Energy expenditure in children undergoing hematopoietic stem cell transplantation

Abstract

Summary:Prior studies suggest that patients undergoing hematopoietic stem cell transplantation (HSCT) for malignancy have nutritional needs that are greater than their estimated needs. To determine whether energy estimation equations accurately predict energy expenditure of pediatric patients undergoing HSCT, we prospectively compared the estimated energy expenditure (EEE) and measured energy expenditure (MEE) of 40 patients at four time-points. We also investigated whether energy requirements changed during the transplant period. MEE was determined by indirect calorimetry. Data from 34 patients (autologous HSCT = 10, allogeneic HSCT = 24) were sufficient for analysis. The World Health Organization equation adequately approximated MEE only on day 14 after HSCT. At all other timepoints, measured energy expenditure was significantly less than estimated energy expenditure obtained by using the WHO equation (applicable to all patients), the Seashore equation (for patients Ͻ15 years of age; n = 19), or the Harris-Benedict equation (for patients у15 years of age; n = 15). The median measured energy expenditure varied significantly over the study period and was greatest on day 14 after HSCT. Until accurate equations have been identified for estimating these patients' needs, the use of indirect calorimetry may be medically warranted. Medical nutrition therapy is an important part of the management of hematopoietic stem cell transplantation (HSCT) in children. During the transplant period, numerous factors can alter nutritional requirements. First, the intense chemotherapy and, in some cases, radiation given before transplantation may cause tissue damage, mucositis, nausea and vomiting, and diarrhea, any of which may increase caloric requirements or lead to protein catabolism.1-3 Second, graft-versus-host disease (GVHD), which often follows allogeneic HSCT, may increase energy requirements and lead to a negative nitrogen balance. 4 Third, the energy requirements of children are increased by the demands of physical growth. Therefore, the goals of medical nutrition therapy in this patient population are to restore or maintain lean body mass, to provide the nutrients needed for recovery of the hematopoietic and immune systems, and to facilitate normal growth and development. 5Prior studies, most of which were conducted in adults undergoing HSCT, revealed that energy needs change throughout the course of transplantation and that patients appear to expend more energy than is estimated by standard predictive equations. 4,6,7 Energy expenditure may be determined by standard estimation equations and through the use of indirect calorimetry. Indirect calorimetry can be extremely useful in the daily nutritional management of hospitalized patients who are at risk for nutritional depletion and who may be suffering from catabolic stress as a result of infection, trama, or treatment complications. 8To date, the energy requirements of pediatric patients undergoing HSCT have not been systematically studied. We prospectively compared the ...

Hematopoietic Stem Cell Transplantation and Current Nutritional Approaches: Review

“…Ayrıca beslenme destek tedavisi ile yaşam kalitesini yükseltmek ve normal büyüme-gelişmenin sağlanması amaçlanmaktadır. 8 KÖK HÜCRE NAKLİ HASTALARINDA BESLENME DURUMUNUN DEĞERLENDİRİLMESİ KHN sonrası hastalarda beslenme durumunun değerlendirilmesi oldukça zordur. Kemoterapi ya da enfeksiyonlardan dolayı immünolojik ölçümler hedef düzeyde olmamakta; biyokimyasal parametreler beslenme durumunu net olarak yansıtma-maktadır.…”

“…DSÖ enerji harcaması denklemi ile ölçülen BMH değerinin, nakil sonrası 14. günde ancak gerçeği yansıttığı saptanmıştır. 8 Yapılan bir çalışmada, standart beslenme programlarının "refeeding" sendromuna neden olabileceği belirtilmiştir. 15 "Refeeding" sendromu, hastanın ihtiyacı olan enerji ve besin ögelerinden fazlasının verilmesiyle meydana gelen, vücutta sıvı artışına neden olarak kardiyak ve pulmoner güçlük yaratan ciddi bir komplikasyondur.…”

“…TPN, meydana gelen akut komplikasyonlarda sıvı, elektrolit ve makro besin ögelerinin dengeli yöneti-mini sağlamada endikedir. 8 Allojeneik-KHN hastalarında kemoterapi ön-cesinde, irritasyon durumlarında ve nakil sonrası 28 gün boyunca TPN'ye ek olarak hastanın oral alımı desteklenmelidir. TPN'de besin kaynaklı barsak kontaminasyonu ve diyare riski minimal durumda olsa da gastrointestinal komplikasyon görülmediği sürece oral alım uyarılmalıdır.…”

Non-surgical oncology – Guidelines on Parenteral Nutrition, Chapter 19

“…In most cases it appears to be sufficient to restrict the amount of energy provided to be slightly more than the resting energy expenditure (see: Influence of malignancies on energy expenditure) [150], [151], [152]. …”

Weekly Measurements Accurately Represent Trends in Resting Energy Expenditure in Children Undergoing Hematopoietic Stem Cell Transplantation

“…1 Among 25 subjects, weekly measurements of REE demonstrated normal energy expenditure prior to transplant with a decline over time, reaching a minimum at 4 weeks posttransplant of approximately 80% of predicted REE. Other studies have similarly found discrepancies between measured and estimated REE, 6,7 suggesting the need to employ indirect calorimetry to improve the accuracy of energy assessment. Monitoring REE is important but consumes time and resources and also represents some burden to the patients.…”