Nutrition in Bone marrow
transplant “BMT”
ARUNDHATI LAHIRI
DIETETICS DEPARTMENT
ADVANCED CENTRE FOR TREATMENT, RESEARCH AND EDUCATION IN CANCER
FEBRUARY 19, 2016
Transplant Process (5 steps)
Conditioning regimen
Stem cell infusion
Neutropenic phase
Engraftment phase
Post-engraftment period
Conditioning regimen
The conditioning regimen destroys the patient’s bone marrow and
malignant cells and makes room for the new bone marrow to develop.
regimen may include chemotherapy, radiation and total body irradiation
depending on the disease being treated and the protocol.
Duration: typically 7 to 10 days.
Complications & nutrition management
Challenges
Nausea , emesis, diarrhea, taste alterations, and overall malaise (considering cytotoxic chemo
drugs and total body radiation)
Treatment procedure
The patient's dietary intake is closely monitored during the conditioning period with
nutrient analysis to determine the need for nutrition support.
Dietary modifications if needed like Bland liquids, Soft solids.
Salivary stimulants and substitutes, gravies and sauces with food
Nutritional supplements; on case to case basis
Transplant Process (5 steps)
Conditioning regimen
Stem cell infusion
Neutropenic phase
Engraftment phase
Post-engraftment period
Stem cell infusion
A day or two following the conditioning regimen, the infusion of stem cells or
marrow will occur.
The stem cells are infused into the individual intravenously through the central
venous line.
Duration: 20 mins – 1 hour; depending on the volume infused
Complications & nutrition management
Challenges
Rare possibility of renal failure
Cryopreserved stem cell contains dimethyl sulfoxide (DMSO) as preservative
Leading to unpleasant smell and taste
Treatment procedure
2 to 4 weeks post transplant are the most critical due to the individual's weakened immune system. They will
be more susceptible to infections, bacteria and viruses.
Advice Neutropenic (Low bacteria) diet due to a decreased ability to fight infection .
The individual should remain on the diet until day 100 post transplant due to the weakened immune system
and development of T cells.
Should continue with neutopenic diet if individual is still receiving immunosuppressive therapy such as
steroids or Cyclosporine or has GVHD.
Aspects of Neutropenia
An abnormally low count of neutrophils (white blood cell)
Neutropenia in adults is generally defined as a count of 1,700 or fewer neutrophils per microliter
of blood.
The cell count indicating neutropenia in children varies with age.
Lower the neutrophil count, more vulnerable to infectious diseases.
Neutropenic diet
A diet for people with weakened immune systems.
protect from bacteria and other harmful organisms found in some food and drinks.
This diet does not allow foods which may contain large amounts of harmful organism.
When the ANC is less than 500 cells/mm3, the patient is often instructed to follow a
neutropenic diet.
Food limitations under neutropenic diet
Food groups Food allowed Food not allowed Recommendation
Cereals and Pulses Sliced bread (prefer toasted), cooked cereals (rice, Sweet rolls or doughnuts, with custards or cream Get fresh stock on weekly basis. Check for
chapathi,porridges), pasta, noodles fillings, cold cereals with nuts or dried druits the quality.
Diary products Pasteurized milk, pasteurized yogurt, cooked Unpasteurised milk, unpasturised cheese or any Use fresh milk daily
custards, or any well cooked desserts. unpasteurised dairy products, cheese with mould,
all yoghurt products with live culture.
Beverages Pasteurized milk, coffee, tea, sterile water and ice, Unpateurized milk or eggnog, unpasteurized fruit Tea/ coffe/ milk to be freshly prepared.
pasteurized fruits juiced (tetra packs) juices, water from well Check date for fruit juice pack
Eggs well cooked egg raw eggs well cooked, no runny yolks
Fats Branded refined oil/ butter/ ghee loose oil from local purchase, salad dressings avoid reheating of oil, store in an air tight
container
Fruits all canned or cooked fruits Fresh fruits, dried fruits Fresh good quality fruits
Soup all cooked soups cold soups, ready to serve soups use fresh soup made from vegetables, aviod
ready made soup
Vegetables all cooked vegetables raw vegetables and salads, fresh garnish prefer to buy fresh on daily basis. If not,
preserve it well in the refrigerator
Others sugar, heat treated honey, jam, jelly, syrup, spices and pepper not cooked with food, uncooked
chocholates, salt and spices added prior to cooking, nuts or seeds, uncooked garnish, nuts and dried
cooked nuts and seeds, vinegar, lemon juice, friuts, raw honey
coconut
Meats and other Meat or fish, dried fish, salami, sausages, old cut
products meats.
