The impact of pretransplant hypoalbuminemia on survival in patients with leukemia who underwent allogeneic hematopoietic stem cell transplantation (alloHSCT): a nutritional problem?

Pediatric adapted risk index to predict 2-year transplant-related mortality post-HSCT in children

ABSTRACT

Several attempts have been made to optimize pretransplant risk assessment to improve hematopoietic stem cell transplantation (HSCT) decision-making and to predict post-HSCT outcomes. However, the relevance of pretransplant risk assessment to the pediatric population remains unclear. We report the results of revalidation of the hematopoietic cell transplantation comorbidity index (HCT-CI) in 874 children who received 944 HSCTs for malignant or nonmalignant diseases at a single center. After finding the HCT-CI invalid in our patient population, we proposed a modified pediatric adapted scoring system that captures risk factors (RFs) and comorbidities (CoMs) relevant to pediatrics. Each RF/CoM was assigned an integer weight based on its hazard ratio (HR) for transplant-related mortality (TRM): 0 (HR < 1.2), 1 (1.2 ≥ HR < 1.75), 2 (1.75 ≥ HR < 2.5), and 3 (HR ≥ 2.5). Using these weights, the pediatric adapted risk index (PARI) for HSCT was devised, and patients were divided into 4 risk groups (group 1: without RF/CoM; group 2: score 1-2; group 3: score 3-4; and group 4: score ≥5). There was a linear increase in 2-year TRM from group 1 to 4 (TRM, 6.2% in group 1, 50.9% in group 4). PARI was successfully validated on an internal and external cohort of pediatric patients. Comparing models using c-statistics, PARI was found to have better performance than HCT-CI in predicting 2-year TRM in children, with Akaike and Schwarz Bayesian information criteria values of 1069.245 and 1073.269, respectively, using PARI, vs 1223.158 and 1227.051, respectively, using HCT-CI. We believe that PARI will be a valuable tool enabling better counseling and decision-making for pediatric patients with HSCT.

Association Between C-Reactive Protein and Albumin Ratios and Risk of Mortality in Patients with Chronic Obstructive Pulmonary Disease

Purpose

This study was to evaluate the association between C-reactive protein (CRP) to albumin (ALB) ratio (CAR) and the risk of mortality in patients with chronic obstructive pulmonary disease (COPD).

Methods

In this retrospective cohort study, clinical data were extracted from the National Institutes of Health National Health and Nutrition Examination Survey (NHANES) database between 2007 and 2010. Cox proportional hazard regressions were performed to assess the association between CAR and 5-year mortality in COPD patients. Subgroup analyses were applied to identify the consistency of the association based on the severity of COPD, gender, body mass index (BMI), smoking status, cardiovascular disease (CVD), and chronic kidney disease (CKD), and diabetes. The area under the curve (AUC) of the receiver operator characteristic (ROC) curve analysis was used to evaluate the predictive performance of CAR.

Results

A total of 1210 COPD patients were included, of which 110 COPD patients (9.09%) had 5-year mortality. The mean follow-up was 57.76 (0.33) months. A higher CAR was associated with an increased risk of 5-year mortality in COPD patients [hazard ratio (HR): 1.94, 95% confidence interval (CI): 1.07 to 3.50, P =0.029)]. Subgroup analysis showed that the association between CAR and mortality was especially suitable for COPD patients with mild COPD, in COPD patients who were still smoking, in COPD patients with BMI <=29.9 kg/m2, in COPD patients who were without CVD, in COPD patients who were without diabetes, and COPD patients who were without CKD. The AUCs of CAR for predicting 1-year, 3-year, and 5-year mortality in COPD patients were 0.735, 0.615, and 0.608, respectively.

Conclusion

CAR is strongly correlated with mortality in patients with COPD and CAR could be served as a prognostic biomarker for patients with COPD. This study may provide a promising prognostic biomarker for risk stratification and clinical management of patients with COPD.

