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The Use of Parenteral Nutrition in a Severely Malnourished Hemodialysis Patient With Hypercalcemia

Heather Ohlrich, RD, LD^*, Kathy Barco, RD, CNSD and Marcia R. Silver, MD, FACP^,

^* Ohio Renal Care Group–Farnsworth, Cleveland, Ohio; Nutrition Services and Division of Nephrology and Hypertension, MetroHealth Medical Center, Cleveland, Ohio; and Case Western Reserve University School of Medicine, Cleveland, Ohio

Correspondence: Heather Ohlrich, Ohio Renal Care Group–Farnsworth, 3764 Pearl Rd., Cleveland, OH 44109. Electronic mail may be sent to hohlrich{at}renalcaregroup.com.

There is a high prevalence of protein-energy malnutrition (PEM) in chronic dialysis patients. Causes of PEM include the catabolic effects of hemodialysis treatments, acidemia associated with end-stage renal disease, common comorbid conditions, and uremia-induced anorexia. Morbidity and mortality increase with PEM. Before considering parenteral nutrition (PN) as a nutrition intervention in a maintenance dialysis patient, all other efforts to promote optimal nutrition need to be exhausted. The first step is careful evaluation of protein-energy status, followed by intensive nutrition counseling. If necessary, this is followed by oral nutrition supplementation, appetite stimulation, enteral tube feedings, and finally PN.

Short-term parenteral nutrition (PN) became a crucial component of the management of a 38-year-old hemodialysis (HD) patient who endured serious complications after kidney transplant rejection. A profound and prolonged malnourished state followed her treatment for necrotizing pancreatitis. She had developed persistent hypercalcemia believed secondary to tertiary hyperparathyroidism (HPT) and immobilization. Later, she developed hungry bone syndrome (HBS) after parathyroidectomy (PTX). She also developed refeeding syndrome after initiation of PN. The patient's persistent, poorly understood hypercalcemia did not resolve even after PTX and removal of all other sources of vitamin D and calcium from her feedings, medications, and dialysis bath. The close communication of the inpatient and outpatient dialysis multidisciplinary teams became a key component to the successful outcome in this complex patient.

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