A Case Study:
Acute
Leukemia
By Rashel Clark
NDFS 4660
Fall 2014
1
Introduction
The patient was a 27 year old female admitted to the hospital for a matched unrelated
donor (MUD) peripheral blood stem cell transplant (PBSCT). The following case study presents
information on the patient’s social and medical history. There will then be an in depth analysis
of the most recent diagnosis, treatment, and nutrition assessment which occurred during the
patient’s hospital stay.
Patient Profile and Social History
The patient was married with two kids. The family owned and operated a gym. The
patient was also a cheerleading coach at the local high school. Both of the kids lived with
grandparents during the chemotherapy and transplant treatments while the husband would
travel back and forth. The children would skype the parents and come visit when possible.
Past Medical History
Previous to 2013 the patient was healthy and had no significant medical history other
than the birth of two children. On October 18th the patient was diagnosed with acute
undifferentiated leukemia (AUL). Four days later 3+7 induction treatment began. On November
7th the patient came to the hospital for the second round of induction therapy. Discharge from
that treatment was on December 20th the patient returned to the hospital January 14th for total
body radiation therapy. This was in preparation for an allogeneic 10/10 MUD PBSCT, which
occurred on January 21st. On February 12th the patient was discharged with homecare.
On June 28th the patient returned to the hospital due to returning symptoms of
leukemia and was diagnosed with relapsed AUL with leukemia cutis, central nervous system
(CNS) disease, low-grade gut graft versus host disease (GVHD), and cytomegalovirus (CMV)
2
enteritis. At this time CLAG-M chemo cycle began. The patient was discharged again with
homecare on July 3rd
Treatment and Progress
The patient was readmitted to the hospital on August 12th for a bone marrow transplant
(BMT) preparative chemotherapy regimen. On August 20th the patient had the second MUD
hematopoietic stem cell transplant (HSCT). Recovery was to occur in the BMT unit until the
patient stabilized and counts recovered. During this time the patient experienced complications
with mucositis and increasing liver function test labs.
These complications led the patient to the Intensive Care Unit (ICU) early September
16th At this time the patient was diagnosed with liver failure, respiratory failure, and hepatic
sinusoidal obstructive syndrome (SOS) formerly known as veno-occlusive disease. The patient
was then discharged and transported to the another hospital to be enrolled in a clinical trial for
the treatment of SOS.
Anthropometrics
From diagnosis to first transplant in January the patient had a 5% weight loss. This
compounded to a 15% weight loss when relapsed AUL was diagnosed in July. Weight then
stabilized until admit for second BMT late August. During the second transplant weight
continued to climb. This brought the patient back within usual body weight range. However,
most of the weight increase was due to edema in the legs and face, and ascites in the abdomen.
A summary of weight progression for the patient can be seen below.
Date/Time
Weight
Weight history
Date/Time
Weight
3
Nov 6th
52.25
Aug 1st
42.80
Dec 1st
50.50
Aug 11th
42.80
Jan 11th
49.50
Aug 20th
44.50
Feb 1st
48.90
Aug 27th
46.90
Mar 18th
42.82
Aug 29th
46.10
Jun 27th
44.70
Sep 1st
47.30
Jul 9th
45.70
Jul 28th
44.00
Biochemical
The patient had many medications on board during the hospital stay. Medications and
dosing would vary depending on the patient’s clinical state and symptoms. In appendix A a
snapshot of medications, dosing, and purpose can be found. All of these medications had
symptoms which were mostly counteracted by other medications that were taken. The patient
mainly experienced symptoms of altered hydration status, anorexia, nausea, vomiting, cramps,
diarrhea, and skin rashes during the hospital stay.
Labs were monitored daily to determine recovery status, monitor possible
complications, total parenteral nutrition monitoring, and transfusion needs. A summary of the
basic metabolic panel in this patient can be seen in Appendix B. Liver function tests can be seen
in Appendix C. These values were indicative of the patient’s major complications which
occurred while the patient was in the hospital recovering from a BMT. The general climb in the
liver values was first thought to be related to total parenteral nutrition (TPN) complications.
However after this was found to not be the problem the values were further investigated by
4
specialists. Lab values indicated liver failure, arrhythmia, tachycardia, and dyspnea when the
patient was transferred to the ICU on September 16th.
