Hyperalimentation in autologous bone marrow transplantation for solid tumors. Comparison of total parenteral versus partial parenteral plus enteral nutrition

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

ESPEN guidelines on nutritional support for polymorbid internal medicine patients

BACKGROUND & AIMS

Polymorbidity (also known as multimorbidity) - defined as the co-occurrence of at least two chronic health conditions - is highly prevalent, particularly in the hospitalized population. Nonetheless, clinical guidelines largely address individual diseases and rarely account for polymorbidity. The aim of this project was to develop guidelines on nutritional support for polymorbid patients hospitalized in medical wards.

METHODS

The methodology used for the development of the current project follows the standard operating procedures for ESPEN guidelines. It started with an initial meeting of the Working Group in January 2015, where twelve key clinical questions were developed that encompassed different aspects of nutritional support: indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Systematic literature searches were conducted in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until April 2016. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations, which were followed by submission to Delphi voting rounds.

RESULTS

From a total of 4532 retrieved abstracts, 38 relevant studies were analyzed and used to generate a guideline draft that proposed 22 recommendations and four statements. The results of the first online voting showed a strong consensus (agreement of >90%) in 68% of recommendations and 75% of statements, and consensus (agreement of >75-90%) in 32% of recommendations and 25% of statements. At the final consensus conference, a consensus greater than 89% was reached for all of the recommendations.

CONCLUSIONS

Despite the methodological difficulties in creating non-disease specific guidelines, the evidence behind several important aspects of nutritional support for polymorbid medical inpatients was reviewed and summarized into practical clinical recommendations. Use of these guidelines offer an evidence-based nutritional approach to the polymorbid medical inpatient and may improve their outcomes.

WITHDRAWN: Nutrition support for bone marrow transplant patients

BACKGROUND

This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates.

OBJECTIVES

To determine efficacy of EN or PN support for patients receiving bone marrow transplant.

SEARCH METHODS

Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006.

SELECTION CRITERIA

RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients.

DATA COLLECTION AND ANALYSIS

Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival.

MAIN RESULTS

In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN.

AUTHORS' CONCLUSIONS

In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Nutrition Issues in Hematopoietic Stem Cell Transplantation: State of the Art

There have been many changes in hematopoietic stem cell transplantation (HSCT) that affect the patient's nutrition support. In the early 1970s, allogeneic transplants were the most common types of HSCTs; today, autologous transplants are the most common. Bone marrow, peripheral blood, and umbilical cord blood all now serve as sources of stem cells. Conditioning therapies include myeloablative, reduced-intensity myeloablative, and nonmyeloablative regimens. New medications are being developed and used to minimize the toxicities of the conditioning therapy and to minimize infectious complications. Supportive therapies for renal and liver complications have changed. In the past, HSCT patients received parenteral nutrition (PN) throughout their hospitalization and sometimes as home therapy. Because of medical complications and cost issues associated with PN, many centers are now working to use less PN and increase use of enteral nutrition. The immunosuppressed diet has changed from a sterile diet prepared under laminar-flow hoods to a more liberal diet that avoids high-risk foods and emphasizes safety in food handling practices. This article will review these changes in HSCT and the impact of these changes on the nutrition support of the patient.

Importance of Parenteral Nutrition in Patients Undergoing Hemopoietic Stem Cell Transplantation Procedures in the Autologous System

OBJECTIVE

The aim of this study was to assess the frequency of parenteral nutrition and to compare the impact of parenteral and oral feeding on the nutrition and clinical status of adults undergoing autologous hemopoietic stem cell transplantation.

METHODS

The study involved 35 patients with neoplasm of the hemopoietic system who underwent hemopoietic cell autotransplantation at the Hematology Clinic (Jagiellonian University, Krakow, Poland). The patients' nutrition status was assessed using body mass index (BMI) values, body mass components, concentration of albumin, and total protein in blood serum. The clinical status evaluation included duration of hematologic reconstruction, concentration of bilirubin, enzyme activity (alanine aminotransferase and aspartate aminotransferase), severity of infections, and duration of hospitalization.

RESULTS

Parenteral nutrition was required in 19 patients. Oral feeding was used in 16 patients. Symptoms of malnutrition on the day preceding the introduction of conditioning treatment were recorded only in patients requiring parenteral nutrition (31.6%). In the posttransplantation period, a statistically significant decrease in body mass was observed in both groups, whereas the share of fatty tissue in total body mass was significantly less in patients (men and women) fed parenterally.

