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

Are We Identifying Malnutrition in Hospitalized Patients with Hematologic Malignancies? Results from a Quality Clinical Audit

Disease-related malnutrition (DRM) is highly prevalent among patients with hematologic malignancies. The aim of the present study was to evaluate the prevalence of DRM in hospitalized patients with hematologic malignancies and investigate the level of awareness of DRM among the medical team treating this group of patients. A cross sectional quality clinical audit took place in two hematology units of a tertiary university hospital. Inpatients were screened within 48 h of their admission using the Malnutrition Universal Screening Tool (MUST) to identify their nutritional risk, and they were reassessed to identify the implemented interventions during their hospitalization. One hundred eighty-five patients were included in the audit analysis. On admission, 37.3% of the audited population was identified as being at high risk of malnutrition according to the MUST score. Forty-nine (26.5%) patients reported reduced food intake during the past 5 days, while four (2.2%) reported no food intake. During the hospitalization, only five patients (2.7%) received nutritional support, as indicated. Low levels of awareness of the early detection and treatment of DMS were found. Moreover, the prevalence of DRM and low nutritional intake was reported to be low. Measures to increase awareness of DMR in the medical team and better coordination of the nutrition support teams is vital to ensure better management and early nutrition intervention in hematological patients.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Optimization of nutrition support practices early after hematopoietic cell transplantation

Nutrition support is often required during hematopoietic cell transplant (HCT) given the gastrointestinal toxicity that frequently precludes adequate protein-calorie intake. This article reviews the latest evidence for enteral versus parenteral nutrition in the adult and pediatric HCT population and addresses key considerations as well as barriers to implement this in practice. Registered Dietitian Nutritionists are key members of the interdisciplinary team to proactively manage enteral nutrition support to provide timely, adequate protein and calories to help prevent malnutrition, loss of lean body mass, and functional decline as well as provide evidence-based diet recommendations. This article also reviews emerging research supporting the role of luminal nutrients to maintain microbiotal diversity.

Lipid Complications after Hematopoietic Stem Cell Transplantation (HSCT) in Pediatric Patients

HSCT (hematopoietic stem cell transplantation) is a widely applied method of treatment of pediatric patients with leukemia and other bone marrow-associated disorders. Metabolic disturbances can appear as procedure side effects. This study aimed to report incidence of lipid and thyroid disorders and time of their onset in pediatric patients after HSCT. There were 198 pediatric patients (123 males) aged 0.5–20 years who were subjected to HSCT. Patients were mostly diagnosed with Acute Leukemia (n = 190). The analysis of lipids, thyroid hormones, and thyroid antibodies levels comprised one month before the HSCT to last follow up visit between 2016 and 2019 (median 3.8 ± 1.8 years after HSCT). In males, the triglycerides levels increased over two times in the course of HSCT in both patients with initially low and elevated HDL (high-density lipoprotein) levels. Most of the lipid disorders occurred in six months after HSCT. Patients treated with L-thyroxine exhibited decreased LDL (low-density lipoprotein) levels. HDL remained at a lower level in males. Thyroid hormone abnormalities were evenly distributed in time until 4 years after HSCT. Patients require long term follow up including lipid metabolism and thyroid function analysis. HSCT survivors demand introduction of polyunsaturated fatty acids into the diet to reduce risk of developing the lipid complications.

Benefit of Reducing Body Weight Loss with A Nutritional Support Pathway in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

This retrospective, historically controlled investigative study examined the benefit of a nutritional support pathway that included nutritional education before the start of conditioning and emphasized oral nutrition in response to nutrition-related adverse events in patients undergoing hematopoietic stem cell transplantation (HSCT).

MATERIAL AND METHODS

Participants were patients undergoing allogeneic HSCT; 46 were in the control group (i.e., did not follow our nutritional pathway) and 36 were in the group that underwent nutritional intervention (enhanced nutrition group). We compared the following parameters between groups from the day before the start of conditioning to the day after completion of parenteral nutrition (PN): percent loss of body weight (%LBW), percent loss of skeletal muscle mass (%LSMM), and estimated basal energy expenditure (EBEE) sufficiency rate. The relationship between each parameter and %LBW was also examined. We also compared nutritional indices, gastrointestinal graft versus host disease (GvHD) grade, oral energy intake, and %LBW between groups.

