Correlation of nutrition-associated parameters with non-relapse mortality in allogeneic hematopoietic stem cell transplantation

Associations of various medical nutrition therapy strategies with body composition, and physical and clinical outcomes in acute myeloid leukemia patients undergoing intensive remission-induction treatment: A multicenter prospective correlational study

BACKGROUND & AIMS

Medical nutrition therapy (MNT) is commonly used in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing intensive remission-induction treatment to prevent malnutrition, particularly the loss of fat-free mass (FFM)/muscle mass, as well as associated adverse outcomes. However, studies examining the associations of proactive versus wait-and-see approaches toward MNT with nutritional, physical, and clinical outcomes in these patients are lacking. Therefore, this study aimed to explore the associations of these different MNT approaches with body composition changes, as well as physical and clinical outcomes in AML/MDS patients undergoing intensive remission-induction treatment. Additionally, the study aimed to explore the relationships between body composition changes and physical and clinical outcomes, and whether these associations varied between the proactive and wait-and-see strategies.

METHODS

In this multicenter prospective correlational study, newly diagnosed AML/MDS patients undergoing intensive remission-induction treatment were included. Patients were treated in one of five hospitals using a proactive approach toward MNT, initiating MNT when nutritional intake became inadequate, or in the single hospital in the Netherlands that followed a wait-and-see strategy, limiting the use of MNT to exceptional and severe cases only. Body composition was assessed at the start of treatment, weekly during admission and at discharge, and handgrip strength, and patient-reported physical functioning and fatigue at treatment initiation and discharge. Information on number of complications, and duration of fever and hospital length of stay (LOS) was collected from medical records. Within-group changes in body composition and between-group differences were tested using paired or independent t, Wilcoxon signed-rank or two-sample tests, respectively, or chi-square/Fisher's exact tests for proportions. The longitudinal patterns between proactive MNT approach/wait-and-see strategy hospitals were compared by means of linear mixed effects models. Associations between body composition changes and physical and clinical outcomes were explored using multiple linear regression models, and compared between proactive MNT approach/wait-and-see strategy hospitals.

RESULTS

In this study, 204 AML/MDS patients (54 % male, mean age: 56.3 ± 13.0 years) were included, of whom 140 underwent treatment in a hospital using a proactive approach toward MNT and 64 in the hospital following a wait-and-see strategy. In the proactive MNT approach hospitals, 57 % of patients received MNT during the first chemotherapy cycle versus 8 % of patients in the wait-and-see hospital (p < 0.0001). Both approaches toward MNT were associated with significant decreases in body weight, FFM/muscle mass, and muscle strength. However, losses in FFM/muscle mass and muscle strength did not differ significantly between the strategies, while body weight loss was lower with the proactive approach (estimated between-group difference during the first cycle: 0.44 kg/week (95 % CI 0.18-0.70 kg/week, p = 0.0008), primarily due to better preservation of fat mass (FM) (p < 0.05). Additionally, the proactive MNT strategy was associated with fewer nutrition impact symptoms (p < 0.0001), fewer complications (p = 0.01), and shorter LOS (33 days (IQR: 27-41) vs 29 days (IQR: 26-34), p = 0.009). Similar results were observed during the second chemotherapy cycle. Furthermore, better maintenance of body weight and indicators of FFM/muscle mass and FM were significantly associated with shorter LOS and fever duration, fewer complications, improved physical functioning and/or reduced fatigue. Several associations differed significantly between the two MNT strategies, given that decreased body composition parameters were associated with worse physical and clinical outcomes in the wait-and-see hospital, while in the proactive MNT approach hospitals these associations were opposite or attenuated and non-significant.

CONCLUSION

In AML/MDS patients undergoing intensive remission-induction treatment, a proactive approach toward MNT should be used, as it was associated with fewer nutrition impact symptoms, fewer complications, shorter LOS, and better body weight maintenance, mainly through better preservation of FM, compared to a wait-and-see strategy. Maintenance of body weight, FFM/muscle mass and/or FM was associated with improved physical and clinical outcomes. Given that proactive use of MNT could not prevent loss of FFM/muscle mass and muscle strength, future research should focus on combined nutritional and physical exercise interventions aimed at reducing these losses.

