Individuals with Hematological Malignancies Before Undergoing Chemotherapy Present Oxidative Stress Parameters and Acute Phase Proteins Correlated with Nutritional Status

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Individuals with Hematological Malignancies BeforeUndergoing Chemotherapy Present Oxidative StressParameters and Acute Phase Proteins Correlated withNutritional StatusCarol ina de Quadros Camargoa, Dayanne da Silva Borgesa, Paula Fernanda de Oliveiraa,

Thayz Rodrigues Chagasa, Joanit a Angela Gonzaga Del Moralb, Giovanna St ef fanel lo Durigonb,

Bruno Vieira Diasb, André Guedes Vieirab, Pat rick Gasparet oc, Erasmo Benício Sant os de

Moraes Trindadea & Everson Araúj o Nunesa

a Post graduat e Program in Nut rit ion, Federal Universit y of Sant a Cat arina, Florianópol is,Brazilb Hemat ology Depart ment , Universit y Hospit al of Federal Universit y of Sant a Cat arina,Florianópol is, Brazilc Pharmacy, Universit y Hospit al of Federal Universit y of Sant a Cat arina, Florianópol is, BrazilPubl ished onl ine: 24 Feb 2015.

To cite this article: Carol ina de Quadros Camargo, Dayanne da Silva Borges, Paula Fernanda de Oliveira, Thayz RodriguesChagas, Joanit a Angela Gonzaga Del Moral, Giovanna St ef fanel lo Durigon, Bruno Vieira Dias, André Guedes Vieira, Pat rickGasparet o, Erasmo Benício Sant os de Moraes Trindade & Everson Araúj o Nunes (2015): Individuals wit h Hemat ologicalMal ignancies Before Undergoing Chemot herapy Present Oxidat ive St ress Paramet ers and Acut e Phase Prot eins Correlat ed wit hNut rit ional St at us, Nut rit ion and Cancer, DOI: 10.1080/ 01635581.2015.1004732

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Individuals with Hematological Malignancies BeforeUndergoing Chemotherapy Present Oxidative StressParameters and Acute Phase Proteins Correlatedwith Nutritional Status

Carolina de Quadros Camargo, Dayanne da Silva Borges, Paula Fernanda de Oliveira,

and Thayz Rodrigues ChagasPostgraduate Program in Nutrition, Federal University of Santa Catarina, Florian�opolis, Brazil

Joanita Angela Gonzaga Del Moral, Giovanna Steffanello Durigon, Bruno Vieira Dias,

and Andr�e Guedes VieiraHematology Department, University Hospital of Federal University of Santa Catarina, Florian�opolis,

Brazil

Patrick GasparetoPharmacy, University Hospital of Federal University of Santa Catarina, Florian�opolis, Brazil

Erasmo Ben�ıcio Santos de Moraes Trindade and Everson Ara�ujo NunesPostgraduate Program in Nutrition, Federal University of Santa Catarina, Florian�opolis, Brazil

Hematological malignancies present abnormal blood cells thatmay have altered functions. This study aimed to evaluatenutritional status, acute phase proteins, parameters of cell’sfunctionality, and oxidative stress of patients with hematologicalmalignancies, providing a representation of these variables atdiagnosis, comparisons between leukemias and lymphomas andestablishing correlations. Nutritional status, C-reactive protein(CRP), albumin, phagocytic capacity and superoxide anionproduction of mononuclear cells, lipid peroxidation and catalaseactivity in plasma were evaluated in 16 untreated subjects. Maindiagnosis was acute leukemia (n D 9) and median body massindex (BMI) indicated overweight (25.6 kg/m2). Median albuminwas below (3.2 g/dL) and CRP above (37.45 mg/L) the referencevalues. Albumin was inversely correlated with BMI (r D ¡0.53).Most patients were overweight before the beginning of treatmentand had a high CRP/albumin ratio, which may indicate anutrition inflammatory risk. BMI values correlated positivelywith lipid peroxidation and catalase activity. A strong correlationbetween catalase activity and lipid peroxidation was found (r D0.75). Besides the elevated BMI, these patients also have elevatedCRP values and unexpected relations between nutritional statusand albumin, reinforcing the need for nutritional counselingduring the course of chemotherapy, especially considering the

correlations between oxidative stress parameters and nutritionalstatus evidenced here.

INTRODUCTION

Cancer is characterized by uncontrolled growth of cells

which might invade tissues and metastasize to distant sites,

causing the host morbidity and, in some cases, death (1).

