Clinical UM Guideline

This document addresses intradialytic parenteral nutrition (IDPN). IDPN involves the infusion of intravenous hyperalimentation formula during dialysis with aim of treating protein calorie malnutrition, which sometimes occurs in individuals with renal failure.

Note: Please see the following related document for additional information:

• CG-MED-89 Home Parenteral Nutrition

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Not Medically Necessary:

Intradialytic parenteral nutrition is considered not medically necessary for all indications.

This document describes clinical studies and expert recommendations regarding the use of intradialytic parenteral nutrition (IDPN) and explains whether IDPN is appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

IDPN is a treatment that provides nutrients through a vein during dialysis sessions. It is used for people with end-stage kidney disease (also called end-stage renal disease or ESRD) who are malnourished and cannot get enough nutrition from food or feeding tubes. IDPN can include a mix of proteins, sugars, and fats, and can be adjusted with vitamins and medicines if needed. It does not require extra time or new blood access, since it is given during dialysis, which already requires access to a person’s veins. Current studies have not shown clear or consistent improvements in long-term health results due to the use of IDPN. Some experts say it may help when other ways of giving nutrition do not work, but others recommend against routine use. More high-quality research is needed to understand when IDPN helps and how much.

What the Studies Show

Some studies have found that people with low albumin (a protein in the blood) levels who received IDPN had lower risk of death after one year compared to those who did not receive IDPN. However, these studies were not randomized, meaning other factors could explain the results. For example, sicker people might not have been chosen to get IDPN, which could make it seem more helpful than it really is. Other studies have shown IDPN can raise levels of albumin and prealbumin, which are signs of better nutrition, but the size of these changes was small and may not lead to better health outcomes.

In one study, people who could not tolerate food supplements were given either IDPN or counseling alone. Those who received IDPN had slightly higher albumin levels and body weight after 3 months, but the difference was not large. Another study showed a stronger improvement in prealbumin levels in the IDPN group, with benefits lasting several weeks after treatment ended. However, that study had a high number or people dropout, and many participants left early due to health problems, hospital stays, or death. The loss of people in a trial is a problem because it may cause the results to be inaccurate. Even though no serious side effects occurred during IDPN treatment, the results do not clearly show that the therapy leads to better survival or quality of life.

Is this Clinically Appropriate?

This treatment is not appropriate because it has not been proven to improve health.

Although some studies suggest IDPN can improve certain lab values, they do not show that it leads to meaningful health improvements like longer life, fewer hospital stays, or better functioning. Some expert guidelines recommend trying IDPN only when oral and tube feeding do not meet nutrition needs. Others do not recommend it at all for people with long-term kidney disease. Better studies are needed to know whether IDPN helps people with poor nutrition during dialysis.

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When services are Not Medically Necessary:
For the following procedure and diagnosis codes, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Summary

In the United States, nearly 808,000 people have end-stage renal disease (ESRD), with malnutrition being a common complication due to multiple contributing factors such as inadequate dialysis, poor intake, and comorbidities. Intradialytic parenteral nutrition (IDPN), delivered during dialysis, has been explored as a nutritional intervention and shows some promise in improving markers like serum albumin and prealbumin in those with protein-energy wasting (PEW). However, clinical trials and reviews have shown inconsistent or inconclusive outcomes, and current guidelines vary, with some advising against routine IDPN use and others suggesting it only when oral and enteral options fail, highlighting the need for more robust, controlled studies.

Discussion

Parenteral nutrition is generally used when individuals are unable to meet nutritional requirements through oral or enteral intake, particularly when gastrointestinal absorption is impaired, nutrient needs are substantial, or fluid restrictions limit adequate intake. Among individuals with end-stage renal disease (ESRD) receiving dialysis, protein-energy wasting (PEW), a form of disease-related cachexia characterized by loss of body protein and energy stores, is common and is associated with increased morbidity and mortality. PEW is the progressive depletion of protein and energy stores (for example, fat and muscle) and is highly prevalent in those who are receiving hemodialysis. Because dialysis sessions already require vascular access, IDPN has been proposed as a practical method of delivering parenteral nutrition during dialysis in an effort to address PEW without requiring additional access or infusion time.

IDPN is the infusion of hyperalimentation formula during a hemodialysis dialysis session. The infusion may consist of a mixture of amino acids, dextrose and lipids delivered via an infusion pump. Multivitamins, electrolytes, trace elements, and drugs such as insulin can be added when necessary. IDPN is an attractive option for those with ESRD since there is no need for additional vascular access. There is no significant increase in the time needed to complete a dialysis session and monitoring by dialysis center staff reduces the risk of electrolyte and mineral imbalance.