Clinical
Before transplant the patient was considered to only have a 10% chance of survival. This
put the patient at a higher risk of complications during the second BMT. Edema in the legs and
abdomen was fairly consistent and controlled as much as possible with Lasix to induce autodiruesing. Mucositis onset began on day two after the transplant and set in by day 5. It was
mostly in the throat but extended through the digestive tract down to the stomach. The patient
had a history of vitamin B12 deficiency and was being treated for this. Frequently the patient
would have no bowel movements for a week even with medications. The patient also
experienced rash, nosebleeds, and hematemesis.
The patient was transferred to the Intensive Care Unit (ICU) early September 16th This
was due to liver failure, arrhythmia, tachycardia, and dyspnea. It was determined the patient
had a sudden onset of hepatic sinusoidal obstructive syndrome (SOS) formerly known as venoocclusive disease. Later that afternoon the patient was discharged and transported to the
another hospital to be enrolled in a clinical trial for the treatment of SOS.
Dietary
Every BMT patient is put on a continuous calorie count and reduced microbial diet due
to the immunosuppression and compromised immune system. The patient suffered from
chemotherapy induced nausea, vomiting, mucositis and anorexia throughout the entire stay at
the hospital. These symptoms severely impacted nutritional status and were the basis upon
which nutrition support was indicated. TPN was the nutrition support chosen due to severe
5
mucositis and concerns for possible GVHD. Below are the patient’s estimated needs which are
increased due to BMT.
Calories
Protein
Fluid
1320-1540
77-102g
1320-1540ml
30-35kcal/kg
1.5-2g/kg
30-35ml/kg
Two complete nutrition assessment notes can be found in Appendix D. The summary of
the patient’s nutritional status and interventions as monitored by the registered dietitian are as
follows:
7/20- 8/17: Reduced microbial diet and calorie counts began upon admit per LDS
hospital protocol with all BMT patients. Calorie counts indicated patient meeting 75% of
estimated needs until 8/15 when intake severely declined due to increasing symptoms
most likely caused by chemotherapy regimen.
Average oral intake: 73% of calorie needs and 60% of protein needs
8/18- 8/20: TPN was initiated to meet half the patient’s estimated needs. This
was due to severe nausea and vomiting resulting in the patient eating less than 50% of
calorie and protein needs for two days per calorie count analysis.
Average oral intake: 14% of calorie needs and 23% of protein needs
Average nutrition support: 52% of calorie needs and 53% of protein needs
8/21- 8/22: TPN was discharged and one liter of Clinimix was started to help
bridge the gap until adequate oral intake was achieved. The emesis and nausea due to
the chemotherapy regimen prior to BMT had resolved at this point so intake was
expected to increase.
Average oral intake: 48% of calorie needs and 51% of protein needs
Average nutrition support: 51% of calorie needs and 53% of protein needs
6
8/23-9/2: TPN was initiated to meet all of the patient’s estimated needs due to
the onset of severe mucositis. This extended down through the esophagus and made it
difficult for the patient to even talk. Calorie counts were discharged at this time due to
the patient’s inability to consume any nutrients.
Average oral intake: 0% of calories and 0% of protein needs
Average nutrition support: 80% of calories and 95% of protein needs
9/3- 9/8 The lipids were taken out of the TPN due to abnormal total bilirubin and
alkaline phosphatase.
Average oral intake: 0% of calories and 0% of protein needs
Average nutrition support: 100% of calorie needs, 100% of protein needs
9/8- 9/16: Lipids were added back into the TPN. The patient had returned from a
computed tomography scan and gastrointestinal (GI) consult due to abnormal lipid
values and abdominal pain. The GI consult dictated that the liver values were likely
related to poor oral intake for an extended period of time and biliary sludge that was
found in the gall bladder. At this time oral intake was further encouraged to help resolve
the problem. Day twenty of hospital stay the patient finally had first oral intake of ½ cup
of noodles. Oral intake was never adequate to discharge or decrease TPN rate for the
rest of hospital stay. Calorie counts were resumed on 9/8/2014 to track oral intake more
closely.
Average oral intake: 2% of calorie needs and 0% of protein needs
Average nutrition support: 98% of calorie needs and 100% of protein needs
Conclusion
7
The hospital admitted a 27 year old female for a second bone marrow transplant. The
patient encountered many clinical complications related to the transplant which negatively
impacted oral intake and thus nutritional status. While the patient was at the hospital
nutritional and medical status was monitored by an entire team of professionals. The patient’s
nutritional status was discussed in depth and even with all of this monitoring the patient
encountered complications related to the bone marrow transplant.
