

    Creat Clear

    GFR ml/ min

    Protein (kg)

    Mineral (Kg)

    Muscle (kg)

    Potassium (g)

    Calcium (g)

    Glycogen (g)

    Dry Weight (kg)

    IDPN

    16.5± 7.9

    7.4± 6.4

    8.5± 3.3

    3.0± 1.14

    22.0± 4.7

    270.9± 411

    872.2± 319

    423.4± 76.4

    58.7± 23.6

    CONTROL

    12.1± 2.6

    4.3± 2.1

    6.6± 3.22

    2.7± 0.85

    17.1± 4.1

    99.4± 15.5

    736.4± 255.5

    346.3± 65.0

    46.3± 6.4


    Table 3 Student’s T test Difference between IDPN and Control Groups


    Differences (p values)

    Weight (kg)

    BMI

    FFM

    (kg)

    FAT

    (kg)

    TBW (Lt)

    ECW (Lt)

    ECW%

    ICW%

    ECW/ ICW

    ECM

    (kg)

    Glyc (g)

    ECF (Lt)

    Plasmma (Lt)

    Ints Fluid (Lt)

    0.006

    0.004

    0.012

    0.046

    0.002

    0.000

    0.003

    0.003

    0.032

    0.007

    0.023

    0.001

    0.001

    0.000

    Differences At 3 Months (p values)

    Weight

    BMI

    FFM

    FAT

    ECW

    BCM

    CRCL

    Muscle

    Glycogen

    Dry wt

    ECS

    ECF

    Plasma

    Ints fluid

    0.018

    0.017

    0.032

    0.032

    0.022

    0.002

    0.033

    0.007

    0.006

    0.042

    0.000

    0.020

    0.003

    0,015


    Table 4 Patients demographic and Anthropometry at baseline, 2 months and at 3 months (IDPN Group).


    Month

    Weight (kg)

    Dry weight (kg)

    BMI kg/ m2

    RMR

    Biceps*** (mm)

    Triceps** (mm)

    Sub Scapular* (mm)

    Suprailiac

    *(mm)

    MUAC*

    (cm)

    WHR

    1

    60.40 ± 19.9

    54.33±

    22.0

    21.50±

    5.80

    1424.17 ± 144.67

    5.18 ± 2.08

    12.48 ± 6.53

    11.56 ± 5.84

    9.0687 ±

    5.10

    23.40

    4.58

    0.86±

    .09

    2

    60.72 ± 21.4

    55.02 ± 22.7

    21.69±

    6.51

    1404.13±

    150.11

    ND

    ND

    ND

    ND

    ND

    ND

    3

    61.11±

    21.2

    58.77±

    23.65

    22.37±

    6.63

    1413.50 ± 152.74

    6.00±

    2.35

    12.72±

    3.75

    10.33±

    2.71

    9.0± 5.19

    23.62 ± 2.24

    0.90±

    0.11

    ND = Not Done at 2 months; Significant difference at *p <0.05% **p< 0.001% , ***p< 0.000 %,


    Table 5a Body composition at baseline, 2 and 3 months (IDPN)


    Month

    FFM

    FFM %

    Fat Mass

    Fat Mass %

    Creatinine Clearance

    GFR ml/min

    Phase Angle

    1

    47.60± 8.5

    81.76± 11.1

    12.76± 14.40

    18.13± 11.1

    15.08± 11.03

    6.50± 9.29

    3.67± 1.37

    2

    46.79± 8.5

    81.05± 12.2

    14.65± 17.63

    20.37± 15.5

    14.81± 8.18

    5.81± 6.55

    3.99± 1.73

    3

    46.93± 8.3

    77.07±

    16.6

    15.00±

    17.23

    20.22± 13.6

    16.55± 7.94

    7.46± 6.45

    4.80± 1.81

    Table 5b Body Composition At Baseline, 2 and 3 Months (IDPN)


    Month

    TBW

    TBW%

    ECW

    ECW%

    ICW

    ICW%

    ECF

    Plasma

    Ints Fluid

    BCM

    ECM

    ECS

    1

    35.78±

    9.17

    60.49±

    8.13

    21.48±

    9.25

    59.47±

    16.76

    14.40±

    7.91

    40.44±

    16.75

    22.37±

    9.81

    4.44±

    1.99

    15.93±

    6.84

    22.93±

    6.73

    24.61±

    6.10

    4.6± 4

    1.20

    2

    35.15±

    8.64

    59.79±

    6.87

    19.93±

    7.47

    57.29±

    16.41

    16.56±

    10.24

    42.91±

    16.54

    21.12±

    7.91

    4.23±

    1.57

    14.99±

    5.55

    23.01±

    6.80

    23.47±

    6.27

    4.66±

    1.20

    3

    35.58±

    8.43

    58.99±

    7.42

    19.51±

    10.59

    47.51±

    14.03

    19.54±

    8.74

    47.84±

    15.68

    17.87±

    5.98

    3.61±

    1.19

    12.91±

    4.32

    24.99±

    6.09

    22.34±

    6.05

    4.92±

    1.13


    Table 5c Body composition at baseline, 2 and 3 months (IDPN)


