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A century of home parenteral nutrition for Crohn's disease
S Galandiuk1, M O'Neill, P McDonald
1Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195.
Insights
Home parenteral nutrition (HPN) for Crohn's disease patients did not reduce surgeries but improved nutrition and quality of life. While HPN has risks like sepsis, it’s vital for survival, preventing malnutrition and dehydration.
Area of Science:
- Gastroenterology
- Clinical Nutrition
- Surgical Outcomes
Background:
- Crohn's disease (CD) management often involves complex nutritional support.
- Home parenteral nutrition (HPN) is utilized for severe cases, particularly with short bowel syndrome or high stoma output.
- The long-term impact of HPN on CD patient outcomes requires further investigation.
Purpose of the Study:
- To evaluate the effect of HPN on the disease course in Crohn's disease patients.
- To assess changes in surgical procedures, medical therapy intensity, and nutritional status.
- To determine the impact of HPN on quality of life and associated complications.
Main Methods:
- Retrospective analysis of 41 Crohn's disease patients on HPN for at least 33 days.
- Data collected over 11 years, totaling 121 patient-years of HPN.
- Comparison of pre-HPN and HPN periods regarding surgery, medication, and nutritional markers.
Main Results:
- No significant difference in surgical procedure frequency between pre-HPN and HPN periods.
- Significant increases in serum albumin and transferrin levels; decreased prednisone use.
- Improved quality of life reported, despite HPN-related complications (sepsis, catheter issues) and mortality.
Conclusions:
- Permanent HPN in Crohn's disease is associated with morbidity and mortality but improves nutritional status and quality of life.
- HPN does not reduce the need for surgery but decreases medical therapy intensity.
- HPN is considered essential for survival in patients with severe malnutrition and dehydration due to Crohn's disease.
Abstract:
During an 11-year period, 41 patients with Crohn's disease were placed on home parenteral nutrition (HPN) for a mean of 1,083 days (range: 33 to 3,258 days). Data were retrospectively analyzed to determine whether HPN had an effect on the course of their disease, i.e., on the number of operative procedures performed and the intensity of required medical therapy. Data represented information obtained during a total of 121 patient-years of HPN for Crohn's disease. The main indications for HPN were short bowel syndrome (66%) and high stoma output. Twenty-four of 41 patients (59%) underwent surgery for Crohn's disease during the course of HPN. There was no significant difference between the number of procedures performed per patient per year of Crohn's disease during pre-HPN and HPN periods (p greater than 0.25). Although there was no significant change in body weight, both serum albumin and transferrin levels increased during HPN (p less than 0.01 and p less than 0.01, respectively). Twenty-nine percent of patients were taking prednisone while on HPN, compared with 54% of patients during the pre-HPN period (p less than 0.01). HPN appeared to result in a significant improvement in the numerically assessed quality of life. During the HPN period, 24 patients had 1 or more HPN-related complications that required 1 to 13 hospital admissions (mean: 1.8). These complications included catheter sepsis in 19 patients, blocked or damaged catheters in 15 patients, and dehydration and/or electrolyte imbalance in 5 patients. Eight patients died, with 7% of deaths secondary to catheter-related sepsis. Although permanent HPN is associated with an identifiable morbidity and mortality and is not associated with a reduction in the frequency of surgery for Crohn's disease, benefits include a decrease in the intensity of medical therapy, an improvement in patients' nutritional state, and a significant perceived improvement in patients' quality of life. Without HPN, we believe all patients would have died secondary to malnutrition and/or dehydration.