Enteral nutrition protects children undergoing allogeneic hematopoietic stem cell transplantation from blood stream infections
Nutrition journal. 2020;19(1):29
Enteral Nutrition (EN) is recommended as first line nutritional support for patients undergoing Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT), but only few studies exist in the literature which compare EN to Parenteral Nutrition (PN) in the paediatric population.Forty-two consecutive paediatric patients undergoing allo-HSCT at our referral centre between January 2016 and July 2019 were evaluated. Post-transplant and nutritional outcomes of patients receiving EN for more than 7 days (EN group, n = 14) were compared with those of patients receiving EN for fewer than 7 days or receiving only PN (PN group, n = 28). In the EN group, a reduced incidence of Blood Stream Infections (BSI) was observed (p = 0.02) (n = 2 vs. n = 15; 14.3% vs. 53.6%). The type of nutritional support was also the only variable independently associated with BSI in the multivariate analysis (p = 0.03). Platelet engraftment was shorter in the PN group than in the EN group for a threshold of > 20*10(9)/L (p = 0.04) (23.1 vs 35.7 days), but this correlation was not confirmed with a threshold of > 50*10(9)/L. The Body Mass Index (BMI) and the BMI Z-score were no different in the two groups from admission to discharge.Our results highlight that EN is a feasible and nutritionally adequate method of nutritional support for children undergoing allo-HSCT in line with the present literature. Future functional studies are needed to better address the hypothesis that greater intestinal eubyosis maintained with EN may explain the observed reduction in BSI.
Dietary intake and Diet Quality of Hematopoietic Stem Cell Transplant Survivors
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2020
BACKGROUND Hematopoietic stem cell transplant (HCT) survivors are burdened by a high prevalence and early onset of chronic disease. Healthy dietary patterns have been associated with lower risks of chronic health conditions in the general population. HCT survivors are susceptible to multiple complications and may result in chronic illness. Unfortunately, no study to date has comprehensively documented the adherence of HCT survivors to the Dietary Guidelines for Americans (DGA), specifically designed to provide guidance for making healthy food choices. The aims of this study were to evaluate diet quality and nutrient intake adequacy of HCT survivors. A secondary aim was to assess their willingness to take part in a future dietary intervention. METHODS Dietary intake of adults, who had undergone autologous or allogeneic HCT for a hematologic disease and were at least 1-y post-transplantation, was assessed using the Block 2014 food frequency questionnaire and diet quality was estimated using the Healthy Eating Index-2015 (HEI-2015). Nutrient intake adequacies of the group were estimated by the Estimated Average Requirement (EAR) cut-point method. RESULTS Survivors' (n=90) HEI-2015 scores averaged 61.6+/-1.1. Adherence to a good quality diet was reported by only 10% of survivors. Intakes of vitamins A, C and D, as well as magnesium and calcium, suggested inadequacy. Fiber intake at 8.9 g per 1000 kcal/d fell below the Adequate Intake recommendation. "Change in taste" was associated with lower quality of diet (p=0.02). HCT survivors within 2 y post-transplant were more receptive to participation in a dietary intervention compared to survivors beyond 2 y (95% vs. 65%, p=0.0013). CONCLUSION Adult HCT survivors reported less than optimal adherence to the 2015-2020 Dietary Guidelines for Americans and had numerous short-fall nutrient intakes. However, their willingness to participate in a dietary intervention was relatively high. These findings reinforce the need to incorporate nutrition into HCT survivor care.
