Oral nutritional support to adult patients with acute intestinal Graft Versus Host Disease (GVHD): A proposal for dietary intervention as a model to clinical trials

Abstract

Acute Graft Versus Host Disease (GVHD) affects about 20%-80% of the patients after the hematopoietic stem cell transplant (HSCT) and it is amongst the main causes of morbidity and mortality both in children and adults. The intestine is one of the most affected organs by GVHD causing important alterations in the nutritional status and quality of life, considering that the dysfunctional intestine could decrease food intake as well as an inappropriate dietary plan could worsen the clinical condition. In addition to GVHD, chemotherapy conditioning regimen suppresses the immune system, promotes mucositis and increases the risk of infectious complications. Taking the above into consideration, when per oral diet is possible; the food choices should be carefully planned and monitored to promote nutritional support and avoid worsening the intestinal function and clinical condition. This work was aimed to present a practice guideline proposal, to be validated, based on literature review, regarding to oral dietary recommendations for acute intestinal GVHD after HTSC. Two research phases were defined: Phase one: evidence-based literature review; Phase 2: Practice Guideline Proposal. 1: Evidence based literature review SEARCH METHODS: A literature review (1997-2019) was performed including PubMed, in English, and Lilacs, in Portuguese electronic database to address the subject of dietary intervention for intestinal GVHD related to the HSCT, with children and adults, whose receiving oral or tube feeding nutrition therapy. The study selection was based on the PRISMA method. Controlled clinical trials were searched. Randomization was not possible considering the rare condition. Two independent authors assessed the abstracts of the selected studies to determine the articles feasible to compose the review as the base to elaborate the practice guideline proposal protocol, object of the present study. To determine the level of evidence of the selected article, GRADE criteria were used. One controlled clinical trial study was included. The study was developed in Japan with a total of 35 patients. The dietary plan was characterized by gradual increasing food consistency/density. They found better nutritional parameters in the treated group, however, following GRADE criteria, we rated the quality of evidence as very low. We could not demonstrate confidence in the effect estimate based on the selected study. However, considering the lack of literature information and the relevance of the topic, we decided to proceed and propose a practice guideline for an oral diet protocol for acute intestinal GVHD as a reference to be a starting point to validate protocols in future clinical trials. 2: Practice Guideline Proposal The criteria to elaborate the protocol were based on the RIGHT Statement. In addition to the literate information about diet and intestinal health, recommendations already adopted in the Service of Bone Marrow Transplant in the Complex Hospital of Clinics of Curitiba, in the state of Paraná, Brazil, were also considered.