Nutrition and Dietetics, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
Centre for Haematology, Imperial College London at Hammersmith Hospital, London, UK.
Clin Nutr. 2019 Apr;38(2):738-744. doi: 10.1016/j.clnu.2018.03.008. Epub 2018 Mar 28.
Allogeneic haematopoietic cell transplantation (HCT) is often associated with poor oral intake due to painful mucositis and gastrointestinal sequalae that occur following a preparative regimen of intensive chemotherapy and/or total body radiation. Although attractive to assume that optimal nutrition improves HCT outcomes, there are limited data to support this. It is also unclear whether artificial nutrition support should be provided as enteral tube feeding or parenteral nutrition (PN).
We analysed day-100 non-relapse mortality (NRM), incidence of acute graft-versus-host disease (GvHD), acute gastrointestinal GvHD, 5-year survival and GvHD-free/relapse-free survival (GRFS) according to both route and adequacy of nutritional intake prior to neutrophil engraftment, together with other known prognostic factors, in a retrospective cohort of 484 patients who underwent allogeneic HCT for haematologic malignancy between 2000 and 2014.
Multivariate analyses showed increased NRM with inadequate nutrition (hazard ratio (HR) 4.1; 95% confidence interval (CI) 2.2-7.2) and adequate PN (HR 2.9; 95% CI 1.6-5.4) compared to adequate enteral nutrition (EN) both P < .001. There were increased incidences of gastrointestinal GvHD of any stage and all GvHD ≥ grade 2 in patients who received PN (odds ratio (OR) 2.0; 95% CI 1.2-3.3; P = .006, and OR 1.8; 95% CI 1.1-3.0; P = .018, respectively), compared to adequate EN. Patients who received adequate PN and inadequate nutrition also had reduced probabilities of survival and GRFS at 5 years.
Adequate EN during the early transplantation course is associated with reduced NRM, improved survival and GRFS at 5 years. Furthermore, adequate EN is associated with lower incidence of overall and gut acute GvHD than PN, perhaps because of its ability to maintain mucosal integrity, modulate the immune response to intensive chemo/radiotherapy and support the gastrointestinal tract environment, including gut microflora.
异基因造血细胞移植（HCT）常因预处理方案中强化化疗和/或全身放疗后出现的疼痛性黏膜炎和胃肠道后遗症而导致口腔摄入不良。尽管人们认为最佳营养可改善 HCT 结局，但目前仅有有限的数据支持这一观点。此外，也不清楚是否应通过肠内管饲或肠外营养（PN）来提供人工营养支持。
我们分析了 2000 年至 2014 年间接受异基因 HCT 治疗血液系统恶性肿瘤的 484 例患者的第 100 天非复发死亡率（NRM）、急性移植物抗宿主病（GvHD）发生率、急性胃肠道 GvHD、5 年生存率和无 GvHD/无复发生存（GRFS），并根据中性粒细胞植入前的营养摄入途径和充足程度以及其他已知预后因素进行了分析。
多变量分析显示，与充足的肠内营养相比，营养摄入不足（危险比（HR）4.1；95%置信区间（CI）2.2-7.2）和充足的 PN（HR 2.9；95%CI 1.6-5.4）均与 NRM 增加相关（均 P<.001）。与充足的肠内营养相比，接受 PN 的患者发生任何阶段的胃肠道 GvHD 和所有≥2 级 GvHD 的发生率均升高（OR 2.0；95%CI 1.2-3.3；P=.006，OR 1.8；95%CI 1.1-3.0；P=.018）。与充足的肠内营养和不足的营养相比，接受充足的 PN 的患者在 5 年内的生存率和 GRFS 也较低。
在早期移植过程中给予充足的肠内营养与降低 NRM、提高 5 年生存率和 GRFS 相关。此外，与 PN 相比，充足的肠内营养与更低的总体和肠道急性 GvHD 发生率相关，这可能是因为它能够维持黏膜完整性、调节对强化化疗/放疗的免疫反应，并支持胃肠道环境，包括肠道微生物群。