CONCLUSION

A supply of 25-30 kcal/kg and 1-1.5 g protein/kg/day as an element of parenteral nutrition (where 20%-30% of the energy requirement was covered by fats, 15%-20% by amino acids, and 50%-55% by glucose) helped prevent the development of malnutrition and restore the functions of the hemopoietic system at a level comparable to that for patients fed naturally.

Gastrointestinal side effects and adequacy of enteral intake in hematopoietic stem cell transplant patients

BACKGROUND

Patients undergoing hematopoietic stem cell transplant (HSCT) can experience gastrointestinal (GI) side effects as a complication of the treatment. Limited research exists describing how the duration and severity of GI side effects influence the consumption of adequate calorie intake in this population. The purpose of this study was to assess differences in GI side effects between patients who consumed adequate calories compared with those who did not.

METHODS

The MD Anderson Symptom Inventory-Gastrointestinal (MDASI-GI) tool was used to record daily GI side effects of 72 HSCT patients. Daily calorie intake was determined via calorie counts. Data were collected from day of transplant until engraftment.

RESULTS

Median percentage of caloric needs consumed for all patients was 49.2% (interquartile range, 35.1-66.6). Calorie intake decreased from baseline to transplant day 8 as severity of GI symptoms increased. An inverse relationship between percentage of caloric needs met and MDASI-GI component score, MDASI-GI symptom score, and lack of appetite score was observed. The only significant difference in MDASI-GI symptom scores between those who consumed adequate calories and those who consumed inadequate calories was for diarrhea; subjects who consumed >60% of caloric needs had significantly lower median diarrhea scores.

CONCLUSION

Most patients consumed <60% of their caloric needs from time of transplant to time of engraftment. More research is needed to provide insight into strategies to increase intake and to describe the implications of prolonged inadequate intake in HSCT patients.

Clinical nutrition guidelines of the French Speaking Society of Clinical Nutrition and Metabolism (SFNEP): Summary of recommendations for adults undergoing non-surgical anticancer treatment

Up to 50% of patients with cancer suffer from weight loss and undernutrition (as called cachexia) even though it is rarely screened or properly handled. Patients' prognosis and quality of life could be greatly improved by simple and inexpensive means encompassing nutritional status assessment and effective nutritional care. These guidelines aim to give health professionals and patients practical and up-to-date advice to manage nutrition in the principal situations encountered during the cancer course according to the type of tumour and treatment (i.e. radio and/or chemotherapy). Specific suggestions are made for palliative and elderly patients because of specific risks of undernutrition and related comorbidities in this subset. Levels of evidence and grades of recommendations are detailed as stated by current literature and consensus opinion of clinical experts in each field.

Total parenteral nutrition in children and adolescents treated with high-dose chemotherapy followed by autologous haematopoietic transplants

Total parenteral nutrition (TPN) is still of great importance for haematopoietic stem cell transplantation (HSCT) patients because one of the major adverse effects of the high-dose therapy followed by HSCT is an inadequate oral nutrition intake. The aim of the study was analysis of TPN of young patients in the HSCT period. Twenty-two patients 1·8–20·8 year-old, median 5·4, treated with high-dose therapy and autologous HSCT because of malignancy were included into the study. Grafts contained 1·35–7·9 × 106, median 3·75 × 106CD34+ cells/kg. Engraftment occurred as follows: granulocytes >0·5 × 109/l on +11 d (8–25); platelets >20 × 109/l on +23 d (12–67). Patients were given isoenergetic, isonitrogenous TPN until they consumed less than 50 % of their required diet orally. Proteins intake was 0·8–2·0 g/kg per d, fats intake 1·0–3·0 g/kg per d. Total non-proteins energies–nitrogen grams index was 140:1–200:1. Supplementation of electrolytes, microelements, trace elements and vitamins was dependent on individual patient requirement. TPN duration did not correlate with CD34+cells number but correlated with platelets reconstitution. The assessment of nutritional condition demonstrated no differences in anthropometric parameters, but increase of serum albumin levels after TPN. Requirement for P3 − was above the normal ranges and correlated positively with platelets reconstitution. Requirement for P3 − and K+was higher in patients with mucositis than in other patients. Any complications due to TPN were observed. Adequately composed isoenergetic and isonitrogenous TPN with replacement of electrolytes according to their requirement in the early post-transplantation period allows not only improvement in nutritional status of patients but also could contribute to reconstitution of haematopoiesis.

