ONC: Hematological Malignancies (HCT): Use of Parenteral Nutrition 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: Use of Parenteral Nutrition (PN)
Parenteral nutrition (PN) should only be used in selected HCT patients due to increased risk of treatment complications, increased cost, and a lack of significant improvement in treatment outcomes. Dietitians should regularly screen and monitor HCT patients for signs of malnutrition and prolonged periods of poor oral intake to identify patients who might benefit from PN. Patients most likely to benefit from PN include patients receiving allogeneic transplants from mismatched donors.
ONC: HCT: Use of Lipid-Based PN Formulations
Patients receiving PN while undergoing HCT should receive 25-30% of energy as lipids. Provision of lipids is necessary to prevent fatty acid deficiency, and may improve blood glucose control.
ONC: HCT: Use of Glutamine-Enhanced PN Formulations
Use of parenteral glutamine to decrease incidence or severity of mucositis or diarrhea following hematopoietic cell transplantation for hematologic malignancies is not currently recommended. No clear evidence indicates that use of parenteral glutamine alters incidence or duration of mucositis or diarrhea. In addition, parenteral glutamine has not been shown to decrease LOS, time to engraftment or the number of infectious complications.
Risks/Harms of Implementing This Recommendation
Use of lipid-based PN formulations:
- TG levels should be monitored regularly while the patient is receiving PN solutions containing lipids. Lipid administration should be slowed, the total dosage decreased, or discontinued if the patient develops hyperlipidemia.
- Some individuals have allergies to components of IV lipid solutions. Discontinue lipids immediately if the patient shows signs of allergic response (dyspnea, cyanosis, flushing, sweating, dizziness, headache, back or chest pain, nausea, or vomiting) (Gottschlich MM, editor, 2001).
Conditions of Application
Use of lipid-based PN formulations:
- See risks and harms
- History of allergic response to lipids
- Pre-existing hypertriglyceridemia.
- Potential Costs Associated with Application
Use of PN
- One RCT, (Lough et al, 1990), one non-randomized clinical trial (Skop et al, 2005), and two retrospective cohort studies (Iestra et al, 1999; Sheean et al, 2004), found that PN should only be used in selected HCT patients because of the increased risk of treatment-related complications and lack of significant differences with treatment outcomes, however differences in study design and PN interventions made comparisons between the studies difficult.
- One cost-benefit analysis (Calvo et al, 2002) found that PN did not result in improved outcomes for allogeneic HCT patients, and may be associated with higher infection rates and cost of care.
- Further research is needed to determine the best use of PN following HCT.
Use of Lipid-Based PN Formulations
- Two RCTs (Lenssen et al, 1998; Muscaritoli et al, 1998) found no statistically or clinically significant differences in rates of infections or other treatment outcomes when comparing PN solutions with >= 25% of energy from lipids to solutions containing lower lipid concentrations.
Use of Glutamine-Enhanced PN Formulations
- One meta-analysis (Murray and Pindoria, 2002) and two RCTs (Piccirillo et al, 2003; Schloerb and Amare, 1993) found no statistically significant differences between glutamine supplementation and placebo in terms of duration of oral mucositis and incidence and severity of diarrhea.
- Results were inconsistent with regard to the effect of parenteral glutamine on severity of oral mucositis, LOS, time to engraftment and number of infectious complications.
Recommendation Strength Rationale
Use of PN: Based on 5 studies (one RCT, one non-randomized clinical trial, two retrospective cohort studies, and one cost-benefit study), conclusion statements are a Grade III.
Use of Lipid-Based PN Formulations: Based on two studies (both RCTs), conclusion statement is a Grade II.
Use of Glutamine-Enhanced PN Formulations: Based on three studies (one meta-analysis and two RCTs), conclusion statements are Grade II and III.
- 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).
Is there a relationship between the use of parenteral glutamine by patients to improve tolerance and support recovery from hematopoietic cell transplant (HCT) and the reduction of mucositis associated with treatment?
Is there a relationship between the intake of parenteral glutamine to improve tolerance and support recovery from a patient undergoing hematopoietic cell transplant (HCT) and the reduction of diarrhea associated with treatment?
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?
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?
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?
Murray SM, Pindoria S. Nutrition support for bone marrow transplant patients (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Chichester, UK: John Wiley & Sons, Ltd.
Piccirillo N, Matteis SA, Laurenti L, Chiusolo P, Sora F, Pittiruti M, Rutella S, Cicconi S, Fiorini A, D'Onofrio G, Sica S. Glutamine-Enriched parenteral nutrition after autologous peripheral blood stem cell transplantation: Effects on immune reconstitution and mucositis. Haematoligica/Journal of Hematology. 2003; 88: 192-200.
Schloerb, P, Amare, M. Total Parenteral Nutrition With Glutamine in Bone Marrow Transplantation and Other Clinical Applications (A Randomized, Double-Blind Study). Journal of Parenteral and Enteral Nutrition, 1993;17(5):407-413.
Iastra JA, Fibbe WE, Zwinderman AH, Romijn JA, Kromhaut D. Parenteral nutrition following intensive cytotoxic therapy: An exploratory study on the need for parenteral nutrition after various treatment approaches for haematological malignancies. Bone Marrow Transplantation. 1999; 23: 933–939.
Lough M, Watkins R, Campbell M, Carr K, Burnett A, Shenkin A. Parenteral nutrition in bone marrow transplantation. Clin Nutr. 1990; 9: 97-101.
Sheean P, Braunschweig C, Rich E. The Incidence of Hyperglycemia in Hematopoietic Stem Cell Transplant Recipients Receiving Total Parenteral Nutrition: A Pilot Study. Journal of the American Dietetic Association, 2004; 104:1352-1360.
Skop A, Kolarzyk E, Skotnicki AB. Importance of parenteral nutrition in patients undergoing hematopoietic stem cell transplantation in the autologous system. J Parenter Enteral Nutr. 2005: 29(4), 241-247.
Lenssen P, Bruemmer BA, Bowden PA, Gooley T, Aker SN, Mattson D. Intravenous lipid dose and incidence of bacteremia and fungemia in patients undergoing bone marrow transplant. Am J Clin Nutr. 1998; 67: 927-933.
Muscaritoli M, Conversano L;Torelli G;Arcese W;Capria S;Cangi. Clinical and Metabolic Effects of Different Parenteral Nutrition Regimens in Patients Undergoing Allogeneic Bone Marrow Transplantations. Transplantation. 1998;66(5):610-6
Calvo MV, Gonzalez P, Alaguero M, Perez-Simon A. Intensive Monitoring Program for Oral Food Intake in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: A Cost-Benefit Analysis. Nutrition Volume 18, Number 9, 2002.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Gottschlich MM, editor. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum; American Society for Parenteral and Enteral Nutrition. Dubuque, IA: Kendall-Hunt Publishing Company, 2001, page 274.