The Department of Veterans Affairs Nutritional Status Classification Scheme Allows for Rapid Assessment of Nutritional Status Prior to Autologous Peripheral Blood Stem Cell Transplantation and Identifies Patients at High Risk of Transplant-Related Complications

Article Outline

• Abstract
• Introduction
• Patients and Methods
  • Study Subjects
  • Nutritional Assessment
  • Patient-, Disease-, and Transplant-Related Characteristics
  • Statistical Analysis
• Results
  • Determination of Pretransplant Nutritional Status
  • Pretransplant Patient Characteristics
  • Posttransplant-Related Toxicities
• Discussion
• Acknowledgments
• References
• Copyright

The nutritional assessment of patients prior to autologous peripheral blood stem cell transplantation (APBSCT) is labor intensive. A simple method of nutritional assessment prior to APSCT would be extremely helpful, especially if this method could identify patients at high risk of transplant-related complications. The Department of Veterans Affairs (VA) developed a Nutritional Status Classification Scheme (NSCS) to identify nutritionally compromised inpatients rapidly and reliably. The objective of this study was to determine if the use of the VA-NSCS could be utilized as a tool for the evaluation of patients prior to APBSCT and to determine if this tool could be used to identify patients at high risk of transplant-related complications. The nutritional status of 128 patients who underwent APBSCT was assessed by a registered dietician, utilizing the VA-NSCS, upon admission to the hospital and prior to conditioning regimen. Patients with moderately compromised nutritional status pretransplantation experienced a higher incidence of infections, longer duration of diarrhea, and longer length of hospital stay when compared to patients with normal or mildly compromised nutritional status. Our study demonstrates that the VA-NSCS, a simple and inexpensive tool to assess nutritional status, was useful in determining the pretransplant nutritional status of patients with lymphogenous malignancies who underwent APBSCT. In addition, this method was able to identify patients at a higher risk of posttransplant complications. Future studies should be undertaken to determine the optimal method for the nutritional assessment of autologous stem cell transplant candidates.

Key words: Nutritional assessment, Lymphoid malignancies, Hematopoietic stem cell transplantation, Transplant-related complications

Back to Article Outline

Introduction 

The nutritional status of patients prior to autologous peripheral blood stem cell transplantation (APBSCT) is an important determinant of posttransplant complications. Many nutritional status assessment tools require tests that are not obtained routinely or require anthropomorphic measurements, which make the assessment of nutritional status labor intensive 1, 2, 3. A simple method of pretransplant nutritional assessment with the capacity to identify patients at high risk of transplant-related complications would be extremely helpful, especially if this method is simple, inexpensive, and does not require specialized tests.

The Department of Veterans Affairs (VA) developed a Nutritional Status Classification Scheme (NSCS) to identify nutritionally compromised inpatients rapidly and reliably. The VA-NSCS takes into account a combination of body weight, routine laboratory tests, and clinical and dietary history. The VA-NSCS is routinely utilized for the nutritional evaluation of inpatients in the VA system. The VA system population is comprised mostly of males (90%), with an average age of 59 years (range: 29-79 years) [4].

The objective of this study was to determine if the use of the VA-NSCS could be utilized as a tool for the evaluation of patients prior to APBSCT and to determine if this tool could be used to identify patients at high risk of transplant-related complications.

Back to Article Outline

Patients and Methods 

A 2-hospital prospective study was conducted at Audie L. Murphy Memorial Veterans Hospital and University Hospital in San Antonio, Texas. The University of Texas Health Science Center at San Antonio institutional review board approved the study protocol, and all patients gave written informed consent before any study-related procedures was performed.

Study Subjects 

One hundred thirty-five consecutive patients, age 18 years or older, who underwent APBSCT for multiple myeloma (MM) or lymphoma at both hospitals between June 22, 2005, and July 14, 2008, were invited to participate in the study. Six patients declined to participate in the study, and 1 patient was considered not evaluable because of his death 5 days after transplantation. The final study cohort consisted of 128 patients. Patients with MM received melphalan (Mel) 100mg/m² daily for 2 days (total 200mg/ m²) as the conditioning regimen. Patients with lymphoma received 1 of 2 conditioning regimens: cyclophosphamide (Cy) 1800mg/m²/day for 4 days, etoposide 400mg/m² every 12hours for 3 days, and carmustine 450mg/m²/day for 1 day (CBV); or carmustine 300mg/m²/daily for 1 day, etoposide 100mg/m² every 12hours for 4 days, cytarabine 100mg/m² every 12hours for 4 days, and Mel 140mg/m²/daily for 1 day (BEAM).

