Вопросы гематологии/онкологии и иммунопатологии в педиатрии. 2024; 23: 78-89
Оценка изменений состава тела у детей после трансплантации гемопоэтических стволовых клеток с использованием метода разведения дейтерия и рентгеноденситометрии: результаты пилотного исследования
https://doi.org/10.24287/1726-1708-2024-23-2-78-89Аннотация
Комплексное изучение нутритивного статуса детей с онкологическими заболеваниями с использованием эталонных методов оценки состава тела представляет интерес для оптимизации режимов нутритивной коррекции в процессе лечения и после его окончания. В статье представлен опыт первой российской апробации метода разведения дейтерия для оценки состава тела у детей в раннем периоде после трансплантации гемопоэтических стволовых клеток (ТГСК). Исследование проводится в рамках проекта МАГАТЭ по применению ядерных методов оценки нутритивного статуса у детей с онкологическими заболеваниями, одобрено независимым этическим комитетом и утверждено решением ученого совета НМИЦ ДГОИ им. Дмитрия Рогачева. С февраля 2021 г. по апрель 2023 г. в исследование были включены 39 пациентов в возрасте от 5 до 17 лет, из которых 4 впоследствии были исключены. Из оставшихся 35 пациентов (25 мальчиков и 10 девочек, медиана возраста 9,7 года) 25 имели диагноз острого лимфобластного лейкоза, 4 – острого миелоидного лейкоза, 3 – апластической анемии, 2 – острого билинейного лейкоза и в 1 случае была установлена лимфома. Обследование проводилось в несколько этапов: за 30–10 сут до ТГСК (этап 1), между –2-ми и +2-ми сутками от ТГСК (этап 2), между 30-ми и 45-ми сутками после ТГСК (этап 3), между 100-ми и 125-ми сутками после ТГСК (этап 4), а также между 280-ми и 380-ми сутками после ТГСК (этап 5). Двое из 35 пациентов прошли все 5 этапов обследования, 21 – 4 этапа, 11 – 3 этапа и 1 – 2 этапа обследования. Все пациенты нуждались в парентеральной нутритивной поддержке, которая проводилась на этапах 2 и 3 (n = 35) и на этапе 4 (n = 7). Начиная с этапа 3 все пациенты получали энтеральную нутритивную поддержку. Процедура обследования включала оценку клинического статуса и лабораторных показателей, биоимпедансный анализ (БИА), антропометрические измерения, оценку фактического питания, объема и качества нутритивной поддержки, а также применение метода разведения дейтерия (МРД) и двухэнергетической рентгеновской абсорбциометрии (ДРА) – только на этапах 1, 4 и 5. МРД был реализован у 8 из 35 пациентов. Число пациентов, для которых состав тела хотя бы на одном этапе был оценен с применением всех 3 рассматриваемых методов (МРД, ДРА и БИА), составило 7 человек, а тех, у кого такие измерения были доступны для двух соседних этапов – 3 человека. Сопоставляли результаты оценки состава тела пациентов на основе МРД, ДРА и БИА. Статистическую значимость индивидуальных изменений и парных оценок состава тела определяли на основе критерия знаковых рангов Вилкоксона для зависимых данных при пороговом уровне значимости p = 0,05. Перед проведением ТГСК 17 из 35 пациентов, согласно классификации значений индекса массы тела Всемирной организации здравоохранения, имели избыточный вес или ожирение, и только 2 из 35 – пониженный вес, что соответствует общим представлениям об адекватном состоянии питания пациентов перед ТГСК. Вместе с тем по данным БИА у 11 из 18 пациентов с нормальным или недостаточным весом наблюдалось повышенное или высокое жироотложение, что может указывать на повышенную вероятность наличия у них катаболических изменений. На этом фоне в раннем периоде после ТГСК (между этапами 1–4) наблюдалось резкое снижение средних значений массы тела и индекса массы тела за счет уменьшения тощей массы (ТМТ) и в меньшей степени жировой массы (ЖМТ), что указывает на прогрессирование катаболических изменений. При сравнении оценок состава тела, полученных с использованием разных методов, наименьшие расхождения наблюдались между результатами МРД и БИА (–1,0 кг для ТМТ). В то же время оценки ТМТ методом ДРА были значимо ниже, чем на основе МРД и БИА (на 2,3 кг и 3,3 кг соответственно), а ЖМТ и %ЖМТ – значимо выше (на 2,6 кг и 3,8 кг, а также на 7,8% и 10,9% соответственно), что может объясняться увеличением гидратации ТМТ. Полученные начальные данные свидетельствуют о согласованности МРД, ДРА и БИА при оценке изменений ТМТ, ЖМТ и %ЖМТ на групповом, но не индивидуальном уровне. Для уточнения этих результатов и сравнения клинической значимости рассмотренных методов оценки состава тела у детей с онкологическими заболеваниями на этапе ТГСК необходимо увеличение размера выборки.
