Parenteral nutrition support after bone marrow transplantation: comparison of total and partial parenteral nutrition during the early posttransplantation period

OBJECTIVE: Bone marrow transplantation (BMT) usually is indicated if the patient's malignant disease involves the marrow or if hazard to the normal marrow is the limiting factor in the aggressive treatment of disease. The success of BMT depends on a complete team with all the resources needed to ensure optimal results. Aggressive nutrition support after BMT is very important. Adequate parenteral nutrition, total (TPN) or partial, followed by enteral nutrition according to the patient's gastrointestinal function is the important principle. METHODS: Between 1996 and 2000, 60 patients, 46 male and 14 female, received BMT in Chang Gung Memorial Hospital. Their ages ranged from 6 to 54 y. Standard TPN was used in 40 patients after BMT, and partial parenteral nutrition was used in the remaining 20 patients. TPN was enriched with branched-chain amino acids (BCAA) when the patient's liver functions were impaired, and cyclic TPN was shifted when the patient's liver functions persistently deteriorated. RESULTS: Most patients improved their nutrition status and increased their body weights, especially those receiving TPN. The patients receiving partial parenteral nutrition decreased their visceral proteins significantly during the course of parenteral nutrition. The BCAA-TPN can maintain a patient's visceral protein better than standard TPN. Only two patients expired because of graft rejection and sepsis; their body weights and nutrition status showed deterioration despite aggressive nutrition support. CONCLUSIONS: We conclude that the nutrition support for patients with BMT is related to the success of marrow transplantation. Parenteral nutrition support, especially with TPN, is important because of frequent gastrointestinal dysfunction during the posttransplantational period, and it is better at maintaining the nutrition status and body weights of patients after BMT. An oral diet can be resumed after the patient's gastrointestinal function has improved and it can be tolerated.     

Cyclic parenteral nutrition during allogeneic bone marrow transplantation

Two adolescents who underwent successful allogeneic bone marrow transplantation were nutritionally managed on a fat-free cyclic parenteral nutrition (PN) regimen. Serum concentrations of prealbumin, albumin, and transferrin were prospectively evaluated to assess the efficacy of nutritional therapy. Both patients tolerated the cyclic PN metabolically. Serial albumin and transferrin concentrations varied slightly and were less sensitive indices of changing nutritional status. In contrast, prealbumin concentrations decreased uniformly during periods of metabolic stress. At the cessation of Pn therapy, all serum proteins were within the normal range. Cyclic PN appears to be a safe, practical approach to the nutritional management of patients undergoing bone marrow transplantation.     

Use of total parenteral nutrition in pediatric bone marrow transplantation

To evaluate the extent of the nutritional stress of pediatric bone marrow transplantation (BMT) and to evaluate the use of total parenteral nutrition (TPN), 35 consecutive pediatric patients who received BMT were studied retrospectively. Voluntary cessation of oral nutrition in almost all patients was observed, and significant decreases of serum albumin levels were seen after BMT. In 85% of these patients, TPN was necessary in response to severe wasting and fasting. No deaths were related to indwelling central venous catheters during the period of 2968 catheter-use days in these severely myelosuppressed patients. The mean of the total daily energy intake was 104% of basal energy expenditure (BEE), and 70% of patients lost their weight. Predicted energy requirement to maintain body weight after BMT would be 128% of BEE from a simple linear regression step in this study. Significant correlations were found between the marrow recovery time and the initial nutritional state, expressed as the percentage of ideal weight height ratio, as well as benign nature of the disease. The use of TPN did not show any beneficial effects on the time course of marrow recovery, although it showed favorable effects on the maintenance of body weight.     

