Department of Medicine, Hematology/Oncology, Goethe-University, 60590 Frankfurt, Germany.
Division of Hematology, Medical University of Graz, Austria.
Clin Nutr. 2021 Apr;40(4):1571-1577. doi: 10.1016/j.clnu.2021.02.030. Epub 2021 Feb 26.
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently associated with impaired oral intake and malnutrition, which potentially increases morbidity and mortality. Therefore, nutrition is one of the major challenges in the post-transplant period.
To document the current clinical approach in nutritional treatment, we designed a questionnaire concerning the current practice in nutrition after alloHSCT and distributed it to German speaking centers performing alloHSCT in Germany, Austria and Switzerland between November 2018 and March 2020. Twenty-eight (39%) of 72 contacted centers completed the survey, 23 from Germany, two from Austria and three from Switzerland, representing 50% of alloHSCT activity within the participating countries in 2018.
All centers reported having nutritional guidelines for patients undergoing alloHSCT, whereby 86% (n = 24) provided a low-microbial diet during the neutropenic phase. The criteria to start parenteral nutrition (PN) directly after alloHSCT seemed to be consistent, 75% (n = 21) of the corresponding centers started PN if the oral nutritional intake or the bodyweight dropped below a certain limit. In the setting of intestinal graft-versus-host disease (GvHD) the current practice appeared to be more heterogenous. About 64% (n = 18) of the centers followed a special diet, added food stepwise modulated by GvHD symptoms, while only four centers regularly stopped oral intake completely (intestinal GvHD grade >1). Half of the centers (54%, n = 15) applied a lactose-free diet, followed by 43% (n = 12) which provided fat- and 18% (n = 5) gluten-free food in patients with intestinal GvHD. Supplementation of micronutrients in acute intestinal GvHD patients was performed by 54% (n = 15) of the centers, whereas vitamin D (89%, n = 25) and vitamin B (68%, n = 19) was added regularly independently of the presence of GvHD. Only 5 (18%) participating centers ever observed a food-associated infection during hospitalization, whereas food-associated infections were reported to occur more often in the outpatient setting (64%, n = 18).
The survey documented a general consensus about the need for nutritional guidelines for patients undergoing alloHSCT. However, the nutritional treatment in clinical practice (i.e. lactose-, gluten- or fat-free in intestinal GvHD) as well as the use of food supplements was very heterogeneous. In line with current general recommendations the centers seemed to focus on safe food handling practice rather than providing a strict neutropenic diet. More high-quality data are required to provide evidence-based nutrition to patients during and after alloHSCT.
异基因造血干细胞移植（alloHSCT）常伴有口腔摄入不足和营养不良，这可能会增加发病率和死亡率。因此，营养是移植后时期的主要挑战之一。
为了记录当前营养治疗的临床方法，我们设计了一份关于 alloHSCT 后营养治疗现状的调查问卷，并于 2018 年 11 月至 2020 年 3 月期间分发给德国、奥地利和瑞士从事 alloHSCT 的德语区中心。在 72 个联系的中心中，有 28 个（39%）完成了调查，其中 23 个来自德国，2 个来自奥地利，3 个来自瑞士，代表了参与国家在 2018 年 alloHSCT 活动的 50%。
所有中心均报告称有 alloHSCT 患者的营养指南，其中 86%（n=24）在中性粒细胞减少期提供低微生物饮食。直接开始肠外营养（PN）的标准似乎是一致的，如果口服营养摄入或体重下降到一定限度，75%（n=21）的相应中心开始 PN。在肠道移植物抗宿主病（GvHD）的情况下，目前的治疗方法似乎更加多样化。约 64%（n=18）的中心采用特殊饮食，根据 GvHD 症状逐步添加食物，而只有 4 个中心完全停止口服摄入（肠道 GvHD 等级>1）。一半的中心（54%，n=15）采用无乳糖饮食，其次是 43%（n=12）提供低脂饮食和 18%（n=5）无谷蛋白饮食在患有肠道 GvHD 的患者中。54%（n=15）的中心在急性肠道 GvHD 患者中补充了微量营养素，而 89%（n=25）的中心常规添加维生素 D，68%（n=19）添加维生素 B，而与 GvHD 无关。只有 5 个（18%）参与中心在住院期间观察到与食物相关的感染，而在门诊环境中报告的与食物相关的感染更为常见（64%，n=18）。
该调查记录了患者在 alloHSCT 期间制定营养指南的普遍共识。然而，临床实践中的营养治疗（即肠道 GvHD 中的无乳糖、无谷蛋白或无脂饮食）以及使用食物补充剂非常多样化。与当前的一般建议一致，中心似乎专注于安全的食物处理实践，而不是提供严格的中性粒细胞减少饮食。需要更多高质量的数据来为 alloHSCT 期间和之后的患者提供循证营养。
