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Scientific Comments
Rev Bras Hematol Hemoter. 2012;34(5):323-33
Comment on: Clinical impact of systematic nutritional care in adults submitted to
allogeneic hematopoietic stem cell transplantation
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is an established form
of treatment for many patients with severe disorders of the hematopoietic system. Although
it is still associated with substantial morbidity and mortality, the results of alloHSCT have
improved considerably over the last decades due to a better understanding of stem cell biology,
the development of molecular techniques that improve donor and patient compatibility and
supportive care measures
(1)
. Transplantation is a complex and expensive procedure that should
involve an interdisciplinary team with a wide range of professionals cooperating to improve
the results.
In this issue, an article entitled “Clinical impact of systematic nutritional care in adults
submitted to allogeneic hematopoietic stem cell transplantation” attempts to demonstrate the
impact of a systematic clinical protocol of nutrition care on the outcomes of transplanted
patients in a single Brazilian institution
(2)
. Although the authors compare the intervention
with a historical group, the patients are similar in nutritional and clinical profiles and the
results point to benefits in reducing the total parenteral nutrition (TPN) period by up to almost
a week. The authors conclude that the implementation of a follow up protocol and nutritional
therapy in adult patients submitted to alloHSCT decreased the length of parental nutrition
and this may have an impact on hospitalization costs and potentially on the occurrence of
medical complications.
Patients undergoing alloHSCT are at increased risk for malnutrition during the
transplant period. Multiple factors, such as gastrointestinal toxicity related to radiation and
chemotherapeutic agents, as well as graft-versus-host disease (GVHD) decrease absorption
in addition to increasing metabolic requirements that contribute to the malnourished state.
Nutritional requirements are increased due to catabolic stress, which may also be induced
by cytoreductive therapy, GVHD, and blood count reconstitution. Nutritional needs in the
alloHSCT population increase by as much as 150% of the estimated basal energy expenditure
(3)
.
Poor nutritional status before hematopoietic stem cell transplantation (HSCT) has been shown
to prolong hospital stay and increase patient morbidity and mortality
(4)
. Moreover, the effects
of alloHSCT continue long after transplantation with nearly 50% of patients not returning to
their pre-transplant weight one year after the procedure
(5)
. The use of TPN in alloHSCT has
shown reductions in hospital stay by as much as 7 days, and poor oral intake after transplant
also predisposes the patient to develop severe acute GVHD
(6)
.
TPN is utilized as adjunctive therapy during transplant in up to 92% of patients
and has demonstrated to improve long-term survival in transplant recipients. Despite
published information outlining nutrition support in these patients, there are no clear
recommendations on the best time to start TPN nor the best composition of nutritional
substrates and supplements
(7,8)
.
Also, the protocols for nutrition assessment, other nutrition support modalities such as
the prophylactic use of low-microbial diets, vitamins and supplements, cultural and regional
habits and the use of enteral nutrition vary in the literature and in clinical practice
(9)
.
In this scenario, systematic nutritional care tailored for regional characteristics might
prevent or decrease severity of the most common debilitating complications of alloHSCT and
optimize resources. Further studies are welcome to define more evidence-based approaches
for nutrition care and to link them with immunology and physiology in alloHSCT science.
References
1. Thomas ED. A history of bone marrow transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, Blume
KG editors. Thomas’ hematopoietic cell transplantation. 5th ed. West Sussex, UK : Wiley–Blackwell;
2009. p. 309–7.
2. Sommacal HM, Gazal CH, Jochims AM, Beghetto M, Paz A, Silla LM, et al. Clinical impact of systematic
nutritional care in adults submitted to allogeneic hematopoietic stem cell transplantation Rev Bras Hematol
Hemoter. 2012;34(5):334-8.
Liane Esteves Daudt
Universidade Federal do Rio Grande do Sul -
UFRGS, Porto Alegre, RS, Brazil
Conflict-of-interest disclosure:
The author declares no competing financial
interest
Submitted: 8/28/2012
Accepted: 8/29/2012
Corresponding author:
Liane Esteves Daudt
Serviço de Hematologia Clínica e TMO
Hospital de Clínicas de Porto Alegre
Ramiro Barcelos 2350 9º Sul
90.035-903 Porto Alegre, RS, Brazil
ldaudt@hcpa.ufrgs.br
www.rbhh.org or www.scielo.br/rbhh
DOI: 10.5581/1516-8484.20120083