[Pre-, per- and post-allogeneic haematopoietic stem cell transplant rehabilitation (SFGM-TC)]

Allogeneic transplantation of haematopoietic stem cells is still the only curative treatment for certain haematological malignancies. This treatment can be responsible for a number of side-effects, leading to multiple and interdependent physical and psychological deficiencies that affect patients' quality of life and social participation, and can be experienced as a handicap, sometimes for several years after the transplant. For several years now, the integration of post-transplant rehabilitation pathways has been becoming more widespread, and initiatives to provide multidisciplinary care at an increasingly early stage are being studied. The aim of this early management is to improve the patient's overall functional state before, during and after the transplant, in order to limit the impact of the treatment and ensure the quickest possible return to a life that is as satisfying as possible. The international literature and the experiments carried out throughout the French-speaking world describe heterogeneous practices. Based on this literature and experience, the aim of this study is to issue homogenous recommendations for good clinical practice and to identify areas for further research into pre-transplant, per-transplant and post-transplant rehabilitation of haematopoietic stem cells.

Impact of Body Mass Index on Outcomes in Pediatric Allogeneic Hematopoietic Stem Cell Transplantation Recipients: A Single-Center Retrospective Study

BACKGROUND

Pediatric patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) face several risk factors influencing transplantation success, including nutritional status as measured by body mass index (BMI).

METHODS

This study analyzed BMI data collected from patients transplanted between 2003 and 2023, and aimed to evaluate whether deviations from normal BMI are associated with poorer clinical outcomes. BMI levels assessed before and after first-line treatment and pre-transplantation were analyzed retrospectively to determine a correlation with survival and post-transplant complications.

RESULTS

Underweight patients had significantly lower 12- and 36-month overall survival rates compared to normal-weight and overweight patients (p = 1.22 × 10-8 and p = 8.88 × 10-8, respectively). Event-free survival was also lower for underweight patients at all time points. A higher pre-transplant BMI increases the risk of acute graft-versus-host disease (GVHD, p = 0.00068). Otherwise, pre-transplant BMI was not significantly correlated with early TRCs and cGVHD. As secondary objectives, this study identified differences in BMI across primary disease groups, with solid tumor patients having the highest BMI and myelodysplastic syndrome patients having the lowest. BMI cut-offs were identified to predict or protect against serious outcomes, including delayed engraftment, TRCs, and acute and chronic GVHD.

CONCLUSIONS

This study highlights the importance of nutritional assessment and management in pediatric patients undergoing allo-HSCT to optimize post-transplant outcomes, as deviations from a normal BMI can significantly impact post-transplant health. These findings underscore the importance of integrating BMI assessment throughout the entire pre-HSCT therapeutic course to identify patients at higher risk for complications and to define more effective nutritional management strategies.

Development of a nomogram to predict the risk of secondary failure of platelet recovery in patients with β-thalassemia major after hematopoietic stem cell transplantation: a retrospective study

Background

Secondary failure of platelet recovery (SFPR) is a common complication that influences survival and quality of life of patients with β-thalassemia major (β-TM) after hematopoietic stem cell transplantation (HSCT).

Objectives

A model to predict the risk of SFPR in β-TM patients after HSCT was developed.

Design

A retrospective study was used to develop the prediction model.

Methods

The clinical data for 218 β-TM patients who received HSCT comprised the training set, and those for another 89 patients represented the validation set. The least absolute shrinkage and selection operator regression algorithm was used to identify the critical clinical factors with nonzero coefficients for constructing the nomogram. Calibration curve, C-index, and receiver operating characteristic curve assessments and decision curve analysis (DCA) were used to evaluate the calibration, discrimination, accuracy, and clinical usefulness of the nomogram. Internal and external validation were used to test and verify the predictive model.

