Nutrition during and after HSCT: The physicians view WHAT IS THE EVIDENCE?

Transcription

1 Nutrition during and after HSCT: The physicians view WHAT IS THE EVIDENCE? Annic Baumgartner, Philipp Schuetz, Medizinische Uniklinik, Kantonsspital Aarau Swiss Blood Stem Cell Transplantation (SBST),

2 Todays menu.. 1. Malnutrition in the medical / oncological population Association vs Causation? Can we improve outcomes? 2. Recommendation for Stem Cell Transplantation patients ASPEN guidelines 3. Current practice across centers in Switzerland Recommendation vs ususal practice Outlook and discussion

3 30 days mortality (%) Malnutrition and Mortality Number of patients Kantonsspital Aarau, 6 month observation (04/ /2013) 4000 patients, ~ 30% at risk for malnutrition (NRS 3 points) NRS 0 /1 NRS 2 NRS 3 NRS 4 NRS 5 Nutritional Risk score (NRS) 0 Schuetz P et al, BMC Emergency Medicine (2013), 13: 12, 122 Schuetz P et al, SMW (2014)

4 Negative effect of Malnutrition on outcomes Is independent of medical population Felder S. et al, Nutrition (2015)

5 Schuetz P, «"Eat your lunch!" - controversies in the nutrition of the acutely, noncritically ill medical inpatient.»; SMW 145:w14132 (2015) Effects of acute and chronic illness chronic endocrine response Testosterone Cortisol gastrointestinal effects: Decreased intestinal motility acute and chronic illness Cortisol energy effects: Change in resting metabolic rate acute endocrine response metabolic effects: insulin resistance brain effects: Loss of appetite Free fatty acids CRP Lipoprotein lipase IL-1β IL-6 inflammatory response muscular effects: catabolism

6 Effects of acute and chronic illness chronic endocrine response Testosterone Cortisol gastrointestinal effects: Decreased intestinal motility acute and chronic illness Cortisol energy effects: Change in resting metabolic rate? acute endocrine response metabolic effects: insulin resistance brain effects: Loss of appetite Free fatty acids CRP Lipoprotein lipase IL-1β IL-6 Adaptation or maladaptation? inflammatory response muscular effects: catabolism Schuetz P, «"Eat your lunch!" - controversies in the nutrition of the acutely, non-critically ill medical inpatient.»; SMW 145:w14132 (2015)

7 Bally M, Blazer P, Bonoure L, Mueller B, Briel M, Schuetz P, JAMA Internal Medicine. 2015:1-11.

8 Nutritional therapy reduces risk for readmissions 22 Trials, 3736 participants Bally M, Blazer P, Bonoure L, Mueller B, Briel M, Schuetz P, JAMA Internal Medicine. 2015:1-11.

9 Nutritional therapy: 2 days shorter LOS Bally M, Blazer P, Bonoure L, Mueller B, Briel M, Schuetz P, JAMA Internal Medicine. 2015:1-11.

10 Ernährung Nutritional auf therapy: der Medizin no effect on was mortality bringts? Bally M, Blazer P, Bonoure L, Mueller B, Briel M, Schuetz P, JAMA Internal Medicine. 2015:1-11.

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12 The EFFORT trial Nutritional screening of consecutive medical inpatients Exclusion of patients: critical care or post-op long-term nutrition terminal condition Inclusion of patients: Nutritional risk score 3 Estimated LOS 5 days Written informed consent Randomization 1:1 Target number: n = up to 3000 Intervention group Individualized early nutritional therapy according nutrition guidelines Control group Standard nutrition provided by hospital kitchen according to patient appetite Daily re-assessment of all patients to optimize treatment Blinded Outcome assessment after 30 and 180 days EFFORT: Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial

13 Todays menu.. 1. Malnutrition in the medical / oncological population Association vs Causation? Can we improve outcomes? 2. Recommendation for Stem Cell Transplantation patients ASPEN guidelines 3. Current practice across centers in Switzerland Recommendation vs ususal practice Outlook and discussion

14 Recommendations from ASPEN (2009): Nutrition Support Therapy in Hematopoietic Cell Transplantation

15 Negative impact of malnutrition and screening No effect on OS by Malnutrition or Weight loss

16 Negative impact of malnutrition and screening What s new?

17 Negative impact of malnutrition and screening Population: patients

18 Nutritional Therapy Similar recommendations in - ESPEN Guidelines EBMT-Handbook Cochrane Review (Murray et al 2008)

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20 Nutritional Therapy 2y-OS 50% vs. 35% (P=0.011) 2y-Relapse 35% vs 60% (p=0.008)

21 Nutritional therapy

22 Nutritional therapy

23 Nutritional therapy However, tolerance of the nasogastric tube was acceptable, and improved as the study progressed. It was mainly related to acceptance by the nursing team of this new feeding technique.