Transplant Process (5 steps)
Conditioning regimen
Stem cell infusion
Neutropenic phase
Engraftment phase
Post-engraftment period
Neutropenic Phase
Patient has weak immune system.
Poor healing, low blood counts & susceptible to infection
Observed under Supportive care and empiric antibiotic therapy
Duration: 2 weeks
Complications & nutrition management
Challenges
Post 5-6 days of transplant, patients develops mucositis, stomatites and
esophagitis, Salivary & Taste alterations, Xerostomia, Dysgeusia which goes
up to grade 4 and remains for 7-10 days
Within 3-4 days of transplant some patients develop diarrhoea
Treatment procedure
Grade 1 & 2 Mucositis
Patients encouraged soft diet + calorie protein dense liquid diet; specifically
avoiding:
acidic foods & juices [orange, pineapple], spices.
very hot & cold foods.
hard & irritating foods - mechanically, thermally, chemically.
Complications & nutrition management
(contd.)
Advisable
small frequent meals at regular intervals.
rinse and cleanse mouth every 2-4 hour.
fluid intake: 2-3 liters per day.
moisten & lubricate mouth frequently.
have sugarless candy.
keep lips moist.
Complications & nutrition management
(contd.)
Grade 3 mucositis
parenteral nutrition followed with oral liquids
Grade 4 mucositis
total parenteral nutrition ‘TPN’
Diarrhoea
antidiarrheal diet (with stool binding agents)
TPN for patients having diarrhoea.
Transplant Process (5 steps)
Conditioning regimen
Stem cell infusion
Neutropenic phase
Engraftment phase
Post-engraftment period
Engraftment Phase
Healing process:
resolution of mucositis and other lesions acquired
fever subsides and infections often begin to clear
Challenges: management of GVHD and prevention of viral infections (especially
CMV).
Duration: 2-4 weeks
Complications & nutrition management
Challenges: No major challenges per se
Blood counts starts improving
Mucositis and diarrhoea starts resolving
Treatment procedure
Patients regains to normal diet
To prevent or correct nutritional deficiency
To minimize weight loss
Transplant Process (5 steps)
Conditioning regimen
Stem cell infusion
Neutropenic phase
Engraftment phase
Post-engraftment period
Post-engraftment Phase
Several months for autologous transplant recipients
1 to 2 years for patients receiving allogeneic or syngeneic transplants
Blood investigations to confirm production of new blood cells and non recurrence
of disease
Bone marrow aspiration: removal of bone marrow sample for examination under
a microscope; essentially to check new marrow functioning.
Hallmarks of this phase: gradual development of tolerance, weaning off of
immunosuppression, management of chronic GVHD.
Duration: Complete recovery of immune function takes months to years.
Post transplant
complications
Graft versus Host Disease (GVHD)
Donor marrow cells react against the tissues of the ‘foreign host’
Skin, gut, and liver most likely to be affected
Acute GVHD < 100 days post transplant
Chronic GVHD > 100 days post transplant
The signs of acute GVHD : skin rashes on hands and feet, cramping, nausea, and
watery or bloody diarrhea are other signs of GVHD in the stomach or intestines. A
rising bilirubin with jaundice may be a sign that acute GVHD has affected the
liver.
GVHD status: Glucksberg Criteria
Staging of acute GVHD Grading of acute GVHD
Stages Skin Liver GI Stage
Diarrhea
0 No rash Bili <2mg/dl Overall grade Skin Liver Gut
<500ml/day
Maculopapular
Diarrhea 500-
1 rash <25% of Bili 2-3 mg/dl I (mild) 1 or 2 0 0
1000ml/day
BSA
Maculopapular
Diarrhea 1000-
2 rash on 25-50% Bili 3-6mg/dl II (moderate) 1–3 1 1
1500ml/day
of BSA
Generalised Diarrhea
3 Bili 6-15mg/dl III (severe) 2 or 3 2 or 3 2 or 3
erythroderma >1500ml/day
Generalised
erythroderma with Severe abdominal IV (life
4 Bili >15mg/dl 2–4 2–4 2–4
bullae and pain +/- ileus threatening)
desgumation
GVHD of Liver
Icterus
Abnormal liver function test accompanying GI
Secretory Diarrhea-10 times/day
Nutrition Management
Total gut rest, until diarrhea reduced to less than 500ml/day
Initial oral feedings: beverages that are iso-osmotic, low fat and lactose free
Gut GVHD
Cells (that lines the gut) damaged by GVHD
Thereby, less able to absorb nutrients and protect from infection
Symptoms; varies basis location and severity
difficulty in swallowing, heartburn, nausea, vomiting, abdominal cramps, poor
nutrients absorption, problems with gut motility, weight loss and acute diarrhea
Gut GVHD - Nutrition management
Dietary guidelines : Low Bacteria, Lactose free, GVHD bland diet
Adults= 1.5g/Kg body weight;
Children= 2g/Kg body weight.