Nutritional Assessment 

A registered dietician at each institution assessed the nutritional status of the patients utilizing the VA-NSCS upon the patient's admission to the hospital and prior to the administration of the conditioning regimen.

The NSCS is a validated instrument developed by the VA that stratifies patients in 4 nutritional levels or status levels: normal, mildly compromised, moderately compromised, and severely compromised based on 7 individual clinical indicators (Table 1). These 7 clinical indicators include nutritional history, unintentional weight loss, weight as body mass index, diet, diagnosis, serum albumin, and total lymphocyte count. Ratings from 1 to 4 are assigned to each of the indicators, and the overall nutritional status is determined by a predefined algorithm in which the 3 indicators with the highest values are added and the total defines the overall nutritional status. As defined in the VA-NSCS algorithm, when data was not available for a clinical indicator, it was not utilized and was not considered in the overall nutritional status determination. The VA-NSCS was modified in our study to exclude the total lymphocyte count because patients with lymphogenous malignancies might have received chemotherapy shortly before admission for transplantation, and abnormalities of the lymphocyte count might not reflect the patient's nutritional status, but rather the effect of recently administered chemotherapy. A minimum of 4 of any of the 7 clinical indicators mentioned above were necessary to determine the overall nutritional status [5].

Table 1. Modified Veterans Affairs Nutritional Status Classification Scheme

Indicator	Normal nutritional status 1	Mildly compromised nutritional status 2	Moderately compromised nutritional status 3	Severely compromised nutritional status 4
Nutritional history	Good appetite, no eating/ digestion problems, independent activities of daily living	Fair appetite, chewing problems, constipation, nausea, requires feeding assistance, restricted ambulation, limited activities of daily living	Poor appetite, vomiting, diarrhea, swallowing problems	No appetite
Unintentional weight loss as a % of usual body weight	Stable weight (no weight loss)	<10% in 6 months	10%–15% in 6 months or <7.5% in 3 months or <5% in 1 month or <2% in 1 week	>15% in 6 months or ≥7.5% in 3 months or ≥5% in 1 month or ≥2% in 1 week
Weight as a % ideal body weight (IBW)	100-90% IBW or <119% IBW	89–81% IBW or 120%–129% IBW	80–75% IBW or 130%–149% IBW	≤74% IBW or ≥150% IBW
Diet	Mechanical, regular	ADA/weight reduction, any consistency other than mechanical, drug-nutrient interaction, lactose free, low fat/low cholesterol, sodium restricted, dysphagia	Fluid restriction (<1000 cc), mineral restricted other than sodium, protein restricted, tube feeding (stable)	Clear liquids >3 days, nothing by mouth >3 days, partial parenteral nutrition, total parenteral nutrition, tube feeding (unstable)
Diagnosis	All surgeries not mentioned, HIV positive, hypertension, psychological disorders, urology disorders	Alzheimer disease, angina, cancer except gastro-intestinal (GI) tract, head, and neck cardiac disease, cellulitis, congestive heart failure (CHF) (stable), chronic obstructive pulmonary disease (COPD), (stable), cerebrovascular accident, dementia, diabetes (controlled), endocrine other, than diabetes, fracture, GI disease (all other) neurological disorders, nutritional anemia, pneumonia, psychological eating disorder, peripheral vascular disease, radiation therapy (except GI tract, head and neck), renal disease, substance abuse, abdominal surgery, total hip replacement, tuberculosis	AIDS, cancer involving GI tract or head and neck, cardiomyopathy, chemotherapy, CHF, (acute), chronic renal failure, COPD (unstable), Crohn's disease, diabetes (uncontrolled), diabetes (newly diagnosed), dysphagia enteritis, esophageal stricture, fracture (traumatic), GI disease with malabsorption or maldigestion, GI bleeding, head trauma, infection with fever, liver disease, neurological disorders, coma, pulmonary disease, oxygen dependent, radiation therapy for GI tract, head and neck spinal cord injury (new), ulcerative colitis	Acute renal failure, cardiac cachexia, GI obstruction, hepatic coma, hepatic encephalopathy, ileus, malnutrition, peritonitis, pulmonary failure ventilator dependent, sepsis
Serum albumin (g/dL)	≥−2 Standard deviations (SD)	−2.3 SD ≤−3.3 SD	−3.5 SD ≤−4.6 SD	≤−4.9 SD

Adapted from the Department of Veterans Affairs Nutritional Status Classification Scheme Handbook 1109.01 dated August 14, 2006.

