Clinical UM Guideline

This document addresses intradialytic parenteral nutrition (IDPN). IDPN involves the infusion of intravenous hyperalimentation formula during hemodialysis 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.

Medically Necessary:

1. Intradialytic parenteral nutrition is considered medically necessary when an individual meets all of the following criteria (A-E):
   1. Receiving maintenance hemodialysis; and
   2. Chronic kidney disease with protein-energy wasting as demonstrated by abnormalities in at least one criterion in both of the following categories (1 and 2):
      1. At least one of the following biochemical indicators:
         1. Serum albumin less than 3.8 g per 100 mL; or
         2. Serum prealbumin (transthyretin) below the laboratory reference range; or
         3. Serum cholesterol less than 100 mg per 100 mL;
            and
      2. At least one of the following body mass and weight status indicators:
         1. Unintentional weight loss greater than or equal to 5% over 3 months, or greater than or equal to 10% over 6 months; or
         2. Body mass index less than or equal to 23 kg/m²;
            and
   3. There is documentation of inadequate response (that is, persistent malnutrition despite greater than or equal to 1-3 months of intervention) or intolerance to oral nutrition, including food supplements or enteral feeding (note: it is generally expected that conservative therapy has been conducted in consultation with a dietician);
      and
   4. Treatment plan indicates the following:
      1. Intradialytic parenteral nutrition will be used in conjunction with oral intake or enteral feeding (when feasible and tolerated);
         and
   5. Individual’s protein and energy requirements will be met by the combined intradialytic parenteral nutrition and oral intake or enteral feeding.
2. Initial authorization
   
   Intradialytic parenteral nutrition is considered medically necessary for an initial authorization period of up to 90 days.
    
3. Continued authorization (recertification)
   
   Continued intradialytic parenteral nutrition is considered medically necessary when all of the following criteria are met:
   1. Ongoing hemodialysis is required; and
   2. One of the following is documented:
      1. Stabilization or gain in dry weight; or
      2. Stabilization or improvement in albumin or prealbumin levels; or
      3. Improvement in functional status (for example, ability to perform physical activities and daily tasks).

Note: Intradialytic parenteral nutrition should be discontinued and oral nutritional supplements attempted when improvements in nutritional status are observed and an individual is able to meet their protein and energy requirements through oral intake or enteral feeding alone. Intradialytic parenteral nutrition should not be considered a long-term approach to nutritional support.

Not Medically Necessary:

Intradialytic parenteral nutrition is considered not medically necessary when the above criteria are not met.

This document describes clinical studies and expert recommendations, and explains whether use of intradialytic parenteral nutrition (IDPN) is clinically 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 nutrition given through a vein during hemodialysis and may include protein, sugar, and fat. It can also include vitamins, minerals, or other needed nutrients. It is used for some adults with chronic kidney disease who have protein-energy wasting (PEW), which means the body is losing protein, fat, or muscle because nutrition needs are not being met. IDPN is meant to add to nutrition from eating by mouth or tube feeding, not replace it.

What the Studies Show

Studies suggest that IDPN may help some adults on maintenance hemodialysis who have PEW. In some studies, people who received IDPN had better nutrition-related lab results, such as albumin or prealbumin, and some had weight gain or better food intake.

The studies also have important limits. Some studies were short and included only small groups. Some found changes in lab results but did not show clear improvement in daily function, hospital stays, quality of life, or survival. Albumin can also change for reasons other than nutrition, such as inflammation or fluid balance. IDPN is more intensive than nutrition taken by mouth or by feeding tube, so the possible benefits need to outweigh the burdens and risks. IDPN should be considered as a temporary support option, not a long-term treatment, and eating by mouth or enteral feeding is preferred when those options are possible.

When is this Clinically Appropriate?

IDPN may be appropriate in these situations:

1. The person is receiving maintenance hemodialysis; and
2. The person has chronic kidney disease with PEW shown by at least one lab finding from the first group and at least one body weight or body size finding from the second group below; and
   1. At least one lab finding is present:
      1. Serum albumin is less than 3.8 g per 100 mL; or
      2. Serum prealbumin, also called transthyretin, is below the lab’s normal range; or
      3. Serum cholesterol is less than 100 mg per 100 mL; and
   2. At least one body weight or body size finding is present:
      1. Unplanned weight loss is at least 5% over 3 months, or at least 10% over 6 months; or
      2. Body mass index (BMI) is 23 kg/m2 or lower; and
3. The person had an inadequate response after at least 1 to 3 months of nutrition treatment, meaning malnutrition continued despite treatment, or the person could not tolerate oral nutrition, food supplements, or enteral feeding. The document says this conservative treatment is generally expected to include a dietitian; and
4. The treatment plan shows that IDPN will be used together with oral intake or enteral feeding when feasible and tolerated; and
5. The person’s protein and calorie needs will be met by the combined plan of IDPN plus oral intake or enteral feeding.

