Total parenteral nutrition vs oral diet in autologous hematopoietic cell transplant recipients

Nutritional care pathways in cancer patients with malignant bowel obstruction: A retrospective multi-centre study

INTRODUCTION

Variation in access to parenteral nutrition (PN) in patients with intestinal failure secondary to malignant bowel obstruction (MBO) exists due to differing practice, beliefs and resource access. We aimed to examine differences in nutritional care pathways and outcomes, by referral to nutrition team for PN in patients with MBO.

METHODS

This is a retrospective cohort study of MBO adults admitted to eight UK hospitals within a year and 1 year follow-up. Demographic, nutritional and medical data were analysed by comparing patients referred (R) or not referred (NR) for PN. Differences between groups were tested by Kruskal-Wallis, Chi-Squared tests and multi-level regression and survival using Cox regression.

RESULTS

232 patients with 347 MBO admissions [median 66yr, (IQR: 55-74yrs), 67 % female], 79/232 patients were referred for PN (R group). Underlying primary malignancies of gynaecological and gastrointestinal origin predominated (71 %) and 78 % with metastases. Those in the NR group were found to be older, weigh more on admission, and more likely to be treated conservatively compared to those in the R group. For 123 (35 %) admissions, patients were referred to a nutrition team, and for 204 (59 %) admissions, patients were reviewed by a dietician. Multi-disciplinary team discussion and dietetic contact were more likely to occur in the R group-123/347 admissions (R vs NR group: 27 % vs. 7 %, P = 0.001; 95 % vs 39 %, P < 0.0001). Median admission weight loss was 8 % (IQR: 0 to 14). 43/123 R group admissions received inpatient PN only, with 32 patients discharged or already established on home parenteral nutrition. Overall survival was 150 days (126-232) with no difference between R/NR groups.

CONCLUSION

In this multi-centre study evaluating nutritional care management of patients with malignant bowel obstruction, only 1 in 3 admissions resulted in a referral to the nutrition team for PN, and just over half were reviewed by a dietician. Further prospective research is required to evaluate possible consequences of these differential care pathways on clinical outcomes and quality of life.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Revisiting Infectious Complications Following Total Parenteral Nutrition Use During Hematopoietic Stem Cell Transplantation

Background

Total parenteral nutrition (TPN) is frequently used to manage caloric needs during hematopoietic stem cell transplantation (HSCT). Previous studies in transplant patients who received TPN have reported widely discordant results with regard to infection and mortality, and risk factors for TPN-related infection remain unclear.

Method

We conducted a retrospective study of all HSCT recipients treated with TPN between 2005 to 2014 at Northwestern Memorial Hospital to determine the incidence and epidemiology of infections. Electronic records were used to identify patients treated with TPN for at least 2 days who developed infection.

Results

Among 198 patients treated with TPN, 30% developed documented infection. Total parenteral nutrition treatment duration (13 vs. 7 days; p < .0001) and the timing of TPN initiation (> day 9 post HSCT; p < .0001) were significantly higher in patients who received TPN and developed infection. Receipt of an allogeneic transplant was associated with increased risk for infection (p < .0138), and day 60 mortality was significantly higher in TPN-treated patients with infection (p < .0001).

Conclusion

Stem cell recipients who receive TPN, especially from an allogeneic donor, have high rates of infection and mortality. Minimizing TPN exposure may reduce the chance for infection.

Effect of malnutrition-driven nutritional support protocol on clinical outcomes in autologous stem cell transplantation patients

PURPOSE

Poor nutrition status in patients receiving high-dose chemotherapy and autologous stem cell transplant (ASCT) has been associated with inferior clinical outcomes. We aim to determine whether a malnutrition-driven nutritional support protocol can improve these outcomes.

METHODS

In this prospective cohort study, we assessed adults for malnutrition who were consecutively admitted for ASCT between October 2017 and March 2019 (n = 251), and provided enteral or parenteral nutrition (EN/PN) to patients who were malnourished early in the transplantation admission. We compared their clinical outcomes with those of a historical cohort admitted between May 2016 and October 2017 (n = 257) for whom nutrition assessment and initiation of EN/PN were not protocol-driven.

RESULTS

Patients receiving ASCT during the intervention period experienced decreased odds of prolonged hospital stay (p = 0.023), central line-associated bloodstream infection (p = 0.015), mucosal barrier injury (p = 0.037), and high weight loss (p = 0.002), in a multivariate analysis as compared with those receiving ASCT during the control period. Outcomes for ICU transfer, deconditioning on discharge, time to platelet engraftment, and unplanned 30-day hospital readmission did not differ significantly between groups.