Hematological malignancies are usually initiated in blood-

forming or immune-related tissues, which start to produce

abnormal cells. The most prevalent diseases in such group are

leukemias and lymphomas. In individuals with leukemia, leu-

kocytes do not perform adequately normal functions and cells

remain for a longer time in the bloodstream. Leukemias can be

divided into chronic and acute forms. The former is character-

ized by slower development and gradual worsening of cell

functions, whereas acute leukemia is characterized by a rapid

increase of abnormal cells in the bloodstream. Lymphomas

can be divided into Hodgkin lymphoma and non-Hodgkin’s,

malignant diseases of the lymphatic system, also considered

hematological malignancies (2).

Mononuclear cells are a heterogeneous group of leukocytes

with several distinct functions. The interaction among them is

responsible for many attributes of the immune system. As an

example, monocytes are recruited to tissues to promote death

of pathogens through the release of reactive oxygen (ROS)

Submitted 17 September 2013; accepted in final form18 November 2014

Address correspondence to Carolina de Quadros Camargo, Post-graduate Program in Nutrition, Federal University of Santa Catarina,Florian�opolis, Brazil. E-mail: [email protected]

1

Nutrition and Cancer, 0(0), 1–9

Copyright � 2015, Taylor & Francis Group, LLC

ISSN: 0163-5581 print / 1532-7914 online

DOI: 10.1080/01635581.2015.1004732

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and nitrogen species, phagocytosis of microorganisms and cell

debris, and also to perform antigen presentation to T cells, trig-

gering a specific defense both against microorganisms and, in

some cases, neoplastic cells. As the functionality of one or sev-

eral immune cells can be altered in hematological malignan-

cies, it is difficult to foresee how such cells are operating in

these diseases (3,4).

Production of ROS and antioxidant enzymes activity are

also altered in patients with hematological malignancies (5).

When not properly neutralized by antioxidant enzymes, reac-

tive species can trigger the formation of chain reactions with

polyunsaturated fatty acids present in the cells’ membrane

lipid bilayer, a process called lipid peroxidation (6). However,

the production of ROS may exert different actions on prolifer-

ation or survival of cells. Although oxidative stress is com-

monly discussed as an important character in carcinogenesis,

malignant cells are also usually sensitive to lipid peroxidation

products (7). Therefore, it is important to know how some of

these parameters are established in these diseases.

Besides the issues regarding cells functionality and the bal-

ance between oxidative stress and antioxidant systems, the

nutritional state is an additional relevant clinical aspect in can-

cer patients. Especially during the course of treatment, acute

phase proteins can be altered as well as the nutritional state

which can be negatively affected, compromising the prognosis

and survival of these patients (8,9). Therefore, to know the

pretreatment nutritional state in such diseases might be an

effective strategy to foreseen, at least in part, the capacity of

the subject in resisting the aggressiveness of the therapeutic

process. Furthermore, the relation between the pretreatment

nutritional state and mononuclear cells functionality is not

completely known in hematological malignancies.

Considering the functionality of mononuclear cells and oxi-

dative stress in hematological malignancies, the relevance of

these parameters and the unknown relations of them with the

pre-treatment nutritional state in these diseases, this study

aimed these parameters in leukemia and lymphoma patients.

In addition, differences among these variables between both

diagnosis and correlations were assayed.

METHODS

This is a descriptive study of the patients diagnosed with

hematological malignancies at the University Hospital of the

Federal University of Santa Catarina, before initiating chemo-

therapy treatment, recruited between November 2012 and

April 2013. All procedures involving human subjects were

approved by the Human Research Ethics Committee of the

Federal University of Santa Catarina. Inclusion criteria were

16 yr or more, hematological malignancy diagnosis, and indi-

cation of chemotherapy treatment. Exclusion criteria included

palliative care, radiotherapy, impossibility of oral ingestion, a

diagnosis of infectious disease, and treatment that included

statins and/or antiinflammatory medicines. All recruited

patients, who accepted to participate, gave written informed

consent. Data collection was performed at the University Hos-

pital of the Federal University of Santa Catarina. At study

entry, anthropometric data were collected and a blood sample

taken, immediately prior to initiating chemotherapy. Nutri-

tional status, C-reactive protein (CRP), and albumin were

assessed. Mononuclear cells’ functions were assessed by

phagocytosis of zymosan and superoxide anion production. To

assess oxidative stress parameters, plasma catalase activity

and plasma lipid hydroperoxides were evaluated.

