Clinical impact of sarcopenia and relevance of nutritional intake in patients before and after allogeneic hematopoietic stem cell transplantation

Considerations for medical nutrition therapy management of the critically ill patient with hematological malignancies: A narrative review

Patients with hematological malignancies (HMs) are more frequently admitted now than in the past to the intensive care unit (ICU) due to more aggressive approaches in primary therapy of HMs and the need for critical care support. Pathophysiological alterations derived from HMs and the different hematological therapies, such as chemotherapy, negatively affect gastrointestinal (GI) function, metabolism, and nutrition status. Further, malnutrition strongly influences outcomes and tolerance of the different hematological therapies. In consequence, these critically ill patients frequently present with malnutrition and pathophysiological alterations that create challenges for the delivery of medical nutrition therapy (MNT) in the ICU. Frequent screening, gauging tolerance, and monitoring nutrition status are mandatory to provide individualized MNT and achieve nutrition objectives. The present review discusses how HM impact GI function and nutrition status, the importance of MNT in patients with HM, and specific considerations for guidance in providing adequate MNT to these patients when admitted to the ICU.

The evolution and impact of sarcopenia in severe aplastic anaemia survivors following allogeneic haematopoietic cell transplantation

BACKGROUND

Sarcopenia is a potential risk factor for adverse outcomes in haematopoietic cell transplantation (HSCT) recipients. We aimed to explore longitudinal body changes in muscle and adipose mass and their prognostic value in allogeneic HSCT-treated severe aplastic anaemia (SAA) patients.

METHODS

We retrospectively analysed consecutive SAA patients who underwent allogeneic HSCT between January 2017 and March 2022. Measurements of pectoral muscle and corresponding subcutaneous fat mass were obtained via chest computed tomography at baseline and at 1 month, 3 months, 6 months, and 12 months following HSCT. Sarcopenia was defined as pectoral muscle index (PMI) lower than the sex-specific median at baseline. Changes in body composition over time were evaluated by generalized estimating equations. Cox regression models were used to investigate prognostic factors affecting overall survival (OS) and failure-free survival (FFS). A nomogram was constructed from the Cox regression model for OS.

RESULTS

We included 298 adult SAA patients (including 129 females and 169 males) with a median age of 31 years [interquartile range (IQR), 24-39 years] at baseline. Sarcopenia was present in 148 (148/298, 50%) patients at baseline, 218 (218/285, 76%) patients post-1 month, 209 (209/262, 80%) patients post-3 month, 169 (169/218, 78%) patients post-6 month, and 129 (129/181, 71%) patients post-12 month. A significant decrease in pectoral muscle mass was observed in SAA patients from the time of transplant to 1 year after HSCT, and the greatest reduction occurred in post 1-3 months (P < 0.001). The sarcopenia group exhibited significantly lower 5-year OS (90.6% vs. 100%, log-rank P = 0.039) and 5-year FFS (89.2% vs. 100%, log-rank P = 0.021) than the nonsarcopenia group at baseline. Sarcopenia at baseline (hazard ratio, HR, 6.344; 95% confidence interval, CI: 1.570-25.538; P = 0.01; and HR, 3.275; 95% CI: 1.159-9.252; P = 0.025, respectively) and the delta value of the PMI at 6 months post-transplantation (ΔPMI6) (HR, 0.531; 95% CI: 0.374-0.756; P < 0.001; and HR, 0.666; 95% CI: 0.505-0.879; P = 0.004, respectively) were demonstrated to be independent prognostic factors for OS and FFS in SAA patients undergoing HSCT, and were used to construct the nomogram. The C-index of the nomogram was 0.75, and the calibration plot showed good agreement between the predictions made by the nomogram and actual observations.

CONCLUSIONS

Sarcopenia persists in SAA patients from the time of transplant to the 1-year follow-up after HSCT. Both sarcopenia at baseline and at 6 months following HSCT are associated with poor clinical outcomes, especially in patients with persistent muscle mass loss up to 6 months after transplantation.

Assessment of rehabilitation practices during hematopoietic stem cell transplantation in the United States: a survey

Background

Rehabilitation therapy is important to treat physical and functional impairments that may occur in individuals receiving physically taxing, yet potentially curative hematopoietic stem cell transplants (HSCT). However, there is scarce data on how rehabilitation is delivered during HSCT in real-life setting. Our objective is to assess the rehabilitation practices for adult patients hospitalized for HSCT in the United States.