Continuous versus cyclic parenteral nutrition during bone marrow transplantation: assessment and follow-up

The aim of this prospective, randomized clinical trial was to compare the efficacy of parenteral nutrition (PN) in adult bone marrow transplant (BMT) patients on a continuous (CON) versus a cyclic (CYC) regimen. Twelve patients received CON PN and 12 CYC PN. The groups were homogeneous. CON PN received 27.2 +/- 3.7 kcal/kg/day and for CYC PN 25.9 +/- 4.2 kcal/kg/day (P= 0.45). The duration of PN was 20.4 +/- 7.9 days and 27.3 +/- 13.4 days respectively (P = 0.14). There were no differences between initial and final body weights, either within or between groups. The initial pre-albumin levels were 16.1 +/- 7.5 mg/dl and 20.1 +/- 4.9 mg/dl in CON PN and CYC PN, respectively (P= 0.22), and these were maintained throughout the study. Blood glucose levels did not differ between groups. Measures of liver function were moderately increased, but with no significant differences between groups. There were no significant differences regarding the efficacy of PN or the appearance of complications between CON PN and CYC PN in patients with BMT.     

Glutamine supplementation in bone marrow transplantation

An increasing number of clinical investigations have focused on supplementation of specialized enteral and parenteral nutrition with the amino acid glutamine. This interest derives from strong evidence in animal models and emerging clinical data on the efficacy of glutamine administration following chemotherapy, trauma, sepsis and other catabolic conditions. Glutamine has protein-anabolic effects in stressed patients and, among many key metabolic functions, is used as a major fuel/substrate by cells of the gastrointestinal epithelium and the immune system. These effects may be particularly advantageous in patients undergoing bone marrow transplantation (BMT), who exhibit post-transplant body protein wasting, gut mucosal injury and immunodeficiency. Studies to date indicate that enteral and parenteral glutamine supplementation is well tolerated and potentially efficacious after high-dose chemotherapy or BMT for cancer treatment. Although not all studies demonstrate benefits, sufficient positive data have been published to suggest that this nutrient should be considered as adjunctive metabolic support of some individuals undergoing marrow transplant. However, BMT is a rapidly evolving clinical procedure with regard to the conditioning and supportive protocols utilized. Thus, additional randomized, double-blind, controlled clinical trials are indicated to define the efficacy of glutamine with current BMT regimens.     

Parenteral nutrition hypersensitivity

Total parenteral nutrition (TPN) is widely used. Although mechanical, septic, and metabolic complications are well known, hypersensitivity skin reactions are rare. We describe a 16-year-old boy with Burkitt's lymphoma who developed a urticarial skin rash when treated with TPN and vitamins. The adverse skin reaction was probably caused by the inactive component of excipient, polysorbate.     

Parenteral nutrition in obstetric patients

PN is required to maintain or restore an anabolic state when oral enteral routes are not feasible. Despite 22 years of experience with PN, its use during pregnancy has only recently been reported. Most of this information is anecdotal but suggests that this mode of therapy is safe, effective, and occasionally lifesaving. PN during pregnancy has been used most often to provide adequate nutrition for those who suffer from prolonged hyperemesis or who have difficulty absorbing adequate nutrients because of such conditions as Crohn's disease. The proper selection and administration of dextrose, fat, protein, vitamins, trace elements, and electrolytes for pregnant women have been associated with favorable perinatal outcomes. Fat emulsion use does not appear to be associated with any abnormal outcomes. Preterm deliveries and intrauterine fetal growth retardation appear to relate to preexisting or coexisting medical or obstetric complications. Principles for PN with all patients would apply during pregnancy. As with any therapy, the benefits must be weighed against the risks and costs. Sufficient favorable clinical experience over the last 10 years suggests that PN is a relatively safe and effective method for reversing maternal malnutrition and promoting normal fetal growth and development.     

Parenteral nutrition for marrow transplant recipients: evaluation of an increased nitrogen dose

