Home Artificial Nutrition (HPN)in adult patients

F. Bozzetti (Milano)

B. Messing (Paris)

M. Staun (Copenhague)

A. Van Gossum (Brussels)

HPN in adultContent

• Indications and Epidemiology

• Venous access care

• Metabolic complications: prevention and treatment

• How to adapt nutritional support?

• HPN in cancer patients

• Training and monitoring

Home Artificial Nutrition (HPN)in adult patients

Indications and Epidemiology

A. Van Gossum (Brussels)

HPN in adultHistory (1)

1. HPN was initiated in North America (Shils et al) and in Western Europe (Solassol et al) in the early seventies

2. HPN programs started in specialized centres that rapidly developped a growing experience

3. At the beginning, HPN was exclusively reserved for patients with life-threatening intestinal failure related to benign diseases

HPN in adultHistory (2)

4. In the meantime, the number of HPN centres increased with a high variable number of patients from one to another centre

5. HPN has been progressively used in patients with intestinal failure related to advanced cancer (carcinomatosis)

6. HPN is now worldwide used in industrialized countries. However, legislations and funding are still lacking in many European countries

Intestinal failureDefinition

A condition in which the intestine is unable to process sufficient food to maintain an

adequate nutritional state ( parenteral nutrition)

The central IV line was considered to be the "artificial gut"

HPNUnderlying diseases

• Benign:– Crohn's disease– mesenteric vascular disease– post-surgical, trauma– intestinal pseudo-obstruction– radiation enteritis– miscellaneous: chronic pancreatitis, mucosal atrophy,

anorexia nervosa,…

• Malignant• AIDS

HPNCauses

• Short bowel syndrome

• Digestive fistula

• Alteration of GI motility

• Chronic intestinal (pseudo-) obstruction (carcinomatosis)

• Intractable diarrhea (AIDS)

• Severe malnutrition

Short bowel syndrome

Major resection of the small bowel

Nutritional and metabolic consequences

Diarrhea, fluid and electrolyte abnormalities, malabsorption, weight loss

Short bowel syndromeParenteral nutrition-dependency

Cut-off values of SB lengths

• End-enterostomy (I) 100 cm

• Jejunocolonic (II) 65 cm

• Jejunoileocolonic (III) 30 cm

Messing B, Transplant Proceedings, 1998

Jejuno-sigmoid anastomosis

Duodenostomy (Foley sonde)

Incidence of HPN from 1 January 97 to 31 December 97

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ESPEN-HAN, Clin Nutr 1999, 18, 135

HPN in adultIncidence / Prevalence

• The point prevalence of HPN is estimated to be 6 to 10 times higher in US than in Europe

• Late available data:– Incidence:

• 3/106 inhabitants/y France (2001-2004)

• 1.65/106 inhabitants/y Spain (2001)

– Point prevalence:• 12/106 inhabitants/y Scotland (2001)

• 9/106 inhabitants/y UK (2001)

Point prevalence and new registrations of adults receiving HPN

(UK)

1996 1997 1998 1999 2000 2001 2002

Point prevalence 207 250 306 344 400 422 465

New registrations 58 84 113 126 134 126 103

Number of reporting centres

21 28 29 25 28 28 34

BANS Registry, 2003

Distribution of underlying diseases for HPN patients in Europe (1997; n = 479)

Radiation enteritis

7%

AIDS2%

Vascular diseases

15%

Crohn's disease

19%

Others18%

Cancer39%

ESPEN-HAN, Clin Nutr 1999, 18, 135

Indications for HPN in 7 different European countries where reporting was assumed to be more than 80% of patients

(1997)

Numberof

patients

Crohn'sdisease

Vascular Cancer Radiation AIDS Others

France 173 16% 23% 27% 15% 0.5% 18.5%

United Kingdom 72 44% 14% 5% 2% - 35%

Belgium 26 12% 15% 23% 15% 35% -

Denmark 15 20% 13% 8% 26% - 33%

The Netherlands 45 13% 11% 60% - - 16%

Spain 31 16% 13% 39% - 6% 25%

Poland 14 14% 50% - 14% - 22%Poland

ESPEN-HAN, Clin Nutr 1999, 18, 135

Outcome at 1 January 1998 for HPN patients enrolled between 1 January 97 and 31 June 97

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ESPEN-HAN, Clin Nutr 1999, 18, 135

HPNComplications

1. Catheter-related – sepsis– venous thrombosis– occlusion– migration

2. Metabolic • liver abnormalities• biliary stones• metabolic bone disease• trace element and/or vitamins deficiencies• manganese toxicity• renal function impairment

3. Psychological4. Quality of life5. Rehabilitation

Long-term HPNComplications (n = 228)

• Hospitalization stays (within 12 previous months): 23 days (0 to 270 d)

• Reasons for hospitalizations:– underlying diseases (37%)– HPN related (30%) (majority: catheter sepsis)– other (33%)

ESPEN-HAN, Clin Nutr 2001, 30, 205

Long-term HPNClinical features

• n = 228 patients

• Depression: 17%

• Opiates use: 8%

• Analgesics use: 35%

• Interest for intestinal transplantation: 8%

ESPEN-HAN, Clin Nutr 2001, 30, 205

Long-term HPN (n = 228)Rehabilitation status

Before AtHPN evaluation

I Able to work full time 50% 35%or looking after home and family unaided

II Able to work part time 14% 33%or looking after home and family with help

III Unable to work but able 12% 23%to cope with HPN unaidedand able to go out occasionally

IV Housebound: needs major 24% 9%assistance

ESPEN-HAN, Clin Nutr 2001, 30, 205

HPN – Indications and EpidemiologyConclusions (1)

1.HPN is worldwide used in industrialized countries

2.In many European countries as well as in US, cancer has become the main indication for HPN

3.For patients with benign diseases, the main indications are short bowel and chronic intestinal motility disorders

HPN – Indications and EpidemiologyConclusions (2)

4.The number of HPN centres increased with a variable degree of expertise

5.The prevalence in US is expected to be 10 times higher than in Europe (from 2 to 12/106 inhabitants)

6.HPN related complications are quite rare and rehabilitation status is good in the majority of the patients