University of Virginia Nutrition
Our February traineeship ran into the first week of March, and our trainees hailed from Maryland, Michigan, Kansas and Texas. We had a great week, no snow, but not quite Spring weather yet. We also just completed our first "Weekend Warrior" traineeship session. We had an awesome group of participants, and hosted some fabulous guest speakers.
Seguy D, Berthon C, Micol J, et al. Enteral Feeding and Early Outcomes of Patients Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative Conditioning. Transplantation 2006;82(6):835-9.
This was a prospective cohort study of patients after myeloablative allogeneic stem cell transplantation. The study compared early post-transplant outcomes of 23 patients that received parenteral nutrition (PN) with 22 patients that received enteral nutrition (EN). Oral intake was encouraged in all patients as long as they could tolerate. The EN group received nocturnal NG feedings starting the first week after transplantation. The goal was to meet 50-70% of estimated needs (30-35 kcal/kg) progressing per individual tolerance over 5 days. If patients did not tolerate EN, they received supplemental/total PN "as required." The PN group began PN when oral intake was less then 2/3 of estimated needs.
The primary study outcomes were 100-day overall survival, and early post-transplant complications including oral mucositis, veno-occlusive disease, infections of any kind, duration of anti-infective treatment, ICU transfer, diarrhea, graft-versus-host disease (GVHD), and length of stay.
Inclusion Criteria were:
This study included 45 consecutive patients that received myeloablative conditioning and allogeneic stem-cell transplant. All patient were offered EN via nasogastric tube (NG), and those that refused NG placement received PN (1 patient remained on oral intake alone).
Major Results reported by authors:
Patients who received EN experienced less acute-grade III/IV graft-versus-host-disease (18%) than those who did not (35%) (p = 0.011). There were no differences between the two groups in the number of infectious episodes, but the EN group had a significantly lower mortality from infection during the first 100 days after transplantation (0 patients EN vs 6 patients PN, p = 0.022).
The authors also reported that in multivariate analyses, only the absence of EN was found to adversely influence 100-day overall survival with a hazard ratio of 8.3.
The authors concluded that EN is a safe and effective method for feeding allogeneic stem-cell transplant patients, and that a randomized trial is warranted to confirm its advantage on early patient outcome.
PN had been a mainstay for providing nutrition support to bone marrow/stem cell transplantation patients due to concerns of intolerance or complications of EN from sinusitis, nausea/vomiting, diarrhea, low platelet counts, among others. The benefits of routine PN post stem-cell transplant have been increasingly called into question (1) with concerns for increased infectious complications, delayed oral intake, and questionable net benefit.
This was not a randomized trial, and there is potential for selection bias because the patient's decision to accept or refuse NG placement dictated placement into a study group. However, this IS a valuable study because there are no large, randomized trials of EN feeding versus PN feeding after stem-cell transplantation. This study does suggest that EN may be feasible in stem-cell transplant patients, as all but two patients were tolerant of NG feedings.
One factor that limits the impact of this study is that 11 patients in the EN group ultimately received PN, resulting in only 11 patients that did not receive PN in the study. Another aspect that should be considered when interpreting the results is that the EN group had a significantly larger percentage of patients that received the stem cells from peripheral blood (28% in EN vs 0% in PN, p = 0.009) which is associated with faster hematopoietic recover, reduced transplant-related toxicity, no GVHD, and earlier hospital discharge.
Take home message:
This is a small, non-randomized pilot study, which limits any conclusions that can be drawn about the outcomes that were reported. However, the value of this study is that EN would appear to be a viable alternative to PN in those patients that require nutrition support post stem-cell transplant. We agree with the investigators that their results warrant the start of a larger randomized study.
•1) Our first Weekend Warrior Mini-Nutrition Support Traineeship was a great success!
Check out our website for dates of the next one:
•2) Check out the latest Practical Gastroenterology articles/info at:
Scroll down to GI Nutrition on the far left column and click on link
Then scroll down to box with links within the nutrition site
Nutrition Articles in Practical Gastroenterology is in the right column:
1) Sharrett MK, Cureton P. Kids and the Gluten-Free Diet. Practical Gastroenterology 2007;XXXI(2):49.
2) Makola D. Diverticular Disease: Evidence for Dietary Intervention? Practical Gastroenterology 2007;XXXI(2):38.
3) Liacouras CA. Eosinophilic Gastrointestinal Disorders. Practical Gastroenterology 2007;XXXI(3):53.
4) Kupper C, Higgins L. Combining Diabetes and Gluten-Free Dietary Management Guidelines. Practical Gastroenterology 2007;XXXI(3):68.
Joe Krenitsky MS, RD
Carol Parrish RD, MS
PS - Please feel free to forward this on to friends and colleagues.