Patient-, Disease-, and Transplant-Related Characteristics 

This was an observational study; the data was collected by personnel not directly involved in the clinical care of the study subjects. Patient- and disease-related characteristics including age, sex, ethnicity, performance status as defined by the Karnofsky score, primary diagnosis, and type of conditioning regimen were obtained before initiation of chemotherapy. Posttransplant variables related to the clinical course and complications obtained included the presence and duration of fever, the presence and duration of diarrhea, the presence of infection, days to neutrophil engraftment (first day of 2 consecutive days of absolute neutrophil count [ANC] ≥500/μL after reaching the ANC nadir), days to platelet engraftment (first day of 2 consecutive days of platelet count ≥20,000/μL without transfusion support after reaching the platelet nadir), days with severe neutropenia (defined as ANC≤500/μL), and length of hospital stay (defined as the time from the first day of the conditioning regimen until hospital discharge). Patients were followed until resolution of all posttranplant-related toxicities.

Statistical Analysis 

Statistical analyses were performed using SAS version 9.3 (SAS Institute Inc., Cary, SC). Patient characteristics, including demographics and clinical information, were expressed as mean and standard deviation, median and interquartile range, and frequency and percentage. Patient characteristics were compared among the 3 nutritional status groups by chi-square test for discrete variables, by analysis of variance for normally distributed continuous variables, and by Kruskal-Wallis test for nonnormally distributed continuous variables. The adjustment for multiple comparisons of variables that yield a significant result such as hospital length of stay and days with diarrhea was performed by Tukey-Kramer method. Karnofsky score was examined with post hoc test, Bonferroni correction, to adjust P-value for multiple comparisons. Infection among nutritional status was evaluated using logistic analysis. A trend analysis was also performed to find the association between the number of patients that developed infection with nutritional status by Mantel-Haenszel chi-square. Finally, we performed multiple regression analysis with stepwise procedure to predict the length (days) of hospital stay and duration (days) of diarrhea as dependent variables, and as independent variables we used nutritional status, infection, and karnofsky score as ordinal number. Independent variables were selected by value of P < .2 from previous univariate analyses. Independent variables were kept in the final model if the value was P < .1. A value of P < .05 was considered to be significant.

Back to Article Outline

Results 

Determination of Pretransplant Nutritional Status 

One hundred thirty-five consecutive patients with lymphogenous malignancies underwent APBSCT during the 3-year recruitment period. Of these, 128 (95%) patients agreed to participate in the study. Nutritional assessments were completed successfully in a single visit for all 128 patients utilizing the clinical and basic laboratory information obtained upon admission to the hospital. On average, a registered dietitian completed the nutritional assessment in <30minutes and the evaluation form in <5minutes. Twenty-six (20%) of our patients had a normal nutritional status as defined by the VA-NSCS, 91(71%) had mildly compromised nutritional status and 11 (9%) had moderately compromised nutritional status. No patient met criteria for severely compromised nutritional status.

Pretransplant Patient Characteristics 

Demographic and baseline clinical characteristics of the 128 evaluable subjects are shown in Table 2. The median age of study subjects was 58 years (range: 19-74 years). Of the 128 patients, 119 (93%) were males and 66 (52%) were Caucasian. Eighty-eight (69%) patients had multiple myeloma (MM) as the underlying diagnosis and received single agent Mel as conditioning regimen. Twenty-nine (23%) patients had non-Hodgkin lymphoma (NHL); of these, 8 patients received BEAM and 21 patients received CBV as conditioning regimen. Only 11 (9%) patients had a diagnosis of Hodgkin lymphoma (HL) and all received CBV as conditioning regimen. The distribution of patient's nutritional status across clinical indicators is illustrated on Table 3. None of the individual clinical indicators consistently predicted for outcome (data not shown).