Nutritional Assessment of Children With Cancer

Regardless of which parts of the world they live in, most children will develop and grow at a similar rate if proper nutrition is ensured. Children from developing countries are at risk for primary malnutrition. Children undergoing anticancer therapy are at higher risk for secondary malnutrition, including obesity and growth retardation. Periodic nutritional assessments are important for planning effective dietary interventions for such children. In this review, we describe malnutrition as it occurs in children with cancer and various ways of assessing the nutritional status of these children, depending on the availability of resources in their local hospitals. Objective and subjective data should be used to complete the nutritional assessment. We discuss screening methods, including the use of subjective global assessment. Different parts of nutritional assessment include medical history; physical examination; biochemical and hematological data, such as visceral proteins, blood glucose levels, and lipid profiles, hemoglobin and hematocrit, and the lymphocyte count; anthropometric measurements; and food and nutrition history. We review medical tests and procedures to determine nutritional status, including nitrogen balance, delayed cutaneous hypersensitivity, prognostic nutritional index, creatinine height index, maldigestion and malabsorption tests, indirect calorimetry, and dual energy X ray absorptiometry (DXA scan). Evaluation and interpretation of data and estimation of nutritional risk are discussed, including proper techniques and use of anthropometric measures, selection and use of growth charts, calculation of caloric and protein needs, and the percentage of calories ingested. These methods will enable local health care providers to accurately assess the nutritional status of children with cancer, identify children at risk, and plan adequate nutritional interventions.

Nutrition support for bone marrow transplant patients

BACKGROUND

This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates.

OBJECTIVES

To determine efficacy of EN or PN support for patients receiving bone marrow transplant.

SEARCH STRATEGY

Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006.

SELECTION CRITERIA

RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients.

DATA COLLECTION AND ANALYSIS

Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival.

MAIN RESULTS

In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN.

AUTHORS' CONCLUSIONS

In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Nutrition support for bone marrow transplant patients

BACKGROUND

This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates.

OBJECTIVES

To determine efficacy of EN or PN support for patients receiving bone marrow transplant.

SEARCH STRATEGY

Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006.

SELECTION CRITERIA

RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients.

DATA COLLECTION AND ANALYSIS

Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival.

MAIN RESULTS

In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN.

AUTHORS' CONCLUSIONS

In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Exploring the Clinical Characteristics of Parenteral Nutrition Recipients Admitted for Initial Hematopoietic Stem Cell Transplantation

There is a paucity of evidence to guide the initiation of parenteral nutrition administration during hematopoietic stem cell transplantation. The purpose of this study was to explore and compare clinical characteristics during early hematopoietic stem cell transplantation to discern if differences existed between those that had parenteral nutrition initiated and those that did not. Medical records of patients admitted for initial autologous or allogeneic hematopoietic stem cell transplantation from two university transplantation centers were evaluated for this retrospective cohort. A multitude of clinical features were evaluated at baseline and in the days preceding parenteral nutrition initiation to investigate potential differences between parenteral nutrition and non-parenteral nutrition subjects, stratified by donor type. To examine the occurrence of events prior to parenteral nutrition administration, a "before" time frame was created for all subjects. For parenteral nutrition subjects, the actual number of hospital days prior to parenteral nutrition initiation was used; however, for non-parenteral nutrition patients, the transplantation-specific average number of days until parenteral nutrition initiation, depicted as "before" (ie, autologous non-parenteral nutrition "before"=hospital days 1 to 10, allogeneic non-parenteral nutrition "before"=hospital days 1 to 13), was used during this parallel timeframe. Differences were assessed using Student's t and Wilcoxon rank sum tests for continuous variables, and chi(2) for categorical variables. Parenteral nutrition was provided to 53% (n=129/245) of autologous and 65% (n=73/112) of allogeneic patients and was typically initiated on transplant day +6 and day +7, respectively. Significant decreases in oral intake patterns (P<0.0001) and a tendency toward infections were observed for autologous (P=0.01) and allogeneic (P=0.07) parenteral nutrition vs non-parenteral nutrition recipients "before." In addition, significantly more mucositis was observed "before" in allogeneic parenteral nutrition vs non-parenteral nutrition patients (P=0.04). Involvement of nutrition professionals is crucial for the design and implementation of future studies to determine for whom and when to commence parenteral nutrition and to discourage its indiscriminant use.

