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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
0
0,5
1
1,5
2
2,5
3
3,5Th
eN
ethe
rlan
ds
Fran
ce
Den
mar
k
Bel
gium U
K
Spa
in
Pol
and
HP
N p
atie
nts/
106 in
habi
tant
s/ye
ar
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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cro
hn
'sd
isea
se,
n=5
0
Vas
cula
r,n
=38
Oth
er,
n=5
7
Rad
iatio
nen
teri
tis,
n=1
9
AID
S, n
=6
Can
cer,
n=1
02
Died
Ceased
Continued
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