Initial approval may be given for up to 90 days. Continued use may be appropriate only when ongoing hemodialysis is still needed and at least one of the following is documented:

1. Dry weight is stable or has increased; or
2. Albumin or prealbumin is stable or has improved; or
3. Functional status has improved, such as being better able to do physical activities and daily tasks.

When is this not Clinically Appropriate?

IDPN is not clinically appropriate when the criteria above are not met. This includes situations where a person does not have clear signs of PEW, is not on maintenance hemodialysis, can meet nutrition needs through oral intake or enteral feeding, or has not had an adequate trial of standard nutrition treatment first.

The studies described in this document show why these limits are used. IDPN may improve some lab results or weight in selected people, but studies have not consistently shown that it improves major health outcomes, such as fewer hospital stays or longer survival. Better studies are needed to know if IDPN improves health. Because IDPN is a more intensive intravenous (IV) treatment and is meant to be temporary, the document says it should not be used as a routine or long-term nutrition approach. IDPN is not clinically appropriate in scenarios other than those listed above.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:
For the following procedure codes when intravenous hyperalimentation formula is infused during a hemodialysis session

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met.

Summary

Intradialytic parenteral nutrition (IDPN) is an extraordinary measure used in treatment of protein-energy wasting (PEW), a common and clinically significant complication among individuals receiving maintenance hemodialysis. PEW is associated with increased morbidity, hospitalization, and mortality. This condition has a multifactorial etiology, including inadequate intake, inflammation, metabolic derangements, and dialysis-related nutrient losses. Nutritional management of PEW follows a stepwise approach in which oral nutritional counseling and supplementation are first-line, followed by enteral nutrition when oral intake is inadequate or not tolerated. These approaches are preferred due to their physiologic delivery and stronger supporting evidence.

IDPN is defined as the infusion of parenteral nutrients during hemodialysis and is intended as a supplemental, time-limited intervention rather than a primary or long-term nutritional strategy. Accordingly, criteria require that IDPN be used in conjunction with oral or enteral intake when feasible and that total protein and energy requirements can be met through the combined approach. This reflects both its role as an adjunctive therapy and the expectation that efforts to optimize oral or enteral intake continue during treatment.

The requirement that individuals are receiving maintenance hemodialysis and have documented PEW reflects the population in whom IDPN has been studied and for whom guideline recommendations apply. Objective biochemical and body composition criteria are required to substantiate the presence of PEW, consistent with its characterization as a state of depleted protein and energy stores associated with adverse outcomes. The requirement for failure of, or intolerance to, oral and enteral nutrition aligns with guideline recommendations that IDPN be reserved for individuals whose nutritional needs cannot be met through preferred routes, and generally after a trial of conservative therapy with dietary counseling.

A requirement for an initial authorization period of up to 90 days is supported by clinical trial durations and guideline positioning of IDPN as a short-term intervention. Continued use is contingent upon objective evidence of benefit, such as stabilization or improvement in weight, nutritional biomarkers, or functional status. This approach reflects the limited and heterogeneous evidence base, in which IDPN has been associated with improvements in surrogate markers such as serum albumin, prealbumin, body weight, and dietary intake in some studies, but has not consistently demonstrated improvements in clinically meaningful outcomes such as mortality or hospitalization.

Guidelines, including the Kidney Disease Outcomes Quality Initiative (KDOQI), assign a weak recommendation based on low-quality evidence and emphasize the need for individualized, time-limited use in selected individuals with PEW who cannot meet nutritional requirements through oral or enteral routes. Similarly, other evidence syntheses and guidelines recommend reserving IDPN for those who fail or cannot tolerate first-line strategies and caution against routine or prolonged use. The requirement for reassessment and discontinuation once nutritional status improves and oral or enteral intake becomes adequate is consistent with this framework and reflects the role of IDPN as a temporary supportive measure rather than definitive therapy.
IDPN is not medically necessary when this guideline’s criteria are not met, particularly in individuals who are able to meet nutritional requirements through oral or enteral means or who lack objective evidence of PEW.