Total parenteral nutrition and hematopoietic stem cell transplantation: an expensive placebo?

SUMMARY

A majority of patients undergoing hematopoietic stem cell transplantation (HSCT) suffer from severe mucositis and enteritis due to cytotoxic therapy and immune dysregulation, resulting in prolonged decreased oral intake, nausea, vomiting and diarrhea. While total parenteral nutrition (TPN) is often given to patients in order to maintain their nutritional status during the peritransplant period, there is conflicting evidence to support its routine use. We evaluated the small number of prospective randomized and nonrandomized controlled trials that assessed important clinical outcomes such as time to engraftment, rates of infection, overall survival and length of hospitalization. We believe that the data do not support the routine use of parenteral nutrition as first-line therapy but should be reserved for those patients who are unable to tolerate enteral feedings. We also believe that glutamine supplementation cannot be recommended to all HSCT recipients as it has been shown to increase morbidity and mortality rates in autologous transplant patients. Further investigations that test accurate monitoring assessments and incorporate specific substrates such as lipids with parenteral and enteral nutrition are warranted. Novel therapies such as recombinant human keratinocyte growth factor and glucagon-like peptide show future promise in modulating the severity and duration of mucositis, minimizing further the need for TPN.

Assessment of nutritional status in organ transplant: is transthyretin a reliable indicator?

Transthyretin has been proposed as a nutritional index to screen for malnutrition and monitor the metabolic response to dietary intervention. In the presence of inflammation, circulating transthyretin levels drop regardless of optimal caloric intake. In this case, due to its rapid turnover, the pattern of transthyretin, monitored by means of repeated measures, could indicate the metabolic status (catabolism vs. anabolism). The aim of this review is to investigate the possible role of transthyretin as a nutritional parameter in organ transplantation. The literature on nutritional assessment in transplantation was reviewed and all the data regarding circulating transthyretin levels were analyzed. It appears that, on the one hand, the transthyretin level reflects closely dietary manipulations; on the other hand, it is affected by the inflammatory status. Consequently, interpretation could be difficult during the acute phase immediately after the transplant. Moreover, the role of transthyretin in monitoring the hepatic synthetic function in liver transplant is discussed. In conclusion, transthyretin is a reliable indicator of nutritional status in transplant candidates and potentially useful in the post-transplant phase if the inflammatory status is taken into account.

Total parenteral nutrition delays platelet engraftment in patients who undergo autologous hematopoietic stem cell transplantation

OBJECTIVES

One of the major challenges in the post-transplant period is nutrition. In this prospective, non-randomized study, total parenteral nutrition (TPN) was given to 31 patients and partial parenteral nutrition (PPN) was given to 30 patients undergoing autologous hematopoietic stem cell transplantation for solid tumors or hematologic malignancies to compare the effects of these parenteral nutrition modalities on post-transplant hematological engraftment, blood chemistry, and supportive therapy requirements.

METHODS

All patients in the TPN group and 17 patients in the PPN group received growth factor in the post-transplant period. Both groups did not differ with respect to sex, age, and reinfused CD34(+) cell numbers.

RESULTS

After transplantation body mass index and body weight decreased significantly in both groups (P < 0.001). Whereas serum albumin concentrations did not decrease significantly in the TPN group, it fell markedly in the PPN group at the end of parenteral nutrition (P = 0.019). After parenteral nutrition, blood chemistry was also remarkable for serum urea and glucose levels, which were elevated significantly in the TPN group (P < 0.001 and P = 0.03, respectively). Patients receiving TPN had a higher incidence of positive microbial cultures and clinical infection than did patients receiving PPN (64.5% versus 40%, P = 0.05). The most striking result was a delay in platelet engraftment for the TPN group compared with the PPN group (15.54 and 12.93 d, respectively; P = 0.014). This difference was also noted in patients using growth factor in the PPN group (P = 0.017). Parallel to these results, platelet transfusion requirement increased in the TPN group compared with the PPN group (1.93 versus 1.16 U, P = 0.004). Both groups were unremarkable for leukocyte recovery and red blood cell transfusion requirement.

CONCLUSIONS

Consequently, TPN has some pitfalls of hyperglycemia, infection tendency, delayed platelet engraftment, and increased platelet transfusion requirement. Therefore, it should not be used as a standard nutrition support for patients undergoing autotransplantation.

