Nutritional support for patients who have had a bone marrow transplant

Murray SM, Pindoria S

Published Online:

January 21, 2009

Bone marrow transplant patients can experience prolonged poor appetite with vomiting and diarrhoea. Malnutrition is a consequence. To prevent this, patients can receive nutritious fluids orally or via a nasogastric tube, or intravenously as parenteral nutrition. The benefits of either route are unclear. Studies were found that compared these interventions but missing data prevents proper assessment of the benefits. However, the limited data available indicates that when patients undergo bone marrow transplantation and are given intravenous fluids and are encouraged to have an oral diet they are less likely to experience infections and are more likely to go home earlier than if they are given standard parenteral nutrition routinely. In the event that patients nutritional intake is inadequate because of an inadequate oral intake or because they are unable to tolerate tube feeding and are given parenteral nutrition with added glutamine they are likely to have less infections but may not necessarily leave hospital earlier.

Abstract (click to read)

Background:

This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates.

Objectives:

To determine efficacy of EN or PN support for patients receiving bone marrow transplant.

Search strategy:

Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006.

Selection criteria:

RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients.

Data collection and analysis:

Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival.

Main results:

In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN.

Authors' conclusions:

In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

This record should be cited as:

Murray SM, Pindoria S. Nutrition support for bone marrow transplant patients. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD002920. DOI: 10.1002/14651858.CD002920.pub3

Assessed as up to date:

April 30, 2008

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Primary Review Group:

Pain, Palliative and Supportive Care Group

Health topics:

Cancer > Palliative and supportive care > Hydration and nutrition

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Nutritional support for patients who have had a bone marrow transplant

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