The impact of pretransplant malnutrition on allogeneic hematopoietic stem cell transplantation outcomes

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.

Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

Nutritional and Body Composition Changes in Paediatric β-Thalassemia Patients Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Study Using Bioelectrical Impedance Analysis

Objective

This retrospective study evaluated nutritional status and body composition changes in paediatric β-thalassemia (β-TM) patients before and after hematopoietic stem cell transplantation (HSCT), using bioelectrical impedance analysis (BIA), and explored their relationship with HSCT outcomes.

Methods

A cohort of 40 paediatric β-TM patients undergoing allogeneic HSCT was assessed for their nutritional status, anthropometric parameters, including body mass index (BMI), weight, and height, and body composition parameters pre-and post-HSCT, focusing on BIA measurements, including intracellular water (ICW), extracellular water (ECW), fat mass (FAT), fat-free mass (FFM), Skeletal Muscle Mass (SMM), soft Lean Mass (SLM), percent body fat (PBF), Body Cell Mass (BCM), Phase angle (PA) and muscle balance pre- and post-HSCT. Post-HSCT clinical outcomes, including acute graft-vs-host disease (aGVHD), engraftment time, oral mucositis (OM), sinusoidal obstruction syndrome (SOS), and diarrhoea in relation to nutrition status after HSCT were analysed.

Results

After HSCT, 28.21% experienced diminished nutritional status, with 71.43% of those who were wasting before HSCT showing diminished nutritional status, significantly higher than the normal group (18.75%, P = 0.012). Anthropometric changes included significant weight reduction (87.5%, 22.15 ± 7.46 vs 20.74 ± 6.57, P < 0.001) and BMI decrease (90%, 15.19 ± 1.70 vs 14.05 ± 1.48, P < 0.001). Body composition parameters, which are FFM, SMM, SLM, ICW, ECW, BCM, and PA (18.26 ± 5.71 vs 17.27 ± 5.19, 8.68 ± 3.30 vs 7.93 ± 3.02, 17.11 ± 5.28 vs 16.06 ± 4.84, 8.19 ± 2.54 vs 7.62 ± 2.31, 5.15 ± 1.58 vs 4.94 ± 1.47, 11.74 ± 3.63 vs 10.92 ± 3.32, 4.42 ± 0.50 vs 3.90 ± 0.57, respectively, P < 0.001) analysis revealed significant decreases. No significant differences in clinical outcomes were observed based on nutritional status.

Conclusion

Paediatric β-TM patients undergoing HSCT exhibit significant changes in nutrition status and body composition, emphasizing the need for focused attention on malnourished children who are more prone to diminished nutritional status. Comprehensive BIA aids in understanding the impact, urging consideration for extended follow-up and larger cohorts in future research.

A Case of Successful Allogeneic Hematopoietic Stem Cell Transplantation in a Severely Underweight Patient with Aplastic Anemia

Allogeneic hematopoietic stem cell transplantation (alloHSTC) is considered definitive and the most effective treatment for young patients diagnosed with severe aplastic anemia. Low body mass index (BMI) is known to be associated with poorer outcomes in stem cell transplantation and higher mortality risks. Malnutrition negatively affects the patient's ability to mobilize stem cells, therefore reducing patients' stem cell production, although the patient's nutritional status improvement with enteral and parenteral nutrition may reduce the risks of stem cell graft failure and graft-vs-host disease (GVHD) occurrence. The present report demonstrates a severely underweight patient with aplastic anemia and a BMI of 11 kg/m2 who was unsuccessfully treated with immunosuppressive therapy followed by alloHSTC.

Proactive enteral nutrition for patients undergoing allogeneic stem cell transplantation- implementation and clinical outcomes

BACKGROUND/ OBJECTIVES

Nutrition support is frequently required post allogeneic haematopoietic progenitor cell transplantation (HPCT) however the tolerance of enteral nutrition (EN) can vary. This mixed methods study aimed to explore staff perceptions, barriers and enablers to the use of EN post HPCT and report the implementation and outcomes of a nutrition protocol.

