Nutritional Support Modalities Research Articles

Enteral Versus Parenteral Nutrition in Patients Undergoing Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis

Purpose : The purpose of this study is to conduct a systematic review to compare the nutritional support level, tolerance, and clinical outcomes obtained with enteral and parenteral nutrition in patients undergoing hematopoietic stem cell transplantation(HSCT). Methods: A computerized search of studies published from database inception to June 12, 2023 was conducted in English language databases including Pubmed, Cochrane Library, Embase, and Web of Science, and in Chinese language databases including China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, and Chinese Biomedical Literature Database (Sinomed). The search strategy was constructed using a combination of subject headings and free-text terms. Search terms included “Stem Cell Transplantat*” “Bone Marrow Transplantation” “Enteral Nutrition” “Parenteral Nutrition”. The inclusion criteria for this intervention study are studies that include patients undergoing hematopoietic stem cell transplantation and compare enteral nutrition versus parenteral nutrition as an intervention. The outcome measures include changes in patient nutritional status, nutritional support tolerance, incidence of infection, incidence of GVHD, length of hospital stay, and number of days to neutrophil engraftment. Studies including conference abstracts and those without full-text availability were excluded. Results: A total of 3,175 relevant articles were identified through the search, and after duplicates and screening, 10 studies with 339 patients were included. The literature screening process is shown in Figure 1, and the included study characteristics are presented in Table 1. The average duration of enteral nutrition in HSCT patients was 10-16 days, while parenteral nutrition lasted on average 14-17.5 days. Nasogastric tube feeding provided 50%-90% of the required nutrition, while intravenous nutrition provided 58%-97% of the required nutrition. Meta-analysis results showed that patients receiving enteral nutrition had a higher degree of weight loss compared to those receiving parenteral nutrition after HSCT [MD=1.97, 95%CI(0.81, 3.12), P<0.001], but had a lower degree of serum albumin decline [MD=2.49, 95%CI(0.82, 4.17), P=0.003], as shown in Figures 2-3. In terms of tolerance, 45%-100% of patients switched from enteral to parenteral nutrition before completing nutritional support, with common reasons being repeated tube displacement, inability to meet nutritional demands, nausea, and diarrhea. Only one study reported bleeding rates, which were 23% for the enteral nutrition group and 30% for the parenteral nutrition group. Meta-analysis results showed no significant differences in the incidence of grade 3-4 GVHD, grade 3-4 gastrointestinal mucositis, incidence of infection, and mean length of hospital stay between the two groups, as shown in Figures 4-7. The quality assessment of included studies is presented in Figure 8. Conclusion: Previous studies have suggested that enteral nutrition may be a cost-effective alternative to parenteral nutrition and could potentially prevent bacterial translocation by stimulating the gastrointestinal mucosa. The American Society for Parenteral and Enteral Nutrition recommends that enteral nutrition should be prioritized for HSCT patients who cannot meet their nutritional needs through oral intake. This study found that enteral and parenteral nutrition provided similar levels of nutritional support, and there were no statistically significant differences in clinical outcomes, such as the incidence of grade 3-4 GVHD, grade 3-4 gastrointestinal mucositis, incidence of infection, and mean length of hospital stay. However, based on patient tolerance, factors such as repeated tube displacement, inability to meet nutritional demands, nausea, and diarrhea may lead to the removal of the tube before reaching the nutritional target, and a switch to parenteral nutrition support. Therefore, when choosing enteral nutrition support, it is essential to evaluate the patient's nutritional needs, nasal and skin mucosa condition, and gastrointestinal function. As the studies included in this review were small sample studies, there may be some bias in the results. Future multi-center, large-sample prospective studies are needed to further compare the risks and benefits of different nutritional support modalities for HSCT patients.

