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  • ESPEN Congress Florence 2008

    Nutritional consequences of cancer therapy

    Continued nutritional support and monitoring in

    cancer

    F. Strasser (Switzerland)

  • Florian Strasser ESPEN 2008

    ESPEN 2008 Saturday, 13th September 2008 14:30 – 16:00

    Educational session – joint with ESMO

    Nutritional consequences of cancer therapy

    Continued nutritional support and

    monitoring in cancer

    Florian Strasser, MD ABHPM

    Oncological Palliative Medicine

    Cantonal Hospital, St. Gallen, Switzerland

    Member of the Palliative Care Working Group of ESMO

    ESPEN 2008 Saturday, 13th September 2008 14:30 – 16:00

    Educational session – joint with ESMO

    Nutritional consequences of cancer therapy

    Continued nutritional support and

    monitoring in cancer

  • Florian Strasser ESPEN 2008

    Prevention of cancer

    through nutritionMalnutrition as risk-factor for

    (curative) anticancer

    treatments (Chemotherapy,

    Surgery, Radiotherapy)

    Malnutrition as consequence of

    complications of anticancer treatments

    (bowel function, mucositis, infections, ...)

    Malnutrition in advanced, incurable cancer:

    multimodal nutritional interventions for

    complex nutritional problems

    Terminal care: changed importance of nutrition

    Nutritional issues in the trajectory of

    cancer illness

    Phasen der Erkrankung

  • Florian Strasser ESPEN 2008

    Fluctuating trajectories of illness

    Information,

    communication

    Distress

    psychosocial

    Autonomy,

    Decisions

    Distress

    physicalIndividual patient trajectories

    Diagnosis Progression (s) End-of-LifeComplication (s)

    In modern oncology (phases of progression, response,

    and treatments) cachexia„s importance fluctuates

  • Florian Strasser ESPEN 2008

    Auswirk-xct

    Weight loss / Malnutrition: independent prognost.

    Factor- Survival: Locally advanced esophageal cancer

    - Survival: Lung cancer

    - Treatment-response, Survival: advanced Head-and-Neck cancer

    - ... Many other examples

    Stahl M, et al.. J Cancer Res Clin Oncol 2004, Oct 5 [Epub ahead of print].

    Tammemagi CM, et al. Cancer 2004;101(7):1655-63.

    Argiris A, Li Y, Forastiere A. Cancer 2004;101(10):2222-9.

    Nutritional complications in patients with

    advanced cancer are frequent and matter

  • Florian Strasser ESPEN 2008

    Cachexia Management: Current Clinical Dilemmas

    Neglected Overtreatment

    „Aggressive“parenteral

    nutrition lacking

    achievable goals4

    Narrow & short effect of

    progestin, corticosteroids5

    Pressure (family, patient)

    preserving the normal6

    Problem not recognized1

    Silent Malnutrition Epidemia2

    Simple starvation overlooked3

    Lack of clinical-guiding

    definition and staging system

    Poor effect of interventions5

    1: Spiro A et al. The views and practice of oncologists towards nutritional support in patients

    receiving chemotherapy. Br J Cancer 2006;95:431-4; 2: European Prospective Investigation into

    Cancer and Nutrition; 3: Omlin AG, Strasser F. Secondary causes of cancer-related anorexia:

    Recognition in daily practice [..]. ASCO 2007; 4: Bozzetti F. Total parenteral nutrition in cancer

    patients. Curr Opin Support Palliat Care 2007;1:281-6; 5: Yavuszen et al. J Clin Oncol 2005;23:8500-

    11; 6: Strasser F et al. Palliative Medicine 2007;21:129-37.

  • Florian Strasser ESPEN 2008

    Detect patients nutritional

    issues in daily care

    Perform a „nutritional“

    staging: domains

    „Nutritional“ support – continued after

    chemotherapy and radiotherapy

    Setting „nutritional“ goals

    in palliative cancer care

    Alleviate burden of

    cachexia and symptoms

  • Florian Strasser ESPEN 2008

    In the absence of simple starvation, cancer

    cachexia is diagnosed by weight loss >5% over the

    last 6 months. Weight loss should be ongoing in

    the last 1 – 2 months.

    In patients with significant fluid retention, large tumor

    mass or obesity (BMI >30kg/m2) significant muscle

    wasting may occur in the absence of weight loss. In

    such patients a direct measure of muscularity is

    recommended.