On September 16th the patient was transferred to the ICU with liver and respiratory
failure and a diagnosis of SOS. The patient was transferred to another hospital for further
treatment in a clinical trial for the treatment of SOS. Due to the sudden onset of these
complications the medical team was unable to stabilize the patient again. The patient passed
away two weeks later.
8
Acute Leukemia Literature Review
There are approximately 48,000 new cases of leukemia diagnosed in the United States
each year. Those living with or in remission from leukemia total about 274,9301. This type of
cancer begins in the bone marrow affecting the white blood cells2. To understand the
physiology of this disease it is important to first examine the bone. The bone is made of an
outside layer of compact bone, spongy bone on the ends, and bone marrow in the center. In a
healthy body the bone marrow makes immature blood stem cells that mature over time. These
stem cells become either a myeloid or lymphoid stem cell. Lymphoid cells become white blood
cells; myeloid cells become red blood cells, white blood cells, or platelets3.
Leukemia causes a malignant transformation to occur at the stem cell level resulting in
abnormal proliferation, clonal expansion, and diminished apoptosis. This leads to normal blood
cells replaced with the malignant, leukemic, cells2. The cause for most leukemia cases is not
known; however once the leukemic shift begins these cells survive better than normal cells1.
This suppresses normal blood cell and bone marrow formation which in turn hinders
hematopoiesis with ensuing thrombocytopenia and granulocytopenia. Due to being a blood
borne illness it can also infiltrate organs such as the liver, spleen, lymph nodes, kidney and
gonads, and central nervous system (CNS)2. Complications for this patient occurred in the CNS
and liver.
The rate at which this occurs depends on the type of leukemia 1. Leukemia is divided into
four classes. The first differentiation is acute or chronic which signifies if the transformation
begins in the mature or immature cells. Next the disease is classified according to if it affects
the myeloid or lymphocytic cells. Acute myeloid leukemia (AML), acute lymphoblastic leukemia
9
(ALL), chronic myeloid leukemia, and chronic lymphocytic leukemia are the four main types of
leukemia1. Acute leukemia will progress rapidly if not treated3. THE PATIENT had been
diagnosed with acute undifferentiated leukemia due to the inability to specify where the
leukemic shift occurred.
Signs and Symptoms
Symptoms generally begin merely days to weeks before diagnosis. Abnormal
hematopoiesis results in the subjective symptoms of anemia, infection, easy bruising, and
bleeding. The anemia and hypermetabolic state will also result in pallor, fatigue, fever, malaise,
weight loss, tachycardia, and chest pain. A patient’s increased risk for bleeding is manifested
through petichiae, easy bruising, epistaxis, bleeding gums, and menstrual irregularity. Leukemic
cell infiltration can cause joint pain, lymphadenopathy, splenomegaly, hepatomegaly, and
leukemia cutis1,2. THE PATIENT presented to the hospital with six weeks of fatigue, weight loss,
bleeding, and joint pain.
When a patient presents at the hospital with these symptoms there are several
diagnostic procedures which take place. A complete blood count will show high or low levels of
white blood cells (WBC) and leukemia cells in the blood1. This test as well as the peripheral
blood smear are the first tests completed. If the test results indicate pancytopenia and
peripheral blasts the patient is diagnosed with acute leukemia. An aspiration or needle biopsy is
then completed to confirm the diagnosis and look for any chromosomal abnormalities. Studying
the results of these tests are also how the typing, classification, and treatment of the leukemia
is determined1,2. The patient initially had a complete blood count and peripheral blood smear
10
which indicated a leukemia diagnosis. A bone marrow biopsy was then completed to try and
type the leukemia. The patient was determined to have acute undifferentiated leukemia.
Medical Treatment
The type of treatment chosen will differ depending on the patient’s age, disease
classification and progression, and prior health status. Regardless of the type of treatment
chosen the goal is the same for every patient; complete remission. Remission is when there is a
restoration of normal blood counts, normal hematopoiesis with less than five percent of
leukemic cells, and elimination of the leukemic clone3. Basic treatment includes two general
categories; supportive and active treatment. The patient was actively involved in both forms of
treatment through the LDS hospital.
Patients need to be closely monitored during therapy. Facilities must be available to
provide supportive care. Transfusions of platelets, packed red blood cells, and granulocytes are
administered as needed to keep lab counts within the parameters the medical staff sets for the
patient2. Patients’ immune systems are suppressed to prevent rejection of the new stem cells.