RESULTS

There was a relationship between %LBW, %LSMM, and EBEE sufficiency rate in both groups. Compared with the control group, the enhanced nutrition group had significantly improved energy intake amount, EBEE sufficiency rate, PN duration, and oral energy intake over time. The enhanced nutrition group also had increased oral energy intake, no difference in gastrointestinal GvHD grade, and improved %LBW compared with the control group.

CONCLUSIONS

Use of our nutritional support pathway in patients undergoing HSCT may be beneficial for %LBW and gastrointestinal GvHD grade, enabling early enhanced nutritional intervention after HSCT.

How to build an allogeneic hematopoietic cell transplant unit in 2016: Proposal for a practical framework

Allogeneic hematopoietic cell transplantation is part of the standard of care for many hematological diseases. Over the last decades, significant advances in patient and donor selection, conditioning regimens as well as supportive care of patients undergoing allogeneic hematopoietic cell transplantation leading to improved overall survival have been made. In view of many new treatment options in cellular and molecular targeted therapies, the place of allogeneic transplantation in therapy concepts must be reviewed. Most aspects of hematopoietic cell transplantation are well standardized by national guidelines or laws as well as by certification labels such as FACT-JACIE. However, the requirements for the construction and layout of a unit treating patients during the acute phase of the transplantation procedure or at readmission for different complications are not well defined. In addition, the infrastructure of such a unit may be decisive for optimized care of these fragile patients. Here we describe the process of planning a transplant unit in order to open a discussion that could lead to more precise guidelines in the field of infrastructural requirements for hospitals caring for people with severe immunosuppression.

Revisiting nutritional support for allogeneic hematologic stem cell transplantation-a systematic review

In 2009, the American Society of Parenteral and Enteral Nutrition and its European counterpart (Euopean Society for Parenteral and Enteral Nutrition) published guidelines regarding nutritional support of patients with hematologic stem cell transplantation. Our aim was to do an up-to-date literature review regarding benefit of nutritional interventions and treatment recommendations. We searched MEDLINE, EMBASE and Cochrane Library for interventional and observational clinical studies. We extracted data based on a predefined case report form and assessed bias. Out of 459 potential abstracts, 13 studies of mostly moderate quality with a total of 18 167 patients were included. Two very large trials reported negative associations of malnutrition and survival, transplant-related mortality and relapse risk. Some trials found enteral nutrition (EN) to be as effective as parenteral nutrition (PN) with lower complication rates. In addition, EN was associated with better survival, less acute GvHD and faster neutrophil recovery. A neutropenic diet was not superior regarding overall survival, but in contrast resulted in higher infection risk. Current moderate quality studies show negative associations of malnutrition and clinical outcomes, with EN being superior to PN. There was no benefit of neutropenic diets. Large, randomized controlled studies are needed to better understand optimal nutritional support in this patient population.

Nutritional issues and body weight in long-term survivors of allogeneic blood and marrow transplant (BMT) in NSW Australia

PURPOSE

The aims of this study were to describe the long-term nutrition, body weight and body image issues facing survivors of Allogeneic Blood and Marrow Transplant (BMT) and their impact on quality of life. It also describes survivors' perception of enteral feeding during BMT.

METHODS

Four hundred and forty-one survivors who had undergone a BMT in NSW, Australia between 2000 and 2012 (n = 441/583) completed the Sydney Post BMT Study Survey (SPBS).

RESULTS

Forty-five percent of survivors less than 2-year post-transplant reported a dry mouth, 36 % reported mouth ulcers and 19 % had diarrhoea. This was consistent across all survivor groups, regardless of time since transplant. Patients with one or more gastrointestinal (GI) symptoms had significantly lower quality of life scores. There was a significant difference in quality of life scores when comparing those with no GI symptoms to those with one or more symptoms (P = <0.0001). Quality of life was significantly higher in those who once again enjoyed mealtimes (P < 0.0001). Males were more likely to be satisfied with their body weight compared to females (P = 0.009). The median body mass index (BMI) for all patients reporting body weight satisfaction was significantly lower (BMI 23.5) than those reporting dissatisfaction (BMI 27.5) (P = <0.0001). Survivors who had a normal BMI had significantly higher rates of body weight satisfaction compared to underweight, overweight and obese survivors (P = <0.0001). Those survivors who were overweight or obese were significantly more likely to be diabetic (P = 0.008).

