Altered oral intake during hematopoietic stem cell transplantation: Patterns and countermeasures

Suvir Singh; Kanwarpal Singh; Jagdeep Singh; Davinder Paul; Kunal Jain

doi:10.4103/injms.injms_173_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 12 | Issue : 3 | Page : 137-141

Altered oral intake during hematopoietic stem cell transplantation: Patterns and countermeasures

Suvir Singh¹, Kanwarpal Singh¹, Jagdeep Singh², Davinder Paul², Kunal Jain²
¹ Department of Clinical Haematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
² Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission	26-Dec-2020
Date of Decision	21-Feb-2021
Date of Acceptance	22-Feb-2021
Date of Web Publication	15-Jul-2021

Correspondence Address:
Dr. Suvir Singh
Department of Clinical Haematology and Stem Cell Transplantation, Dayanand Medical College, Ludhiana, Punjab
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_173_20

Abstract

Introduction: Hospitalization for stem cell transplantation leads to reduced oral intake, often requiring parenteral nutrition (PN). Preserving enteral nutrition sustains gut mucosa and microbiota and potentially reduces long-term complications. We provide a short report on patterns of altered dietary intake in stem cell transplant recipients and simple measures that can be taken to mitigate the same. Methods: Patients undergoing autologous and allogeneic stem cell transplantation over an 11 month period were included. Baseline calorie and protein intake was calculated according to the National Institute of Nutrition (India) guidelines. Steps to maintain oral intake included: patient education pretransplant, allowance of home food and packaged food (cookies/chocolates), shift to semisolid or liquid diet, and symptomatic local analgesia for all patients with mucositis. Results: A total of 16 patients were included in the analysis, (male:female = 10:6), with a median age of 43 years (range, 6–67). Median body mass index at baseline was 22.5 kg/m² (range, 11.9–31.8 kg/m²). Median calorie intake at baseline was 26.8 kcal/kg/day (range, 18–51) and protein intake was 0.47 g/kg/day (range 0.19–0.87). During the course of treatment, maximum grade of mucositis was grade III in 9 and grade II in seven patients. The median caloric deficit from baseline at lowest intake was -79% (range, +11 to − 96%), with the nadir occurring by median day 6.5 (range,-1–12). At the time of discharge, the median oral intake was 70% of baseline (range, −1.2% to + 175%). Most patients had a median of − 4.3% (range, −15% to + 0.4%) of weight loss at discharge. No patient required PN during admission. One patient died as a result of regimen-related toxicity. Conclusions: Patients undergoing stem cell transplantation demonstrated significantly low oral intake at admission which further significantly reduced over the course of hospitalization. Pretransplant optimization of calorie intake, patient education, dietary modification, and in-hospital symptomatic control along with daily monitoring of calorie intake is essential so that reduction can be picked up early and corrective actions are taken.

Keywords: Bone marrow transplant, cancer, diet, leukemia, transplant

How to cite this article:
Singh S, Singh K, Singh J, Paul D, Jain K. Altered oral intake during hematopoietic stem cell transplantation: Patterns and countermeasures. Indian J Med Spec 2021;12:137-41

How to cite this URL:
Singh S, Singh K, Singh J, Paul D, Jain K. Altered oral intake during hematopoietic stem cell transplantation: Patterns and countermeasures. Indian J Med Spec [serial online] 2021 [cited 2023 Jun 9];12:137-41. Available from: http://www.ijms.in/text.asp?2021/12/3/137/321459

Introduction

Stem cell transplantation is a potentially curative approach to several hematologic diseases and requires administration of a preparative regimen comprising high-dose chemotherapy with or without radiotherapy. Preparative regimens have evolved over the years and are considerably less toxic, but can still be associated with significant nonhematologic toxicity.^[1] Most transplant recipients experience reduction in oral intake due to a combination of mucositis, infections, or chemotherapy-induced nausea/vomiting (CINV). This is associated with short- and long-term malnutrition, which can adversely affect clinical outcomes.^[2] Maintaining enteral intake has been shown to preserve gut flora and mucosal function, potentially reducing the risk of graft-versus-host disease (GVHD) and infections.^[3] Several factors affect enteral nutrition, including toxicity of preparative regimen, previous dietary habits, and sociocultural factors. As the period of reduced oral intake is predictable, most guidelines recommend initiation of parenteral nutrition (PN) when oral intake falls below 50%60%.^[4] However, PN is fraught with high costs and infectious complications and may constitute a significant proportion of overall transplant costs in resource-constrained settings. We present a short report detailing the patterns of dietary changes seen during stem cell transplantation and possible steps to mitigate the same.