24 Nutritional therapy

25 Neutropenic diet and infection risk v

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27 Neutropenic diet and infection risk ESPEN Guidelines 2009 (Bozzetti et al.) Neutropenic diet is not mentioned National Comprehensive Cancer Network (NCCN) guidelines on prevention and treatment of infectious complications 2009 Neutropenic diet is not mentioned

28 Neutropenic diet and infection risk

29 Todays menu.. 1. Malnutrition in the medical / oncological population Association vs Causation? Can we improve outcomes? 2. Recommendation for Stem Cell Transplantation patients ASPEN guidelines 3. Current practice across centers in Switzerland Recommendation vs ususal practice Outlook and discussion

30 Guidelines on nutritional therapy in Switzerland ASPEN Guidelines 1) Nutritional Screening a) Parameters 2) Nutritional support (NS) a) Regular vitamin substitution b) TPN: Indication, use, dosage, duration 3) Use of EN USB USZ HUG Screening by nutritionists automatically according to NRS (Kondrupp 2002) 1a) Weight loss, BMI, quantitative food consumption, disease and age 2a) Supradyn; Vitamin D individually 2b)Indication SmofKabiven: NRS 2-3 Dosage kcal: BASA-ROT (Valentini 2003) Dosage protein: 1,2-1,5g/kg Supplements: Addamel, Soluvit, Vitalipid Discontinuation: oral intake >/= 50% Very rarely used Produce: Isosource Protein Fibre Supplements: Supradyn Screening by nutritionists automatically according to NRS (Kondrupp 2002) 1a) Weight loss, BMI, quantitative food consumption, disease and age 2a) Vitamin K individually b) Indication SmofKabiven (auto)/nutriflex lipid spezial (allo): - Oral intake < 500kcal for 5d - or 3-5d if malnutrition is present - or orale intake < 60% for 10-14d Dosage kcal: 30kcal/kg/d (Bozzetti 2009) Dosage protein 1,2-2g/kg Supplements: Cernevit + Addamel Discontinuation: Oral intake > 60% Very rarely used Supplements: Supradyn until oral intake >1600kcal/d Pretransplant assessment by dietitians Screening according internal guidelines 1a) Indirect calorymetry; bioelectrical impendace analysis; 24h-diet recall; Physical activity; height and weight 2a) Individually. No multivitamin b) Indication NS: not defined (quant.) Dosage: Harris Benedict; indir.calorym. Supplements PN: Addamel, Cernevit, Dipeptiven (if diarrhea), Omegaven Discontinuation: - oral intake >60% daily needs - UAW: Severely incresed liver enzymes, hypertriglyceridemia, hyperglycemia EN (Novasource) = 1 st choice for NS PN if: intolerance EN, refusal, severe dysfunction of GIT) Discontinuation/dosage as above 4) Use of Glutamin parenterally? Indication: No orale intake at all Dosage: ml/d Not used Indication: Severe diarrhea Dosage: 1.5ml/kg/d i.v. 6) Nutritional support in GvHD Indication: NRS and malnutrition preexisting (ESPEN guidelines 2009) Dosage kcal: Valentini 2012 EN not used Indication: NRS >/= 3 General recommendations: reduced fat intake, little fibres and lactose, isotonic drinks Inadequat oral intake: TPN (30kcal/kg) Indication EN/PN : Severe diarrhea Dosage: Harris Benedict, indir.calorym.. Outpatient counselling 1x/week, medical counselling if weight loss or eating difficulties

31 Guidelines on nutritional therapy in Switzerland ASPEN 5) Neutropenic diet/low bacterial diet USB USZ HUG Differentiation of populations a) Prednisone >10g/d or active GvHD b) Prednisone <10g/d and no active GvHD c) No immunosuppression MAC-HSCT only In-hospital or out-hospital none In-hospital or out-hospital Mesures concerning hygene Detailed description Detailed description (out-hospital patient) Not mentioned Food consumption Reheating > 70 C Cooled food <6h Warm tea <12h No reheating No reheating Convenience food Only small packs Consume <24h Consume <24h Consume <24h Return to usual practice No immunosuppression No active GvHD After recontamination Max. D+100 According to medical prescription

32 Guidelines on nutritional therapy in Switzerland ASPEN 5) Neutropenic diet/low bacterial diet Consensus Difference Dairy products No raw milk or milk products No probiotics No soft cheese Cheese: - processed cheese (Schmelzkäse) - Fondue/Raclette Eggs No raw/ soft boiled eggs (3min) Fried eggs (allowed in USB) Meat/Fish No raw, dried, smoked or salted meat or fish No poultry with bones Sausages (allowed in USB) Cereales Raw cereals Bread containing nuts, dried fruit or seeds Fruit, Nuts, Vegetables Varia No unwashed and unpeeled fruit No dried fruit No uncooked nuts, no seeds, no sprouts raw lettuce, raw and unpeeled vegetables raw herbs No fresh pepper and other herbs Unpasteurized fruit juice Tap water, ice cubes Mineral water or soda without gas in > 0.5l Thick-/thin peel-fruit no specification USZ, no unpeeled fruit USB Peeled vegetables Tea from tea-bags

33 Conclusions 1. Patients after stem cell transplantation who develop malnutrition are at increase risk Association vs Causation? 2. There is a lack of evidence how to address this problem Larger RCTs are needed 3. If possible enteral nutrition (vs parenteral) should be favored 4. In Switzerland there is no consensus regarding nutritional support in stem cell transplantation patients Type of nutritional support? Neutropenic Diet?

34 Nutritional support in GvHD Summary - Few studies, little evidence - Patients with GvHD have higher risk of mortality (van der Meij et al 2013) - EN during HSCT seems to be a protective factor (Seguy et al 2006) - Oral upgrade diets appear to be safe (level C). - No data on mortality risk reduction by nutritional intervention in active GvHD

35 Parenteral glutamine Evidence of 11 small RCTs and systematic search No reproduceable benefit on morbidity and mortality Trend towards - Fewer infections - Shorter LOS - Faster neutrophil recovery