CONCLUSION

This study revealed an important relationship between gastrointestinal symptoms, body weight and body image and survivor's quality of life. It provides further support for the importance of nutrition therapy post-BMT.

Nutritional assessment as predictor of complications after hematopoietic stem cell transplantation

Introduction

Nutritional support is pivotal in patients submitted to hematopoietic stem cell transplantation. Nutritional status has been associated with time of engraftment and infection rates. In order to evaluate the association between nutritional parameters and clinical outcomes after transplantation a cohort of transplant patients was retrospectively evaluated.

Methods

All 50 patients transplanted between 2011 and 2014 were included. The nutritional status before transplantation, ten days after transplantation and before discharge was assessed including anthropometry, body mass index, albumin, prealbumin and total urinary nitrogen.

Results

The median follow-up time was 41 months and the median age of patients was 41 years. Thirty-two underwent allogeneic and 18 autologous transplants. Diagnoses included acute leukemias (n = 27), lymphoma (n = 7), multiple myeloma (n = 13), and aplastic anemia (n = 3). Thirty-seven patients developed mucositis (three Grade 1, 15 Grade 2, 18 Grade 3 and one Grade 4), and twenty-two allogeneic, and five autologous transplant patients required total parenteral nutrition. Albumin and total urinary nitrogen were associated with length of hospital stay and platelet and neutrophil engraftment. None of the nutritional parameters evaluated were associated with overall survival. Non-relapse mortality was 14% and overall survival was 79% at 41 months of follow-up.

Conclusions

After hematopoietic stem cell transplantation, high catabolism was associated with longer length of hospital stay, the need of total parenteral nutrition and platelet and neutrophil engraftment times. Nutritional parameters were not associated with overall survival.

Nutritional support in patients undergoing haematopoietic stem cell transplantation: a multicentre survey of the Gruppo Italiano Trapianto Midollo Osseo (GITMO) transplant programmes

A survey within Italian haematopoietic stem cell transplant (HSCT) programmes was performed, in order to obtain a snapshot of nutritional support (NS) in patients undergoing HSCT. The primary objective was to verify whether an evidence-based practice (EBP) approach to NS was implemented in HSCT centres. A multicentre survey was performed by questionnaire, covering the main areas of NS (screening, treatment planning, monitoring, nutritional counselling, and methods of nutritional support). The results indicated a significant variation between clinical practice and evidence-based guidelines in terms of clinical pathways, decision-making, and care provision regarding NS. Further research is required to identify reasons for the limited application of EBP and measures that may be undertaken to address such issues. Development of a multidisciplinary educational programme in order to raise awareness of the issue should be undertaken.

Patient satisfaction with nutrition services amongst cancer patients treated with autologous stem cell transplantation: a comparison of usual and extended care

BACKGROUND

This study aimed to determine patient satisfaction with clinical nutrition services delivered by an accredited practicing dietitian amongst cancer patients treated with autologous stem cell transplantation that was provided with usual and extended care at 100 days post-transplantation.

METHODS

Patients were randomised to receive usual nutrition care or extended nutrition care during the course of their stem cell transplantation. After hospital discharge, usual care patients received no further nutrition support, whereas extended care patients received telephone dietary counselling from the same dietitian for up to 100 days post-transplantation. The patient satisfaction with clinical nutrition service questionnaire was completed anonymously at 100 days post-transplantation. Group comparisons were made using independent t-tests.

RESULTS

Thirty-seven patients consented to participate in the study (54% male; mean age 58.7 ± 9.5 years; median body mass index 26.8 kg m(-2) , range 16.4-47.6 kg m(-2) ); 33 patients completed the study and 28 patients returned the questionnaire (response rate = 85%). All components of the questionnaire were rated highly by both groups; there was no significant difference between the groups (P > 0.05). Although not statistically significant, extended care patients who received at least three telephone calls rated a higher overall satisfaction compared to those who received less calls; this difference was clinically important (score difference = 0.56).

CONCLUSIONS

Cancer patients treated with autologous stem cell transplantation were satisfied with usual and extended nutrition care. Extended care patients who received at least three telephone calls after hospital discharge were more satisfied than those with less frequent intervention. Further exploration regarding the frequency and intensity of nutrition service is required.