Results

The nomogram based on pretransplant serum ferritin, hepatomegaly, mycophenolate mofetil use, and posttransplant serum albumin could be conveniently used to predict the SFPR risk of thalassemia patients after HSCT. The calibration curve of the nomogram revealed good concordance between the training and validation sets. The nomogram showed good discrimination with a C-index of 0.780 (95% CI: 70.3-85.7) and 0.868 (95% CI: 78.5-95.1) and AUCs of 0.780 and 0.868 in the training and validation sets, respectively. A high C-index value of 0.766 was reached in the interval validation assessment. DCA confirmed that the nomogram was clinically useful when intervention was decided at the possibility threshold ranging from 3% to 83%.

Conclusion

We constructed a nomogram model to predict the risk of SFPR in patients with β-TM after HSCT. The nomogram has a good predictive ability and may be used by clinicians to identify SFPR patients early and recommend effective preventive measures.

Pretransplantation predictors of survival in nonremission acute myeloid leukemia treated with haploidentical transplantation using steroid-based GVHD prophylaxis

Haploidentical hematopoietic cell transplantation (HCT) using glucocorticoids for acute graft-versus-host disease prophylaxis (GC-haplo) may become a curative treatment option for nonremission acute myeloid leukemia (AML). This retrospective study aimed to identify pre-HCT predictors of survival in a cohort of 97 nonremission AML treated with GC-haplo in Hyogo Medical University Hospital between 2010 and 2020. Relapse and primary induction failure included in 70 (72%) and 27 (28%) patients, respectively. Sixty-one patients (63%) had undergone previous HCT. Multivariate analysis revealed that ≤ 6 months' duration between first complete remission (CR1) and first relapse (Rel1) (CR1-Rel1 interval) (hazard ratio 2.11, 95% confidence interval [CI] 1.15-3.89, P = 0.016) and serum albumin before starting the conditioning treatment of ≤ 3.5 g/dL (hazard ratio 1.80, 95%CI 1.09-2.96, P = 0.022) as risk factors for overall survival. Among three groups categorized according to serum albumin and CR1-Rel1 interval, the best 3-year overall survival was observed in patients with albumin > 3.5 g/dL and CR1-Rel1 interval > 6 months or primary induction failure (50.2%, 95%CI 28.9%-68.3%, P < 0.001), revealing that survival could be predicted using albumin and past CR duration in patients with very high-risk AML not in remission before GC-haplo.

Medical nutrition therapy during intensive remission-induction treatment and hematopoietic stem cell transplantation in acute myeloid leukemia patients: Hematologists' experiences and perspectives

BACKGROUND & AIMS

The European Societies for Clinical Nutrition and Metabolism (ESPEN) and Blood and Marrow Transplantation (EBMT) recommend enteral nutrition (EN) as the first-choice medical nutrition therapy in acute myeloid leukemia (AML) patients undergoing intensive treatments, including high-dose remission-induction chemotherapy and hematopoietic stem cell transplantation (HSCT). However, parenteral nutrition (PN) remains the preferred method of nutrition support in current clinical practice. The aim of this qualitative study was to gain insight into hematologists' experiences and perspectives regarding the choice and ESPEN/EBMT recommendations on EN versus PN.

METHODS

Online semi-structured interviews were conducted with one hematologist from each of the 21 hospitals offering intensive AML treatments in the Netherlands, using Microsoft Teams. Interviews were audio-recorded, transcribed verbatim and thematically analyzed using Atlas. ti. One hundred nineteen hematologists working in the same hospitals were invited to complete a short online questionnaire survey (SurveyMonkey®) regarding their knowledge and opinion on the ESPEN/EBMT guidelines recommending EN over PN during intensive AML treatments. The results of this survey are presented in a descriptive way.