The nutrition risk index is associated with bacteraemia within 30 days after autologous stem cell transplantation in patients with multiple myeloma
Transplant infectious disease : an official journal of the Transplantation Society. 2020;:e13302
OBJECTIVES To assess whether the nutrition risk index (NRI) is associated with the risk of bacteraemia within the first days after autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM). MATERIALS AND METHODS Retrospective cohort study of adult patients with MM taken to ASCT at the Hospital Universitario San Ignacio (Bogota, Colombia) between 2005 and 2019. The outcome of interest was the incidence of bacteraemia at 30 days. Multivariate analysis was used to identify if the NRI was associated with bacteraemia, controlling by different confounding variables. RESULTS 124 patients with a median age of 58.5 years, (IQR 54 - 64) were included. 47.1% were in stage ISS III. 36.0% had moderate or severe malnourishment (NRI <97.5). 11.2% presented bacteraemia in the first 30 days after transplantation. In the univariate analysis, the NRI <97.5 was associated with bacteraemia (OR 1.88; 95% CI 1.30 - 2.72, p = 0.001), however this association was not significant in the multivariate analysis, unlike the presence mucositis (OR 11.59; 95% CI 1.9-68.3, <0.01), one or more previous lines of therapy (OR 12.0; 95% CI 2.1 - 67.4; p <0.01) and duration of aplasia (OR 1.70; 95% CI 1.2-2.4, p <0.01) CONCLUSIONS Patients with moderate or severe malnourishment have a higher incidence of bacteraemia in the 30 days post ASCT in patients with MM. Additional risk factors associated with bacteraemia include the presence of mucositis, one or more previous lines of therapy, and the duration of aplasia.
Evaluation of nutritional risk factors in hematopoietic stem cell transplantation-eligible patients
Einstein (Sao Paulo, Brazil). 2020;18:eAO5075
OBJECTIVE To evaluate the nutritional risk factors in patients eligible for hematopoietic stem cell transplantation. METHODS A cross-sectional, descriptive study conducted with patients recruited from an hematology outpatient clinic. Study variables included demographic and clinical data, patient-generated global subjective assessment findings, anthropometric indicators, food intake and oxidative stress levels. The level of significance was set at 5% (p<0.05). RESULTS The sample comprised 72 patients, mean age of 48.93 years (14.5%). Multiple myeloma was the most prevalent condition (51.4%) in this sample. Most patients (55.6%) were overweight according to body mass index and at risk of cardiovascular disease according to waist circumference, conicity index and percentage of body fat. Sarcopenia was associated with risk of cardiovascular disease, hip-to-waist ratio (p=0.021), muscle strength depletion (p<0.001), food intake (p=0.023), reduced functional capacity (p=0.048), self-reported well-nourished status; p=0.044) and inadequate vitamin B6 (p=0.022) and manganese (p=0.026) intake. Elevated oxidative stress, detected in 33.3% of patients in this sample, was not associated with sarcopenia. CONCLUSION Most patients in this sample were overweight and sarcopenic. Lean mass depletion was associated with risk of cardiovascular disease, reduced muscle strength, food intake changes, reduced functional capacity, self-reported well-nourished status and inadequate intake of vitamin B6 and manganese, but not with oxidative stress.
Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Adults
Einstein (Sao Paulo, Brazil). 2020;18:Ae4530
The nutritional status of patients submitted to hematopoietic stem cell transplant is considered an independent risk factor, which may influence on quality of life and tolerance to the proposed treatment. The impairment of nutritional status during hematopoietic stem cell transplant occurs mainly due to the adverse effects resulting from conditioning to which the patient is subjected. Therefore, adequate nutritional evaluation and follow-up during hematopoietic stem cell transplant are essential. To emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to the nutritional assessment of the patient, the Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplant: Adults was prepared, aiming to standardize and update Nutritional Therapy in this area. Dietitians, nutrition physicians and hematologists from 15 Brazilian centers thar are references in hematopoietic stem cell transplant took part.
