Nutrition Management of the Bone Marrow Transplant Patient - - PowerPoint PPT Presentation

Nutrition Management of the Bone Marrow Transplant Patient Complicated by Graft versus Host Disease

Heather Diamond UC San Diego Dietetic Intern May 26, 2015

Patient History

 Subject Patient: HHH  50 year old, FLT3-positive acute myelogenous leukemia (AML) in

November 2013.

 s/p allogeneic hematopoietic stem cell transplant on October

31, 2014. Patient’s sister served as a matched donor.

 Hospital stay was prolonged due to steroid refractory graft

versus host disease (GVHD) of the gut and skin. She was discharged on January 23, 2015 after a three-month hospital stay.

 Returned back to the hospital on February 11, 2015 with failure

to thrive, severe acidosis and likely GVHD of the gut.

Allogeneic HSC Transplant

 Associated with an increased risk

for graft versus host disease

 Approximately 30-60% of

allogeneic HSC transplant recipients will acquire GVHD (1).

Stage Skin Liver GI tract

No rash due to GvHD Bilirubin <2 mg per 100 ml

• r 35 mol/l

None (<280 ml/m2)

I

Maculopapular rash <25%

• f body surface area

without associated symptoms Bilirubin from 2 to <3 mg/100 ml or 35– 50 mol/l Diarrhea >500– 1000 ml/day (280– 555 ml/m2); nausea and emesis

II

Maculopapular rash or erythema with puritis or

• ther associated

symptoms 25% of body surface area or localized desquamation Bilirubin from 3 to <6 mg/100 ml or 51– 102 mol/l Diarrhea >1000– 1500 ml/day (556– 833 ml/m2); nausea and emesis

III

Generalized erythroderma; symptomatic macular, papular or vesicular eruption with bullous formation or desquamation covering 50% of body surface area Bilirubin 6 to <15 mg/100 ml or 103– 225 mol/l Diarrhea >1500 ml/day (>833 ml/m2); nausea and emesis

IV

Generalized exfoliative dermatitis or bullous eruption Bilirubin >15 mg/100 ml

• r >225 mol/l

Diarrhea >1500 ml/day (>833 ml/m2); nausea and

• emesis. Abdominal pain or

ileus

NIH consensus criteria for classification of late acute and chronic GVHD. Blood Marrow Transplant 2009;114:702-708

Nutrition Related Consequences of GVHD

Nutrition Recommendations

Estimated Needs: BMT Patients

 25-30 kcals / 30-35 kcals/kg  Protein: 1.2-1.5 g/kg

Estimated Needs: BMT Patients w/ GVHD

 30-35 kcals/kg  Protein: 1.5-2 g/kg. Needs may be even higher in patients with

significant malabsorption and/or protein losses (2).

Vitamin/Mineral Supplementation

 Varied  MVT w/out minerals

Nutrition Support

 PO intake (alternate menu, nutrition supplements/shakes)  Low microbial while neutropenic  Enteral nutrition  Parenteral nutrition  GVHD of the Gut: GVHD Diet w/ advancement per MD

GVHD Dietary Guidelines

Phase 1

Complete Bowel Rest (NPO) TPN + IV Fluids usually continue

Phase 2

Clear Liquids: lemon lime soda, ginger ale, gatorade, bottled water , strained fruit juices (no apple, prune,

• range), broths, jello, frozen

ice, popsicles,. *White rice or plain spaghetti noodles per MD

• rder

Phase 3

Corn flakes, Rice Krispies, Special K, plain spaghetti noodles, steamed white rice, pretzels, plain bagel, English muffin, white bread/white dinner roll, saltines, unsalted crackers, jelly, sugar (All Phase 2 foods) *Soy milk, Lactaid milk per MD.

