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)
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)
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%).
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)
— Nancy T., Facility Administrator Large Dialysis Organization
Every patient has distinctive nutritional needs and intradialytic parenteral nutrition (IDPN) is unique as each formula is based on specific needs of the individual patient. IDPN is covered by most commercial insurance plans and is not part of a bundled payment.
Our experts strive to determine the optimal treatment dose so that protein malnourished patients receive the customized formulation best suited to meet the individual patient needs.
Pentec Health provides uniquely tailored, patient specific IDPN formulations designed to replenish protein losses while minimizing fluid and dextrose content.
Ample protein is provided in weight based formulations to optimize protein repletion critical to improving nutrition status.
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.
Pentec Health provides Intraperitoneal Parenteral 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.