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

Outcome of allogeneic stem cell transplantation (alloSCT) is hampered by substantial non-relapse mortality (NRM). Given its impact on organ function and immune response, the nutritional status has been suggested as relevant for NRM. We aimed to evaluate the association of NRM with nutritional status prior to alloSCT and in the post-SCT course. In a retrospective single-center study, we analyzed 128 alloSCTs. Besides standard characteristics, nutrition-associated parameters BMI, serum total protein, and serum albumin were recorded before conditioning and at various time points after alloSCT. Association with NRM was evaluated by univariate and multivariate survival analysis. The cohort comprised patients with a median BMI of 26 kg/m² (16.7–46.9 kg/m²), median serum total protein of 59 g/l (41–77 g/l), and serum albumin of 36 g/l (22–46 g/l) before SCT. NRM at d₊₁₀₀ was 14.8% and at 1 year 26.6%. Prior to SCT, only serum albumin deficiency was associated with increased NRM (p = .010) in multivariate analysis. After SCT (d₊₃₀ and d₊₁₀₀), all nutrition-associated parameters decreased (p < .002), but no association of deteriorating nutritional status with NRM was found. In multivariate analysis, serum albumin (p = .03) and severe albumin deficiency (p = .02) correlated with NRM at d₊₃₀ and d₊₁₀₀, while BMI and serum total protein did not. In our study, albumin deficiency, particularly prior to alloSCT, shows a strong correlation with NRM. This finding may add to monitoring, risk evaluation, and counseling of patients and serve as a rational for interventions to improve the nutritional status in patients undergoing SCT.

A Systematic Review of the Literature and Perspectives on the Role of Biomarkers in the Management of Malnutrition After Allogeneic Hematopoietic Stem Cell Transplantation

Malnutrition is a common problem after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and could impair immune function. Immune dysfunction after allo-HSCT may be linked with infections, GVHD, and relapse and negatively affect the outcome. Aim of this review was to identify malnutrition biomarkers, potentially useful for immune-system monitoring, in the setting of allo-HSCT. After a systematic search, no satisfying biomarker was found, except for citrulline. Citrulline could be useful in monitoring gastrointestinal function after allo-HSCT and its role in the complex relationship with immune-system function ought to be better explored. A multi-omics approach, including biomarkers and PRO (patient reported outcomes) is, in our opinion, the optimal way to study the relationship between malnutrition and transplant outcomes.

Discharge Disposition Following Hematopoietic Cell Transplantation: Predicting the Need for Rehabilitation and Association with Survival

Many hematopoietic cell transplantation (HCT) recipients require rehabilitation due to deconditioning following intensive conditioning regimens and immune reconstitution. HCT recipients are preferentially discharged to home to avoid the risk of exposure to healthcare-associated infection in a rehabilitation facility (RF), with a caregiver who has been provided specific education about the complexity of post-HCT care. This study was conducted to determine the incidence of discharge to an RF following HCT, identify pre-HCT and peri-HCT risk factors for discharge to an RF, and estimate the effect of discharge disposition on overall survival (OS). This retrospective, matched 1:4 case-control study included 56 cases over a 10-year period from a single institution. Controls were matched by transplantation type (autologous versus allogeneic) and date of transplantation. The incidence of discharge to an RF was 2.2%. Controlling for disease, increasing age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04 to 1.15; P < .001), female sex (OR, 3.11; 95% CI, 1.32 to 7.32; P = .01), high-risk HCT Comorbidity Index (HCT-CI) score (≥3) (OR, 3.44; 95% CI, 1.39 to 8.52; P = .008), decreasing pre-HCT serum albumin (OR, 2.60; 95% CI, 1.07 to 6.38; P = .037), and development of acute kidney injury during HCT (OR, 4.10; 95% CI, 1.36 to 12.40; P = .012) were associated with discharge to an RF. Discharge to an RF was associated with worse OS and higher nonrelapse mortality (NRM) compared with discharge to home (1-year OS, 70.5% [95% CI, 55.8% to 81.1%] versus 88.8% [95% CI, 83.6% to 92.4%], P < .001; 100-day NRM: 9.5% [95% CI, 3.5% to 19.2%] versus 1.8% [95% CI, 0.6% to 4.3%]; P = .03). Discharge to an RF following HCT is a rare event but associated with poor OS. Modifiable risk factors for discharge to an RF, including serum albumin as a measure of nutrition and reversible HCT-CI components, should be prospectively studied to determine the effect of mitigation on discharge disposition and survival.