Parenteral nutrition support after bone marrow transplantation: comparison of total and partial parenteral nutrition during the early posttransplantation period

OBJECTIVE

Bone marrow transplantation (BMT) usually is indicated if the patient's malignant disease involves the marrow or if hazard to the normal marrow is the limiting factor in the aggressive treatment of disease. The success of BMT depends on a complete team with all the resources needed to ensure optimal results. Aggressive nutrition support after BMT is very important. Adequate parenteral nutrition, total (TPN) or partial, followed by enteral nutrition according to the patient's gastrointestinal function is the important principle.

METHODS

Between 1996 and 2000, 60 patients, 46 male and 14 female, received BMT in Chang Gung Memorial Hospital. Their ages ranged from 6 to 54 y. Standard TPN was used in 40 patients after BMT, and partial parenteral nutrition was used in the remaining 20 patients. TPN was enriched with branched-chain amino acids (BCAA) when the patient's liver functions were impaired, and cyclic TPN was shifted when the patient's liver functions persistently deteriorated.

RESULTS

Most patients improved their nutrition status and increased their body weights, especially those receiving TPN. The patients receiving partial parenteral nutrition decreased their visceral proteins significantly during the course of parenteral nutrition. The BCAA-TPN can maintain a patient's visceral protein better than standard TPN. Only two patients expired because of graft rejection and sepsis; their body weights and nutrition status showed deterioration despite aggressive nutrition support.

CONCLUSIONS

We conclude that the nutrition support for patients with BMT is related to the success of marrow transplantation. Parenteral nutrition support, especially with TPN, is important because of frequent gastrointestinal dysfunction during the posttransplantational period, and it is better at maintaining the nutrition status and body weights of patients after BMT. An oral diet can be resumed after the patient's gastrointestinal function has improved and it can be tolerated.

Nutrient support in hematopoietic cell transplantation

High-dose cytoreduction and hematopoietic stem cell infusion form the basis for treatment of hematologic cancers, defects or failure of hematopoiesis, and some solid tumors. As an antitumor therapy, allogeneic hematopoietic cell transplantation (HCT) is superior to autologous HCT by induction of a graft-vs-tumor effect. However, recipients of allografts suffer higher transplant-related mortality owing to graft-vs-host disease (GVHD). Nutrition support research must recognize that HCT is a heterogeneous modality whose short and long-term outcomes are affected by transplant type, preparative regimens, diagnosis, disease stage, age, and nutritional status. The field of HCT will diversify further as lower dose cytoreduction and mixed chimerism grafts allow expansion of the technique to older patients and to other diseases.

Intensive enteral nutrition support in paediatric bone marrow transplantation

This study retrospectively analyses the experience with an intensive enteral feeding protocol in children undergoing BMT at the National Paediatric BMT Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin. Fifty-three patients were transplanted between January 1996 and December 1998; 42 patients received allogeneic transplants, (19 unrelated) and 11 were autologous. Indications included ALL (21), ANLL (3), CML (3), JCML (1), MPS (5), WAS (2), AA/FA (6), NHL/HD (3) and solid tumours (9). Nasogastric (NG) tubes were inserted electively either during conditioning or within the first week when voluntary oral intake had decreased. Nineteen patients were commenced on a whole protein-based formula, 28 on a semi-elemental preparation and two were commenced on an elemental feed. All were maintained on an elemental formula during the period of maximal gut toxicity. Tubes which were vomited were promptly replaced and morphine infusions were routinely employed until mucositis had resolved. Of 49 evaluable patients, 42 (86%) were maintained exclusively on enteral nutrition and seven required parenteral nutrition. Seven patients weighed <85% ideal body weight (IBW) at discharge (range 75-84), only one of whom was <85% IBW at 3 months. Twenty-two patients continued on NG feeds following discharge (median 41 days). No patient had veno-occlusive disease. The programme was overwhelmingly endorsed by patients and/or parents but required intensive multidisciplinary counselling to ensure success.

