ABSTRACT
Type 3 intestinal failure (IF) is known to negatively impact bone metabolism contributing to increased prevalence of osteoporosis and associated increases in morbidity and mortality. It has been challenging to appropriately monitor for these pathologies under the restrictions imposed by the ongoing COVID-19 pandemic. We performed a retrospective audit assessing compliance with current guidelines1. All type 3 IF patients receiving home parenteral nutrition (HPN) prescribed at a national centre prior to 1st May 2021 were included. Data was collected from hospital electronic recorded, de-identified and collated on an excel spreadsheet that was securely stored on a departmental computer. 270 patients fulfilled inclusion criteria (35.5% male, mean age 54.0 ± 17.5 years). The mean age at HPN initiation was 45.8 ± 18.5 years and the mean number of years on HPN was 8.2 ± 7.2 years. The maximum duration of HPN administration in this cohort was 37 years. DEXA scan results performed within the preceding 5 years were available for 23.0% of patients. Of these scans 96.8% of patients had evidence of reduced bone density (45.2% osteopenic, 51.6% osteoporotic). Comparing DEXA results at diagnosis and in the last 5 years, a majority (54.2%) of patients progressed or remained osteoporotic, with 8.3% showing improvement in bone density and 4.2% of patients having a return to normal bone density. 59.6% of patients had blood tests performed within the preceding 12 months. 54.4% of patients had undergone plasma vitamin D levels measurement. Vitamin D levels were found to be low (<50nmol/L) in 32.7%. 44.4% of patients were receiving vitamin D supplementation of which 86.7% were prescribed oral supplements and 13.3% intramuscular supplements. 31.3% of patients with osteoporosis were on bisphosphonate therapy. These results demonstrate high prevalence of metabolic bone disease amongst type 3 IF patients on HPN. This highlights a potentially modifiable risk of low-trauma fracture which has a very high morbidity and mortality index. Our findings regarding the prevalence and longitudinal changes in bone density are in agreement with the published ESPEN surveys2,3. The results also demonstrate poor compliance with current guidelines. We believe this reflects the challenges of obtaining non-emergent scans and blood test due to COVID-related restrictions as well as our patients’ very understandable fear of exposure should they attend hospital for a face-to-face review. It is also possible that some of these tests were performed locally, due to many patients living far away from our national referral centre, and thus not visible to the audit team. These findings have highlighted the need for greater education and prompted our group to increase our focus on metabolic bone disease during clinic interactions and to create a subsection of our database for tracking DEXA intervals for this patient cohort. References 1. Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016;35: 247-307. 2. Pironi L, Labate AM, Pertkiewicz M, et al. Prevalence of bone disease in patients on home parenteral nutrition. Clin Nutr 2002;4: 289-296 3. Pironi L, Tjellesen L, De Francesco A, et al. Bone mineral density in patients on home parenteral nutrition: a follow-up study. Clin Nutr. 2004 Dec;23(6):1288-302