A Multi-Institutional Retrospective Study Suggests That Optimal Enteral Nutrition (EN) Influences Outcomes after Hematopoietic Stem Cell Transplantation in Children and Adults

Background: Although small studies have linked poor nutritional status pre- hematopoietic stem cell transplant (HSCT) to metabolic derangements post-HSCT, no large study has studied the influence of nutritional support initially after HSCT on clinical outcomes. We hypothesized that better enteral (EN) or parenteral nutrition (PN) before and peri-HSCT would correlate with improved nutritional status and fewer complications after HSCT including graft-versus-host disease (GVHD).  We conducted a multi-institutional, IRB approved retrospective study to compare the nutritional status of patients who received EN, PN, or suboptimal nutrition in the week before and the first 4 weeks post-HSCT using a novel nutritional summary score.  Method: We devised the nutrition summary score by assigning a number from 0-2 (0=no/poor EN/PN, 1=PN for goal calories, and 2=EN for majority of goal) weekly for the 5 weeks (-1, 1, 2, 3, 4) per patient; the scores were summed (total summary score ranged from 0-10).  Nutritional assessments and outcomes were abstracted from medical records at day 28, day 100, and 1 year after HSCT.  Results: Data were captured from 162 patients (78% pediatric and 22% adult) from 5 institutions. Patients were a median age of 10.34 years (range: 1-75), 58% male, and 75% received myeloablative, 17% reduced intensity, and 8% non-myeloablative HSCT. At the pre- and peri- HSCT period, few patients had gastric tubes (6/162) but 44% (72/162) had nasogastric tubes for EN.   The majority (89%) engrafted by day +28, and GVHD rates reflect the predominance of pediatric patients with only 14% (22/162) grade I-II acute GVHD (aGVHD), 17% (27/162) grade III-IV aGVHD, 10% (17/162) limited chronic, and 10% (16/162) chronic extensive GVHD. Mean summary nutrition scores and % EN for each time point were: pre-BMT: 1.42 and 70% EN, week 1: 1.41 and 64%, week 2: 1.3 and 52%, week 3: 1.3 and 54%, and week 4 1.3 and 58%.  The day +28 albumin was correlated directly with the summary nutrition score (p<0.0001). The weight 100 days after HSCT was also associated with summary nutritional score (p=0.017), while chronic extensive GVHD was associated with lower nutrition score (p=0.047).  Using only patients who received EN at some point (at least one value of 2 in the 5 weeks), weight at day 28 (p=0.002) and day 100 (p<0.002), and lower risk of cGVHD (p< 0.04) all were significant, suggesting that EN contributed to these outcomes. Conclusions: Our data suggest that EN and PN in the pre- and peri-HSCT period correlate with better nutrition after HSCT including albumin at day +28 and weight at day +100 and that these may influence risk for chronic extensive GVHD, a major complication of HSCT.   Further, our data suggest that EN initially after HSCT may be important, and support a prospective study to evaluate whether interventions to improve enteral alimentation enhance outcomes and diminish the risk of chronic extensive GVHD.