SUBJECT/ METHODS

A survey on barriers and enablers to the use of EN was developed and distributed to medical and nursing staff. Data on nutrition and clinical outcomes was collected for 12 months post implementation of a new nutrition protocol.

RESULTS

Thirty staff completed the survey, key barriers identified included uncertain EN tolerance, lack of confidence in nasogastric tube placement and insufficient training and resources. Eighty-four patients commenced EN, 23 changed to PN (27%) and 61 received EN only (73%). In total 36 patients received PN and eight patients oral nutrition support only. There was a difference in type of conditioning (p = 0.025) and nutritional status (p = 0.016) between patients who received PN vs EN only, with a higher proportion of malnourished patients receiving PN (23% vs 5%). Patients who received PN had a longer length of hospital stay (median 22 vs 19 days, p = 0.012) and lower rate of survival to day 100 (81% vs 95%, p = 0.036) than patients who received EN.

CONCLUSION

The use of EN may lead to improved clinical outcomes compared to PN therefore should be implemented as first line nutrition support.

Enteral nutrition optimization program for children undergoing blood & marrow transplantation: A quality improvement project

BACKGROUND

Malnutrition in children and young adults undergoing blood and marrow transplantation (BMT) increases morbidity and mortality. Addressing this via optimization of enteral nutrition can potentially improve outcomes.

METHODS

This Quality Improvement project utilized pre-post-intervention design and post-intervention survey to evaluate a novel program optimizing enteral nutrition support in children undergoing BMT. All patients aged 0-18 who were admitted during the 16-week implementation period followed the Enteral Nutrition Optimization Program from pre-BMT through discharge. Data on biometric indicators, complications, and post-transplant milestone time markers were evaluated via Mann-Whitney U, Fisher's exact, and Chi-square tests as indicated using SPSS™ Version 27. A separate sample of clinical providers completed a post-intervention survey to evaluate the feasibility and acceptance of the intervention.

FINDINGS

Six patients received the intervention, with 12 patients evaluated. There were no statistical differences between groups on measured evaluations of weight loss (0.15 kg vs +0.4 kg, p = 0.39), malnutrition (2 vs 3, p = 0.545), graft-versus-host-disease (2 vs 2, p = 1), time to engraftment (platelets day 22 vs 20.5, p = 0.589), infections (p = 0.368), and length of stay (32.5 days vs 31 days, p = 1). The provider sample of 45 participants showed overall feasibility and acceptance of the intervention (88.9% agreed or strongly agreed).

DISCUSSION

Feasibility and acceptance were high, resulting in increased use of nasogastric and gastrostomy tubes. Though no clinical significance, interpretation is limited due to the small sample size.

PRACTICE IMPLICATIONS

Implementing a novel nutritional support program resulted in a culture shift towards enteral nutrition optimization. Further studies are needed to determine clinical impacts.

The Promise of Precision Nutrition for Modulation of the Gut Microbiota as a Novel Therapeutic Approach to Acute Graft-versus-host Disease

Acute graft-versus-host disease (aGVHD) is a severe side effect of allogeneic hematopoietic stem cell transplantation (aHSCT) that has complex phenotypes and often unpredictable outcomes. The current management is not always able to prevent aGVHD. A neglected actor in the management of aGVHD is the gut microbiota. Gut microbiota dysbiosis after aHSCT is caused by many factors and may contribute to the development of aGVHD. Diet and nutritional status modify the gut microbiota and a wide range of products are now available to manipulate the gut microbiota (pro-, pre-, and postbiotics). New investigations are testing the effect of probiotics and nutritional supplements in both animal models and human studies, with encouraging results. In this review, we summarize the most recent literature about the probiotics and nutritional factors able to modulate the gut microbiota and we discuss the future perspective in developing new integrative therapeutic approaches to reducing the risk of graft-versus-host disease in patients undergoing aHSCT.

