MNT for Stem Cell Transplant Flashcards
Blood stem cells are produced in the __ ___ and can become any kind of cell that the body needs
Bone marrow
Stem cells are constantly ___ and ___ into different types of blood cells, replacing older and worn-out blood cells in the body
Diving and maturing
Stem cells produce billions of new ___ ___ every day
Blood cells
If the stem cells cannot make enough new blood cells, many serious __ ___ can occur
Health problems
Stem cells are immature blood cells that can be removed from the blood or bone marrow of a patient or donor and the ___ and stored
Frozen
If someone is getting a stem cell transplant, high doses of ____ and/or radiation therapy are needed to kill existing bone marrow that is producing the cancerous cells before the transplant
Chemotherapy
The infused stem cells replace the blood-forming cells that were destroyed by the ___ ____ by growing into and restoring the body’s blood cells
Cancer treatment
Currently, 85% of transplants performed at UPMC Cancer Center use stem cells from ___ ___
Peripheral blood
Stem cell transplant shave the potential to cure a variety of __ and ___ diseases that may be incurable with conventional therapy
Benign and hematologic
What are some examples of common diseases treated with stem cell transplants?
-Acute Myelogenous Leukemia (AML)
-Chronic Myelogenous Leukemia (CML)
-Hodkin’s Lymphoma
-Non-Hodgkins Lymphoma
-Myelodysplastic Syndrome (MDS)
-Multiple Myeloma (MM)
-Aplastic anemia
Stem cell transplant allows for high doses of ___ or ___ therapy to be used for disease treatment
Chemotherapy or raditation
Bone marrow becomes depressed due to the higher doses of chemotherapy and/or radiation used and the transplanted stem cells will eventually restore normal __ __ production
Blood cell
An ____ stem cell transplant means that stem cells are harvested from the patient prior to other cancer treatments, purged or abnormal cells, and transplanted into the patient
Autologous
Autologous stem cell transplants are commonly used for…
-Lymphomas
-Lyelomas
-Testicular cancer
-Less commonly used for leukemia
Autologous stem cell transplants are the predominant type of transplant used in ___ ___
Older adults
____ stem cell transplants are when a physician collects and transplants stem cells from a donor who matches the recipients’ cells
Allogenic
What are the two types of allogenic stem cell transplants?
-Sibling (SIB)
-Matched unrelated donor (MUD)
A ____ stem cell transplant is from an identical twin
Syngenic
We can also perform ___ ___ blood transplants where stem cells are harvested from the umbilical cord blood and transplanted
Umbilical cord
Recent studies have shown that umbilical cord transplants are just as effective as transplants from ___ ___
Unrelated donors
A ____ transplantation is when a half-matched bone marrow transplant that has been successful in “curing” patients of some cancers and blood disorders
Haploidentical
With haploidentical transplantation, a physician administers just enough chemotherapy to suppress the immune system, which keeps the patient from ___ the donated marrow without harming their organs
Rejecting
Haploidentical transplantation has ____ side effects and also expands the potential donor pool, making more patients eligible for the transplant
Milder
A stem cell transplant consists of what three major parts?
