Dynamic nutritional changes between relapse and second allogeneic transplantation predict survival in acute leukemia

Relapse after a first allogeneic hematopoietic stem cell transplantation (HSCT1) remains a major therapeutic challenge in acute leukemia, and second transplantation (HSCT2) is frequently considered for selected patients. Although pre-transplant nutritional status has been associated with outcomes after HSCT2, the prognostic significance of changes in nutritional status between relapse and HSCT2 remains unclear. This multicenter retrospective study analyzed 67 patients with acute myeloid leukemia or acute lymphoblastic leukemia who underwent HSCT2 after relapse following HSCT1. Nutritional status was evaluated using serum albumin, Geriatric Nutritional Risk Index (GNRI), and body mass index (BMI) at relapse and before HSCT2. In multivariate analysis, declines in serum albumin and GNRI during this interval were independently associated with inferior overall survival, whereas BMI decline was not significant. Declines in albumin and GNRI were significantly associated with impaired performance status, but not associated with disease status at HSCT2 or treatment intensity after relapse. A composite model integrating nutritional decline and disease status at HSCT2 stratified patients into distinct prognostic groups. These findings suggest that declines in nutrition-associated indices during the relapse-to-HSCT2 interval may reflect impaired physiological reserve and provide additional prognostic information beyond disease status at transplantation.