CONCLUSION

A malnutrition-driven nutritional support protocol may improve outcomes for ASCT patients.

Nutritional Intervention for a Patient with Acute Lymphoblastic Leukemia on Allogeneic Peripheral Blood Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) causes many complications such as anorexia, nausea, vomiting, diarrhea, and mucositis. Most patients undergoing HSCT have risk for malnutrition in the process of transplantation so artificial nutrition support is required. The purpose of this case report is to share our experience of applying nutrition intervention during the transplantation period. According to HSCT process, the change of the patient's gastrointestinal symptoms, oral intake and nutritional status was recorded. By encouraging oral intake and providing parenteral nutrition, the patient had only 0.3%, losing weight during the transplantation period. In conclusion, it emphasized that the nutritional status changes during the HSCT period should be closely monitored and nutritional management through appropriate nutritional support and interventions in hospital and after discharge.

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.

Could enteral nutrition improve the outcome of patients with haematological malignancies undergoing allogeneic haematopoietic stem cell transplantation? A study protocol for a randomized controlled trial (the NEPHA study)

BACKGROUND

Myeloablative allogeneic haematopoietic stem cell transplantation (allo-HSCT) is a major procedure usually accompanied by multifactorial malnutrition, prompting the recommendation of systematic artificial nutritional support. Parenteral nutrition (PN) is usually administered during allo-HSCT, essentially for practical reasons. Recently published data suggest that enteral nutrition (EN), given as systematic artificial nutrition support, could decrease grade III-IV graft-versus-host disease (GVHD) and infectious events, which are associated with early toxicity after allo-HSCT and then have an impact on early transplant-related mortality (D100 mortality).

METHODS/DESIGN

We report on the NEPHA trial: an open-label, prospective, randomised, multi-centre study on two parallel groups, which has been designed to evaluate the effect of EN compared to PN on early toxicity after an allo-HSCT procedure. Two hundred forty patients treated with allo-HSCT for a haematological malignancy will be randomly assigned to two groups to receive either EN or PN. The primary endpoint will assess the effect of EN on D100 mortality. Secondary endpoints will compare EN and PN with regards to the main haematological, infectious and nutritional outcomes.

DISCUSSION

The impacts of nutritional support should exceed the limits of nutritional status improvement: EN may directly reduce immunological and infectious events, as well as decrease early transplant-related morbidity and mortality. EN and PN need to be prospectively compared in order to assess their impacts and to provide treatment guidelines. (Clinical trials gov number: NCT01955772; registration: July 19th, 2013).

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.

Challenges and outcomes of a randomized study of early nutrition support during autologous stem-cell transplantation

Patients undergoing myeloablative conditioning regimens and autologous stem-cell transplantation (asct) are at high risk of malnutrition. This randomized study aimed to determine if early nutrition support (commenced when oral intake is less than 80% of estimated requirements) compared with usual care (commenced when oral intake is less than 50% of estimated requirements) reduces weight loss in well-nourished patients undergoing high-nutritional-risk conditioning chemotherapy and asct. In the 50 well-nourished patients who were randomized, the outcomes evaluated included changes in weight and lean body mass (mid-upper arm circumference), length of stay, time to hemopoietic engraftment, and quality of life (Memorial Symptom Assessment Scale - Short Form). On secondary analysis, after exclusion of a single extreme outlier, both groups demonstrated significant weight loss over time (p = 0.0005). Weight loss was less in the early nutrition support group at time of discharge (mean: -0.4% ± 2.9% vs. -3.4% ± 2.6% in the usual care group, p = 0.001). This difference in weight was no longer observed at 6 months after discharge (mean: -1.0% ± 6.8% vs. 1.4% ± 6.1%, p = 0.29). In practice, an early start to nutrition support proved difficult because of patient resistance and physician preference, with 8 patients (33%) in the control group and 4 (15%) in the intervention group not commencing nutrition support when stipulated by the study protocol. No significant differences between the groups were found for other outcomes. In well-nourished patients receiving asct, early nutrition support maintained weight during admission, but did not affect other outcomes. Interpretation of results should take into consideration the difficulties encountered with intervention implementation.

