Objective: The objective of this study is to document the patterns of usage regarding intradialytic parenteral nutrition (IDPN) within in-center hemodialysis units in Australia. Design and Methods: This study used purposive non-probabilistic sampling to obtain details of the proportion of units using IDPN; formulations used; infusion rates; and barriers and enablers to usage. All participants were practicing renal dietitians in Australia. The participants were recruited from professional nephrology networks and completed a cross-sectional self-administered online survey. Results: A total of 68 responses were received, representing 41% of dialysis units in Australia. Half did not use IDPN at all, and one-third (38.2%) used it regularly. The most common IDPN formulations used were triple phase bags (48.3%) and lipid-only infusions (22.6%). Variation in practice was seen regarding maximum infusion rates for some formulations. Costs for IDPN were borne by dialysis units (74%) or pharmacy (16%). Barriers to the use of IDPN included bureaucratic hurdles and misconceptions about IDPN as an effective form of nutrition support. The presence of a protocol, support from medical and other staff, and dietitian experience were enablers to the use IDPN. Conclusions: IDPN use in Australia is not uncommon. This survey extends the small evidence base about the practice of IDPN and identified some important variations in practice. Some barriers to IDPN use could be overcome with further training to support staff. Enablers to IDPN use include protocols with defined responsibilities and access to experienced clinicians

