Weight and HCT Outcome

Transcription

1 Objectives Identify RD nutrition assessment and monitoring parameters for adult and pediatric hematopoietic cell transplant (HCT) patients. Medical Nutrition Therapy: Role of the RD in the HCT population Understand the various types of weights and weightbased calculations. Understand the impact of pre-hct weight/ weight loss during treatment and outcome. Nursing Management of the Blood and Marrow Transplant Patient June 29, 2018 Discuss appropriate nutrition support recommendations & possible implications in gut GVHD. Paula Charuhas Macris, MS, RD, CSO Describe nutrition interactions associated with immunosuppressive medications Weight and Weight-Based Definitions Actual Weight: Weight taken on a scale. Weight and HCT Outcome Ideal Weight: Adjusted Weight: Body Surface Area (BSA): Body Mass Index (BMI): BMI = weight (kg)/[height(m)] 2 4 Deeg HJ. Impact of patient weight on non-relapse mortality after marrow transplantation. Bone Marrow Transplant. 1995;15: Weight history <95% ideal weight: significantly poor prognosis; <85% ideal weight: even poorer prognosis What s happening now with obesity on the rise? 5 1

2 Fuji S. Impact of pretransplant body mass index on the clinical outcome after allogeneic hematopoietic SCT. Bone Marrow Transplant. 2014;49: Pretransplant BMI affected the risk of relapse and NRM after allogeneic HCT (n=>12,000). Obesity = risk factor for NRM. risk of NRM in overweight and obese vs. normal wt (HR 1.19 and HR 1.43, respectively). Underweight = risk factor for poor OS because of an risk of relapse. risk of relapse in the underweight group and in the overweight and obese groups vs normal wt (HR, 1.16, 0.86, and 0.74, respectively). OS in underweight group vs. normal wt (HR 1.10, P=0.018). Gleimer M. Baseline body mass index among children and adults undergoing allogeneic hematopoietic cell transplantation: clinical characteristics and outcomes. Bone Marrow Transplant. 2015;50: Obese pstients = risk of NRM at 3 years vs. normal weight patients. (n=~900) BMI was not significantly associated with acute or chronic GVHD. Obese patients = relapse vs. normal weight patients. Risk of GVHD in overweight group vs. normal weight. 7 8 Baumgartner A. Association of nutritional parameters with clinical outcomes in patients with acute myeloid leukemia undergoing hematopoietic stem cell transplantation. Ann Nutr Metab. 2016;69: Low initial BMI and more pronounced weight loss during HCT are strong prognostic indicators associated with lower survival and worse disease outcomes (n=156 AML patients). 10 year follow-up. Compared to patients with a baseline BMI (kg/m2) of 20-25, a low BMI <20 was associated with long-term mortality (70 vs. 49%, adjusted hazard ratio 1.97, 95% CI , p = 0.036). A more pronounced weight loss during HCT (>7% vs. <2%) was associated with higher risk for bacterial infections (p = 0.059) and fungal infections (p = 0.032), and longer hospital stays (64 vs. 38 days, adjusted mean difference 25.6 days [ ], p < 0.001). Intervention research is needed to investigate whether nutritional therapy can reverse these associations. Weight and Pediatric HCT Outcome White M. Survival in overweight and underweight children undergoing hematopoietic stem cell transplantation. Eur J Clin Nutr. 2012: 66: Hoffmeister PA. Body mass index and arm anthropometry predict outcomes after pediatric allogeneic hematopoietic cell transplantation for hematologic malignancies. Biol Blood Marrow Transplant. 2013;19: High BMI associated with worsened survival. Anthropometry Retrospective review of 733 pediatric HCT patients Arm circumference and triceps skinfold Association between low muscle reserves, pretransplant, and poorer survival 9 10 SCCA HCT Medical Nutrition Therapy Model Role of the RD Pre-HCT Nutrition Assessment Serial Reassessment Education Multidisciplinary Rounds 12 2