The medications work in several different points. Most often the mediation will suppress T and
B lymphocyte ability to complete the immune response; and thus lower the likelihood of
antigen and antibody development which would kill the new stem cells. While the
immunosuppression does help the engraftment to take place it also inhibits the body’s immune
response to harmful bacterial, viral, or fungal subjects4. Thus antibiotic and antifungal drugs
are used to keep infections at bay in this population. Hydration is twice the daily maintenance
volume. Urine alkalinization should be kept at a pH of 7-8 to help prevent hyperuricemia,
hyperphosphatemia, and hyperkalemia, or tumor lysis syndrome2.
11
Besides supportive care another important part of leukemia treatment is the active
fight against the disease with the goal of complete remission. The specific treatment regimen
will largely depend on the type of leukemia and the health status and desires of the patient.
Chemotherapy and radiation therapy are often used at some point in the treatment.
Chemotherapy uses drugs to either stop the leukemic cells from dividing or kills the cells. Most
often this is used as a combination therapy to help it be more effective3. Induction therapy is
the most common first line of defense against leukemia. Radiation therapy uses high-energy xrays or other types of radiation to kill the leukemic cells or keep them from continuing to grow
and divide3. Often this therapy is used as a total body radiation to prepare the body for a stem
cell transplant4. Since diagnosis The patient had different types of chemotherapy treatments,
total body irradiation therapy, and induction treatment.
Removal and replacement of stem cells is considered a bone or stem cell transplant. A
bone marrow transplant (BMT) is a patient’s only option to complete recovery after diagnoses
of leukemia. Over 50,000 of these procedures occur each year4. Chemotherapy is administered
and then stem cells are replaced through an infusion. These new cells restore the body’s blood
cells3. New cells come from the bone marrow (HSCT), peripheral blood (PBSCT), or umbilical
blood. The patient underwent a MUD PBSCT for the second transplant since diagnosis.
There are three different types of bone marrow transplants. Autologous transplants
have the cells harvested from the patient. This therapy usually involves fewer complications
and only has a 5-10% mortality rate. Syngeneic HSCT do not occur very often because it is when
the cells are collected from an identical twin. Allogeneic HSCT stem cells are collected from a
donor whose humal leukocyte antigens (HLA) match the patient’s. This is ideally a related
12
donor; although sometimes it is necessary to reach out to unrelated donors through several
international volunteer agencies4. THE PATIENT cells were harvested through an allogeneic
source.
Allogeneic PBSCT is the preferred treatment for acute leukemia and is the treatment the
patient received in the hospital. It has been shown to have a higher percentage of success when
compared with just chemotherapy treatment as a means of treatment for this population.
Allogeneic PBSCT showed in a variety of multicenter trials in comparison with bone marrow
transplant to have a stronger GVH effect, faster engraftment, less transplant related
complications, and a reduced treatment cost. Although a registry shows that chronic GVHD is
more prevalent in PBSCT4,5. However relapse was 38% higher in a study with 89 patients. But
the transplant related mortality was lower in PBSCT compared to HSCT6.
Medical Nutrition Therapy
Patients undergoing an allogeneic stem cell transplant are prone to malnutrition due to
the intense treatment. Corresponding symptoms of changes in appetite, taste, salivary
function, gastric emptying, and intestinal function cause low intake and can last for extensive
periods of time7. Further symptoms include gastrointestinal complications, vomiting, oral
mucositis, diarrhea, protein loss due to enteropathy, inflammatory syndrome, infections,
hepatic sinusoidal obstructive syndrome, and GVHD. All of these symptoms and complications
compound together to make the patient’s metabolic needs very high in order to prevent
catabolism8. THE PATIENT experienced all of these symptoms at some point during the hospital
stay; although the worst complications were SOS, mucositis, and gastrointestinal complications.
13
Routinely parenteral nutrition (PN) is the method of choice for nutrition support in this
population. The study of enteral nutrition (EN) versus PN in BMT patients is a new field. Under a
Cochrane review this area still needs further evaluation and expertise, but there are several
studies that have come to these same conclusions9. With enteral nutrition patients were found
to have “lower duration of fever (2 vs 5 days), reduced need for empirical antifungal therapy (7
vs 17), lower rate of central venous catheter placement, and a lower rate of transfer to the
intensive care unit (2 vs 8). Although the early death rate of 14% was the same in both of the
groups. There was also no increased risk of GVHD in the enteral nutrition group”9.