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Pediatric Hematology/Oncology and Immunopathology. 2024; 23: 78-89
Evaluation of body composition changes in children after hematopoietic stem cell transplantation using the deuterium dilution method and double-energy X-ray absorptiometry: results from a pilot study
https://doi.org/10.24287/1726-1708-2024-23-2-78-89Abstract
A comprehensive investigation of nutritional status of children with oncological diseases using reference methods of body composition analysis is of interest for optimizing nutritional support during and after cancer treatment. In this paper, we report the first clinical use of the deuterium dilution method for body composition assessment in children in the early period after hematopoietic stem cell transplantation (HSCT) in Russia. Our study is carried out as a part of the IAEA project on applying nuclear methods for the evaluation of nutritional status in childhood cancer. It was approved by the Independent Ethics Committee and the Scientific Council of the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology. From February 2021 to April 2023, the study enrolled 39 patients aged 5 to 17 years, 4 of whom were subsequently excluded. Out of the remaining 35 patients (25 boys and 10 girls with the median age of 9.7 years), 25 were diagnosed with acute lymphoblastic leukemia, 4 with acute myeloid leukemia, 3 with aplastic anemia, 2 with acute bilineal leukemia, and 1 with lymphoma. The children were assessed at the following time points: between day –30 and day –10 of HSCT (time point 1); between day –2 and day +2 of HSCT (time point 2); between day +30 and day +45 after HSCT (time point 3), between day +100 and day +125 after HSCT (time point 4), and between day +280 and day +380 after HSCT (time point 5). Two patients were assessed at all 5 time points, 21 patients – at 4 time points, 11 patients – at 3 time points, and 1 patient – at two time points. All the patients required parenteral nutrition between time points 2 and 3 (n = 35). Out of these, 7 patients also received parenteral nutrition support from time point 3 to 4. All the patients were given enteral nutrition support starting from time point 3. Evaluations at each time point included clinical status assessment, laboratory testing, a bioimpedance analysis (BIA), anthropometric measurements, the assessment of oral intake as well as the amount and quality of nutritional support. Measurements using the deuterium dilution method (DDM) and a dual-energy X-ray absorptiometry (DXA) were performed only at time points 1, 4, and 5. The DDM was applied in 8 out of 35 patients. Body composition was measured using all three methods (DDM, DXA, and BIA) at least at one time point in 7 patients and at two adjacent time points in 3 patients. The results of body composition assessment using the DDM, DXA and BIA were compared. The statistical significance of individual changes and differences between paired measurements of body composition were evaluated using the Wilcoxon signed-rank test for dependent data with a threshold significance level of p = 0.05. Before HSCT, 17 out of 35 patients were overweight or obese according to the body mass index (BMI) thresholds set by the World Health Organization, and only 2 out of 35 patients were underweight, which corresponds to the common understanding of nutritional status in children before HSCT. Nevertheless, according to BIA findings, 11 out of 18 patients with normal or reduced BMI had an increased or high body fat percentage (%BF), which may be an evidence of a catabolic state. Between time points 1 and 4, there was a sharp decrease in mean body weight and BMI due to a reduction in fat-free mass (FFM) and, to a lesser extent, in fat mass (FM), indicating the progression of catabolic changes. A comparison of body composition estimates obtained by the DDM, DXA, and BIA revealed the smallest differences between the DDM and BIA measurements (–1.0 kg difference for FFM). However, the estimates of FFM obtained by DXA were significantly lower than those obtained by the DDM and BIA (by
2.3 kg and 3.3 kg, respectively), while FM and %BF estimated by DXA were significantly higher than those estimated by the DDM and BIA (by 2.6 kg and 3.8 kg, and by 7.8% and 10.9%, respectively) which could be explained by an increase in FFM hydration. Our preliminary data demonstrate good agreement between the DDM, DXA and BIA in assessing FFM, FM and %BF changes at a group level, but not at an individual level. A larger sample size is needed to clarify the obtained results and to compare the clinical significance of these methods of body composition assessment in children with cancer during and after HSCT.
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