Discussion

PEW is common among individuals receiving maintenance hemodialysis and is associated with increased morbidity, hospitalization, and mortality. The etiology is multifactorial and includes inadequate dietary intake, inflammation, metabolic derangements, and nutrient losses related to dialysis. Given these risks, nutritional management is a central component of care and follows a stepwise approach prioritizing oral and enteral strategies before consideration of parenteral supplementation.

First-line therapy for PEW consists of nutritional counseling and oral nutritional supplements, which have demonstrated the ability to improve caloric and protein intake and may improve nutritional status in individuals with chronic kidney disease. When oral intake remains inadequate or is not tolerated, enteral nutrition is recommended as the next step. These approaches are preferred due to their physiologic delivery through the gastrointestinal tract and broader evidence base supporting their use.

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. 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. IDPN is intended as a supplemental, time-limited intervention rather than a primary or long-term nutritional strategy. IDPN does not replace oral or enteral intake but is used to augment nutritional delivery in individuals who are unable to meet requirements through these routes.

In 2020, the KDOQI work group published a Clinical Practice Guideline for Nutrition in CKD (Ikizler, 2020). The guideline defines PEW as “the complexity of nutritional and metabolic alterations that exist in CKD.” For those individuals with end stage renal disease (ESRD), PEW is 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. The work group also addresses parenteral supplementation. Specifically, for adults with chronic kidney disease and PEW, the guideline states:

In adults with CKD with protein-energy wasting, 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.

A multicenter randomized trial by Marsen in 2017 demonstrated improvements in prealbumin, a surrogate marker of nutritional status, with IDPN compared with nutritional counseling alone. However, this study did not show consistent improvement in albumin or other clinical endpoints, and the clinical significance of prealbumin changes remains uncertain.

Similarly, a randomized controlled trial by Kittiskulnam in 2022 reported that individuals with PEW who were intolerant to oral nutritional supplements reported that IDPN was associated with increases in serum albumin, body weight, and dietary intake over a 3-month period compared with dietary counseling alone. This study’s findings were limited by small sample size, short duration, and lack of demonstrated differences in functional or inflammatory outcomes.

Observational data provide additional supportive but limited evidence. A large retrospective analysis by Slusser-Hogan in 2025 reported that IDPN use was associated with mean increases in serum albumin of approximately 0.33 g/dL over 6 months, with most individuals demonstrating a measurable response. While these findings suggest improvement in nutritional biomarkers, the study design lacks a control group and is subject to selection bias and confounding, limiting conclusions regarding causality or impact on clinical outcomes.

Systematic reviews and evidence syntheses have consistently highlighted these limitations. A review by Anderson in 2019 found that IDPN does not consistently improve clinically meaningful outcomes such as mortality, hospitalization, or quality of life when compared with oral supplementation or dietary counseling, and the overall strength of evidence remains low due to methodological limitations and heterogeneity across studies.

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 nutrition supplement 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- to 4-hour hemodialysis sessions 3 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. Importantly, improvements in serum albumin should be interpreted with caution. Albumin is influenced by multiple factors, including inflammation, fluid status, and hepatic synthesis, and is not a direct measure of nutritional intake or status. While increases in albumin may reflect improved protein availability, they do not necessarily translate into improved clinical outcomes. The ESPEN positioning reflects both the physiologic preference for enteral feeding and the limited and heterogeneous evidence base for IDPN.

Taken together, the evidence suggests that IDPN can provide supplemental nutritional support and is associated with improvements in surrogate markers such as serum albumin and, in some studies, body weight and dietary intake. However, there is insufficient high-quality evidence demonstrating consistent benefits in clinically meaningful outcomes. Additionally, IDPN is resource-intensive and should not be used in place of established first-line therapies.

In this context, IDPN is most appropriately considered for individuals receiving maintenance hemodialysis who have PEW and are unable to meet nutritional requirements despite appropriate trials of nutritional counseling, oral supplementation, and, when feasible, enteral nutrition. Use should be individualized, time-limited, and accompanied by ongoing efforts to optimize oral or enteral intake.