-Conditioning phase
-Infusion of stem cell transplant
-Engraftment
The conditioning phase is designed to destroy ____ ___ that are resistant to conventional doses of chemo without causing fatal organ toxicity
Tumor cells
The choice of ___ ___ varies based on patient and disease characteristics as well as donor availability
Conditioning regimen
After conditioning is complete, the patient receives their ____
Transplant
____ refers to the types of chemotherapy given and is dependent on the protocol and the disease
Conditioning
Common chemotherapeutic agents:
-Vincristine
-Cisplatin
-Busulfan
-Carboplatin
-Melphalan
-Etoposide
-Topotecan
-Cyclophosphamide
Step 1 of apheresis is ____, and is when whole blood is collected though a tube from a vein in one arm
Collection
Step 2 of apheresis is called ____ and is when the blood is filtered through an apheresis machine, which separates the stem cells from the blood
Separation
Step 3 of apheresis is ___ ___ ___ and is when stem cells are collected for storage
Stem cell storage
Step 4 of apheresis is ___, when the rest of the blood is returned through a tube to a vein in the other arm
Return
When stem cells are transplanted, cells are infused through a patients’ __ __ over several hours
Central line
While transplantation is happening, patients are closely monitored for…
-Fever
-Chills
-Hives
-Low blood pressure
-Shortness of breath
____ is when the donated stem cells take hold and begin producing normal blood cells
Engraftment
Defined at UPMC Shadyside, white blood cells are considered engrafted when absolute neutrophil count is above ___ for 2 consecutive days or ___ cells on one day
500; 1,000
Platelet engraftment is defined as an unsupported count greater than ____
20,000
The average time to engraftment with an autologous stem cell transplant is…
day 15-25
The average time to engraftment with an allogeneic stem cell transplant is…
Day 13-24
Advantages of an autologous stem cell transplant:
-No HLA matching requirement
-No GVHD
-No need for immune suppression
Disadvantages of autologous stem cell transplant:
-Possibility of stem cell damage from prior therapy leading to delay in engraftment
-Possibility of contamination with tumor
With autologous stem cell transplant, there is a ___ risk of complications but ____ risk of relapse
Lower; higher
Advantages of allogenic stem cell transplant:
-Stem cells have not been exposed to chemotherapy
-Stem cell product is free of tumor
Disadvantages of allogenic stem cell transplant:
-Donor availability uncertain
-GVHD
-Higher risk of complications
With allogenic stem cell transplant, there is a ____ risk of complications but a ___ risk of relapse
Higher; lower
The outcome of stem cell transplant depends on many patient factors like…
-Age
-Disease factors (diagnosis, disease state, prior therapy)
-Donor factors (human leukocyte antigen, gender match)
-Transplantation (conditioning regimen, stem cell source, GVHD prophylaxis, engraftment)
A nutrition history includes…
-Disease state
-Previous treatment history
-Relevant other PMHx
-Problems impacting appetite
-GI symptoms
-Mucositis, stomatitisis, xerostomia
-Taste alterations
After transplantation, patients should receive a ___ ____ diet comprised of food that contains low numbers of potentially harmful microbes
Low microbial
Tips for a low microbial diet:
– Fresh fruits & vegetables are washed well under clean running water
– Avoid raw or rare-cooked meat, fish, & eggs. All meat should be cooked to a “well-done” stage
– Avoid raw honey
– Avoid foods that are visibly rotten and/or have mold
– Do not keep leftovers for >3 days
– Do not share food and drinks with other people
– Make sure all dairy products are pasteurized
– Keep hot foods hot and cold foods cold
– Use proper hand hygiene before handling food and during food preparation
Anthropometric data should include…
-UBW/pre-illness weight
-IBW
-Adjusted weight for IBW > 120%
-Weight loss history (intentional vs unintentional; significant vs not significant)
The prognosis of ____ patients is less favorable
Underweight
Biochemical data should include…
-Serum protein (Albumin; and prealbumin->desired)
-Basic metabolic panel (glucose, K, BUN, Cr, Mg, PO4, Calcium)
-Liver function tests
-Absolute neutrophil count
-Platelets, WBC
If someone has a low absolute neutrophil count (<500), recommend the ____ diet (it has not been proven, but UPMC Shadyside follows the CDC guidelines)
Neutropenic diet
Formula for calculating absolute neutrophil count:
WBC x (% Neutrophils + % Bands)
(or you could look at the ABS neutrophils if available)
Immediately post transplant, energy needs are between ___-___ kcal/kg/actual weight but usually go between 30-35 kcal/kg
25-35
You should use ___ ___ ___ if patient is obese/overweight
Adjusted body weight
In acute GVHD/sepsis, recommend ___-___ kcal/kg of actual body weight
30-50
After stem cell transplant, recommend ___-___ g of protein ber kg of body weight
1.3-1.5
If someone has metabolic stress, is on corticosteroid treatment, or has GVHD, increase protein recommendations to ___-___ g/kg
1.5-2
Protein needs are adjusted for renal failure and/or hepatic encephalopathy, may need to decreased to ___ grams/kg
0.8
Nausea/vomiting is common with stem cell transplants; what can we recommend to help?
-Cold, bland food
-Small, frequent meals
-Open dishes on the other side of the room
-Eat when not nauseated or after antiemetic given
Anorexia is also common with stem cell transplant; what can we recommend to help?