Phase 4

Limit 2 yolks/day, flour and corn tortillas, rye bread, roast beef, turkey, ham sandwiches on white bread, 2% milk, pineapples, honeydew melon, cantaloupe, watermelon, green beans, cooked onions, sherbet (All Phase 3, 4 foods)

Initial Nutrition Assessment

 Seen by nutrition upon admission as a skin trigger

Anthropometrics at Admission:

 Height: 4’9” Admit Weight: 167#

BMI: 27.47 Estimated Nutrition Needs at Admit:

 1350-1575 calories per day (30-35 kcals/45 kg Adj BW) and 67-90 g

protein per day (1.5-2 g/kg AdjBW)

 Averaging 7 BM/day

Initial Nutrition Diagnosis:

 Altered GI fxn r/t medical condition including GVHD of the gut AEB

persistent diarrhea.

Nutrition Recommendations



If active GVHD, rec changing to GVHD diet II > III > IV > V

 Diet advancement per MD  Goal diet: Carb limited diet  Insulin regimen to maintain POCT BS goal of < 180 mg/dl  Whole blood zinc, Vitamin D and B12 to assess deficiency  Addition of MVT w/out minerals  Imodium and Metamucil to manage loose stools

Clinical Course

 Up to sixteen bowel movements a day  TPN from February 22nd to March 5th  D15%, AA5% running at 55 ml/hr x 24 hrs  Lipids initially held r/t patient’s history of hypertriglyceridemia

until baseline measured

 180 ml/day of 20% intralipids was added (15 ml/hr x 12 hrs)  TGs measured weekly

Ref. Range 12/7/2014 22:40 12/12/201 4 22:30 12/26/2014 23:10 1/8/2015 21:50 1/11/2015 21:00 1/16/2015 20:20 1/19/2015 00:45 2/21/2015 23:20 Triglycerides Latest Range: 10-170 mg/dL 276 (H) 219 (H) 270 (H) 199 (H) 196 (H) 217 (H) 465 (H) 160

• Ref. Range

10/16/2014 12:15 1/19/2015 00:45 2/11/201 5 00:01 Glyco Hgb (A1C) Latest Range: 4.8-5.9 % 7.2 (H) 6.0 (H) 5.8

• Ref. Range

12/1/2014 00:00 12/28/2014 23:20 1/11/2015 21:00 2/21/2015 23:20 3/8/2015 21:10 Prealbumin Latest Range: 20-40 mg/dL 7 (L) 32 35 22 32

Clinical Course

Sample Calorie Count Results

4/3/15 305 Calories, 25g Protein (23% of calorie goal, 37% of protein goal) 4/4/15 245 Calories, 7g Protein (18% of calorie goal, 10% of protein goal) 4/5/15 280 Calories, 7g Protein (20% of calorie goal, 10% of protein goal)

 PO diet restarted w/ calorie count  Back and forth between GVHD II, GVHD III and GVHD IV  Progression to Stage 3 GVHD of Liver  TPN not appropriate given LFTs  EN recs provided

04/08/15 119 lb 04/07/15 120 lb 04/06/15 119 lb 04/05/15 117 lb 04/02/15 123 lb 03/31/15 125 lb 03/30/15 120 lb 03/29/15 126 lb 03/27/15 130 lb

• Ref. Range 4/6/2015

15:20 4/6/2015 23:30 4/7/2015 23:40 4/9/2015 00:02 4/9/2015 20:35 4/10/2015 21:30 4/11/2015 22:00 4/12/2015 21:45 Alkaline Phos Latest Range: 35- 140 U/L 361 (H) 397 (H) 414 (H) 443 (H) 367 (H) 374 (H) 388 (H) 535 (H) ALT (SGPT) Latest Range: 0- 33 U/L 34 (H) 36 (H) 31 33 30 30 30 35 (H) AST (SGOT) Latest Range: 0- 32 U/L 32 34 (H) 22 22 24 26 35 (H) 38 (H) Bilirubin, Dir Latest Range: <0.2 mg/dL 8.0 (H) 8.2 (H) 9.3 (H) 8.3 (H) 10.0 (H) 8.0 (H) 7.1 (H) Bilirubin, Tot Latest Range: <1.20 mg/dL 7.86 (H) 9.14 (H) 9.15 (H) 10.72 (H) 9.59 (H) 11.47 (H) 9.09 (H) 8.32 (H)