    Detect patients nutritional issues in daily care:

    Weight loss

    Clinical Cachexia Expert consensus,

    ongoing Delphi procedure

    Mid-arm circumference, BIA (?), DEXA, L4-CT-scan

  • Florian Strasser ESPEN 2008

    Detect patients nutritional issues in daily care:

    Screening in daily care – implement locally

    Then:

    How much

    percent of

    your

    normal

    oral intake

    you take in

    now?

    Look at

    plates !

  • Florian Strasser ESPEN 2008

    Perform a „nutritional“ staging

    Domains of cancer cachexia

    The following key components are of high value for

    clinical assessment of cancer cachexia:

    ● Anorexia/ ▼food intake (central, chemosensory, gut)

    ● Catabolic drive (Tumor, Inflammation, Hypogonadism)

    ● Decreased muscle mass and strength

    ● Impact of cachexia (Distress, Physical function)

    ● Other factors (e.g. anemia, loss of fat mass)

    Clinical Cachexia Expert consensus,

    ongoing Delphi procedure

  • Florian Strasser ESPEN 2008

    Specific

    symptoms &

    complications

    impacting

    nutrition

    Nausea

    Vomiting

    Constipation

    Diarrhea

    Defecation after meal

    Pain

    Dyspnoea

    Fatigue

    Anxiety/depression

    Sense of hopelessness

    Stomatitis

    Dysgeusia

    Dental problems

    Difficulty chewing

    Dysosmia

    Xerostomia

    Thick saliva

    Dysphagia

    Epigastric pain

    Abdominal pain

    Many frequent symptoms and complications in

    Palliative Cancer Care can contribute to Cachexia

    Perform a „nutritional“ staging

    „Simple starvation“

  • Florian Strasser ESPEN 2008

    Normal

    Survival

    Pre-cachexia Cachexia syndrome Advanced cachexia

    Death

    Subtle loss metabolic/endocrine

    change

    Weight loss Reduced food intake

    Systemic inflammation

    Severe muscle wasting Fat loss

    Immunocompromised

    < 3 months? 3 – 9 months? > 6-9 months?

    Fearon K. Eur J Cancer

    2008; 2008;44,1124-32

    Cancer cachexia is a spectrum from early to late.

    Not all patients will progress down the spectrum.

    Clinical Cachexia Expert consensus,

    ongoing Delphi procedure

    Perform a „nutritional“ staging

    Stages

  • Florian Strasser ESPEN 2008

    Patients with late, severe, cancer cachexia have

    advanced muscle wasting (+ - loss of fat).

    Patients have a low performance status and it is

    evident that the burden of artificial nutritional

    support would out-weigh any potential benefits, the

    prognosis of survival is too short to reverse

    depletion.

    Therapeutic interventions focus typically on

    alleviating the consequences/complications of

    cachexia, e.g. psychosocial eating-related distress.

    Clinical Cachexia Expert consensus,

    ongoing Delphi procedure

    Perform a „nutritional“ staging

    Late stage

  • Florian Strasser ESPEN 2008

    Symptoms in cachexia assessment:

    „A family of distinct characters“

    A Symptoms mirroring the pathogenesis of cachexiaEarly satiety, appetite loss, no desire to eat, weakness

    B Symptoms & syndromes causing simple starvation

    Pain, vomiting, dyspnea,

    C Symptoms reflecting the impact of cachexia

    Fatigue, eating-related distress

    Perform a „nutritional“ staging

    Symptoms

  • Florian Strasser ESPEN 2008

    Ed2 Assess – Step1

    Body Mass Index: actual kg/cm2

    Weight loss: kg before 2 & 6 mts

    Nutritional intake: % reduction pat. estimate

    Symptom: subjective loss of appetite

    (nausea, early satiety, etc.)

    Tumor: Catabolic drive, CRP?

