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

Abstract

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.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Graft- versus -host disease

“…This is due to the direct toxic effects of the treatment or secondary complications, such as infections and a-GVHD itself. (15) Moderate to severe GVHD and the multi-drug regimens used in its prevention and treatment result in profound and prolonged immunosuppression. Despite advances in management, GVHD remains a significant problem.…”

“…Nutritional therapy is of utmost importance as a treatment support to counteract the deleterious effects of GVHD and to circumvent the adverse effects of medications. (15,25,77,78)…”

“…According to a systematic review by Baumgartner et al, (15) several studies compared EN with PNT, showing superior results for the enteral route and moderate to high tolerance to the tube, and PNT is recommended only in cases of gastrointestinal insufficiency. EN is contraindicated when there are hemodynamic instability and/or worsening of abdominal pain, abdominal distension, mucositis, diarrhea, incoercible vomiting, paralytic ileus, and intestinal bleeding.…”

“…There are no clear literature data on the impact of the pre-HSCT nutritional status as a cause of higher or lower incidence of GVHD, nor on the best way to perform its assessment. (13)(14)(15)(16) Some studies report that high rates of malnutrition (17) and worsening of nutritional status are associated to more severe GVHD in the GIT, mouth, and lung. (18) On the other hand, despite the heterogeneity of the studies, and although no one knows exactly by what mechanism this interference occurs, both obesity and malnutrition are associated with a higher risk of GVHD.…”

“…(20) However, the relation between GVHD and deficient states, such as vitamin deficits, is well known. (14)(15)(16) In the immediate post-transplant period (30 to 50 days), the nutritional needs reflect the increased caloricprotein intake due to conditioning, infections, a-GVHD, fever, and other metabolic complications, affecting mainly the protein balance, energy requirements, and micronutrient metabolism. (21,22) The nutritional status in a-GVHD or c-GVHD is affected by several symptoms, which are widely discussed later, such as prolonged hospital stay and high doses of corticosteroids, which profoundly affect the body composition with increased muscle loss, fluid retention, and increased visceral fat, impairing even more the nutritional status.…”