Pertinent Medications

Nutritionally Relevant Medications Steroids (Prednisone, Prednisolone, Solu-Medrol, Solu-Cortef)

Altered fluid/electrolyte balance Hyperphagia, Mood Swings, Hypertension, Weigh Gain, Hyperglycemia, Hyperlipidemia, Osteoporosis, Decreased Activation of Vitamin D, Altered Protein Metabolism by increasing proteolysis and inhibits insulin’s ability to promote anabolism

Tacrolimus

Nephrotoxicity, Hypertension, Hyperglycemia, Hyperkalemia, Hypomagnesemia, Diarrhea

Antibiotics

Diarrhea, Nausea/Vomitting, Altered Gut Flora

Patient Prognosis

 HHH continued to suffer from severe diarrhea and Stage Three

GVHD of the liver. Her prognosis was very poor.

 In mid April, the patient made the decision to be placed on

comfort care

 HHH passed in mid-April

References



1. Preudhoome, Claude. Cooperative gene mutations in acute myeloid leukemia: a review of literature. Leukemia: 2008; 22: 916.



2. Roberts S, Thompson J. Graft vs Host Disease: Nutrition Therapy in a Challenging Condition. American Society for Parenteral & Enteral Nutrition, Nutr Clin Practice 2005: 20: 440.



3. Hadjibabaie M, Iravani M, Taghizadeh M, A-Jafari, A. Evaluation of nutritional status in patients undergoing hematopoietic SCT. Bone Marrow

• Transplantation. 2008, 42, 469-473.



• 4. Osamu I, Shigetoshi N, Terumi H, Miki K, Kiyoko I. Nutritional support for patients suffering from intestinal graft versus host disease after allogenic

hematopoietic stem cell transplantation. American Journal of Hematology. 2006; 81 747-752.



5. Pzepiorka D, Weisdorf D, Martin P. Consensus on Acute GVHD Grading. Bone Marrow Transplantation. 1995, 15(6):825-828.



6. Ball LM, Egeler, RM. Acute GVHD: pathogenesis and classification. Bone Marrow Transplantation. 2008, 41. 558-564.



7. Vigorito AC, Campregher PV, Storer BE et al. Evaluation of NIH consensus criteria for classification of late acute and chronic GVHD. Biol Blood Marrow Transplant 2009;114:702-708.



• 8. Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-

host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant 2005; 11:945.



• 9. Graaf de P, Meij der Van, Langius JAE, Visser OJ. Nutritional support in patients with GVHD of the digestive tract: state of the art. Bone Marrow
• Transplantation. 2013; 48: 474-482.



• 10. Mattson, J. Westin, S. Edlund S. Poor oral nutrition after allogenic stem cell transplantation correlates significantly with severe graft-versus-host-
• disease. Bone Marrow Transplantation. 2006; 38: 629-633.



• 11. Kyle UG, Chalandon Y, Miralbell R, Karsegard VL, Hans D, Trombetti A et al. Longitudinal follow-up of body composition in hematopoietic stem cell

transplant patients. Bone Marrow Transplant 2005; 35: 1171–1177



• 12. Weisdorf DJ, Snover DC, Haake R, Miller WJ, McGlave PB, Blazar B et al. Acute upper gastrointestinal graft-versus-host disease: clinical significance and

response to immunosuppressive therapy. Biol Blood Marrow Transplant. 1990; 76: 624–629



• 13. Sanders JE. Chronic graft-versus-host disease and late effects after hematopoietic stem cell transplantation. Int J Hematol. 2002; 76(Suppl 2): 15–28.



• 14. Milligan DW, Quick A, Barnard DL. Vitamin B12 absorption after allogeneic bone marrow transplantation. J Clin Pathol. 1987; 40: 1472–1474.



• 15. Ripamonti C, Fulfaro F. Taste alterations in cancer patients. J Pain Symptom Manage. 1998; 16: 349–351.