Nutritional status as a predictor of adverse events and survival in pediatric autologous stem cell transplant

Nutritional status is recognized as an independent and modifiable risk factor of outcome in stem cell transplant. Our research aim was to evaluate the impact of body mass index (BMI) and serum albumin on the prevalence of adverse events and survival in autologous transplant in children. A retrospective study was conducted of autologous transplants performed between 2006 and 2017 in the Children's Hospital Zagreb, Croatia. Nutritional status was assessed at the times of diagnosis, procedure, and discharge using BMI (underweight, normal, obese) and serum albumin (grades 1-4). Adverse events (fever, gastrointestinal toxicity, electrolyte disturbances, dysglycemia) and outcome (3-year, relapse, mortality) were documented. Seventy-seven children (54.5% males, mean age 7.9 years) underwent autologous transplant, mostly for neuroblastoma. In terms of BMI and albumin, which showed significant positive correlation at diagnosis (p = 0.026) and transplant (p = 0.016), most participants were well nourished. Average post-transplant weight loss was 4%. Major toxicities were severe mucositis (72.7%) and hypophosphatemia (31.2%). Relapse and mortality rates were 35.1% and 42.9%, respectively. Hypokalemia (p = 0.041) and hypomagnesemia (p = 0.044) were more prevalent in the underweight group, while obese children experienced significantly less severe mucositis (p = 0.016) and hypophosphatemia (p = 0.038). There was no significant difference regarding outcome among children of different nutritional status, although undernourished children tended to have lower relapse and mortality rates. In conclusion, underweight children are significantly more prone to severe electrolyte disorders and mucositis, and although statistical significance was not reached, are more likely to survive.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Adults

The nutritional status of patients submitted to hematopoietic stem cell transplant is considered an independent risk factor, which may influence on quality of life and tolerance to the proposed treatment. The impairment of nutritional status during hematopoietic stem cell transplant occurs mainly due to the adverse effects resulting from conditioning to which the patient is subjected. Therefore, adequate nutritional evaluation and follow-up during hematopoietic stem cell transplant are essential. To emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to the nutritional assessment of the patient, the Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplant: Adults was prepared, aiming to standardize and update Nutritional Therapy in this area. Dietitians, nutrition physicians and hematologists from 15 Brazilian centers thar are references in hematopoietic stem cell transplant took part.

Baseline Renal Function and Albumin are Powerful Predictors for Allogeneic Transplantation-Related Mortality

Biomarkers measured in blood chemistry before allogeneic hematopoietic stem cell transplantation (HSCT) may reflect patients' physiological status. We hypothesized that selected markers are predictive for nonrelapse mortality (NRM) following transplantation and could contribute to risk assessment. We investigated the value of pre-HSCT albumin, estimated glomerular filtration rate (eGFR), and alkaline phosphatase (AlkP) in predicting NRM. We retrospectively analyzed clinical and laboratory data from 1217 patients receiving a first HSCT in 2 European centers between 2003 and 2015. Transplantation indications and conditioning regimens were diverse. Patients had a median age of 55 years and hematopoietic cell transplantation comorbidity index (HCT-CI) scores of 0 (24%), 1 to 2 (39%), and ≥3 (37%). Cutoffs of eGFR <60 mL/min, albumin <3.5 g/dL, and AlkP >180 IU/L corresponded with 8.8%, 8.3%, and 6.5% of the patients, respectively. eGFR and albumin were associated with increased risk and higher cumulative incidence of day-100, 1-year, and 2-year NRM, both as continuous or categorized variables. A similar pattern was observed for AlkP, except for day-100 NRM. In multivariable analyses, eGFR and albumin were consistently among the top risk factors for early and late-term NRM, abrogating the role of age. Prediction models for day-100, 1-year, and 2-year NRM based only on HCT-CI resulted in c-statistics of .565, .575, and .577, respectively. Addition of both biomarkers increased c-statistics for day-100, 1-year, and 2-year NRM to .651, .633, and .624, respectively. Albumin and eGFR are prognostic biomarkers for NRM after HSCT and improve the discriminative power of the HCT-CI.

