Five-Year Experience of Early Enteral Feeding in Patients Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative Conditioning.

Since the early 2003 with the encouraging preliminary results of our pivotal study (Seguy, transplantation), all pts refereed to our unit for myeloablative Allogenic Stem Cell Transplantation (allo-CST) were offered right away enteral feeding via a naso-gastric tube (NGT). The aim of this work was to investigate the evolution of our practices regarding nutritional support and its impact on early outcomes over the last five years. During a systematic individual pre-transplantation interview, all pts were provided with comprehensive information regarding NGT feeding. They received advice on an ongoing basis from a multidisciplinary team. Between Jan 01 and Dec 05, 121 pts who underwent myeloablative allo-SCT were offered EN. Among them, 94 (78%) agreed to receive EN (EN group) and 27 (22%) refused the NGT (without EN group: WEN group) and received either parenteral nutrition (PN) (n=22) or oral feeding only (n=5). The NGT was inserted shortly after transplantation. Bacteriological high-controlled oral diet intake was encouraged for as long as the patient was able to sustain it. The daily oral intake was scheduled to provide 100% of estimated requirements for energy (30–35 kcal/kg/day). Overnight NGT feeding, was gradually increased depending on the patient’s tolerance in order to reach 50–70% of energy requirement within 5 days. In case of intolerance toward EN, additional or total PN was given. In the WEN group, pts received PN when total oral intake was less than two-thirds of the average energy requirement over 5 days. Except for the pts’ age (EN-group, 38y vs WEN 28y, p=.038), the two groups were comparable in terms of initial pts’ characteristics and transplantation modalities. Median duration of EN was 14 days (1–59) and 61 pts received no additional PN while the median duration of the PN was 12 days (2–70). There was no significant difference between the two groups regarding duration of hospitalization, nutritional status at discharge and duration and grade of mucositis. Significant differences were observed, however: engraftment, 100% vs 93%, p=.05, duration of neutropenia, 20d (10–64) vs 25d (18–100), p=.0001 and thrombopenia 27d (6–100) vs 56d (50–100), p=.014; serum albumine level at discharge < 35g/L, 45% vs 76%, p=.005 for EN-group vs WEN-group, respectively. Pts with EN developed less often acute grade III/IV GVHD (9% vs 37%; p=0.001) and non-bacterial infections (9% vs 41%; p=.0002). In addition, pts with enteral feeding had better 100-day survival (92% vs. 67%, P=0.001) with less infection-related deaths. In multivariate analysis the absence of enteral nutrition was the only factor adversely influencing 100-day survival (CI 95%: 1.55–14.9 0.646; P=.007). In order to evaluate the practices over time regarding nutritional support in our unit, we compared the initial period (2001–02) when pts (n=41) had the choice between EN and PN with the second period (2003–05) when EN was offered systematically (n=80). In the second period, pts received less often PN (73% vs. 31%, p<.0001) and more often EN (49% vs. 93%, p<.0001) with longer duration (10d vs. 15d; p=.001). In addition, EN started earlier after transplantation (5d vs 2d, p=.004).

CONCLUSION: EN has been well tolerated and dramatically reduced the proportion of pts requiring PN. This study confirms the positive impact of EN on early outcome of pts undergoing myeloablative allo-CST. When possible EN should be preferred to PN.