Nutritional Status and Characterization Data

Anthropometric data were measured by a nutritionist, using

a platform digital scale, Tanita�, model A 061 (Company

Tanita Corporation, Tokyo, Japan), and an inelastic tape to

measure weight and height, respectively. The usual weight

(last 6 mo) was self-reported by the participant. Triceps skin-

folds were measured with Lange Skinfold Caliper California�

anthropometer (Beta Technology Incorporated, Santa Cruz,

CA) and arm circumference [used to calculate mid-upper arm

muscle circumference (MUAMC)] with an inelastic tape. The

adequacy of the MUAMC was calculated dividing mid-upper

arm muscle circumference obtained by mid-upper arm muscle

circumference of the 50th percentile considering sex and age

of the individual, according to Frisancho (10). All anthropo-

metric measurements followed standard techniques (11). Body

mass index (BMI) was calculated dividing weight by the

square of the height (11) and percentage of weight loss (in the

last 6 mo) was the ratio between the difference of the current

and usual weight and current weight of the individual, multi-

plied by 100. Date of birth, diagnosis and comorbidities were

obtained from the patient’s chart.

Isolation of Plasma and Mononuclear Cells

Venous blood samples were collected into tubes containing

lithium-heparin as anticoagulant. Blood was centrifuged

(400 g) and the plasma was collected after centrifugation and

frozen immediately at ¡80�C for posterior catalase and lipid

peroxidation assays. Mononuclear cells were isolated by cen-

trifugation on a Ficoll-PaqueTM PLUS gradient. Cells were

collected and washed twice with saline. Afterwards, cells were

resuspended in RPMI 1640 culture medium (Sigma-Aldrich

Co., St. Louis, MO, USA) and the number of cells was deter-

mined using an automated cell counter (Advia� 60 Hematol-

ogy System, Bayer, Leverkusen, Germany). Cells were used

for functional assays immediately after cell isolation.

Cell Adhesion

An aliquot of a suspension containing 106 mononuclear

cells/ml was placed in each assay well of a 96-well cell culture

plate and incubated at 37�C for 1 h. The culture medium was

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discarded and 50% methanol was added for fixation. After

10 min, a Giemsa solution was added and incubated for addi-

tional 40 min at room temperature. The supernatant was dis-

carded and the wells were washed. Finally, 50% methanol was

added and, after 30 min at room temperature, the plates were

read at 550 nm using a microplate reader (12) (Apollo-8

Absorbance Microplate Reader LB 912, Berthold Technolo-

gies GmbH & Co. KG, Bad Wildbad, Germany).

Phagocytosis of Zymosan by Mononuclear Cells

The method described by Pipe et al. (13) was adapted.

Mononuclear cells were seeded in 96-well flat-bottomed tissue

culture plates (105 cells in 100 mL). Neutral red-stained zymo-

san was added and the plates were incubated for 30 min.

Then, cells were fixed with Baker’s formol-calcium solution

(4% formaldehyde, 2% sodium chloride, 1% calcium acetate)

for 30 min. The neutral red stain was extracted with 0.1 mL of

acidified alcohol (10% acetic acid, 40% ethanol in distilled

water) for 30 min. The absorbance was read on a microplate

reader at 550 nm and the results normalized by cell adhesion.

Superoxide Anion Production by Mononuclear Cells

Superoxide anion production by mononuclear cells was

measured by the reduction of nitroblue tetrazolium, using the

method described by Choi et al. (14). Suspensions containing

105 mononuclear cells were incubated at 37�C in the presence

of phorbol 12-myristate 13-acetate and nitroblue tetrazolium.

Then, cells were fixed with 50% methanol for 10 min and air-

dried. Reduction of nitroblue tetrazolium results in the forma-

tion of blue formazan, which was solubilized by 30 min incu-

bation with potassium hydroxide and dimethyl sulfoxide per

well. The absorbance was read at 550 nm and the results were

normalized by cell adhesion.

Plasma Catalase Activity

This assay was adapted from the procedures described by

Aebi (15). Data were expressed as mmol of consumption of

H2O2 per minute and normalized by plasma protein concentra-

tion (protein concentration was measured using the method of

Bradford) (16).

