Safety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre

doi:10.1016/S1590-8658(03)00074-4

Digestive and Liver Disease

Volume 35, Issue 5, May 2003, Pages 314-324

https://doi.org/10.1016/S1590-8658(03)00074-4 Get rights and content

Abstract

Background. Comparisons between safety and efficacy of home parenteral nutrition and of intestinal transplantation for treatment of chronic intestinal failure derived from observational studies.

Aims. To present the 16-year experience of home parenteral nutrition by the Chronic Intestinal Failure Centre of Bologna University.

Patients. A total of 40 adult patients were enrolled between 1986 and 2001.

Methods. Safety indices: survival and cause of death, catheter-related bloodstream infection, deep vein thrombosis, liver disease. Efficacy indices: nutritional and rehabilitation status, quality of life (SF36 instrument), re-hospitalisation rate. Statistics: Kaplan–Maier analysis and Cox model for survival probability and risk factors; logistic regression for catheter-related bloodstream infection risk factors.

Results. Survival rates at 1, 3 and 5 years were 97, 82 and 67% respectively. Survival was higher in patients ≤40 years. One death was home parenteral nutrition-related. Incidence of catheter-related bloodstream infection: 0.30/year home parenteral nutrition, was lower in patients treated by a specialized nursing protocol. Incidence of deep vein thrombosis was 0.05/year home parenteral nutrition. Hepatosteatosis occurred in 55%. Body weight remained stable or increased in 80%. Rehabilitation was total or partial in 74%. Re-hospitalisation rate was 0.70/year home parenteral nutrition. Quality of life scored significantly lower than in healthy populations in six out of eight domains.

Conclusions. Home parenteral nutrition is a safe and efficacious therapy for chronic intestinal failure. Survival compares favourably with survival after intestinal transplantation.

Introduction

Intestinal failure has been defined as a reduction in the functioning gut mass below the minimum amount necessary for adequate digestion and absorption of nutrients [1]. This can be due to four major pathophysiological conditions: short bowel syndrome, motility disorders of the small bowel, intestinal fistulas and small bowel parenchymal disease [2]. Intestinal failure may be an acute or chronic condition and may be secondary to benign or malignant disease. Chronic intestinal failure (CIF) due to benign disease is a rare condition with an estimated incidence of two to three patients/10⁶ inhabitants per year [3], [4].

Treatment of CIF may be either medical or surgical. Home parenteral nutrition (HPN) is the ‘artificial gut’ for the medical treatment of CIF, first utilized in 1968 [5]. Epidemiological data showed that about 20–50% of patients who started HPN had a reversible CIF and were able to stop treatment after 1–2 years [4], [6], [7]. Surgical treatment of irreversible CIF secondary to benign disease consists of non-transplant options aimed at increasing the absorptive capacity of a short bowel [8] or of intestinal transplantation (ITx). The first ITx in humans was performed in the early 1960s but difficulties, mainly related to rejection and intense immunosuppression, slowed its progression until recent years [9]. Expected survival after ITx still remains lower [10], [11], [12] than expected survival on HPN [4], [6], [13], [14], [15], making HPN the treatment of choice for irreversible CIF too. Current indications for ITx are divided into three categories: failure of HPN due to life-threatening HPN-related complications or lack of venous access, locally invasive tumours of the abdomen and intestinal failure with high risk of mortality [16], [17]. HPN dependency with none of the above problems per se is not an indication for ITx, but some patients may be interested in ITx as a result of their unwillingness to accept long-term HPN or on account of their extremely poor quality of life on HPN. Patients with CIF who are candidates for either HPN or ITx must be informed about the safety and efficacy of the treatments. This information is available from observational studies.

In this study, the safety and efficacy of HPN for CIF in patients treated at a single centre over 16 years are reported.

Section snippets

Patients

All patients with CIF but without AIDS or a malignant disease, who were enrolled in the HPN program of the Chronic Intestinal Failure Centre of the Department of Internal Medicine and Gastroenterology, University of Bologna, between October 1986 and May 2001, were evaluated. The Centre is an approved Regional Referral Centre for CIF, but also accepts patients from all over the country. The Centre assesses the degree of intestinal failure, prescribes medical treatment and is responsible for

Patient population

Between October 1986 and 31 May 2001, 40 adult patients were treated with 50 cycles of HPN (Table 1). A patient was considered to have undergone more than one cycle of HPN if: (a) treatment was stopped on account of a reversible CIF and resumed later on account of a relapse of the CIF (intermittent cycle); (b) type of management of the infusion line was changed (passing from HCD management to Service management or vice versa) without interrupting the HPN (continuous cycle). A total of 31

Discussion

Results show that HPN is a safe and good efficacious therapy for CIF in adults. Data obtained retrospectively and those collected prospectively were similar, and the overall results are in keeping with those reported by previous surveys.

