Click below to watch recordings of our webinars and learn about various topics impacting kidney health.

IDPN: Back to Basics

10 surprising facts that you don’t know about dialysis patients

Myths & Facts about Home Therapies

Current Trends in CKD

Metabolic Syndrome and the CKD Patient (CEU Offering)

Getting to the Heart of the Matter

Protein Energy Wasting (PEW): Factors in Chronic Kidney Disease (CKD)

PEW is a frequent complex complication of CKD Stage 5 Dialysis (CKD-5D) whose origins can be attributed to the progression of CKD as well as consequent to CKD-5D. Several contributing factors to PEW include (but are not limited to): decreasing glomerular filtration rate (GFR) with retention of uremic toxins altering appetite and consequent decreased nutrient intake, micronutrient deficiencies, inflammation, co-morbid conditions, metabolic acidosis, and imposed protein intake limitations in CKD. Low protein intake (nPNA/nPCR) has demonstrated strong association to adverse outcomes in CKD. (1) Once on maintenance dialysis, protein and energy requirements increase and catabolic effects of the dialysis procedure induce loss of amino acids and protein resulting in negative nitrogen balance. In contrast to the increased nutritional needs, it appears the actual protein intake of patients whether receiving maintenance hemodialysis (MHD) or peritoneal dialysis (PD) remains suboptimal. (1,2)

Interpreting Serum Albumin

Low albumin may be difficult to interpret whether it represents a marker of inflammation (negative acute phase response), or malnutrition (inadequate intake), or is a marker of co-existing inflammation and malnutrition. Studies have demonstrated both low protein intake and a high state of inflammation may be associated with low albumin and that inflammation and protein intake have opposing effects on serum albumin. (3,4) Randomized controlled trials have demonstrated that low albumin can be evidenced where inflammation is not present and that albumin can improve in the face of inflammation. (5,6)

Albumin: Mortality, Hospitalization and Re-Hospitalization

The biochemical marker serum albumin as a component of PEW in CKD-5D has consistently been shown to be a strong independent marker of outcomes over the past several decades. One recent large scale observational study (n=135,545) utilizing USRDS data to examine factors associated with hospitalization for infection among Medicare beneficiaries starting HD between 2005-2008, determined that compared to a reference group of patients with albumin >4.0g/dL, patients with albumin of <3.5g/dL at dialysis initiation had more than 20% increase in the rate of infection-related hospitalization.(7) Another recent study (n=349) was reviewed to identify factors predictive of a 30-day re-hospitalization in HD patients. In this study, patients with an albumin <3.3/dL were associated with higher readmission rates. (8) According to the 2017 USRDS data report, hospitalization represents a significant societal and financial burden, accounting for approximately 33% of total Medicare expenditures for dialysis patients. (9) Additionally, 35% of dialysis patients have an unplanned re-hospitalization within 30 days of discharge and re-hospitalization rates for dialysis patients are more than double that of older Medicare beneficiaries without a diagnosis of kidney disease (35.2% vs. 15.4%).

Addressing and Treating PEW

Regardless of the reason for low albumin, studies addressing prevention and treatment of low albumin remain paramount due to strong association with outcomes such as mortality, hospitalization, re-hospitalization and their associated costs. Studies have demonstrated in both HD and Peritoneal Dialysis (PD) patient populations that small incremental increases of albumin are associated with better outcomes. (10,11) Expert key opinion leaders in renal nutrition research have developed an algorithm inclusive of oral nutrition supplements and enteral and parenteral therapies (inclusive of Intradialytic Parenteral Nutrition (IDPN) and Intraperitoneal nutrition (IPN)).(12) These therapies have demonstrated to be effective in increasing albumin and promoting positive nitrogen balance and protein synthesis. (6,13-20) The CMO’s of the largest dialysis chains in the U.S. have also proposed an algorithm, similar to the one proposed by renal nutrition research experts, which addresses malnutrition, and offers support for the use of additional IDPN therapy. This can be found in literature published by other large organizations which are recognized as having expertise in both renal and nutrition support. (21,22,23)

Proplete IDPN Formulas

Pentec Health provides uniquely tailored, patient specific IDPN formulations designed to replenish protein loss while minimizing fluid and dextrose content.

Protein Provision

Ample protein is provided in weight based formulations to optimize protein repletion critical to improving nutrition status.

Minimized Volume Formulations

Final formula volume is minimized by using highly concentrated base solutions for Amino Acids.