Plasma Lipid Hydroperoxides

The method described by Nourooz-Zadeh et al. (17) was

used. The plasma was homogenized with methanol and then

centrifuged. The supernatant was transferred to 6 wells of a

96-well plate; 3 of these wells triphenyl phosphate (TPP) was

added and only methanol was added in the remaining three.

The samples were incubated for 30 min and then added a

FOX-2 solution and incubated again. The absorbance was read

at 550 nm. The value of absorbance of the samples treated

with TPP was subtracted from the absorbance value of the

samples without TPP, a standard curve is made with known

concentrations of hydrogen peroxide. The results were

expressed in mmol /mg of protein.

Quantification of CRP, Albumin, and Hemogram

CRP was determined by immunonephelometry (Siemens

Dade Behring Inc., Newark, DE) (18) and albumin was deter-

mined by an automated colorimetric method (Siemens Health-

care Diagnostics Inc., Newark, DE) using bromocresol purple

as a color reagent (19). To obtain a complete blood count an

automated hematology analyzer Sysmex XE-2100D (Sysmex

Corporation, Kobe, Hyogo, Japan) was used.

Statistical Analyses

Quantitative variables are presented as median and inter-

quartile range considering all were asymmetric. Categorical

variables are presented in categories and frequencies. To cor-

relate variables, Pearson or Spearman tests were used accord-

ing to data distribution, after logarithmic transformation. To

compare results of leukemias and lymphomas diagnosis,

Mann-Whitney test was used, differences were considered sta-

tistically significant at P < 0.05. Statistical analyses were per-

formed using STATA� statistical software version 11.0 for

Windows (StataCorp, TX).

RESULTS

Characteristics of the Study Subjects

Thirty-seven new patients diagnosed with hematological

malignancies were treated by the medical staff at the Univer-

sity Hospital of the Federal University of Santa Catarina in the

period of November 2012 to April 2013. Of these, 19 were not

considered eligible for the present study according to the

exclusion criteria. Of the 18 eligible subjects, 2 refused to

FIG. 1. Flowchart describing the process of entry into the study.

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participate. Thus, 16 patients were included in the study and

participated in data collection, as flowchart presented in Fig. 1.

Ten subjects were female (62.5%) with the median age of

47 yr old, ranging between 18.7 and 79.6 yr. The primary

diagnosis of hematologic malignancy was acute leukemia, rep-

resented by 9 individuals (56.2%). Other diagnoses were

chronic leukemia, Hodgkin’s lymphoma, non-Hodgkin’s

lymphoma, and multiple myeloma. Nine patients had no

comorbidities, the remaining 7 presented osteoporosis, type II

diabetes, hypertension, rheumatoid arthritis, depression, gastri-

tis, gastric ulcer, hiatal hernia, esophagitis, hypothyroidism.

Such data are summarized in Table 1.

Nutritional Status, Acute Phase Proteins, and Hemogram

Nutritional state variables, acute phase proteins, and hemo-

gram data are shown in Tables 2 and 3. Regarding nutritional

variables, shown in Table 2, BMI, percentage of weight loss,

and adequacy of mid-upper arm muscle circumference, it was

observed that most of the individuals was overweight accord-

ing to BMI (median D 25.6 kg/m2). Despite the large varia-

tion, the median percentage of weight loss was 0.96%, not

considered a significant loss according to the classification of

Blackburn et al. (20). The median adequacy of mid-upper arm

muscle circumference (99.5%) indicates that individuals were

well nourished according to this parameter. The median values

of albumin, hematocrit, hemoglobin, red blood cells count,

and platelets were lower than the reference values. CRP was

648% higher than the reference value (median D 37.45 mg/L).

For MUAMC, both diagnoses presented similar results, BMI

was slightly higher at p75 in leukemias patients, and, in gen-

eral, lymphoma patients presented lower BMI values. Albumin

concentrations were heterogeneous in patients with leukemia

and were slightly higher (6.4%) than in patients with lym-

phoma, these differences were not significant.

Description of the Parameters of Mononuclear Cells’Functionality and Plasma Oxidative Stress

Results for phagocytic capacity and superoxide anion pro-

duction of mononuclear cells, plasma catalase activity and

plasma lipid peroxidation are shown in Figure 2. Median of

phagocytic capacity was 77.9% higher in patients diagnosed

with lymphoma compared to those diagnosed with leukemia,

but this difference was not statistically significant. On the

other hand, superoxide anion production by mononuclear cells

and plasma catalase activity were 231.6% and 73.8%, respec-

tively, higher in leukemia than in patients with lymphoma. For

lipid peroxidation, the median values were almost the same

for both diagnoses, although the values for leukemia were

more heterogeneous than for lymphomas.

Correlations Between Study Variables

Some variables were selected to be correlated. Of all corre-

lations analysis performed in this study, only the relevant were

chosen to be presented here. Albumin had a moderate inverse

correlation with BMI (r D ¡0.53), with the adequacy of

MUAMC (r D ¡0.35) and a moderate and positive correlation

with percentage of weight loss (r D 0.68). Furthermore, CRP

correlated weakly and positively with BMI (r D 0.17), moder-

ate and positively with adequacy of MUAMC (r D 0.32), and

moderately and inversely with percentage of weight loss (r D

¡0.55). Considering mononuclear cell functions and nutri-

tional status correlations, only phagocytic capacity and BMI

had a moderate and inverse correlation (r D ¡0.31).Other cor-

relations were considered weak (data not shown). Catalase

activity had a moderate and positive correlation with BMI and

MUAMC (r D 0.42 and 0.41, respectively) and a moderate

inverse correlation with percentage of weight loss. Lipid

hydroperoxides were also moderately correlated with BMI

(r D 0.37) and percentage of weight loss (r D ¡0.42). Super-

oxide anion production had a weak and inverse correlation

with plasma catalase activity (r D ¡0.13) and a weak positive

correlation with plasma lipid peroxidation (r D 0.26). Plasma

lipid peroxidation had a strong and positive correlation with

plasma activity of catalase (r D 0.75).

DISCUSSION

The individuals studied here were overweight, according to

BMI, unlike what is usually expected in cancer patients. In

such diseases the deterioration of the patients’ nutritional sta-

tus apparently occurs after the beginning of treatment, and

probably as a consequence of it. Malihi et al. (21) conducted a

study to monitor the nutritional status of patients older than

15 yr diagnosed with acute leukemia before and after

TABLE 1

Participant characteristics (n D 16)

Variable n %

Gender

Female 10 62.5

Male 6 37.5

Age – Mean (minimum; maximum) 16 47 (18.70; 79.60)

Diagnosis

Acute Leukemia 9 56.2

Chronic Leukemia 1 6.2

Hodgkin Lymphoma 2 12.5

Non-Hodgkin Lymphoma 3 18.7

Multiple Myeloma 1 6.2

Comorbidities

Absent 9 56.3

Present 7 43.7

Comorbidities: Osteoporosis, type 2 diabetes, hypertension, rheumatoid arthritis,depression, gastritis, gastric ulcer, hiatal hernia, esophagitis, hypothyroidism.

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chemotherapy. They observed that, before chemotherapy,

none of the patients, assessed by Patient-Generated Subjective

Global Assessment, presented severe malnutrition (19.05%

were moderately malnourished and 80.95% were eutrophic).

Otherwise, after chemotherapy, 76.01% were classified as

moderately malnourished, 15.87% were severely malnour-

ished, and only 7.94% were eutrophic. Noteworthy, the pres-

ence of weight excess and obesity for such patients early in

treatment might be considered advantageous. Brunner et al.

(22) evaluated the association between BMI at diagnosis and

survival of patients with 60 yr or older with acute myeloid leu-

kemia. Mortality risk increased for patients with a BMI less

than 25 kg/m2 compared to those with BMI higher than or

equal to 30kg/m2. Similarly, Medeiros et al. (23) assessed the

BMI of 1974 adult patients with acute myeloid leukemia,

before chemotherapy treatment, and found that obesity was

associated with better response to the treatment and survival

rates equivalent to those of eutrophic individuals. Better sur-

vival rates were also observed in obese or overweight patients

with lymphoma and diffuse large B cell lymphoma, a type of

non-Hodgkin lymphoma (24).

Evaluation of serum albumin is considered a simple method

for estimating visceral proteins. Malnutrition and systemic

inflammation suppress the synthesis of albumin (25), charac-

terizing it as a negative acute phase protein. In the present

study we found similar concentration of albumin (but lower

than the reference values) for both diagnoses, though slightly

higher for diagnoses of leukemia. Correlating values of serum

TABLE 2

Body weight, height, body mass index, percentage of weight loss, adequacy of mid-upper arm muscle circumference, C-reactive

protein (CRP), albumin and CRP/Albumin ratio of untreated subjects with hematological malignancies (n D 16)

Parameter Median (IQR) Reference value

Body weight (kg) —

All subjects 68.7 [63.7; 79.7]

Leukemia (n D 10) 70.9 [66.0; 81.3]

Lymphoma (n D 5) 64.0 [63.5; 64.6]

Height (m) —

All subjects 1.63 [1.54; 1.73]

Leukemia (n D 10) 1.61 [1.53; 1.80]

Lymphoma (n D 5) 1.60 [1.59; 1.67]

Body mass index (kg/m2) 18.5–24.9

All subjects 25.6 [24.0; 29.2]

Leukemia (n D 10) 26.5 [24.9; 28.2]

Lymphoma (n D 5) 22.7 [22.4; 25.5]

Percentage of weight loss in the last 6 months (%) —

All subjects 0.96 [-1.43; 5.76]

Leukemia (n D 10) 4.64 [0.00; 6.30]

Lymphoma (n D 5) -0.54 [-0.79; -0.13]

Adequacy of mid-upper arm muscle circumference (%) —

All subjects 99.5 [86.9; 111.1]

Leukemia (n D 10) 103.9 [86.9; 111.1]

Lymphoma (n D 5) 95.3 [86.3; 106.3]

Serum CRP (mg/L) < 5.0

All subjects 37.4 [7.2; 68.8]

Leukemia (n D 10) 26.1 [7.6; 54.4]

Lymphoma (n D 5) 63.9 [6.8; 91.5]

Serum Albumin (g/dL) 3.4–5.0

All subjects 3.2 [2.8; 3.6]

Leukemia (n D 10) 3.3 [2.8; 3.6]

Lymphoma (n D 5) 3.1 [3.1; 3.4]

CRP/Albumin ratio —

All subjects 13.7 [2.0; 23.6]

Leukemia (n D 10) 8.9 [2.1; 18.1]

Lymphoma (n D 5) 20.6 [2.0; 31.5]

IQR: Interquartile Range; CRP: C-Reactive Protein.

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albumin of both diagnoses with indicators of nutritional status,

a moderate inverse correlation was observed with BMI and

MUAMC and strong and positive with percentage of weight

loss. It is expected, in principle, that a better nutritional status

(greater BMI, better adequacy of MUAMC, and less percent-

age of weight loss) would also lead to a greater concentration

of serum albumin, whereas the opposite was found. Consider-

ing newly diagnosed patients were evaluated, it can be pro-

posed that the correlations presented here might be a sign that

physiological changes do not present the same timing when

compared to anthropometrical ones. In hematological malig-

nancies there is another interesting point to be considered in

the relation between albumin and BMI, the prevalence of such

diseases seems to present a direct relation to overweight and

obesity (26,27). Therefore, the expected correlation between

serum albumin and BMI might be disrupted in these diseases

due to commonly high BMI values presented by these patients.

The same unexpected relation with BMI was seen when

CRP and BMI data were contrasted. CRP is a positive acute

phase protein that has its synthesis increased in the liver when

this organ is stimulated by mediators (28) produced by normal

and malignant cells. CRP values were higher in patients with

lymphoma than those with leukemia. Studies consider CRP as

an independent predictor of clinical outcomes or a parameter

for prognosis in patients with certain types of lymphomas

(29,30). As a consequence of high CRP and low albumin

serum concentrations, the ratio between such variables

resulted high values, this parameter may indicate inflammatory

nutritional risk (31). Therefore, a close attention to these

patients must be paid during their clinical course.

In hematological malignancies, it is important to assess the

leukocytes functionality, especially considering that undiffer-

entiated cells and that the chemotherapy treatment might

increase morbidity and mortality of these patients (32). Hof-

mann et al. (33) observed that newly diagnosed patients with

myeloid or acute lymphoblastic leukemia had lower neutrophil

phagocytic capacity than healthy individuals. Hubel et al. (34),

which evaluated the phagocytic capacity of neutrophils from

patients with acute nonlymphocytic leukemia before chemo-

therapy, found that patients with higher phagocytic capacity

also had fewer or milder infections than patients with lower

phagocytic capacity. It is expected, therefore, as shown in this

study, that leukemia patients present a lower mononuclear

cells’ phagocytic capacity compared to patients with lympho-

mas, probably due to the greater number of blast cells in the

peripheral blood. Noteworthy, a moderate and inverse correla-

tion was found between phagocytic capacity and BMI, sug-

gesting that weight excess may be linked with an impaired

leukocyte function in these patients.