Methods

A 48-question online survey with cancer centers with the top 10% HSCT volumes (per American registries). We obtained data on patient characteristics, rehabilitation therapy details (timing, indication, administering providers), physical function objective and subjective outcome measures, and therapy activity precautions.

Results

Fourteen (out of 21) institutions were included. Rehabilitation therapy referrals occurred at admission for all patients at 35.7% of the centers for: functional decline (92.9%), fall risk (71.4%), and discharge planning (71.4%). Participating institutions had physical therapists (92.9%), occupational therapists (85.7%), speech language pathologists (64.3%) and therapy aides (35.7%) in their rehabilitation team. Approximately 71% of centers used objective functional measures including sit-to-stand tests (50.0%), balance measures (42.9%), and six-minute walk/gait speed (both 35.7%). Monitoring of blood counts to determine therapy modalities frequently occurred and therapies held for low platelet or hemoglobin values; but absolute neutrophil values were not a barrier to participate in resistance or aerobic therapies (42.9%).

Discussion

Rehabilitation practices during HSCT varied among the largest volume cancer centers in the United States, but most centers provided skilled therapy, utilized objective, clinician and patient reported outcomes, and monitored blood counts for safety of therapy administration.

Comparison of pre- and posttransplant energy expenditure in patients undergoing hematopoietic stem cell transplantation and evaluation of associated factors

OBJECTIVES

Patients undergoing hematopoietic stem cell transplantation may present with metabolic alterations that can have an effect on their energy expenditure and nutritional status. This project aimed to compare the pre- and posttransplant energy expenditures of patients undergoing hematopoietic stem cell transplantation as well as related factors.

METHODS

This prospective study was conducted at a single center. Patients, undergoing autograft or allograft, were evaluated before transplantation and on the 10th and 17th d posttransplantation. Energy expenditure was measured by indirect calorimetry. Diet intake was assessed by a 24-h dietary recall. Infectious and noninfectious complications were analyzed between days 1 to 10 after transplantation and days 11 to 17 after transplantation. Paired model analyses were carried out to identify the pretransplantation and posttransplantation periods.

RESULTS

Twenty patients were evaluated with a mean age of 45.6 ± 17.2 y; a majority were male sex (65%), and the most frequent diagnoses were chronic myeloid leukemia (25%) and multiple myeloma (25%). Energy expenditure increased by 15% posttransplantation, and the energy requirement per kilogram of weight was 23 kcal/kg at day 10 after transplantation. Throughout the posttransplantation period, 45% of the patients required nutritional therapy. Negative energy and negative protein balance were observed at all analyzed times. Phase angle (P = 0.018), fever (P = 0.014), mucositis grades I to II (P = 0.018), and the total number of infectious and noninfectious events (P = 0.043) were associated with an increase in energy expenditure at day 10 after transplantation.

CONCLUSIONS

Energy expenditure increased after transplantation compared with pretransplantation in 50% of patients. Phase angle, fever, grades I to II mucositis, and infectious and noninfectious events were associated with increased energy expenditure at day 10 after transplantation.

The European Society for Blood and Marrow Transplantation (EBMT) roadmap and perspectives to improve nutritional care in patients undergoing hematopoietic stem cell transplantation on behalf of the Cellular Therapy and Immunobiology Working Party (CTIWP) and the Nurses Group (NG) of the EBMT

Malnutrition is the most common comorbidity during the continuum of hematopoietic stem cell transplant (HSCT) and negatively impacts clinical outcomes, response to therapy, quality of life, and costs. The intensive conditioning regimen administered before transplant causes inflammatory damages to the gastrointestinal system, which themselves contribute to trigger graft versus host disease (GvHD) in the allogeneic setting. GvHD and other post-transplant complications such as infections adversely affect food intake and gut absorption of nutrients. Consequently, patients exhibit signs of malnutrition such as weight loss and muscle wasting, thus triggering a "vicious circle" that favours additional complications. Among HSCT centres, there is marked variability in nutritional care, from screening for malnutrition to nutritional intervention. The present paper, elaborated by the Cellular Therapy and Immunobiology Working Party and the Nurses Group of the European Society for Blood and Marrow Transplantation, aims at defining a roadmap that identifies the main nutritional critical issues in the field of HSCT. This document will be propaedeutic to the development of clinical algorithms to counteract risk factors of malnutrition, based on scientific evidence and shared among HSCT centres, and thus maximize transplant outcomes.