Pentec Health’s contracts and relationships with manufacturers help to ensure provision of therapy during times of national shortage.

Low Dextrose Provision

- IDPN formulas are designed to provide enough dextrose to allow amino acids to be used for protein synthesis) while limiting the dextrose infusion rate to lower the risk of increased blood glucose levels.

- Dietitians and pharmacists review each formula to ensure glucose utilization rates are not exceeded.


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“We have been using your IDPN products at Pentec Health for the last 2 years and have been completely satisfied with the product and the customer service. You have been extremely helpful and professional in accomplishing our standards of service excellence to our patients in our facility. I applaud all of your visits, calls and email correspondence which enables me to give Pentec an A+ in Customer Service. Thanks for providing this service for our patients. We take pride in helping our patients achieve the best healthcare outcomes possible, and we are indebted to you for assisting us in this process.”

Nancy T. Facility Administrator Large Dialysis Organization

Proplete IPN for PD Patients

Pentec Health provides Intraperitoneal Nutrition (IPN) therapy for the peritoneal dialysis patient. The formulas are designed to replenish protein losses seen during peritoneal dialysis, along with dextrose reduction and providing dialysis.

Addition of IPN to a dialysis prescription is 1-2-3 Easy!

  1. Pentec Health compounds each IPN bag by adding the prescribed amount of amino acids into the dialysate bags made by Baxter/Fresenius. The bag is then shipped to the patient’s home to replace one of their regular bags.
  2. No separate hook up is typically required by the patient so there is no risk of contamination.
  3. There is usually no special training needed, the bag is administered in the same way as the regular dialysis bag.

Added benefits from the addition IPN therapy

  1. Improvement with fluid overload, when needed.
  2. Patients receive less dextrose overall.
  3. IPN ready bag is delivered directly to patient’s home.

Pentec Health supports you and your patients every step of the way.

Pentec Health supports you and your patients every step of the way

  1. The IPN formula must be refrigerated, so Pentec Health provides the patient with a refrigerator to meet this need.
  2. Our expert pharmacy staff is on call 24/7/365 to address any questions or concerns.
  3. We dedicate a Clinical Case Manager to communicate with the PD nurse to discuss and help personalize the current PD prescription and IPN prescription.

Clinical Team

The clinical team at Pentec Health specializes in the management of malnutrition within the ESRD population. IDPN and IPN are the only therapies dispensed from the renal pharmacy which allows Pentec Health’s clinical team to provide unparalleled expertise.

Renal Pharmacists

Pentec Health’s renal pharmacists specialize in the provision of nutrition solutions (IDPN and IPN) for renal patients. Our staff includes pharmacists board certified in nutrition support that are available on-call 24/7.

Nutrition Experts

Each patient is admitted onto service in coordination with Pentec Health’s renal dietitians who assist in choosing the optimal formula. After starting service, routine follow-up is performed to ensure proper response and tolerance to therapy.

Electrolyte Management

If additional additives are required, Pentec Health’s pharmacists will assist in the management of electrolyte disorders, including refeeding syndrome. After assisting with the initial order, routine follow-up is performed to monitor therapy and provide suggestions for dosing adjustments. Oral supplementation and dietary recommendations are also provided.

Quality Assurance

Pentec Health maintains established protocols and quality control measures which ensure the safe and accurate compounding of every sterile preparation dispensed to the patients entrusted to our care. Our Pharmacy Quality team performs environmental monitoring, which meets and exceeds the requirements of USP 797 guidelines for sterile compounding. This includes daily non-viable particle testing, daily final product testing, monthly air viable and surface sampling, and personnel monitoring within the clean room to ensure the sterility and quality of the nutritional solutions dispensed by Pentec Health.

Referral and Therapy Process

Reimbursement

  • Pentec Health has existing contracts with both government and private insurers.
  • Pentec Health’s Insurance Coordinators are familiar with all requirements for reimbursement and provide the patient with optimal opportunities for therapy coverage.
  • All insurance verification and prior authorizations from insurance carriers are handled by Pentec Health’s experienced reimbursement team.

Delivery of Product

All IDPN and IPN solutions are delivered via shipping courier using a validated shipping procedure to ensure proper temperature controls are maintained throughout the shipping process.

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It has been amazing watching his transformation to a man that needed someone to help walk into the clinic and never had much to say. He is always calling me over now to tell me something about what he is doing around the house.

