Using a generic definition of cachexia in patients with kidney disease receiving haemodialysis: a longitudinal (pilot) study.

BACKGROUND: Research indicates that cachexia is common among persons with chronic illnesses and is associated with increased morbidity and mortality. However, there continues to be an absence of a uniformed disease-specific definition for cachexia in chronic kidney disease (CKD) patient populations. OBJECTIVE: The primary objective was to identify cachexia in patients receiving haemodialysis (HD) using a generic definition and then follow up on these patients for 12 months. METHOD: This was a longitudinal study of adult chronic HD patients attending two hospital HD units in the UK. Multiple measures relevant to cachexia, including body mass index (BMI), muscle mass [mid-upper arm muscle circumference (MUAMC)], handgrip strength (HGS), fatigue [Functional Assessment of Chronic Illness Therapy (FACIT)], appetite [Functional Assessment of Anorexia/Cachexia Therapy (FAACT)] and biomarkers [C-reactive protein (CRP), serum albumin, haemoglobin and erythropoietin resistance index (ERI)] were recorded. Baseline analysis included group differences analysed using an independent t-test, dichotomized values using the χ2 test and prevalence were reported using the Statistical Package for the Social Sciences 24 (IBM, Armonk, NY, USA). Longitudinal analysis was conducted using repeated measures analysis. RESULTS: A total of 106 patients (30 females and 76 males) were recruited with a mean age of 67.6 years [standard deviation (SD) 13.18] and dialysis vintage of 4.92 years (SD 6.12). At baseline, 17 patients were identified as cachectic, having had reported weight loss (e.g. >5% for >6 months) or BMI <20 kg/m2 and three or more clinical characteristics of cachexia. Seventy patients were available for analysis at 12 months (11 cachectic versus 59 not cachectic). FAACT and urea reduction ratio statistically distinguished cachectic patients (P = 0.001). However, measures of weight, BMI, MUAMC, HGS, CRP, ERI and FACIT tended to worsen in cachectic patients. CONCLUSION: Globally, cachexia is a severe but frequently underrecognized problem. This is the first study to apply the defined characteristics of cachexia to a representative sample of patients receiving HD. Further, more extensive studies are required to establish a phenotype of cachexia in advanced CKD.

Estimating the Prevalence of Muscle Wasting, Weakness, and Sarcopenia in Hemodialysis Patients.

OBJECTIVES: Haemodialysis (HD) patients suffer from nutritional problems, which include muscle wasting, weakness, and cachexia, and are associated with poor clinical outcomes. The European Working Group for Sarcopenia in Older People (EWGSOP) and Foundations for the National Institute of Health (FNIH) have developed criteria for the assessment of sarcopenia, including the use of non-invasive techniques such as bioelectrical impedance assessment (BIA), anthropometry, and hand grip strength (HGS) dynamometry. This study investigated the prevalence of muscle wasting, weakness, and sarcopenia using the EWGSOP and FNIH criteria. METHODS: BIA was performed in 24 females (f) and 63 males (m) in the post-dialysis period. Total skeletal muscle mass and appendicular skeletal muscle mass were estimated and index values (i.e., muscle mass divided by height2 [kg/m2]) were calculated (Total Skeletal Muscle Index (TSMI) and Appendicular Skeletal Muscle Index (ASMI)). Mid-arm circumference and triceps skin-fold thickness were measured and mid-upper arm muscle circumference (MUAMC) calculated. HGS was measured using a standard protocol and Jamar dynamometer. Suggested cut-points for low muscle mass and grip strength were utilized using the EWGSOP and FNIH criteria with prevalence estimated, including sarcopenia. RESULTS: The prevalence varied depending on methodology: low TSMI (moderate and severe sarcopenia combined) was 55% for whole group: 21% (f) and 68% (m). Low ASMI was 32% for whole group: 25% (f) and 35% (m). Low MUAMC was 25% for whole group: 0% (f) and 30% (m). ASMI highly correlated with Body Mass Index (r = 0.78, P < .001) and MUAMC (r = 0.68, P < .001). Muscle weakness was high regardless of cut-points used (50-71% (f); 60-79% (m)). CONCLUSIONS: Internationally, this is the first study comparing measures of muscle mass (TSMM and ASMM by BIA and MUAMC) and muscle strength (HGS) using this specific methodology in a hemodialysis population. Future work is required to confirm findings.

