Impact of protein-energy malnutrition on outcomes among patients with diffuse large B cell lymphoma admitted for inpatient chemotherapy.
Authors: Deenadayalan Vaishali , Kumi Dennis Danso , Shah Mihir , Obeidat Khaldun , Vakil Jay , Rodriguez Alarcon Pierre Alexander , Turk Ekrem , Weir Catherine , Gupta Shweta , Zia Maryam 
Published: June 2022

e19539

Background: Protein-Energy Malnutrition (PEM) is a major factor contributing to morbidity and mortality in cancer patients. Chemotherapy causes anorexia, decreasing the caloric intake and affects the lean body mass which requires significant energy expenditure to surmount. Empiric data does not abound on the effect of PEM and its impact on the outcomes of patients receiving chemotherapy, specifically in diffuse large B cell lymphoma (DLBCL). Methods: A retrospective cohort study was designed using data from 2016 to 2018 combined National Inpatient Sample (NIS) database. Adult patients (age > 18) admitted for chemotherapy with a principal diagnosis of DLBCL were identified using the International Diseases Classification code, 10th revision. They were stratified into two cohorts based on presence of a secondary diagnosis of PEM. Primary outcomes assessed were mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes included a diagnosis of neutropenia, urinary tract infections (UTI), septic shock, bacteremia, candida sepsis, acute kidney injury (AKI), acute liver failure, and acute respiratory failure (ARF). Multivariate linear and logistic regressions were used to adjust for confounders. Results: There was a total of 76,425 adult hospitalizations for chemotherapy among patients with DLBCL out of which 2.32% had a secondary diagnosis of PEM. PEM was associated with an increased odds of mortality, 3.94% vs 0.37% (AOR :12.69, p < 0.001, 95% CI: 6.34 – 25.38). There was also an increased LOS in patients with PEM, 7.55 days vs 4.96 days (adjusted difference of 2.74 days, p < 0.001, 95% CI: 1.88 – 3.61), as well as an increase in total charge, 97,500.55 USD vs 60,600.12 USD (adjusted difference of 37,109 USD, p < 0.001, 95% CI: 20,139.59 – 54,080.18). Similarly, the presence of PEM was associated with increased odds of several secondary outcomes measured, including neutropenia (AOR : 1.87, p < 0.001, 95% CI: 1.29 – 2.69), candida sepsis (AOR : 12.28, p = 0.033, 95% CI: 1.22 – 123.39), septic shock (AOR : 14.11, p < 0.001, 95%CI: 6.31 – 31.52), bacteremia (AOR : 5.51, p < 0.001, 95% CI: 2.61 – 11. 63), ARF (AOR : 7.83, p < 0.001, 95% CI: 4.75 – 12.92) and an increased odds of AKI (AOR : 1.87, p < 0.001, 95% CI: 1.37 – 2.55) compared to the other cohort. However, there was no difference in the odds of UTI and acute liver failure between the two groups. Conclusions: Clinical outcomes among patients with DLBCL during chemotherapy admissions are worse in patients with PEM and are associated with a 4-fold increased odds of death and attendant increase in LOS and total charge. The odds of secondary adverse clinical outcomes including neutropenia, bacteremia, candida sepsis, septic shock, AKI, and ARF are also increased. Prospective trials to evaluate PEM as an independent prognostic marker of chemotherapy tolerance and adequate nutritional support can improve the clinical outcomes.