ESPEN Guidelines on Parenteral Nutrition: On Cardiology and Pneumology

doi:10.1016/j.clnu.2009.04.023

Clinical Nutrition

Volume 28, Issue 4, August 2009, Pages 455-460

https://doi.org/10.1016/j.clnu.2009.04.023 Get rights and content

Summary

Nutritional support is becoming a mainstay of the comprehensive therapeutic approach to patients with chronic diseases. Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are frequently associated with the progressive development of malnutrition, due to reduced energy intake, increased energy expenditure and impaired anabolism. Malnutrition and eventually cachexia have been shown to have a negative influence on the clinical course of CHF and COPD, and to impinge on patients' quality of life. Nutritional support in these patients should be therefore considered, particularly to prevent progressive weight loss, since restoration of lean and fat body mass may not be achievable. In CHF and COPD patients, the gastrointestinal tract is normally accessible and functioning. Although recent reports suggest that heart failure is associated with modifications of intestinal morphology, permeability and absorption, the clinical relevance of these are still not clear. Oral supplementation and enteral nutrition should represent the first choices when cardiopulmonary patients need nutritional support, particularly given the potential complications and economic burden of parenteral nutrition. This appropriately preferential enteral approach partly explains the lack of robust clinical trials of the role of parenteral nutrition in CHF and COPD patients. Based on the available evidence collected via PubMed, Medline, and SCOPUS searches, it is recommended that parenteral nutrition is reserved for those patients in whom malabsorption has been documented and in those in whom enteral nutrition has failed.

Summary of statements: Parenteral Nutrition in Cardiology
Subject	Recommendations	Grade	Number
Background	The prevalence of cardiac cachexia, defined from weight loss of at least 6% in 6 months, has been estimated at about 12–15% in patients in New York Heart Association (NYHA) classes II–IV. The incidence of weight loss >6% in CHF patients with NYHA class III/IV is approximately 10% per year. CHF affects nutritional state, energy and substrate metabolism.	B	1.1
	The mortality in CHF patients with cardiac cachexia is 2–3 times higher than in non-cachectic CHF patients.	B	1.2
	Although there is limited evidence that gut function is impaired in CHF, decreased cardiac function can reduce bowel perfusion and lead to bowel wall oedema, resulting in malabsorption.	B	1.3
Indications	Although there is no evidence available from well-designed studies, PN is recommended to stop or reverse weight loss in patients with evidence of malabsorption, on the basis that it improves outcome in other similar conditions and there is a plausible physiological argument for it.	C	1.4
Indications	Currently there is no indication for PN in the prophylaxis of cardiac cachexia. Further studies are needed to assess the impact of the parenteral administration of specific substrates on cardiac function.	C	1.5
Contra-indications	There are no specific contraindications to PN in CHF patients. However, considering that cardiac function is decreased and water retention is frequently found in CHF patients, it is recommended that PN should be avoided, other than in patients with evidence of malabsorption in whom enteral nutrition has been shown, or is strongly expected, to be ineffective.	B	1.6
Implementation	When feeding CHF patients, either enterally or parenterally, fluid overload must be avoided.	C	1.6

Summary of statements: Parenteral Nutrition in Respiratory Medicine
Subject	Recommendations	Grade	Number
Background	Between 25% and 40% of patients with advanced COPD are malnourished.	B	2.1
Background	Being underweight and having low fat-free mass are independently associated with a poor prognosis in patients with chronic respiratory insufficiency, especially in COPD.	B	2.2
Indications	There is no evidence showing that gut function is impaired in COPD patients. Therefore, considering that enteral nutrition is less expensive and associated with fewer and less severe complications than parenteral nutrition, enteral nutrition should represent the first approach to patients with COPD in need of nutritional support.	B	2.3
Indications	There is limited evidence that COPD patients intolerant of EN profit from PN. Small studies do however suggest that, in combination with exercise and anabolic pharmacotherapy, PN has the potential to improve nutritional status and function.	C	2.4
Effect of PN	Loss of body weight is correlated with increased morbidity and mortality. However, due to the lack of studies of its effects, it is not possible to be sure if prognosis is influenced by the provision of PN.	B	2.5
Regimen selection	In patients with stable COPD, glucose-based PN causes an increase in the respiratory CO₂ load. PN composition should accordingly be orientated towards lipids as the energy source. There is not sufficient evidence to recommend specific lipid substrates.	B	2.6

Section snippets

Does COPD have an influence on nutritional state, energy and substrate metabolism?