Percutaneous endoscopic gastrostomy tubes in pediatric bone marrow transplant patients

BACKGROUND AND OBJECTIVES

Nourishing a child undergoing bone marrow transplant (BMT) is essential, but the optimal method to achieve this is not established. The objectives of the study were to investigate the incidence and risk factors for complications of gastrostomy tubes in patients with BMT.

METHODS

A retrospective chart review was conducted of pediatric patients who received a percutaneous endoscopic gastrostomy (PEG) either for BMT or for other indications during a 3-year period. Occurrences of complications, absolute neutrophil count (ANC) at time of PEG placement, and ANC at time of complication were reviewed for both BMT and the comparison group.

RESULTS

Of the 11 subjects in the BMT group, 4 (36%) had a major complication of infection related to PEG and 3 of those required PEG removal. Two of the 4 subjects who developed a major complication were moderately neutropenic at the time of PEG placement and all subjects were neutropenic at the time of complication. Of the 30 subjects in the comparison group, only 1 (2.8%) had a major complication with cellulitis. There were no statistically significant differences between the 2 groups before PEG placement for age, weight, albumin, or white blood cell count. The incidence of complication in BMT compared with the comparison group was significant (P=0.01).

CONCLUSIONS

Our findings support that ANC should be considered before placement of PEG, significant neutropenia may be a contraindication for PEG placement in BMT patients, and other modalities for nutrition support might need to be considered.

Nutrition challenges in a patient with sinusoidal obstructive syndrome following an allogeneic stem cell transplant: a case study

Nutrition management of patients undergoing a hematopoietic stem cell transplant (HSCT) can be challenging. Fluid, macronutrient, and micronutrient needs are often altered due to a variety of therapy-associated complications and changes in metabolism. Sinusoidal obstructive syndrome (SOS) is a complication characterized by fluid retention, ascites, and painful hepatomegaly that may complicate provision of adequate nutrition to HSCT patients. The nutrition implications and interventions in a patient who developed SOS following an allogeneic matched unrelated donor (Allo/MUD) HSCT are reviewed in the case report.

Nutrition and physical activity guidelines for cancer survivors

Cancer survivors are often highly motivated to seek information about food choices, physical activity, and dietary supplements to improve their treatment outcomes, quality of life, and overall survival. To address these concerns, the American Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer survivorship to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer. This report summarizes their findings and is intended to present health care providers with the best possible information with which to help cancer survivors and their families make informed choices related to nutrition and physical activity. The report discusses nutrition and physical activity guidelines during the continuum of cancer care, briefly highlighting important issues during cancer treatment and for patients with advanced cancer, but focusing largely on the needs of the population of individuals who are disease free or who have stable disease following their recovery from treatment. It also discusses select nutrition and physical activity issues such as body weight, food choices, food safety, and dietary supplements; issues related to selected cancer sites; and common questions about diet, physical activity, and cancer survivorship.

Dietary and nutritional needs of patients undergoing therapy for head and neck cancer

BACKGROUND

Nutrient and caloric intake is critical during therapy for head and neck cancer.

METHODS

The authors review the oral complications experienced by, and dietary and nutritional needs of, patients during therapy. They also present recommendations for oral care and calorie and nutrient intake.

CONCLUSIONS

Oral health care professionals can assist patients during treatment for cancer in maintaining oral, systemic and nutritional health, as well as in controlling oral symptoms. Recovery from the acute toxicities of therapy often requires diet modification, tube feeding or both to meet patients' energy and nutrient demands.

CLINICAL IMPLICATIONS

Effective management of oral complications of therapy for cancer is necessary to facilitate oral intake throughout treatment. Oral health care professionals should be part of the multidisciplinary team helping meet the needs of patients during treatment.