RESULTS

Fifty-nine hematologists participated in this study (42% overall response rate), of which 21 in the semi-structured interviews (response rate 100%) and 38 in the online survey (response rate 32%). Hematologists considered medical nutrition therapy important for prevention and treatment of malnutrition and associated adverse outcomes in AML patients undergoing intensive remission-induction treatment and HSCT. However, opposed to the ESPEN/EBMT guidelines, the vast majority of hematologists were hesitant or reluctant to use EN instead of PN as the first-choice medical nutrition therapy in these patients. The most frequently cited barriers to use EN were the expected low feasibility and tolerance of EN, feeding tube-related discomfort and bleeding risk, and patient refusal. Other barriers to follow the guidelines on EN were related to personal factors, including hematologists' knowledge (lack of awareness and familiarity) and attitude (lack of agreement, outcome expectancy, experience, success, motivation, and learning culture), guideline-related factors (lack of evidence and applicability), and external factors (lack of collaboration and resources). Facilitators included strategies for nutrition education and dissemination of nutritional guidelines, interprofessional and patient collaboration, availability of feeding tubes that can be inserted without endoscopy and stronger scientific evidence.

CONCLUSIONS

Hematologists recognized the importance of medical nutrition therapy for reducing malnutrition and related negative outcomes during intensive AML treatments. However, contrary to the ESPEN/EBMT guidelines, they preferred PN instead of EN as the medical nutrition therapy of first choice. To reduce compliance barriers, interventions should focus on improving hematologists' knowledge of medical nutrition therapy and dietary guidelines, enhancing success rates of EN by adequately triaging patients eligible for EN and inserting duodenal feeding tubes using an electromagnetic sensing device without endoscopy, developing decision aids and multidisciplinary guidelines and care pathways. Furthermore, future trials should focus on the feasibility and benefits of EN versus PN both during remission-induction treatment and HSCT.

Weight loss post-allogeneic stem cell transplant is associated with increased transplant-related mortality

PURPOSE

Allogeneic stem cell transplant (allo-HSCT) patients are at risk of malnutrition and weight loss from impaired oral intake resulting from gastrointestinal toxicities, dysgeusia, and psychological effects.

METHODS

A retrospective review of 264 adult patients transplanted at Princess Margaret Cancer Centre who achieved relapse-free survival up to 3 months after allo-HSCT was performed.

RESULTS

Overall incidence of patients who experienced WL (WL) ≥ 10% from HSCT to 3-month post-transplant was 45.9% and from HSCT to 6 months was 56.6%. Patients with ≥ 10% WL from allo-HSCT at 3 months and 6 months had similar 2-year overall survival (OS) compared to those with < 10% WL, 55.7% vs 62.8% (HR = 1.38, p = 0.11) and 71.1% vs 77.2% (HR = 1.37, p = 0.27), respectively. Patients with ≥ 10% WL 3 and 6 months from allo-HSCT also had similar 2-year relapse-free survival (RFS) compared to those with < 10% WL, 48.1% vs 55.8% (HR = 1.26, p = 0.22), and 62.7% vs 69.8% (HR = 1.29, p = 0.31), respectively. The 2-year transplant-related mortality (TRM) was higher for those with ≥ 10% WL from allo-HSCT to 3 months, 35.4% vs 16.9% (HR = 2.39, p = 0.0007) and 6 months, 22% vs 8% (HR = 3.1, p = 0.0034). Although statistical significance was not observed for OS or RFS, patients who experienced ≥ 10% WL 3- and 6-months post allo-HSCT experienced higher 2-year TRM. These results highlight the importance of early intervention and close monitoring of weight post allo-HSCT.

CONCLUSION

Approaches to WL post allo-HSCT should be multifaceted and include members of the interdisciplinary team in order to decrease TRM.

A longitudinal multidimensional rehabilitation program for patients undergoing allogeneic blood and marrow transplantation (CaRE-4-alloBMT): Protocol for a phase II feasibility pilot randomized controlled trial

BACKGROUND

Allogeneic blood and marrow transplantation (alloBMT) is a curative treatment for blood cancers associated with various treatment-related adverse events and morbidities. Current rehabilitation programs are limited for patients undergoing alloBMT and research is urgently needed to test the acceptability and effectiveness of these programs. In response, we developed a 6-month multidimensional longitudinal rehabilitation program that spans from pre transplant to 3 months post transplant discharge (CaRE-4-alloBMT).

