异基因造血干细胞移植患儿移植后饮食变化影响因素分析

doi:10.12372/jcp.2024.23e1246

摘要/Abstract

摘要：

目的研究异基因造血干细胞移植（alloHSCT)患儿移植前后饮食摄入量变化相关影响因素，并分析饮食摄入量与住院期间临床结局相关性。方法对2018年4月至2023年8月住院治疗的144例接受alloHSCT患儿的临床资料进行回顾性分析。患儿预处理前，移植后0 d、14 d、30 d行饮食摄入调查及营养状况分析。采用广义估计方程分析饮食摄入量变化影响因素，Spearman相关性分析与临床结局相关性。结果患儿预处理前饮食摄入热量为1315.20(922.15~1600.88) kcal/d，占推荐目标热量百分比为90.85%(80.10%~103.00%)，移植0 d及移植14 d，热量分别下降为344.95(66.85~532.50) kcal/d，377.90(108.43~689.40)kcal/d，饮食摄入热量占推荐目标热量百分比分别下降为25.50%(4.20%~46.25%)，23.50%(7.21%~50.08%)，三大营养素摄入均显著减少，移植30 d饮食摄入量及三大营养素上升，饮食摄入热量上升至721.45(285.75~1252.25) kcal/d，占推荐目标热量百分比58.00%(21.50%~81.92%)(P均<0.001)。广义估计方程分析显示年龄(P<0.001)、口腔黏膜炎(P=0.023)、Ⅱ~Ⅳ度急性移植物抗宿主病（aGVHD，P<0.001)、发热时间（P=0.005）、移植前STAMP筛查高风险（P=0.026）均与饮食摄入变化显著相关。与饮食摄入无关的因素包括alloHSCT前营养状况、疾病诊断、移植类型等。alloHSCT后患儿饮食摄入与年龄体质指数Z评分（BMI-Z）值下降、住院时间、住院费用负相关，r分别为(-0.516，-0.238，-0.465)，P值分别为(<0.001，0.011，<0.001)。结论移植后，不同营养状况、疾病诊断、移植类型的患儿的饮食摄入热量及三大营养素均显著下降，饮食摄入量与住院期间不良临床结局负相关。应关注移植后所有患儿饮食及营养素摄入变化，特别是年龄越大、STAMP高风险，或是患有口腔黏膜炎、Ⅱ~Ⅳ度aGVHD、感染重的患儿，及时提供有效营养干预，以助于改善临床结局。

关键词: 异基因造血干细胞移植, 膳食调查, 营养风险筛查, 营养不良

Abstract:

Objective To investigate influencing factors of dietary changes in children undergoing allogeneic hematopoietic stem cell transplantation (alloHSCT) and to analyze the correlation between reduced dietary intakes and clinical outcomes during hospitalization. Methods We collected data of 144 children undergoing alloHSCT from hospital between April 2018 and August 2023. Dietary intakes and nutritional status were assessed prior to transplantation and on day 0, +14 and +30 after alloHSCT. The relationship between post-transplant clinical outcomes and dietary intakes was analyzed using Spearman correlation analysis. Results The baseline energy intake was 1315.20 (922.15-1600.88) kcal/d, representing 90.85% (80.10%-103.00%) of the dietary reference intakes (DRIs). On day 0, +14 of transplantation, the calorie intake decreased to 344.95 (66.85-532.50) kcal/d and 377.90 (108.43-689.40) kcal/d, the percentage of dietary caloric intake in DRIs decreased to 25.50% (4.20%-46.25%) and 23.50% (7.21%-50.08%), respectively. The intake of macronutrient also significantly decreased. By day +30 post-transplantation, dietary intake and macronutrient increased, with dietary intake increased to 721.45 (285.75-1252.25) kcal/d, accounting for 58.00% (21.50%-81.92%) of DRIs (P<0.001 ). The generalized estimation equation analysis showed that age (P<0.001), oral mucositis (P=0.023), Ⅱ-Ⅳ acute graft versus host disease (aGVHD, P<0.001), length of cumulative febrile episodes (P=0.005), and a high risk of STAMP before transplantation (P=0.026) were significant influencing factors for changes in dietary intake. The negative correlation between dietary intake of children undergoing alloHSCT and decrease in BMI-Z, length of hospital stay, and inpatient treatment costs was observed, with r values of (-0.516, -0.238, -0.465) and P values of (<0.001, 0.011, <0.001) respectively. Conclusion After alloHSCT, dietary intake and macronutrient of children with varying nutritional status, disease diagnosis, and transplant types significantly decreased. This reduction in dietary intake was associated with adverse clinical outcomes. Attention should be given to the changes in dietary intake and macronutrient in all children post-transplantation, especially for those of older age, high risk of STAMP, or with oral mucositis, Ⅱ-Ⅳ grade aGVHD, and severe infection. Timely and effective nutritional interventions are essential.

Key words: allogeneic hematopoietic stem cell transplantation, dietary analysis, nutritional risk screening, malnutrition

颜莓, 唐维兵, 方拥军, 黄婕, 朱亭, 付金玉, 夏晓娜, 刘长伟, 万园园, 潘键. 异基因造血干细胞移植患儿移植后饮食变化影响因素分析[J]. 临床儿科杂志, 2024, 42(11): 955-961.