Table 2. Pretransplant Characteristics of Study Population (n=128)

Age, years
Mean∗	56.51±10.60
Median (range)	58 (19-74)
Sex, n (%)
Male	119 (93)
Female	9 (7)
Ethnicity, n (%)
White	66 (52)
African American	24 (19)
Hispanic	34 (27)
Other	4 (3)
Primary diagnosis, n (%)
Multiple Myeloma	88 (69)
Non-Hodgkin Lymphoma	29 (23)
Hodgkin Lymphoma	11 (9)
Conditioning regimens, n (%)
Melphalan	88 (69)
BEAM	8 (6)
CBV	32 (25)
Median Karnofsky score (range)	90 (70-100)

BEAM indicates Carmustine, Cytarabine, Etoposide, and Melphalan; CBV, Cyclophosphamide, Etoposide, and Carmustine.

Table 3. Distribution of Patient's Overall Nutritional Status across Clinical Indicators

No statistically significant differences between the 3 nutritional status groups were observed with respect to age, sex, ethnicity, or diagnosis before transplantation (Table 4). A larger proportion of patients with lymphoma who had moderately compromised nutritional status received BEAM as conditioning regimen instead of CBV (χ²=10, P=.041). This corresponds to the fact that in our program, the BEAM regimen is reserved for patients with lower performance status or multiple comorbidities. In fact, the median Karnofsky performance status score before the initiation of the conditioning regimen was significantly higher in patients with normal and mildly compromised nutritional status compared with those with moderately compromised nutritional status (χ²=14.72, P=.001) (Table 4).

Table 4. Patient Characteristics Stratified by Nutritional Status

Pretransplant patient characteristics	Normal	Mildly compromised	Moderately compromised	P-value
Median age, years (range)	58 (19-74)	58 (23-74)	60 (46-73)	.289∗
Sex, n (%)
Male	25 (96%)	85 (93%)	9 (82%)
Female	1 (4%)	6 (7%)	2 (18%)	.283†
Ethnicity, n (%)
Caucasian	13 (50%)	46 (51%)	7 (64%)
African American	6 (23%)	17 (19%)	7 (64%)
Hispanic	6 (23%)	25 (27%)	3 (27%)
Other	1 (4%)	3 (3%)	0 (0%)	.946†
Primary diagnosis, n (%)
Multiple myeloma	16 (61%)	64 (70%)	8 (73%)
Non-Hodgkin lymphoma	8 (31%)	18 (20%)	3 (27%)
Hodgkin lymphoma	2 (8%)	9 (10%)	0 (0%)	.628†
Conditioning regimen, n (%)
Melphalan	16 (61%)	64 (70%)	8 (73%)
CBV	6 (23%)	25 (27%)	1 (9%)
BEAM	4 (15%)	2 (2%)	2 (18%)	.041†
Median Karnofsky score (range)	90 (80-100)	90 (70-100)	80 (80-90)	.001‡

BEAM indicates carmustine, cytarabine, etoposide and melphalan; CBV, cyclophosphamide, etoposide and carmustine.

Posttransplant-Related Toxicities 

The posttransplant-related toxicities, as well as engraftment and length of hospital stay of the study cohort are illustrated on Table 5. As expected, two-thirds of the patients experienced fever and, in 40% of them, infection was documented. Diarrhea was the most common toxicity observed in our patient population. Our median length of hospital stay was 18 days, relatively long, because in our program patients are not discharged until most toxicities have resolved.

Table 5. Treatment-Related Toxicities Stratified by Nutritional Status

	Study population	Normal	Mildly compromised	Moderately compromised
Posttransplant-related variables	n=128	n=26	n=91	n=11	P-value
Fever, n (%)
Yes	86 (67)	16 (62%)	63 (69%)	7 (64%)
No	42 (33)	10 (38%)	28 (31%)	4 (36%)	.736∗
Diarrhea, n (%)
Yes	110 (86)	23 (88%)	77 (85%)	10 (91%)
No	18 (14)	3 (12%)	14 (15%)	1 (9%)	.781∗
Infection, n (%)
Yes	51 (40)	5 (19%)	38 (42%)	8 (73%)
No	77 (60)	21 (81%)	53 (58%)	3 (27%)	.008∗
Days with fever†	2.54±3.56	2.19±2.37	2.70±3.95	2.09±2.47	.745‡
Days with diarrhea†	7.02±5.45	6.54±3.99	6.61±5.07	12.00±9.20	.010‡
Days to neutrophil engraftment†	10.87±1.43	11.00±1.06	10.87±1.57	10.60±0.84	.388‡
Days to platelet engraftment†	13.34±4.37	13.85±4.50	13.29±4.55	12.40±1.71	.722‡
Days with severe neutropenia†	7.50±2.40	8.73±2.44	8.52±2.44	7.73±1.90	.591‡
Length of hospital stay (days)†	20.94±11.55	18.58±4.05	20.42±10.74	30.82±22.08	.009‡

