ONC: Hematological Malignancies (HCT): Determination of Calorie Needs 2008
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
ONC: HCT: Determination of Calorie Needs
Use indirect calorimetry to measure REE for adult patients with hematologic malignancies undergoing allogeneic HCT. When indirect calorimetry is not available, limited evidence indicates that the estimated energy requirements are 30-35 kcal per kg per day during the first month post-transplant, and may be higher during acute GVHD and/or for patients receiving >75% of their total daily energy intake via PN.
Risks/Harms of Implementing This Recommendation
- Anxiety may be caused by indirect calorimetry procedures employing a face mask or canopy.
- In some individuals, estimation of REE with predictive equations will lead to under- or over-feeding.
Conditions of Application
This recommendation applies to adult patients receiving myeloablative allogeneic HCT. Energy needs may be different for patients receiving non-myeloablative and/or autologous HCT.
- The studies reviewed for this recommendation only reviewed HBE as an energy estimating equation. See energy expenditure and energy assessment recommendations in the Critical Illness Guideline for information on other conditions. For more information on measuring vs. estimating RMR, see Determining Resting Metabolic Rate.
- The AARC Clinical Practice Guidelines (1994) recommend that measurements may be indicated in patients with several conditions including:
- Cancer with residual tumor
- Extreme obesity
- The AARC Clinical Practice Guidelines (1994) also provide recommendations for hazards and complications, limitations of the procedures and infection control.
- Measures should be conducted by specialty-trained personnel who have documented and demonstrated proficiency to calibrate, operate and maintain the calorimeter and to recognize calorimeter values within the normal physiologic range.
Potential Costs Associated with Application
Cost of equipment, supplies and staff needs to be addressed in all indirect calorimetry measurements.
- Two studies (one positive-quality longitudinal study and one positive-quality RCT) suggest that patients receiving HCT for hematologic malignancies require, on average, 30-35 kcal per kg per day to maintain nitrogen balance and body weight during the first month post-transplant.
- Further research is needed to determine the effects of hematologic malignancies and HCT on patients' actual REE.
Recommendation Strength Rationale
Based on two positive-quality (longitudinal and RCT) studies, conclusion statement is a Grade II.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Geibig CB, Owens JP, Mirtallo JM;Bowers D, Nahikian-Nelms M, Tutschka P. Parenteral nutrition for marrow transplant recipients:evaluation of an increased nitrogen dose. Journal of Parenteral and Enteral Nutrition.1991:15(2):184-188.
Szeluga DJ, Stuart RK, Brookmeyer R, Utermohlen V, Santos GW. Energy requirements of parenterally fed bone marrow transplant recipients. J Parenter Enteral Nutr. 1985 Mar-Apr; 9(2): 139-143.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
American Association for Respiratory Care (AARC). Metabolic measurement using indirect calorimetry during mechanical ventilation. Clinical practice guidelines. Respir Care. 1994; 39 (12): 1, 170-1, 175.