ESPEN Congress Glasgow A. Van Gossum

Transcription

1 ESPEN Congress Glasgow 2002 ESPEN Guideline Reports HOME ARTIFICIAL NUTRITIONAL SUPPORT (HANS) Current status in Europe A. Van Gossum

2 HOME ARTIFICIAL NUTRITIONAL SUPPORT (HANS) Current status in Europe A. VAN GOSSUM (Brussels) with the collaboration of ESPEN-HAN Working Group Indications - complications - metabolic bone disease - cancer ESPEN - Glasgow 2002

3 Home Artificial Nutrition HPN HEN Prevalence 4-12/ / Pub Med articles

4 Poland Indications for HPN in 7 different European countries where reporting was assumed to be more than 80% of patients Number of patients Crohn's disease Vascular Cancer Radiation AIDS Others France % 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% % Spain 31 16% 13% 39% - 6% 25% Poland 14 14% 50% - 14% - 22% Clin Nutr 1999, 18, 135

5 Outcome at 1 January 1998 for HPN patients enrolled between 1 January 97 and 31 June % 100% 80% 60% 40% Died Ceased Continued 20% 0% Crohn's disease, n=50 Vascular, n=38 Other, n=57 Radiation enteritis, n=19 AIDS, n=6 Cancer, n=102 Clin Nutr 1999, 18, 135

6 HPN in incurable cancer patients Criteria for an appropriate decision Insufficient or impossible oral/enteral feeding Willingness of the patient Expected survival time > 3 months Karnofsky score index > 50* Awareness of the diagnosis and the prognosis *S. Gervasio (P-183) *Bozzetti F. Clin Nutr 1999, 18 (suppl 1), 49

7 HPN in incurable cancer patients Recommendations for an appropriate decision 1. Communication (amongst care givers patient (relatives)) 2. Distinction between effects and benefits 3. Adoption the trial-and-error method (eventual withdraw of HPN) Bozzetti F. and V. Clin Nutr 2001, 20 (suppl 2), 23

8 n = 228 patients Long-term HPN Complications (I) 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%) Clin Nutr 2001, 30, 205

9 Metabolic bone diseases in HPN patients Prevalence Alteration of bone mineral density: T-score < - 1 SD: 84% T-score < SD: 41% Bone pain: 35% Bone fracture: 10% Pironi L. and ESPEN-HAN Group. Clin Nutr 2002, 4, 289

10 Metabolic bone disease Prevention Aluminium contamination less than 25 µg/l* Daily amounts of minerals: Ca = mmol P = mmol Mg = 4-12 mmol Acetate to avoid acidosis Not too much sodium because of risk of sodium - induced hypercalciuria Intravenous vitamin D: 200 IU *Boggio Bertinet D. (0-59) Pironi L. Clin Nutr 2001 (20), 43

11 Metabolic bone disease Treatment Patients with low BMD, low serum PTH, low serum 1,25-dihydroxyvitamin D and normal serum 25-hydroxyvitamin D candidates for vitamin D withdrawal 1 Oral calcium whenever possible Estrogen for perimenopausal women Biphosphonates 2-3 Glucagon-like peptide Verhage A. et al. JPEN 1995, 19, 431-6; 2 Haderslev K. Am J Clin Nutr 2002, 76, 4, D'Aoust L. et al. (0.48); 4 Haderslev K. Scand J Gastroenterol 2002, 37, 392

12 HPN-related liver diseases Prevention 1. To encourage oral food intake 2. To prefer cyclical regimen 3. To limit intestinal bacterial overgrowth 4. To avoid environmental toxic factors (alcohol, virus, drugs) 5. To treat - rapidly and adequately - any septic episode

13 HPN-related liver diseases Prevention 6. To provide less than 1 g lipid/kg/day (data about the composition of lipid emulsion are scarce) and overfeeding (BMI < 25) 7. To protect bile salt composition by providing urso-deoxycholic acid in case of cholestasis 8. To propose a liver (combined with intestine) transplantation in case of cirrhosis with hepatic failure

14 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 Clin Nutr 2001, 30, 205

15 HEN Disability and dependency Full normal activity 1/6 of adults House bound 50% Total help 59% Nursing home 40% Elia M. BANS Report, 2001

16 Outcome of HEN patients n = 47 Patients (mean age 64 ± 27 y.) Mean duration of HEN: 242 ± 494 days 20% died during the first month on HEN* 35% died after more than 1 month on HEN 33% resumed full oral nutrition 7% discontinuation 5.5% dependency *factors associated with death: dementia, neurologic disease, head and neck cancer, AIDS, age over 70 y. Schneider S., et al. JPEN 2001; 25: 203

17 Home Artificial Nutrition Nutrition Team (Hospital) Home Care Service Home Care Givers (professionals, relatives) Education and Patient Peer support 3 Social and psychological assistance MCN 1 Telemedicine - ISDN line 2 General practitioner 1 McKee R. (0.28); Chambers A. (0.29); Smith C. JPEN 2002, 26, 159