Conley, Marguerite

Lambert, Kelly

English

Research Online

University of Wollongong Research Online Faculty of Science, Medicine and Health - Papers: Part B Faculty of Science, Medicine and Health 2020 Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians Kelly Lambert University of Wollongong, klambert@uow.edu.au Marguerite Conley Princess Alexandra Hospital Follow this and additional works at: https://ro.uow.edu.au/smhpapers1 Publication Details Citation Lambert, K., & Conley, M. (2020). Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians. Faculty of Science, Medicine and Health - Papers: Part B. Retrieved from https://ro.uow.edu.au/smhpapers1/1225 Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library: research-pubs@uow.edu.au Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians Abstract Objective: The objective of this study is to document the patterns of usage regarding intradialytic parenteral nutrition (IDPN) within in-center hemodialysis units in Australia. Design and Methods: This study used purposive non-probabilistic sampling to obtain details of the proportion of units using IDPN; formulations used; infusion rates; and barriers and enablers to usage. All participants were practicing renal dietitians in Australia. The participants were recruited from professional nephrology networks and completed a cross-sectional self-administered online survey. Results: A total of 68 responses were received, representing 41% of dialysis units in Australia. Half did not use IDPN at all, and one-third (38.2%) used it regularly. The most common IDPN formulations used were triple phase bags (48.3%) and lipid-only infusions (22.6%). Variation in practice was seen regarding maximum infusion rates for some formulations. Costs for IDPN were borne by dialysis units (74%) or pharmacy (16%). Barriers to the use of IDPN included bureaucratic hurdles and misconceptions about IDPN as an effective form of nutrition support. The presence of a protocol, support from medical and other staff, and dietitian experience were enablers to the use IDPN. Conclusions: IDPN use in Australia is not uncommon. This survey extends the small evidence base about the practice of IDPN and identified some important variations in practice. Some barriers to IDPN use could be overcome with further training to support staff. Enablers to IDPN use include protocols with defined responsibilities and access to experienced clinicians. Publication Details Lambert, K. & Conley, M. (2020). Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians. Journal of Renal Nutrition, 30 (2), 163-167. This journal article is available at Research Online: https://ro.uow.edu.au/smhpapers1/1225 1  Abstract  1 Title: Practice patterns relating to the use of IDPN in Australian hemodialysis units: results 2 from a survey of renal dietitians. 3 Objective: To document the patterns of usage regarding intradialytic parenteral nutrition 4 (IDPN) within in-centre hemodialysis units in Australia.  5 Design and methods: This study used purposive non-probabilistic sampling to obtain details 6 of the proportion of units using IDPN; formulations used; infusion rates; and barriers and 7 enablers to usage. All participants were practicing renal dietitians in Australia. The 8 participants were recruited from professional nephrology networks and completed a cross 9 sectional self-administered online survey. 10 Results: A total of 68 responses were received, representing 41% of dialysis units in 11 Australia. Half did not use IDPN at all, and one third (38.2%) used it regularly. The most 12 common IDPN formulations used were triple phase bags (48.3%) and lipid only infusions 13 (22.6%). Variation in practice was seen regarding maximum infusion rates for some 14 formulations. Costs for IDPN were borne by dialysis units (74%) or pharmacy (16%).  15 Barriers to the use of IDPN included bureaucratic hurdles and misconceptions about IDPN as 16 an effective form of nutrition support. The presence of a protocol, support from medical and 17 other staff and dietitian experience were enablers to use.   18 Conclusion: IDPN use in Australia is not uncommon. This survey extends the small evidence 19 base about the practice of IDPN and identified some important variations in practice. Some 20 barriers to IDPN use could be overcome with further training to support staff. Enablers to 21 IDPN use include protocols with defined responsibilities and access to experienced clinicians. 22 Keywords: IDPN, parenteral nutrition, cross sectional survey, dietitian, nephrology 23 2  INTRODUCTION  1 Protein Energy Wasting in patients undertaking dialysis is common with a prevalence of 28-2 54% 1. Intradialytic parenteral nutrition (IDPN) is a form of supplemental intravenous 3 nutrition support available only to hemodialysis patients. It is considered in malnourished 4 individuals who are having difficulty meeting adequate nutrition orally 2. One obvious 5 limitation associated with IDPN is that only a proportion of an individuals’ nutritional 6 requirements are able to be delivered during dialysis. Several reviews have also reported that 7 there is limited evidence of significant clinical benefit 3-6 mainly because of limitations 8 relating to study design 5,7. Although IDPN use has been reported as widespread in North 9 America 4, recent data regarding current IDPN usage is lacking. In the United States, prior to 10 initiation of Medicare Part D coverage in 2008, the rate of IDPN use was 2.1-3.6 per 1,000 11 patients 8. However, Medicare is no longer tracking IDPN usage, and Medicare Part D and 12 other insurers have not consolidated this information.  