A detailed analysis of the current status of intestinal transplantation in Latin America

Abstract

Purpose of review Latin America and the Caribbean represent a vast territory, with very different economic and healthcare realities, which result in significant disparities in the management of intestinal failure patients throughout the region. Since 1968, multiple attempts have been done to accomplish a successful intestinal transplant; but it was not until 2004, with the establishment of multidisciplinary programs, that large series with long-term results could be obtained. Currently, three countries (Colombia, Argentina, and Brazil) in the region are actively performing these procedures. Recent findings A total number of 135 intestinal transplants have been performed; 11 attempts before 2004, and 124 after that period, 66 transplants were done in Argentina (42 in children), 40 in Colombia, 15 in Brazil (1 child), 2 in Costa Rica and 1 in México; 76% have been isolated, whereas 2 were done with living donors. Summary Publications are still scarce, and compliance to existing registries remains limited. The challenge for the next years is to develop more ‘comprehensive units’ and extend home parenteral nutrition availability in the rest of the region. Regional cooperation and networking need to be set, in order to achieve regional self-sufficiency and improve long-term results.

Postsurgical Intestinal Rehabilitation Using Semisynthetic Glucagon‐Like Peptide‐2 Analogue (sGLP‐2) at a Referral Center: Can Patients Achieve Parenteral Nutrition and sGLP‐2 Independency?

“…Although HPN has become the first‐line and gold‐standard treatment, 4–8 during the last century, the developing field of intestinal transplantation motivated physicians to consider it as the best, albeit the last, alternative for those patients undergoing complications related to replacement therapy. Nevertheless, the long times on the waiting list, lack of appropriate donors, high incidence of rejection, increasing need for experts and teams (not available in every country), and evolving long‐term survival (which, although improving, remains lower than expected for PN) has brought experts to increase the applicability of medical and surgical rehabilitation 17–28 …”

“…Therefore, we wrote a protocol to show the benefit of combining surgery followed by GLP‐2 analogues to reduce this time frame, aiming to minimize PN access–related complications and increase PN‐free time. The results of this initial approach were favorable for patients and have allowed the evolution of new prediction models to assess patients’ possibility of rehabilitation after the procedure, as well as to measure the benefit of using sGLP‐2 for their final anatomy 13,14,20 . These results encouraged us and gave support and reassurance to the insurance companies to admit the need to approve sGLP‐2 use and to recognize the benefit of covering the expensive costs of this drug in a middle‐income country or a country from a global emerging market or economy.…”

“…16,40 Patients unable to rehabilitate continued to receive HPN as the only alternative until complications related to this support developed, and they had to be considered transplant candidates. [17][18][19][20] Recently, the focus has switched to promoting intestinal rehabilitation by using the semisynthetic recombinant analogue of human glucagon-like peptide-2 (sGLP-2), named teduglutide. Native GLP-2 is a meal-stimulated enterohormone secreted by enteroendocrine L cells on the distal ileum and proximal colon that inhibits gastric emptying and gastric acid secretion, stimulates intestinal blood flow, increases intestinal barrier function, and enhances nutrient and fluid absorption, promoting the expansion of the intestinal mucosa via the stimulation of crypt cell growth and enterocyte apoptosis reduction.…”

Rehabilitación del intestino utilizando un Análogo Semisintético del Péptido 2 similar al Glucagón (sGLP-2). Primera experiencia con Teduglutide en Uruguay.

“…(3)(4)(5)(6)(7)(18)(19)(20) No obstante, a pe-sar del desarrollo del trasplante de intestino a nivel mundial, los resultados no han sido los deseados. A esto se suma que existen importantes limitaciones de accesibilidad al procedimiento (15)(16)(17)(18)(19)(20)(21) . Estos hechos han reflotado el interés en el campo de la rehabilitación de pacientes con FIC.…”

“…Se ha promovido la rehabilitación intestinal como objetivo primario para recuperar la suficiencia del intestino e independizarse de la NPC. Los avances en las técnicas quirúrgicas y sobre todo en el tratamiento médico han hecho posible que, hasta pacientes con menos de 20 cm de intestino puedan alimentarse e hidratarse por vía oral sin necesidad de NP o trasplante (15)(16)(17)(18)(19)(20)(21) . Los pacientes con FIC que han logrado resultados favorables en cuanto a su sobrevida y rehabilitación son particularmente aquellos que accedieron a una NPD segura y de calidad, que fueron tratados en centros especializados que cuentan con un programa multidisciplinario compuesto por clínicos, cirujanos, gastroenterólogos, nutriólogos, nutricionistas, enfermeros, psicólogos, intensivistas, infectólogos, paliativistas y asistentes sociales.…”