SEVERE MALNUTRITION .4.

M.P., a 56-year-old, nondiabetic while male with a history of chronic renal failure secondary to membranous glomerulonephritis and hypertension was started on CAPD. Significant medical history included a pituitary tumor removal 30 years previously, a seizure disorder, and hypothyroidism controlled on medications. Nutritional assessment at initiation of CAPD revealed a 6' 2'' tall individual with an actual body weight (ABW) of 83 kg equivalent to 90% of the ideal body weight (IBW) of 89 kg. Pertinent laboratory data revealed HgB 6.7, Hct 19.3, WBC 3.1 with 29% lymphocytes, BUN 157 mg/dl, S. creatinine 7.9 mg/dl, serum total protein (STP) 4.7 g/dl, serum albumin (SA) 2.7 g/dl, S. calcium 7.2 mg/dl, and inorganic phosphorus 8.0 mg/dl. He was judged to be mildly depleted of visceral protein stores and was placed on a diet consisting of 2400 Kcal and 80-100 g protein/day. Sodium and potassium were limited to 2.0 g/day. After nine months on CAPD with nutritional counseling, his nutritional status did not change and weight remained at 83 kg, with a STP of 4.5 g/dl and SA of 2.3 g/dl. In depth dietary and psychosocial evaluations revealed noncompliance with the recommended diet, due to depression and anorexia as well as his family's inability to support him or to cope with his illness. At this point oral nutritional supplementation was started in the form of Nepro 240 g/day which provided an additional 475 Kcal and 16.6 g of protein. During the subsequent three months on this regimen, no increase in body weight, SA, or STP occurred. After 12 months of CAPD, his body weight (BW) fell to 77 kg (85% of IBW). At this time his STP was 4.4 g/dl, and SA level decreased to 2.1 and subsequently to 1.6 g/dl. The patient felt very weak and anorexic. He was lethargic with a flat affect, depressed, nonambulatory, nonfunctioning, and dependent; therefore admission to a nursing home became an issue for the family members. He was hospitalized, with the diagnosis of severe malnutrition and failure to thrive, for parenteral nutritional support. Since he was on CAPD, it was not then possible to provide parenteral nutrition, for practical and financial reasons. The patient was switched from CAPD to hemodialysis (HD) so he could receive intradialytic parenteral nutrition (IDPN) therapy. IDPN therapy consisted of a 1 l solution of 500 ml of 11.4% amino acids, providing 60 g of protein equivalent, 250 ml of 50% dextrose and 250 ml of 20% intralipid, providing 1190 Kcal. IDPN therapy was administered by an infusion pump into the venous drip chamber, over the 4 hr HD treatment, three times per week for six months. After three months on IDPN, the patient's weight rose to 84 kg (94% of IBW), STP to 7.0 g/dl and SA to 3.4 g/dl. After six months on IDPN, PCR improved to 1.76 g/kg/day with a Kt/V of 1.08. STP rose to 6.6 g/dl with SA at 3.7 g/dl. He also had improvement in general well-being, increased physical activity, and good psychological outlook. His appetite returned to normal and he was able to return home from the nursing home to his family. Blood sugar, cholesterol, and triglyceride levels were monitored during IDPN therapy, and no side effects were encountered. IDPN therapy was discontinued at this point, and the patient continued to have oral nutritional supplements and repeated nutritional counseling. Six months post IDPN therapy the patient's BW was maintained at 84.5 kg, BUN of 100 mg/dl, S. creatinine 9.4 mg/dl, STP 7.3 g/dl and SA of 4.0 g/dl, with a PCR of 1.2 g/kg/day.