The posttransplant-related toxicities stratified by nutritional status are illustrated in Table 5. There were no statistically significant differences in the frequency of transplant-related toxicities between patients who had normal nutritional status and patients who had mildly compromised nutritional status. However, there were significant differences among the nutritional status of patients for duration of diarrhea, F (2, 123)=4.80, P=.010, and length of hospital stay, F (2, 124)=4.95, P=.008. Patients who had moderately compromised nutritional status experienced significantly longer duration of diarrhea (12 days) compared to patients with normal nutritional status (6.5 days, P=.018) and to patients with mildly compromised nutritional status (6.6 days, P=.008). In addition, patients who had moderately compromised nutritional status also experienced significantly longer length of hospital stay (30.8 days) when compared to patients with normal nutritional status (18.6 days, P=.008) and to patients with mildly compromised nutritional status (20.4 days, P=.012).

Patients with moderately compromised nutritional status were compared against the other 2 nutritional status groups. There was a trend of higher infection rate among increasing nutritional compromise patients from 19% to 73% (MH χ²=9.46, P=.02). Patients with moderately compromised nutritional status were 11 times more likely to develop an infection following APBSCT than patients with normal nutritional status (Wald χ²=8.29, odds ratio [OR] 11.24, confidence interval [CI] 2.42-58.82, P=.004). We did not find a significant difference in infection rate between patients with moderately versus mildly compromised nutritional status (Wald χ²=0.05, OR 3.72, CI 0.93-15.0, P=.823).

Stepwise multiple regression analysis corroborated that length of hospital stay was significantly influenced by nutritional status, F (2, 126)=3.39, P=.037, and infection, F (1, 126)=4.20, p=.042, and that duration of diarrhea was influenced only by nutritional status, F (2, 125)=3.93, P=.022. Of interest, the Karnofsky performance status score did not significantly influenced the length of hospital stay or duration of diarrhea.

Back to Article Outline

Discussion 

Nutritional disorders occur frequently in patients with cancer because of multiple factors. Chemotherapeutic agents have multiple side effects on the gastrointestinal tract including nausea, vomiting, diarrhea, and mucositis. In addition, cancer patients frequently suffer from anorexia, xerostomia, and dysgeusia, which make oral intake difficult. Complications of cancer therapies such as infection can induce high metabolic stress and tissue catabolism. For these reasons, patients referred for consideration of APBSCT frequently have compromised nutritional status.

Despite recommendations that routine nutritional evaluation be carried out before APBSCT transplantation [6], few clinical trials report the pretransplant nutritional status. A hurdle to the assessment of pretransplant nutritional status is that some nutritional assessment methods require specialized tests and anthropomorphic measurements, which make nutritional assessments labor intensive. A simple method of nutritional assessment would be extremely helpful, especially if this method is quick, inexpensive, and able to identify patients at high risk of transplant-related complications. We found that the VA-NSCS, a simple and inexpensive tool to assess nutritional status, was useful in determining the pretransplant nutritional status of patients who underwent APBSCT. Nutritional assessments were completed in 1 visit for all study patients without the need of obtaining specialized tests. In addition, this method was able to identify patients at a higher risk of posttransplant complications. Patients with moderately compromised nutritional status pretransplantation experienced a higher incidence of infections, longer duration of diarrhea, and longer length of hospital stay when compared to patients with normal or mildly compromised nutritional status.

We also found a significant difference in the Karnofsky performance status score between the moderately compromised nutritional status group and the normal and mildly compromised nutritional status groups. This finding is in agreement with other studies that have found an association between low performance status and low lean body mass index in patients with hematologic malignancies [7]. A state of malnutrition prior to APBSCT has been associated with more severe transplant-related toxicities such as longer time for neutrophil engraftment, longer length of hospital stay, and higher peritransplant mortality 6, 8, 9, 10. Concordance with the results of these studies supports our findings that the NSCS is useful in the APBSCT setting.