Between 25% and 40% of patients with advanced COPD are malnourished (B).

Comments: clinically relevant weight loss (5% within three months, or 10% within 6 months) is found in 25–40% of all cases in whom lung function is severely impaired (FEV1 < 50%). Muscle wasting, defined as fat-free mass index (FFMI) <16 kg/m² in males, and <15 kg/m² in females, is found in 25% of patients with GOLD stages 2 and 3, and in up to 35% of cases with severe disease (GOLD stage 4)32, 33 (IIb). A French

Conflict of interest

Conflict of interest on file at ESPEN ([email protected]).

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Cited by (66)

What Is the Role of Parenteral and Enteral Nutrition in Patients With Cancer and With Noncancer Illness?
2023, Evidence-Based Practice of Palliative Medicine, Second Edition
Though clinicians, patients, and families often hope that artificial nutrition (AN) may extend and improve life, in the palliative care setting this is probably only true when quality of life is already adequate and prognosis is limited by nutritional deficiency rather than underlying disease. The increased cost, complications, and immunosuppression associated with parenteral nutrition (PN) as compared with enteral nutrition (EN) mean that if AN is indicated the enteral route should always be used if possible. As with all forms of nutrition support, the catabolic state resulting from the cancer anorexia-cachexia syndrome (CACS) that affects up to 80% of cancer patients means that AN by any route has no role in the care of patients with advanced cancer who are losing weight. However, in cancer patients with good functional status and quality of life and those with head and neck cancer who are unable to consume sufficient calories, gastrostomy may be beneficial. Unfortunately, enteral feeding likely does not provide any benefits for patients with advanced dementia and may even increase aspiration. Careful hand feeding and comfort feeding are reasonable options for addressing goals of providing care and nutrition to these patients. In the last weeks and months of life, careful and compassionate communication about AN that acknowledges both the emotional/cultural significance of food and the absence of data supporting a beneficial effect from PN can lead to better decisions.
Relevance of nutritional assessment and treatment to counteract cardiac cachexia and sarcopenia in chronic heart failure
2021, Clinical Nutrition
Citation Excerpt :
In this sense, it has been widely recommended to consider parenteral nutritional support when oral feeding is not sufficient and the digestive apparatus is not functioning after 3–5 days, if oral/enteral intake is expected to be below half of the energy requirement for more than one week, or there is evidence of malabsorption [102]. A low fluid intake is also advised [103]. Thus, the use of a central catheter is suggested, avoiding the peripheral line as far as possible, since it requires high volumes to guarantee a tolerable osmolarity for the peripheral vein.
Chronic heart failure (CHF) is frequently associated with the involuntary loss of body weight and muscle wasting, which can determine the course of the disease and its prognosis. While there is no gold standard malnutrition screening tool for their detection in the CHF population, several bioelectrical and imaging methods have been used to assess body composition in these patients (such as Dual Energy X-Ray Absorptiometry and muscle ultrasound, among other techniques). In addition, numerous nutritional biomarkers have been found to be useful in the determination of the nutritional status. Nutritional considerations include the slow and progressive supply of nutrients, avoiding high volumes, which could ultimately lead to refeeding syndrome and worsen the clinical picture. If oral feeding is insufficient, hypercaloric and hyperproteic supplementation should be considered. β-Hydroxy-β-methylbutyrate and omega-3 polyunsaturated fatty acid administration prove to be beneficial in certain patients with CHF, and several interventional studies with micronutrient supplementation have also described their possible role in these subjects. Taking into account that CHF is sometimes associated with gastrointestinal dysfunction, parenteral nutritional support may be required in selected cases. In addition, potential therapeutic options regarding nutritional state and muscle wasting have also been tested in clinical studies. This review summarises the scientific evidence that demonstrates the necessity to carry out a careful nutritional evaluation and nutritional treatment to prevent or improve cardiac cachexia and sarcopenia in CHF, as well as improve its course.
Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure
2021, Journal of the American College of Cardiology
Deterioration of nutritional status during hospitalization in patients with chronic heart failure increases mortality. Whether nutritional support during hospitalization reduces these risks, or on the contrary, may be harmful due to an increase in salt and fluid intake, remains unclear.
The purpose of this trial was to study the effect of nutritional support on mortality in patients hospitalized with chronic heart failure who are at nutritional risk.
A total of 645 patients with chronic heart failure (36% [n = 234] with acute decompensation) participated in the investigator-initiated, open-label EFFORT (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients) trial. Patients were randomized to protocol-guided individualized nutritional support to reach energy, protein, and micronutrient goals (intervention group) or standard hospital food (control group). The primary endpoint was all-cause mortality at 30 days.
Mortality over 180 days increased with higher severity of malnutrition (odds ratio per 1-point increase in Nutritional Risk Screening 2002 score: 1.65; 95% confidence interval [CI]: 1.21 to 2.24; p = 0.001). By 30 days, 27 of 321 intervention group patients (8.4%) died, compared with 48 of 324 (14.8%) control group patients (odds ratio: 0.44; 95% CI: 0.26 to 0.75; p = 0.002). Patients at high nutritional risk showed the most benefit from nutritional support. Mortality effects remained significant at 180-day follow-up. Intervention group patients also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; odds ratio: 0.50; 95% CI: 0.34 to 0.75; p = 0.001).
Among hospitalized patients with chronic heart failure at high nutritional risk, individualized nutritional support reduced the risk for mortality and major cardiovascular events compared with standard hospital food. These data support malnutrition screening upon hospital admission followed by an individualized nutritional support strategy in this vulnerable patient population. (Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial [EFFORT]; NCT02517476)