Some patients reported intolerance of enteral support during treatment. One way to try
and increase this tolerance is by slowing the rate. The tube should be placed before mucositis
sets in to promote tolerance9. On the other side EN in some studies had increased morbidity,
diarrhea, hyperglycemia, and delayed engraftment; but less weight loss and less body fat. It can
sometimes be a challenge to provide safe enteral access after transplant preparative regimens
due to coagulopathy, risk of aspiration pneumonia, sinusitis, diarrhea, ileus, abdominal pain,
delayed gastric emptying, and vomiting. Once neutrophil and platelet counts have returned and
GI tract is healed, EN is a safe transition step from PN to oral diet7. The following are guidelines
set by the American Society for Parenteral and Enteral Nutrition in regards to nutrition support
during BMT.
1. “All patients undergoing hematopoietic cell transplantation with myeloablative
conditioning regimens are at nutrition risk and should undergo nutrition screening to
identify those who require formal nutrition assessment with development of a nutrition
care plan.
14
2. Nutrition support therapy is appropriate in patients undergoing hematopoietic cell
transplantation who are malnourished and who are anticipated to be unable to ingest
and/or absorb adequate nutrients for a prolonged period of time (7-14 days). When
parenteral nutrition is used, it should be discontinued as soon as toxicities have resolved
after stem cell engraftment.
3. Enteral nutrition should be used in patients with a functioning gastrointestinal tract in
whom oral intake is inadequate to meet nutrition requirements.
4. Pharmacologic doses of parenteral glutamine may benefit patients undergoing
hematopoietic cell transplantation.
5. Patients should receive dietary counseling regarding foods which may pose infectious
risThe patient and safe food handling during the period of neutropenia.
6. Nutrition support therapy is appropriate for patients undergoing hematopoietic cell
transplantation who develop moderate to severe graft-vs-host disease accompanied by
poor oral intake and/or significant malabsorption”7.
Disease Management
Aggressive therapy of acute leukemia is necessary in order to decrease mortality rates.
The improved medical and supportive treatment in these patients has greatly increased the
complete remission rates. Therapy has to be aggressive to achieve complete remission because
partial remission offers no benefits for the patient. 60-70% of adults are expected to achieve
the status of being disease free. More than 25% of adults are expected to survive three or more
years and may be cured. 60% of adults younger than 60 are expected to have remission at some
15
point in their life. So while diagnosis rates have gone up over the years, mortality rates have
fallen3.
Stem cell transplant short and long term outcomes are affected by diagnosis, disease
stage, transplant type, degree of donor histocompatibility, preparative regimen, stem cell
source, age, prior therapy, and nutrition status7. Long-term recovery can have fatigue and
physical debilitation persist for many months after treatment. Long term complications can be
GVHD, obstructive lung disease, cataracts, aseptic vascular bone necrosis, gonadal and ovarian
failure, dental decay, hemolytic uremia syndrome, renal dysfunction, hemosiderosis, and
secondary tumors4. THE PATIENT only had a 10% chance of surviving the second BMT due to
complications and prior health status.
Disease relapse can occur months or years after transplant. Alternatives for allogeneic
relapsed transplants are a second transplant or stimulation of the donor antitumor effect by
stopping GVHD drugs or infusing more donor cells4.