METHODS

This study is a phase II randomized controlled trial (RCT) conducted at the Princess Margaret Cancer Centre in patients undergoing alloBMT. A total of 80 patients stratified by frailty score will be randomized to receive usual care (n = 40) or CaRE-4-alloBMT plus usual care (n = 40). The CaRE-4-alloBMT program includes individualized exercise prescriptions, access to online education through a dedicated self-management platform, wearable technology for remote monitoring, and remote tailored clinical support. Feasibility will be assessed by examining the recruitment and retention rates and adherence to the intervention. Safety events will be monitored. Acceptability of the intervention will be assessed through qualitative interviews. Secondary clinical outcomes will be collected through questionnaires and physiological assessments at baseline (T0, 2-6 weeks pre-transplant), transplant hospital admission (T1), hospital discharge (T2), and 3 months post-discharge (T3).

CONCLUSION

This pilot RCT study will determine the feasibility and acceptability of the intervention and study design and will inform full-scale RCT planning.

The emerging role of nutritional support in the supportive care of pediatric patients undergoing hematopoietic stem cell transplantation

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) represents a potentially curative strategy for many oncological, hematological, metabolic, and immunological diseases in children. The continuous effort in ameliorating supportive care represents one of the cornerstones in the improvement of outcome in these patients. Nowadays, more than ever nutritional support can be considered a key feature. Oral feeding in the early post-transplant period is severely impaired because of mucositis due to conditioning regimen, characterized by, mainly by vomiting, anorexia, and diarrhea. Gastrointestinal acute graft-versus-host-disease (GvHD), infections and associated treatments, and other medications, such as opioids and calcineurin inhibitors, have also been correlated with decreased oral intake. The consequent reduction in caloric intake combined with the catabolic effect of therapies and transplantation-related complications with consequent extended immobilization, results in a rapid deterioration of nutritional status, which is associated with decreased overall survival and higher complication rates during treatment. Thus, nutritional support during the early post-transplantation period becomes an essential and challenging issue for allo-HSCT recipients. In this context, the role of nutrition in the modulation of the intestinal flora is also emerging as a key player in the pathophysiology of the main complications of HSCT. The pediatric setting is characterized by less evidence, considering the challenge of addressing nutritional needs in this specific population, and many questions are still unanswered. Thus, we perform a narrative review regarding all aspects of nutritional support in pediatric allo-HSCT recipients, addressing the assessment of nutritional status, the relationship between nutritional status and clinical outcomes and the evaluation of the nutritional support, ranging from specific diets to artificial feeding.

Relationship Between Pretransplantation Nutritional Status and Outcome in Adults with Acute Myelogenous Leukemia Undergoing Allogeneic Hematopoietic Cell Transplantation

Pretransplantation nutritional status may impact outcome after allogeneic hematopoietic cell transplantation (HCT). Various simple screening tools have been developed and used to identify patients at risk of malnutrition; however, how best to use these screening tools is unclear, and their accuracy for the prediction of adverse outcomes is unknown. To investigate how these different measures contribute to outcome prediction, we examined a large cohort of adults with acute myelogenous leukemia (AML) who underwent allogeneic HCT in first or second remission at our institution between April 2006 and May 2021. We assessed the prognostic role of the Nutrition Risk Index (NRI), which combines weight loss and serum albumin, in 970 adults with AML in first or second remission who had usual body weight information available at AML diagnosis or relapse and before HCT. A low NRI at the time of conditioning for HCT was associated with higher nonrelapse mortality (hazard ratio [HR], .97; 95% confidence interval [CI], .95 to .98; P < .001) and relapse risk (HR, .98; 95% CI, .96 to .99; P < .001) and decreased relapse-free survival (HR, .97; 95% CI, .96 to .98; P < .001) and overall survival (HR, .97; 95% CI, .96 to .98; P < .001), as was a low pre-HCT serum albumin level. After multivariable adjustment, NRI, but not weight loss alone, was associated with outcome. The predictive ability of NRI was overall relatively low and comparable to that of serum albumin, with a C-statistic not exceeding .59. Taken together, our data indicate that pre-HCT level of serum albumin, an acute-phase protein recognized to more accurately reflect the severity of the inflammatory response compared with poor nutritional status, but not weight loss, is independently associated with post-HCT outcome in patients with AML. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Nutritional modulation of the gut microbiome in allogeneic hematopoietic stem cell transplantation recipients