Patient on steriods= additional 500 gms; as steriod causes muscle to breakdown.
Diet not irritating GI tract
Restrictions: milk & milk products like cheese, yogurt, ice-cream; resulting in diarrhea & abdominal cramps.
Recommendation: Soya milk/ low lactose food
Fat: Stools generally foamy with foul smell; causing cramps and diarrhea.
Recommendation : Medium Chain Triglycerides ‘MCT’.
Fiber: Stools more bulky and irritate GI tract
Avoid indigestible Carbohydrates.
Calcium & Vitamin D supplements : for bone health
Potassium: for effective muscles ; tend to lose with diarrhea
Nutritional support for GVHD patients undergoing Bone marrow transplant
Phase Type of diet Foods to be introduced Recipe specifications
Phase I Bowl rest IV Nutrition recommended Rice kanji, clear vegetable soup, Moong dal water, No oil to be added in any food provided to the patient.
-MVI to be added daily to TPN Appy drink, Real fruit juices (after staining) Initially half appy/ fruit juice+ half water
- Idealy trace
elements to be added on
alternate days
Phase II Liqiuid diet Soyamilk, Buttermilk, Lassi, supplement(peptide based, negligible Soyamilk (half sofit+ half water)
lactose content, semielemental feed) Novasourse paptide, Pentasure
critipep, Peptamin
Phase III Introduction of solid food Refined wheat flour Least fibre veg- dudhi, padwal, Maida roti made with 1tsp oil while kneading dough
kakdi, pumpkin Rice,Moong dal
Rawa, Vermecelli, White bread
Khichdi(rice+ moong dal) Soft cooked rice+ Plain moong dal
Supplement (high calorie, high protein, low fibre, low lactose) Upma/ sheera/ Idli (rice+ rawa) Bread toast/ upma
Introduce Resource/ Fresubin/ Ensure or for diabetic
Glucerna/ Fresubin DM/Resource Diabetic (only one serving in a day)
Phase IV Diet Expansion Refined wheat flour: whole wheat flour (1:1) Roti
Boiled egg white (2 daily)
Rice Egg whites + Bread toast
Potato Rice Dosa/ Rice Idli
Sabudana
Sabudana khichdi without groundnuts and less oil
Dal: Tuar, masur dal Rice tuar dal khichdi or plain rice dal (dla of thick consistency)
2-3 serving per day
Supplement (high calorie, high protein, low fibre, low lactose)
Phase V Continued diet expansion (only Cereal: Daliya, Nachni, whole wheat bread Daliya upma/ daliya porridge, nachini kheeer/ nachni dosa
when all symptoms of GVHD Pluses: Matki, moong Usal
relieved) Veg: Tomato, capsicum,
corn Cornflakes with low fat milk
Milk and milk products: cow's milk
Egg whole
Supplement (high calorie, high protein, low fibre, low lactose) 3 serving a day depending upon the nutritional requirement of the patient.
Phase VI Wean over to a normal diet Cereal: Jowar, bajra Bhakri/ Roti
Pulses: Rajmah, chole, peas, besan Sattu
Milk: Buffaloes milk if preferred,
green leafy veg: palak initially in grinded form like soup, if tolerated
then other GLV can be started,
other veg: parwar, ladies finger, field beans
Veno-occlusive disease ‘VOD’
A potentially serious liver problem which is caused by highdoses of
chemotherapy or radiation given to the individual prior to transplant.
The blood vessels carrying blood to the liver become swollen or obstructed,
impairing the liver's ability to remove toxins, drugs and other waste products from
the blood stream.
