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Changes in nutritional status and serum proteins in children with acute lymphoblastic leukemia during induction therapy: a single-centre report from China

Over the past several decades, the 5-year relative survival for childhood acute lymphoblastic leukemia (ALL) has exceeded 90% due to improvements in treatment and support care [1]. Patients with leukemia usually exhibit an increase in nutritional risk due to both disease and anticancer treatment. The literature suggests that up to 50% of children and adolescents with cancer in low and middle-income countries (LMICs) and 10–50% in highincome countries (HICs) experience malnutrition [2]. Unfortunately, little is known about nutritional status in Chinese pediatric ALL patients. In this study, we aim to assess the changes in nutritional status and serum proteins in children during induction therapy. We also evaluate the impact of nutritional status at diagnosis on the event-free survival (EFS) of Chinese pediatric ALL patients. This was a single-centre study involving children with newly diagnosed ALL at Children’s Hospital of Nanjing Medical University. The patients were treated with the CCCG2015 protocol. The details of the protocol are reported elsewhere [3]. The 4-week induction treatment regimen consisted of corticosteroids, vincristine, daunorubicin and pegaspargase. This study was performed in accordance with the Helsinki Declaration. Informed consent was obtained from patients (over 8 years old) or parents/guardians at the time of enrollment. This study was approved by the ethics committee of the Children’s Hospital of Nanjing Medical University. Body mass index (BMI) was calculated by dividing weight (kg) by the square of height (cm). BMI z-score ( 5 years old) and weight-for-height (W/H) z-score (1–5 years) were estimated according to the World Health Organization (WHO) standards [4]. BMI or W/H z-score <3.0, <2.0, >1.0 and >2.0 were defined as severe thinness, thinness, overweight and obese, respectively. Biochemical indexes including total protein (TP), albumin (Alb) and prealbumin (Pre-Alb) were detected at diagnosis and on day 28 via blood tests. Documented clinical or microbiological infections and serious adverse events (SAEs), including serious infection, thrombosis, pancreatitis, tumor lysis syndrome, pneumonia requiring oxygen support, serious hemorrhage and any other conditions requiring admission to the intensive care unit, were recorded. The absolute BMI z-score or W/H z-score and serum protein levels at different time points were compared using the Wilcoxon rank-sum test. One-way ANOVA was used to analyze the differences in serum protein levels between different subgroups. EFS was analyzed using Kaplan-Meier survival analysis. Events were defined as time of relapse, failure to achieve complete remission, and death due to treatment-related complications. Patients lost to follow-up were censored at their last known date of contact. A p-value of 0.05 or less was considered to be statistically significant. A total of 162 pediatric ALL patients aged 1–14 years from March 2018 to November 2019 were enrolled. There were 95 (58.4%) boys and 57 (41.6%) girls. The median age was 54months (range from 14 to 181months). One boy died on the 20th day of the induction phase due to severe pancreatitis. The distribution of nutritional status is shown in Figure 1(a). Five patients (3.1%) were undernourished (2 were severely thinner and 3 were thinner, retrospectively), whereas 20 (12.3%) were overweight and 8 (4.9%) were obese. At the end of induction therapy, 43 (26.7%) patients had undernutrition, including 10 with severe thinness and 33 with thinness. Sixteen (9.9%) were overweight, while 102 (63.4%) remained normal. The prevalence of patients with malnutrition (undernutrition and overnutrition) increased from 20.3% to 36.6% during induction therapy. Approximately 129 (80.1%)