-Small frequent meals
-Even if not hungry at all, encourage patient to eat at least a little (sometimes it is okay if they can’t eat much for a couple days)
What should we recommend to patients with diarrhea?
-Encourage adequate hydration
-May need soft GI diet/low fiber diet
____ is caused by injury to the mouth tissue from conditioning regimens and/or radiation
Mucositis
Severe mucositis can lead to…
-Sever pain
-Hemorrhage
-Infection
-Upper airway edema
-Airway compromise
Supportive care for mucositis:
-Opioids
-Good oral hygiene
-Avoidance of spicy, acidic, hard and hot food and beverages
-Use of saline rinses
Preventative care for mucositis includes ___ and ___ ___
Cryotherapy and lase therapy
Mucositis is one of the main reasons why ___ ___ is not frequently used; feeding tube can irritate the mucous membranes, making it difficult to place a tube (TPN may be required)
Enteral nutrition
__ ___ ___ ___ is a noninvasive, simple, and atraumatic therapeutic management corresponding to a local application of a high-density monochromatic narrow-band light source
Low Level Laser Therapy (LLLT)
LLLT is becoming more common in the clinical setting as a treatment option for preventing and treating oral mucositis as it can…
-Promote pain relief
-Reduces oral mucositis incidence and its severity
What can be done to help those with xerostomia (dry mouth)?
-Mouthwashes without alcohol
-Sugarless gum or hard candies
-Mouth moisturizer, artificial saliva
-Moist foods with extra sauce
Taste changes are a common side effect of chemotherapy; they can be either ___ or ____
-Hypogeusia (reduced ability to taste)
-Dysgeusia (distortion of the sense of taste)
Tips for patients with taste changes:
-Use plastic utensils, plastic plate, seasonings, salt, sugar, lemon drops before meals, saline or baking soda mouth rinse
Patients receive ____ transfusions to counteract low counts
Platelet
One of the reasons why enteral nutrition is not frequently used is because placing a tube may cause ___ with bleeding
Irritation
Low platelet count is a major factor that holds patients in the hospital for ___ days
Extended
__ __ ___ ___ is one of the major complications that can occur after an allogenic stem cell transplant in which the newly transplanted material attacks the transplant recipient’s body
Graft versus host disease
The onset of acute GVHD is when neutrophil count is less than or equal to ___ after transplant
100
What organs are most affected by CVHD?
-Skin
-Liver
-Gut
Classical symptoms of GVHD include…
-Maculopapular rash
-Anorexia
-Profuse diarrhea
-Abdominal cramps
-Ileus or hepatitis
A ___ can be done to confirm the diagnosis of GVHD
Biopsy
There is a specialized diet for GVHD that has __ distinctive stages
5
Chronic GVHD has features resembling autoimmune and other immunologic disorders such as…
-Scleroderma
-Sjogren syndrome
-Wasting syndrome
Symptoms of GVHD usually present within ___ ___ after allogenic stem cell transplant and are often preceded by a history of acute GVHD
3 years
Manifestations of chronic GVHD may be restricted to a single organ or tissue or may be ____
Widespread
Reported incidence rates of chronic GVHD after allogenic stem cell transplant range from __-___%
6-80%
The diagnosis of GVHD requires…
-Distinction from acute GVHD
-Presence of at least one diagnostic clinical sign of chronic GVHD or presence of at least one distinctive manifestation confirmed by pertinent biopsy or other relevant tests
-Exclusions of other possible diagnoses
There is no standard regimen for the prevention of GVHD, and different combinations of ____ are given at different institutions
Medications
Some common medications that are given to prevent GVHD include…
-Methotrexate
-Cyclosporine
-Tacrolimus
-Mycophenolate mofetil
-Sirolimus
-Corticosteroids
-Antithymocyte globulin (ATG)
-Alemtuzumab
-Cyclophosphamide
It is important to alter ___ when making the diagnosis of GVHD of the gut, once diagnosis is confirmed
Diet
The phase of the diet refers to the patients’ ____ and guides the RD as to which stage diet should be followed
Symptoms
Progression of diet occurs as symptoms improve and can ___ from patient to patient
Vary
In phase I of GVHD, someone might have what symptoms?
-Cramping
-Voluminous diarrhea (>1L)
-Nausea
-Emesis
What is the diet for phase I of GVHD?