Prognostic Impact of Quantifying Sarcopenia and Adipopenia by Chest CT in Severe Aplastic Anemia Patients Treated With Allogeneic Hematopoietic Stem Cell Transplantation

RATIONALE AND OBJECTIVES

To investigate the prognostic role of chest CT-defined sarcopenia and adipopenia in severe aplastic anemia (SAA) patients treated with hematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

This was a retrospective study of 123 consecutive SAA patients treated with HSCT. CT imaging was performed to quantify the pectoralis muscle (including major and minor) index (PMI) and the corresponding subcutaneous adipose tissue index (SAI). Sarcopenia and adipopenia were defined as PMI and SAI lower than the respective sex-specific medians. Correlations of the PMI and SAI with anthropometric indexes were calculated. Transplant-related outcomes were compared between the sarcopenia and adipopenia groups. Prognostic factors for overall survival (OS) and fail-free survival (FFS) were identified by Cox regression and were used to create a nomogram. The accuracy of the nomogram was evaluated by ROC curves.

RESULTS

PMI showed good correlation with BMI and fat-free mass index (p < 0.001). SAI correlated with BMI and fat mass index (p < 0.001). The sarcopenia group (47.2%) had a significantly worse 3-year OS (90.8% vs. 77.6%, p = 0.045) and 3-year FFS (89.2% vs. 74.1%, p = 0.035) than the nonsarcopenia group. Sarcopenia status and diagnostic category were used to construct the nomogram of OS, as these were independent prognostic factors in the multivariate analysis for OS and FFS (p < 0.05). The area under the curve of the nomogram at one year and three years was 0.801 and 0.721, respectively.

CONCLUSION

Sarcopenia indicates a poor prognosis in SAA patients undergoing HSCT. Intensive supportive care is suggested for SAA patients with sarcopenia before transplantation.

The Critical Exploration into Current Evidence behind the Role of the Nutritional Support in Adult Patients Who Undergo Haematogenic Stem Cell Transplantation

Haematopoietic stem cell transplantation (HSCT) is a treatment option for many haematological conditions in patients of all ages. Nutritional support is important at each stage of treatment, but particular nutritional needs and dictated support occur during the preparatory (conditioning regimen) and post-transplant periods. Patients may require nutritional treatment by the enteral or parenteral route. The quantitative and qualitative composition of meals may change. Vitamin requirements, including vitamin D and vitamin C, might also be different. An adequately composed diet, adapted to the needs of the patient, may influence the occurrence of complications such as graft-versus-host disease (GvHD), gastrointestinal disorders, infections, and reduced survival time. Haematological diseases as well as transplantation can negatively affect the intestinal flora, with negative consequences in the form of mucosal inflammation and disorders of a functional nature. Currently, aspects related to nutrition are crucial in the care of patients after HSCT, and numerous studies, including randomized trials on these aspects, are being conducted. This study serves the critical analysis of current scientific evidence regarding nutritional support for patients after HSCT.

Prognostic value of low muscle mass at the 12th thoracic vertebral level in multiple myeloma treated with transplantation: CAREMM-2101 study

PURPOSE

Autologous hematopoietic stem cell transplantation (ASCT) has been introduced as a standard treatment for newly diagnosed multiple myeloma (NDMM) following novel agent-based induction chemotherapy. This study investigated whether pre-ASCT low muscle mass evaluated using the paraspinal muscle index (PMI) at the 12th thoracic vertebra (T12) level is a reliable prognostic marker in NDMM after chemotherapy.

METHODS

A multi-center registry database was retrospectively analyzed. Between 2009 and 2020, 190 patients with chest computed tomography images underwent frontline ASCT following induction therapy. The PMI was defined as the value of the paraspinal muscle area at the T12 level divided by the square of the patient's height. The cut-off value indicating a low muscle mass was sex-specific, using the lowest quintiles.

RESULTS

Of the 190 patients, 38 (20%) were in the low muscle mass group. The low muscle mass group had a lower 4-year overall survival (OS) rate than the non-low muscle mass group (68.5% vs. 81.2%; P = 0.074). The median progression-free survival (PFS) in the low muscle mass group was significantly shorter compared with the non-low muscle mass group (23.3 months vs. 29.2 months; P = 0.029). The cumulative incidence of transplant-related mortality (TRM) was significantly higher in the low muscle mass group than in the non-low muscle mass group (4-year probability of TRM incidence, 10.6% vs. 0.7%; P < 0.001). In contrast, no significant difference in the cumulative incidence of disease progression was found between the two groups. Multivariate analysis revealed that low muscle mass was associated with significant negative outcomes for OS [(hazard ratio (HR): 2.14; P = 0.047], PFS (HR: 1.78; P = 0.012), and TRM (HR: 12.05; P = 0.025).

CONCLUSION

Paraspinal muscle mass may have a prognostic role in NDMM patients who undergo ASCT. Patients with low paraspinal muscle mass have lower survival outcomes compared to non-low muscle mass group.

Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant

PURPOSE

Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT.

PATIENTS AND METHODS

In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017.

RESULTS

In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03).

CONCLUSION

A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

Impact of muscle loss in children with hematologic malignancies undergoing allogeneic hematopoietic cell transplantation

The widespread recognition of the concept of sarcopenia, or muscle loss, has impacted the prognosis of patients undergoing high-intensity treatments. We focused on the effect of muscle loss on the prognosis of pediatric patients with hematologic diseases. A total of 65 patients with hematologic malignancies who underwent allogeneic HCT once were investigated. The change in cross-sectional psoas muscle area (PMA) measured on computed tomography (CT) images was expressed as the muscle loss index (MLI), which was calculated by dividing the pre-HCT PMA by the baseline PMA. In this study, patients with MLI values less than 0.85 were classified into the muscle loss group. Muscle loss was observed in 27 patients (41.5%). Patients who experienced muscle loss were older than those who did not. Muscle loss was an independent predictor of higher non-relapse mortality (NRM) (p = 0.012) and inferior overall survival (OS) (p = 0.045) at 5 years. Multivariate analysis showed that muscle loss was an independent risk factor for higher NRM (p = 0.046), and inferior EFS (p = 0.048). Muscle loss observed pre-HCT may be a predictor of increased NRM, poor OS and EFS in pediatric patients with hematologic malignancies undergoing allogeneic HCT.

Allogeneic haematopoietic stem cell transplantation and patient falls: impact of lower extremity muscle strength

OBJECTIVES

Patients undergoing allogeneic haematopoietic stem cell transplantation (allo-HSCT) have a higher risk of falls than those receiving other therapies for haematological disorders. This study aimed to investigate the impact of pretransplant lower extremity muscle strength (LEMS) on post-transplant falls.

METHODS

In this retrospective cohort study, patients aged ≥18 years who underwent allo-HSCT were included. All data were extracted from medical records. LEMS was defined as the knee extension force measured by a handheld dynamometer divided by the patient's weight. The receiver operating characteristic (ROC) curve was used to calculate the optimal LEMS cut-off value for prediction of falls. Patients were categorised into low and normal LEMS groups based on the cut-off value. The impact of pretransplant LEMS on post-transplant falls was analysed using a Cox proportional hazards model.

RESULTS

In total, 101 patients were analysed. During the observation period, falls occurred in 32 patients (31.7%). The ROC curve analysis results showed that the optimal LEMS cut-off value for prediction of falls was 45.4% per body weight. In multivariate analysis, pretransplant low LEMS was a significant predictor of falls in model 1 with patient characteristics as a confounding factor and model 2 with medications-inducing falls as a confounding factor, respectively (model 1: HR 3.23, 95% CI 1.37 to 7.64; model 2: HR 2.82, 95% CI 1.20 to 6.59).

CONCLUSIONS

Pretransplant LEMS was a significant predictor of post-transplant falls. The results of this study may help to prevent falls in patients undergoing allo-HSCT.

Body Composition Impacts Hematopoietic Stem Cell Transplant Outcomes in Both Autologous and Allogeneic Transplants: A Systematic Review

According to World Health Organization, over 50,000 hematopoietic stem cell transplants (HSCTs) are performed annually worldwide. Though HSCT can extend life-expectancy and improve disease-related health burdens, it is not without risks. Post-transplant overall survival is improving; therefore, it is imperative that factors contributing to or impeding further improvements are well understood. The purpose of this systematic review is to explore current data on body composition (specifically weight loss, BMI, obesity and sarcopenia) and the relation to HSCT outcomes. A literature search was conducted via PubMed and Web of Science databases. Key words included "body composition," "sarcopenia," "hematopoietic stem cell transplant," "malnutrition," "body mass index," and "obesity." Results indicated that 16 out of 18 analyzed studies found a statistically significant relationship between body composition, in particular higher BMI and weight loss, and at least one survival-related outcome variable (eg., non-relapse mortality, overall survival and/or relapse). Based on the findings of this review, body composition, whether evaluated before or during HSCT, can impact a wide variety of post-transplant outcomes. This speaks to the importance of evaluating patients pre-transplant, identifying potential risk factors for worsened outcomes, and providing immediate interventions in order to optimize transplant outcomes.