Patients Undergoing Myeloablative Chemotherapy and Hematopoietic Stem Cell Transplantation Exhibit Depleted Vitamin C Status in Association with Febrile Neutropenia
Patients undergoing myeloablative chemotherapy and hematopoietic stem cell transplantation (HSCT) experience profound neutropenia and vulnerability to infection. Previous research has indicated that patients with infections have depleted vitamin C status. In this study, we recruited 38 patients with hematopoietic cancer who were undergoing conditioning chemotherapy and HSCT. Blood samples were collected prior to transplantation, at one week, two weeks and four weeks following transplantation. Vitamin C status and biomarkers of inflammation (C-reactive protein) and oxidative stress (protein carbonyls and thiobarbituric acid reactive substances) were assessed in association with febrile neutropenia. The vitamin C status of the study participants decreased from 44 +/- 7 micromol/L to 29 +/- 5 micromol/L by week one (p = 0.001) and 19 +/- 6 micromol/L by week two (p < 0.001), by which time all of the participants had undergone a febrile episode. By week four, vitamin C status had increased to 37 +/- 10 micromol/L (p = 0.1). Pre-transplantation, the cohort comprised 19% with hypovitaminosis C (i.e., <23 micromol/L) and 8% with deficiency (i.e., <11 micromol/L). At week one, those with hypovitaminosis C had increased to 38%, and at week two, 72% had hypovitaminosis C, and 34% had outright deficiency. C-reactive protein concentrations increased from 3.5 +/- 1.8 mg/L to 20 +/- 11 mg/L at week one (p = 0.002), and 119 +/- 25 mg/L at week two (p < 0.001), corresponding to the development of febrile neutropenia in the patients. By week four, these values had dropped to 17 +/- 8 mg/L (p < 0.001). There was a significant inverse correlation between C-reactive protein concentrations and vitamin C status (r = -0.424, p < 0.001). Lipid oxidation (thiobarbituric acid reactive substances (TBARS)) increased significantly from 2.0 +/- 0.3 micromol/L at baseline to 3.3 +/- 0.6 micromol/L by week one (p < 0.001), and remained elevated at week two (p = 0.003), returning to baseline concentrations by week four (p = 0.3). Overall, the lowest mean vitamin C values (recorded at week two) corresponded with the highest mean C-reactive protein values and lowest mean neutrophil counts. Thus, depleted vitamin C status in the HSCT patients coincides with febrile neutropenia and elevated inflammation and oxidative stress.
Geriatric nutritional risk index as a useful prognostic factor in second allogeneic hematopoietic stem cell transplantation
Annals of hematology. 2020
Second allogeneic hematopoietic stem cell transplantation (allo-HSCT) has a low survival outcome and a high non-relapse mortality (NRM) rate which is a major obstacle to this treatment. We hypothesized that the status of malnourishment after first allo-HSCT as represented by the geriatric nutritional risk index (GNRI) could be used as a prognostic factor to determine the outcomes of second allo-HSCT. A total of 108 patients with a median age of 42 (range, 17-69) years, who received second allo-HSCT for disease recurrence after first allo-HSCT from our institution, were included in this study. Low GNRI had a significant impact on NRM at 2 years after second allo-HSCT: 56.9% in patients with GNRI ≤ 92 compared with 27.5% in patients with GNRI > 92 (P = 0.002). In multivariate analysis, GNRI of ≤ 92 was the only significant factor for NRM (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.15-4.56, P = 0.018). High-risk disease status at second allo-HSCT (HR 2.74, 95% CI 1.46-5.14, P = 0.002) and GNRI of ≤ 92 (HR 1.70, 95% CI 1.02-2.82, P = 0.042) were identified as significant factors for overall survival (OS). A score of 1 was assigned to each factor, and the OS rate at 2 years after second allo-HSCT decreased according to the score: 53.0% in patients with score 0, 32.3% with score 1, and 2.5% with score 2 (P < 0.001). In conclusion, GNRI could be a useful predictor for the outcomes of second allo-HSCT. A prospective study in other cohorts is warranted to validate the findings of our study.