Impact of COVID-19 on nutritional status during the first wave of the pandemic

Background & aimsPatients affected by COVID-19 may develop disease related malnutrition (DRM) due to the catabolic situation, symptoms that interfere with intake and prolonged hospital stay. This study aims to know the percentage of patients admitted for COVID-19 who required artificial nutrition (AN), their clinical characteristics, as well as the prevalence of DRM and the risk of sarcopenia at hospital discharge and after 6 months.Material and methodsObservational, prospective study, with successive inclusion of adult patients admitted for COVID-19 in whom institutional nutritional support (NS) care protocol was applied. Those who received AN underwent a nutritional screening by Short Nutritional Assessment Questionnaire (SNAQ) and an assessment by Subjective Global Assessment (SGA) at hospital discharge, as well as a screening for sarcopenia (SARC-F test) and SNAQ re-test 15 days and 6 months after by a phone call. Symptoms related to food intake, anthropometric and analytical data were also collected.ResultsWe evaluated 936 patients with a mean age of 63.7 ± 15.3 years; predominantly male (59.7%), overweight 41%, obesity 40.4%; hypertension 52.9%; diabetes mellitus 26.6% and cancer 10.4%. The stay hospital length was 17.3 ± 13.8 days and 13.6% patients died during hospitalization. The modality of nutritional support was: 86.1% dietary adaptation + oral nutritional supplements (ONS); 12.4% enteral nutrition (EN) by nasogastric (NG) tube; 0.9% parenteral nutrition (PN) and 0.6% EN plus PN. Focusing on patients who received AN, follow-up post discharge was possible in 62 out of 87 who survived. Of these, at the time of hospital discharge, 96.7% presented nutritional risk by SNAQ and 100% malnutrition by SGA (20% B; 80% C). During admission, 82.3% presented intense anorexia and the mean weight loss was 10.9 ± 6 Kg (p < 0.001). Fifteen days after being discharged, 12.9% still had anorexia, while hyperphagia appeared in 85.5% of the patients and risk of sarcopenia by SARC-F was present in 87.1% of them. Six months after discharge, 6.8% still had anorexia and 3.4% hyperphagia, with a global weight gain of 4.03 ± 6.2 Kg (p=<0.0001). Risk of malnutrition was present in only 1.7% of the patients, although risk of sarcopenia persisted in 49.2%.ConclusionAll patients admitted by COVID-19 for whom EN or PN were indicated following an institutional protocol still presented malnutrition at hospital discharge, and almost all showed risk of sarcopenia, that persisted in almost half of them at 6 months. These findings suggest that nutritional and functional problems persist in these patients after discharge, indicating that they require prolonged nutritional support and monitoring.

Intradialytic Parenteral Nutrition: A Method of Copper Replacement

Copper is essential trace metal which plays vital role in electron transport reactions, iron hemostasis, pigment formation, neurotransmitter production, connective tissue biosynthesis and antioxidant defense mechanisms. A 58-year-old Caucasian man with ESRD on intermittent hemodialysis, chronic diarrhea and malabsorption after gastric bypass surgery on Intradialytic parenteral nutrition (IDPN) was evaluated for anemia with sub optimal response to high doses of erythropoietin and pancytopenia suspicious of myelodysplastic syndrome. Investigations listed in Figure 1. Bone Marrow biopsy showed refractory cytopenias with multi-lineage dysplasia. Cytogenetics showed no definitive immunophenotypic evidence of high-grade hematopoietic neoplasia, lymphoproliferative disease or plasma cell dyscrasia. He was started on daily oral therapy with copper gluconate with no improvement in the hematological parameters. Copper chloride was added to IDPN with improvement of all hematological parameters and copper levels [figure 2]. On attempting to withdraw therapy, severe drop in copper and cell counts were noted and was corrected with resumption of IDPN with copper supplementation. Copper deficiency can present as anemia and leukopenia, thrombocytopenia. Typical bone marrow findings mimic myelodysplastic syndrome including left shift in granulocytic & erythroid maturation & presence of ringed sideroblasts/hemosiderin containing plasma cells. Neurologic manifestations include ataxia, myeloneuropathy and cognitive deficits. Unlike neurologic deficits, hematologic manifestations can be reversed with copper supplementation. The current adult recommended intake is 0.9mg/day. The American society for metabolic and Bariatric surgery clinical practice recommend treatment of mild to moderate deficiency with oral (3-8mg/dl) and IV copper (2-4mg/dl) for severe deficiency. Oral supplementation may fail in patients with gastric bypass as copper is absorbed in stomach and duodenum. IDPN is relatively safe and efficacious modality of nutritional support which allows the administration of nutrients through extracorporeal circuit during hemodialysis in these patients. Other causes of copper deficiency include Post gastric bypass surgery, Excessive zinc ingestion or overloading during hemodialysis, celiac disease, cystic fibrosis, IBD and Bacterial overgrowth.2453_A Figure 1. Initial Patient Laboratory Values2453_B Figure 2. Hematological changes during treatment with copper. WBC - White blood cell count, HB - Hemoglobin, IDPN - Intradialytic Parenteral Nutrition, Oral - Oral supplementation