L.J., RD Large Dialysis Chain

References

1. Kovesdy C, Shinaberger C, Kalantar Zadeh K. Epidemiology of nutrient intake in ESRD Semin Dial. 2010 ; 23: 353–358.

2. Ikizler TA. Nutrition support for the chronically wasted or acutely catabolic chronic kidney disease patient. Semin Nephrol. 2009; 29:75-84.

3. Y. Kim _ M. Z. Molnar _ M. Rattanasompattikul et al. Relative contributions of inflammation and inadequate protein intake to hypoalbuminemia in patients on maintenance hemodialysis. Int Urol Nephrol. 2013 Feb;45:215-27

4. Kaysen G, Chertow G, Adhikarla R. et al. Inflammation and dietary protein intake exert competing effects on serum albumin and creatinine in hemodialysis patients, Kidney International, Vol. 60 (2001), pp. 333–340

5. Leon J, Albert J, Gilchrist G et al. Am J Kidney Dis. 2006;48:28-36

6. Cano NJ, Fouque D, Roth H, Aparicio M, et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol. 2007;18:2583-91.

7. Dalrymple LS, Mu Y, Nguyen DV, Romano PS, Chertow GM, Grimes B, Kaysen GA, Johansen KL. Risk Factors for Infection-Related Hospitalization in In-Center Hemodialysis. Clin J Am Soc Nephrol. 2015;10(12):2170-2180.

8. Flythe JE, Katsanos SL, Hu Y, Kshirsagar AV, Falk RJ, Moore CR. Predictors of 30-Day Hospital Readmission among Maintenance Hemodialysis Patients: A Hospital's Perspective. Clin J Am Soc Nephrol. 2016;11(6):1005-1014.

9. U.S. Renal Data System, USRDS 2017 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2017

10. Chiu PF. Tsai CD, Wu CL et al. Trajectories of serum albumin predict survival of peritoneal dialysis patients: a 15 year follow-up study. Medicine 2016;95:1-7

11. Mak R, Ikizler A, Kovesdy P et al. Wasting in chronic kidney disease. J Cachexia Sarcopenia Muscle. 2011;9-25.

12. Kalantar Zadeh K, Cano N, Budde K et al. Diets and enteral supplements for improving outcomes in chronic kidney disease Nature Reviews Nephrology 2011;7:369-384

13. Hiroshige K, Iwamoto K, Kabashima N. Prolonged use of intradialysis parenteral nutrition in elderly malnourished chronic hemodialysis patients. Nephrology Dialysis Transplantation. 1998; 13:2081-2087.

14. Korzets A, Azoulay O, Ori Y, et al. The use of intradialytic parenteral nutrition in acutely ill haemodialyzed patients. Journal of Renal Care. 2008; 34:14-18.

15. Dezfuli A, Scholl D, Lindenfeld S, et al. Severity of hypoalbunemia predicts response to intradialytic parenteral nutrition in hemodialysis patients. J Ren Nutr. 2009; 19:291-297.

16. Chertow G, Lazarus JM, Lyden ME et al Laboratory surrogates of nutritional status after administration of intraperitoneal AA based solutions in ambulatory peritoneal dialysis patients. Journal of Renal Nutrition 1995;5:116-123

17. Tjiong HL, Vanden Berg JW, Wattimena JL et al. Dialysate as food: combined amino acid and glucose dialysate improves protein anabolism in renal failure patients on automated peritoneal dialysis. J Am Soc Nephrol. 2005; 16:1486-93

18. Pupim L, Flakoll, P, Brouilette Intradiaytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest. 2002 110: 483-492

19. Tjiong HL, Vanden Berg JW, Wattimena JL et al. Dialysate as food: combined amino acid and glucose dialysate improves protein anabolism in renal failure patients on automated peritoneal dialysis. J Am Soc Nephrol. 2005; 16 (5): 1486-93

20. Pupim L, Flakoll P, Brouilette . Nutritional supplementation acutely increases albumin fractional synthetic rate in chronic hemodialysis patients. J Am Soc Nephrol. 2004 15: 1920-1926

21. Parker T, Johnson D, Nissenson A, Creating an open dialogue on improving dialysis care: part 1 nutrition. Nephrol News Iss. 2013;27:22-24.

22. Worthington P, Balint J,Becktold M, et al. When is parenteral nutrition appropriate? Consensus recommendation. JPEN;2017; 41:324-377.

23. [No authors listed]. K/DOQI clinical practice guidelines for nutrition in adult renal failure, National Kidney Foundation. Am J Kidney Dis. 2000; 35:S1-S140.