Allogeneic haematopoietic stem cell transplantation-clinical outcomes: impact of leg muscle strength

OBJECTIVES

Muscle strength decline is reported to predict mortality in many cancers. However, there is little knowledge of the relation between muscle strength decline and clinical outcomes of allogeneic haematopoietic stem cell transplantation (allo-HSCT). This study aimed to determine the impact of pre-transplant lower extremity muscle strength (LEMS) on post-transplant overall survival (OS) and non-relapse mortality (NRM).

METHODS

In this retrospective cohort study, 97 adult patients underwent allo-HSCT during 2012-2020. LEMS was defined as knee extension force divided by patient's body weight. The patients were divided into low and high LEMS groups based on pre-transplant LEMS. OS was measured using the Kaplan-Meier method and the Cox proportional hazards model. The cumulative incidence of NRM was evaluated using the Fine and Gray method, with relapse considered as a competing risk event.

RESULTS

Probability of OS was significantly lower in the low LEMS groups (HR 2.48, 95% CI 1.20 to 5.12, p=0.014) than in the high LEMS group on multivariate analysis. Five-year OS was 25.8% and 66.4% in the low and high LEMS groups, respectively. Risk of NRM was significantly higher in the low LEMS group (HR 4.49, 95% CI 1.28 to 15.68, p=0.019) than in the high LEMS group. The cumulative incidence of NRM was 41.4% and 11.1% in the low and high LEMS groups, respectively.

CONCLUSIONS

Pre-transplant LEMS was a significant factor in predicting OS and NRM.

Ruxolitinib exposure in patients with acute and chronic graft versus host disease in routine clinical practice-a prospective single-center trial

Purpose

Knowledge on Ruxolitinib exposure in patients with graft versus host disease (GvHD) is scarce. The purpose of this prospective study was to analyze Ruxolitinib concentrations of GvHD patients and to investigate effects of CYP3A4 and CYP2C9 inhibitors and other covariates as well as concentration-dependent effects.

Methods

262 blood samples of 29 patients with acute or chronic GvHD who were administered Ruxolitinib during clinical routine were analyzed. A population pharmacokinetic model obtained from myelofibrosis patients was adapted to our population and was used to identify relevant pharmacokinetic properties and covariates on drug exposure. Relationships between Ruxolitinib exposure and adverse events were assessed.

Results

Median of individual mean trough serum concentrations was 39.9 ng/mL at 10 mg twice daily (IQR 27.1 ng/mL, range 5.6–99.8 ng/mL). Applying a population pharmacokinetic model revealed that concentrations in our cohort were significantly higher compared to myelofibrosis patients receiving the same daily dose (p < 0.001). Increased Ruxolitinib exposure was caused by a significant reduction in Ruxolitinib clearance by approximately 50%. Additional comedication with at least one strong CYP3A4 or CYP2C9 inhibitor led to a further reduction by 15% (p < 0.05). No other covariate affected pharmacokinetics significantly. Mean trough concentrations of patients requiring dose reduction related to adverse events were significantly elevated (p < 0.05).

Conclusion

Ruxolitinib exposure is increased in GvHD patients in comparison to myelofibrosis patients due to reduced clearance and comedication with CYP3A4 or CYP2C9 inhibitors. Elevated Ruxolitinib trough concentrations might be a surrogate for toxicity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00280-021-04351-w.

The prevalence of sarcopenia and relationships between dietary intake and muscle mass in head and neck cancer patients undergoing radiotherapy: A longitudinal study

PURPOSE

Our study aims to investigate dietary intake characteristics and their association with skeletal muscle mass in head and neck cancer patients treated with radiotherapy.

METHODS

From March 2017 to August 2018, patients with head and neck cancer who received radiotherapy at our affiliated hospital were enrolled. Dietary intake was assessed through 24-hr dietary recall and skeletal muscle mass was evaluated by bioelectrical impedance analysis at three-time points. Appendicular skeletal muscle mass was adjusted for height squared defined sarcopenia and correlated with dietary intake by generalized estimating equations (GEE).

RESULTS

This study sample comprised 287 patients [median age: 54 years; 187 (65.2%) men]. Median dietary intake at post-treatment was 14.95 kcal/kg/day energy and 0.63 g/kg/day protein. Skeletal muscle mass decreased significantly in all patients. The prevalence of sarcopenia increased from 24.4% before treatment to 46.7% at the end of treatment. Exploratory univariate GEE analysis revealed that radiotherapy time-point, male-gender, age ≥60 and decreased dietary energy intake significantly impacted on muscle loss represented by the appendicular skeletal muscle index. After controlling covariates, dietary energy intake was only positively associated with muscle loss in women (P = 0.013, 95% CI = 0.003-0.027) but not in men (P = 0.788, 95% CI = -0.007-0.009).