Methods

Setting

This study was conducted as a prospective, observational study in the division of stem cell transplantation of a tertiary care teaching hospital. All patients admitted for autologous or allogeneic stem cell transplantation from July 2019 to October 2020 were included in the analysis.

Aims and objectives

The primary objective was to describe the patterns of dietary intake in patients admitted for autologous and allogeneic stem cell transplantation. Secondary objectives included assessment of factors modifying oral intake.

Protocols to maintain dietary infection control

The universal protocol followed for dietary management for patients undergoing a transplant included the following.

All patients admitted in the bone marrow transplant (BMT) unit met a trained dietician pre-admission to discuss dietary preferences
To maintain sterility, all food was terminally pressure cooked. To ensure this, all food items were placed in a steel container which was steamed in a pressure cooker. The pressure cooker was opened only once it reached inside the BMT unit to avoid contamination
A high threshold was kept for initiating PN to minimize costs and risk of fungal infections. Patients who had no oral intake at all for 48 h with severe mucositis were considered for PN
Calorie and protein intake was calculated for all patients at baseline and on a daily basis by the BMT nursing staff based on 24 h recall. Caloric content of food was obtained from standardized tables published by the National Institute of Nutrition (NIN), which lists caloric and protein content of Indian foods
Centre for International Blood and Marrow Transplant Research scoring system was used to document mucositis following preparative regimens.

Protocols adopted to maintain oral intake

The following steps were taken to reduce the requirement of PN and ensure oral intake as much as possible. For patients where no oral intake was possible, PN was considered as part of protocol:

Patients and families met dietary services before admission to discuss food preferences
BMT consent form included a detailed description of mucositis and reduced oral intake in detail to prepare patients beforehand
Homemade food was allowed for local patients as long it was terminally pressure cooked
During the period of hospital stay, no restrictions on dietary intake were imposed, with the exception of milk and processed milk products during the first 28 days
Packaged food, such as chocolates and cookies were allowed for all patients if requested
Ice chips were made with water and juice to provide local relief of pain and change of taste.

Statistical analysis

Data were described in terms of range; mean ± standard deviation (frequencies [number of cases]) and relative frequencies (percentages) as appropriate. All statistical calculations were done using Statistical Package for the Social Science (SPSS) SPSS 21 version (SPSS Inc., Chicago, IL, USA) statistical program for Microsoft Windows.

Results

A total of 16 patients were included in the analysis, including 10 males and 6 females. The median age of the group was 43 years (range, 6–67). All patients were diagnosed to have hematologic malignancies, except three patients who had solid organ tumors undergoing autologous transplantation. The median body mass index (BMI) of the cohort at the time of admission to BMT was 22.5 kg/m² (range, 11.9–31.8). The baseline median calorie intake per kg of body weight was 26 kcal/kg/day (range 18.5–51.2 kcal/kg/day) and median protein intake was 0.47 g/kg/day (range, 0.19–1.2 g/kg/day). All patients received myeloablative chemotherapy without irradiation as part of the conditioning regimen. [Table 1] summarizes baseline characteristics, and [Table 2] summarizes calorie and protein intake at baseline.

Table 1: Baseline characteristics of transplant recipients

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Table 2: Details of baseline caloric and protein intake

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After initiation of preparative regimens, a reduction in caloric intake was noted for all patients. The median lowest caloric intake was 5.8 kcal/kg/day (range, 1.03-23) and the maximal caloric deficit from baseline was −79% (range, −96 to +11%). The lowest point of oral intake was reached on day 6.5 (range, −1 to +12) posttransplantation. PN was not used for any patient.

At discharge, median caloric intake as percentage of baseline was 70% (range 1.1%–175%). Reduction of caloric intake from baseline was present in 11 patients, while an increase above baseline was noted for five patients. [Figure 1] shows median caloric intake with interquartile ranges at baseline and at the time of discharge. Weight loss was noted in most patients at the time of discharge, with median weight loss being − 4.3% (range, −15.3% to + 0.42%). The corresponding BMI loss was − 4.5% (range, −18.11 to + 0.4%), demonstrated in [Figure 2]. Change in weight at discharge compared to baseline weight is summarized for all patients in [Figure 3]. Early transplant-related mortality was noted in one patient with germ cell tumor as a result of hepatic and renal dysfunction due to regimen-related toxicity. All other patients were uneventfully discharged and are on regular follow-up.