The impact of malnutrition on mortality and complications of hematopoietic stem cell transplantation in patients with acute leukemia

BACKGROUND & AIMS

Malnutrition is common in hematopoietic stem cell transplantation (HSCT) patients. However, there are few studies on the association between malnutrition and post-transplant outcomes, with inconsistent results. No standard screening tool has been established for malnutrition in these patients. Previous research suggests the Global Leadership Initiative on Malnutrition (GLIM) criteria is effective in predicting outcomes in other cancers. This study investigates the link between malnutrition based on the GLIM criteria with mortality and complications following allogeneic HSCT.

METHODS

This single-center, observational, longitudinal, and prospective study of 98 adult leukemia patients at the Hematology Center of Shariati Hospital in Tehran, Iran, monitored patients before transplantation until 100 days after the procedure, focusing on overall survival and mortality as a primary outcome, and secondary endpoints including oral mucositis, acute GVHD, infection during hospitalization, and readmission rates.

RESULTS

This study involved 98 allogeneic HSCT patients with a median age of 38 years old, 64.3 % with acute myeloid leukemia (AML), and 35.7 % with acute lymphoblastic leukemia (ALL). Among them, 26.5 % were categorized as malnourished based on GLIM criteria. During 100 days of follow-up, 13 patients died, but there was no significant difference in overall survival and mortality between malnourished and well-nourished patients. Malnourished patients demonstrated a noticeable upward trend in the incidence of oral mucositis, hospital readmission, and infection during their hospitalization. It is important to highlight that although this observed trend is discernible, it did not attain statistical significance in statistical analyses (P > 0.05).

CONCLUSION

The current study determined that, when assessed using the GLIM criteria, malnutrition did not exert a statistically significant influence on survival, mortality, or complications within the specified age range of 18-55 years, underscoring its limited impact on this cohort of younger patients.

Malnutrition and clinical outcomes post alloSCT

BACKGROUND

Malnutrition has been linked with higher risk of poor outcomes post-allogeneic stem cell transplantation (alloSCT); however, few studies have used a validated nutrition assessment tool such as the Patient Generated Subjective Global Assessment (i.e., PG-SGA) to measure nutritional status and investigate associations with long-term clinical outcomes. The present study aimed to assess the incidence of malnutrition prior to alloSCT and determine whether there was an association between nutritional status pre-transplant and post-transplant clinical outcomes including acute kidney injury, graft-versus-host disease, intensive care admission, need for haemodialysis and survival.

METHODS

A retrospective analysis of 362 patients (213 males:149 females, mean ± SD age = 47.8 ± 14.1 years) who underwent alloSCT from 2008 to 2013 was conducted. Data on clinical outcomes were obtained for 5 years post-transplant.

RESULTS

Fifteen percent (n = 56) of patients were identified as malnourished pre-admission. Malnutrition was associated with longer hospital stay (p = 0.007), increased requirement for haemodialysis (p = 0.016) and increased admissions to the intensive care unit (p = 0.003). There was no association between malnutrition and acute kidney injury, graft-versus-host disease or survival. Following multivariate analyses, malnutrition remained significantly associated with increased admission rates to the intensive care unit (odds ratio = 3.8, 95% confidence interval = 1.3-10.5, p = 0.011) and increased length of hospital stay > 30 days (odds ratio = 3.6. 95% confidence interval = 1.8-7.4, p ≤ 0.001).

CONCLUSIONS

These findings add importance to the need for nutrition screening and assessment to be routinely undertaken for patients prior to alloSCT and throughout hospitalisation to provide early nutrition intervention for the prevention of malnutrition, poor clinical outcomes and increased healthcare costs.

Nutritional Status at Diagnosis as Predictor of Survival from Childhood Cancer: A Review of the Literature

Few studies so far have examined the impact of nutritional status on the survival of children with cancer, with the majority of them focusing on hematological malignancies. We summarized published evidence reporting the association of nutritional status at diagnosis with overall survival (OS), event-free survival (EFS), relapse, and treatment-related toxicity (TRT) in children with cancer. Published studies on children with leukemia, lymphoma, and other solid tumors have shown that both under-nourished and over-nourished children at cancer diagnosis had worse OS and EFS. Particularly, the risk of death and relapse increased by 30-50% among children with leukemia with increased body mass index at diagnosis. Likewise, the risk of TRT was higher among malnourished children with osteosarcoma and Ewing sarcoma. Nutritional status seems to play a crucial role in clinical outcomes of children with cancer, thus providing a significant modifiable prognostic tool in childhood cancer management. Future studies with adequate power and longitudinal design are needed to further evaluate the association of nutritional status with childhood cancer outcomes using a more standardized definition to measure nutritional status in this population. The use of new technologies is expected to shed further light on this understudied area and give room to person-targeted intervention strategies.