13  14 Unlike the practice in the United States 4, and counter to recommendations in guidelines 9,  15 the prescription of IDPN in Australia is not restricted. IDPN can be prescribed to any 16 malnourished hemodialysis patient as a first line of nutrition support if deemed appropriate 17 by the dietitian and/or the treating team. There are scarce details though on the nature of 18 Australian IDPN practice patterns apart from one conference abstract from 2009 10. The 19 results indicated there were significant variations in practice, with a wide range of formulas, 20 rates of infusion and monitoring procedures. No further exploration of this has been 21 undertaken in the past decade, despite an exponential increase in hemodialysis patient 22 numbers 11, and greater clarification for clinicians regarding the definition of protein energy 23 wasting 12. No guidelines exist regarding ideal or safe infusion rates for IDPN, and anecdotal 24 discussions between renal dietitians suggests that variations in infusion rates exist. Given 25 3  these evidence gaps, the aims of this study were therefore to describe the practice patterns of 1 Australian renal dietitians regarding the use of IDPN. The specific objectives were to (i) 2 estimate the proportion of hemodialysis units using IDPN (ii) describe the most common 3 formulations of IDPN used (iii) describe the typical infusion rates used (iv) describe barriers 4 and enablers to usage and (v) suggest recommendations for clinical practice.  5 METHODS 6 A ten-item questionnaire was developed by two experienced renal dietitians (XX and XX) 7 based on the objectives of the study. The first three questions collected demographic 8 information about the dialysis unit such as location and the size of the unit (number of 9 patients). The remaining questions explored the solutions used; the department responsible 10 for payment; details of the maximum IDPN infusion rate and monitoring; and barriers and 11 enablers to use of IDPN. The questionnaire was uploaded to the web based online 12 Surveymonkey platform 13. Respondents were asked to describe or forward a copy of their 13 IDPN protocol or policy to the corresponding author if they had one to allow further 14 examination of practice variation.  15  16 Invitations to participate were sent to all seven state convenors of the Dietitians Association 17 of Australia renal interest group. These were then distributed to all members of the interest 18 group at the state level. For those who were known to be non-members of the association but 19 practising as renal dietitians, the surveys were distributed directly via email. To ascertain 20 response rate, the number and location of all dialysis units in Australia were obtained from 21 the Australian New Zealand Dialysis and Transplant Registry 14.  22 RESULTS 23 A total of 68 responses were received, representing 112 (41%) haemodialysis units in 24 Australia. The median number of patients in each unit that responded was 60 patients 25 4  (interquartile range: 40-113). One state returned no responses during the survey period, 1 however this represented only three dialysis units (or 1%) nationally. Protocols were 2 described by 15 respondents. An additional four indicated that they had a draft policy or 3 protocol to guide practice. Protocols for the use of IDPN were also received from an 4 additional eight respondents. All protocols described that initiation of IDPN was at the 5 discretion of the dietitian after a comprehensive nutrition assessment. Only four units (12.1%) 6 who used IDPN did not have a formal protocol / policy or procedure.  7 Of the units who responded to the survey, half (50%) reported that they did not use IDPN; 8 38.2 % used IDPN regularly; 10.3% used it rarely and 1.5% were unsure. The most 9 frequently used formulation was a 3 in 1 / triple phase formulation of parenteral nutrition 10 (48.3%); followed by lipid only infusions (22.6%); then lipids and amino acids 11 simultaneously (16.1%) (Figure 1). Two units (2.5%) reported using amino acids only, and 12 two units (2.5%) used both triple phase and lipid only infusions depending on patient needs.  13 A total of 34 responses were received regarding infusion rates. The maximum or goal 14 infusion rate for triple phase formulations was reported as either 125ml (25%) or 250ml per 15 hour, with most reporting 250 ml per hour (75%) (Figure 2). For amino acid only infusions, 16 there was very little variation, and all reported using a maximum infusion rate of 125ml/ 17 hour. The most common infusion rate was 125ml/ hour for lipid only infusions, with other 18 maximum rates of 100ml, 150ml and 250ml/ hour reported. No response regarding infusion 19 rate was reported by 21 units (61.7%). Of the 31 units who responded, the most frequent 20 funder for IDPN was the dialysis unit (74%), followed by pharmacy (16%). Costs ranged 21 from $16 AUD for a 500ml bottle of lipid; to $25 AUD for a 500ml bottle of amino acids; 22 and a range of $65-84 AUD for a 1L bag of a triple phase formulation.  23 5  The most common barriers to IDPN use are shown in Figure 3. Respondents suggested that 1 bureaucracy was a significant hurdle to use. This ranged from cumbersome paperwork to 2 initiate IDPN to logistical hurdles. For example, one respondent reported that: “When IDPN 3 is suggested by the dietitian, the renal unit registrar has to consider the request, then discuss 4 with nephrologist. Then, a referral has to be made to the gastro unit to assess the patient for 5 suitability”. Another respondent stated that “our protocol on IDPN use requires two trained 6 registered nurses to be in attendance. But in some of our units we only have a dialysis 7 technician and one registered nurse present”. Perceptions about the cost of IDPN and 8 misconceptions by doctors that IDPN is an ineffective form of nutrition support were also 9 barriers: “Nephrologists think that it is too costly with limited evidence” and “it is difficult to 10 prove that much of it (IDPN solution) is absorbed”. 11 Enablers to the use of IDPN are shown in Figure 4. The presence of a protocol or policy 12 facilitated use in many units. Support from medical, nursing staff, and multidisciplinary staff 13 was considered important. One respondent stated: “Having a protocol with defined 14 responsibilities in place is important as well as adequate training for staff”. Access to or the 15 presence of dietitians with experience using IDPN were also reported to be important 16 enablers to use. Training on IDPN use and confidence also featured as common enablers.  