MON-P102: Outcomes of Nutritional Support Modalities in Maintenance Hemodialysis Patients

MON-P102: Outcomes of Nutritional Support Modalities in Maintenance Hemodialysis Patients

MON-P103: Positive Incomes of Nutritional Support Modalities in Terms of Inflammation and Cardiovascular Status

MON-P103: Positive Incomes of Nutritional Support Modalities in Terms of Inflammation and Cardiovascular Status

Nutrizione parenterale intradialitica: indicazioni, aspetti pratici e limiti

La malnutrizione, o deplezione proteico-energetica (Protein Energy Wasting, PEW), è una condizione frequente nei pazienti con malattia renale cronica in stadio terminale (End Stage Renal Disease, ESRD) e si associa a un significativo aumento del rischio di mortalità e morbilità già caratteristicamente elevato in questa popolazione. Dal momento che uno dei meccanismi principali della PEW nell'ESRD è rappresentato dall'insufficiente assunzione di nutrienti, la supplementazione nutrizionale orale viene ampiamente utilizzata come efficace prima scelta nella prevenzione e nel trattamento della PEW. Tra gli altri approcci proposti come modalità di supporto nutrizionale per i pazienti con ESRD, la nutrizione parenterale intradialitica (IDPN) ha assunto di recente un ruolo importante in pazienti selezionati. Tuttavia, sebbene l'IDPN riesca a migliorare lo stato metabolico/nutrizionale nell'ESRD, le evidenze riguardo alla relazione tra questa modalità di supporto nutrizionale e una riduzione del tasso di ospedalizzazione e del rischio di mortalità sono ancora limitate. Questa rassegna si propone di fare il punto sulle pratiche più utilizzate nel trattamento della PEW nell'ESRD, concentrandosi in particolare sul ruolo dell'IDPN come modalità di integrazione nutrizionale per i pazienti in emodialisi. A tale scopo, verranno illustrati gli aspetti quantitativi e qualitativi dell'IDPN, i problemi pratici legati alla sua gestione, le indicazioni e i limiti della metodica.

Intradialytic parenteral nutrition in end-stage renal disease: practical aspects, indications and limits

Protein-energy malnutrition (PEW) is highly prevalent in patients with end-stage renal disease (ESRD) and is associated with a significant increase of the already high mortality and morbidity risk typical of this clinical setting. Since a key mechanism of PEW in ESRD is inadequate nutrient intake, oral nutritional supplements are extensively employed, and have been demonstrated to be highly effective in PEW prevention and treatment. Intradialytic parenteral nutrition (IDPN), i.e. the administration of nutrients through the extracorporeal circuit during hemodialysis, has also been proposed as a modality of nutritional support for patients with ESRD. However, even though metabolic/nutritional status is improved by this nutritional approach, the evidence linking IDPN to decreased hospitalization rate and lower mortality risk is still scant. The aim of the present paper is to review the role of IDPN as a modality of nutritional supplementation for ESRD patients on hemodialysis. To this end, quantitative and qualitative aspects, practical management, the indications, and limits of IDPN are discussed. On the basis of the available evidence, it is suggested that IDPN is a safe and efficacious modality of nutritional support in ESRD, and could represent an adjunctive strategy for patients with reduced spontaneous dietary intake when intensive dietetic counseling and oral supplementation have failed.