Short-term follow-up of the nutritional status of children undergoing autologous peripheral blood stem cell transplantation

A prospective longitudinal study was conducted to analyze the evolution of the nutritional status of 34 children (12 girls and 22 boys), aged 1.5-15.8 years (median age 9.06), undergoing autologous peripheral blood stem cell transplantation (PBSCT). The nutritional status was evaluated at baseline, days +1 and +7, discharge, and day +30 by dietary or parenteral intake, anthropometric and laboratory measurements, and nitrogen balance. At baseline, changes in anthropometric (53%) and biochemical measurements (83%) are frequent but mild. The mean caloric intake was normal. Children with normal values for the anthropometric parameters all had an intake > 80% (p < .01). No correlation was found between the anthropometric and biochemical parameters. During transplantation, significant changes (p < .001) were found for energy intake, albumin, transferrin, and nitrogen balance. Fibronectin, prealbumin, and retinol-binding protein showed only a few changes. All but prealbumin recovered on day +30. No correlation was found between the nutritional status and toxicity or infection in children undergoing autologus PBSCT. The changes in the nutritional status observed at the start of transplantation correlated with the nutrional intake. Anthropometric and biochemical changes are complementary. The results may be ascribable to the fact that the patients in this series had mild malnutrition.

Nutritional support of the cancer patient: issues and dilemmas

Malnutrition in cancer patients results from multifactorial events and is associated with an alteration of quality of life and a reduced survival. A simple nutritional assessment program and early counselling by a dietitian are essential to guide nutritional support and to alert the physician to the need for enteral (EN) or parenteral nutrition (PN). A daily intake of 20-35 kcal/kg, with a balanced contribution of glucose and lipids, and of 0.2-0.35 g nitrogen/kg is recommended both for EN and PN, with an adequate provision of electrolytes, trace elements and vitamins. EN, always preferable for patients with an intact digestive tract, and PN are both safe and effective methods of administering nutrients. The general results in clinical practice suggest no tumor growth during nutritional support. The indiscriminate use of conventional EN and PN is not indicated in well-nourished cancer patients or in patients with mild malnutrition. EN or PN is not clinically efficacious for patients treated with chemotherapy or radiotherapy, unless there are prolonged periods of GI toxicity, as in the case of bone marrow transplant patients. Severely malnourished cancer patients undergoing major visceral surgery may benefit from perioperative nutritional support, preferably via enteral access. Nutritional support in palliative care should be based on the potential risks and benefits of EN and PN, and on the patient's and family's wishes. Research is currently directed toward the impact of nutritional pharmacology on the clinical outcome of cancer patients. Glutamine-supplemented PN is probably beneficial in bone marrow transplant patients. Immune diets are likely to reduce the rate of infectious complications and the length of hospital stay after GI surgery. Further studies are needed to determine the efficacy of such novel approaches in specific populations of cancer patients, and should also address the question of the overall cost-benefit ratio of nutritional pharmacology, and the effect of nutritional support on length and quality of life.

Nutritional support in children undergoing bone marrow transplantation

Nutritional status and 'well-being' were compared prospectively in 39 children (mean age 8.1 years) who received nutritional support following bone marrow transplantion (BMT): 20 received enteral tube feeding (ETF; six received parenteral nutrition [PN] subsequently) and 19 with oral mucositis received PN (one received ETF subsequently). Poor nutritional status (height for age and/or weight for height and/or mid-arm circumference z-scores <-1) was present in 18 patients and was associated with a longer hospital stay (P = 0. 01). Both ETF and PN groups were comparable with respect to age, pretransplant nutritional status and conditioning regimens. No significant deterioration in anthropometric indices in either group occurred following BMT. However, significant correlations were found between the duration of ETF (and not PN) and improvements in nutritional status. Furthermore, PN was associated with more frequent exocrine pancreatic insufficiency than ETF (P = 0.001). Oral mucositis was associated with poorer 'well being' at the start of PN compared with ETF (P < 0.0001), but this was reversed by the end of PN. Bone marrow recovery, hospital stay and positive blood cultures were similar in the two groups. Hypomagnesaemia, hypophosphataemia and biochemical zinc deficiency were common in both groups but hypoalbuminaemia and biochemical selenium deficiency were worse in the PN group. In conclusion, both ETF and PN are effective in maintaining nutritional status post-BMT. When ETF is tolerated, it is associated with better nutritional response. With the existing ETF and PN regimens close monitoring of the trace element and mineral status is required.