16
Appendix A
Medication
*BIOTENE ANTIBACTERIAL
ACETAMINOPHEN (TYLENOL)
ACYCLOVIR (ZoviRAX)
CALCIUM CARBONATE (TUMS)
DOCUSATE SODIUM (COLACE)
DiphenhydrAMINE (BENADRYL)
ENOXAPARIN (LOVENOX)
HYDROmorphOne 0.2MG/ML (100ML
DRIP/PCA)
LORAZEPAM (ATIVAN)
MAGNESIUM SULFATE
METOPROLOL (LOPRESSOR)
MICAFUNGIN SODIUM
MIRALAX 17GM [GLYCOLAX]
PALONOSETRON HCL(ALOXI)
PANTOPRAZOLE (PROTONIX)
POTASSIUM CHLORIDE
PROCHLORPERAZINE (COMPAZINE)
Penicillin G Potassium
SENNA(SENOKOT)
TEMAZEPAM (RESTORIL)
Dose Frequency
15 ml QID, PRN
500 mg Q 6 HRS, PRN
500 mg Q 12 HRS
500 mg PRN
100 mg DAILY, PRN
12.5
Q 4 HRS, PRN
mg
30 mg DAILY
Purpose
Antibacterial
Analgesic
Antiviral
Diarrhea
Stool Softener
20 mg Q 1000 HRS
Analgesic
0.5 mg
4 gm
5 mg
50 mg
1 EA
0.25
mg
40 mg
40 meq
5 mg
1
MMU
10 ml
Q 4 HRS, PRN
AS DIRECTED
TID, PRN
DAILY
DAILY, PRN
Sleep/anxiety
Stool Softener
Antihypertensive
Antifungal
Stool Softener
Q 72 HRS
Antinausea
BID
AS DIRECTED
Q 4 HRS, PRN
Antigerd
Supplement
Antinausea
DAILY
Supplement
BID, PRN
AT BEDTIME,
15 mg
PRN
Sleep/anxiety
Anticoagulant
Stool Softener
Sleep/anxiety
17
Appendix B
Na
Last Reference 137Range: 146
Units:
K
Cl
CO2
3.5-5.0 98-109 19-30
Anion
Gap
Glucose
(Na Cl
CO2)
3-16
65-99
BUN
Creatinine
6-21
0.52-0.99
8.4-10.4
mg/dL
mg/dL
mmol/ mmol/ mmol/ mmol/ mmol/
mg/dL mg/dL
L
L
L
L
L
Ca
09/16
137
4.7
102
25
10
225 H
27 H
0.62
8.8
09/14
133 L
4.5
101
27
5
85
22 H
0.76
9.0
09/14
133 L
4.8
103
23
7
137 H
14
0.63
8.5
09/14
135 L
3.6
113 H
16 L
6
133 H
11
0.59
6.5 L
09/13
134 L
4.8
104
24
6
113 H
13
0.57
8.5
09/11
138
4.5
105
26
7
102 H
15
0.55
9.0
09/09
139
5.0
106
25
8
104 H
16
0.53
9.1
09/07
139
4.7
107
24
8
98
14
0.49 L
9.4
09/06
139
4.4
107
25
7
112 H
13
0.48 L
9.2
09/04
139
3.7
106
26
7
112 H
13
0.43 L
9.1
09/02
142
3.7
107
27
8
113 H
17
0.43 L
9.3
08/31
140
3.7
109
24
7
124 H
12
0.39 L
9.3
08/30
139
3.7
108
23
8
111 H
12
0.41 L
9.1
08/28
139
4.1
107
26
6
117 H
12
0.41 L
9.2
08/26
142
3.8
108
28
6
102 H
12
0.44 L
9.2
08/24
139
3.8
109
26
4
108 H
10
0.49 L
9.0
18
Appendix C
Hepatic Function Panel
Show more...
Test Prot Albumin
Status
Last Reference Range:
Units:
Bili,
Total
Bilirubin,
Direct
Bilirubin,
Indirect
Alk
Phos
ALT
AST
6.0-8.4
3.3-4.8
0.2-1.3
0.0-0.5
0.2-1.3
40-120
9-52
9-40
g/dL
g/dL
mg/dL
mg/dL
mg/dL
U/L
U/L
U/L
09/16
Final
5.0 L
2.7 L
2.2 H
1.4 H
0.8
234 H 644 H 875 H
09/14
Final
5.0 L
2.6 L
1.2
0.8 H
0.4
345 H 109 H 166 H
09/13
Final
5.0 L
2.7 L
1.1
0.7 H
0.4
384 H
48
66 H
09/11
Final
5.9 L
3.0 L
0.7
0.3
0.4
425 H
52
52 H
09/09
Final
5.8 L
3.1 L
0.7
0.3
0.4
441 H
61 H
53 H
09/06
Final
6.0
3.2 L
1.0
0.5
0.5
266 H
44
39
09/04
Final
6.1
3.3
1.7 H
1.0 H
0.7
249 H
44
38
08/02
Final
6.8
3.9
0.7
0.3
0.4
110
55 H
24
07/13
Final
6.8
3.7
0.9
0.3
0.6
119
37
16
Specimen
Type
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
Serum or
Plasma
19
Appendix D
September 5th
Assessment:
Pt is a 27y/o female admitted for Bu/Flu MUD BMT. Currently 111% of admit weightdecreasing fluids d/t edema in abdomen and ankle. Medications noted. Labs: ALP elevated and
trending up, T-bili elevated and trending down- lipids stopped in TPN. Continues on full TPN d/t
mucositis, nausea, and vomitting. Hasn't recieved lipids in TPN for the past 2 days d/t elevated
liver panel. Plans to keep lipids out of TPN again today until liver panel normalizes. Over the
past 3 days, TPN has provided 88% of energy needs and 100% of protein needs. Still no oral
intake. However, energy provided from TPN will trend down without lipids.
