Pediatric Intestinal Transplant Listing Criteria – A Call for a Change in the New Era of Intestinal Failure Outcomes

Abstract

Current listing indications used for intestinal transplantation (IT) were proposed in 2001. We undertook the present single center study to see if these criteria are still valid. The 2001 criteria (advanced cholestasis, loss of >50% central venous catheter (CVC) sites, !2 sepsis/year, ultrashort bowel) were compared in children with intestinal failure in old era-1998-2005 (N ¼ 99) to current era-2006-2012 (N ¼ 91) to predict the need for IT using sensitivity, specificity, NPV and PPV. Two 2001 criteria had poorer predictive value in the current era: Advanced cholestasis (PPV 64% old vs. 40% current era; sensitivity 84% vs. 65%, respectively) and ultrashort bowel (PPV 100% old vs. 9% current era; sensitivity 10% vs. 4%, respectively). Three newly proposed criteria had high predictive value: !2 ICU admissions (p ¼ 0.0001, OR 23.6, 95% CI 2.7-209.8), persistent bilirubin >75 mmol/L despite lipid strategies (p ¼ 0.0005, OR 24.0, 95% CI 3.2-177.4), and loss of !3 CVC sites (p ¼ 0.0003, OR 33.3,).There was 98% probability of needing IT when two of these new criteria were present. The 2001 IT criteria have limited predictive ability in the current era and should be revised. A multicenter study is required to validate the findings of this single center experience.

Visceral transplantation in patients with intestinal-failure associated liver disease: Evolving indications, graft selection, and outcomes

“…In a single center study evaluating pediatric patients treated in a modern era, historical listing criteria were no longer predictive of mortality or need for transplantation. (67) In this study, cholestasis was only predictive if a patient failed 6 weeks of liver sparing lipid strategies. If validated in a larger study, this data will likely continue to contribute to the changing role of transplantation for the patient with IF.…”

<p>Multidisciplinary Management in Pediatric Ultrashort Bowel Syndrome</p>

“…However, with the likelihood of survival on home PN approaching 90% at 5 years, exceeding that of intestinal transplantation (60%), there has been a proposal to remove the diagnosis of USBS as an indication for bowel transplantation. 30 A recent publication by Burghardt et al found that in the old era of increased mortality, the diagnosis of USBS was previously strongly predictive of requiring an intestinal transplant (positive predictive value = 100%), but in the current era of improved survival, USBS diagnosis had a decreased positive predictive value of 9%. 30…”

Impact of Clinical Use of Parenteral Lipid Emulsions on Bile Acid Metabolism and Composition in Neonatal Piglets

“…While neonates were traditionally at greatest risk of death from IFALD, recent advances in parenteral lipid formulations have markedly improved outcomes . Evidence is emerging that use of soybean oil (SO) promotes IFALD, while lipid emulsions containing fish oil (FO) may prevent and can treat IFALD.…”

“…While neonates were traditionally at greatest risk of death from IFALD, recent advances in parenteral lipid formulations have markedly improved outcomes. 2 Evidence is emerging that use of soybean oil (SO) promotes IFALD, 3 while lipid emulsions containing fish oil (FO) may prevent 4 and can treat 5,6 IFALD. Possible reasons for improved outcomes with FO-containing lipid emulsions can be related to compositional differences, including added vitamin E, lower amounts or absence of phytosterols, and key differences in fatty acid composition, including the presence of eicosapentaenoic acid and docosahexaenoic acid in FO.…”