The use of total parenteral nutrition in bone marrow transplant (BMT) recipients is well recognized. These patients as a result of treatment with chemotherapy and immunosuppressive agents undergo catabolic stress. The metabolic effect of an increased nitrogen dose during total parenteral nutrition (TPN) was studied in 28 BMT patients. Patients were given TPN formulas providing a nitrogen intake of either 267 +/- 44 mg of N/kg/d or 330 +/- 60 mg of N/kg/d. Total calories, nonprotein and protein, were held constant at 40 kcal/kg/d for all patients. Data was collected for three periods posttransplant beginning at 3 days posttransplant through day 16. Both study TPN formulas improved patient weight and TIBC values over baseline. Nitrogen balance (NB) values were not significantly different at any study period. However, an overall group effect favored the H-N formula (p less than 0.01). BMT patients undergo catabolic stress which was reflected by average values of 24-hour urine urea nitrogen increasing from 8.1 +/- 4 g/d at baseline to 19.8 +/- 7.2 g/d at period 3 (p less than 0.01). The H-N formula did not differentially increase blood urea nitrogen or serum creatinine levels. Metabolic cart measures also showed no increase in metabolic rate, oxygen consumption, carbon dioxide production, or percent contribution of protein to total metabolic expenditure. Providing a caloric intake of 40 kcal/kg/d was excessive, where 30 to 35 kcal/kg/d would meet metabolic demands. Pertinent clinical outcomes including length of stay, relapse rate, and survival were monitored, but no conclusions could be drawn in this study. The H-N formula was more effective in reducing loss of lean body mass without causing detrimental metabolic effects in BMT patients.     

Food and nutrition services in bone marrow transplant centers

Nutrition care for bone marrow transplant recipients is recognized as vital for a successful transplant, yet little research has been done to determine the most effective foodservice methods. Many decisions regarding methods for the oral feeding of bone marrow transplant patients are based on tradition and/or individual judgments. This study surveyed marrow transplant centers to identify existing food and nutrition services that could be used as a basis for developing a foodservice protocol. A survey instrument was developed and sent to all chief dietitians (no. = 35) affiliated with transplantation centers in the United States. Four of the 30 respondents reported changing from the traditional sterile diet to either a low-bacteria or a modified house diet. Problems of limited availability of single-serve sterile foods, lack of standardization of recipes, and low patient acceptance of autoclaved sterile foods were reported as reasons for the move toward less stringent dietary procedures. The responses clearly indicate the need for additional research before a foodservice model can be established.     

Nutritional support in children undergoing bone marrow transplantation

Nutritional status and 'well-being' were compared prospectively in 39 children (mean age 8.1 years) who received nutritional support following bone marrow transplantion (BMT): 20 received enteral tube feeding (ETF; six received parenteral nutrition [PN] subsequently) and 19 with oral mucositis received PN (one received ETF subsequently). Poor nutritional status (height for age and/or weight for height and/or mid-arm circumference z-scores <-1) was present in 18 patients and was associated with a longer hospital stay (P = 0. 01). Both ETF and PN groups were comparable with respect to age, pretransplant nutritional status and conditioning regimens. No significant deterioration in anthropometric indices in either group occurred following BMT. However, significant correlations were found between the duration of ETF (and not PN) and improvements in nutritional status. Furthermore, PN was associated with more frequent exocrine pancreatic insufficiency than ETF (P = 0.001). Oral mucositis was associated with poorer 'well being' at the start of PN compared with ETF (P < 0.0001), but this was reversed by the end of PN. Bone marrow recovery, hospital stay and positive blood cultures were similar in the two groups. Hypomagnesaemia, hypophosphataemia and biochemical zinc deficiency were common in both groups but hypoalbuminaemia and biochemical selenium deficiency were worse in the PN group. In conclusion, both ETF and PN are effective in maintaining nutritional status post-BMT. When ETF is tolerated, it is associated with better nutritional response. With the existing ETF and PN regimens close monitoring of the trace element and mineral status is required.     

Parenteral nutrition in acute renal failure

This article reviews the current practice of parenteral feeding in patients with acute renal failure. Assessment of nutritional requirements and the provision of nutrients are discussed. Practical guidelines are provided for dietitians to use in the clinical setting.     

骨髓移植并发非感染性肺综合征

骨髓移植 (BMT)是将别人或自己的骨髓移植到体内 ,其本质是移植造血干细胞。由于干细胞有不断自我复制和分化为成熟血细胞 (红、白细胞、巨核细胞 )及免疫活性细胞的能力 ,故移植后可重建受者的骨髓造血和修复人体淋巴组织与单核细胞的免疫功能。BMT包括同卵挛生同胞间的移植 (     

Parenteral nutrition: multidisciplinary management

Parenteral nutrition may be needed to give nutritional support to patients with severe acute (temporary or reversible) or chronic intestinal failure. Parenteral nutrition needs to be given only by health workers trained in its use otherwise life-threatening complications (especially sepsis) may occur.