Survival on HPN was 97% at 1 year, 83% at 3 years and 68% at 5 years. Prognosis was better in younger patients, while a non-significant statistical trend was observed towards a better prognosis in patients with Crohn’s disease compared with those with other

Conflict of interest statement

None declared.

References (45)

N.A. Scott et al.
Spectrum of intestinal failure in a specialised unit
Lancet
(1991)
M. Mughal et al.
Home parenteral nutrition in United Kingdom and Ireland
Lancet
(1986)
A. Van Gossum et al.
Home parenteral nutrition in adults: a European survey in 1997
Clin Nutr
(1999)
B. Messing et al.
Prognosis of patients with non-malignant chronic intestinal failure receiving long-term home parenteral nutrition
Gastroenterology
(1995)
B. Messing et al.
Long-term survival and parenteral nutrition dependence in adult patients with short bowel syndrome
Gastroenterology
(1999)
L. Howard et al.
Current use and clinical outcome of home parenteral and enteral nutrition therapies in the Unite States
Gastroenterology
(1995)
T. O’Hanrahan et al.
The role of home parenteral nutrition in the management of intestinal failure-report of 400 cases
Clin Nutr
(1992)
P.P. Keohane et al.
Effect of catheter tunnelling and nutrition nurse on catheter sepsis during parenteral nutrition: a controlled trial
Lancet
(1983)
A.L. Buchman et al.
Catheter thrombosis and superior/inferior vena cava syndrome are rare complications of long term parenteral nutrition
Clin Nutr
(1994)
A.D. Pithie et al.
The incidence, aetiology and management of central venous catheter thrombosis during parenteral nutrition
Clin Nutr
(1987)

A. Van Gossum et al.

Clinical, social and rehabilitation status of long-term home parenteral nutrition patients: results of a European multicentre survey

Clin Nutr

(2001)

S. Chan et al.

Incidence, prognosis and etiology of end-stage liver disease in patients receiving home parenteral nutrition

Surgery

(1999)

C.R. Fleming et al.

Home parenteral nutrition as primary therapy in patients with extensive Crohn’s disease of the small bowel and malnutrition

Gastroenterology

(1977)

B. Messing et al.

Home parenteral nutrition in adults: a multicentre survey in Europe

Clin Nutr

(1989)

E. Steiger et al.

Morbidity and mortality related to home parenteral nutrition in patients with gut failure

Am J Surg

(1983)

S. Galandiuk et al.

A century of home parenteral nutrition for Crohn’s disease

Am J Surg

(1990)

C.R. Fleming et al.

Intestinal failure

S.J. Dudrick et al.

Long-term total parenteral nutrition with growth, development, and positive nitrogen balance

Surgery

(1968)

Y. Panis

Short bowel syndrome: surgical options

Clin Nutr

(2001)

W. Schraut

Current status of small bowel transplantation

Gastroenterology

(1988)

Y. Niv et al.

Small bowel transplantation: a clinical review

Am J Gastroenterol

(1999)

K. Abu-Elmagd et al.

Clinical intestinal transplantation: a decade of experience at a single center

Ann Surg

(2001)