A large retrospective observational cohort study compared 1,679 individuals receiving IDPN with 22,517 individuals who did not receive IDPN (Chertow, 1994). After multivariable adjustment, IDPN use was statistically associated with lower 1-year mortality among individuals with marked hypoalbuminemia (generally ≤ 3.3-3.4 g/dL). In contrast, IDPN use among individuals with normal serum albumin levels was associated with higher mortality. However, because the study was nonrandomized and subject to substantial confounding by indication and other potential biases, the findings demonstrate association rather than causation and do not establish that IDPN improves survival.

Three additional nonrandomized, uncontrolled studies have reported associations between IDPN and improved nutritional parameters and survival outcomes (Capelli, 1994; Foulks, 1994; Pupim, 2002). In the retrospective cohort described by Capelli et al., individuals selected for IDPN demonstrated higher survival rates compared with untreated controls, with a reported relative risk favoring treatment on Cox analysis. Similarly, Foulks et al. observed lower mortality and hospitalization rates among “responders” to IDPN, although this analysis was not randomized and outcomes were stratified post hoc by biochemical response. Pupim et al. demonstrated acute improvements in whole-body and skeletal muscle protein balance during IDPN administration; however, this short-term metabolic study was not designed to evaluate clinical endpoints such as mortality. While these findings suggest a potential association between IDPN and improved outcomes, the absence of randomization and contemporaneous controlled comparison in these studies introduces substantial risk of selection bias and residual confounding. In particular, individuals selected to receive IDPN may have differed systematically from untreated controls in ways not fully captured by reported baseline variables. In Foulks et al., improved survival was limited to biochemical “responders,” raising the possibility that response status reflects underlying health or reversibility of illness rather than a direct treatment effect. Although these studies demonstrate that individuals treated with IDPN, particularly those demonstrating biochemical improvement, were observed to have lower mortality rates, uncontrolled designs cannot establish causality or confirm that IDPN independently reduces mortality. Determining the direct contribution of IDPN to survival requires adequately powered, prospective randomized controlled trials.

Literature reviews have consistently found that the evidence supporting IDPN for PEW in individuals receiving hemodialysis is limited and inconclusive. (Anderson, 2019; Dukkipati, 2010). Dukkipati et al. (2010) noted that most studies found at that time were small, nonrandomized, of short duration, and relied primarily on surrogate nutritional markers rather than clinically meaningful outcomes, with inadequate control for oral intake and other confounders. Similarly, an updated systematic review by Anderson et al. (2019) concluded that IDPN did not demonstrate improvement in mortality, hospitalization, quality of life, or clinically relevant nutritional thresholds compared with dietary counseling or oral supplementation. Anderson graded the overall strength of evidence as low or insufficient due to methodological limitations and heterogeneity. Collectively, these reviews do not establish consistent improvement in clinically meaningful outcomes with IDPN beyond that which can be achieved through recommended first-line nutritional therapies.

In 2022, Kittiskulnam and colleagues published a single-center, open label, randomized controlled trial that evaluated the effects of IDPN on nutritional outcomes in individuals with PEW who were unable to tolerate oral nutritional supplements. Participants were randomized in a 1:1 fashion to either receive IDPN plus standard counselling (treatment group, n=18) or intensive dietary counselling (control group, n=20) for 3 months. Participants were then followed for an additional 3 months. After 3 months of IDPN, the mean serum albumin level increased by 0.3 g/dL (95% confidence interval [CI]; 0.2-0.4) from baseline and was higher in the treatment group (3.8 ± 0.2 g/dL) compared to the control group (3.5 ± 0.3 g/dL) (p=0.01). Body weight increased from 59.3 ± 12.1 kg to 61.2 ± 11.9 kg after 3 months of treatment while it remained unchanged in the control group (from 55.4 ± 11.2 to 56.1 ± 11.4 kg, p=0.22). Malnutrition-inflammation score (MIS) improved in the IDPN group; however, there were no significant differences in muscle mass, handgrip strength, serum prealbumin, or inflammatory biomarkers between groups. After 6 months of follow-up (3 months after discontinuation of IDPN), the average serum albumin in the treatment group decreased by 0.1 (95% CI; -0.3 to 0.4) g/dL but was still slightly higher when compared with baseline (3.7 ± 0.2 vs. 3.5 ± 0.3 g/dL, respectively, p=0.04). Although statistically significant, the 0.3 g/dL increase in albumin represents a modest biochemical change. The study was limited by small sample size, short duration, open-label design, and lack of assessment of clinical outcomes such as hospitalization, functional improvement, or survival. Improvements were observed primarily in surrogate laboratory and weight-based measures, without corresponding gains in objective measures of muscle mass or strength. Therefore, while the trial suggests short-term biochemical improvement with IDPN in selected individuals unable to tolerate oral supplementation, the clinical significance and durability of these findings remain uncertain. Serum prealbumin can serve as a marker for progress since it can be a predictor of mortality and hospitalization and an indicator for morbidity and mortality in malnourished hemodialysis individuals during nutritional therapy.