Enteral nutrition after bone marrow transplantation

Nutritional insult after bone marrow transplantation (BMT) is complex and its nutritional management challenging. Enteral nutrition is cheaper and easier to provide than parenteral nutrition, but its tolerance and effectiveness in reversing nutritional depletion after BMT is poorly defined. Nutritional status, wellbeing, and nutritional biochemistry were prospectively assessed in 21 children (mean age 7.5 years; 14 boys) who received nasogastric feeding after BMT (mean duration 17 days) and in eight children (mean age 8 years, four boys) who refused enteral nutrition and who received dietetic advice only. Enteral nutrition was stopped prematurely in eight patients. Greater changes in weight and mid upper arm circumference were observed in the enteral nutrition group, while positive correlations were found between the duration of feeds and increase in weight and in mid upper arm circumference. Vomiting and diarrhoea had a similar incidence in the two groups, while fever and positive blood cultures occurred more frequently in the dietetic advice group. Diarrhoea occurring during enteral nutrition was not associated with fat malabsorption, while carbohydrate malabsorption was associated with rotavirus infection only. Enteral feeding did not, however, affect bone marrow recovery, hospital stay, general wellbeing, or serum albumin concentrations. Hypomagnesaemia, hypophosphataemia, zinc and selenium deficiency were common in both groups. In conclusion, enteral nutrition, when tolerated, is effective in limiting nutritional insult after BMT. With existing regimens nutritional biochemistry should be closely monitored in order to provide supplements when required.

Phase II study of intensive chemotherapy with autologous bone marrow transplantation in patients in complete remission of disseminated breast cancer

BACKGROUND

This trial studied the disease-free survival after high-dose chemotherapy in patients in complete remission of metastatic breast cancer.

PATIENTS AND METHODS

Thirty women, mean age 42.2 years (range 33-55) with metastatic breast cancer, received high-dose chemotherapy in a phase II study. Patients were eligible if they were < or = 55 years of age, had achieved complete remission within 6 months of the initiation of chemotherapy, and had a WHO performance scale of 0 or 1. The high-dose regimen consisted of melphalan 180 mg/m2 and mitoxantrone 60 mg/m2 both divided over 3 days. On day 7 bone marrow and/or peripheral stem cells were infused. After bone marrow recovery, external beam radiation was administered to sites of previous metastatic disease in 15 patients.

RESULTS

Apart from leuko- and thrombocytopenia, mucositis was the major side effect. One patient died during the bone marrow transplant period due to an aspergillus infection. The median follow-up since high-dose chemotherapy is 25 months (range 13 to 56 months). The median disease-free survival since high-dose chemotherapy is 27 months and the disease free survival is still 43% with an overall survival of 53% at 3 years. In two patients tumor relapse occurred only in the brain; in one patient the only relapse sign was a meningeal carcinosis. At the moment 17 patients are disease-free (13(+)-56+) months after high-dose chemotherapy.

CONCLUSION

Until now this high-dose regimen in selected patients with complete remission after induction chemotherapy for metastatic breast cancer has a promising disease free survival.

Enteral nutrition support in a child after bone marrow transplantation

Bone marrow transplantation (BMT) has been associated with numerous negative side effects, which include prolonged anorexia. Historically, parenteral nutrition has been the method of choice for nutrition support. The possibility that enteral feedings may be a practical form of nutrition therapy for those BMT patients who have prolonged anorexia and who have adequate gastrointestinal function was investigated. RR, a 10-year-old male, was diagnosed with acute lymphocytic leukemia in March 1989. The patient received a bone marrow transplant in July 1992 from a human leukocyte antigen genotype-matched sibling. Because of the patient's prolonged anorexia, he was started on enteral feedings via a percutaneous endoscopic gastrostomy feeding tube on day +63. Over the next 300 days of enteral nutrition support the patient's nutritional status improved as demonstrated by an increased weight and height and the maintenance of normal visceral protein stores. This suggests that enteral feedings may be beneficial for those BMT patients who have prolonged anorexia and have adequate gastrointestinal function.

Diarrhea and weight loss after bone marrow transplantation in children

To define the determinants of diarrhea after bone marrow transplantation (BMT) and its nutritional sequelae, the medical records of 20 consecutive children (median age, 9 years; 13 boys and 7 girls) undergoing BMT at Children's Hospital in Birmingham, UK were surveyed. All patients who received total body irradiation (TBI) required parenteral nutrition (PN). Seventy-eight percent of TBI patients and 73% of children who received allografts developed diarrhea compared with only 27% of non-TBI patients and 22% of those who received autografts (P < 0.05). Ninety percent of children with diarrhea required PN. Duration of PN in these children was longer than in those without diarrhea who requested PN (P < 0.05). Despite PN, weight loss at discharge was still greater in the study group (P < 0.05). Diarrhea was associated with a significant fall in serum albumin (P < 0.005). Diarrhea and weight loss occur in children after BMT despite active PN support. Pretransplant TBI and the use of allografts are important determinants of these complications.

