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  • Assessment
    Is there a relationship between a patient's intake of dietary protein and the risk of acute graft-versus-host-disease associated with allogeneic hematopoietic cell transplant for hematologic malignancy?
    • Conclusion

      One study, a positive quality retrospective cohort analysis, found that oral protein intake within 17 days of allogeneic bone marrow transplant was associated with decreasing the risk of acute GVHD. A prospective randomized trial is needed to support to evaluate the role of protein intake in acute GVHD.

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between hematopoietic cell transplant and its long-term affect on the nutritional intake (calories, protein) of transplant survivors?
    • Conclusion
      One study, a neutral-rated, retrospective, descriptive study, found that patients with extensive chronic GVHD as a result of allogeneic HCT were twice as likely to consume less than 85% estimated caloric needs one-year after HCT as compared to patients with limited or no GVHD. Protein intake was not affected one-year post transplant.
    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
  • Intervention
    Is there a relationship between the use of parenteral nutrition vs. control to reduce symptoms and support recovery and the reduction of symptoms associated with inpatient treatment for allogeneic hematopoietic cell transplant?
    • Conclusion

      One cost-benefit analysis (negative quality) found that PN did not result in significantly improved outcomes for allo-HCT patients.  Parenteral nutrition was associated with increased rates of infection and subsequently higher costs.  The researchers concluded that intensive nutritional monitoring to eliminate unnecessary PN can result in significant cost savings for allo-HCT providers.

       

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between the use of parenteral nutrition vs. control to reduce symptoms and support recovery and the reduction of symptoms associated with inpatient treatment for hematopoietic cell transplant for breast cancer patients?
    • Conclusion

      One neutral quality RCT found that while prophylactic PN preserved nutritional status and lean body mass better than oral diet in well-nourished breast cancer patients undergoing auto-HCT, there were no differences found in LOS or survival between the two groups.   The researchers concluded that well-nourished breast cancer patients who have no major complications or prolonged poor oral intake will probably not benefit from PN while undergoing auto-HCT.  Because of its expense and risk for infectious complications, PN should be used in appropriate breast cancer patients only. 

       

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between the use of parenteral nutrition vs. control to reduce symptoms and support recovery and the reduction of symptoms associated with inpatient treatment for hematopoietic cell transplant?
    • Conclusion

      Four studies (1 RCT of neutral quality; 1 nonrandomized clinical trial of positive quality; 2 retrospective cohort studies of positive quality) found that PN should be used only in appropriately selected HCT patients due to an increased risk of treatment complications associated with PN as well as a lack of significant differences in long-term outcomes.  Criteria for patient selection for PN includes malnutrition and/or severe GI dysfunction.  Differences in types of studies and patient populations studied, differences in PN regimens, study design flaws, varying types of cancers studied, varying types of conditioning regimens used, and variations in type of transplant make it difficult to compare studies and draw conclusions.  Further research is needed to determine the best use of PN in HCT patients.

       

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between the use of parenteral nutrition vs. control to reduce symptoms and support recovery and the reduction of symptoms associated with outpatient treatment for hematopoietic cell transplant?
    • Conclusion

      One (1) + quality randomized, controlled trial (Charuhas et al, 1997) found that outpatient PN delays resumption of oral intake (p = 0.049), and that use of IV fluids for hydration as an alternative to PN does not have adverse patient outcomes in terms of weight loss, hospital readmissions, relapse of malignancies, or survival to 150 days post-transplant.  Although weight loss was statistically greater (p = 0.004) for the IV fluids group, the amount lost was not clinically significant.  Costs associated with provision of IV fluids were substantially less than costs of providing PN.  Charuhas et al. concluded that PN should be reserved for HCT outpatients who exhibit severe GI malfunction.  Further study is needed to determine the most appropriate use of PN in outpatient treatment for HCT.

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between a patient's increased protein intake via total parenteral nutrition to improve tolerance and support recovery from hematopoietic cell transplant and the reduction of complications associated with hematopoietic cell transplant?
    • Conclusion
      One small, positive quality, randomized trial compared the use of standard nitrogen TPN to high-nitrogen TPN, with equal caloric values and found that the high-nitrogen formula better preserved nitrogen balance without causing clinical complications. No other positive findings were noted. Larger trials are needed to find statistical significance in other clinical outcomes.
    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between a patient's intake of branched chain amino acid-enriched total parenteral nutrition to improve tolerance and support recovery from hematopoietic cell transplant (HCT) for hematologic malignancy, and the reduction of complications associated with HCT?
    • Conclusion

      One randomized, double-blinded positive quality study evaluated the use of BCAA-enriched PN in patients receiving HCT for hematologic malignancies. No differences in treatment related complications (sepsis, fever, GVHD, elevated LFTs, steroid requirements, pneumonia, nitrogen balance) or outcomes (time to engraftment, resumption of oral intake) were observed between patients receiving 23% BCAA and 45% BCAA-enriched PN solutions. 

       

    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between a patient's nutritional intake (protein and calories) from total parenteral nutrition as compared to peripheral parenteral nutrition to improve tolerance and support recovery from hematopoietic cell transplant (HCT), and the reduction of complications associated with HCT?
    • Conclusion
      Three studies (one positive quality prospective randomized group trial, one neutral quality retrospective cohort, and one neutral quality non-randomized study) compared the effectiveness of using TPN vs. PPN in the post-BMT period. The nutritional content of the solutions, duration of nutritional supplementation, consideration and quantification of ad lib oral intake, type of malignancy, and differing cancer treatment regimens (autologous vs. allogeneic cell transplantation) varied among the studies. Evaluation of outcomes is further limited by small sample size (2 studies) and poor study design (2 studies) and limited data reported (1 study). The only study, although limited by small sample size, that had similar calorie and protein intake in both TPN and PPN/EN solutions (25 g N/day and 136:1 calorie:nitrogen) showed that either solution was effective in supporting recovery from bone marrow transplant by maintaining body weight and nitrogen balance without causing additional complications. The other two studies had inadequate nutritional support in the PPN solution and the results varied (one favored TPN, the other PPN). A larger, prospective randomized trial with equivocal nutritional content in TPN and PPN solutions and similar treatment regimens is needed.
    • Grade: III
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006
       
    Is there a relationship between the use of a lipid-based TPN solution to improve tolerance and support recovery in hematopoietic marrow transplant patients, and the reduction of complications associated with hematopoietic marrow transplant?
    • Conclusion
      Two randomized trials (positive quality) noted no significant differences between a standard lipid-based TPN solution to TPN solution with little or no lipids for time to engraftment, disease relapse, incidence of infection, and incidence and time to onset of graft-versus-host disease in patients undergoing hematopoietic marrow transplant for hematologic malignancy. The larger trial (512 patients) focused on controlling blood glucose to <200 mg/dL and therefore did not have evidence of hyperglycemia, while the smaller study (66 patients) did not maintain glucose levels at <200 mg/dL and had incidence of hyperglycemia.
    • Grade: II
      • Grade I means there is Good/Strong evidence supporting the statement;
      • Grade II is Fair;
      • Grade III is Limited/Weak;
      • Grade IV is Expert Opinion Only;
      • Grade V is Not Assignable.
      • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
      • Moderate (B) means we are moderately confident in the effect estimate;
      • Low (C) means our confidence in the effect estimate is limited;
      • Very Low (D) means we have very little confidence in the effect estimate.
      • Ungraded means a grade is not assignable.
    • Search Plan and Results: HCT: Calories, Protein, Lipids, Nutritional Intake, EN/PN 2006