3 Clinical MNT Picture nutrient requirements due to: Metabolic complications Fever RD assesses: Nutrient intake Intake vs output Role of Registered Dietitian (RD) Assesses input/output (emesis, diarrhea) and weight trend Assesses IVF/electrolyte needs Determines appropriate timing to initiate/discontinue nutrition support Preparative regimen Acute GVHD Infection Weight trend GI symptoms Lab Trends Initiates calorie counts to determine intake vs needs Educates patient regarding appropriate tolerable food sources pending regimenrelated toxicity 14 Nutrient Goals Macris PC. Medical nutrition therapy in hematopoietic cell transplantation. In: Leser M (ed), Oncology Nutrition for Clinical Practice. Chicago: Academy of Nutrition and Dietetics, Adjusted weight used for patients >120% ideal weight Calorie and protein requirements are significantly elevated during HCT: Calorie needs = kcal/kg Protein needs = g/kg Fluid requirements are significantly elevated due to: Nephrotoxic conditioning regimens Immunosuppressive agents Antimicrobial agents Fluid needs = 1,500 ml x Body Surface Area (BSA) Nutrient Goals Serial nutrition assessment by RD important to address post-hct complications that affect: Nutrient intake Absorption Utilization Anthropometry Oral Intake vs Enteral vs Parenteral How to feed the HCT patient? 17 3

4 Immunosuppressed Pt Diet Boyle NM. Bacterial foodborne infections after hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2014;20: Washed fruit/vegetables are allowed. Follows CDC guidelines for pregnant women. Start if neutropenic, with conditioning regimen and duration of IMM meds. 10-year retrospective review found 12/4069 (0.3%) developed foodborne illness within 1 st year post-hct. Nutrition Support Identify and prevent or correct protein-energy malnutrition and metabolic abnormalities. Preserve lean tissue. Promote growth and development in children. Maximize quality of life Nutrition Support Both European and American nutrition societies recommend using EN as first-line support in patients with a functional gut. Refeeding Syndrome Refeeding syndrome = fluid, micronutrient, electrolyte, and vitamin imbalances that occurs within the first few days after refeeding nutritionally compromised patients. Potentially life-threatening. Enteral-indications/updated standard practice 2017* Parenteral-indications/updated standard practice 2016* *Standard Practice Guidelines in CORE/FYI Enteral Nutrition Benefits of Enteral Nutrition Guieze R. Enteral versus parenteral nutritional support in allogeneic haematopoietic stem-cell transplantation. Clin Nutr. 2014;33: Seguy D. Better outcome of patients undergoing enteral tube feeding after myeloablative conditioning for allogeneic stem cell transplantation. Transplantation. 2012;94: Indications for EN support during HCT: Intact GI tract Inability to meet needs via po route Chronic oral/esophageal GVHD with need for long-term nutrition support Ongoing weight loss Ventilation Maintains mucosal integrity and gut barrier function Stimulates of mucosal repair incidence of hyperglycemia incidence of infection cost incidence of grade III-IV gut GVHD compared to PN use

