Total parenteral nutrition and hematopoietic stem cell transplantation: an expensive placebo?

Abstract

Summary:A majority of patients undergoing hematopoietic stem cell transplantation (HSCT) suffer from severe mucositis and enteritis due to cytotoxic therapy and immune dysregulation, resulting in prolonged decreased oral intake, nausea, vomiting and diarrhea. While total parenteral nutrition (TPN) is often given to patients in order to maintain their nutritional status during the peritransplant period, there is conflicting evidence to support its routine use. We evaluated the small number of prospective randomized and nonrandomized controlled trials that assessed important clinical outcomes such as time to engraftment, rates of infection, overall survival and length of hospitalization. We believe that the data do not support the routine use of parenteral nutrition as first-line therapy but should be reserved for those patients who are unable to tolerate enteral feedings. We also believe that glutamine supplementation cannot be recommended to all HSCT recipients as it has been shown to increase morbidity and mortality rates in autologous transplant patients. Further investigations that test accurate monitoring assessments and incorporate specific substrates such as lipids with parenteral and enteral nutrition are warranted. Novel therapies such as recombinant human keratinocyte growth factor and glucagon-like peptide show future promise in modulating the severity and duration of mucositis, minimizing further the need for TPN. Bone Marrow Transplantation (2005) 36, 281-288.

Enteral nutrition: a first option for nutritional support of children following allo-SCT?

“…29 PN was also associated with an increased risk of line infections and metabolic disturbances such as hyperglycaemia and hypertriglyceridaemia, cholestatic liver disease and fluid overload state. 5,20,32 PN potentiates hepato-biliary disorders that may contribute to cholestasis due to sepsis, drug toxicity and veno-occlusive disease in allo-SCT patients. 13,33 The low frequency of aGVHD, and particularly its gut manifestations, suggests that EN started early may decrease both its incidence and severity.…”

New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition

“…Glutamine deserves further study to elucidate its interactions with methotrexate and to investigate its effects on autologous HSCT patients. Supplementation of glutamine should be considered in the design of future randomized, controlled clinical trials and in the metabolic support of individuals undergoing marrow transplantation and cancer (60,62).…”

Biochemical indices for the assessment of nutritional status during hematopoietic stem cell transplantation: are they worth using? A single center experience

“…TPN is a treatment potentially associated with significant limitations including a fluid overload state and hepatic dysfunction. It can increase the number of subclavian vein thromboses, 9,11 delay platelet engraftment, 29 increase catheter-related/ associated infections 9,11,30 and suppress normal appetite. 9 The current practice for the timing of TPN depends on the transplant center.…”

“…12 Plasma concentrations of so-called anabolic proteins such as ALB, transferrin (TRF), retinol-binding protein (RBP) and prealbumin (transthyretin, PAB) are frequently used to estimate nutritional status and to monitor the efficacy of nutritional support. 11,13 However, they may be affected by nonnutritional variables, such as infections, hyperhydratation or liver and renal insufficiency. They have short half-lives, merely reflecting recent nutritional changes.…”

“…7,8 Thus, nutritional assessment in patients undergoing HSCT is very important and can rationalize nutritional support. [9][10][11] ALB has a half-life of 20 days, so a decrease in its concentration is related to long periods of nutritional deficit, assuming that hydratation is stable. 12 Plasma concentrations of so-called anabolic proteins such as ALB, transferrin (TRF), retinol-binding protein (RBP) and prealbumin (transthyretin, PAB) are frequently used to estimate nutritional status and to monitor the efficacy of nutritional support.…”