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Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

ABSTRACT: The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on 'Access to pharmacist and dietitian at HD units' (2.65 ± 0.21) and 'Access to continuous medical education on managing PEW patients on HD' (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

SUBMITTER: Singh BKS

PROVIDER: S-EPMC9602673 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

Singh Birinder Kaur Sadu BKS Khor Ban-Hock BH Sahathevan Sharmela S Gafor Abdul Halim Abdul AHA Fiaccadori Enrico E Chinna Karuthan K Ng See-Hoe SH Karupaiah Tilakavati T

Healthcare (Basel, Switzerland) 20221020 10

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implement ...[more]

PMID: 36292538

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Project description:In hemodialysis (HD) patients, protein-energy wasting (PEW) is highly prevalent and firstly treated with oral nutritional supplements (ONS). The extent to which intradialytic parenteral nutrition (IDPN) contributes to improve PEW status in HD patients intolerable to ONS remains unclear. Maintenance PEW HD patients being unable to tolerate ONS adverse effects, and having spontaneous energy and protein intake of ≥ 20 kcal/kg/day and ≥ 0.8 g/kg/day, respectively were randomly assigned 1:1 into IDPN and control groups. In IDPN group, most concentrated 3-in-1, fish-oil based parenteral nutrition was infused during HD for 3 months. The control group received intensive dietary counselling once weekly for 3 months. Both groups were then followed for additional 3 months after intervention. A total of 38 patients were randomized (mean age 67.6 years). After 3 months, serum albumin was significantly higher in the IDPN (n = 18) compared with control group (from 3.5 ± 0.3 to 3.8 ± 0.2 vs from 3.6 ± 0.3 to 3.5 ± 0.3 g/dL, respectively, p = 0.01). Spontaneous dietary intake (p = 0.04), body weight (p = 0.01), and malnutrition inflammation score (MIS, p = 0.01) were improved in the IDPN, but not in the control group. Muscle mass, strength, serum prealbumin, interleukin-6, high sensitivity-c reactive protein, and acylated ghrelin were not significantly different but leptin levels increased in the control group after 3 months (p = 0.03). At 6 months, serum albumin in the IDPN group was persistently higher than baseline (p = 0.04). Neither volume overload nor uncontrolled hyperglycemia was found throughout the study. In conclusion, a 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and MIS; and appeared to be superior to continuing intensive dietary counselling among HD patients intolerable to ONS. The impacts of IDPN therapy on clinical outcomes may require larger scale with longer period of study.

Project description:BackgroundIn response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers' experiences and challenges in collecting and using data for decision making.ObjectiveThe aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making.MethodsIn-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences.ResultsData were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors.ConclusionsThe use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

Project description:Muscle wasting, low protein intake, hypoalbuminemia, low body mass, and chronic fatigue are prevalent in hemodialysis patients. Impaired creatine status may be an often overlooked, potential contributor to these symptoms. However, little is known about creatine homeostasis in hemodialysis patients. We aimed to elucidate creatine homeostasis in hemodialysis patients by assessing intradialytic plasma changes as well as intra- and interdialytic losses of arginine, guanidinoacetate, creatine and creatinine. Additionally, we investigated associations of plasma creatine concentrations with low muscle mass, low protein intake, hypoalbuminemia, low body mass index, and chronic fatigue. Arginine, guanidinoacetate, creatine and creatinine were measured in plasma, dialysate, and urinary samples of 59 hemodialysis patients. Mean age was 65 ± 15 years and 63% were male. During hemodialysis, plasma concentrations of arginine (77 ± 22 to 60 ± 19 μmol/L), guanidinoacetate (1.8 ± 0.6 to 1.0 ± 0.3 μmol/L), creatine (26 [16-41] to 21 [15-30] μmol/L) and creatinine (689 ± 207 to 257 ± 92 μmol/L) decreased (all P < 0.001). During a hemodialysis session, patients lost 1939 ± 871 μmol arginine, 37 ± 20 μmol guanidinoacetate, 719 [399-1070] μmol creatine and 15.5 ± 8.4 mmol creatinine. In sex-adjusted models, lower plasma creatine was associated with a higher odds of low muscle mass (OR per halving: 2.00 [1.05-4.14]; P = 0.04), low protein intake (OR: 2.13 [1.17-4.27]; P = 0.02), hypoalbuminemia (OR: 3.13 [1.46-8.02]; P = 0.008) and severe fatigue (OR: 3.20 [1.52-8.05]; P = 0.006). After adjustment for potential confounders, these associations remained materially unchanged. Creatine is iatrogenically removed during hemodialysis and lower plasma creatine concentrations were associated with higher odds of low muscle mass, low protein intake, hypoalbuminemia, and severe fatigue, indicating a potential role for creatine supplementation.