Nutritional intake and nutritional status by the type of hematopoietic stem cell transplantation

The aim of this study was to investigate the changes of nutritional intake and nutritional status and analyze the association between them during hematopoietic stem cell transplantation. This was a retrospective cross sectional study on 36 patients (9 Autologous transplantation group and 27 Allogeneic transplantation group) undergoing hematopoietic stem cell transplantation at The Catholic University of Korea, Seoul St. Mary's Hospital from May to August 2010. To assess oral intake and parenteral nutrition intake, 24-hour recall method and patient's charts review was performed. Nutritional status was measured with the scored patient-generated subjective global assessment (PG-SGA). The subjects consisted of 6 (66.7%) males and 3 (33.3%) females in the autologous transplantation group (auto), 12 (44.4%) males and 15 (55.6%) females in the allogeneic transplantation group (allo). The mean age was 40.9 ± 13.6 years (auto) and 37.8 ± 11.0 years (allo). The average hospitalized period was 25.2 ± 3.5 days (auto) and 31.6 ± 6.6 days (allo), which were significant different (p < 0.05). Nutritional intake was lowest at Post+1wk in two groups. In addition, calorie intake by oral diet to recommended intake at Post+2wk was low (20.8% auto and 20.5% allo) but there were no significant differences in change of nutritional intake over time (Admission, Pre-1day, Post+1wk, Post+2wk) between auto group and allo group by repeated measures ANOVA test. The result of nutritional assessment through PG-SGA was significantly different at Pre-1day only (p < 0.01). There was a significant negative correlation between the nutritional status during Post+2wk and the oral calorie/protein intake to recommended amount measured during Post+1wk and Post+2wk (p < 0.01). These results could be used to establish evidence-based nutritional care guidelines for patients during hematopoietic stem cell transplantation.

Digestive complaints in patients with hematologic malignancies undergoing bone marrow transplantation

The aim of this study was to assess the severity and frequency of complaints affecting the digestive system in 57 patients with hematological malignancies, who underwent allogeneic (Group I, n = 22) and autologous (Group II, n = 35) hematopoietic stem cell transplantation. Chemotherapy-related toxicities affecting the digestive system (mucositis, nausea/vomiting, diarrhea) were assessed according to the WHO scale for organ toxicity. Selection of the feeding route (oral or parenteral) depended on the tolerance to oral nutrition. Parenteral nutrition (PN) was introduced when oral intake represented ≤ 50% of the total energy requirement over 2 days. PN was started in the third 24-h period. 63.6% of patients undergoing allogeneic transplantation and 54.3% of patients undergoing autologous transplantation needed PN. Ailments affecting the digestive system began in both groups during the administration of conditioning chemotherapy and gradually decreased in the posttransplantation period. Mucositis grade 3/4 requiring PN was observed in 85% patients in Group I and 52.7% patients in Group II. In Group I, grade 3 diarrhea was observed only in patients requiring PN. Severe grade 3/4 organ toxicity from chemotherapy was the main indication for PN in patients undergoing hematopoietic stem cell transplantation.

Quality-of-life measurement in randomized clinical trials in breast cancer: an updated systematic review (2001-2009)

BACKGROUND

Quality-of-life (QOL) measurement is often incorporated into randomized clinical trials in breast cancer. The objectives of this systematic review were to assess the incremental effect of QOL measurement in addition to traditional endpoints (such as disease-free survival or toxic effects) on clinical decision making and to describe the extent of QOL reporting in randomized clinical trials of breast cancer.

METHODS

We conducted a search of MEDLINE for English-language articles published between May-June 2001 and October 2009 that reported: 1) a randomized clinical trial of breast cancer treatment (excluding prevention trials), including surgery, chemotherapy, hormone therapy, symptom control, follow-up, and psychosocial intervention; 2) the use of a patient self-report measure that examined general QOL, cancer-specific or breast cancer-specific QOL or psychosocial variables; and 3) documentation of QOL outcomes. All selected trials were evaluated by two reviewers, and data were extracted using a standardized form for each variable. Data are presented in descriptive table formats.

RESULTS

A total of 190 randomized clinical trials were included in this review. The two most commonly used questionnaires were the European Organization for Research and Treatment of Cancer QOL Questionnaire and the Functional Assessment of Cancer Therapy/Functional Assessment of Chronic Illness Therapy. More than 80% of the included trials reported the name(s) of the instrument(s), trial and QOL sample sizes, the timing of QOL assessment, and the statistical method. Statistical power for QOL was reported in 19.4% of the biomedical intervention trials and in 29.9% of the nonbiomedical intervention trials. The percentage of trials in which QOL findings influenced clinical decision making increased from 15.2% in the previous review to 30.1% in this updated review for trials of biomedical interventions but decreased from 95.0% to 63.2% for trials of nonbiomedical interventions. Discordance between reviewers ranged from 1.1% for description of the statistical method (yes vs no) to 19.9% for the sample size for QOL.