l-Arginine treatment improves angiogenic response and reduces matrix metalloproteinase activity in chronic heart failure patients with coronary artery disease
2018, PharmaNutrition
Citation Excerpt :
Cumulative evidence has demonstrated that L-arginine, which is classified as semiessential or conditionally essential amino acid, being the only precursor for endogenous NO production, affects the cardiovascular system and prevents the onset of CAD [18]. The European Society for Clinical Nutrition and Metabolism (ESPEN) (2009) guidelines recommended L-arginine for CHF treatment [19]. The majority of current experimental and clinical studies demonstrate beneficial effects of L-arginine on endothelium in conditions associated with its hypofunction due to reduced NO synthesis, and regulation of vascular hemostasis through antiplatelet, anticoagulatory and profibrinolytic activities [20].
l-Arginine is an important dietary amino acid with well-established role in cardiovascular health as a precursor of NO synthesis, however its effects on angiogenesis-related proteins in coronary artery disease (CAD) are not completely known. This study was undertaken to evaluate effects of l-arginine on the levels of key angiogenic regulators and matrix metalloproteinase (MMP) activity in sera of chronic heart failure (CHF) patients with CAD. Thirty-three patients were divided into two groups: 1) received only the standard treatment (control group, n = 13); 2) received l-arginine intravenous infusions in the dose of 4.2 g /100 mL for 7 days, followed by oral supplementation in the daily dose of 6 g for 3 months (n = 20). Significant up-regulation of vascular endothelial growth factor (VEGF) was found immunochemically in sera of l-arginine-treated patients as compared to control individuals. Serum MMP-2 and -9 activities were dramatically reduced after l-arginine treatment. Decrease in circulating levels of angiostatin and degradation products of fibronectin, a predominant constituent of the endothelial basement membrane, could result from l-arginine-induced inhibition of MMP activities. Our findings indicate that l-arginine rebounds the angiogenic balance in favour of improving neovascularization that potentially contributes to cardiovascular benefits in CHF patients with CAD.
COPD Patients with Acute Exacerbation Who Developed Refeeding Syndrome during Hospitalization Had Poor Outcome: A Retrospective Cohort Study
2018, International Journal of Gerontology
Citation Excerpt :
Second, the sample size was small, statistic inference might be misleading. In summary, nutrition is good for the malnourished patients,32–36 but it might turn bad if some precautions are not taken in advance during nutritional implementation. RFS is diet-induced and presents itself with a wide spectrum of clinical manifestations, from rather no or nonspecific symptoms to potentially life-threatening complications37 in patients who are malnourished from whatever cause, but it is preventable.
The study retrospectively investigated risk factors for refeeding syndrome in COPD patients with acute exacerbation and its impact on clinical outcomes.
We retrospectively reviewed discharge notes of patients with primary diagnosis of COPD with acute exacerbation from August 2014 to December 2015. Demographic data, BMI, the last post-bronchodilator FEV₁, case-mixed index (CMI), APACHE-II score, average daily total energy intake (TEI) and adjusted by current BW to obtain average daily total energy intake index (TEII) of the first four hospitalization days, the initial ABG with calculated P_aO₂/F_iO₂ were collected. Laboratory RFS was arbitrarily defined as either serum P or Mg declined 15% or more after feeding in comparison with the pre-feeding one and fell below the lower limit of normal ranges.
61 patients were eligible for analysis and 38% had RFS. Univariate analyses showed that advanced age, low BMI, high TEII, low post-bronchodilator FEV₁, high APACHE-II score, low P_aO₂/F_iO₂, high P_aCO₂, low pH, and leukocytosis at admission were risk factors for RFS. However, multiple logistic regression revealed that only BMI, TEII and the last post-bronchodilator FEV₁ were the risk predictors for RFS. Those who developed RFS had high risk to suffer from delirium, be intubated and receive invasive mechanical ventilation with difficult weaning from the ventilator, and have longer LOS. No in-hospital mortality was found.
RFS should not be overlooked in COPD patients with acute exacerbation. Awareness of this feeding-related complication is mandatory for early diagnosis and appropriate management to prevent morbidity and mortality.
Increased energy and/or protein intake improves anthropometry and muscle strength in chronic obstructive pulmonary disease patients: a systematic review with meta-analysis on randomised controlled clinical trials
2023, British Journal of Nutrition
Approximately one-in-ten reproductive age adults in the USA follow a plant-based diet, yet there is limited information on the influence of vegan and vegetarian diets on the mineral composition of breast milk. This study explored the major and trace mineral composition in breast milk and associations with maternal diet patterns. We used a cross-sectional design to collect a single sample of breast milk from individuals following vegan (n 23), vegetarian (n 19) and omnivore (n 21) diet patterns. Plant-based diet (n 42) was defined as following either vegan or vegetarian diets. Sixteen minerals were assessed using inductively coupled plasma mass spectrometry and inductively coupled plasma optical emission spectrometry. Data were evaluated using traditional statistical techniques and five different machine learning approaches. The distribution of Se (median; quartile 1 and 3) was significantly different between groups (vegetarians 21, 18–26 µg/l; vegans 19, 18–25 µg/l and omnivores 17, 14–20 µg/l; P = 0·007) using a Kruskal–Wallis test. Machine learning techniques also identified Se as a potential biomarker for differentiating breast milk by maternal diet pattern. Individuals following a plant-based diet generally had a lower BMI, higher breast milk Se and lower breast milk I and Fe concentrations compared with those following omnivore diets. This suggests that maternal dietary pattern (plant-based v. omnivore) may be helpful clinical information to consider when caring for the breast-feeding dyad, with the strongest evidence related to differences in Se concentration.