Fluid accumulates in the liver, causing swelling and tenderness of the liver.
Can develop in 1-3 weeks post transplant.
Symptoms: jaundice, an enlarged liver, pain and tenderness in the area of the liver,
rapid weight gain, edema, and accumulation of fluid in the abdominal cavity
(ascites)
VOD – Nutrition management
Concentrated parental nutrients
Judicious fluid & electrolytes management
Close monitoring of macro & micro nutrients based on tolerance and response of
the individual.
Branch Chain Amino Acid formula is recommended for encephalopathic patients.
Nutrition Preevaluation
for Allogeneic and Autologus Transplant
Education on Low bacteria diet and Eating safely guidelines
Education on recording food intake/calorie counts
Review of patients prior use if any of oral supplements, appetite stimulants,
enteral nutrition
and/or parenteral nutrition (PN).
Assessment of current nutritional status
Education on nutrition support (EN and PN) during transplant
·Assessment of food allergies
Discharge Planning
Education on high calorie/high protein diet
Education on lactose free, bland or mucositis diets
Provision of oral supplement of choice and instruction on how to use
Follow up with outpatient dietitian as needed
Low fat well balanced diet to maintain healthy body weight for those who receive
steroids.
BMT infrastructure: ACTREC
No. of beds: 6
Other inclusions: 1 pantry
Nurse: Patient ratio – 1:1 during day time ; 2:1 during night shifts
Housekeeping staff: 3 attendants during morning shift, 2 during general shift
and 2 during night shift
Separate BMT ward: No. of beds 6 for pre and post transplant patients
Daily diet for BMT unit
Early morning (7:00 am): Tea + Biscuits
Tea prepared in microwave using tea bags. Small packets of
biscuits stored in the pantry
Breakfast (8:30 am);
2 Boiled eggs + Ragi porrridge + Regular Indian breakfast (upma/
poha/ vermicelli/ rice dosa)
Midmorning (11:00 am): Vegetable Soup
Lunch (12:30 pm): Variety Rice+ Dal or kadhi+ chapathi + Vegetables +
dessert + curd or buttermilk
Daily diet for BMT unit (contd.)
Cyclic menu of 14 days. Cooked food sent from kitchen.
Packed curd and tetrapack buttermilk stored in the BMT
pantry
Egg preparations are provided with lunch 2 times a week
Evening Snack (4:00 pm): vegetable noodles/Boiled
chana or green peas saute/Besan omlette/instant rawa
idli etc
Late evening (6:00pm): Vegetable soup
Dinner (8:00 pm): Same as lunch
Bed time (9:30 pm): Milk/ Soyamilk/ Buttermilk
Daily diet for BMT unit (contd.)
Instant food items storage in the
pantry: Tetrapack Soyamilk (natural and flavoured), Tetrapack
Buttermilk, Tetrapack Fruit juices (Real, Tropicana, Appy), one time use tomato sauce and mix
fruit jam sachets, Butterchiplets, small packets of Biscuits (no cream variety), sliced bread
packets, salt and sugar sachets.
All food items cooked with freshly ground spices in the kitchen; Garam masala and chillies are
avoided.
Green leafy vegetables, Soya granules, Paneer, cheese or any other processed foods are avoided.
Separate anti-diarrheal diet option available; apple stew, potato stew, carrot saute, rice kanji,
arrow root kanji etc.
Nutritional supplements are prescribed as and when required.
All food items are replenished weekly
Food items are
passed through UV light for 5 minutes before storage.
Pantry equipment
BMT Pantry well equipped with Toaster, Microwave, Refrigerator, Water purifier,
Hot flasks, Cutleries and crockeries
All crockeries and cutleries are washed each time after use and autoclaved at 134
degrees celcius for 7 minutes on a regular basis.
Food Serving protocol:
Phase I:
Food is cooked in kitchen and filled in tiffin carriers
The carrier is then put in a pressure cooker and steamed to one whistle
The pressure cookers are brought to BMT ward on trolleys
Passed through UV light for 5 minutes
The cookers are then transferred to the kitchen pantry and opened only at the time of
serving patients
Phase II:
Feeding tray/plates laid out
Cookers opened and tiffin carriers placed on trays/plates
Cutleries are microwaved for 3 minutes and handled using tissues
Serving tray taken to the patient
Cooker returned to the kitchen
Thank You