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ESPEN guideline on chronic intestinal failure in adults – Update 2023
2023, Clinical Nutrition
In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.
The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.
The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is “strong consensus” for 148 (99.3%) and “consensus” for one (0.7%) recommendation. The grade of consensus for the statements is “strong consensus” for 14 (87.5%) and “consensus” for two (12.5%).
It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study
2023, Nutrition
Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent—rather than competing—events, leading to an upward bias of the retrieved estimates.
The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center.
All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS).
The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35–2.01), type 3 SBS (SHR = 0.38; 0.15–0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22–0.83), and reconstructive surgery (SHR = 0.11; 0.02–0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16–1.64) and presence of stoma (SHR = 0.30; 0.12–0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10–15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99–6.30), and reconstructive surgery (SHR = 2.86; 1.44–5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66–0.94) and presence of stoma (SHR = 2.64; 1.38–5.07) in non-SBS patients.
Surgical procedures strongly affected mortality and weaning risk in CIF patients.
Survival in patients initiating home parenteral support due to nonmalignant short bowel syndrome compared with background population
2022, Clinical Nutrition ESPEN
Survival has frequently been studied and reported in patients with long term intestinal failure (IF). However, studies comparing the survival and mortality rates with the background population are rare. This study compares the survival in an adult IF, non-malignant, short bowel syndrome (SBS) cohort with a control group and with age- and sex-specific background mortality rates.
Patients with SBS, defined by a small bowel length of 200 cm or less, due to non-malignant disease, were included and followed until death or censoring on 31 December 2017. Causes of deaths occurring during home parenteral support (HPS) were assessed by review of the charts. Each case was matched with ten controls from the background population according to year of HPS initiation, age, and sex, and their survival was compared. Furthermore, age- and sex-specific mortality rates of the background population were used to calculate the standardized mortality ratio (SMR) and excess mortality.
After five years, patients who initiated HPS had a relative survival of 76%. The SMR was 5.0 and the excess mortality was 50 per 1000 years. HPS-related deaths were assessed to account for 11% of deaths during HPS and occurred with an incidence of 10 per 1000 years. The excess mortality was as low as 15 per 1000 years in cases aged less than 40 years. Patients weaning off HPS had a mortality rate closer to that expected in the background population.
In adult patients with a non-malignant cause of SBS-IF, the excess mortality was 50 per 1000 years. However, HPS related deaths were rarely registered with an incidence of 10 HPS related deaths per 1000 HPS treatment years.
Outcome of adult patients receiving parenteral support at home: 36 years’ experience at a tertiary referral centre
2021, Clinical Nutrition
Patients with intestinal failure often need long-term home parenteral support (PS). We aimed to determine how the underlying diagnosis, complications and survival had changed over the last 36 years in the UK's largest IF centre.
978 adult home PS patient records were analysed from January 1979 until October 2016. The age, sex, underlying aetiology, complications and survival was compared over 5-year periods.
Pre-1990 to 2011–2016, numbers increased from 29 to 451, the mean age of patients increased from 31 ± 16.5 to 52 ± 17.6 years. The percentage of patients with IF due to surgical complications increased (3.4%–28.8%, p < 0.001)), while those with inflammatory bowel disease decreased (37.9%–22.6%, p < 0.001). Complication of home PS reduced: catheter related blood stream infections (CRBSI) 71.4% to 42,2%, CVC thrombosis 34.5%–5.3%. Intestinal failure associated liver disease (IFLAD) 10.3%–1.8%. Patients with dysmotility, scleroderma and a congenital aetiology had the highest incidence of CRBSI and CVC Thrombosis. Overall survival was greater pre-1995 [HR 0.2–0.4 (p = 0.02)] most likely associated with an increase in mean age. Survival for patients without malignancy was 90%, 66%, 55%, 45%, 33% and 25% at 1,5, 10, 15, 20 and 30 years respectively. Multivariate analysis demonstrated a relationship between survival and age of starting home PS; type of home PS; presence or absence of the colon in continuity; and underlying aetiology.
Demand for home PS is increasing in particular for advanced malignancy, post-surgical complications and older more co-morbid patients. Complications of home PS are reducing over the last 30 years and 10-year survival for non-malignant aetiologies improving. Survival and changes in aetiology in intestinal failure.
ESPEN practical guideline: Clinical nutrition in chronic intestinal failure
2021, Clinical Nutrition
This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.
ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.
This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.
This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
Long-term outcome of patients with Crohn's disease on home parenteral nutrition
2020, Nutrition
In patients with Crohn's disease (CD) and intestinal failure, home parenteral nutrition (HPN) is a necessary lifesaving treatment. The aim of this study was to investigate the long-term outcomes of patients with CD after initiation of HPN.
This study included patients with CD receiving HPN for intestinal failure. The patients were treated at Osaka University Hospital between January 2000 and December 2019. Patients’ demographic characteristics, HPN dependence and complications, and mortality were analyzed. HPN dependence was estimated using the Kaplan–Meier method. Cox regression analysis was used for between-group comparisons.
Twenty-one patients with CD received HPN. HPN dependence rates were 85%, 75%, 75%, and 64%, respectively, at 2, 5, 10, and 15 y after HPN initiation. Patients who weaned off HPN exhibited lower rates of immunomodulator therapy and additional intensive CD treatment (P < 0.05). Multivariate analysis revealed that not requiring additional intensive CD treatment was a significant factor in weaning off HPN. Two patients (9%) died, at a median of 14.9 y after HPN initiation, due to HPN-related liver disease and CD-associated carcinoma. Among all patients, 61% experienced catheter-related bloodstream infections (CRBSIs), with an incidence of 0.32/1000 catheter-days. Methicillin-resistant bacteria and Candida spp. each accounted for 27% of all pathogens detected in CRBSI.
Patients with CD receiving HPN had a good prognosis, despite frequent CRBSIs in which methicillin-resistant bacteria and fungi were common pathogens. Some patients with CD can wean off HPN, even after a long period of HPN treatment. A stable disease condition during HPN might be an important factor for weaning off HPN.

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Alimentary TractSafety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre

Abstract

Introduction

Section snippets

Patients

Patient population

Discussion

Conflict of interest statement

Lancet

Lancet

Clin Nutr

Gastroenterology

Gastroenterology

Gastroenterology

Clin Nutr

Lancet

Clin Nutr

Clin Nutr

Clin Nutr

Surgery

Gastroenterology

Clin Nutr

Am J Surg

Am J Surg

Intestinal failure

Long-term total parenteral nutrition with growth, development, and positive nitrogen balance

Surgery

Short bowel syndrome: surgical options

Clin Nutr

Current status of small bowel transplantation

Gastroenterology

Small bowel transplantation: a clinical review

Am J Gastroenterol

Clinical intestinal transplantation: a decade of experience at a single center

Ann Surg

Alimentary Tract
Safety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre