Online Exclusive Article

The Impact of Hyperglycemia on Hematopoietic Cell Transplantation Outcomes: An Integrative Review

Jill Olausson

Marilyn J. Hammer

Veronica J. Brady

hyperglycemia, hematopoietic cell transplantation, outcomes, integrative review
ONF 2014, 41(5), E302-E312. DOI: 10.1188/14.ONF.E302-E312

Problem Identification: Many patients undergoing hematopoietic cell transplantation (HCT) for hematologic malignancies experience hyperglycemic events during treatment, leading to adverse outcomes. Understanding how hyperglycemia during the acute HCT treatment phase impacts outcomes is vital for preventing and mitigating adverse events. This integrative review evaluates the impact of hyperglycemia on adult patients undergoing HCT.

Literature Search: PubMed, MEDLINE®, and CINAHL® electronic databases were used to identify relevant articles.

Data Evaluation: The final sample for this integrative review included 12 empirical quantitative reports of clinical patient outcomes. Of the 12, 10 are retrospective, 1 is case-control, and 1 is prospective.

Data Analysis: Content analysis was used to synthesize and summarize findings.

Presentation of Findings: A review of published literature found associations between hyperglycemia and infection, time to engraftment, development of acute graft-versus-host disease, length of stay, and overall survival. Patient-related risk factors for hyperglycemia included older age, preexisting diabetes, and insulin resistance (i.e., prediabetes). Patients of normal weight experiencing hyperglycemia had worse outcomes than patients who were overweight or obese. Treatment-related risk factors for hyperglycemia include dose and duration of immunosuppressants, specifically corticosteroids, treatment with antihyperglycemic medications, and use of total parenteral nutrition.

Implications for Nursing Practice: HCT is one of the most complex treatments for hematologic disorders. The transplantation nurse, as part of an interdisciplinary team, plays an essential role in glycemic control during the acute phase of HCT. Understanding the effects of hyperglycemia, as well as factors that place the patient at risk for hyperglycemia, allows the nurse to make well-informed, proactive interventions aimed at glycemic control.

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    Administration on Aging. (2013). Aging statistics. Retrieved from
    American Diabetes Association. (2013). Standards of medical care in diabetes—2013. Diabetes Care, 36(Suppl. 1), S11-S66. doi:10.2337/dc13-S011
    Anagnostopoulos, A., & Giralt, S. (2002). Critical review on non-myeloablative stem cell transplantation (NST). Critical Reviews in Oncology/Hematology, 44, 175-190.
    Antin, J. H. (2002). Clinical practice. Long-term care after hematopoietic-cell transplantation in adults. New England Journal of Medicine, 347, 36-42.
    Appelbaum, F. R., Forman, S. J., Negrin, R. S., & Blume, K. G. (Eds.). (2009). Thomas' hematopoietic cell transplantation: Stem cell transplantation (4th ed.). Chichester, UK: Wiley-Blackwell.
    Barton-Burke, M., Dwinell, D. M., Kafkas, L., Lavalley, C., Sands, H., Proctor, C., & Johnson, E. (2008). Graft-versus-host disease: A complex long-term side effect of hematopoietic stem cell transplant. Oncology (Williston Park), 22(11, Suppl. Nurse Ed), 31-45.
    Butler, S. O., Btaiche, I. F., & Alaniz, C. (2005). Relationship between hyperglycemia and infection in critically ill patients. Pharmacotherapy, 25, 963-976.
    Centers for Disease Control and Prevention. (2011). National diabetes fact sheets: National estimates and general information on diabetes and prediabetes in the Unites States. Retrieved from
    Centers for Medicare and Medicaid Services. (2010). Hospital inpatient perspective payment system. Retrieved from
    Cutler, C., & Antin, J. H. (2005). An overview of hematopoietic stem cell transplantation. Clinics in Chest Medicine, 26, 517-527.
    Dean, R. M., & Bishop, M. R. (2003). Graft-versus-host disease: Emerging concepts in prevention and therapy. Current Hematology Reports, 2, 287-294.
    Derr, R. L., Hsiao, V. C., & Saudek, C. D. (2008). Antecedent hyperglycemia is associated with an increased risk of neutropenic infections during bone marrow transplantation. Diabetes Care, 31, 1972-1977.
    Donihi, A. C., Raval, D., Saul, M., Korytkowski, M. T., & DeVita, M. A. (2006). Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients. Endocrine Practice, 12, 358-362.
    Egi, M., Bellomo, R., Stachowski, E., French, C. J., & Hart, G. (2006). Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology, 105, 244-252.
    Fernandez-Miranda, C., Guijarro, C., de la Calle, A., Loinaz, C., Gonzalez-Pinto, I., Gomez-Izquierdo, T., … del Palacio, A. (1998). Lipid abnormalities in stable liver transplant recipients—Effects of cyclosporin, tacrolimus, and steroids. Transplant International, 11, 137-142.
    Fuji, S., Kim, S. W., Mori, S., Fukuda, T., Kamiya, S., Yamasaki, S., … Takaue, Y. (2007). Hyperglycemia during the neutropenic period is associated with a poor outcome in patients undergoing myeloablative allogeneic hematopoietic stem cell transplantation. Transplantation, 84, 814-820.
    Fuji, S., Kim, S. W., Mori, S., Kamiya, S., Yoshimura, K., Yokoyama, H., … Fukuda, T. (2009). Intensive glucose control after allogeneic hematopoietic stem cell transplantation: A retrospective matched-cohort study. Bone Marrow Transplant, 44, 105-111.
    Garg, R., Bhutani, H., Alyea, E., & Pendergrass, M. (2007). Hyperglycemia and length of stay in patients hospitalized for bone marrow transplantation. Diabetes Care, 30, 993-994.
    Gebremedhin, E., Behrendt, C. E., Nakamura, R., Parker, P., & Salehian, B. (2012). Severe hyperglycemia immediately after allogeneic hematopoietic stem-cell transplantation is predictive of acute graft-versus-host disease. Inflammation, 36, 177-185. doi:10.1007/s10753-012-9533-7
    Godbout, J. P., & Glaser, R. (2006). Stress-induced immune dysregulation: Implications for wound healing, infectious disease and cancer. Jouranl of Neuroimmune Pharmacology, 1, 421-427.
    Goerner, M., Gooley, T., Flowers, M. E., Sullivan, K. M., Kiem, H. P., Sanders, J. E., … Storb, R. (2002). Morbidity and mortality of chronic GVHD after hematopoietic stem cell transplantation from HLA-identical siblings for patients with aplastic or refractory anemias. Biology of Blood and Marrow Transplantation, 8, 47-56.
    Griffith, M. L., Jagasia, M., & Jagasia, S. M. (2010). Diabetes mellitus after hematopoietic stem cell transplantation. Endocrine Practice, 16, 699-706.
    Griffith, M. L., Jagasia, M. H., Misfeldt, A. A., Chen, H., Engelhardt, B. G., Kassim, A., … Jagasia, S. M. (2011). Pretransplantation c-peptide level predicts early posttransplantation diabetes mellitus and has an impact on survival after allogeneic stem cell transplantation. Biology of Blood and Marrow Transplantation, 17, 86-92.
    Hammer, M. J., Casper, C., Gooley, T. A., O'Donnell, P. V., Boeckh, M., & Hirsch, I. B. (2009). The contribution of malglycemia to mortality among allogeneic hematopoietic cell transplant recipients. Biology of Blood and Marrow Transplant, 15, 344-351.
    Hammer, M. J., & Voss, J. G. (2012). Malglycemia and cancer: Introduction to a conceptual model [Online exclusive]. Oncology Nursing Forum, 39, E275-E287. doi:10.1188/12.ONF.E275-E287
    Inzucchi, S. E. (2006). Clinical practice. Management of hyperglycemia in the hospital setting. New England Journal of Medicine, 355, 1903-1911.
    Jones, J. A., Qazilbash, M. H., Shih Y. C., Cantor, S. B., Cooksley, C. D., & Elting, L. S. (2008). In-hospital complications of autologous hematopoietic stem cell transplantation for lymphoid malignancies: Clinical and economic outcomes from the Nationwide Inpatient Sample. Cancer, 112, 1096-1105.
    Karanes, C., Nelson, G. O., Chitphakdithai, P., Agura, E., Ballen, K. K., Bolan, C. D., … Confer, D. L. (2008). Twenty years of unrelated donor hematopoietic cell transplantation for adult recipients facilitated by the National Marrow Donor Program. Biology of Blood and Marrow Transplant, 14(9, Suppl.), 8-15.
    Karnchanasorn, R., Malamug, L. R., Jin, R., Karanes, C., & Chiu, K. C. (2012). Association of hyperglycemia with prolonged hospital stay but no effect on engraftment after autologous hematopoietic stem cell transplantation. Endocrine Practice, 18, 508-518.
    Klein, C. J., Stanek, G. S., & Wiles, C. E., 3rd. (1998). Overfeeding macronutrients to critically ill adults: Metabolic complications. Journal of the American Dietetic Association, 98, 795-806.
    Melnyk, B. M. (2004). Integrating levels of evidence into clinical decision making. Pediatric Nursing, 30, 323-325.
    Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., … Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care, 32, 1119-1131.
    Ninin, E., Milpied, N., Moreau, P., Andre-Richet, B., Morineau, N., Mahe, B., … Richet, H. (2001). Longitudinal study of bacterial, viral, and fungal infections in adult recipients of bone marrow transplants. Clinical Infectious Disease, 33, 41-47.
    Pasquini, M. C. (2013). Current use and outcome of hematopoietic stem cell transplantation: CIBMTR summary slides. Retrieved from
    Pidala, J., Kim, J., Kharfan-Dabaja, M. A., Nishihori, T., Field, T., Perkins, J., … Anasetti, C. (2011). Dysglycemia following glucocorticoid therapy for acute graft-versus-host disease adversely affects transplantation outcomes. Biology of Blood and Marrow Transplantation, 17, 239-248.
    Prieto, J. M., Blanch, J., Atala, J., Carreras, E., Rovira, M., Cirera, E., & Gasto, C. (2002). Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation. Journal of Clinical Oncology, 20, 1907-1917.
    Ramos-Cebrian, M., Torregrosa, J. V., Gutierrez-Dalmau, A., Oppenheimer, F., & Campistol, J. M. (2007). Conversion from tacrolimus to cyclosporine could improve control of posttransplant diabetes mellitus after renal transplantation. Transplantation Proceedings, 39, 2251-2253.
    Rentschler, L. M. (2010). Association between hyperglycemia and hospital lenght of stay in patietns undergoing hematopoeitic stem cell tranplantation. Endocrinologist, 20, 232-235.
    Sheean, P. M., Braunschweig, C., & Rich, E. (2004). The incidence of hyperglycemia in hematopoietic stem cell transplant recipients receiving total parenteral nutrition: A pilot study. Journal of the American Dietetic Association, 104, 1352-1360.
    Sheean, P. M., Freels, S. A., Helton, W. S., & Braunschweig, C. A. (2006). Adverse clinical consequences of hyperglycemia from total parenteral nutrition exposure during hematopoietic stem cell transplantation. Biology of Blood and Marrow Transplantation, 12, 656-664.
    Turina, M., Christ-Crain, M., & Polk, H. C., Jr. (2006). Diabetes and hyperglycemia: Strict glycemic control. Critical Care Medicine, 34(9, Suppl.), S291-S300.
    Van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., … Bouillon, R. (2001). Intensive insulin therapy in critically ill patients. New England Journal of Medicine, 345, 1359-1367.
    Vanhorebeek, I., Langouche, L., & Van den Berghe, G. (2007). Tight blood glucose control: What is the evidence? Critical Care Medicine, 35(9, Suppl.), S496-S502.
    Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546-553. doi:10.1111/j.1365-2648.2005.03621.x