Intradialytic parenteral nutrition and intraperitoneal nutrition.

Intradialytic parenteral nutrition and intraperitoneal nutrition are methods to provide supplemental nutrition support to patients with chronic kidney disease (also referred to as end-stage renal disease) while they are receiving dialytic therapy. There has been considerable controversy over indications and benefits of intradialytic parenteral nutrition and intraperitoneal nutrition. A major stumbling block had been problematic reimbursement for the therapy under Medicare. Medicare Part D has alleviated some of the reimbursement obstacles and has increased interest in reexamining the benefits and burdens of supplemental nutrition support therapies for patients receiving dialysis.

Practice paper of the American Dietetic Association: Home care--opportunities for food and nutrition professionals.

Home care continues to expand. With this growth are opportunities for registered dietitians (RDs) to demonstrate the vital role that they play not only in providing optimal nutrition care, but also in contributing to each patient's quality of life. Home care nutrition services range from individual patient counseling to managing and monitoring parenteral nutrition. RDs' knowledge of nutrition, reimbursement, and new technologies position them to improve care and control costs. Current roles and responsibilities along with emerging areas of professional growth give RDs a multitude of options to provide and expand their services and value in home care.

Home care for the elderly.

The increasing numbers of older (>65 years) Americans will increase the demand for home health services including support services (nursing, physical therapy, occupational therapy, durable medical equipment, and respiratory therapy), infusion therapies, palliative care, and hospice. The unique characteristics and specific needs of this population must be addressed to optimize patient outcomes. The American Society for Parenteral and Enteral Nutrition has established standards for clinicians providing nutrition support in the home and provides practice guidelines for nutrition support and geriatrics. Certification in gerontological care is available for dietitians, pharmacists, physicians, and nurses. The key to optimal care for older adults is to find the confluence of expertise in nutrition support and geriatrics.

Micronutrient assessment in long-term home parenteral nutrition patients.

Assessment of micronutrient status of patients requiring long-term parenteral nutrition (PN) continues to be a challenge for clinicians. The scientific literature primarily consists of small studies and case reports. There are no evidence-based guidelines available. Clinicians rely on clinical assessment according to the patient's disease process, medication regimen, physical examination, and history of nutrient intake to determine existence or risk of micronutrient deficiency and toxicity. This paper will examine current scientific evidence and existing recommendations for the micronutrient assessment and management of patients requiring long-term PN.

Bridging the continuum: nutrition support in palliative and hospice care.

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.

Nutrients and wound healing: still searching for the magic bullet.

Clinicians in nearly all practice areas are confronted with the challenges associated with delayed and impaired wound healing. Although nutrition plays a critical role in the healing process, controversy exists regarding the optimal nutrition regimen. This article reviews literature related to nutrition interventions that facilitate wound healing. The limitations of the research that forms the scientific basis of many nutrition recommendations are also examined. The limited availability of rigorously performed clinical studies to develop evidence-based guidelines for nutrition support in wound care emphasizes the need for further research and underscores the importance of individualizing the nutrition care plan for each patient.

Hepatic proteins and nutrition assessment.

Serum hepatic protein (albumin, transferrin, and prealbumin) levels have historically been linked in clinical practice to nutritional status. This paradigm can be traced to two conventional categories of malnutrition: kwashiorkor and marasmus. Explanations for both of these conditions evolved before knowledge of the inflammatory processes of acute and chronic illness were known. Substantial literature on the inflammatory process and its effects on hepatic protein metabolism has replaced previous reports suggesting that nutritional status and protein intake are the significant correlates with serum hepatic protein levels. Compelling evidence suggests that serum hepatic protein levels correlate with morbidity and mortality. Thus, serum hepatic protein levels are useful indicators of severity of illness. They help identify those who are the most likely to develop malnutrition, even if well nourished prior to trauma or the onset of illness. Furthermore, hepatic protein levels do not accurately measure nutritional repletion. Low serum levels indicate that a patient is very ill and probably requires aggressive and closely monitored medical nutrition therapy.