Diagnosis:
Inadequate oral intake (NI 2.1) related to decreased ability to consume sufficient energy,
nutrients as evidenced by calorie counts, need for TPN, mucositis.
Predicted suboptimal nutrient (NI 1.4) intake related to planned procedure, therapy or
medication predicted to decrease ability to consume sufficient energy or nutrients as evidenced
by transplant.
Intervention:
 TPN to meet all of estimated needs
 Lipids removed from TPN
 Encourage beginning oral intake
 Calorie Counts
Monitoring/Evaluation:
RD to monitor TPN, weight, and labs closely.
August 25th
Assessment:
Pt is a 27y/o female admitted for Bu/Flu MUD BMT. Wt is currently 110% of admit weight. Labs:
Mag low- increasing mag in TPN to 4 mg daily, ALT/AST elevated, alb and creat low- TPN to
meet protein goal. Pt with poor oral intakes d/t severe mucositis. Clinimix has been d/c'd and
TPN started on 8/23 that has provided 46% of energy needs and 70% of protein needs. Plans for
TPN to provide 100% of energy and protein needs until mucositis resolves/improves.
Diagnosis:
Inadequate oral intake (NI 2.1) related to decreased ability to consume sufficient energy,
nutrients as evidenced by calorie counts, need for TPN, mucositis.
Predicted suboptimal nutrient (NI 1.4) intake related to planned procedure, therapy or
medication predicted to decrease ability to consume sufficient energy or nutrients as evidenced
by transplant.
20
Intervention:
 TPN to meet all of estimated needs
Monitoring/Evaluation:
RD to monitor TPN, weight, and labs closely.
21
References
1. Leukemia and Lymphoma Society.
http://www.lls.org/#/resourcecenter/freeeducationmaterials/leukemia/. Updated 2012.
Accessed: September 20, 2014.
2. Porter RS, Kaplan JL. The Merck Manual of Diagnosis and Therapy. 19th edition.
Whitehouse Station, NJ: Merck Sharp and Dohme Corporation; 2011.
3. National Cancer Institute.
http://www.cancer.gov/researchandfunding/snapshots/leukemia. Updated September
8, 2014. Accessed September 18, 2014.
4. Hasse J, Blue L. Comprehensive Guide to transplant Nutrition. Chicago, Illinois: American
Dietetic Association; 2002
5. Zhang W, Yang D, Wang J, et al. Allogeneic Peripheral Blood Stem Cell Transplantation is
a Promising and Safe Choice for the Treatment of Refractory/Relapsed Acute
Myelogenous Leukemia, Even with a Higher Leukemia Burden. Biology Of Blood &
Marrow Transplantation [serial online]. April 2013;19(4):653-660. Available from:
Academic Search Premier, Ipswich, MA. Accessed September 24, 2014.
6. Liu Q, Liu C, Xu X, et al. Peripheral blood stem cell transplantation compared with bone
marrow transplantation from unrelated donors in patients with leukemia: A single
institutional experience. Blood Cells, Molecules & Diseases [serial online]. June 15,
2010;45(1):75-81. Available from: Academic Search Premier, Ipswich, MA. Accessed
September 24, 2014.
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7. August D, Huhmann M. A.S.P.E.N Clinical Guidelines: Nutrition Support therapy during
Adult Anticancer Treatment and in Hematopoietic Cell Transplantation. Journal of
Parenteral and Enteral Nutrition. V33(5):472-500 2009
8. Seguy D, Berthon C, Micol J, et al. Enteral Feeding and Early Outcomes of Patients
Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative
Conditioning.Transplantation. September 2006;82: 835-839
9. Guizee R, Lemal R, Cabrespine A, et al. Enteral versus parenteral nutritional support in
allogeneic haematopoietic stem-cell transplantation. Clinical Nutrition2014 v33 533-538
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