Neutrophil Engraftment and Graft-Versus-Host Disease in Elderly Patients Undergoing Hematopoietic Stem Cell Transplantation: Importance of Body Composition Assessment and Geriatric

Introduction: It is well established that the loss of muscle mass is the biggest change that occurs with aging and may lead to decline of muscle strength and functionality. In 1989, Irwin Rosenberg proposed the term "sarcopenia" to describe this decline in muscle mass is related to aging. Patients with hematologic malignancies are usually well nourished before undergoing the hematopoietic stem cell transplantation (HSCT). However, changes in body composition after HSCT have been the subject of studies. After HSCT, complications such as infections and graft-versus-host disease (GVHD) might affect the weight and body composition. Immunosuppressive therapy and corticosteroids also alter skeletal muscle metabolism. Thus, treatment and complications after HSCT exert large negative effects on lean muscle mass, especially in elderly patients.

Objective: The aim of this study is to determine whether measures of body composition predict outcomes after HSCT within the context of an older population.

Material and Methods: We performed a retrospective longitudinal study through review of medical records of 48 patients ≥ 60 years undergoing HSCT at Hospital Israelita Albert Einstein, from 2013 to 2015, with tomography scans (CTs) in their clinical course within 60 days before or 15 days after HSCT. Body composition data were analyzed in CTs in T4 level by Sliceomatic® program. Descriptive statistics were calculated by SSPS program for age, body mass index, hand grip and corporal composition parameters.

Results: Of the 48 patients evaluated, 24 were male. The median age was 67 years (± 4.2). In relation to underlying disease, it was observed that 35.4% had a diagnosis of multiple myeloma, 18.8% of myelodysplastic syndrome, 14.6% of lymphoma, 10.4% of myeloid leukemia acute and 10.8% between the diagnoses a lower proportion as amyloidosis, cutaneous lymphoma and lymphocytic lymphoma. Regarding the type of HSCT, 50% was autologous, 45.8% was allogeneic and 4.2% was haplodidentical. In relation to body mass index (BMI), 45.8% of patients were in the normal range, 21% overweight and 5% considered underweight. The Hand Grip median was 29 kgf (± 9.2). Of the 48 patients evaluated, neutrophil engraftment had a median of 13 days (± 4.3); 17 patients had acute GVHD, 9 Grade I-II and 8 with Grade III-IV. 60.4% of patients are alive, of the 19 deaths, 10 were not related to relapse. CTs evaluation found an average muscle area of 151cm2 (± 41) and subcutaneous adipose tissue of 230.5 cm2 (± 78). The only positive correlation was found between neutrophil engraftment and subcutaneous adipose tissue (r = 0.8, p <0.05).

Discussion: This study has limitations due to the small number of patients. However, we conclude that the reduction of toxicity related to HSCT through the analysis of body composition by CT scans is an emerging area of research, feasible, reliable and no charge to the patient, since CT scans are part of the clinical routine of these patients. Identify a reversible pre-transplant condition that is associated with worse outcomes may allow intervention measures such as greater nutritional support and exercise to improve pre-transplant candidates.

Conclusion: In our older patient cohort undergoing HSCT had a strong correlation between neutrophil engraftment and subcutaneous adipose tissue. The assessment of body composition for this group of patients may provide data associated with prognosis changing nutritional and geriatric practice for better results.