Project description:Background and aimProtein-energy wasting (PEW) is critically associated with the reduced quality of life and poor prognosis of hemodialysis patients. However, the diagnosis criteria of PEW are complex, characterized by difficulty in estimating dietary intake and assessing muscle mass loss objectively. We performed a cross-sectional study in hemodialysis patients to propose a novel PEW prediction model.Materials and methodsA total of 380 patients who underwent maintenance hemodialysis were enrolled in this cross-sectional study. The data were analyzed with univariate and multivariable logistic regression to identify influencing factors of PEW. The PEW prediction model was presented as a nomogram by using the results of logistic regression. Furthermore, receiver operating characteristic (ROC) and decision curve analysis (DCA) were used to test the prediction and discrimination ability of the novel model.ResultsBinary logistic regression was used to identify four independent influencing factors, namely, sex (P = 0.03), triglycerides (P = 0.009), vitamin D (P = 0.029), and NT-proBNP (P = 0.029). The nomogram was applied to display the value of each influencing factor contributed to PEW. Then, we built a novel prediction model of PEW (model 3) by combining these four independent variables with part of the International Society of Renal Nutrition and Metabolism (ISRNM) diagnostic criteria including albumin, total cholesterol, and BMI, while the ISRNM diagnostic criteria served as model 1 and model 2. ROC analysis of model 3 showed that the area under the curve was 0.851 (95%CI: 0.799-0.904), and there was no significant difference between model 3 and model 1 or model 2 (all P > 0.05). DCA revealed that the novel prediction model resulted in clinical net benefit as well as the other two models.ConclusionIn this research, we proposed a novel PEW prediction model, which could effectively identify PEW in hemodialysis patients and was more convenient and objective than traditional diagnostic criteria.

Project description:The transition from secondary school to college or university is a well-known and well-studied risk period for weight and/or fat gain and not meeting the dietary recommendations. Higher education acts as a promising setting to implement nutrition interventions. An important condition for intervention success is that interventions are implemented as intended by the protocol and integrated in the institutional policy. Unfortunately, to date, there is only little understanding of the factors influencing adoption and implementation of nutrition interventions in higher education settings. This study aimed to provide insight into stakeholders' perspectives on facilitators and barriers to adoption and implementation of nutrition interventions promoting healthy and sustainable diets among higher education students in Flanders. Eight online group interviews and three online individual interviews were conducted involving a total of 37 stakeholders (e.g., staff of student services and student restaurants) from ten Flemish higher education institutions with varying food policy quality scores, and one external catering company which provides catering in higher education institutions. A semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR-framework) was used to facilitate the interviews. Afterwards, the data were analyzed using a combined inductive and deductive thematic approach led by the CFIR-framework. Most of the institutions' food policies focused on the provision and promotion of healthy and sustainable nutrition. Therefore, the reported factors in the present study consequently relate primarily to these two strategies. Stakeholders preferred to adopt low cost and institution-tailored interventions supported by experts and evidence, considering them easier and less resourceful to implement in the specific context of the institution. They stressed the importance of considering both students' and institution stakeholders' needs and perspectives in the development of nutrition interventions and implementation plans. Furthermore, interventions should be focused on a combination of different ecological levels and various strategies. Future interventions should be developed participatively and should be focused on a combination of both individual and environmental levels. Higher education institutions are encouraged to use opportunities such as creating win-win situations within the institution, working together with research groups and engaging students through student associations. The findings of this research add to the literature on implementation science and inform future development and implementation of nutrition interventions in higher education settings.

Project description:BackgroundTo improve health and academic learning in schoolchildren, the Active School programme in Stavanger, Norway has introduced physically active academic lessons. This is a teaching method combining physical activity with academic content. The purpose of this paper was to evaluate the response to the physically active lessons and identify facilitators and barriers for implementation of such an intervention.MethodsFive school leaders (principals or vice-principals), 13 teachers and 30 children from the five intervention schools were interviewed about their experiences with the 10-month intervention, which consisted of weekly minimum 2 × 45 minutes of physically active academic lessons, and the factors affecting its implementation. All interviews were transcribed and analysed using the qualitative data analysis program NVivo 10 (QSR international, London, UK). In addition, weekly teacher's intervention delivery logs were collected and analysed.ResultsOn average, the physically active academic lessons in 18 of the 34 weeks (53%) were reported in the teacher logs. The number of delivered physically active academic lessons covered 73% of the schools' planned activity. Physically active lessons were well received among school leaders, teachers and children. The main facilitators for implementation of the physically active lessons were active leadership and teacher support, high self-efficacy regarding mastering the intervention, ease of organizing physically active lessons, inclusion of physically active lessons into the lesson curricula, and children's positive reception of the intervention. The main barriers were unclear expectations, lack of knowledge and time to plan the physiclly active lessons, and the length of the physically active lessons (15-20 min lessons were preferred over the 45 min lessons).ConclusionPhysically active academic lessons were considered an appropriate pedagogical method for creating positive variation, and were highly appreciated among both teachers and children. Both the principal and the teachers should be actively involved the implementation, which could be strengthened by including physical activity into the school's strategy. Barriers for implementing physically active lessons in schools could be lowered by increasing implementation clarity and introducing the teachers to high quality and easily organized lessons.Trial registrationClinicaltrail.gov ID identifier: NCT03436355 . Retrospectively registered: 16th of Feb, 2018.

Dataset Information

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

Publications

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

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