Early Death in Children With Acute Lymphoblastic Leukemia: Does Malnutrition Play a Role?

Abstract

The study aim was to correlate malnutrition and early death in children with acute lymphoblastic leukemia (ALL). A study was conducted in 100 consecutive children with ALL. An analysis included clinical and laboratory parameters as well as co-morbidity factors. Forty patients were standard risk and 60 high risk. Multivariate analysis showed variables of statistical importance, including female gender (p 010), ALL high-risk (p 04), and infection (p 036). Malnutrition (p 1.0) and poverty (p 0.5) did not influence. Early mortality was documented in 15/100 (15%) patients. The study shows that high-risk ALL and infection represent the leading causes of early mortality.

Perspective: Creating the Evidence Base for Nutritional Support in Childhood Cancer in Low- and Middle-Income Countries: Priorities for Body Composition Research

“…In Pakistan, underweight children with ALL were at higher risk of relapse and mortality compared with normal-weight children ( 71 ). Although the relation between weight/body size and survival is supported across HICs and LMICs by meta-analyses and review articles ( 68 , 72 , 73 ), several studies have concluded that there is no relation between weight/body size and survival ( 74–77 ). The reason for the discrepancy in results is likely due to the different classification of malnutrition based on weight and body size, and this highlights the need for studies to assess the link between FM and FFM and survival in children with cancer in LMICs.…”

Alterations of Nutritional Status in Childhood Acute Leukemia

“…The main effect of malnutrition on treatment, is due to an alteration of the biodisponibility of antineoplastic drugs, which is achieved through the following mechanisms: a) changes in absorption, eg for drugs like methotrexate and 6 mercaptopurine, b) the decreased drug transport by the reduction or lack of plasmatic proteins, and c) by decrease in hepatic metabolism of the antineoplastic mainly caused by a lack of enzymatic activity by cytochrome P450. [28][29][30][31][32][33][34][35][36][37] Furthermore. highlight the importance of studying on the subject of how malnutrition affects the prognosis of patients with ALL, because in some of the studies did not allow conclusions to determine whether the association exists in some of these studies were given the limitations by factors such as inadequate sample size, the inconsistency in how to assess the nutritional status between studies, and also have not been studied other possible complications in the evolution of these patients, such as relapse, abandonment in the treatment, among others.…”

“…[8,29,41] According to Reilly J, et al, There are three mechanisms that explain the direct influence of malnutrition on survival of patients with ALL: The first, means that if there is a greater severity of malnutrition, there will be a greater severity of leukemia this because as we know, malnutrition is a surrogate marker of the disease state, the second mechanism is related to immune system dysfunction that occurs in malnourished patients, which would cause increased susceptibility to potentially serious infections could lead to the death of the patient, and finally, a mechanism related to adipose tissue, which has as one of its main functions being a facilitator to take place the pharmacokinetics of many anticancer drugs, this tissue is functionally and structurally altered in malnutrition, resulting in a lower effective antineoplastic drugs and greater toxicity and that both could be potential factors sufficient to endanger the patient's life, however this mechanism has been studied by other authors who found no such effect. [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] Therefore, it is believed that malnutrition alone is a major factor in poor prognosis and survival of patients with ALL, however, it is noteworthy that most of the studies performed, are from developed countries and / or where it is mainly evaluated the impact of malnutrition on long-term survival, so it is necessary to know whether the association also exists in developing countries, because these populations have certain characteristics, such as frequencies malnutrition and deaths occur primarily during the first year of treatment much higher, and it also has been reported as one of the main obstacles to improved survival rates in patients with ALL. [39,[42][43][44][45]…”

“…This was a retrospective study where the follow up was done during the phases of induction to remission, and the results were as follow: 14.9% of children without malnourishment died during treatment phase, while 5.1% of patients without malnourishment perished in this stage of treatment Therefore, it was concluded that malnutrition didn't play an important role in early mortality in children with ALL. [37] In a retrospective cohort done in El Salvador with 469 patients, besides BMI index, triceps skinfolds and Mid Upper Arm Circumference were taken into consideration. This study concluded that malnourishment had no association with mortality during treatment.…”

“…[39] There's controversial information about the relationship between the effects of malnutrition in the evolution of patients with ALL, mostly because even with a wide range of studies, some conclude there's a significant relation between these factors [24,28,44] while others conclude that there's no relation. [37][38][39]49] One of the reasons is the bias in the classification of malnutrition, since in some studies like Pedroza and collaborators [38] the World Health Organization (WHO) charts are used, and in Rivera Luna and collaborators [37] they used the charts of the National Health and Nutrition Examination Survey (NHANES), while in the study conducted by Lobato Mendizabal and collaborators the charts of Ramos Galván were taken into account [44] and at last the study of Mejía Aranguré and collaborators used Federico Gómez' charts. [24] In the studies mentioned, the sample was taken only from one or two hospital sources, so it's important to conduct a multicentre study that can show a wider panorama of the effects of malnourishment in the evolution of children with ALL.…”