Variability of Nutritional Practices in Peritransplant Period after Allogeneic Hematopoietic Stem Cell Transplantation: A Survey By the Complications and Quality of Life Working Party of the EBMT

Background: Malnutrition after hematopoietic stem cell transplantation (HSCT) can occur rapidly in the absence of nutritional support and may have a negative impact on mortality and morbidity as well as serious long-term effects. The nutritional care process in the transplant setting is dynamic, consisting of screening, assessment, development of a nutritional care plan, monitoring and follow up. It needs a multidisciplinary approach, education and patient/care giver's compliance. Following the general policy of the European Society for Blood and Marrow Transplantation (EBMT) to aim at standardizing transplantation procedures, the Complications and Quality of Life Working Party and Nursing Research Group have carried out a survey among EBMT centers about their current nutritional practices.

Results: All transplant centers reporting to the EBMT were invited to participate. Ninety centers (19%) responded. Most centers (72%) have guidelines or standard operating procedures defining nutritional interventions during HSCT but only 35% of centers have a fully available nutritional support team. Nutritional status is formally assessed before HSCT in 57% of centers and in 49% of centers after discharge, while the time and modality of nutritional counselling varies highly. In the early post-HSCT period, most centers (94%) use either low-microbial diet alone or with food fortification and nutritional supplements. Gluten-free diet has been abandoned by most of the centers (80%), as well as lactose-free diet (60%), except in special conditions such as lactose intolerance. So long as patients are not in aplasia, most centers (66%), allow family members to bring appropriately prepared food in from outside the hospital. Twenty-six percent of centers use immune-nutrients for the modulation of host defense mechanisms, and the most used immune-nutrient is glutamine (in 82% of cases). In the need of nutritional support, the most common method for "first line" intervention is the use of oral nutritional supplements (40% of centers), followed by parenteral nutrition (25% of centers) and food fortification (15% of centers). Tube feeding as primary intervention is used only in 4% of centers. As many as 25% of centers use parenteral nutrition as prophylaxis for malnutrition, usually after a total body irradiation (TBI)-based conditioning regimen (in 65% of cases). Most formulations used for parenteral nutrition are standardized preparations (60%), while the rest use individualized formulas. Twelve centers use tube feeding routinely as a prophylactic measure, usually by a nasogastric tube (in 95% of cases). Commercially-available formulas are uniquely used for tube feeding and one third of the centers use disease-specific products as well. Finally, only 66% of centers use standard protocols for nutritional problems of patients affected by gastrointestinal graft-versus-host disease (GI GVHD). This inevitably leads to different practices in the management of GI GVHD confirmed by this survey. In 22% of centers oral intake is stopped if diarrhea volume exceeds 500 ml, 34% of centers stop oral intake over 1000 ml of diarrhea, 24% of centers over 1500 ml, while 19% of centers do not stop oral intake until severe pain and/or ileus develops. Similarly, introduction of parenteral nutrition depending on the stage of the GVHD shows great variability among the centers.

Conclusion: There is marked variation between EBMT centers in nutritional practices. However, current results could be useful for the development of recommendations toward a more standardized nutritional care process and improvement of patients' outcome.