rev bras hematol hemoter. 2014;36(6):392–393
Revista
Brasileira
de
Hematologia
e
Hemoterapia
Brazilian
Journal
of
Hematology
and
Hemotherapy
w w w . r b h h . o r g
Scientific
comment
Comment
on
“Nutritional
status
of
patients
submitted
to
transplantation
of
allogeneic
hematopoietic
stem
cells:
a
retrospective
study”
夽
Erin
M.
Schmidt,
Kerry
K.
McMillen
∗SeattleCancerCareAlliance,Seattle,UnitedStates
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Availableonline1October2014
Adultpatientsundergoinghematopoieticcelltransplantation (HCT)varywidelyintermsoftheirrequirementfornutrition interventionandassessmentofnutrientneeds.Multiple fac-torsthroughouttheHCTprocessimpactnutritionalstatusand theneedfornutritioninterventionsuchastypeof condition-ingregimen,degreeofregimen-relatedtoxicity,infectionand graft-versus-hostdisease(GVHD).
Asdemonstrated in thestudy by Ferreiraet al. entitled “Nutritionalstatusofpatientssubmittedtotransplantation ofallogeneichematopoieticstemcells:aretrospectivestudy”, nutritionstatusisadverselyaffectedearlypost-HCTby high-dose conditioning regimens requiring hospitalization and parenteralnutrition(PN)support.1However,regardlessofthe
patient’searlypost-HCTtoxicities,theirnutritionstatuscan also bedrastically affected by later complications such as acute/chronicGVHDand/orcytomegalovirus(CMV)enteritis. Long-termcomplicationsresultingfromimmunosuppressive medicationssuchassteroid-induceddiabetesmellitus, osteo-porosis, hyperlipidemia and metabolic syndrome can also affectnutritionstatusformonthstoyearsafterHCT.
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.bjhh.2014.06.001. 夽
SeepaperbyFerreiraetal.onpages420–3.
∗ Correspondingauthorat:SeattleCancerCareAlliance,Seattle,WA,UnitedStates. E-mailaddress:[email protected](K.K.McMillen).
Werecommendaninitialnutritionassessmentbya reg-istered dietitianforall patientsundergoing allogeneic HCT due totheanticipated nutritionissues associatedwiththe conditioning regimen. Ideally, the initial nutrition assess-ment occurs prior to starting the conditioning regimen and includes anthropometrics, laboratory data, diet com-position/preferences, oral/gastrointestinal symptoms and comorbidities.Ifapatientisidentifiedashighnutritionrisk pre-HCT, intensivedietcounselingand/ornutritionsupport mayberecommendedinthepre-HCTtimeframeinorderto maximizenutritionstatusattimeofhospitaladmission. Addi-tionally,serialnutritionassessmentisnecessarytoaddress post-HCTcomplicationsthatalternutrientintake,absorption, andutilization.2
Parenteral nutrition is not uniformly indicated for all patients with less use among reduced-intensity and non-myeloablativepatients.3–7LengthoftimeonPNinthisstudy
may beinfluencedbythefactthatthe majorityofpatients receivedbonemarrowinfusionvs.peripheralbloodstemcell infusionwhich isassociatedwithshorterengraftment and
http://dx.doi.org/10.1016/j.bjhh.2014.09.008
revbrashematolhemoter.2014;36(6):392–393
393
decreaseddaysofparenteralnutritionsupport.8Close
moni-toringbyanutritionsupportteam,includingadietitian,helps preventoverfeedingand minimizes hyperglycemia particu-larlywhileapatientmaystillbemeetingapercentageoftheir calorieneedsorally.Thedietitiancanalsodetermine appro-priatetimingtodiscontinuePNtherebyminimizinglengthof daysonnutritionsupportandcost.9Asregimen-related
toxi-citiesresolve,itisimportanttostresstolerablefoodssuchas lowfiber,andsoftorpureedfoodstoincreasecalorie-protein intakeandallowsafediscontinuationofPN.PNcanbesafely discontinuedoncepatientsmeet30%ofestimatedneeds with-outsignsofmalabsorption.10,11
Controversy exists regarding “neutropenic diet pre-cautions”. Many hospitals continue to restrict fresh fruits/vegetables, yogurts, spices and herbs despite the factthatstudieshaveshownthatstrict“neutropenic diets” donotdecrease infection rates.2,12,13 Greater availability of
these foods may, in fact, improve flavor, palatability and tolerance as oral and gastrointestinal symptoms resolve allowingexpeditedcalorie-proteinintake.
WithlateronsetGVHD,whetheracuteorchronic,nutrition counselingisimportanttohelppatientsmakefoodchoicesfor besttoleranceandsymptommanagementwhilestillmeeting calorie-proteingoalstopreserveleanbodymass.Oftendiet and/ortexturemodificationarerequiredfororaland gastroin-testinalGVHD.Insomecases,particularlywithchronicGVHD, enteral nutrition may be the best option to meet calorie-proteingoalswheneverfeasible.Enteralnutritionismorecost effectiveandmaintainsmucosalintegritywithlowerriskof infection.14,15
Weagree that nutritionstatus is compromised in allo-geneicHCTpatientsduringtheirhospitalstay.However,for allallogeneicHCT patients,itisimportanttoconsiderthat theirlifelongnutritionstatusmaycontinuetobeinfluenced bysequelaeresultingfromHCT.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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