Alteration of Taste Acuity in Pediatric Cancer Patients after Treatment Completion: A Cross-Sectional Study Using a Filter-Paper Disc Method

Taste acuity of adult patients undergoing cancer treatment has been well investigated; however, studies of taste acuity after completion of cancer treatment are limited, particularly in children. This study aimed to assess taste acuity in pediatric cancer patients after treatment completion. Seventy-three patients who had completed cancer treatment (median age, 13 years; range, 7 - 18 years) and had not received any further treatment for at least 6 months were enrolled. Eighty-one healthy children (median age, 10 years; range, 8 - 19 years) served as controls. We determined the thresholds for four tastes (sweet, salty, sour, and bitter) using the filter-paper disc method. There was no significant difference in the thresholds of taste acuity for the four test solutions between the patient and control groups. The duration since treatment completion (<5 years vs. ≥5 years) had no significant impact on taste acuity for the four test solutions. The threshold for tasting salt was significantly higher in the group that had received chemotherapy + radiation and/or hematopoietic stem cell transplantation than that in the group that had received chemotherapy-only. Our results indicated that taste acuity after treatment completion in pediatric cancer patients was the same as that in healthy children. However, some treatment modalities were correlated with an impaired ability to taste salt. Gustatory test results should be considered while deciding nutritional support modalities after treatment completion in pediatric cancer patients.

Nutritional Support for Patients Sustaining Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies

BackgroundIn traumatic brain injury (TBI), the appropriate timing and route of feeding, and the efficacy of immune-enhancing formulae have not been well established. We performed this meta-analysis aiming to compare the effects of different nutritional support modalities on clinical outcomes of TBI patients.MethodsWe systematically searched Pubmed, Embase, and the Cochrane Library until October, 2012. All randomized controlled trials (RCTs) and non-randomized prospective studies (NPSs) that compared the effects of different routes, timings, or formulae of feeding on outcomes in TBI patients were selected. The primary outcomes included mortality and poor outcome. The secondary outcomes included the length of hospital stay, the length of ventilation days, and the rate of infectious or feeding-related complications.Findings13 RCTs and 3 NPSs were included. The pooled data demonstrated that, compared with delayed feeding, early feeding was associated with a significant reduction in the rate of mortality (relative risk [RR] = 0.35; 95% CI, 0.24–0.50), poor outcome (RR = 0.70; 95% CI, 0.54–0.91), and infectious complications (RR = 0.77; 95% CI, 0.59–0.99). Compared with enteral nutrition, parenteral nutrition showed a slight trend of reduction in the rate of mortality (RR = 0.61; 95% CI, 0.34–1.09), poor outcome (RR = 0.73; 95% CI, 0.51–1.04), and infectious complications (RR = 0.89; 95% CI, 0.66–1.22), whereas without statistical significances. The immune-enhancing formula was associated with a significant reduction in infection rate compared with the standard formula (RR = 0.54; 95% CI, 0.35–0.82). Small-bowel feeding was found to be with a decreasing rate of pneumonia compared with nasogastric feeding (RR = 0.41; 95% CI, 0.22–0.76).ConclusionAfter TBI, early initiation of nutrition is recommended. It appears that parenteral nutrition is superior to enteral nutrition in improving outcomes. Our results lend support to the use of small-bowel feeding and immune-enhancing formulae in reducing infectious complications.

Enteral Tube Feeding: A Clinical Perspective on Recent Advances

Enteral feeding has been recognized as the preferred modality of nutritional support for patients in whom the gastrointestinal tract is either totally or partially functional.

Prognostic Significance of Epithelioid Granulomas Found in Rectosigmoid Biopsies at the Initial Presentation of Pediatric Crohn's Disease