Patients receiving a second allo-HSCT for disease recurrence after first allo-HSCT (n=108)
Patients with low score on the geriatric nutritional risk index (GNRI </= 92) (n=60)
Patients with a high score on the geriatric nutritional risk index (GNRI >92) (n=48)
Low GNRI had a significant impact on NRM at 2 years after second allo-HSCT: 56.9% in patients with GNRI </= 92 compared with 27.5% in patients with GNRI > 92. In multivariate analysis, GNRI of </= 92 was the only significant factor for NRM (hazard ratio [HR] 2.29). High-risk disease status at second allo-HSCT (HR 2.74) and GNRI of </= 92 (HR 1.70) were identified as significant factors for overall survival (OS). A score of 1 was assigned to each factor, and the OS rate at 2 years after second allo-HSCT decreased according to the score: 53.0% in patients with score 0, 32.3% with score 1, and 2.5% with score 2.
Nutritional status as a predictor of adverse events and survival in pediatric autologous stem cell transplant
Pediatric hematology and oncology. 2020;:1-15
Nutritional status is recognized as an independent and modifiable risk factor of outcome in stem cell transplant. Our research aim was to evaluate the impact of body mass index (BMI) and serum albumin on the prevalence of adverse events and survival in autologous transplant in children. A retrospective study was conducted of autologous transplants performed between 2006 and 2017 in the Children's Hospital Zagreb, Croatia. Nutritional status was assessed at the times of diagnosis, procedure, and discharge using BMI (underweight, normal, obese) and serum albumin (grades 1-4). Adverse events (fever, gastrointestinal toxicity, electrolyte disturbances, dysglycemia) and outcome (3-year, relapse, mortality) were documented. Seventy-seven children (54.5% males, mean age 7.9?years) underwent autologous transplant, mostly for neuroblastoma. In terms of BMI and albumin, which showed significant positive correlation at diagnosis (p?=?0.026) and transplant (p?=?0.016), most participants were well nourished. Average post-transplant weight loss was 4%. Major toxicities were severe mucositis (72.7%) and hypophosphatemia (31.2%). Relapse and mortality rates were 35.1% and 42.9%, respectively. Hypokalemia (p?=?0.041) and hypomagnesemia (p?=?0.044) were more prevalent in the underweight group, while obese children experienced significantly less severe mucositis (p?=?0.016) and hypophosphatemia (p?=?0.038). There was no significant difference regarding outcome among children of different nutritional status, although undernourished children tended to have lower relapse and mortality rates. In conclusion, underweight children are significantly more prone to severe electrolyte disorders and mucositis, and although statistical significance was not reached, are more likely to survive.
Effect of malnutrition-driven nutritional support protocol on clinical outcomes in autologous stem cell transplantation patients
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2020
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.
Sarcopenia among patients after allogeneic hematopoietic stem cell transplantation and the impact of chronic graft-versus-host disease
Journal of cancer research and clinical oncology. 2020
PURPOSE This study investigated the frequency and characteristics of sarcopenia among patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT) with a specific focus on the chronic graft-versus-host disease (cGVHD) population and its association with malnutrition, vitamin D and clinical characteristics. METHODS We assessed sarcopenia, vitamin D levels, and nutritional status in 73 patients who underwent allo-HSCT, of which 45 were diagnosed with cGVHD. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria. RESULTS Sarcopenia was diagnosed in 19.2% of patients after allo-HSCT with statistically no significant difference between cGVHD and non-cGVHD patients. The risk factor for sarcopenia was the male gender. Sarcopenia in allo-HSCT patients correlated strongly with malnutrition and with current corticosteroid treatment (p < 0.005). Among cGVHD patients sarcopenia additionally correlated strongly with the number of prior systemic immunosuppressive therapy lines (p < 0.005) and moderately with the intensity of immunosuppression, cGVHD severity global rating assessed by both the health care provider and the patient and joint and fascia cGVHD involvement (p < 0.05). Vitamin D deficiency was found in more than 54.8% of patients, but the correlation to sarcopenia was not found. CONCLUSION Sarcopenia was found to be common in long term survivors of allo-HSCT independently of the cGVHD diagnosis. Prospective longitudinal studies are needed for a better understanding of factors affecting the development of sarcopenia after allo-HSCT.