CONCLUSION

Reporting of QOL methodology could be improved.

Immunohematopoietic stem cell transplantation in Cape Town: a ten-year outcome analysis in adults

BACKGROUND AND OBJECTIVES

Immunohematopoietic stem cell transplantation has curative potential in selected hematologic disorders. Stem cell transplantation was introduced into South Africa in 1970 as a structured experimental and clinical program. In this report, we summarize the demography and outcome by disease category, gender, and type of procedure in patients older than 18 years of age who were seen from April 1995 to December 2002.

PATIENTS AND METHODS

This retrospective analysis included 247 individuals over 18 years of age for whom complete data were available. These patients received grafts mostly from peripheral blood with the appropriate stem cell population recovered by apheresis.

RESULTS

Patient ages ranged from 20 to 65 years with a median age of 42 years. There were 101 females and 146 males. There were no withdrawals and 63% survived to the end of the study. At 96 months of follow-up, a stable plateau was reached for each disease category. Median survival was 3.3 years (n=6, 14.6%) for acute lymphoblastic anemia, 3.1 years (n=44, 18%) for acute myeloid leukemia, 2.8 years (n=47, 19%) for chronic granulocytic leukemia, 2.8 years (n=71, 29%) for lymphoma, 1.5 years (n=23, 9%) for myeloma, 1.43 years (n=10, 4%) for aplasia, and 1.4 years (n=38, 15%) for a miscellaneous group comprising less than 10 examples each. Multivariate analysis showed that only diagnosis and age had a significant impact on survival, but these two variables might be interrelated. There was no significant difference in outcome by source of graft.

CONCLUSION

The results confirm that procedures carried out in a properly constituted and dedicated unit, which meets established criteria and strictly observes treatment protocols, generate results comparable to those in a First World referral center. Low rates of transplant-related mortality, rejection and graft-versus-host disease are confirmed, but the benefits cannot be extrapolated outside of academically oriented and supervised facilities.

Pediatric immunohematopoietic stem cell transplantation at a tertiary care center in Cape Town

INTRODUCTION AND STUDY DESIGN: We conducted a retrospective analysis of consecutive referrals of patients under 18 years of age undergoing immunohematopoietic stem cell transplantation to assess the influence of age, diagnosis, graft type and gender on survival. We also contrasted program activity and outcome to that reported from a state hospital in the same geographical area over a comparable period.

METHODS

Conditioning employed either a sequential combination of fractionated 12Gy whole body and 6Gy total nodal irradiation separated by 120mg/kg of cyclophosphamide in patients over 15 years of age. Alternatively, the latter agent was combined initially with oral busulphan and later the intravenous equivalent. Neuroblastoma cases were prepared using a different regimen. In allografts the harvested product underwent ex vivo T-cell depletion with the humanized version of anti-CD 52 monoclonal antibody designated Campath 1H. No additional immunosuppression was given except where matched unrelated volunteer donors were employed.

RESULTS

Sixty-eight procedures were carried out in 61 patients over a 6-year period. Of 11 with acute myeloid leukemia, 8 are alive and well whereas 8 of the 14 with the lymphoblastic variant have died. Of the remaining 12 with hematologic malignancy, all but 2 are alive. Ten of the 17 with aplasia are alive as are all with thalassemia or sickle cell disease. None of the four variables tested affected survival.

CONCLUSION

Our analysis indicates that the standardized preparative regimen, coupled with a now well-established immunosuppressive regimen, is as effective in patients under 18 years of age as in adults. Our analysis also indicates that in a resource-scarce or developing country, it is mandatory to limit high-risk and relatively expensive procedures to active teams that enjoy international accreditation, whether these be in the state or private sector.

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.

Prognostic factors in the resumption of oral dietary intake after allogeneic hematopoietic stem cell transplantation (HSCT) in children

BACKGROUND

Parenteral nutrition (PN) is a common supportive care therapy in patients undergoing hematopoietic stem cell transplantation (HSCT). Inadequate oral dietary intake may necessitate prolonged courses of PN, which have been associated with metabolic, infectious, and hepatobiliary complications. The objective of this study was to identify demographic, clinical, and nutrition factors associated with the resumption of oral dietary intake following HSCT.

METHODS

This was an observational cohort study of 37 children undergoing allogeneic HSCT. Repeated-measures regression analysis was performed to identify factors associated with the resumption and macronutrient composition of oral nutrient intake after HSCT.

