September 2013 e-journal club 1
We had a great September traineeship week with wonderful trainees from Wenatchee, WA (2); Bethesda, MD; Montreal, Canada, and Dhahran, Saudi Arabia. Our trainees were treated to our first fall-like cooler days of the season.
The journal club article for September dealt with a topic with very limited data – EN Vs. PN in the adult stem-cell transplant patient.
Guièze R, Lemal R, Cabrespine A, et al. Enteral versus parenteral nutritional support in allogeneic haematopoietic stem-cell transplantation. Clin Nutr. 2013 Jul 31. [Epub ahead of print]
This was a retrospective study of 56 patients that had allogeneic haematopoietic stem-cell transplantation (HSCT) and received either parenteral nutrition (PN) or enteral nutrition (EN) support. All patients received education about nutrition and nutrition support modalities prior to the transplantation, then the patients were allowed to self-select the type of nutrition support they desired. The standard protocol for the transplant unit was for all patients to begin the nutrition support of choice on day +1 post-HSCT.
EN was provided via a 9-Fr NG tube with a polymeric formula. EN and PN was provided on a nocturnal cycle to provide 50-70% of estimated needs initially. Nutrition support was increased to meet full needs of 30-35 kcals and 1.2-1.5 gm protein/kg if patients were unable to take significant oral intake. Nutrition support was stopped when oral intake, “approached energy and protein requirements.”
The paper did not designate primary and secondary outcomes, but stated that the study was designed to “evaluate the effect of initial nutritional support with EN versus PN on early outcome after allo-HSCT.”
Inclusion and Exclusion Criteria:
HSCT between 1/2009 and 10/2010, aged >16 years, received nutritional support post-HSCT, and available for a minimum of 100 days follow up post-HSCT.
Patients with progressive disease at transplantation, or with a history of prior HSCT.
Sixty-five patients underwent allogeneic HSCT during the study period, but only 56 patients met inclusion/exclusion criteria (28 PN, 28 EN). Four patients did not require nutrition support. The EN and PN groups had similar baseline characteristics. The median duration of EN was 14 days (range: 2-79 days) and the median PN duration was 16.5 days (range: 1-119 days).
There were 12 patients in the EN group who received supplementation with PN (median 12.5 days). EN was discontinued in 8 patients after a median of 14 days because of local intolerance (includes altered body image), repeated vomiting (n= 2), or displaced (n= 2) or clogged (n= 2) tubes that were not replaced due to mucositis. In 4 patients, EN had to be decreased, or could not be increased to meet full energy requirements due to GI intolerance (suspected malabsorption related to acute graft-versus-host disease (GVHD) (n= 3) and abdominal distention/vomiting (n= 1)). In the PN group, 4 patients received additional EN for a median of 35.5 days due to cardiac or hepatic intolerance of full PN.
There was no significant difference in the incidence of nausea/emesis, number of days receiving anti-emetic medications, diarrhea, anti-diarrheal medications, albumin/prealbumin, hematological recovery, incidence of oral mucositis, the incidence and severity of acute GVHD, or 100 day mortality between the EN and PN groups.
There was a statistically significant increase in the duration of fever (5 versus 2 days; p < 0.01), need for empiric antifungal therapy (17/27 versus 7/23 patients, p < 0.01), in the PN group compared to the EN group.
There was also a trend towards increased removal of the central line due to bloodstream infections (n= 9) or sepsis with hemodynamic instability (n= 3) (p = 0.051) and a greater need for exogenous insulin (36% versus 12%, respectively) (p = 0.1) in the PN Group compared to the EN Group.
“Compared with PN, EN was associated with a lower risk of infection in allo-HSCT, without an increase in the incidence of graft-versus-host disease.”
This is a modest sized, retrospective study where patients self-selected into the mode of nutrition support used. In any study without random allocation into groups, there is an unavoidable introduction of bias. However, there is such limited data about EN in the HSCT population, even an observational/retrospective study adds to our pool of information.
Similar to a previous non-randomized study from 2006 (1), it appears that EN post-HSCT is often feasible, meets nutrition needs, and does not provoke increased GVHD. It is noteworthy, that when patients are educated about the potential risks and benefits of the different methods for nutrition support, that many patients were willing to accept NG placement. This study does document the difficulties associated with the NG route of feeding post HSCT due to discomfort or cosmetic/body image issues leading to attrition of EN access in nearly 1/3 of the patients. The results of this study do suggest that even in the setting of infection prophylaxis, PN may be a risk for increased infectious complications compared to EN support. A larger, randomized study will be required before the potential infection risks from PN post HSCT can be established.
One observation about this study is the standard protocol of starting nutrition support immediately on post HSCT day 1 is very different than our standard practice. It is unclear that there is an immediate need for specialized nutrition support post HSCT, and at UVAHS, we would not begin PN or EN because patients did not meet full nutrition needs with oral intake X 1 day. There is limited data, but we may find that discretion is the better part of valor with providing nutrition support post-HSCT, similar to those patients in the ICU (2). It would be valuable for future studies in the adult HSCT population to include groups randomized to delayed, or even no specialized nutrition support.
Our Take Home Message (s)
1. EN is feasible in many patients post allogeneic stem cell transplant, however, maintaining NG access and management of GI symptoms can limit successful EN.
2. There is a need for larger randomized studies of EN compared to PN in this patient populations so patients and caregivers can make informed choices about the route and timing of nutrition support post HSCT.
1. 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):835-839.
See our Feb/March 2007 ejournal club:
2. Casaer MP, Mesotten D, Hermans G,et al. Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med. 2011; 365(6):506-517.
Other News on the UVAHS GI Nutrition Website: (www.ginutrition.virginia.edu):Upcoming Webinars 2012/2013
--October: Enteroclysis, Small Bowel Follow Through, Barium Swallow: What Does it All Mean? The Basics of Radiology for the Nutrition Support Clinician
--November: Nutrition in ALS
--December: Case Studies in Nutrition Support: GI Case StudiesCheck out What’s New
-- “Nutrition Support Blog”
--Glassman K. Low Serum Phosphorus Got You Down? Practical Gastroenterology 2013;XXXVII(8):28.
Joe Krenitsky MS, RD
Carol Rees Parrish MS, RD
PS – Please feel free to forward on to friends and colleagues.