Nutrition Therapy For Hematopoietic Cell Transplantation-Chapter 16

Question 1

What are the calorie needs for adults adolescents and young children under HCT?

Answer 1

ADULTS basil needs X 1.3 to 1.5

ADOLESCENTS basil needs X 1.4 to 1.6

YOUNG CHILDREN basil needs X 1.6 to 1.8

Question 2

What are the PROTEIN needs for adults, adolescents and children undergoing HCT?

Answer 2

Adults 1.5 grams /kg/day
15 to 18 years. 1.8 g /kg/day
11 to 14 years. 2.0 grams /kg/day
7 to 10 years. 2.4 grams /kg/day
Birth to 6 years. 2.5 to 3 grams /kg/day

Question 3

What are the carbohydrates of someone undergoing H CT?

Answer 3

50 to 60% carbohydrate

Question 4

What are the calculations to determine fluid needs in patients with HCT?

Answer 4

1-10 kg. ….100mL x kg

11-20 kg…1000mL for 1st 10kg+50mL per kg for each additional11-20kg

21-40 kg…1500mL for 1st 20kg+20mL per kg for each additional kg over 20

> 40kg:. 1500mL/m2 body surface area

Question 5

Can patients receiving HCT when should enteral nutrition be considered?

Answer 5

Nonmyeloablative conditioning regimens with a functioning GI tract

Low-risk HCT (autologous or matched related donor)

Long-term eating problems after engraftment

Resolution of conditioning related mucositis and esophagitis

Adequate platelet recovery

Question 6

Which type of patients receiving HCT should be considered candidates for parenteral nutrition?

Answer 6

Patients receiving Myeloablative conditioning regimens with a high GI toxicity profile

Those with refractory gut GVHD

Malnourished patients that can’t obtain adequate Nutrition By enteral nutrition alone

Note : PN should be discontinued once still sends have engrafted and toxicities have resolved

Question 7

Which types of HCT patients should follow a food restricted diet ? And for how long?

Answer 7

Autologous transplant patients should follow the diet during the first 3 months after HCT

Allogenic transplant patients should follow the diet until immunosuppressive therapy is discontinued

Question 8

What are the food restrictions on the diet for immunosuppressed patients on HCT?

Answer 8

• raw and undercooked meat ,eggs ,sausage and bacon
• raw tofu, unless pasteurized or packaged
• all luncheon meats, unless cooked to steaming
• smoked Seafood, such as lox, kippered, fish jerky , Nova- Style, or pickled fish
• unpasteurized milk , unpasteurized cheese or yogurt
• , blue cheese, gorgonzola, Roquefort or Stilton cheese
• Brie, Camembert, feta, farmer’s cheese
• Queso blanco, queso Fresco cheese
• cheese with chili peppers or other vegetables
• Fresh, refrigerated salad dressings
• unwashed Raw frozen fruit and vegetables and sprouts(such as alfalfa and mung beans)
• raw or unpasteurized honey
• Unpasteurized fruit and vegetable juices
• Boil well water for 15 to 20 minutes and consume within 48 hours

Question 9

What are the calcium requirements of patients on HTC also on corticosteroid therapy or having osteoporosis?

Answer 9

Age 7 to 12 months. 600 mg of calcium
1 - 3 years. 1000 mg of calcium per day
4 to 8 years. 1200 mg
>9 years. 1500 mg

Question 10

What additional nutrients may be needed during HTC when parenteral nutrition is administered and why?

Answer 10

Extra VITAMIN C may be needed to promote tissue recovery after cytoreductive therapy
<31kg: additional 250 mg/day
>31 kg: additional 500 mg/

Increase CALCIUM during corticosteroid therapy/osteoporosis , 1,500 mg in adults per day

Increase ZINC if large volume diarrhea 1mg/100mL stool

Question 11

What is sinusoidal obstructive syndrome (SOS)

Answer 11

It occurs to the patient receiving HCT. It occurs in 0- 50% of patients.
It generally occurs about 10 to 20 days after cytoreduction therapy
Is characterized by toxic injury to the sinusoidal and venular epithelium.
Symptoms include weight gain, ascites, right upper quadrant tenderness, painful hepatomegaly, hyperbilirubinemia and renal dysfunction

Question 12

What Medical Nutrition Therapy is needed to deal with Sinusoidal obstructive syndrome or SOS?

Answer 12

Parenteral nutrition fluids should be administered as well as medical volumes

A reduction of both oral and intravenous SODIUM is needed to minimize fluid retention

If serum BILIRUBIN increases to > 10 mg /dL, monitor serum TRIGLYCERIDE levels

If bilirubin is > 10 mg/dL, remove COPPER and MANGANESE from parenteral nutrition fluid

Question 13

A side effect of HCT could be renal impairment. What nutrition interventions can be done to correct or improve the situation?