In 2017, Marsen and colleagues published a prospective, multicenter, randomized, open label, controlled trial assessing the effect of IDPN on prealbumin in 107 individuals receiving maintenance hemodialysis complicated by PEW. Participants in the treatment group (n=53) received nutritional counselling along with three administrations of IDPN a week over a period of 16 weeks. Participants in the control group received nutritional counselling only (n=54). Completion rates differed between the groups: 32/53 participants (60.4%) in the intervention group and 47/54 participants (87.0%) in the control group completed all trial visits. Overall, 28 participants discontinued the trial prematurely. Reasons for dropping out included death (11 participants), adverse events, prolonged hospitalization leading to inability to receive the IDPN intervention, lack of efficacy, loss to follow-up, need for IDPN treatment in the control group, and withdrawal of consent. For those in the intervention group, mean increase in serum prealbumin from baseline to week 16 was 26.31 mg/L (± 58.66 mg/L) compared with a decrease of 1.84 mg/dL (± 49.35 mg/L) in the control group (p=0.02). Those in the intervention group had a sustained prealbumin response to intradialytic parenteral nutrition therapy observed 6 weeks following therapy (change from baseline: 30.74 ± 58.06 mg/L at week 22; p=0.04), followed by a slow decline at week 12 post intervention (change from baseline: 15.08 ± 59.55 mg/L at week 28), while for those in the control group, the mean prealbumin levels remained unchanged from baseline (1.44 ± 50.52 mg/L at week 22; 0.10 ± 56.63 mg/L at week 28). There were no acute side effects during administration of intradialytic parenteral nutrition.

The strengths of the study by Marsden et al. include its randomized, multicenter design and clearly defined inclusion criteria for moderate to severe PEW, which enhance internal validity and target a clinically relevant population. The trial was prospectively powered for its primary endpoint and demonstrated a statistically significant increase in serum prealbumin in the intervention group compared with nutritional counseling alone. However, several limitations temper interpretation of the findings. The trial was open label without a sham control, introducing potential performance and detection bias. The primary endpoint was a surrogate biochemical marker (prealbumin), and the study was not powered to assess clinically meaningful outcomes such as mortality, hospitalization, functional status, or quality of life. No significant improvements were observed in secondary nutritional parameters (albumin, protein catabolic rate, phase angle, SGA score, or SF-12). Attrition was higher in the intervention group, and multiple post-randomization exclusions required imputation methods, which may introduce bias. Mortality and hospitalization were numerically higher in the IDPN arm, although the study was not powered to evaluate these outcomes. Overall, the study demonstrates short-term improvement in a surrogate nutritional marker but does not establish improvement in clinically meaningful health outcomes.

A 2021 European Society for Clinical Nutrition and Metabolism (ESPEN) Guideline on Clinical Nutrition in Hospitalized Individuals with Acute or Chronic Kidney Disease (Fiaccadori, 2021) recommends that IDPN be reserved for malnourished, non-critically ill individuals with kidney failure receiving maintenance hemodialysis who fail to respond to, or cannot tolerate, oral nutritional supplements or enteral nutrition. They note that the gastrointestinal route remains preferred, and IDPN should not be used routinely or prior to appropriate trials of dietary counseling and oral nutritional supplements, given its time limitation (typically administered during 3-4 hour hemodialysis sessions three times weekly) and lack of demonstrated superiority over oral strategies. ESPEN assigns this recommendation a Grade A with strong consensus (91.7% agreement), indicating that it is supported by consistent evidence from randomized controlled trials. In support of this position, the guideline cites a 2014 narrative review by Sabatino and colleagues, the 2017 randomized trial by Marsen evaluating changes in prealbumin, and the 2019 systematic review by Anderson examining the effectiveness of IDPN in individuals with protein-energy wasting. However, this recommendation acknowledges that IDPN has not shown superiority to oral nutritional supplements and that overall evidence in this population remains limited in scope and heterogeneity. Notably, the broader guideline emphasizes that much of the nutrition literature in kidney disease is constrained by a paucity of high-quality data, and many other recommendations rely on lower levels of evidence or expert consensus.

In 2010, the American Society for Parenteral and Enteral Nutrition (ASPEN) published Clinical Guidelines for Nutrition Support in Adult Acute and Chronic Renal Failure (Brown, 2010). These guidelines recommend IDPN should not be used as a nutritional supplement in malnourished individuals with stage V chronic kidney disease receiving hemodialysis (Grade C). This recommendation was based primarily on small observational studies and one randomized controlled trial demonstrating improvements in surrogate markers such as serum albumin and body weight, but no demonstrated survival advantage. The authors acknowledged the limited strength of the available evidence and called for larger randomized trials to better define any potential clinical benefit. This renal-specific ASPEN guideline has not been directly updated since its 2010 publication.