17 Free text comments were grouped thematically into two areas:(i) Use of lipid and amino acid 18 formulations were driven by a desire to avoid administration of excessive glucose and fluid 19 overload. Some sites reported that they wished to use other formulations but stated that 20 hospital or health department parenteral nutrition tender policies or purchasing procedures 21 made access to other formulations difficult (ii) Many respondents reported that they did not 22 develop their own protocols, but rather had adapted protocols from other sites, usually those 23 with more experience in IDPN use or from sites who used a similar formulation to theirs.  24 6  DISUSSION  1 This survey provides useful insights into the practical use of IDPN in Australia.  In addition 2 to the need for well conducted randomised trials, it appears that training on IDPN for 3 dietitians and medical staff about the practicalities of patient selection, choice of formulation, 4 rate of delivery, and commencement and monitoring procedures would be useful. Practical 5 training for nursing staff may also be required. The results of this study expand on previous 6 reports on IDPN use in Australia 10 and importantly describe barriers and enablers to the use 7 of this form of nutrition support. One of the limitations of the survey is that the selection 8 criteria and accurate details on the number of patients receiving IDPN was not described. 9 Despite widespread distribution of the survey through professional networks, the relatively 10 low response rate also provides indirect insights into the shortage of renal dietitians and 11 dietetic staffing levels of dialysis units in Australia15. Units not represented are suspected to 12 have infrequent or no dietetic staffing.  Given that IPDN use is substantial in the Australian 13 setting, we support previous calls in the literature 6 for longer term randomised clinical trials 14 to be undertaken 16  and establishment of a clinical registry to expand the knowledge base and 15 record hard outcomes associated with IDPN use.    16 PRACTICAL APPLICATION 17 This paper describes the use of IDPN in Australia. The results of this study suggest that 18 training and the presence of experienced staff who know how to use IDPN facilitate its use. 19 Strategies to overcome bureaucratic hurdles and enhance awareness of the potential benefits 20 of IDPN may lead to more widespread use of this form of nutrition support in the Australian 21 context. 22 REFERENCES 23 7  1. Carrero JJ, Thomas F, Nagy K, et al. Global Prevalence of Protein-Energy Wasting in Kidney 1 Disease: A Meta-analysis of Contemporary Observational Studies From the International 2 Society of Renal Nutrition and Metabolism. J Ren Nutr. 2018;28(6):380-392. 3 2. Cano NJ, Aparicio M, Brunori G, et al. ESPEN Guidelines on Parenteral Nutrition: adult renal 4 failure. Clin Nutr. 2009;28(4):401-414. 5 3. Anderson J, Peterson K, Bourne D, Boundy E. Effectiveness of Intradialytic Parenteral 6 Nutrition in Treating Protein-Energy Wasting in Hemodialysis: A Rapid Systematic Review. J 7 Ren Nutr. 2019. 8 4. Anderson J, Peterson K, Bourne D, Boundy E. Evidence Brief: Use of Intradialytic Parenteral 9 Nutrition (IDPN) to Treat Malnutrition in Hemodialysis Patients. 2018. 10 5. Bossola M, Tazza L, Giungi S, Rosa F, Luciani G. Artificial nutritional support in chronic 11 hemodialysis patients: a narrative review. J Ren Nutr. 2010;20(4):213-223. 12 6. Sigrist MK, Levin A, Tejani AM. Systematic review of evidence for the use of intradialytic 13 parenteral nutrition in malnourished hemodialysis patients. J Ren Nutr. 2010;20(1):1-7. 14 7. Dukkipati R, Kalantar-Zadeh K, Kopple JD. Is there a role for intradialytic parenteral 15 nutrition? A review of the evidence. Am J Kidney Dis. 2010;55(2):352-364. 16 8. U.S. Renal Data System. USRDS Annual Data Report: Atlas of Chronic Kidney Disease and 17 End-Stage Renal Disease in the United States; Volume 2: Chapter 9, Special Studies. National 18 Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 19 Bethesda, MD, 2010. 20 9. Brown RO, Compher C. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and 21 chronic renal failure. JPEN J Parenter Enteral Nutr. 2010;34(4):366-377. 22 10. Coster K, Lambert K, Crosby C, Chan S. A targeted cross sectional survey of current practice 23 in intradialytic parenteral nutrition (IDPN) provision in Australia and New Zealand. 24 Nephrology. 2009; 14(suppl1):A6. 25 11. ANZDATA Registry. The 41st Annual ANZDATA Report. Appendix A. Incident data. 2018; 26 http://www.anzdata.org.au/v1/report_2018.html  27 12. Sabatino A, Regolisti G, Karupaiah T, et al. Protein-energy wasting and nutritional 28 supplementation in patients with end-stage renal disease on hemodialysis. Clin Nutr. 29 13. Surveymonkey.com. 2018; c1999-2012.:http://www.surveymonkey.com  30 14. ANZDATA Registry. Parent Hospitals - Transplanting Hospitals - Satellite Haemodialysis Units. 31 2018; http://www.anzdata.org.au/documents/pdf/Hospitals.pdf. 32 15. Crosby C PA, Barnes P, Lambert K, Rounsley K. A Survey of Renal Dietitian Staffing in New 33 South Wales. Nephrology. 2010;15(Supplement 4):44 (069). 34 16. Sarav M, Friedman AN. Use of Intradialytic Parenteral Nutrition in Patients Undergoing 35 Hemodialysis. Nutr Clin Pract. 2018;33(6):767-771. 36  37 Figure 1. Types of formulations used for IDPN reported by renal dietitians in Australia.     2157520246810121416Amino acids only 3 in 1 / triple phasesolutionLipid only Amino acids & lipid Lipid & 3 in 1Figure 2. Maximum infusion rates for IDPN reported by renal dietitians in Australia.     012345678910not stated 125 ml/hr 250ml/hr 100ml/hr 150ml/hrAmino acids3 in 1 / triple phase solutionsLipidsFigure 3. Barriers to the use of IDPN reported by renal dietitians in Australia.    Note: Respondents could state more than one barrier    17    17    14    11    11    10    10    6    5    4    024681012141618Figure 4. Enablers to the use of IDPN reported by renal dietitians in Australia.   Note: Respondents could state more than one enabler   13 131465 54 4 4 40246810121416

Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians

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Practice Patterns Relating to the Use of Intradialytic Parenteral Nutrition in Australian Renal Units: Results From a Survey of Renal Dietitians

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