Nutritional status and quality of life in adults undergoing allogeneic hematopoietic stem cell transplantation

Although the effects of malnutrition on morbidity and mortality in adult patients undergoing allogeneic hematopoietic stem cell transplantation are clear, the relationship with quality of life (QOL) is less clear. The purpose of this study was to assess the relationship between malnutrition and QOL. A prospective observational study was conducted in 36 adult patients undergoing allogeneic hematopoietic stem cell transplantation. Adapted criteria of the Global Leadership Initiative on malnutrition have been used for the diagnosis of malnutrition in clinical settings. A cancer linear analog scale was used to assess QOL. Overall QOL at 14 days after allogeneic hematopoietic stem cell transplantation was 37.1 (95% CI 2.9–45.39) in patients without severe malnutrition, versus 16.0 (95% CI − 6.6 to 38.6) in patients with severe malnutrition (p = 0.05). At discharge, it was 48.0 (95% CI 38.4–57.6) versus 34.0 (95% CI 4.1–63.9) (p = 0.27). The results of our study suggest that patients with severe malnutrition at discharge tend to have worse QOL. A larger cohort of patients is required to confirm this hypothesis.

Vitamin requirements during stem cell transplantation: a systematic review

Patients undergoing stem cell transplantation (SCT) are at high risk of malnutrition during the acute post-transplantation period. This systematic review aimed to collate and analyse the evidence for vitamin requirements post-SCT. A systematic search of five databases was conducted to include studies published until March 2021. The review utilised the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework. Inclusion criteria consisted of adults undergoing SCT who received vitamin supplementation or had their vitamin levels monitored up to 100 days post-SCT. Studies with paediatric patients or those that looked at vitamin derivates such as folinic acid were excluded. Main outcomes included vitamin deficiency and relevant clinical outcomes. Eleven studies (n = 11) were eligible for inclusion with five rated as neutral quality and six as positive quality. Five studies focused on allogenic SCT, two on autologous SCT and the remaining included a mix of both. Eight studies monitored vitamins levels post-SCT, and seven studies provided vitamin supplementation. Three studies (one provided supplementation) found a high prevalence of vitamin D deficiency (23-60%) prior to SCT. Findings indicate an unclear association between vitamin deficiency and post-SCT complications including acute graft-versus-host-disease, oral mucositis, and mortality. The GRADE certainty of evidence across these outcomes was low or very low. It is unclear if supplementation is needed during SCT, though assessing vitamin D levels prior to transplant should be considered. Further large observational studies or randomised control trials are required to establish vitamin requirements and guide supplementation protocols during SCT.

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.

Correlation of nutrition-associated parameters with non-relapse mortality in allogeneic hematopoietic stem cell transplantation

Outcome of allogeneic stem cell transplantation (alloSCT) is hampered by substantial non-relapse mortality (NRM). Given its impact on organ function and immune response, the nutritional status has been suggested as relevant for NRM. We aimed to evaluate the association of NRM with nutritional status prior to alloSCT and in the post-SCT course. In a retrospective single-center study, we analyzed 128 alloSCTs. Besides standard characteristics, nutrition-associated parameters BMI, serum total protein, and serum albumin were recorded before conditioning and at various time points after alloSCT. Association with NRM was evaluated by univariate and multivariate survival analysis. The cohort comprised patients with a median BMI of 26 kg/m² (16.7–46.9 kg/m²), median serum total protein of 59 g/l (41–77 g/l), and serum albumin of 36 g/l (22–46 g/l) before SCT. NRM at d₊₁₀₀ was 14.8% and at 1 year 26.6%. Prior to SCT, only serum albumin deficiency was associated with increased NRM (p = .010) in multivariate analysis. After SCT (d₊₃₀ and d₊₁₀₀), all nutrition-associated parameters decreased (p < .002), but no association of deteriorating nutritional status with NRM was found. In multivariate analysis, serum albumin (p = .03) and severe albumin deficiency (p = .02) correlated with NRM at d₊₃₀ and d₊₁₀₀, while BMI and serum total protein did not. In our study, albumin deficiency, particularly prior to alloSCT, shows a strong correlation with NRM. This finding may add to monitoring, risk evaluation, and counseling of patients and serve as a rational for interventions to improve the nutritional status in patients undergoing SCT.