Establishing a clinical phenotype for cachexia in end stage kidney disease - study protocol.

BACKGROUND: Surveys using traditional measures of nutritional status indicate that muscle wasting is common among persons with end-stage kidney disease (ESKD). Up to 75% of adults undergoing maintenance dialysis show some evidence of muscle wasting. ESKD is associated with an increase in inflammatory cytokines and can result in cachexia, with the loss of muscle and fat stores. At present, only limited data are available on the classification of wasting experienced by persons with ESKD. Individuals with ESKD often exhibit symptoms of anorexia, loss of lean muscle mass and altered energy expenditure. These symptoms are consistent with the syndrome of cachexia observed in other chronic diseases, such as cancer, heart failure, and acquired immune deficiency syndrome. While definitions of cachexia have been developed for some diseases, such as cardiac failure and cancer, no specific cachexia definition has been established for chronic kidney disease. The importance of developing a definition of cachexia in a population with ESKD is underscored by the negative impact that symptoms of cachexia have on quality of life and the association of cachexia with a substantially increased risk of premature mortality. The aim of this study is to determine the clinical phenotype of cachexia specific to individuals with ESKD. METHODS: A longitudinal study which will recruit adult patients with ESKD receiving haemodialysis attending a Regional Nephrology Unit within the United Kingdom. Patients will be followed 2 monthly over 12 months and measurements of weight; lean muscle mass (bioelectrical impedance, mid upper arm muscle circumference and tricep skin fold thickness); muscle strength (hand held dynamometer), fatigue, anorexia and quality of life collected. We will determine if they experience (and to what degree) the known characteristics associated with cachexia. DISCUSSION: Cachexia is a debilitating condition associated with an extremely poor outcome. Definitions of cachexia in chronic illnesses are required to reflect specific nuances associated with each disease. These discrete cachexia definitions help with the precision of research and the subsequent clinical interventions to improve outcomes for patients suffering from cachexia. The absence of a definition for cachexia in an ESKD population makes it particularly difficult to study the incidence of cachexia or potential treatments, as there are no standardised inclusion criteria for patients with ESKD who have cachexia. Outcomes from this study will provide much needed data to inform development and testing of potential treatment modalities, aimed at enhancing current clinical practice, policy and education.

Critical data at the crossroads: the National Health and Nutrition Examination Survey faces growing challenges.

NHANES needs urgent attention to ensure its future, which is facing emerging challenges associated with data collection, stagnant funding that has undercut innovation, and the increased call for granular data for subpopulations and groups at risk. The concerns do not rest merely on securing more funding but focus on the need for a constructive review of the survey to explore new approaches and identify appropriate change. This white paper, developed under the auspices of the ASN's Committee on Advocacy and Science Policy (CASP), is a call to the nutrition community to advocate for and support activities to prepare NHANES for future success in a changing nutrition world. Furthermore, because NHANES is much more than a nutrition survey and serves the needs of many in health fields and even commercial arenas, effective advocacy must be grounded in alliances among the survey's diverse stakeholders so that the full range of expertise and interests can engage. This article highlights the complicated nature of the survey along with key overarching challenges to underscore the importance of a measured, thoughtful, comprehensive, and collaborative approach to considering the future of NHANES. Starting-point questions are identified for the purposes of focusing dialog, discussion forums, and research. In particular, the CASP calls for a National Academies of Sciences, Engineering, and Medicine study on NHANES to articulate an actionable framework for NHANES going forward. With a well-informed and integrated set of goals and recommendations that could be provided by such a study, a secure future for NHANES is more readily achievable.

Nutritional support and brain tissue glucose metabolism in poor-grade SAH: a retrospective observational study.