Leukemia patients demonstrated greater superoxide anion

production when compared to patients with lymphoma,

although this difference was not significant. Leukemic cells

contain high concentrations of reactive oxygen species, due to

changes in pro and antioxidant pathways. Increased production

TABLE 3

Hematological parameters of subjects with untreated hematological malignancies (n D 16)

Parameter Median (IQR) Reference value

Hematocrit (%) M: 40.0–52.0 / F: 37.0–47.0

All subjects 25.4 [20.6; 35.9]

Leukemia (n D 10) 21.3 [20.4; 25.4]

Lymphoma (n D 5) 36.1 [30.5; 196.6]

Hemoglobin (g/dL) M: 13.0–18.0 / F: 12.0–16.0

All subjects 8.3 [7.2; 11.8]

Leukemia (n D 10) 7.6 [6.9; 8.8]

Lymphoma (n D 5) 11.9 [9.8; 64.0]

Erythrocytes (106/mm3) M: 4.5–6.0 / F: 4.0–5.2

All subjects 2.5 [2.2; 4.1]

Leukemia (n D 10) 2.2 [2.1; 2.8]

Lymphoma (n D 5) 4.4 [3.6; 215.3]

Leukocytes (cells/mm3) 3.800–11.000

All subjects 7860 [4840; 22480]

Leukemia (n D 10) 11205 [5300; 27370]

Lymphoma (n D 5) 6490 [3955; 8535]

Platelets (units/mm3) 150.000–440.000

All subjects 58000 [33000; 136000]

Leukemia (n D 10) 47500 [28000; 74000]

Lymphoma (n D 5) 159000 [136000; 242000]

IQR: Interquartile Range; M: Male; F: Female.

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of reactive species may be either due to activation of onco-

genes and as a result of mutations independent of oncogenic

activity in mitochondria and cytochrome p450, for example

(5). According to Er et al. (35), the generation of superoxide

anion by leukocytes was significantly higher in patients with

acute myeloid leukemia than in healthy individuals. The super-

oxide anion seems to promote a malignant phenotype in

tumoral (36) environment. Increased production of superoxide

anion in leukemia patients, as observed in the present study,

may promote genetic instability, higher survival, cell growth

and motility, lipid peroxidation, amino acid oxidation, and

damage to DNA (5), if in imbalance with antioxidant protec-

tion. Superoxide dismutase is the enzyme responsible for the

dismutation of superoxide anion into molecular oxygen and

hydrogen peroxide, which is then processed by the catalase

enzyme (5). The correlations between superoxide anion, cata-

lase activity, or lipid peroxides concentration were mostly

weak. This was probably because the superoxide anion was

assessed in mononuclear cells and other parameters were

assayed in plasma. It is worthy to mention that superoxide

anion production is not always modified in hematological

malignancies (37).

As previously mentioned, superoxide dismutase enzyme

reduces concentrations of superoxide anion, creating hydrogen

peroxide, which is decomposed into a hydroxyl radical and

can cause cellular damage. Catalase, in turn, coordinates the

decomposition of 2 molecules of hydrogen peroxide to water

and molecular oxygen (5). Zelen et al. (37) evaluated catalase

activity in plasma of untreated patients with chronic lympho-

cytic leukemia (CLL) and observed an increment in such

activity compared to the activity of healthy individuals. The

same authors also noted that disease progression was associ-

ated with significantly higher catalase activity. In myeloid leu-

kemias, high catalase activity contributes both to disease

progression and resistance to therapy, as a tumor promoter. On

the other hand, in lymphocytic leukemia, reduced catalase

activity contributes to the acquisition of a genomic instability,

favoring mutations, lower defense against peroxides, and a

permissive environment for secondary mutations (5).

Collado et al. (38) evaluated the catalase activity of circu-

lating lymphocytes from untreated patients with CLL and

observed lower activity of this enzyme when compared with

healthy subjects. Zaric et al. (39), also when evaluating

patients with CLL in different stages of the disease, found that

catalase activity in plasma of patients with more advanced dis-

ease was higher than in healthy controls and in patients with

less advanced disease, whereas activity in the cell lysate was

lower. Differences can arise due to experimental conditions

FIG. 2. Phagocytic capacity (A) and superoxide anion production (B) by peripheral mononuclear cells. Plasma lipid hydroperoxides (mmol/mg of protein) (C)

and catalase activity (mM/min/mg of protein) (D) of nontreated subjects with leukemia (n D 10) or lymphoma (n D 5).