In the 2020 update of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in CKD (Ikizler, 2020), the work group addresses parenteral supplementation in Guideline 4.1. Specifically, for adults with chronic kidney disease and PEW, the guideline states: “we suggest a trial of TPN for CKD 1-5 patients (2C) and IDPN for CKD 5D on MHD patients (2C), to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake.” The designation of 2C reflects a weak (Level 2) recommendation based on low-quality evidence under the GRADE framework. The work group noted that adequately powered and long-term trials comparing the independent effects of IDPN and oral nutritional supplements on nutritional status, morbidity, mortality, and quality of life remain needed. Consistent with this limited and heterogeneous evidence base, KDOQI positions IDPN as a conditional, short-term intervention for selected individuals with PEW whose protein and energy needs cannot be met by oral or enteral routes, rather than as routine therapy.

In conclusion, current evidence for the use of IDPN does not demonstrate consistent, clinically meaningful improvement in health outcomes nor establish superiority or equivalence to established alternatives. Guideline support is conditional and based on low-quality evidence. Use of IDPN is therefore considered to be not medically necessary.

Intradialytic Parenteral Nutrition (IDPN): A method of intravenously delivering nutritional substances (carbohydrate, protein, fat, and required trace elements) to individuals during dialysis.

Intravenous: Within a vein or veins.

Parenteral nutrition: Provision of nutrients intravenously.

Peer Reviewed Publications:

1. Anderson J, Peterson K, Bourne D, Boundy E. Effectiveness of intradialytic parenteral nutrition in treating protein-energy wasting in hemodialysis: a rapid systematic review. J Ren Nutr. 2019; 29(5):361-369.
2. Capelli JP, Kushner H, Camiscioli TC, et al. Effect of intradialytic parenteral nutrition on mortality rates in end stage renal disease care. Am J Kidney Dis. 1994; 23(6):808-816.
3. Carrero JJ, Severs D, Aguilera D, et al. Intradialytic parenteral nutrition for patients on hemodialysis: when, how and to whom? Clin Kidney J. 2022; 16(1):5-18.
4. Chertow GM, Ling J, Lew NL, et al. The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients. Am J Kidney Dis. 1994; 24(6):912-920.
5. Dukkipati R, Kalantar-Zadeh K, Kopple J. Is there a role for intradialytic parenteral nutrition? A review of the evidence. Am J Kidney Dis. 2010; 55(2):352-364.
6. Foulks CJ. The effect of intradialytic parenteral nutrition on hospitalization rate and mortality in malnourished hemodialysis patients. J Renal Nutr. 1994; 4(1):5-10.
7. Kittiskulnam P, Banjongjit A, Metta K, et al. The beneficial effects of intradialytic parenteral nutrition in hemodialysis patients with protein energy wasting: a prospective randomized controlled trial. Sci Rep. 2022; 12(1):4529.
8. Korzets A, Azoulay O, Ori Y, et al. The use of intradialytic parenteral nutrition in acutely ill haemodialysed patients. J Ren Care. 2008; 34(1):14-18.
9. Marsen TA, Beer J, Mann H; et al. Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial. Clin Nutr. 2017; 36(1):107-117.
10. Pupim LB, Flakoll PJ, Brouillette JR, et al. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest. 2002; 110(4):483-492.
11. Rambod M, Kovesdy CP, Bross R, et al. Association of serum prealbumin and its changes over time with clinical outcomes and survival in hemodialysis patients. Am J Clin Nutr 2008; 88(6):1485-1494.
12. Sabatino A, Regolisti G, Karupaiah T, et al. Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis. Clin Nutr. 2017; 36(3):663-671.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Brown RO, Compher C, Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010; 34(4):366-377.
2. Fiaccadori E, Sabatino A, Barazzoni R, et al. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr. 2021; 40(4):1644-1668.
3. Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020; 76(3 Suppl 1):S1-S107.
4. National Institute of Diabetes and Digestive and Kidney Diseases. Fast facts on kidney disease. September 2024. Available at: https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease. Accessed on January 21, 2026.

1. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Kidney failure. October 2017. Available at: https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure. Accessed on January 21, 2026.
2. National Kidney Foundation. Kidney failure (ESRD) symptoms, stages, & treatment. September 5, 2023. Available at: https://www.kidney.org/kidney-topics/kidney-failure. Accessed on January 21, 2026.

Dialysis
IDPN
Intradialytic parenteral nutrition

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