-NPO for bowel rest
-TPN with increased calorie and protein needs (35 kcal/kg and 1.8 g of protein/kg)
Symptoms of phase II of GVHD:
-Diarrhea volume decreasing
-Forming of stool
-Significantly less to no cramping
-No emesis
What is the diet plan for phase II GVHD?
-Continue TPN is started
-Start clear, isotonic, low residue, lactose free beverages
Symptoms of phase III GVHD:
-Stool is formed (pudding-like)
-No emesis
-Decreasing diarrhea frequency and volume
-Tolerating phase II diet without complications
What is the diet plan for phase III of GVHD?
-Wean TPN as oral intake increases
-Progress to solid foods
-Limit fat intake (20gm/day), lactose-free, low insoluble fiber, free of gastric irritants, high soluble fiber
Symptoms of phase VI GVHD:
-Formed stool
-Minimal cramping
-Tolerating >50% of nutritional needs orally
What is the diet plan for phase IV GVHD?
-Wean TPN as oral intake increases
-Continue to expand diet adding more starches, protein, and fatty foods; continue lactose free
Symptoms of stage V GVHD:
-No GI cramping
-Normal stool
-Normal transit time
What is the diet plan for stage V GVHD:
-Discontinue TPN
-Advance diet to regular by adding one new food per day and assess tolerance
The patient’s nutritional status, ability to eat, and degree of oral and GI toxicity determine if ___ ___ ___ is indicated
Total parenteral nutrition
For patients with a ___ degree of GI toxicity including GVHD of the gut, TPN may be initiated; for patients with less toxic conditioning regimens, the period of inadequate oral intake may extend longer before TPN is considered
High
At Shadyside, the ___ ___ ___ team will determine if patients are deemed appropriate for TPN
Nutrition Support Service
After transplant, someone is discharged after…
-Engraftment
-There is no indication of infection
-Tolerance of medications
-Able to eat and drink to get sufficient fluids and nourishment
-No severe treatment complications
-The patient is medically stable and physically able to function outside the hospital
There is a ____ recovery period after autologous stem cell transplant than after allogenic stem cell transplantation
Shorter
It often take the immune system ___-___ months to recovery from an autologous transplant
3-12
It often takes at least ___-___ months to recover nearly normal blood cell levels and immune cell function after an allogenic transplant
6-12
Immune recovery can take longer if the patient has ____ and required additional GVHD therapy
GVHD
In early recovery, someone should follow and well-balanced diet for ___ and ___, as well as maintain good blood glucose control and good electrolyte levels
Repair and recovery
Tips for dining out after stem cell transplant:
-Eat early to avoid crowds
-Ask that food may be made fresh
-Avoid raw fruits and vegetables when dining out
-Do not eat salsa or other fresh condiments that are not refrigerated
-Ask for single-serve condiment packages
-Avoid salad bars, buffets, etc.
-Check the overall condition of the restaurant
What are some long-term complications of stem cell transplant?
-Organ complications
-Endocrine risk
-Risk for bone loss and subsequent osteoporosis
-Infertility
-Chronic GVHD
-Mental health
-Relapse
-Secondary cancer
If a non-mainstream approach is used together with complementary medicine, it is considered ____
Complimentary
If a non-mainstream approach is used in place of conventional medicine, it is considered ____
Alternative
What are three categories of alternative and complementary medicine?
-Natural products (herbs, vitamins, minerals, probiotics)
-Mind and body practices (acupuncture, massage, meditation, yoga, etc)
-Other complementary health approaches (traditional healer, Chinese medicine, etc)
A substantial amount of scientific evidence suggest that some complementary health approaches may help to manage some ____ of cancer and side effects of treatment
Symptoms
There is no convincing evidence that any complementary health approach is effective in ____ cancer or causing it to go into remission
Curing
A 2012 study indicated that taking a ____/____ ___ may slightly reduce the risk of cancer in older men
Multivitamin/mineral supplement
____ conventional cancer treatment can decrease the chances of remission or cure
Delaying
Some ___ health approaches may interfere with cancer treatments or be unsafe for cancer patients
Complementary
What are some common complementary approaches to cancer?
-Acupuncture
-Ginger
-Massage therapy
-Mindfulness stress reduction
-Yoga
-Hypnosis
-Herbal supplements
