Therapeutic Efficacy of Intestinal and Multivisceral Transplantation: Survival and Nutrition Outcome

Abstract

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare & Medicaid Services (CMS) recognized intestinal, combined liver-intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life-threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long-term survivors, with full rehabilitation and restoration of quality of life.

Update on intestinal rehabilitation after intestinal transplantation

“…Improvements in the timing of referral are also expected to benefit long-term outcomes with respect not only to survival, but also growth, metabolic bone disease and renal function. Adapted from [11 ].…”

“…The formation of chylomicrons is dependent on intact lymphatic channels, but the body appears to be able to compensate in the first 2-3 weeks after transplant by forming collaterals around the lymphatics of the vascular ansatomoses [10 ]. Another common practice is use of low-dose lipids (1 g per kg or 1 g per 100 ml feed) and/or medium-chain triglyceride as this lipid source is absorbed directly via the portal vein [11 ]. This explains why the incidence of chylous ascites after ITx is minimal [10 ].…”

“…The programme at the Necker Hospital in Paris routinely supplements the diet of small bowel transplant recipients with daily doses of vitamin D (600-900 IU), vitamin A (1500 IU) and vitamin E (5 mg) [3 ]. The team at the University of Pittsburgh have noted that vitamin B 6 may need to be supplemented in the diet of their transplant population [11 ]. Long-term nutrition monitoring is important and should also include monitoring of serum concentrations of B 12 , zinc, selenium and iron as well as investigations for detection of osteoporosis in high-risk cases, so that treatment with bisphosphonates can be offered [5].…”

“…Using a prognostic scoring system to identify costs, which would have been incurred by patients who were not transplanted, a review in the UK in 2006 concluded that small bowel transplantation in children was cost-effective (but with wide confidence intervals) [23]. Data about long-term cost-effectiveness from published data in the United States [11 ] suggest that ITx is a cost-effective alternative to parenteral nutrition -see summary in Table 2. The limitation of the above analysis is that it does not take into account quality of life of the individual or the risk of premature death from transplantation, but it is likely that those patients experiencing complications of parenteral nutrition are likely to gain more from small…”

Pyridoxal-5′-phosphate deficiency after intestinal and multivisceral transplantation

“…The timing of discontinuation of PN, TF, and achievement of CNAwas recorded for each recipient. Full details of the postoperative care and nutritional management of the intestinal transplant recipients were described elsewhere (18,19).…”