    Function: Physical functioning

    Pat. & Relatives: eating-related distress

    kg/cm, kg , ,

    Perform a „nutritional“ staging

    Simple (?) staging in practice

  • Florian Strasser ESPEN 2008

    Assessment tool to guide management of patients

    with cancer cachexia

    Stores Amount of depletion, prognosis

    Intake Central, taste, smell, gut dysmotility

    Simple starvation – secondary causes

    Potential Cancer control (chance), inflammation

    Performance Physical function, distress

    Screening tool: weight loss, physical function

    Outcomes for clinical anti-cachexia treatment trials:

    muscle strenght (handgrip), muscle mass, function, other

    Perform a „nutritional“ staging

    Future: Cancer Cachexia Assessment System

  • Florian Strasser ESPEN 2008

    Detect patients nutritional

    issues in daily care

    Perform a „nutritional“

    staging: domains

    „Nutritional“ support – continued after

    chemotherapy and radiotherapy

    Setting „nutritional“ goals

    in palliative cancer care

    Alleviate burden of

    cachexia and symptoms

  • Florian Strasser ESPEN 2008

    Case 1/3

    61-y man, cardia-carcinoma (uT3 uN1 M1)

    Metastasis:liver, peritoneal, gluteal, bones

    Day 1 second cycle chemotherapy (ECF)

    45 kg, 2 mts ago 51 kg, 164 cm, BMI 19.6, oral

    intake 25% of normal, appetite 5/10

    Stomatitis G1, h/o abd. Surgery, CRP 21 g/dl

    Early satiety 6/10, nausea 4/10, dysphagia

    1/10, fatigue 8/10, abdominal pain 3/10

    Wife distressed what to cook, wants TPN

    Acetaminophen, novamine, osmotic laxative

    How do YOU manage a patient in your practice?

  • Florian Strasser ESPEN 2008

    Setting „nutritional“ goals in

    palliative cancer care

    Screen for symptom, check impact, prioritize

    Cause-directed

    treatments if

    reversible, and

    treatment

    appropriate

    Alleviate

    suffering from

    multi-

    dimensional

    consequences

    Empower

    patient and

    family to

    understand

    cachexia

    Diagnosis and multidimensional assessment of

    cachexia and its impact: far more than weight loss

  • Florian Strasser ESPEN 2008

    Ed10.1 Best Tx Step 6

    rarely

    rarely

    Zinc

    div.

    SSRI

    short

    short

    short

    short

    short

    short

    Nutritional Interventions

    Prokin

    etics

    Cortic

    ost.

    Proges

    tine

    Other

    drugs.

    Suppl.

    iv, oral

    Couns

    Team

    Effect likely

    Effect possible - uncertain

    No effect

    Setting „nutritional“ goals

    Which „nutritional“ intervention for which goal?

    Loss of weight - survival

    Loss of appetite

    Oral intake

    Body composition, BMI

    - Edema

    Physical function

    Quality of life

    - Fatigue - Asthenia

    - Early satiety

    - Nausea

    - Taste problems

    - Dyspnea

    Psychosocial distress

    Existential distress

  • Florian Strasser ESPEN 2008

    Pharmacological anti-cachexia treatments*

    Increase of nutritional intake: oral, enteral, TPN

    Relieve eating-related distress

    Decide on physical activity interventions

    Reversibility of cachexia: go for anticancer

    treatment

    Balance priorities in advanced cancer care(symptoms, family, use limited time, …)

    * Yavuszen et al., JCO 2006; Strasser F. Curr Opinion Supp Pall Care, 12.2007

    Setting „nutritional“ goals

    Multidimensional nutritional interventions

  • Florian Strasser ESPEN 2008

    Ed5.2 TPN example

    Progestins:

    Presence of anorexia: symptom alleviation

    Body weight: improve body „image“ (fat, water)

    Berenstein & Ortiz. Cochrane Database Syst Rev 2005;(2):CD004310.

    Multidimensional nutritional interventions

    Established pharmacological treatments

    Prokinetics:

    Presence of early satiety, chronic nauses

    Corticosteroids:

    Overall “well-being” boost if “inflammation”

  • Florian Strasser ESPEN 2008

    Corticosteroids

    20 bis 50 mg Prednisolon-Aequivalent for 1 to 2 weeks

    Appetite, Nausea, Fatigue, Wellbeing short (!) better

    After 3-4 Weeks: Myopathy, Infect., Insuline resistance

    Progestins

    Megestrol acetate (Megestat 2-4 x 160mg) or

    Medroxyprogesteron acetate (Farlutal 800mg)

    appetite better after 4-7 days, price, thromboembolism 5%

    Prokinetics

    Metoclopramid 10 - 15 mg 30 Min before meals, or

    Domperidon (Motilium), ev. tegaserod

    Early satiety, chronic Nausea; Extrapyramidal AE

    Yavuszen et al., JCO 2006 Strasser F, Bruera ED. Hematol Oncol Clin North Am 2002;16:589-617.

