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Clinical impact of systematic nutritional care in adults submitted to allogeneic hematopoietic stem cell transplantation
Rev Bras Hematol Hemoter. 2012;34(5):334-8
nutritional therapy, to the variability in current management and to
the lack of external validation of management strategies
(8,15)
. Current
criteria for the prescription of PN range from routine use in all
patients with severe malnutrition to prolonged periods (7 to 10 days)
of minimal oral intake or significant weight loss (> 10% of body
weight) during treatment
(16-19)
.
The effects of nutritional care practices on quality of life, toxicity,
and prognosis in cancer patients are still unknown. However, there is
evidence to support the assertion that earlynutritional supplementation
may prevent or decrease the severity of the most common debilitating
complications of HSCT
(20)
. Therefore, the present study sought to
assess the clinical impact of systematic nutritional care on a sample of
patients submitted to allogeneic HSCT.
Methods
This double cohort study was carried out on a sample of adult
patients (age >18 years) undergoing allogeneic HSCT. Two groups
of patients were formed relating to two assessment periods: from
April 2003 to April 2004, which constituted the Non-intervention
Group (NIG), and from March 2006 to January 2008, which
constituted the Intervention Group (IG). The intervention evaluated
in this study, systematic nutritional care for HSCT patients, was
implemented in 2005; therefore, patients admitted over the
course of this year were not included in the study, as this was a
transitional period for adaptation. All patients were enrolled only
once, at the time of HSCT. Patients admitted for retransplantation
or management of HSCT complications were not included.
The NIG was constructed retrospectively through analysis of
the database of the Department of Hematology at the Hospital de
Clínicas de PortoAlegre (HCPA), Brazil, where the studywas carried
out. In 2005, the HCPA Physician Nutrition Specialist Service,
Nutrition and Dietetics Service and Department of Hematology
jointly developed and implemented a protocol of routine, systematic
nutritional care for all adult HSCT patients (Figure 1).
The IG was assessed prospectively for the same variables
analyzed in the NIG, as described below. IG follow-up was led by
the medical and nutritional teams of the HSCT unit. No changes were
made in the type of diet or supplemental nutrition provided between
the pre-intervention and post-intervention periods, but criteria for
institution and discontinuation of PN, according to oral intake, were
established.Clinical andnutritional parameterswereassessedbymeans
of a standard protocol, which was used in both groups. Nutritional
assessment was carried out by a staff dietitian in the HSCT unit or by
a previously trained student dietitian on admission and throughout the
hospital stay. Body mass index (BMI), mid-upper arm circumference
(MUAC), triceps skinfold thickness (TSF), and percent weight loss
(%WL) were assessed. Weight was measured at the HSCT unit using
digital scales with stadiometer (OS 180 A®, Urano). MUAC was
measured with a flexible, non-stretch anthropometric measuring tape
(Barlow®) and TSF, with a skinfold caliper (Cescorf®), in accordance
with World Health Organization (WHO) recommendations. BMI,
%WL and MUAC were calculated as per WHO recommendations
(19)
.
Mortality, infection,andprolongedhospitalstaywereconsidered
dependent variables. Hospital-acquired infection was defined as any
infection that developed during hospitalization, regardless of site
of origin, in accordance with the local Hospital-Acquired Infection
Table 1 - Distribution of indications for hematopoietic stem cell
transplantation in the Non-intervention and Intervention Groups
Disease
NIG NIG
n (%)
n (%)
Aplastic anemia
5 (8.8)
4 (11.7)
Myelodysplasia
3 (5.3)
7 (20.6)
Hodgkin’s disease
2 (3.5)
2 (5.9)
Leukemia, acute biphenotypic or lymphoblastic
8 (14.1)
3 (8.8)
Leukemia, chronic lymphocytic
2 (3.5)
0
Leukemia, acute myeloid
14 (24.6)
9 (26.5)
Leukemia, chronic myeloid
15 (26.3)
6 (17.7)
Lymphoma, T-cell
2 (3.5)
0
Lymphoma, non-Hodgkin
4 (7.02)
3 (8.8)
Multiple myeloma
2 (3.5)
0
Table 2 - Median age, gender, distribution, graft type and conditioning
regimen for the Non-intervention and Intervention Groups
NIG IG
p-value
Age (years) - median (range)
37 (19-55) 35 (19-60)
0.249
Females - n (%)
35 (61.4) 14 (41.2)
0.063
Males - n (%)
22 (38.6) 20 (58.8)
Related-donor - n (%)
57 (100) 25 (73.5)
0.000
Unrelated-donor - n (%)
0 9 (26.5)
Myeloablative conditioning - n (%)
43 (75.4) 27 (79.4)
0.665
Non-myeloablative conditioning - n (%)
14 (24.6)
7 (20.6)
Control Committee (HAICC) protocols. Prolonged length of stay
was defined as any hospitalization exceeding the mean length
expected for HSCT recipients, i.e. 56 days.
Statistical analysis
Study variables were analyzed in the SPSS 17.0. software
environment. The Shapiro-Wilk test was used to determine
normality and variables were then expressed as means and
standard deviations or medians and ranges depending on their
distribution. Relative frequencies (percentages) were also used in
describing the sample. Significance was set for a p-value < 0.05.
Results
TheNIG (pre-implementation of the study intervention, 2002–
2004) comprised 57 patients whereas the IG (post-implementation,
2006–2008) comprised 34 patients. Table 1 shows the distribution
of hematological diseases of patients in each of the study groups.
Table 2 shows the demographic profile of the two groups
and the distribution of graft type and conditioning regimen.
Anthropometric assessment showed no significant pre-
hospitalization weight loss in either group. Mean weight loss was
0.83% (range: -1.48 to 4.8%) in the NIG and 0.14% (range: -3.8 to
4.8%) in the IG. Mean BMI was 25.28 kg/m
2
(range: 22.65 to 28.03
kg/m
2
) in the NIG and 24.89 kg/m
2
(range: 21.95 to 28.82 kg/m
2
) in the
IG
(21)
. There were no significant differences between groups in respect
to anthropometric parameters (DCT, CB and CMB) on admission.