Unlocking the Complex Flavors of Dysgeusia after Hematopoietic Cell Transplantation

Dysgeusia is a frequently occurring symptom after hematopoietic cell transplantation (HCT) that has important long-term effects on physical, nutritional, and immunologic recovery, as well as on quality of life. Despite the relevance of this symptom, the study of dysgeusia in patients undergoing HCT has been limited, owing in part to its complexity. In this article, we review normal taste function and its clinical evaluation, discuss how dysgeusia uniquely affects patients undergoing HCT, and examine distinct, transplantation-related contributors to dysgeusia that may help elucidate strategies to ultimately reduce this symptom burden after transplantation.

Low serum albumin levels prior to pediatric allogeneic HCT are associated with increased need for critical care interventions and increased 6-month mortality

Poor nutritional status in HCT patients is a negative prognostic factor. There are no pediatric studies evaluating albumin levels prior to HCT and need for critical care interventions. We hypothesized that pediatric patients with low albumin levels, routinely measured 30 days (±10 days) prior to allogeneic HCT, have a higher risk of critical care interventions in the post-transplant period. We performed a 5-year retrospective study of pediatric patients who underwent allogeneic HCT for any indication. Patients were categorized based on albumin level. Hypoalbuminemia was defined as <3.1 g/dL. A total of 73 patients were included, with a median age of 7.4 years (IQR 3.3, 13.2). Patients with hypoalbuminemia had higher needs for critical care interventions including non-invasive ventilation (44% vs 8%, P=.01), mechanical ventilation (67% vs 17%, P<.01), and vasoactive therapy (56% vs 16%, P=.01). Patients with hypoalbuminemia also had a higher 6-month mortality (56% vs 17%, P=.02). Our data demonstrate that children undergoing allogeneic HCT with hypoalbuminemia in the pretransplant period are more likely to require critical care interventions and have higher 6-month mortality. These findings identify an at-risk population in which nutritional improvements may be instituted prior to HCT in hopes of improving outcomes.

Design and Validation of an Augmented Hematopoietic Cell Transplantation-Comorbidity Index Comprising Pretransplant Ferritin, Albumin, and Platelet Count for Prediction of Outcomes after Allogeneic Transplantation

Pretransplant values of serum ferritin, albumin, and peripheral blood counts were previously suggested to provide prognostic information about hematopoietic cell transplantation (HCT) outcomes. Whether these "biomarkers" have prognostic value independent of each other and the HCT-comorbidity index (HCT-CI) is unknown. We analyzed data from 3917 allogeneic HCT recipients at multiple sites in the United States and Italy using multivariate models including each biomarker and the HCT-CI. Data from all sites were then randomly divided into a training set (n = 2352) to develop weights for the relevant biomarkers to be added to the HCT-CI scores and a validation set (n = 1407) to validate an augmented HCT-CI compared with the original index. Multivariate analysis with data from one site showed that ferritin, albumin, and platelets-not neutrophils or hemoglobin-were independently associated with increased nonrelapse mortality (NRM) and decreased overall survival. Findings were validated in data from the other sites. Subsequently, in a training set from all sites, ferritin >2500 mg/dL (hazard ratio [HR], 1.69); albumin 3 to 3.5 g/dL (HR, 1.61) and <3.0 g/dL (HR, 2.27); and platelets 50 to <100,000 (HR, 1.28), 20 to <50,000 (HR, 1.29), and <20,000 (HR, 1.55) were statistically significantly associated with NRM. Weights were assigned to these laboratory values following the same equation used to design the original index. In the validation set, the addition of the biomarkers to the original index to develop an augmented HCT-CI resulted in a statistically significant increase in a higher c-statistic estimate for prediction of NRM (P = .0007). Ferritin, albumin, and platelet counts are important prognostic markers that further refine the discriminative power of the HCT-CI for transplant outcomes.