The prognostic significance of epithelioid granulomas in Crohn's disease (CD) remains controversial. We have determined the prognostic significance of epithelioid granulomas noted in endoscopic rectosigmoid biopsies obtained from untreated pediatric patients at initial presentation of CD. Data collected from 19 subjects with rectosigmoid granulomas and inflammation (Group 1) were compared to those obtained from another 37 subjects (Group 2) with CD of the rectosigmoid, but in whom no granulomas were present. Both groups had similar ages at disease onset [Group 1: 11.6 + 3.6; Group 2: 10.4 + 4.0 years (X + SD)]. At diagnosis, Group 1 had more extensive CD (small bowel and colon involvement, with Group 1 74% versus Group 2 30%; isolated rectosigmoid involvement, with Group 1 11% versus Group 2 35%; p &lt; 0.01). Perianal disease was also more common in Group 1 (58% versus 27% Group 2; p &lt; 0.05). However, CD activity scores and clinical laboratory findings were comparable. Duration of follow‐up was identical (5.6 + 3.3 years) for both groups. By the end of the period of follow‐up, 43% of Group 2 had developed small bowel involvement, but Group 1 continued to have more extensive CD (p &lt; 0.05). Perianal fistulae and abscesses and anal stenosis were more frequent in Group 1. Throughout this period, the need for oral and parenteral corticosteroids, 6‐mercaptopurine, and nutritional support modalities were similar in the two groups. Although the number of subjects requiring hospitalization and the number of hospitalizations per patient were similar in both groups, Group 1 had more surgery (p &lt; 0.05). Rectosigmoid epithelioid granulomas appear, therefore, to be a finding associated with a poorer prognosis when discovered at the time of initial diagnosis of CD in children.

Prognostic significance of epithelioid granulomas found in rectosigmoid biopsies at the initial presentation of pediatric Crohn's disease.

The prognostic significance of epithelioid granulomas in Crohn's disease (CD) remains controversial. We have determined the prognostic significance of epithelioid granulomas noted in endoscopic rectosigmoid biopsies obtained from untreated pediatric patients at initial presentation of CD. Data collected from 19 subjects with rectosigmoid granulomas and inflammation (Group 1) were compared to those obtained from another 37 subjects (Group 2) with CD of the rectosigmoid, but in whom no granulomas were present. Both groups had similar ages at disease onset [Group 1: 11.6 +/- 3.6; Group 2: 10.4 +/- 4.0 years (X +/- SD)]. At diagnosis, Group 1 had more extensive CD (small bowel and colon involvement, with Group 1 74% versus Group 2 30%; isolated rectosigmoid involvement, with Group 1 11% versus Group 2 35%; p less than 0.01). Perianal disease was also more common in Group 1 (58% versus 27% Group 2; p less than 0.05). However, CD activity scores and clinical laboratory findings were comparable. Duration of follow-up was identical (5.6 +/- 3.3 years) for both groups. By the end of the period of follow-up, 43% of Group 2 had developed small bowel involvement, but Group 1 continued to have more extensive CD (p less than 0.05). Perianal fistulae and abscesses and anal stenosis were more frequent in Group 1. Throughout this period, the need for oral and parenteral corticosteroids, 6-mercaptopurine, and nutritional support modalities were similar in the two groups. Although the number of subjects requiring hospitalization and the number of hospitalizations per patient were similar in both groups, Group 1 had more surgery (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in Liver Function Tests in Patients with Inflammatory Bowel Disease on Enteral Nutrition

Morphologic and functional hepatic changes occur in inflammatory bowel disease (IBD). Patients with this disease often require the administration of artificial nutritional support. Liver function tests (LFT) derangement is a widely recognized side-effect of total parenteral nutrition (TPN). Therefore, the use of this modality of nutritional support may be an additional factor to cause hepatic damage in IBD patients. However whether or not the same occurs in patients receiving total enteral nutrition (TEN) is not well-established. The aim of the present study was to evaluate the effect of TEN upon LFT in patients with moderate to severe acute attacks of IBD, by means of a prospective, controlled, and nonrandomized design. Forty-nine patients were included; 29 (11 patients with ulcerative colitis and 18 with Crohn's disease) received TEN, and 20 (11 with ulcerative colitis and 9 with Crohn's disease) did not. Both groups were homogeneous regarding age, sex, disease activity index, nutritional status, and length of the study (24.8 +/- 1.3 vs 23.9 +/- 16.8 days). In all cases, weekly measurements of serum alkaline phosphatase, GOT, and GPT were performed. There were no significant differences in LFT at the beginning of the study between groups. The percentage of patients showing derangement of some LFT during the study did not differ between both groups: six of 29 (20.6%) in TEN group vs three of 20 (15%) in control group. Six out of the nine patients (in both groups) who developed LFT derangement had one or more causes, other than TEN for explaining hepatic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)