CONCLUSION

While the loss in skeletal muscle is more prevalent in men receiving radiotherapy, the effects of dietary energy intake were only associated with women. A prospective randomized clinical trial is required to identify the appropriate amount of dietary energy supplement by gender in cancer patients treated with radiotherapy.

Food intake of children and adolescents submitted to allogeneic hematopoietic stem cells transplantation

ABSTRACT Objective Describe the dietary intake of children and adolescents submitted to allogeneic hematopoietic stem cell transplantation. Methods Data from 0 to 19-year-old patients’ medical records who were submitted to the procedure from January 2012 to September 2017 were used. These medical records provided anthropometric, food intake control and symptoms data for three moments: three days before infusion (M1), the infusion day (M2), and 25 days after the cell infusion (M3). This study was approved by the Ethics in Research Committee (17-0267). Results The patients presented weight loss (p>0.001) and a decrease in body mass index (p>0.001) in M1 versus M2 and M3. The means of calorie intake (p=0.031), protein (p=0.006), lipid (p=0.017), dietary fiber (p=0.035), calcium (p=0.005), iron (p=0.012), and sodium (p=0.022) had a reduction from M1 to M2 and an increase from M2 to M3. There was a decrease in mean intake of carbohydrates and calories per kilo from M1 to M2 and an increase from M2 to M3. The nutritional status was related to temperature above 37ºC (p<0.001) and to mucositis (p=0.001), in M1 and M2. There was a correlation of dietary intake with the presence of temperature above 37ºC (p=0.019) in M2 and M3. Conclusion Reduced intake and worsening of the patients’ previous nutritional status appear to interfere with allogeneic hematopoietic stem cell transplantation and its complications, such as the presence of temperature above 37ºC and mucositis.

Risks of Muscle Atrophy in Patients with Malignant Lymphoma after Autologous Stem Cell Transplantation

OBJECTIVE

Muscle atrophy is associated with autologous stem cell transplantation (ASCT)-related outcomes in patients with malignant lymphoma (ML). However, the impact of ASCT on muscle mass remains unclear in patients with ML. The aims of this study were to investigate changes in muscle mass and risk profiles for muscle atrophy after ASCT.

METHOD

We enrolled 40 patients with refractory ML (age 58 [20-74] years, female/male 16/24, body mass index (BMI) 21.1 kg/m² [17.1-29.6]). Psoas muscle mass was assessed using the psoas muscle index (PMI) before and after ASCT.

STATISTICAL ANALYSIS USED

Independent factors associated with a severe decrease rate of change in PMI were evaluated by decision-tree analysis, respectively.

RESULTS

PMI was significantly decreased after ASCT (4.61 vs. 4.55 cm²/m²; P=0.0425). According to the decision-tree analysis, the regimen was selected as the initial split. The rates of change in PMI were -5.57% and -3.97% for patients administered MCEC and LEED, respectively. In patients who were administered LEED, the second branching factor was BMI. In patients with BMI < 20.3 kg/m², the rate of change in PMI was -7.16%. On the other hand, the rate of change in PMI was 4.05% for patients with BMI ≥ 20.3 kg/m².

CONCLUSION

We demonstrated that muscle mass decreased after ASCT in patients with ML. Patients who received MCEC and patients with low BMI were at risk for a decrease in muscle mass.

The geriatric syndrome of sarcopenia impacts allogeneic hematopoietic cell transplantation outcomes in older lymphoma patients

Older patients with advanced hematologic malignancies are increasingly considered for allogeneic hematopoietic cell transplantation (allo-HCT) yet their survival outcomes remain suboptimal. We and others have previously shown that pre-HCT multi-morbidity and functional limitation and post-HCT geriatric syndromes significantly impact outcomes. Sarcopenia, an accelerated loss of muscle mass and function, has been increasingly recognized in older cancer patients. We identified 146 lymphoma patients 50 years or older who were allografted from 2008 to 2018 at our institution and found that before allo-HCT, 80 (55%) patients were sarcopenic. Pre-HCT sarcopenia was significantly associated with overall survival, progression-free survival, and nonrelapse mortality independent of multi-morbidity and functional limitation. In 6-month landmark analysis, post-HCT sarcopenia remained significantly associated with survival. Our findings illustrate the high prevalence and profound impact of sarcopenia on survival. While requiring prospective confirmation, preemptive, longitudinal, and multidisciplinary interventions for sarcopenia are warranted to improve HCT outcomes for older patients.