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) represents a potentially curative strategy for many oncological and non-oncological diseases, but it is associated with marked morbidity and mortality. The disruption of gut microbiota (GM) eubiosis has been linked to major allo-HSCT complications, including infections and acute graft vs. host disease (aGvHD), and correlates with mortality. This increasing knowledge on the role of the GM in the allo-HSCT procedure has led to fascinating ideas for modulating the intestinal ecosystem in order to improve clinical outcomes. Nutritional strategies, either by changing the route of nutritional supplementation or by administering specific molecules, are increasingly being considered as cost- and risk-effective methods of modulating the GM. Nutritional support has also emerged in the past several years as a key feature in supportive care for allo-HSCT recipients, and deterioration of nutritional status is associated with decreased overall survival and higher complication rates during treatment. Herein we provide a complete overview focused on nutritional modulation of the GM in allo-HSCT recipients. We address how pre transplant diet could affect GM composition and its ability to withstand the upsetting events occurring during transplantation. We also provide a complete overview on the influence of the route of nutritional administration on the intestinal ecosystem, with a particular focus on the comparison between enteral and parenteral nutrition (PN). Moreover, as mounting evidence are showing how specific components of post-transplant diet, such as lactose, could drastically shape the GM, we will also summarize the role of prebiotic supplementation in the modulation of the intestinal flora and in allo-HSCT outcomes.

Clinical course of Coronavirus Disease-19 in patients with haematological malignancies is characterized by a longer time to respiratory deterioration compared to non-haematological ones: results from a case-control study

BACKGROUND

We evaluated clinical features and risk factors for mortality in patients with haematological malignancies and COVID-19.

METHODS

Retrospective, case-control (1:3) study in hospitalized patients with COVID-19. Cases were patients with haematological malignancies and COVID-19, controls had COVID-19 without haematological malignancies. Patients were matched for sex, age and time of hospitalization.

RESULTS

Overall, 66 cases and 198 controls were included in the study. Cases had higher prior corticosteroid use, infection rates, thrombocytopenia and neutropenia and more likely received corticosteroids and antibiotics than controls. Cases had higher respiratory deterioration than controls (78.7% vs 65.5%, p = 0.04). Notably, 29% of cases developed respiratory worsening > 10 days after hospital admission, compared to only 5% in controls. Intensive Care Unit admission and mortality were higher in cases than in controls (27% vs 8%, p = 0.002, and 35% vs 10%, p < 0.001). At multivariable analysis, having haematological malignancy [OR4.76, p < 0.001], chronic corticosteroid therapy [OR3.65, p = 0.004], prior infections [OR57.7, p = 0.006], thrombocytopenia [OR3.03, p < 0.001] and neutropenia [OR31.1, p = 0.001], low albumin levels [OR3.1, p = 0.001] and ≥ 10 days from hospital admission to respiratory worsening [OR3.3, p = 0.002] were independently associated with mortality. In cases, neutropenia [OR3.1, p < 0.001], prior infections [OR7.7, p < 0.001], ≥ 10 days to respiratory worsening [OR4.1, p < 0.001], multiple myeloma [OR1.5, p = 0.044], the variation of the CT lung score during hospitalization [OR2.6, p = 0.006] and active treatment [OR 4.4, p < 0.001] all were associated with a worse outcome.

CONCLUSION

An underlying haematological malignancy was associated with a worse clinical outcome in COVID-19 patients. A prolonged clinical monitoring is needed, since respiratory worsening may occur later during hospitalization.