Although several methodologies have been utilized for the assessment of nutritional status in patients undergoing transplantation 3, 8, it is not clear which method is more appropriate in this setting [11]. Future studies should be undertaken to determine the optimal method for the nutritional assessment of autologous stem cell transplant candidates, taking into consideration the ability to perform the nutritional evaluation rapidly and cost effectively.

The results of this study can be generalized to patients with lymphogenous malignancies undergoing APBSCT. Other studies should be performed with patients undergoing allogeneic peripheral blood stem cell transplantation (PBSCT). It would be important to replicate this study in other patient population and compare it to other studies previously described 8, 9, 10. It will also be important to determine if the VA-NSCS could be utilized as a screening measure for intensive nutritional interventions such as total parenteral nutrition (TPN).

In summary, this study demonstrates that the VA-NSCS allows for rapid evaluation of the nutritional status of patients with lymphogenous malignancies before APBSCT. Patients with moderately compromised nutritional status had a higher incidence of infections, longer duration of transplant-related complications, and longer length of hospital stay. Future studies should focus on the use of VA-NSCS in patients undergoing allogeneic transplantation and in patients with myelogenous malignancies. Ultimately, early interventions or novel supportive care studies should be considered for those patients identified with as higher risks of posttransplant complications.

Back to Article Outline

Acknowledgments 

This work was presented in part as an oral presentation at the 50th Annual Scientific Meeting of the American Society of Hematology, San Francisco, CA, December 2008.

Financial disclosure: The authors have nothing to disclose.

Back to Article Outline

References 

1. Muscaritoli M, Conversano L, Cangiano C, et al. Biochemical indices may not accurately reflect changes in nutritional status after allogeneic bone marrow transplantation. Nutrition. 1995;11:433–436
   • View In Article
   • MEDLINE
2. Taskinen M, Saarinen UM. Skeletal muscle protein reserve after bone marrow transplantation in children. Bone Marrow Transplant. 1996;18:937–941
   • View In Article
   • MEDLINE
3. Rzepecki P, Barzal J, Sarosiek T, Szczylik C. Biochemical indices for the assessment of nutritional status during hematopoietic stem cell transplantation: are they worth using? A single center experience. Bone Marrow Transplant. 2007;40:567–572
   • View In Article
   • CrossRef
4. Hiller L, Lowery JC, Davis JA, Shore CJ, Striplin DT. Nutritional status classification in the Department of Veterans Affairs. J Am Diet Assoc. 2001;101:786–792
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (724 KB)
   • CrossRef
5. Lowery JC, Hiller LD, Davis JA, Shore CJ. Comparison of professional judgment versus an algorithm for nutrition status classification. Med Care. 1998;36:1578–1588
   • View In Article
   • MEDLINE
   • CrossRef
6. Raynard B, Nitenberg G, Gory-Delabaere G, et al. Summary of the standards, options and recommendations for nutritional support in patients undergoing bone marrow transplantation (2002). Br J Cancer. 2003;89(Suppl 1):S101–S106
   • View In Article
   • CrossRef
7. Kyle UG, Chalandon Y, Miralbell R, et al. Longitudinal follow-up of body composition in hematopoietic stem cell transplant patients. Bone Marrow Transplant. 2005;35:1171–1177
   • View In Article
   • MEDLINE
   • CrossRef
8. Hadjibabaie M, Iravani M, Taghizadeh M, et al. Evaluation of nutritional status in patients undergoing hematopoietic SCT. Bone Marrow Transplant. 2008;42:469–473
   • View In Article
   • CrossRef
9. Horsley P, Bauer J, Gallagher B. Poor nutritional status prior to peripheral blood stem cell transplantation is associated with increased length of hospital stay. Bone Marrow Transplant. 2005;35:1113–1116
   • View In Article
   • MEDLINE
   • CrossRef
10. Schulte C, Reinhardt W, Beelen D, Mann K, Schaefer U. Low T3-syndrome and nutritional status as prognostic factors in patients undergoing bone marrow transplantation. Bone Marrow Transplant. 1998;22:1171–1178
    • View In Article
    • MEDLINE
11. Rzepecki P, Barzal J, Sarosiek T, Oborska S, Szczylik C. Which parameters of nutritional status should we choose for nutritional assessment during hematopoietic stem cell transplantation?. Transplant Proc. 2007;39:2902–2904
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (98 KB)
    • CrossRef