A concise review on factors influencing the hematopoietic stem cell transplantation main outcomes

BACKGROUND AND AIMS

As a curative procedure, hematopoietic stemcell transplantation (HSCT) is an approved treatment for many malignant orbenign hematologic and non-hematologic diseases. There are different outcomes of HSCT, as well as several parameters influencing these outcomes.

METHODS

We had searched scientific sources like Web ofScience and PubMed with a combination of keywords such as HSCT, engraftment,survival, outcomes, etc. Totally, 80 articles were included.

RESULTS

Here we have reviewed the effective factors onmain outcomes of HSCT including engraftment, survival, graft versus hostdisease, and Mobilization. Also, the prediction of hematological reconstitutionand some novel suggestions leading to better outcomes are reviewed.

CONCLUSION

The study will be applicable for improvedmanagement of autologous and allogeneic HSCT process to increase the procedureefficiency.

Current practice in nutrition after allogeneic hematopoietic stem cell transplantation - Results from a survey among hematopoietic stem cell transplant centers

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently associated with impaired oral intake and malnutrition, which potentially increases morbidity and mortality. Therefore, nutrition is one of the major challenges in the post-transplant period.

METHODS

To document the current clinical approach in nutritional treatment, we designed a questionnaire concerning the current practice in nutrition after alloHSCT and distributed it to German speaking centers performing alloHSCT in Germany, Austria and Switzerland between November 2018 and March 2020. Twenty-eight (39%) of 72 contacted centers completed the survey, 23 from Germany, two from Austria and three from Switzerland, representing 50% of alloHSCT activity within the participating countries in 2018.

RESULTS

All centers reported having nutritional guidelines for patients undergoing alloHSCT, whereby 86% (n = 24) provided a low-microbial diet during the neutropenic phase. The criteria to start parenteral nutrition (PN) directly after alloHSCT seemed to be consistent, 75% (n = 21) of the corresponding centers started PN if the oral nutritional intake or the bodyweight dropped below a certain limit. In the setting of intestinal graft-versus-host disease (GvHD) the current practice appeared to be more heterogenous. About 64% (n = 18) of the centers followed a special diet, added food stepwise modulated by GvHD symptoms, while only four centers regularly stopped oral intake completely (intestinal GvHD grade >1). Half of the centers (54%, n = 15) applied a lactose-free diet, followed by 43% (n = 12) which provided fat- and 18% (n = 5) gluten-free food in patients with intestinal GvHD. Supplementation of micronutrients in acute intestinal GvHD patients was performed by 54% (n = 15) of the centers, whereas vitamin D (89%, n = 25) and vitamin B₁₂ (68%, n = 19) was added regularly independently of the presence of GvHD. Only 5 (18%) participating centers ever observed a food-associated infection during hospitalization, whereas food-associated infections were reported to occur more often in the outpatient setting (64%, n = 18).

CONCLUSION

The survey documented a general consensus about the need for nutritional guidelines for patients undergoing alloHSCT. However, the nutritional treatment in clinical practice (i.e. lactose-, gluten- or fat-free in intestinal GvHD) as well as the use of food supplements was very heterogeneous. In line with current general recommendations the centers seemed to focus on safe food handling practice rather than providing a strict neutropenic diet. More high-quality data are required to provide evidence-based nutrition to patients during and after alloHSCT.