    Etabl. Pharmak. Th ACS

    Multidimensional nutritional interventions

    Established pharmacological treatments: Dose ..

  • Florian Strasser ESPEN 2008

    Multidimensional nutritional interventions

    Increasing nutritional intake

    Various forms of nutritional „support“3

    Conscious control of eating1

    Individual counseling2

    Oral supplements2

    Enteral nutrition

    Parenteral nutrition4

    1: Shragge J et al., submitted

    2: Ravasco P et al. J Clin Oncol 2005; 23:1431-8

    3: Stratton RJ, Elia M: Eur J GE Hep 2007;19:353-8

    4: Hoda D et al., Cancer 2005;103:863

  • Florian Strasser ESPEN 2008

    Assess and improve intake of calories and protein

    Assess patients„ individual eating habits

    Check frequencies of daily meals1

    Empower patients to change their daily habits

    Help patients and family members to understand

    (early satiety, no hunger, taste changes, etc.)

    Multidimensional nutritional interventions

    Nutritional counselling

    1: Alberta nutrtition group 2008

  • Florian Strasser ESPEN 2008

    Few studies supporting clearly effectivityStratton et al., Clin Nutr 1999

    Mixed population including cancer patients

    Supplements

    Tolerability of oral supplements in patients with

    advanced cancer poor (taste, aversion, ..)

    Taste and smell problems frequent

    Bernhardson et al. Self-reported taste and smell changes during cancer chemotherapy. Support

    Care Cancer 2007 Aug 21

    Hutton et al. Chemosensory dysfunction is a primary factor in the evolution of declining

    nutritional status and quality of life in patients with advanced cancer. J Pain Symptom

    Manage 2007;33:156

    Multidimensional nutritional interventions

    Increasing nutritional intake: oral supplements

    BUT: NS are important in individualized daily care

  • Florian Strasser ESPEN 2008

    In pts having catabolic metabolism (active

    cancer), “artificial” increase of kaloric (nutritional)

    intake is inefficient, and causes adverse effects.

    Ed6 - TPN unselected

    VA TPN Clin Study Group NEJM 1991:325:525

    Bozzetti F, et al. Nutrition 12(3):163-7,1996

    Klein S, et al. Am J Clin Nutrition 66,683-706, 1997

    Torelli GF et al. Nutrition 15(9):665-7,1999

    Winter SM. Am J Med 109(9):723-6, 2000

    Many studies confirm in-effectivity of TPN:

    - adjunctive to chemotherapy or radiotherapy

    - Cachectic pts with “intact” bowel function

    Multidimensional nutritional interventions

    Increasing nutritional intake: Parenteral Nutrition

  • Florian Strasser ESPEN 2008

    Ed5.2 TPN example

    Duerksen DR et al. Is there a role for TPN in

    terminally ill patients with bowel obstruction?

    Nutrition. 2004 Sep;20(9):760-3. N=9

    Home parenteral nutrition studies

    Multidimensional nutritional interventions

    Increasing nutritional intake: Parenteral Nutrition

  • Florian Strasser ESPEN 2008

    Elements of eating-related distress1

    ● Contra-intuitive, unpredictable inability to eat and weight loss

    ● Existential distress (loss of weight and control)

    ● Change of cooking habits, cooking as expression of love

    ● Couples coping: trying, searching advice, pressure, accept

    Item-bank development for assessment

    1 Strasser F et al. Palliative Medicine 2007;21:129-37

    Emerging awareness of psychosocial consequences

    of cachexia: 12 papers identified in systematic

    literature review2, EAPC 2008

    Multidimensional nutritional interventions

    Alleviate psychosocial distress related to eating

  • Florian Strasser ESPEN 2008

    Anti-neoplastic interventions

    may contribute to stabilization of weight loss and

    anorexia (several data: pancreatic ca., NSCLC, CRC,..)

    But nutritional intake NOT measured

    Antineopl

    Multidimensional nutritional interventions

    Improve cancer-caused catabolism and anorexia

    Or do they cause muscle wasting? [taxans]

    Is neuromuscular dysfunction contributing to muscle

    loss?