Intensive chemotherapy with autologous bone marrow transfusion as primary treatment in women with breast cancer and more than five involved axillary lymph nodes

Patients with breast cancer and a high number of involved axillary lymph nodes have a poor prognosis, despite adjuvant chemotherapy. The 5-year disease-free survival (DFS) in this group amounts to 30-40% and the 10-year DFS is only 15-20%. Therefore, new treatment modalities are being sought for this group of patients. The aim of the present study was the evaluation of the efficacy of high-dose chemotherapy combined with autologous bone marrow support. 24 patients with a primary breast cancer with more than five involved axillary lymph nodes received, after surgery, six courses of induction chemotherapy followed by ablative chemotherapy and reinfusion of autologous bone marrow. All patients were premenopausal or less than 2 years postmenopausal. Induction chemotherapy consisted of methotrexate (MTX) 1.5 g/m2 intravenous (i.v.) and 5-fluorouracil (5-FU) 1.5 g/m2 i.v. on day 1, prednisone 40 mg/m2 orally on days 2-14, doxorubicin 50 mg/m2 i.v. and vincristine 1 mg/m2 i.v. on day 14. Courses were repeated six times every 4 weeks. 10 patients received cyclophosphamide 7 g/m2 i.v. and etoposide 1.5 g/m2 i.v. as intensive regimen, in 14 patients this comprised mitoxantrone 50 mg/m2 i.v. and thiotepa 800 mg/m2 i.v. Reinfusion of autologous marrow followed on day 7. Finally, patients received locoregional radiotherapy for extranodal disease and tamoxifen 40 mg daily orally over a period of 2 years. The median age of patients was 42 years, range 29-54. The median number of involved nodes was 10. During induction therapy, fever requiring i.v. antibiotics occurred in 4% of 144 courses, 14% of patients suffered from mucositis WHO grade 2-3, and the other patients had mucositis grade 1. During the ablative chemotherapy, 1 patient died, 6 developed septicaemia, 5 showed mucositis grade 3-4 and the other patients had mucositis grade 1 or 2. In the follow-up, 1 patient died from acute cardiac failure. Reversible radiation-induced pneumonitis occurred in 7 out of 14 irradiated patients; symptoms started directly following radiotherapy and lasted for several weeks, but disappeared in due course. During follow-up, 2 patients with six and > 10 positive nodes, respectively, have relapsed after 18 and 36 months, both in the cyclophosphamide/etoposide regimen. Median observation is 3 years, disease-free survival at 5 years is predicted to be 84%. Intensive treatment in these patients with high numbers of involved axillary lymph nodes is a toxic regimen, but may improve the chance of surviving free of disease.

Nutrition support in bone marrow transplant recipients

Bone marrow transplantation is a complex therapy designed as curative for a variety of malignant and nonmalignant diseases. It is a highly invasive procedure that uses high-dose chemotherapy and may also include radiation treatment. This results in immunosuppression that is often followed by infection, graft-vs-host disease, pulmonary complications, veno-occlusive disease of the liver, and metabolic and nutritional abnormalities. Parenteral nutrition has been the mainstay of nutrition support in patients undergoing bone marrow transplantation. Parenteral nutrition has not been uniformly successful in improving nutritional status or outcome. Enteral nutrition offers many theoretical advantages but is often not well tolerated. Coordinated efforts of the health care team are needed to optimize the nutrition support of these complicated cases.

Total parenteral nutrition and nutritional assessment and leukaemic children undergoing bone marrow transplantation

The aggressive radiotherapy and chemotherapy used in conditioning regimens for children with leukaemia undergoing bone marrow transplantation (BMT) cause a severe catabolic state. Total parenteral nutrition (TPN) is indispensable in the management of these patients. 25 children with leukaemia undergoing BMT were studied to evaluate the efficacy of TPN and the value of anthropometric parameters and biochemical variables (albumin, retinol-binding protein and prealbumin) in monitoring nutritional status in the critical post-BMT phase. The complications of TPN were mainly metabolic, generally mild and easily controlled. The hyperalimentation solution and infusion line were not responsible for infection in any patient. The marked variations in anthropometric parameters and albumin expected in such patients were not observed in our children due to the nutritional support given. Prealbumin and retinol-binding protein showed statistically significant, positive variations (P less than 0.01), thus proving sensitive indices of the response to nutritional repletion.