The Department of Veterans Affairs Nutritional Status Classification Scheme Allows for Rapid Assessment of Nutritional Status Before Autologous Peripheral Blood Stem Cell Transplantation and Identifies Patients at High-Risk of Transplant-Related Complications

Background: The nutritional assessment of patients prior to autologous peripheral blood stem cell transplantation (APBSCT) is labor intensive because it requires anthropomorphic measurements and biochemical tests not obtained routinely before transplantation. A simple method of nutritional assessment prior to APSCT would be extremely helpful, especially if this method could identify patients at high risk of transplant-related complications. The Department of Veterans Affairs (VA) Nutritional Status Classification Scheme (NSCS) uses an objective algorithm that does not rely on judgment, it uses data that can be easily obtained upon patient’s admission to the hospital, and has been rigorously validated.

Objective: The objective of this study was to determine if the NSCS could be applied to patients prior to APBSCT and to determine if this tool could identify patients at high risk of transplant-related complications.

Design: The nutritional status of 128 patients who underwent APBSCT was assessed by a registered dietician, utilizing the NSCS, upon admission to the hospital and prior to conditioning regimen. The NSCS stratifies patients in 4 nutritional levels: normal, mildly-compromised, moderately-compromised and severely-compromised, based on 7 indicators. These 7 indicators include nutritional history, unintentional weight loss, weight as a percent of ideal body weight, diet, diagnosis, serum albumin and total lymphocyte count. Ratings from 1 to 4 were assigned to each of the indicators mentioned above, and the overall nutritional status was determined by a pre-defined algorithm. Total lymphocyte count was excluded from our analysis since patients with lymphoid malignancies require chemotherapy that lowers the lymphocyte count and abnormalities of the lymphocyte count are frequently related to chemotherapy and not to the patient’s nutritional status. As defined in the NSCS algorithm, when data was not available for an indicator, it was not rated and was not considered in the overall nutritional status determination. A minimum of 4 indicators was necessary to determine an overall nutritional status.

Results: 128 consecutive patients with lymphoid malignancies who underwent APBSCT from June 2005 thru May 2008 were included in the study. Their mean age was 57 years (19–74) and 119 (93%) were males. Of the 128 patients, 88 (69%) had multiple myeloma, 29 (23%) had non-Hodgkin’s lymphoma and 11 had Hodgkin’s lymphoma. Conditioning regimens included single agent melphalan in 88 (69%), the combination of cyclophosphamide, etoposide and BCNU (CBV) in 32 (25%); 8 (6%) received the combination of BCNU, etoposide, cytarabine and melphalan (BEAM). There were no statistically significant differences between nutritional status and age, sex, diagnosis or conditioning regimen before transplantation.

Nutritional assessments were completed successfully in a single visit for all patients utilizing the clinical and basic laboratory information obtained upon admission to the hospital. Study patients met criteria for three of the 4 NSCS nutritional status levels before transplantation: 91 (71%) had mildly-compromised nutritional status, 26 (20%) had a normal nutritional status and 11 (9%) had moderately-compromised nutritional status. No patient met criteria for severely-compromised nutritional status. There were no statistically significant differences in the frequency of transplant-related toxicities between patients who had normal nutritional status and patients who had mildly compromised nutritional status. However, patients who had moderately compromised nutritional status experienced a higher incidence of diarrhea (p = .009), infection (p = .014) and also had a longer length of hospital stay (p = .009) when compared to patients with normal nutritional status or with patients with mildly-compromised nutritional status.

Conclusion: The NSCS allowed for rapid evaluation of the nutritional status of patients before APBSCT. Patients with moderately-compromised nutritional status, as defined by the NSCS, had a higher incidence of transplant-related complications including infection and diarrhea and also had a longer length of hospital stay. Future studies should focus on the use of NSCS in patients receiving total body irradiation as part of their conditioning regimen and in patients undergoing allogeneic transplantation.