Effect of Early Recognition of Malnutrition and Targeted Nutrition Support on Clinical Outcomes in Autologous Stem Cell Transplant Patients

Field: Medicine (Health Sciences)

ObjectivePatients (pts) admitted to hospital for autologous stem cell transplant (ASCT) are at risk for malnutrition. American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines recommend nutrition screening and targeted nutrition support for ASCT pts. However, these recommendations are not always followed due to lack of clear evidence of benefit and concern that nutrition support may be associated with increased risk of infection or delayed time to platelet engraftment. We evaluated clinical outcomes in consecutive ASCT pts receiving nutrition assessment and targeted nutrition support based on malnutrition status.MethodsA historical control group included consecutive pts admitted for ASCT January 2016 to October 2017 (n = 308). Beginning in October 2017, all ASCT pts (n = 148) received nutrition assessment and intervention to optimize oral intake and were included in the intervention group. Pts diagnosed with malnutrition using Academy of Nutrition and Dietetics-ASPEN criteria and continuing with <50% estimated needs by day +5 of ASCT were recommended for enteral or parenteral nutrition (EN or PN). Hospital length of stay (LOS) from date of stem cell infusion, central line associated bloodstream infections (CLABSI), days to platelet engraftment, ICU transfers, and 30-day unplanned readmissions were measured prospectively. Prolonged LOS was defined as >15 days after transplant. Pt characteristics included age, Karnofsky performance status (KPS), first vs. subsequent ASCT, and malnutrition risk indicated by a score ≥2 on the validated Malnutrition Screening Tool (MST). Mann-Whitney U tests comparing patients vs. historical controls and logistic regressions were conducted using SPSS (version 25), with p <0.05 considered significant.ResultsForty-nine pts (33%) met criteria for EN/PN, 40 of whom (82%) received one or both interventions. One pt received EN alone, 37 PN alone, and two EN + PN, for a mean duration of 9.05 days. Pts in the intervention group had lower odds of prolonged LOS (OR = 0.484, 95% CI: 0.259-0.906) and CLABSI (OR = 0.259, 95% CI: 0.073-0.925) in models controlled for age, KPS, first vs. subsequent ASCT, and MST score, with no difference in days to platelet engraftment (p = 0.987). No pt receiving PN or EN was diagnosed with CLABSI. ICU transfer and 30 day readmission rates did not differ between groupsConclusionIdentifying malnutrition, optimizing oral intake and providing early, targeted nutrition support to ASCT pts can improve clinical outcomes. Patients (pts) admitted to hospital for autologous stem cell transplant (ASCT) are at risk for malnutrition. American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines recommend nutrition screening and targeted nutrition support for ASCT pts. However, these recommendations are not always followed due to lack of clear evidence of benefit and concern that nutrition support may be associated with increased risk of infection or delayed time to platelet engraftment. We evaluated clinical outcomes in consecutive ASCT pts receiving nutrition assessment and targeted nutrition support based on malnutrition status. A historical control group included consecutive pts admitted for ASCT January 2016 to October 2017 (n = 308). Beginning in October 2017, all ASCT pts (n = 148) received nutrition assessment and intervention to optimize oral intake and were included in the intervention group. Pts diagnosed with malnutrition using Academy of Nutrition and Dietetics-ASPEN criteria and continuing with <50% estimated needs by day +5 of ASCT were recommended for enteral or parenteral nutrition (EN or PN). Hospital length of stay (LOS) from date of stem cell infusion, central line associated bloodstream infections (CLABSI), days to platelet engraftment, ICU transfers, and 30-day unplanned readmissions were measured prospectively. Prolonged LOS was defined as >15 days after transplant. Pt characteristics included age, Karnofsky performance status (KPS), first vs. subsequent ASCT, and malnutrition risk indicated by a score ≥2 on the validated Malnutrition Screening Tool (MST). Mann-Whitney U tests comparing patients vs. historical controls and logistic regressions were conducted using SPSS (version 25), with p <0.05 considered significant. Forty-nine pts (33%) met criteria for EN/PN, 40 of whom (82%) received one or both interventions. One pt received EN alone, 37 PN alone, and two EN + PN, for a mean duration of 9.05 days. Pts in the intervention group had lower odds of prolonged LOS (OR = 0.484, 95% CI: 0.259-0.906) and CLABSI (OR = 0.259, 95% CI: 0.073-0.925) in models controlled for age, KPS, first vs. subsequent ASCT, and MST score, with no difference in days to platelet engraftment (p = 0.987). No pt receiving PN or EN was diagnosed with CLABSI. ICU transfer and 30 day readmission rates did not differ between groups Identifying malnutrition, optimizing oral intake and providing early, targeted nutrition support to ASCT pts can improve clinical outcomes.