Overview of nutritional approach in hematopoietic stem cell transplantation: COVID-19 update

Table 1 The EBMTR recommendations for the management of COVID-2019 in HSCT patients[25]

No.
1	All recipients are required to have tested negative for COVID-19 RT-PCR before starting conditioning regimen irrespective of respiratory symptoms
2	All recipients who are to be accepted for HSCT should be advised 14 d of home isolation before starting transplant conditioning. It should also be recommended to avoid unnecessary clinical visits to reduce the risk
3	For patients who have had close contact with a person diagnosed with COVID-19, performance of all transplant-related procedures should not be performed within at least 14 d and preferably 21 d from the last date of contact. The recipient is advised to be closely monitored for COVID-19 symptoms. COVID-19 RT-PCR negativity must be confirmed before any transplant procedure is undertaken
4	For confirmed COVID-19 patients with high-risk malignancies, HSCT should be delayed for a minimum of 14 d until the patient is asymptomatic and has at least 2 consecutive negative RT-PCR tests ≥ 24 h apart. In patients infected with COVID-19 with low-risk malignancies, HSCT must be delayed for a 3 mo

EBMT: European Society for Blood and Marrow Transplantation; RT-PCR: reverse transcription polymerase chain reaction; HSCT: hematopoietic stem cell transplantation.

Table 2 Nutritional support therapy recommendations in hematopoietic stem cell transplantation patients by phases[9]

	Oral/EN			PN (Digestive intolerance)
	Severe malnutrition
	No		Yes	No	Yes
Before transplantation	Normal protein: Low microbial diet		High protein EN	Minimal EN, normal protein PN	Minimal EN, high protein PN
Conditioning regimen (–7 to 0 d)1	High protein: Low microbial diet		High protein EN, supplements	Minimal EN, normal protein PN, glutamine	Minimal EN, high protein PN, glutamine
After Transplantation
Phase I2 (0–30 d)	Low microbial diet, EN	High protein EN, glutamine		Minimal EN, normal protein PN, glutamine	Minimal EN, high protein PN, glutamine
Phase II3 (30–90 d)	Decrease EN, bland diet	Normal protein EN, supplements		EN 50% + PN 50%, normal protein	EN 50% + PN 50%, high protein
Phase III4 (> 90 d)	Standard, bland diet	Standard diet, supplements		EN 100% or normal protein bland diet	EN 100% or high protein bland diet

In some sources, durations are given as follows:

¹-10 to 0 d.

²0 to +21 d.

³+21 to +100 d.

⁴> 90 d. EN: Enteral Nutrition; PN: Parenteral Nutrition.

Table 3 Nutritional approach in specific complications

Special complications	Nutritional approach
Vomiting/nausea	Developing a diet plan which includes salty or sour foods, cold and clear liquids, small frequent meal portions, low-fat and low-fiber foods
	Starting parenteral nutrition or postpyloric enteral nutrition if symptoms are severe
Dysgeusia	Promotion of good oral hygiene
	Developing a diet plan which includes a variety of highly spicy, tasty foods (unless mucositis/esophagitis) to optimize oral intake
Xerostomia	Development of a diet plan which includes the use of highly-moist foods, saliva stimulants (e.g. citric acid drinks, sugarless sugar, sugar-free gum) to optimize oral intake
	Supplementation with additional oral or IV fluids as needed
	Making a saliva substitute
Mucositis	Developing a diet plan with varying texture/temperature foods and drinks in addition to providing adequate vitamin/mineral supplements to optimize oral intake
	Consideration of enteral or parenteral nutrition if oral intake is insufficient
Diarrhea	Discontinuing oral intake if stool exceeds approximately 2000 mL/d for several days
	Consideration of parenteral nutrition in prolonged lack of oral intake
	Intake of soluble fiber
	Maintaining a low lactose diet and prescribing lactase enzymes in the presence of lactose intolerance
	Developing a diet plan including low-fat, low-insoluble fiber
	Avoiding gastrointestinal irritants/stimulants and irritating disaccharides
Constipation	Development of a diet plan which increases insoluble fiber and fluid intake
	Promotion of physical activity
	Assessment of the need for pharmacological intervention
Anorexia	Eating smaller portions and more frequently
	Consumption of high-calorie snacks

Table 4 Nutritional approach in immunosuppressed patients

Food restrictions
1	Raw and undercooked meat, fish, shellfish, poultry, eggs, sauce
2	Unpasteurized or raw milk, cheese, yoghurt and other dairy products, soft cheeses, delicatessen cheeses, cheeses containing hot peppers or other uncooked vegetables, cheeses with molds
3	Foods containing raw or uncooked meat, tofu, pre-cooked cold meats, pickled fish, tempeh, raw eggs
4	Raw cereal products, unpackaged bread, cakes, pastries, cream cakes, dried fruits, nuts or coconut
5	Unwashed and unpeeled raw fruit, damaged fruit, berry fruits (strawberry, raspberry, blackberry), grapes (unless peeled), unroasted raw nuts, unpasteurized juice, dried fruit
6	Unwashed raw vegetables or herbs, delicatessen salad Herbs and spices should not be sprinkled on food after cooking
7	Well water (unless tested annually and found safe), cold brewed tea made with lukewarm or cold water, prepared and brewed unpasteurized fruit or vegetable juices
8	Uncooled, cream filled pastry products
9	Unwrapped or communally used butter, margarine, spreads or ghee, fresh salad dressings containing aged cheese or raw eggs, stored in refrigerated case
10	Raw or unpasteurized honey, herbal and non-traditional nutritional supplements, brewer's yeast if eaten without cooking
Food safety recommendations
General	Particular care should be taken when handling, preparing and consuming food to avoid contracting a foodborne illness. 4 steps to follow in terms of food safety: (1) Cleaning: Washing hands, surfaces and products; (2) Separation: Avoiding cross-contamination; (3) Cooking: Cooking at proper temperature; and (4) Chilling: Refrigerate immediately
Shopping	Always check expiration dates. Avoid purchasing food close to its expiration date and never consume after the specified date. Do not buy damaged packaged food such as crushed boxes or ripped packages. Do not taste foods in supermarkets. Buy perishable foods first, then frozen perishables and finally refrigerated perishable products. Check for water on the floor by meat stands, freezers or refrigerators. Avoid hot places when carrying food
Storage	Store raw and cooked food separately. Check if your fridge and freezer are at the right temperature. Adjust refrigerator temperature to below 5C, freezer below 18C. Discard wastes after 3 d of refrigeration. Never leave perishable products out of the refrigerator for more than 2 h
Preparation	Wash hands thoroughly with hot water and soap before and after touching food. Use separate cutting boards to prepare beef, fish, chicken or vegetables. Prefer boards made of glass to wooden ones. Use only treated water to prepare food and clean the surface before you start preparation. Make sure canned food is clean. Wash cans before opening
Cooking	Avoid using a microwave for cooking; it can be used to heat food or defrost frozen food. Cook food thoroughly; pay special attention to larger portions and thicker cuts of meat. When warming pre-prepared food, check that the temperature inside the product is the same. Never reheat preheated food. Never re-freeze thawed frozen food
Eating out	It is safer to avoid eating and drinking outside while on a clean food diet. If you have to eat out, use sauces, condiments, salt and sugar only in disposable bags. Check that the toilets are clean and that there is soap to wash hands. Avoid iced drinks of unknown origin