Home Artificial Nutrition (HPN) in adult patients

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Home Artificial Nutrition (HPN)in adult patients

• F. Bozzetti (Milano)
• B. Messing (Paris)
• M. Staun (Copenhague)
• A. Van Gossum (Brussels)

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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

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Home Artificial Nutrition (HPN)in adult
patientsIndications and Epidemiology

• A. Van Gossum (Brussels)

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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

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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

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Intestinal failureDefinition

• A condition in which the intestine is unable to
  process sufficient food to maintain an adequate
  nutritional state (? parenteral nutrition)

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

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HPNCauses

• Short bowel syndrome
• Digestive fistula
• Alteration of GI motility
• Chronic intestinal (pseudo-) obstruction
  (carcinomatosis)
• Intractable diarrhea (AIDS)
• Severe malnutrition

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Short bowel syndrome

• Major resection of the small bowel
• Nutritional and metabolic consequences
• Diarrhea, fluid and electrolyte abnormalities,
  malabsorption, weight loss

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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
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Jejuno-sigmoid anastomosis
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Duodenostomy (Foley sonde)
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Incidence of HPN from 1 January 97 to 31 December
97
ESPEN-HAN, Clin Nutr 1999, 18, 135
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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)

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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
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Distribution of underlying diseases for HPN
patients in Europe (1997 n 479)
ESPEN-HAN, Clin Nutr 1999, 18, 135
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Indications for HPN in 7 different European
countries where reporting was assumed to be more
than 80 of patients (1997)
ESPEN-HAN, Clin Nutr 1999, 18, 135
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Outcome at 1 January 1998 for HPN patients
enrolled between 1 January 97 and 31 June 97
ESPEN-HAN, Clin Nutr 1999, 18, 135
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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. Psychological
• 4. Quality of life
• 5. Rehabilitation

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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
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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
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Long-term HPN (n 228)Rehabilitation status

• Before At
• HPN 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 unaided and able to go out
  occasionally
• IV Housebound needs major 24
  9 assistance

ESPEN-HAN, Clin Nutr 2001, 30, 205
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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

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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