    Month

    Phase Angle

    Protein kg

    Mineral kg

    Muscle

    TBK mg

    Calcium mg

    Glycogen

    1

    3.67± 1.37

    8.56± 2.76

    3.16± .89

    20.77± 5.39

    138.94± 143.2

    857.96± 249.3

    429.13± 74.9

    2

    3.99± 1.73

    8.52± 2.72

    3.11± .85

    20.85± 5.21

    109.8± 32.60

    798.56± 332.8

    424.42± 77.9

    3

    4.80± 1.81

    8.59± 3.30

    3.08± 1.14

    22.03± 4.7

    270.9± 411.8

    872.20± 319.6

    423.42± 76.4


    Table 6 Biochemical profile of patients (IDPN)


    HB

    ESR

    CRP

    Homocys- tein

    Choles- terol

    HDL

    LDL

    VLDL

    Trigly

    Blood sugar R

    S

    Albumin

    Prealbu- min

    7.50±

    1.96

    73.50±

    4.04

    2.31±

    .900

    32.1± 8.6

    145.5±

    38.6

    38.25±

    10.10

    79.00±

    23.09

    29.6 ± 4.85.20

    142.5±

    025.9

    105.0±

    40.41

    3.61±

    .0.85

    25.2±

    8.23

    6.90±

    0.0

    71.00±

    1.15

    2.5±

    0.61

    38.2± 5.9

    129.0±

    19.6

    31.25±

    2.02

    74.00±

    17.32

    25.6±

    3.6

    120.0±

    .00

    102.0±

    32.3

    4.14±

    0.13

    31.07±

    3.21



    There was significant difference in the actual body weight and dry weight of the patients at baseline (p 0.000) and at 3 months (p 0.000). There was an increase in gross values of GFR from baseline to month 3, although increase was not statistically significant. Paired t test between baseline and month 3 showed that there was significant difference in biceps skin fold (p 0. 000), triceps (p 0.001), subscapular (0.010), suprailliac (p 0.023) MUAC (P 0.042) BMI (p 0.003)

    and phase angle (p 0.028).

    Patients demographic and anthropometry is given in Table

  2. Body composition of patients in IDPN group for month 1,2 and 3 is given in Tables 5a-5c. There was significant difference in baseline and month 3 fat free mass and fat mass. Although TBW remained constant during three months of intervention, there was significant decrease in ICW, plasma fluid and interstitial fluid. Phase angle increased significantly (p 0.003) from baseline 3.67± 1.37 to 4.80± 1.81at month 3.

Biochemical profile of the patients is given in Table 6. All the patients were anemic,had high ESR, CRP and homocysteine levels. Lipid profile of the patients was normal (Table 6) Significant increase in serum albumin (3.61± 0.85 to 4.14±

0.13 g/dL) and prealbumin (25.2± 8.23 to 31.07± 3.21 g/dl) was observed from baseline to month 3 as positive effect of amino acid infusion. None of the patients complaint of side effects of IDPN.


Discussion:

With growing epidemiological evidence relating diet and its constituentstochronicdiseases concernhas focused oneating appropriate amounts to maintain the specific and unique physiological functions of that nutrient. Renal insufficiency has adverse effect on endocrine function and nutrient metabolism. Patients with CKD have a decreased ratio of essentialtononessentialaminoacids, apatternthatisobserved in protein-calorie malnutrition. However, abnormalities in plasma aminoacids in patients with renal insufficiency cannot be explained on the basis of malnutrition alone because these abnormalities also occur when protein intake is optimal suggesting that abnormal levels in plasma might be the result of changes in amino acid metabolism caused by renal insufficiency, inflammation and acidemia. The plasma levels of branched chain aminoacids (BCAA) valine, leucine and isoleucine and of their respective ketoacids are decreased, with valine being reduced to a greater extent than others. The potential mechanism responsible for this decrease in BCAA might be related to oxidation of such aminoacids in skeletal muscle as a consequence of metabolic acidosis. Patients with renal insufficiency also have decreased plasma threonine and lysine and serine (because of decreased production from glycine in kidney) levels. Levels of aminoacids such as glycine, citruilline, cystine, aspartate, methionine, and both

1- and 3- methylhistidine are increased in these patients. Metabolites of sulfur-containing aminoacids accumulate in blood. Changes in body composition have been analyzed by measurements of anthropometry, bioelectric impedance and total body nitrogen. Most reports of such measurements in ESRD patients show that the prevalence of reduced protein stores among these patients is 20 to 50%. IDPN, if administered judiciously can help normalize amnio acid pools in ESRD patients.

