| BackgroundAllogeneic hematopoietic stem cell transplantation(allo-HSCT)is widely used in the therapy of hematological diseases for its clinical value.With the development of allo-HSCT technology,the nutrition issues of allo-HSCT patients are getting more attentions,Which is common among allo-HSCT patients.10%-50%of patients with hematological malignancies are suffered from malnourishment before transplantation,whose nutritional status will be further impaired after transplantation,up to 80%rate of chances the malnutrition will be occurred.Even more than 55%of patients experience significant weight loss and BMI reduction during transplantation until discharge,It is firmly confirmed that malnutrition is a risk factor for the prognosis of allo-HSCT patients.Continuous malnutrition will not only affect the immune system and transplantation arrangement,but also increase of prolonged hospitalization,increased complications,transplantation mortality and recurrence rates.Obviously,reasonable nutritional intervention is beneficial,but as the first choice of nutritional support for allo-HSCT,parenteral nutrition(PN)may cause sepsis,metabolic complications,liver disease,intestinal mucosal atrophy,etc.In the updated international guidelines of the Enteral and Parenteral Nutrition Society in Europe and the United States,enteral nutrition(EN)is recommend as the first-line nutritional support for patients undergoing hematopoietic stem cell transplantation(HSCT),some foreign hematopoietic stem cell transplantation centers begin to take EN support for patients undergoing allo-HSCT first and get favorable clinical outcomes,which is lack of research in China.Furthermore,it is found that oral EN could promote mucosal repair and shorten hospitalization in allo-HSCT patients.EN with glutamine(Gln)component can not only improve the nutritional status of patients,but also enhance the immune response and reduce the damage of gastrointestinal function caused by chemotherapy.These foreign research achievements and clinical experience in China will optimize nutritional intervene during allo-HSCT,which may benefit allo-HSCT patients.Objective1.To collect the data of allo-HSCT patients nutritional status at different time during laminar flow ward treatment,and explore the effect of nutrition on clinical outcomes further.2.To provide reference for allo-HSCT patients nutritional therapy,by researching the influence of optimized nutritional intervene on nutritional status and clinical outcomes.Methods1.Descriptive research method was taken.In the retrospective investigation,135patients who received allo-HSCT in the Hematopoietic stem cell Transplantation Center of the Department of Hematology of the Second Affiliated Hospital of Army Medical University,these patients from September 2020 to September 2021 were selected as the research objects of the first part.The relevant nutritional indicators including height,weight,body mass index(BMI),serum albumin(ALB),serum prealbumin(PA),serum total protein(TP)and hemoglobin(Hb)of allo-HSCT patients were collected through the hospital electronic medical record system within 48 hours after entering the laminar flow ward,1day before transplantation,7 days and 14 days after transplantation,and 48 hours after leaving the laminar flow ward.Meanwhile,the hematopoietic reconstitution time(granulocyte reconstitution time,megakaryocyte reconstitution time)of allo-HSCT patients were collected to study the impact of nutritional changes.2.70 patients who received allo-HSCT in the Hematopoietic stem cell Transplantation Center of the Department of Hematology of the Second Affiliated Hospital of Army Medical University from January 2022 to December 2022 were selected as the second part as randomized controlled trial.They were randomly divided into the intervention group and controlling group.Intervention group patients were received optimized nutrition intervene,improve the timing,programme and approach of nutritional interventions,the clinical experienced dietitian in the research group was responsible for nutrition consultation,nutrition education and nutrition treatment once the patients entering the laminar flow ward,health education intervention on rational nutrition knowledge for each patient and the family members,including universal balanced diet,special diet,diet misunderstandings,special medical food use,etc.EN and PN support are taken as Nutrition therapy,EN is followed up and adjusted by dietitians during the whole laminar flow ward treatment period,which is full nutrition formula with the whole protein preparation,short peptide preparation and Gln preparation.The nutritionist provide EN guidance according to the patient’s gastrointestinal symptoms,while the patient’s total oral intake is less than 60%of the recommended amount for more than 3 days,the nutritionist will take the clinician to perform PN.For control group,the patients are treated with conventional nutritional