ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients

Summary

Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.

Summary of statements: Home Parenteral Nutrition (HPN) in adult patients
Subject	Recommendations	Grade	Number
Indications	Home parenteral nutrition support should be used in patients who cannot meet their nutritional requirement by enteral intake, and who are able to receive therapy outside an acute care setting.	B	1.1
	Incurable cancer patients may enter a HPN program if they are unable to meet their nutritional requirements by oral or enteral route and there is a risk of death due to malnutrition. It is not a contraindication for HPN that oncologic treatment has been stopped.	C	1.2
	HPN is not recommended for patients with incurable disease and a short life-expectancy.	C	1.3
The nutrition support team in HPN	The expertise of a nutrition support team (NST) is recommended for HPN.	C	2
Prescription of HPN	The electrolyte composition of the HPN regimen should reflect fluid losses.	C	3.1.1
	The total calories should normally be 20–35 kcal/kg per day.	C	3.1.3.1
	The non-protein energy provision should be 100–150 kcal for every gram of nitrogen in the HPN.	C	3.1.4.1
	The unstressed adult HPN patient will require 0.8–1.0 g amino acids/kg per day.
	For long-term HPN treatment (>6 months) the provision of intravenous lipid should not exceed 1 g/kg per day. Essential fatty acids should be supplied.	C	3.1.6.1
	The daily requirement for essential fatty acids is 7–10 g, which corresponds to 14–20 g LCT fat from soya oil and 30–40 g LCT fat from olive/soya oil.
	MCT/LCT and fish oil emulsions also appear safe and effective.
Intravenous catheters and devices	Tunneled central catheters are used, as permanent access is required for long-term parenteral nutrition.	C	4
	Implanted ports are an acceptable alternative.
	PICC-lines are intended for shorter-term use and cannot be recommended for HPN patients.
	Cyclic administration of parenteral nutrition is recommended.	B	4.1
	The use of infusion pumps is recommended, but is not practiced in all European countries.	B	4.3
Improving prognosis in HPN	Prognosis in HPN is mainly governed by the underlying disease, but poor outcomes related to the HPN itself come from problems with catheters and the associated vessels. It is important to preserve lines and to protect the vessels as best possible. Reference should be made to the ESPEN guidelines on central venous catheters. In line sepsis in HPN a conservative approach with antibiotics is normally advocated before removing the catheter.	C	5
Education and training	There should be a formal teaching program for the patient and/or carer. The teaching program should include catheter care, pump use, and preventing, recognizing and managing complications. Experienced nurses are usually best placed to take responsibility for the teaching program.	C	5
	The use of specific brochures or videotapes for teaching, and affiliation with national support organizations, are associated with better outcomes.	C	5.1
	Training is usually carried out in an in-patient setting, but training at home can be considered	C	5.2
Monitoring	Biochemistry and anthropometry should be measured at all visits; measurement of trace elements and vitamins are recommended at intervals of 6 months. Bone mineral density assessment by DEXA scanning is recommended at yearly intervals.	C	6
Liver disease in HPN	HPN-associated liver disease is related to the composition of the HPN and to the underlying disease or coexisting liver disease. The fat/glucose energy ratio should not exceed 40:60 and lipids should comprise no more than 1 g/kg per day.	B	7
	All forms of over-feeding should be avoided.	B	7
	Glucose administration in excess of 7 mg/kg per min, and continuous HPN are also considered risk factors.
	Prevention of chronic cholestasis is of utmost importance. Infections, in particular line sepsis must be promptly controlled to help prevent deterioration of any liver abnormalities.	B	7.1
Management of underlying disease	Underlying disease related factors must be strictly controlled, by treating inflammation and minimizing the dosage of bone damaging drugs.	C	7.1
Optimization of the nutrient admixture during chronic care	Aluminum contamination of HPN should be less than 25 μg/lThe amount of sodium should be no more than required, to avoid sodium induced hypercalciuriaThe calcium, magnesium and phosphate content of the HPN should maintain normal serum concentrations and 24-h urinary excretion.The recommended ratio is 1mmol of calcium to 1mmol of phosphate.The amount of amino acids prescribed should not be greater than losses, in order to limit hypercalciuria.	B	8.1
	The recommended intravenous dose of vitamin D is 200 IU/day.	C	8.2
	Consider vitamin D withdrawal in patients with low bone mineral density (BMD), low serum parathyroid hormone, and 1,25-dihydroxyvitamin D concentrations associated with normal 25-hydroxivitamin D.
	Reducing infusion rates may decrease hypercalciuria.
	Bisphosphonates (such as clodronate 1500 mg iv or pamidronate 20 mg iv every 3 months), may maintain BMD in patients with osteopenia.	B	8.3
Intestinal transplantation in HPN patients	The indication for intestinal transplantation is irreversible, benign, chronic intestinal failure associated with life-threatening complications of HPN. Present data do not support direct referral for intestinal transplantation of patients with high risk of death due to underlying disease, chronic dehydration or significantly impaired quality of life. In all patients an individual case-by-case decision is required.	B	11.1
	The timing of patient referral is key to obtaining best graft and patient survival. Early referral is recommended to minimize mortality from HPN related complications whilst on the waiting list.	C	11.2
	The highest survival rates are observed among younger individuals, those at home rather than in hospital, and in patients managed in experienced transplant centers. There has been steady improvement in patient and graft survival.	B	11.2