Sarcopenia among patients after allogeneic hematopoietic stem cell transplantation and the impact of chronic graft-versus-host disease

PURPOSE

This study investigated the frequency and characteristics of sarcopenia among patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT) with a specific focus on the chronic graft-versus-host disease (cGVHD) population and its association with malnutrition, vitamin D and clinical characteristics.

METHODS

We assessed sarcopenia, vitamin D levels, and nutritional status in 73 patients who underwent allo-HSCT, of which 45 were diagnosed with cGVHD. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria.

RESULTS

Sarcopenia was diagnosed in 19.2% of patients after allo-HSCT with statistically no significant difference between cGVHD and non-cGVHD patients. The risk factor for sarcopenia was the male gender. Sarcopenia in allo-HSCT patients correlated strongly with malnutrition and with current corticosteroid treatment (p < 0.005). Among cGVHD patients sarcopenia additionally correlated strongly with the number of prior systemic immunosuppressive therapy lines (p < 0.005) and moderately with the intensity of immunosuppression, cGVHD severity global rating assessed by both the health care provider and the patient and joint and fascia cGVHD involvement (p < 0.05). Vitamin D deficiency was found in more than 54.8% of patients, but the correlation to sarcopenia was not found.

CONCLUSION

Sarcopenia was found to be common in long term survivors of allo-HSCT independently of the cGVHD diagnosis. Prospective longitudinal studies are needed for a better understanding of factors affecting the development of sarcopenia after allo-HSCT.

Computed tomography-defined sarcopenia: prognostic predictor of nonrelapse mortality after allogeneic hematopoietic stem cell transplantation: a multicenter retrospective study

We analyzed clinical cutoffs for defining computed tomography (CT) methods for sarcopenia and examined the prognostic value of CT for allogeneic hematopoietic stem cell transplantation (allo-HCST) outcomes of patients with myeloid malignancy. One hundred twenty-five adult patients with acute myeloid leukemia and myelodysplastic syndrome who underwent first allo-HSCT between 2000 and 2017 were included. Sarcopenia was assessed using CT-based skeletal muscle index (SMI) and mean muscle attenuation at L3. A statistical difference in SMI was confirmed between sarcopenia (n = 52) and nonsarcopenia (n = 73) patients. There were no significant correlations of muscularity with age, performance status, or other characteristics of HSCT. After 2 years, overall survival (OS) was 43.5% and 70.1%, disease-free survival was 52.9% and 68.6%, nonrelapse mortality (NRM) was 20.8% and 8.4%, incidence of acute GVHD (≥ grade 2) was 38.8% and 39.1%, that of chronic GVHD was 53.2% and 37.3%, and median duration of hospitalization was 88 days and 74 days (P = 0.026), respectively, in the sarcopenia and nonsarcopenia groups. Multivariate analysis showed that presence of sarcopenia is a novel adverse factor for high NRM and poor OS. Pretransplant CT-defined sarcopenia is correlated with decreased OS, increased NRM, and prolonged hospitalization.

Evaluation of nutritional risk factors in hematopoietic stem cell transplantation-eligible patients

Objective

To evaluate the nutritional risk factors in patients eligible for hematopoietic stem cell transplantation.

Methods

A cross-sectional, descriptive study conducted with patients recruited from an hematology outpatient clinic. Study variables included demographic and clinical data, patient-generated global subjective assessment findings, anthropometric indicators, food intake and oxidative stress levels. The level of significance was set at 5% (p<0.05).

Results

The sample comprised 72 patients, mean age of 48.93 years (14.5%). Multiple myeloma was the most prevalent condition (51.4%) in this sample. Most patients (55.6%) were overweight according to body mass index and at risk of cardiovascular disease according to waist circumference, conicity index and percentage of body fat. Sarcopenia was associated with risk of cardiovascular disease, hip-to-waist ratio (p=0.021), muscle strength depletion (p<0.001), food intake (p=0.023), reduced functional capacity (p=0.048), self-reported well-nourished status; p=0.044) and inadequate vitamin B6 (p=0.022) and manganese (p=0.026) intake. Elevated oxidative stress, detected in 33.3% of patients in this sample, was not associated with sarcopenia.