  • Florian Strasser ESPEN 2008

    Cachexia is one among other problems: prioritize

    • Pain-Syndromes (80%)

    • Fatigue (90%)

    • Loss of Appetite & Weight (80%)

    • Nausea / Vomiting (90%)

    • Anxiety (25%)

    • Shortness of Breath (50%)

    • Delirium-Agitation (80%)

    • Depressive Symptoms (30%)

    • Social / Family Distress (>30%)

    • Existential Distress (>30%)

    Teunisen & Graeff, EAPC 2007. Volume 4 Topics Pall Care. Walsh D Supp Care Cancer 2000. Vainio A

    J Pain Symp Manag 1996. Reuben DB Arch Intern Med 1988. Dewys WD Am J Med 1980

    Cachexia causes (also) symptom interactions

    • Pain-Syndromes (80%)

    • Fatigue (90%)

    • Loss of Appetite & Weight (80%)

    • Nausea / Vomiting (90%)

    • Anxiety (25%)

    • Shortness of Breath (50%)

    • Delirium-Agitation (80%)

    • Depressive Symptoms (30%)

    • Social / Family Distress (>30%)

    • Existential Distress (>30%)

    Multidimensional nutritional interventions

    Multidimensional aspects of suffering

  • Florian Strasser ESPEN 2008

    Cachexia involves typically the „whole“ family

    Family members are partners

    in care, involved in nursing,

    organisation, enhancing

    compliance (and pressure), …

    Family members are suffering from losses, role

    change, misunderstandings, etc.

    Multidimensional nutritional interventions

    Unity of care involving families in care concepts

  • Florian Strasser ESPEN 2008

    Goals Palliative Care

    ● Self efficacy

    ● Sense of coherence

    ● Security

    ● Support families

    Competencies

    ● Symptom management

    ● Decision making

    ● Networking support

    ● Caregivers counselling

    1

    Is Cachexia

    important?

    Multidimensional nutritional interventions

    Priorities in advanced cancer care

  • Florian Strasser ESPEN 2008

    Cachexia assessment requires acknowledgment

    of multidimensional aspects.

    Specialized approaches („cachexia“

    clinics1,2) consist of multi-diciplinary

    teams covering nutritional, psycho-

    social-spiritual, physical, medical,

    and nursing aspects (among other)

    Cachexia assessment & management is teamwork

    1 Dalal S, et al., EAPC 2008 #396; 2 Strasser F et al, ESMO 2006

    2

    Multidimensional nutritional interventions

    Delivery of care by multi-professional teams in

    various care settings

  • Florian Strasser ESPEN 2008

    Current approach (St.Gallen Nutrition & Fatigue Clinic)

    ● ESAS

    ● MMSQ

    ● HADS

    ● SACS*

    ● SIF*

    ● 2-d oral intake

    ● Diet type

    ● Social net

    ● FICA*

    ● Coping

    ● ERD*

    ● Function: FIM

    ● Preferred PA*

    SACS: secondary anorexia & cachexia checklist; SIF: single-item fatigue

    domains; ERD: eating related-distress; PA: physical activities; FICA: Faith

    Interventions: nutritional, anti-

    cachexia drugs, counselling

    (understanding, calman-gap,

    meaning), secondary anorexia

    treatment, physical activity,

    oncological, social net.

  • Florian Strasser ESPEN 2008

    Screen ALL patients for nutritional problems

    (weight, kcal, anorexia, BMI+, fatigue, distress, ..

    Identify and treat secondary anorexia/cachexia

    (different causes in trajectory of illness)

    Estimate primary anorexia/cachexia:

    catabolic drive: inflammation (CRP) – tumor (assess)

    If give additional nutrition: monitor goals and

    adverse events (incl. distress, wrong priorities)

    Work in an interdisciplinary team, cultivate

    multidimensional professional care (alternative Tx)

    Conclusion

    Nutrition: To do or not to do?

    Conclusions – take home

  • Florian Strasser ESPEN 2008

    Contact

    [email protected]

    [email protected]

    Thank you!

  • Florian Strasser ESPEN 2008

  • Florian Strasser ESPEN 2008

    Cancer Cachexia close to End-of-Life

    Does cachexia – a normal feature of dying - hurt?