Figure 1: Median, lower and upper quartiles of data intake for all patients at the time of admission and discharge. The two dots in the first group indicate outliers

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Figure 2: Line chart showing the comparison of body mass index at baseline and at discharge. A fall in body mass index is noted for all except one patient at discharge

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Figure 3: Graph showing percentage weight deficit for all patients

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Discussion

Enteral nutrition during stem cell transplantation is affected due to a combination of high-dose chemo/radiotherapy, mucositis, bleeding, and infections, placing transplant recipients at the risk of malnutrition and potentially inferior clinical outcomes. Our report provides a glimpse into patterns of nutritional disturbances seen during the process of transplantation in an Indian setting. We observe suboptimal caloric intake for all patients at baseline, which is reduced significantly during the period of hospitalization. Reduced oral intake persists at the time of discharge and is associated with discernible weight loss. With basic measures in liaison with dietary and nursing services, we were able to avoid the use of PN for all patients.

There are several incentives in maintaining enteral nutrition during transplantation. Loss of gut microbiota diversity caused by chemotherapy is shown to increase the risk of GVHD and infections.^[5] This is potentiated by the use of broad-spectrum antibiotics, ubiquitously used during transplantation.^[6] Enteral nutrition promotes the recovery of gut microbiota and improves diversity, potentially reducing the risk of GVHD.^[3] It also maintains gut mucosal integrity and favorably modifies local immune responses. This is shown to translate into lower nonrelapse mortality and improved GVHD and relapse-free survival), providing an impetus to maintain oral nutrition as far as possible.^[7]

When compared to dietary recommendations, our study indicates suboptimal caloric intake at baseline for all patients. The NIN guidelines recommend a caloric intake of 38–58 kcal/kg/day for adult males and 34–51 kcal/kg/day for females, based on the level of physical activity, which is much higher than that noted in our cohort.^[8] A suboptimal caloric intake may be expected due to the recent administration of chemotherapy before admission for transplantation. Additionally, the high cereal – low protein nature of Indian diets may also exacerbate the above deficit.^[9] These factors must be considered and optimized before admission for transplant.

We noted the lowest caloric intake during the 1^st week posttransplantation, with a median deficit of approximately 80% from baseline. This is in keeping with other reports, which indicate maximum reduction in oral intake by the first seven days.^[10] This timeline coincides with the maximum severity of physical symptoms such as mucositis, CINV, and oral pain which preclude oral intake. Mucositis is noted with up to 60% of patients receiving high-dose chemotherapy-based conditioning and is one of the most important factors affecting oral intake.^[11] Multiple nonphysical factors also contribute to reduced oral intake and must be actively identified and corrected. Patients with excessive psychological stress and a negative perception toward treatment outcomes have a greater reduction in dietary intake posttransplant.^[12] Alteration of “taste” also contributes to reduced oral intake, but is difficult to characterize and must be discussed upfront with patients.^[13] All our patients were educated on the same, which presumably allowed preservation of some enteral nutrition to tide over the worst symptoms.

The effect of posttransplant weight loss on transplant outcomes is contentious. Western data indicate that short-term weight loss is common but does not correlate with adverse posttransplant outcomes.^[14] However, posttransplant weight loss of more than 10% in Asian populations has been shown to predict for worse long-term outcomes and requires further validation in indigenous cohorts.^[15]

Guidelines for nutritional intake during transplantation have been published by the American Society for Parenteral and Enteral Nutrition^[16] and European Society for Clinical Nutrition and Metabolism (ESPEN).^[4] Both guidelines suggest screening patients at risk of malnutrition and initiation of PN if caloric intake is expected to fall below 60% for a period of ten or more days. However, PN significantly adds to the cost of hospitalization and is associated with a risk of hyperglycemia^[17] and fungal infections,^[18] and cannot be universally recommended in resource-constrained settings.

Dietary habits are shaped by socioeconomic, geographic, and personal factors, and implementing uniform guidelines without local modifications is onerous. Several reports indicate marked variability from published guidelines in real-world practice, even in high-income countries with established protocols.^[19],[20]

To keep costs low and promote enteral nutrition, we adopted several simple interventions. Home-cooked food was allowed for local patients, allowing individual food preferences to be met. Packaged foods such as cookies or chocolates were allowed on a short-term basis. Ice candy or frozen juice ice chips are shown to improve taste and reduce local pain and were liberally allowed.^[21]

Our report provides a glimpse into the pattern of dietary changes observed in stem cell transplant recipients, with most patients having marked and persistent reduction in oral intake after admission, associated with weight loss. It is essential to discuss the same with patients before admission so that they are equipped to handle this expected complication. Most importantly, simple short-term modifications to local foods may allow the continuation of enteral feeding and avoid costs and complications associated with PN.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

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Figures

[Figure 1], [Figure 2], [Figure 3]

Tables

[Table 1], [Table 2]

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