Answer 13

Maximize nutrition support with in fluid allowance

Correct electrolyte imbalances

Provide continuous renal replacement therapy

Eliminate copper and manganese from parenteral nutrition if there is renal dysfunction

Decrease protein if there is renal or hepatic dysfunction

Question 14

Graft-versus-host disease is a side effect HCT and is a immunological reaction against the host tissue. What major organs are affected by this reaction?

Answer 14

The major organs targeted are the skin liver and GI tract

Question 15

What are side effects of graft-versus-host disease( GVHD)

Answer 15

Nausea, vomiting, anorexia, diarrhea, abdominal pain, intestinal protein losses and fat malabsorption

Question 16

What type of diet changes can be helpful in graft-versus-host disease (GVHD)?

Answer 16

Emphasizing foods low in lactose, fiber, acid and in fat.

Patients with fat malabsorption may also benefit from pancreatic enzyme replacement therapy

Question 17

What are the long-term (80-100 days post transplant) nutrition related complications of graft-versus-host diseas

Answer 17

Weight gain (due to corticosteroid therapy), weight loss, sensitivity to spicy or acidic Foods, dry mouth, stomatitis, anorexia, reflux and diarrhea.

Question 18

Osteoporosis is another complication of HTC and is seen in as many as____percent as early as 1 year post transplant. What can be done to help reverse bone loss in these?

Answer 18

As many as 50% of these patients see osteoporosis one year after transplant

Chemo and steroid therapy can cause bone loss

Calcium and vitamin D supplementation May benefit when serum 25-OH VITAMIN D levels are<30ng/mL in those treated with steroid therapy

Can benefit from suppln of 1000-1500 IU/D day

Bio phosphate therapy along with calcium and D can help to reverse bone loss

Regular weight bearing and muscle strengthening exercises are also recommended

Question 19

It is common to see ENDOCRINE problems in HTC patients particularly long-term transplant survivors. What complications are common?

Answer 19

Metabolic syndrome, hyperlipidemia, insulin resistance, diabetes, obesity, and hypertension

Both in Adult & pediatric transplant patients

Pediatric HCT survivors are more likely to develop DIABETES and HYPERTENSION than the general population

Question 20

What mineral supplementation should be avoided during and after HCT transplantation as well as a multiple vitamin containing this mineral.

Answer 20

Iron overload Is frequent and iron supplementation should be avoided

Question 21

What are the late effects of HCT?

Answer 21

Secondary malignancies, ocular complications, avascular necrosis, chronic pulmonary effects, thyroid dysfunction, gonadal hormone insufficiency

Question 22

What diet should one with Graft versus host disease follow when they are experiencing GI cramping, large volume watery diarrhea, depressed serum albumin, reduced GI Transit time, small bowel obstruction or diminished bowel sounds or nausea and vomiting

Answer 22

This patient should be on BOWEL REST and on an NPO diet

Question 23

What diet should a patient with graft vs host disease follow if they are experiencing minimal GI cramping, diarrhea<500 mL /day, improved GI Transit time, and infrequent nausea and vomiting

Answer 23

They could be introduced to oral feeding including a PHASE 2 isotonic, low-residue, low lactose diet

Question 24

A treatment used for prophylaxis and treatment of gvhd called
anti thymocyte globulin

What is its nutritional side effects

Answer 24

Nausea and vomiting, diarrhea and stomatitis

Question 25

A z a t h i o p r i n e

side effects

Answer 25

nausea and vomiting, Anna rexia, diarrhea, mucosal ulceration, esophagitis, steatorrhea

Question 26

Betlomethasone Diproionate

Side effects

Answer 26

Xerostomia, dysgeusia, nausea

Question 27

Budesonide

Side effects

Answer 27

None known

Question 28

Corticosteroids

Side effects

Answer 28

Sodium and fluid retention resulting in weight gain or hypertension, hyperphagia, hyperkalemia, skeletal muscle catabolism and atrophy, gastric irritation and peptic ulceration, osteoporosis, growth retardation in children, decreased insulin sensitivity and impaired glucose tolerance, resulting in hyperglycemia or steroid-induced diabetes, hyperlipidemia

Question 29

Cyclosporine

Side effects

Answer 29

Nausea and vomiting, nephrotoxicity, hypo magnesia, hyperkalemia

Question 30

Extra Corporeal photophesis

Answer 30

Intravenous fluid may be necessary to maintain adequate hydration status, monitor calcium status as the citrate anticoagulant can bind calcium and induce hypocalcemia

Question 31

Methotrexate side effects

Answer 31

Nausea and vomiting, and I rexia, mucositis and esophagitis, diarrhea, renal and hepatic changes

Question 32

Monoclonal antibodies side effects

Answer 32

Nausea, liver toxicity

Question 33

Sirolimus side effects

Answer 33

Hypertriglyceridemia

Question 34

Thalidomide

Answer 34

Constipation, nausea, xerostomia