Examining low bacterial dietary practice: a survey on low bacterial food

Patients with haematological malignancies have periods of neutropenia caused by the disease process and subsequent treatments, during which time they are at an increased risk of developing life threatening infections. Historically, many measures have been initiated to protect patients during this time. One such measure has been to provide a low bacterial diet to minimise the number of pathogens ingested from food. However, scientific literature lacks any substantial evidence confirming whether this is beneficial in the management of these patients while guidelines are often unclear and give conflicting advice. A detailed survey was carried out to examine the use of low bacterial diets considering criteria, conditions and specific dietary products. One hundred and eight questionnaires were completed, mainly European. Ninety-five (88%) centres used guidelines to advise practice for inpatients. Although 88% of the hospitals have guidelines, when these were examined there were enormous differences in both the guidelines themselves and the way in which they are implemented. The restrictions seen are varied and sometimes even contradict each other. Forty-eight (44%) of the respondents imposed restrictions on all products mentioned. Conditions for starting or stopping dietary restrictions were also diverse. This survey highlights the need to attempt to standardise dietary restrictions in a patient group for whom good nutrition is paramount.

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.

Enteral Feeding and Early Outcomes of Patients Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative Conditioning

The purpose of this study was to evaluate the impact of enteral nutrition on early outcome of patients after myeloablative allogeneic stem cell transplantation (allo-SCT). From January 2001 to January 2003, 22 patients agreed to receive enteral nutrition via a nasogastric feeding tube; the remaining 23 patients received parenteral nutrition (n=22) or standard oral feeding (n=1). Early complications and factors influencing 100-day overall survival (OS) were investigated. Patients who received enteral nutrition developed less often acute-grade III/IV graft-versus-host disease (18%) than those who did not (35%) (P=0.011). In addition, this group showed lower mortality from infection during the first 100 days after transplantation. In multivariate analyses, only the absence of enteral nutrition was found to adversely influence 100-day OS with a hazard ratio of 8.3. Enteral nutrition is a safe and effective method for feeding allo-SCT patients. A randomized trial is warranted to confirm its advantage on early patient outcome.

Palifermin improves severe mucositis, swallowing problems, nutrition impact symptoms, and length of stay in patients undergoing hematopoietic stem cell transplantation

GOAL OF WORK

The aim of this study was to compare palifermin, a recombinant form of human keratinocyte growth factor, with standard treatment on outcomes in patients receiving a high dose of chemotherapy conditioning regimen, undergoing hematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

Over a 1-year period, a series of 59 patients were included: 32 patients (palifermin) were compared with 27 patients (standard treatment). Outcomes assessed at day 8 posttransplantation were mucositis, swallowing, nutrition impact symptoms, dietary intake, time to engraftment, length of stay, infection, and cumulative dose and duration of narcotic administration.

MAIN RESULTS

There was a significant reduction in the incidence of severe oral mucositis (13 vs 48%, p=0.003), swallowing problems (p=0.044), number of nutrition impact symptoms experienced (4.9 vs 6.0, p=0.003), and length of stay (14 vs 18 days, p=0.026) in the palifermin group compared to standard care. There was no significant difference in infection, dietary intake, time to engraftment or cumulative dose and duration of narcotic administration between groups.

CONCLUSIONS

Beneficial outcomes were observed from the use of palifermin in patients undergoing HSCT after a high dose of chemotherapy conditioning regimen. A randomized clinical trial is needed to confirm these results.

Antimyopathic effects of carnitine and nicotine

PURPOSE OF REVIEW

The clinical course of most chronic diseases is associated with declined energy intake and nutrient-resistant progressive myopathy, characterized by accelerated proteolysis and impaired function. This anorexia/cachexia syndrome leads to deterioration of quality of life, and increased morbidity and mortality. The clinical efficacy of currently available therapeutic strategies is limited and more effective treatments are needed.

RECENT FINDINGS

Chronic systemic inflammation, triggered and sustained by cytokines, and increased oxidative stress contribute to the pathogenesis of the anorexia/cachexia syndrome. Carnitine and nicotine have recently been tested as immunomodulating and antioxidant agents. In particular, carnitine supplementation has been shown to reduce chronic inflammation and oxidative stress in hemodialysis patients and, in cancer patients, yielding to reduced fatigue and improved outcome. Nicotine is able to induce the anti-inflammatory activity of the vagus nerve. In animal models of sepsis and cancer, the nicotine-induced supplementation resulted in better protection of nutritional status and improved survival.

SUMMARY

In the continuous effort to develop more efficacious strategies against the anorexia/cachexia syndrome, carnitine and nicotine may represent a further therapeutic tool. More clinical studies are needed, however, before their use can be routinely suggested.