YAN Mei, TANG Weibing, FANG Yongjun, HUANG Jie, ZHU Ting, FU Jinyu, XIA Xiaona, LIU Changwei, WAN Yuanyuan, PAN Jian. Analysis of factors influencing dietary changes in children undergoing allogeneic hematopoietic stem cell transplantation[J]. Journal of Clinical Pediatrics, 2024, 42(11): 955-961.

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参考文献 19

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项目	总计
年龄[M(P₂₅~P₇₅)]岁	6.8(3.19~10.25)
性别[n(%)]
男	89(61.80)
女	55(38.20)
诊断[n(%)]
恶性疾病
急性髓系白血病	40(27.78)
急性淋巴细胞白血病	9(6.25)
急性幼粒单核细胞	5(3.47)
骨髓增生异常综合征	3(2.08)
急性混合型白血病	3(2.08)
慢性粒细胞白血病	3(2.08)
T细胞淋巴瘤	1(0.69)
EBV相关T细胞白血病	1(0.69)
噬血细胞综合征	5(3.47)
神经母细胞瘤	2(1.39)
非恶性疾病
再生障碍性贫血	40(27.78)
免疫缺陷疾病	9(6.25)
地中海贫血	6(4.17)
先天性角化不良	1(0.69)
粘多糖贮积症	8(5.56)
肾上腺脑白质营养不良	1(0.69)
先天性血小板减少症	2(1.39)
先天性中性粒细胞减少症	1(0.69)
遗传性非球型溶血性贫血	2(1.39)
岩藻糖苷贮积症	1(0.69)
克罗恩病	1(0.69)
移植类型[n(%)]
亲属	69(47.92)
非亲属	75(52.08)
预处理方案[n(%)]
清髓方案	97(67.36)
非清髓方案	47(32.64)
aGVHD[n(%)]
0~Ⅰ度aGVHD	100(69.44)
Ⅱ~Ⅳ度aGVHD	44(30.56)
预处理前BMI-Z[n(%)]
≤-2SD	12(8.33)
-2<BMI-Z<2SD	117(81.25)
≥2SD	15(10.42)
口腔黏膜炎[n(%)]
是	44(30.56)
否	100(69.44)
预处理前STAMP评分[n(%)]
高风险（≥4分）	38(26.39)
低中风险（<4分）	106(73.61)
EN支持[n(%)]
是	84(58.33)
否	60(41.67)
PN支持[n(%)]
是	105(72.92)
否	39(27.08)
发热时间[M(P₂₅~P₇₅)]/d	6.5(3.0~10.0)
激素使用时间[M(P₂₅~P₇₅)]/d	13.5(0~19.0)
PN使用时间[M(P₂₅~P₇₅)]/d	11.5(0~20.0)

变量	回归系数	标准差	OR(95%CI)	P
年龄	-0.017	0.004	0.983（0.976~0.990）	<0.001
性别
男	0.071	0.034	1.074（1.004~1.148）	0.037
女	0		1
移植类型
亲属	0.044	0.034	1.045(0.979~1.116)	0.184
非亲属	0		1
疾病诊断
恶性	-0.041	0.033	0.952(0.892~1.016)	0.212
非恶性	0		1
预处理方式
清髓	-0.049	0.033	0.952(0.892~1.016)	0.142
非清髓	0		1
aGVHD
Ⅱ~Ⅳ度GVHD	-0.131	0.031	0.877(0.825~0.933)	<0.001
0~Ⅰ度GVHD	0		1
口腔黏膜炎
是	-0.106	0.032	0.899（0.845~0.958）	<0.001
否	0		1
移植前BMI-Z
BMI-Z≤-2SD	-0.025	0.066	0.976（0.858~1.109）	0.707
-2SD<BMI-Z<2SD	0.032	0.048	1.033（0.940~1.135）	0.503
BMI-Z≥2SD	0		1
入院STAMP评分
高风险≥4分	-0.097	0.036	0.907（0.845~0.974）	0.007
中低风险<4分	0		1
激素使用时间	-0.003	0.002	0.997（0.993~1.000）	0.072
发热时间	-0.011	0.003	0.990（0.984~0.995）	<0.001

项目	回归系数	标准差	OR(95%CI)	P
年龄	-0.015	0.004	0.985（0.978~0.992）	<0.001
男性	0.051	0.029	1.052（0.994~1.113）	0.078
Ⅱ~Ⅳ度aGVHD	-0.111	0.026	0.895(0.850~0.942)	<0.001
口腔黏膜炎	-0.062	0.027	0.940(0.891~0.992)	0.023
发热时间	-0.007	0.003	0.993(0.988~0.998)	0.005
高STAMP评分	-0.065	0.029	0.937（0.885~0.992）	0.026

项目	r值	P
BMI-Z下降	-0.516	<0.001
中性粒细胞重建时间	-0.084	0.384
血小板重建时间	-0.005	0.962
住院时间	-0.238	0.011
住院费用	-0.465	<0.001