HEMATOLOGICAL MALIGNANCIES AND NUTRITIONAL STATUS 7

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and working methods (39) still, as pointed out by Irwin et al.

(5), catalase seems to have contradictory roles depending on

type of leukemia and treatment status. In the present study,

there was a wide variation for both catalase activity and for

lipid peroxidation in subjects with leukemia, such variation

may be due to leukemia types and disease stage.

As Zelen et al. (37), who observed an increase in both cata-

lase activity and lipid peroxidation products in plasma of indi-

viduals with CLL, a strong positive correlation between

catalase activity and plasma lipid hydroperoxides was also

revealed in the present study. This might indicate that higher

concentrations of lipid peroxides can promote stimulation of

antioxidant enzymatic system, at least involving catalase, in

these patients. However, lipid peroxides concentration are not

always high in hematological malignancies as showed by the

study of Devi et al. (40), which assessed lipid peroxidation in

plasma of patients with different types of leukemia before

treatment. In the same study, although the generation of super-

oxide anion was high, they found no difference for this param-

eter among the various diagnoses of leukemia.

Similar correlations were found when analyzing if catalase

activity and lipid hydroperoxides were in some way related to

nutritional status, indicating that patients with higher BMI val-

ues and lower percentage of weight loss had higher values of

catalase activity and lipid hydroperoxides. Furukawa et al.

(41) investigating if the oxidative stress was increased in obese

individuals, also positively correlated lipid peroxidation (eval-

uated as plasma thiobarbituric acid reactive substances) with

BMI and waist circumference. Ahmad et al. (42,43), evaluated

lipid peroxidation measuring thiobarbituric acid reactive sub-

stances and lipid hydroperoxides, in subjects with chronic

myeloid leukemia, observed an increase in the lipid peroxida-

tion comparing with values of healthy individuals. The study

of Ahmad et al. (42) have attributed such finding to the

increased generation of free radicals or inadequate clearance

of these species by the antioxidant enzymes. In contrast, the

present study observed a weak correlation between generation

of superoxide anion and lipid peroxidation, the generation of

superoxide anion might be balanced by greater antioxidant

enzyme response. Although we cannot confirm this hypothe-

sis, future studies can be planned to assess such question.

Limitations due to factors such as the heterogeneity of the

diagnoses and the restricted number of subjects included need

to be mentioned. Another limitation found in this study was

the wide age range of the participants, this difference can lead

to biological variation in parameters of cell functionality as

well as differences in oxidative stress parameters and nutri-

tional status of individuals. Future studies must control these

potential confusing factors.

CONCLUSION

Individuals with hematological malignancies are mostly

overweight, according to BMI. This observation might be

responsible to the disruption of the expected relations between

serum albumin or CRP and BMI in clinical nutrition. These

patients also presented clinically relevant alterations in serum

albumin and CRP, suggesting a high nutritional inflammatory

risk. Mononuclear cell functions tend to be decreased in leuke-

mia, when compared to patients with lymphoma. BMI values

correlated inversely with phagocytic capacity of mononuclear

cells, and positively with lipid peroxidation and catalase activ-

ity. In plasma, a strong correlation between plasma lipid per-

oxides concentration and catalase activity was observed. This

information can be potentially applied in further studies to

investigate oxidative stress in these patients with repercussions

to antineoplastic therapy and nutritional interventions. The

findings of the present study reinforce that, besides their BMI,

patients with hematological malignancies require nutritional

counseling. This is especially relevant considering that chemo-

therapy treatment can potentially seriously over compromise

the nutritional status.

ACKNOWLEDGMENTS

We thank the Postgraduate Program in Nutrition, Federal

University of Santa Catarina; Coordination of Improvement of

Higher Education Personnel; National Council for Scientific

and Technological Development; Hematology and Oncology

Department, University Hospital of Federal University of

Santa Catarina; and Luiz Felipe de Souza, student of the Labo-

ratory of Cellular Defenses, for his help in the analysis of cata-

lase activity.

FUNDING

Financial support was provided by the Postgraduate Pro-

gram in Nutrition, Federal University of Santa Catarina; the

National Council for Scientific and Technological Develop-

ment; and the Scholarship Program-Social Demand-Coordina-

tion of Improvement of Higher Education Personnel.

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