INTRODUCTION: We sought to determine the effect of nutritional support and insulin infusion therapy on serum and brain glucose levels and cerebral metabolic crisis after aneurysmal subarachnoid hemorrhage (SAH). METHODS: We used a retrospective observational cohort study of 50 mechanically ventilated poor-grade (Hunt-Hess 4 or 5) aneurysmal SAH patients who underwent brain microdialysis monitoring for an average of 109 hours. Enteral nutrition was started within 72 hours of admission whenever feasible. Intensive insulin therapy was used to maintain serum glucose levels between 5.5 and 7.8 mmol/l. Serum glucose, insulin and caloric intake from enteral tube feeds, dextrose and propofol were recorded hourly. Cerebral metabolic distress was defined as a lactate to pyruvate ratio (LPR)>40. Time-series data were analyzed using a general linear model extended by generalized estimation equations (GEE). RESULTS: Daily mean caloric intake received was 13.8±6.9 cal/kg and mean serum glucose was 7.9±1 mmol/l. A total of 32% of hourly recordings indicated a state of metabolic distress and <1% indicated a state of critical brain hypoglycemia (<0.2 mmol/l). Calories received from enteral tube feeds were associated with higher serum glucose concentrations (Wald=6.07, P=0.048), more insulin administered (Wald=108, P<0.001), higher body mass index (Wald=213.47, P<0.001), and lower body temperature (Wald=4.1, P=0.043). Enteral feeding (Wald=1.743, P=0.418) was not related to brain glucose concentrations after accounting for serum glucose concentrations (Wald=67.41, P<0.001). In the presence of metabolic distress, increased insulin administration was associated with a relative reduction of interstitial brain glucose concentrations (Wald=8.26, P=0.017), independent of serum glucose levels. CONCLUSIONS: In the presence of metabolic distress, insulin administration is associated with reductions in brain glucose concentration that are independent of serum glucose levels. Further study is needed to understand how nutritional support and insulin administration can be optimized to minimize secondary injury after subarachnoid hemorrhage.

Effect of malnutrition on outcomes in patients with heart failure: A large retrospective propensity score-matched cohort study.

BACKGROUND: Heart failure (HF) is highly prevalent, whereas malnutrition is generally associated with poorer hospital outcomes, and it is not uncommon in patients with HF. Prior studies of the effect of malnutrition on HF outcomes are limited in size and quality. This study aims to elucidate the association between malnutrition and hospital length of stay (LOS), mortality, and discharge destination in patients with HF. METHODS: This is a retrospective review of medical records for inpatients admitted with a primary diagnosis of HF in 2018. Patients with HF and severe protein-calorie malnutrition were compared with those without malnutrition. A two-sided t-test was conducted between patients who have HF with and without malnutrition on hospital outcomes. Multivariate logistic regression was developed to identify potential predictors of malnutrition. A propensity score was calculated for each patient and matched cases (malnutrition with nonmalnutrition) to balance covariates and reduce bias. RESULTS: For N = 7079, the median age was 75 years, with 15.79% having severe malnutrition. Overall mortality was 5.57% (394 deceased) . There were significant associations between malnutrition and both mortality (relative risk, 2.22; P < 0.001) and LOS (10 vs 5 days, P < 0.001) in patients with HF. Significantly fewer patients with malnutrition were discharged home (odds ratio, 0.41; P < 0.001). CONCLUSION: Patients with HF and malnutrition have higher risk for mortality, increased LOS in the hospital, and decreased chance of being discharged home. Continued study of this population is required to better predict which patients with malnutrition will respond to nutrition interventions.

Disease-Related Malnutrition and Enteral Nutrition.

There are many misconceptions surrounding the diagnosing and treatment of malnutrition and around feeding people with enteral nutrition (EN). Often the decisions made by clinicians are made from anecdote or guidelines that may be out of date or supported by low-quality evidence. In this article, we will discuss different aspects of diagnosing malnutrition and delve deeper into the science and evidence behind certain recommendations. Our goal is to better equip the reader with the most current data-supported recommendation, such as indications, contraindications, complications of EN, tube and ostomy complications, types and use of specialized enteral formulas, and home management.

Parenteral Nutrition.

Parenteral nutrition (PN) is a therapy to nourish patients who cannot tolerate feeding via the gut. Though a life-saving intervention, it does have risks associated. In this article, we aim to dispel myths associated with PN. Practitioners who manage critically ill patients or patients with intestinal failure should be equipped with evidence-based knowledge of PN including the indications, contraindications, feasibility, complications, and long-term management of PN.

Reduction of Unnecessary Gastrostomy Tube Placement in Hospitalized Patients.