This study was undertaken to see if IDPN had beneficial effect on nutritional status. Despite the fact CRP , ESR and homocysteine levels were high in our cohort, study showed that twice weekly infusion of amino acids significantly improved serum albumin, prealbumin levels, biceps,triceps, subscapular, suprailliac skin folds , MUAC, GFR and ICW. Ingestion of protein or intravenous infusion of amino acids acutely elevates glomerular filtration rate (GFR) and renal plasma flow (RPF) by unknown mechanisms. Endothelium derived relaxing factor (EDRF), now known to be nitric oxide derived from metabolism of L-arginine, participates in local regulation of vascular tone. Study by Tolins (1991) has shown that intravenous infusion of a 10% mixed amino acid solution at 1 ml/hr had no effect on systemic blood pressure but induced significant increases in GFR and renal plasma flow (RPF)10-13 In this study we found that the GFR increased from 6.50± 9.29 ml/min at baseline to 7.46± 6.45 ml/min after 3 months of AA infusion (24 times in 3 months). The GFR in control group did not show any improvement. There was significant difference between IDPN group and controls

in almost all the parameters.

Post Transplant Recovery: Nutritional status and psychological stress have been shown to be an influential factor on the rate of wound healing. Study on 52 living kidney donors has shown that higher pre-operative life stress, lower optimism and lower conscientiousness are associated with delayed wound healing in living kidney donors for both outcomes. Increased emotional stability is associated with faster wound healing as demonstrated by a change in median intensity. This study was undertaken to see the effect of nutritional status on post transplant outcomes. One patient

be high. Increased catabolism i.e., a) blood membrane interactions, b) dialysate amino acid, protein and glucose losses, c) acidosis, d) inflammation) is a potential cause of loss of lean body mass in patients undergoing HD. In our cohort, one patient was mildly malnourished, 4 were moderately malnourished and 6 were severely malnourished.

The number of nitrogen studies conducted in this group of patients are limited, but these studies suggest that a significantly higher intake of around 1.2 g/kg b.w./d. is required indicating that obligatory nitrogen losses are substantially greater in these patients. Energy requirement for these patients is 35 kcal/kg b.w./d. or more. Anorexia is yet another cause reduced intake of energy and protein. Factors that may contribute to anorexia include: underdialysis, comorbidity, medicationandpsychologicalfactors. Advanced CRF is associated with appetite suppression, however, HD can improve this condition. Moreover nutritional status improves after dialysis is initiated. Our study has shown, that despite dietary counseling, patients were not able to take 1.2g/kg/d of protein and 35 kcal/kg/d of energy. Despite poor dietary intake, IDPN showed positive effect on serum albumin, prealbumin and body composition.

To prevent malnutrition IDPN can be considered safe and effective means to improve nutritional status of dialysis dependent ESRD patients. There is now evidence that intradialytic nutritional supplementation is capable of reversing the HD associated net whole body and skeletal muscle protein catabolism.


Conclusion:

IDPN is a convenient and safe therapeutic intervention that provides nutrition during the HD procedure. It can help in rehabilitating a severely malnourished patient and improve post transplant outcomes.

Acknowledgements: This study was funded under Intramural research projects scheme,awarded by Research Committee, Sanjay Gandhi Post graduate Institute of Medical Sciences Lucknow. This work was presented at ASN Renal Week, Philadelphia, USA.

who had undergone renal transplant before completion of

study and hence was considered drop out had no episode of rejection both during his stay at kidney transplant unit and after discharge and he had good wound healing. IDPN had positive effect on his post transplant recovery. All the patients who underwent transplant had good nutritional status and good wound healing.

Physical Improvement: Patient who were weak, were having hypocaloric food intake, had functional impairment (required assistance in movements) had dramatic recovery with aminoacid infusion twice weekly for 3 months. They became independent and could move around without assistance and could get back to normal life.

Malnutrition, inflammation and atherosclerosis (MIA) syndrome is common in end stage renal disease. In our patients we found levels of homocystein, ESR and CRP to

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