Table 3.

Suggested parameters to assess the safety and tolerance of IDPN

Parameter	Frequency of measurements	Comments and suggested management	Frequency of occurrence
Symptoms related to reaction to IDPN: Nausea, vomiting, discomfort, hypotension, respiratory distress, and cardiac arrhythmias (rare)	In each HD session and especially during the first week of IDPN	• If reaction suspected, stop IDPN.	Very rare
Hemodynamic monitoring (BP, heart rate) and volume status should be closely monitored during and after hemodynamic monitoring	During and after each HD session.	• Assess dry weight and adequate length of dialysis session for an adequate ultrafiltration rate (< 10 mL/kg/hour).• Ultrafiltration rate should be adjusted accordingly to remove the extra fluid IDPN provides.	Common (changes in dry weight)
Blood glucose levelsa	• In patients with diabetes, measure glucose before the start dialysis, after 2 hours, and before finishing dialysis treatment.• In patients who do not have diabetes, measure as in patients with diabetes during the first 3 dialysis sessions, and then discontinue monitoring unless results were outside of safe blood glucose ranges.b	In case of hyperglycemia:• Subcutaneous short-acting insulin when glucose >12 mmol/L (>220 mg/dL) in increasing doses depending on blood glucose levels. In case of hypoglycemia:• Teach patients about the signs and symptoms of hypoglycemia.• Encourage all patients receiving IDPN to bring 15- to 30-g carbohydrate snack to the dialysis session and consume it 20–30 minutes before the end of the dialysis session.	Common in patients with diabetes and prediabetesVery rare if insulin is not used
Liver tests (alkaline phosphatase, ALT, total bilirubin) and blood triglycerides	Before dialysis session during the first 2 weeks, and then every 4–6 weeks to coincide with regular dialysis blood work.	In case of significant disturbances, stop IDPN and resume it once solved.	Very rare

^aBlood may be drawn by finger poke or from the HD line. If drawn from the HD line and the result is high, repeat the test using the finger poke method to verify results (recirculation may result in falsely elevated blood glucose levels). ALT: alanine aminotransferase; BP: blood pressure; HD: hemodialysis; IDPN: intradialytic parenteral nutrition.

^bAfter three dialysis sessions, a pattern of persistently raised blood glucose levels is apparent in patients without diabetes, and then monitoring may be interrupted if results are inside of safe blood glucose ranges {e.g. <12 mmol/L [<220 mg/dL]} and the patient does not require additional subcutaneous insulin. Otherwise, glucose monitoring before the start of dialysis, after 2 hours, and before finishing dialysis treatment should be maintained.