BACKGROUND: Many patients undergoing gastrostomy tube placement at one academic medical center were able to resume an oral diet prior to discharge or did not survive hospitalization. The objective of this study was to reduce placement of nonbeneficial gastrostomy tubes and to maintain or improve adherence to gastrostomy tube guidelines. METHODS: In February 2017 the Acute Care Surgery service began an initiative in which gastrostomy tube placement was deferred until the patient was deemed medically stable for discharge. This study retrospectively reviewed all patients who underwent percutaneous endoscopic gastrostomy (PEG) tube placement at Columbia University Irving Medical Center, January 2014-January 2017, prior to the intervention, and February 2017-December 2019, after the intervention. Primary outcomes included the proportion of patients undergoing PEG tube placement who resumed an oral diet or who died during the index hospital stay. Secondary outcomes included the timing of the PEG tube placement. RESULTS: PEGs were placed in 240 patients in the preintervention period and in 171 patients in the postintervention period. In the postintervention period, there was a lower percentage of patients resuming oral diet after PEG placement (17.1% vs. 7.6%, p = 0.0049), a lower duration between stroke diagnosis and PEG placement (mean of 21.0 days vs. 17,1 days, p = 0.0305), and a lower duration between PEG placement and hospital discharge (mean of 19.7 days vs. 13.6 days, p = 0.0035). CONCLUSION: Intentional delay in PEG placement until patients were medically stabilized and approaching discharge was associated with a reduction in unnecessary procedures and an overall reduction in the number of procedures, while maintaining alignment with clinical guidelines and avoiding delays in discharge attributable to the procedure.

Nasal Feeding Tubes Are Associated with Fewer Adverse Events than Feeding via Ostomy in Hospitalized Patients Receiving Enteral Nutrition.

BACKGROUND: Surgical feeding ostomies (eg, gastrostomy) have become required by many nursing facilities for all patients receiving enteral nutrition, whether for short- or long-term use. These policies lack supportive evidence. Comparisons of adverse event rates between surgical and natural orifice tubes are few and lacking in the inpatient setting. Additionally, we hypothesize that adverse events related to feeding tubes are underreported. We sought to quantify adverse events to test the relative safety of surgical feeding ostomies and natural orifice (eg. nasogastric or orogastric) feeding tubes in hospitalized patients. METHODS: This was a prospective observational cohort study of enterally fed inpatients using semiweekly focused physical examination, scripted survey, and chart review. RESULTS: All tube-fed patients admitted to a large, urban, academic hospital received semiweekly bedside evaluation and chart review over a 9-week period (n = 226 unique patients, mean 6.25 visits each, total 1118 observations). Demographics were comparable between 148 subjects with natural orifice and 113 subjects with surgical feeding tubes. A higher incidence of adverse events was observed with surgical tubes (3.34 vs 1.25 events per 100 subject days, P < .001). Only 50% of all adverse events were documented in the medical record. More patients with surgical tubes were discharged to skilled nursing facilities (58% vs 24%). CONCLUSIONS: Surgical feeding tubes are associated with significantly higher in-hospital adverse event rates when compared with natural orifice (nasal or oral) feeding tubes. Policies requiring surgical feeding ostomies should be reevaluated.

Safe care transitions for patients receiving parenteral nutrition.

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Factors associated with delayed enteral nutrition in the intensive care unit: a propensity score-matched retrospective cohort study.

BACKGROUND: Guidelines recommend enteral nutrition (EN) within 48 h of admission to the medical intensive care unit (ICU) in appropriate patients. However, delayed EN is still common. OBJECTIVES: This study sought to identify risk factors for delayed EN ordering in the ICU and to examine its association with patient outcomes. METHODS: This was a retrospective study from 2010-2018. Adult patients were included if they were admitted to the medical ICU for >48 h, were appropriate for EN, and had an order for EN placed within 30 d of admission. The primary outcome was ordering of EN, classified as early if ordered within 48 h of ICU admission and otherwise as delayed. Propensity score matching was used to examine the relation between delayed EN and ICU-free days, and outcomes such as length of ICU admission, length of hospitalization during 30 d of follow-up, and mortality. RESULTS: A total of 738 (79%) patients received early EN and 196 (21%) received delayed EN. The exposures most strongly associated with delayed EN were order placement by a Doctor of Medicine compared with a dietitian [adjusted OR (aOR): 2.58; 95% CI: 1.57, 4.24] and use of vasopressors within 48 h of ICU admission (aOR: 1.78; 95% CI: 1.22, 2.59). After propensity score matching to balance baseline characteristics, delayed EN ordering was significantly associated with fewer ICU-free days, longer ICU admissions, and longer hospitalizations, but not mortality, compared with early EN. CONCLUSIONS: Provider-level factors were associated with delayed ordering of EN which itself was associated with worse outcomes. Interventions directed at providers may increase timely EN in the ICU and improve outcomes.

