Intestinal transplantation: Indications and prospects

Abstract

Intestinal transplantation (IT) can involve small bowel transplantation alone, or be associated with liver or multivisceral transplantation. Although IT is the radical treatment for intestinal failure, home parenteral nutrition (PN) remains the treatment of choice for this disease. Indications for IT are still debated. A recent study showed that early referral for IT is recommended for patients with life-threatening combined liver and intestinal failure or for patients with invasive intra-abdominal desmoid tumors. In the same study, no survival benefit was shown for patients undergoing IT for ultra-short bowel or major complications related to the PN catheter; indications still need to be fully assessed. While short-term outcomes for IT have improved dramatically (one-year survival for small bowel-alone IT is now 80% versus 0-28% in the 1980s), long-term outcomes have not improved much since the introduction of Tacrolimus in the 1990s: five-year survival still does not exceed 60%. Some prospective developments could improve these results: the use of multivisceral grafts, the use of Sirolimus and Thymoglobulins in the immunosuppressive treatment, or the use of new biochemical markers for early diagnosis of graft rejection.

Assessing Non-Invasive Liver Function in Patients with Intestinal Failure Receiving Total Parenteral Nutrition—Results from the Prospective PNLiver Trial

“…This reflects advances in PN mixtures, medical treatments, and patient-centred multidisciplinary care [23]. However, progressive liver disease and the loss of central venous access are limiting factors for long-term survival and are still leading indications for small bowel transplantation in patients with IF [24]. The ability to detect early liver dysfunction is vitally important for appropriately timing specialist referrals and determining the correctly indicated transplantation, as higher mortality is seen in intestine-liver transplantations than in intestine-alone transplantations [25,26].…”

“…Data presented as mean ± standard deviation. SBS-QoL, Short Bowel Syndrome-Quality of Life.The SF-36 Physical Component Summary (PCS) showed a significant improvement in quality of life from baseline to 6 months (29(24)(25)(26)(27)(28)(29)(30)(31)(32)(33) vs. 39(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46); 0.002), stayed constant between the 6 and 12 month time points(39 (31-46) vs. 36(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46); p = 0.069) and slightly improved between 12 and 24 months (36(30)(31)(32)(33)(34)(35)...…”

Novel Therapeutic Approaches for Mitigating Complications in Short Bowel Syndrome

“…mTOR is known to regulate biological processes such as translation, ribosome genesis, glucose metabolism, and hypoxic injury response [ 101 ]. Rapamycin use is well documented as an immunosuppressive for intestinal transplant in extreme cases of SBS, as well as management of peritoneal sclerosis [ 15 , 102 , 103 , 104 , 105 , 106 ]. However, in the context of SBS and TPN induced injury, rapamycin has been shown to be useful as a therapeutic for autophagy reduction in PNALD.…”

Orthotopic Liver Transplantation: Indications and Contraindications

“…Initial signs of liver involvement by intestinal failure are hypersplenism and bilirubinemia. High levels are in favor of CLIT/MVT; in case of intermediate values, indication for CLIT/MVT is based on histology and liver function (translated by signs of portal hypertension, encephalopathy, hypoalbuminemia, and coagulation disorders) (Beyer-Berjot et al 2012).…”