5 Parenteral Nutrition HCT Timeline Indications for PN support during HCT: Myeloblative conditioning regimen with severe GI toxicity Severe intestinal GHVD or high-volume diarrhea Suboptimal nutrition support from enteral route Anticipated length of poor oral intake > than 3 days HCT Clinical Course 25 Parenteral Nutrition Nonmyeloablative vs Ablative Regimens vs RIC Diaconescu R. Morbidity and mortality with nonmyeloablative compared with myeloablative conditioning before hematopoietic cell transplantation from HLA-matched related donors. Blood. 2004;104: Topcuoglu P. Case-matched comparison with standard versus reduced intensity conditioning regimen in chronic myeloid leukemia patients. Ann Hematol. 2012;91: Parenteral Nutrition Stern JM. Impact of a randomized, controlled trail of liberal vs conservative hospital discharge on energy, protein, and fluid intake in patients who received marrow transplants. J Am Diet Assoc. 2000;100: Charuhas PM. A double-blind randomized trial comparing outpatient parenteral nutrition with intravenous hydration: effect on resumption of oral intake after marrow transplantation. JPEN. 1997;21: nonmyeloablative vs 73 myeloablative HCT. Minimal need for PN in nonmyeloablative due to mucositis and other severe GI toxicities. RIC vs myeloablative HCT: - mucositis (46% vs 93%, p=<0.0001) - need for PN (21% vs 77%, p<0.001) PN not uniformly indicated for all patients. Provision of PN can be safely discontinued, without adverse effects during HCT, when: Patients consume at least 30% energy needs Patients are without evidence of malnutrition, malabsorption, or other significant GI toxicities Discontinuation of PN results in earlier resumption of oral intake post-transplant Gut Microbiome Andermann TM. Microbiota manipulation with prebiotics and probiotics in patient undergoing stem cell transplantation. Curr Hematol Malig Rep. 2016;11: Gastrointestinal GVHD: Gut Microbiota Manipulation Intestinal microbiota helps to maintain the physical, functional, and immunologic barriers within the GI tract Diversity is important Intestinal microbiota is a modulator of GI immune homeostasis Growing evidence that the gut microbiota may contribute to the development of post-hct complications, including GVHD Probiotics have the potential to change the gut flora to support the development and sustainability of a healthier microbiota 29 5

6 Gastrointestinal GVHD: Gut Microbiota Manipulation Probiotics - Live microorganisms - Most common species: Lactobacillus, Bifidobacterium - May alter the composition of the intestinal microflora and improve the mucosal barrier - Examples: yogurt, kefir, acidophilus milk Gastrointestinal GVHD: Gut Microbiota Manipulation Jeng RR. Intestinal Blautia is associated with reduced death from graft-versus-host disease. Biol Blood Marrow Transplant. 2015;21: bacterial diversity associated with GVHD mortality Probiotics: Recommend pasteurized food sources (yogurt, kefir, acidophilus milk) rather than supplements during the immediate post-transplant course More human studies needed in the HCT population before specific recommendations can be made Prebiotics are also important! 32 Medications Impact on Nutrition/Diet Medication MMF Interaction with all calcium, not just dairy Helpful to outline times patient can consume calcium GI toxicity, consider myfortic Consider coconut milk-based products Tacrolimus/CSP Magnesium wasting Also interactions with grapefruit + pomegranate juice/bitter orange/earl Grey tea (bergamot) Sirolimus Elevated TG levels 34 Prednisone Medical Nutrition Therapy glucose Bone health Body image Examples of interventions by RD -Start accu-checks if glucose >180 mg/dl x 2 -Basal vs premeal insulin -Calcium -Vitamin D -Weight gain -Decreased LBM 35 6

7 Diarrhea management Evaluate dietary fiber content Small, frequent meals Ensure patient is adequately hydrated Consider lactose-intolerance Consider oral magnesium supplementation Refer to RD for counseling/evaluation Late effects: pancreatic exocrine insufficiency Hyponatremia Restrict free water Include sodium-containing fluids Do not tell patients to add salt to foods! Refer to RD for patient education 37 Yes! 38 No! Metabolic Syndrome Metabolic Syndrome Increased risk of heart disease and DM Increased at day 80 and 1 year 1 st treatment is diet modification All calories are not created equal Metabolic syndrome appears early post-hct McMillen K. Metabolic syndrome appears early after hematopoietic cell transplantation. Metabolic Syndrome and Related Disorders. 2014;12: :1 frequency of metabolic syndrome compared with NHANES data (n=86) in survivors >1 year post-transplant. Majhail NS. High prevalence of metabolic syndrome after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 2009;43: Statistically significant difference in the incidence of cardiometabolic traits in childhood survivors compared to controls. Chow EJ. Increased cardiometabolic traits in pediatric survivors of acute lymphoblastic leukemia treated with total body irradiation. Biol Blood Marrow Transplant. 2010;16: Thank you! 41 7