Post-acute COVID-19 syndrome.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.

Malnutrition Diagnosis in Critically Ill Patients Using 2012 Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Standardized Diagnostic Characteristics Is Associated With Longer Hospital and Intensive Care Unit Length of Stay and Increased In-Hospital Mortality.

BACKGROUND: Standardized diagnostic criteria for malnutrition were developed by the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) in 2012. The criteria as a whole has had little validation, and the effect of underlying condition on the impact of malnutrition has not been well studied. We measured the association between severe malnutrition and hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality among critically ill inpatients. METHODS: We analyzed hospital records from 5606 patients whose admission included an ICU stay. Associations between severe malnutrition and LOS and mortality were examined by multivariable linear and logistic regression. RESULTS: Thirteen percent were diagnosed with severe malnutrition. These had significantly longer hospital LOS (18 [interquartile range 10-35] days vs 8 [5-14] days), total ICU LOS (7 [3-15] days vs 3 [1-6] days) and in-hospital mortality (odds ratio [OR] 2.78, 95% confidence interval [CI] 2.33-3.31), compared with those without severe malnutrition. After adjusting for demographics, we found significant interactions between severe malnutrition and ICU location. Patients with malnutrition in the cardiothoracic surgery ICU experienced the largest increases in hospital LOS (21.10 days, 95% CI 18.58-23.61), ICU LOS (12.14 days, 95% CI 10.41-13.87), and in-hospital mortality (OR 8.78, 95% CI 5.11-15.07). CONCLUSION: Critically ill patients diagnosed with severe malnutrition based on the AND/ASPEN diagnostic characteristics experienced longer hospital and ICU LOS and increased mortality. The magnitude of effect of malnutrition was modified by ICU location, underscoring the need to identify the major comorbidities associated with malnutrition.

Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has impacted all aspects of our population. The "Troubling Trichotomy" of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations.

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations used as a source of energy and essential fatty acids in parenteral nutrition. Issues associated with ILE use are distinctly different from oral fat and arise from emulsion stability, dose, and infusion tolerance. Since 1975, soybean oil has been the consistent source oil used in ILE formulations in the US. Partly because of safety concerns with the soybean-based ILE and frequent and long-standing problems with product inventory shortages, new ILE products have become available. Gaps in ILE best practices create a risk for ILE safety errors in prescribing, compounding, and administration of these products. This paper provides information on appropriate indications, dosing, and methods to avoid potential errors with ILE products in the US. This paper (Part 1) will focus on ILE background, information, and recommendations for adult patients, whereas Part 2 of this series will focus on neonatal and pediatric patient-specific information.

ASPEN Consensus Recommendations for Refeeding Syndrome.

INTRODUCTION: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. METHODS: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. FINDINGS/RECOMMENDATIONS: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. CONCLUSIONS: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.

The Relationship Between Parenteral Nutrition and Central Line-Associated Bloodstream Infections: 2009-2014.

BACKGROUND: Parenteral nutrition (PN) administered via central venous catheter has been identified as an independent risk factor for central line-associated bloodstream infections (CLABSIs). The aim of this study was to provide an updated description of the relationship between PN and CLABSI and assess temporal trends in CLABSI rates for individuals who received PN from 2009-2014, after the Centers for Medicare & Medicaid declared CLABSI a "never event." METHODS: Using data obtained from all adult patient discharges between January 1, 2009, and December 31, 2014, from 2 affiliated hospitals in a large health system in New York City, univariate and multivariate analyses were performed to examine the relationship between PN and CLABSIs as well as temporal trends. RESULTS: Among 38,674 patients with central lines, 3517 developed CLABSIs and 767 patients were prescribed PN. PN was an independent risk factor for developing CLABSI among our patients (odds ratio [OR], 2.65; 95% confidence interval [CI], 2.20-3.19). The incidence of CLABSI among patients who were prescribed PN was not significantly different across the years of this study, even after adjusting for severity of illness. CONCLUSION: PN remains a significant risk factor for CLABSIs; further work is needed to identify effective strategies to reduce rates of CLABSI among patients receiving PN.