intervention,which included nutrition education and nutrition therapy.Nutritionist encourage patients to take sterile diet by mouth,and nutrition therapy including single bottle infusion of sugar water,amino acids,fat emulsion,and"all-in-one"intravenous nutrition therapy when necessary.In the study,nutritionists will follow up the patientsallo-HSCT patients every three days,mainly about the dietary intake and gastrointestinal symptoms,the daily oral food intake data of the two groups is recorded by two trained professional nurses.The nutritional status and gastrointestinal symptoms of the allo-HSCT patients are assessed by a fixed nutritionist at the time of entering and leaving the LSF ward.Nutritional status was assessed by anthropometry,patient-generated subjective global assessment(PG-SGA),body composition,and handgrip strength.Gastrointestinal symptoms include nausea,vomiting,diarrhea,and oral mucositis.At the same time,the serum protein,blood routine,hematopoietic reconstruction time and health economic indicators of the two groups are collected during the period.At the end of the study,the nutritional follow-up is conducted60 days and 90 days after transplantation.Finally,all the collected indicators of the two groups were compared to comprehensively evaluate the differences in nutritional status and clinical outcomes.3.Statistics are analyzed by the Statistical Program for Social Sciences(SPSS)software 26.0,these data are described by percentage,and chi-square test or Fisher’s exact test is used for hypothesis testing.The normal distribution was described by mean±standard deviation,the hypothesis test is performed by t test,the non-normal distribution is described by median(lower quartile,upper quartile),the hypothesis test is performed by rank sum test,and the comparison between different time points is performed by repeated measures analysis of variance.Kaplan-Meier analysis is used to compare the outcome indicators with time and independent variables,and the logrank test is used to compare the hematopoietic reconstruction rate between groups.Significant differences are defined as P<0.05.Results1.Through the investigation of nutritional status of allo-HSCT patients in the laminar flow ward,it is found that weight,BMI,ALB,PA,TP and Hb of allo-HSCT of patients when leaving the laminar flow ward are significantly lower than those at the time of entering the laminar flow ward,and the abnormal rates of ALB,PA,TP and Hb were significantly higher than those when entering the laminar flow ward,and the differences were statistically significant(P<0.01);During the treatment in laminar flow ward,the average weight loss of allo-HSCT patients is 7%(4%,9%),and 67.4%of the patients’body weight lost≥5%.For allo-HSCT patients with ALB<40g/L before transplantation,the hematopoietic reconstitution time of granulocytes and megakaryocytes will be delayed(P<0.05);Compared with patients’BMI≥24kg/m~2before transplantation,the granulocyte reconstitution time of patients with BMI<18.5kg/m~2is delayed.2.The optimized nutritional intervene of patients with allo-HSCT in laminar flow ward shows that compared with conventional nutritional intervention,the optimized nutritional intervene can improve the nutritional status and PG-SGA score of allo-HSCT patients in the early stage of transplantation,increase the intake of energy and protein,and improve the symptoms of diarrhea(P<0.05),although there’s no statistically significant difference in the changes of grip strength and body composition(BF,SLM,FFM,SMM,PBF)(P>0.05),it can be seen that the reduction of the intervention group is lower than the control group.There are no significant differences between the two groups in the length of hospital stay,length of stay in the laminar flow ward,hospitalization expenses and hematopoietic reconstruction time(P>0.05).At 60 days of transplantation,the weight loss of the intervention group was lower than the control group,and there is a statistically significant difference(P=0.047).At 90 days of transplantation,there is no significant difference in weight loss between the two groups(P>0.05),but it could be seen that the intervention group have a lower decline than the control group.Conclusion1.The level of BMI and ALB before transplantation of Allo-HSCT patients are correlated with hematopoietic reconstitution time;After treatment in a laminar flow ward during the window period,patients’nutritional status changes are complex and nutritional loss is severe.2.After optimal nutrition intervene for allo-HSCT patients,their nutritional loss during treatment in the laminar flow ward will be reduced,and their nutritional status is improved,which shows positive impact on the PG-SGA score,the extent of weight loss,oral intake,and the incidence of diarrhea.Optimized nutritional interventions will not add financial burden and slow the extent of early weight loss after transplantation. |
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