    EXPECTATIONS

    STATUS

    Function

    or

    eating

    or

    other

    TIME

    Status - Expect

    Calman gap1:

    difference of

    expectations

    and reality

    Meaning of Eating2,3

    „my daily bred give

    me today“

    Eating = life

    Love Eating

    Cultural & religious

    differences

    1: Calman KC. Quality of life in cancer patients-an hypothesis. J Med Ethics 1984; 10: 124-7

    2: Mintz S.W et al, The Anthropology of food and eating, 2002

    3: Salomonsson, Ethnologia Scaninavia 1990

    Misunderstanding of „what happens with me“: hurts

    New meaning and hope with less function & food

  • Florian Strasser ESPEN 2008

    Cancer cachexia is defined by a negative energy

    and protein balance driven by a variable

    combination of reduced food intake and

    hypermetabolism.

    Over its course, cachexia is associated with

    functional impairment.

    A key defining feature is ongoing loss skeletal

    muscle mass which is not fully reversed by

    conventional nutritional support.

    Cancer Cachexia (working) Definition

    Clinical Cachexia Expert consensus,

    ongoing Delphi procedure

    Evans WJ et al.

    Cachexia: A new

    definition. Clin

    Nutr 2008 Aug 19.

  • Florian Strasser ESPEN 2008

    Limited life time implicating concurrent priorities

    until death and likelihood to reach “nutritional” goals

    Key aspects of Palliative Care in Cachexia 5/7

    Time to response

    days wks mts

    Weight loss - survival

    Loss of appetite

    Nutritional intake

    Body composition

    - Edema

    Function physical

    Quality of life

    - Fatigue (physical)

    Eating-related Distress

    Goals for cachexia treatment change of time

  • Florian Strasser ESPEN 2008

    Current dilemmas in clinical decision making

    Decisions to make: Pharmacological

  • Florian Strasser ESPEN 2008

    Ed5.2 TPN example

    Hoda D et al. (Mayo-Group), Cancer 2005;103:863

    52 Pat., incurable, advanced cancer, 1979-99, Mayo

    Retrospective review of Home-TPN

    Indication:Bowel obstruction (n=20)

    Shortbowel-Syndr., Malabsorption (n=16)

    Fistula (n=11)

    Dysmotility (n=3)

    Nausea/vomiting, mucositis (n=2, n=1)

    Anorexia (n=2)

    Overall survival: 5 months (1-154)

    Complications: 18 Infections, 4 Thrombosis, ..

    Current dilemmas in clinical decision making

    Decisions to make: „gut does not work“: TPN

    Does gut really

    not work???

  • Florian Strasser ESPEN 2008

  • Florian Strasser ESPEN 2008

    Ed10.2 ERD

    Goal-directed relieve of Eating-related Distress

    A role for psycho-social-existential counseling?

    Appetite Fluctuating, unpredictable, disgust

    Inability to eat Predictable but dread of starving

    Loss of weight Difficult to control, unpredictable

    Eating Weight not linked

    Insecurity What is healthy? Adaption, learning

    Partnership Pressure, caring by food, innovative

    Social contacts Limitations practical, „normal“

    Professionals Not helpful advice, foresight

    Weak/Death Fight a loosing battle ready to die

    Strasser F et al. Eur Assoc. Pall Care, 2004

  • Florian Strasser ESPEN 2008

    Nutrition: To do or not to do?

    Nutritional counselling

    Ravasco P et al. J Clin Oncol 2005; 23(7): e-pub

    110 Patients colorectal-carzinoma radiotherapy

    Group 1: „nutritional counselling“

    Group 2: Oral protein-supplements

    Group 3: Eat what you want

    Effektive for calories and protein intake

  • Florian Strasser ESPEN 2008 Ravasco P et al. J Clin Oncol 2005; 23(7)

    EBer Suppl Free

    Nutr couns

    Nutrition: To do or not to do?

    Nutritional counselling: multidimensional care

  • Florian Strasser ESPEN 2008

    - Estimate catabolic drive

    - Inflammation: CRP 100, (PIF)

    - Reversibility- Stabilization: when expected?

    - Before start of TPN

    - Agreement with patient and proxies when and

    based on which criteria withdraw TPN

    - Repeated evaluation if goals met and how tolerable

    - after (1-) 2 – 4 weeks

    - clinically, prealbumin, (transferrin)

    - Safety: phosphat et al.

    - Impact on quality-of-life

    TPN yes or no

    Multidimensional nutritional interventions

    Increasing nutritional intake: Parenteral Nutrition