Enteral nutrition: The provision of essential nutrients through a tube directly into the gastrointestinal tract to prevent or treat disease-related malnutrition in individuals unable to consume adequate nutrients by mouth. The tube bypasses the oral cavity and delivers liquid nutrition into the stomach or small intestine. Enteral nutrition is indicated when individuals have a functioning gastrointestinal tract but cannot meet nutritional requirements orally due to conditions such as critical illness, dysphagia, neurologic disease, gastrointestinal or liver disease, cancer (particularly head and neck or esophageal), cystic fibrosis, chronic obstructive pulmonary disease, and kidney disease.

Intradialytic parenteral nutrition (IDPN): The administration of parenteral nutrients (for example, amino acids, dextrose, and lipids, with or without electrolytes, vitamins, and trace elements) during a hemodialysis session. IDPN is used as a supplemental, time-limited nutritional intervention to augment oral or enteral intake.

Maintenance hemodialysis: An ongoing renal replacement therapy for individuals with chronic kidney failure (end-stage renal disease) that uses diffusion and ultrafiltration to remove metabolic waste, excess fluid, and rebalance electrolytes to sustain life. Conventional maintenance hemodialysis is typically performed 3 times weekly for approximately 4 hours per treatment in a dialysis clinic or at home. The therapy removes solutes such as urea through concentration gradients between blood and dialysate while simultaneously removing fluid through ultrafiltration.

Nutritional counseling: A member-centered intervention that uses behavioral change techniques to assess dietary habits, provide education, and support individuals in adopting and maintaining healthy eating behaviors to prevent or manage chronic diseases. It is recognized as a first-line approach in the management of numerous chronic conditions including cardiovascular disease, diabetes, chronic kidney disease, and obesity. The nutrition care process includes four essential domains: nutrition assessment (evaluating dietary behaviors and habitual food intake), nutrition diagnosis (identifying key nutrient/dietary behavior patterns influencing health), nutrition intervention (dietary counseling and education), and nutrition monitoring and evaluation (tracking progress and adapting goals).

Oral nutritional supplements: Liquid or semi-solid multinutrient products containing macronutrients and micronutrients that are provided to replace or supplement normal oral food intake in individuals who cannot meet their nutritional needs through diet alone. Standard formulations typically provide 200 to 300 kcal and 10 to 20 g of protein per 100 mL, with specialized formulations available for specific conditions such as diabetes, sarcopenia, and gastrointestinal disorders.

Parenteral nutrition: The intravenous administration of nutrients, including carbohydrates, proteins, fats, vitamins, and minerals, used when oral or enteral intake is insufficient or not feasible.

Protein-energy wasting (PEW): A clinical condition in individuals with acute or chronic kidney disease characterized by depletion of body protein and energy stores (including loss of muscle and fat mass), associated with increased morbidity and mortality. PEW is identified using a combination of biochemical, anthropometric, and dietary indicators and may result from inadequate intake as well as disease-related metabolic and inflammatory processes.

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. Arroyo-Serrano P, Alonso-Dominguez R, Mas-Fontao S, et al. Nutritional strategies to address malnutrition in dialyses patients: a systematic review. Nutrients. 2025; 17(21):3478.
3. 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.
4. 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.
5. Cederholm T, Bosaeus I. Malnutrition in adults. N Engl J Med. 2024; 391(2):155-165.
6. Flythe JE, Watnick S. Dialysis for chronic kidney failure: a review. JAMA. 2024; 332(18):1559-1573.
7. Kabasawa H, Hosojima M, Kanda E, et al. Efficacy and safety of intradialytic parenteral nutrition using ENEFLUID® in malnourished patients receiving maintenance hemodialysis: an exploratory, multicenter, randomized, open-label study. PLoS One. 2024; 19(12):e0311671.
8. 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.
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.
13. Slusser-Hogan M, Haight J, Gabriel L, et al. Intradialytic parenteral nutrition during in-center hemodialysis of patients leads to increase in albumin without compromising safety: retrospective analysis. Kidney360. 2025; 6(9):1532-1540.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Bechtold ML, Brown PM, ASPEN Enteral Nutrition Committee. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr. 2022; 46(7):1470-1496.
2. 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.
3. 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.
4. Fouque D, Kalantar-Zadeh K, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int. 2008; 73(4):391-398.
5. 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.
6. 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 March 24, 2026.
7. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults without cardiovascular disease risk factors: US Preventive Services Task Force Recommendation Statement. JAMA. 2022; 328(4):367-374.

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 March 24, 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 March 24, 2026.

Dialysis
IDPN
Intradialytic parenteral nutrition

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