RESULTS

Mean oral dietary intake during the first 2 weeks after HSCT was <280 kcal/d. At all times, oral carbohydrate intake was high, ranging from 58% to 74% of oral energy. Age, time since transplant, degree of oral mucositis, and severity of graft-vs-host disease (GVHD) were all significantly correlated with the resumption of oral energy intake, as well as oral intake of carbohydrates. Oral protein and fat intake were also associated with elapsed time since HSCT, severity of mucositis, and GVHD. Factors not associated with oral dietary intake included gender, pre-HSCT nutrition status, diagnosis, type of donor, and infections.

CONCLUSIONS

Children undergoing HSCT exhibit a marked reduction in oral dietary intake and a preference for a diet high in carbohydrates. Careful attention should be directed to the oral dietary intake and nutrient requirements of children during HSCT, especially in younger patients and those who experience severe mucositis or GVHD.

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.

Do Data Support Nutrition Support? Part I: Intravenous Nutrition

Intravenous (parenteral) nutrition has been advocated widely as adjunctive care in patients with a variety of underlying diseases. However, the enthusiasm for this therapeutic intervention was based largely on expert opinion. Because the best way to assess the efficacy of any treatment is to test it in a randomized controlled trial, this review will focus on data that was derived from such studies. Using established search strategies, randomized controlled trials were sought that compared one of two forms of intravenous nutrition: parenteral nutrition (nitrogen and >or=10 kcal/kg/day of non-protein calories for >or=5 days) or protein-sparing therapy (nitrogen and fewer non-protein calories) with no type of artificial nutrition beyond regular food and/or standard (5%) dextrose. The randomized controlled trials were stratified by the underlying disease state. The clinical outcomes of interest were mortality, morbidity (total/infectious complications), and/or duration of hospitalization. More than 100 randomized controlled trials failed for the most part to demonstrate that intravenous nutrition had any effect on clinical outcome. There were a few exceptions. In patients undergoing attempted curative surgery for upper gastrointestinal cancer, the use of preoperative parenteral nutrition seemed to reduce the incidence of major postoperative complications. However, this benefit was only found in low-quality randomized controlled trials. Findings conflict regarding the use of parenteral nutrition in patients with acute pancreatitis or undergoing bone marrow transplantation. Parenteral nutrition was harmful when provided to patients undergoing radiation or chemotherapy for cancer. Although no randomized controlled trials exist, it is assumed that parenteral nutrition is useful in patients with an inadequate gastrointestinal tract ("short gut"). Thus, for the most part, randomized controlled trials comparing intravenous nutrition to no artificial nutrition have not shown that this medical intervention is of benefit.

Should patients with cancer be offered nutritional support: does the benefit outweigh the burden?

Nutrition support has been widely advocated as adjunctive therapy for a variety of underlying illnesses, including surgery and medical oncotherapy (radiation or chemotherapy for cancer). Both parenteral and enteral nutrition have been mistakenly viewed as feeding, when, in fact, they are medical interventions with associated risks and costs. The argument that nutrition support has to be provided to patients to prevent 'starving to death' confuses the difference between dying in a malnourished state and dying as a direct consequence of nutrient deprivation; cancer patients fit into the former category. As is true for any other medical intervention, efficacy is best established by randomized controlled clinical trials. When these forms of nutrition support have been so assessed, they have not usually been found to be any more efficacious than food on a tray or intravenous 5% dextrose solutions. In fact, parenteral nutrition actually caused harm in patients receiving medical oncotherapy (more total and infectious complications and fewer tumor responses). With regard to cancer patients, the only benefit that was demonstrated was the use of preoperative parenteral nutrition in patients undergoing attempted curative surgery for cancer of the upper gastrointestinal tract (esophagus, stomach, or pancreas). As nutrition support has associated complications (infections, mechanical problems with the tubes, and metabolic problems from the infusates) as well as costs, it cannot be recommended for cancer patients with the exception of the preoperative care of those with upper gastrointestinal malignancies and the occasional patient with gastrointestinal tract inadequacy owing to a slow-growing lesion.

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.

Role of Parenteral Nutrition in Cancer Patients Undergoing High-Dose Chemotherapy Followed by Autologous Peripheral Blood Progenitor Cell Transplantation

High-dose chemotherapy followed by autologous bone marrow or peripheral blood progenitor cell transplantation represents a recognized option in the treatment of solid tumors and hematologic diseases. Patients receiving high-dose chemotherapy are traditionally supported with parenteral nutrition with the aim to prevent malnutrition secondary to gastrointestinal toxicity and metabolic alterations induced by the conditioning regimens. Nevertheless, well-defined guidelines for its use in this clinical setting are lacking and there are several areas of controversy.