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ESPEN Guidelines on Parenteral Nutrition: On Cardiology and Pneumology

Summary

Section snippets

Does COPD have an influence on nutritional state, energy and substrate metabolism?

Conflict of interest

Lancet

Lancet

Chest

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

J Nutr

Respir Med

Chest

Neurol Clin

Clin Chest Med

J Am Diet Assoc

AJCN

Respir Med

Respir Med

The epidemiology of heart failure

Eur Heart J

Eur J Heart Fail

Prognosis and therapy approaches of cardiac cachexia

Curr Opin Cardiol

Catabolism in chronic heart failure

Eur Heart J

Contribution of skeletal muscle atrophy to exercise intolerance and altered muscle metabolism in heart failure

Circulation

Cachexia: common, deadly, with an urgent need for precise definition and new therapies

Am J Cardiol

Cytokines and neurohormones relating to body composition alterations in the wasting syndrome of chronic heart failure

Eur Heart J

Increased resting metabolic rate in patients with congestive heart failure

Ann Intern Med

Daily energy expenditure in free-living heart failure patients

Am J Physiol

Hormonal changes and catabolic/anabolic imbalance in chronic heart failure: the importance for cardiac cachexia

Circulation

Elevated circulating levels of tumor necrosis factor in severe chronic heart failure

N Engl J Med

Plasma cytokine parameters and mortality in patients with chronic heart failure

Circulation

Gastro-intestinal protein loss in elderly patients with cardiac cachexia

Age Ageing

Fat malabsorption in elderly patients with cardiac cachexia

Age Ageing