Conclusion

Most patients in this sample were overweight and sarcopenic. Lean mass depletion was associated with risk of cardiovascular disease, reduced muscle strength, food intake changes, reduced functional capacity, self-reported well-nourished status and inadequate intake of vitamin B6 and manganese, but not with oxidative stress.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Adults

The nutritional status of patients submitted to hematopoietic stem cell transplant is considered an independent risk factor, which may influence on quality of life and tolerance to the proposed treatment. The impairment of nutritional status during hematopoietic stem cell transplant occurs mainly due to the adverse effects resulting from conditioning to which the patient is subjected. Therefore, adequate nutritional evaluation and follow-up during hematopoietic stem cell transplant are essential. To emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to the nutritional assessment of the patient, the Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplant: Adults was prepared, aiming to standardize and update Nutritional Therapy in this area. Dietitians, nutrition physicians and hematologists from 15 Brazilian centers thar are references in hematopoietic stem cell transplant took part.

Long-term outcome of renal function in children after stem cell transplantation measured by estimated glomerular filtration rate

BACKGROUND

Stem cell transplantation (SCT) outcomes have improved over the last three decades, with many patients being rescued with this treatment. However, improved outcomes have led to issues with long-term sequelae. One of these sequelae in children is renal dysfunction, an index of which is estimated using glomerular filtration rate (eGFR).

PROCEDURE

We retrospectively analyzed eGFR in 83 pediatric patients who received SCT. Data from all patients extended up to 12 months or more post SCT. The median follow-up time was 127.7 months (range 12.0-268.8 months).

RESULTS

Eighteen patients (21.7%) had low eGFR (<90 ml/min/1.73 m² ) post SCT. Cumulative incidence of low eGFR was 25.8 ± 2.0%. Nine (10.6%) patients had a low eGFR pre-SCT. However, pre- and post-SCT incidence of low eGFR were not correlated. Meanwhile, only two patients (2.4%) exhibited severe renal dysfunction, with eGFRs < 60 ml/min/1.73 m² . Independent risk factors for low eGFR were solid tumor and use of fludarabine. Moreover, age at SCT ≥ 7 years was also a long-term post-SCT risk factor for low eGFR in all patients.

CONCLUSION

Independent post-SCT long-term risk factors for low eGFR in children were solid tumor and use of fludarabine. Moreover, age at SCT ≥ 7 years was a post-SCT long-term risk factor for low eGFR across all patients.

Comorbidities, age, and other patient-related predictors of allogeneic hematopoietic cell transplantation outcomes

INTRODUCTION

Allogeneic hematopoietic cell transplantation (HCT) provides potential cure to a large number of malignant and nonmalignant hematological disorders. With the development of non-myeloablative and reduced-intensity conditioning regimens, allogeneic HCT can nowadays be offered to a number of older or medically unfit patients. Up until the twenty-first century, chronological age was considered a hypothetical barrier. Recent reports, however, have shown that comorbidities, function, and other patient-related factors influence HCT outcomes at a higher magnitude than age alone. Areas covered: To define the eligibility of older or medically unfit patients for allogeneic HCT, a range of factors have to be considered. To solve this considerable issue, we need to further understand the mechanism and consequences of aging, such as chronic inflammation, sarcopenia, and especially the structure of frailty. Domains covering functional, physical, mental, social, nutritional, bone, and other health statuses should be evaluated and considered. Expert commentary: In this review we merge the current assessment tools with the potential approaches to objectify functional resources, as well as with possible methods to improve these resources in older or otherwise medically unfit patients prior to allogeneic HCT.

Amino acid kinetics and the response to nutrition in patients with cancer

PURPOSE

Amino acids are involved in many physiological processes in the body and serve as building blocks of proteins which are the main component of muscle mass. Often patients with cancer experience muscle wasting, which is associated with poor outcomes. The purpose of this paper is to discuss amino acid kinetics in cancer, review the evidence on the response to nutrition in patients with cancer, and to give recommendations on the appropriate level of amino acid or protein intake in cancer. Current evidence shows that amino acid kinetics in patients with cancer are disturbed, as reflected by increased and decreased levels of plasma amino acids, an increased whole body turnover of protein and muscle protein breakdown. A few studies show beneficial effects of acute and short-term supplementation of high protein meals or essential amino acid mixtures on muscle protein synthesis.

CONCLUSIONS

Cancer is associated with disturbances in amino acid kinetics. A high protein intake or supplementation of amino acids may improve muscle protein synthesis. Future research needs to identify the optimal level and amino acid mixtures for patients with cancer, in particular for those who are malnourished.