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Pascher A. [Indications and results of intestinal transplantation for short bowel syndrome after mesenteric ischemia]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:375-381. [PMID: 38427034 DOI: 10.1007/s00104-024-02052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Intestinal transplantation (ITx) is the only causal treatment for complicated chronic intestinal failure after mesenteric ischemia and impending failure of parenteral supplementation. Isolated or combined ITx with the inclusion of the intestine is associated with demanding immunological, perioperative and infection associated challenges. AIM The characterization of chronic intestinal failure, the indications, transplant survival, transplantation techniques and success rates. MATERIAL AND METHODS Collection, summary and critical appraisal of international guidelines, the guidelines of the German Medical Chamber, and the international literature. RESULTS The first successful ITx were performed in 1987 and 1988 at the University of Kiel Germany and the University of Pittsburgh, USA. The number of ITx rose continuously but in phases from the end of the 1990s to over 200 per year but has currently decreased to 100-150 per year due to optimized intestinal rehabilitation. While the 1‑year and 3‑year transplant survival rates were 30% and 20% before 1991, they increased in phases up to 60% and 50%, respectively, after 1995 and have now achieved almost 80% and 70%, respectively. CONCLUSION The substantial improvement in the results of ITx can be partly explained by progress in operative techniques, intensive care medicine and a better understanding of mucosal immunity; however, optimized strategies in immunosuppression as well as prevention of infectious diseases and malignancies have also made decisive contributions.
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Affiliation(s)
- Andreas Pascher
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
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2
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Garcia J, Oltean M, Rumbo C, Sharkey L, Kaufman SS, Ramos Boluda E, Gupte G, Martinez M, Moon J, Raghu V, Segovia MC, Sudan D, Talbotec C, Varkey J, Gondolesi GE, Mazariegos G, Venick R. Endoscopic Surveillance of the Intestinal Allograft: Recommendations From the Intestinal Rehabilitation and Transplant Association Working Group. Transplantation 2024; 108:827-835. [PMID: 37723639 DOI: 10.1097/tp.0000000000004785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Intestinal transplant (ITx) rejection lacks a reliable noninvasive biomarker and rejection surveillance relies on serial endoscopies and mucosal biopsies followed by histologic assessment. Endoscopic biopsies are also essential for identifying other ITx-related complications such as infectious, allergic, and inflammatory graft enteritis as well as post-transplant lymphoproliferative disease or graft versus host disease. In spite of its central role in ITx, published guidelines on endoscopy and biopsy are lacking and significant variability between centers in terms of timing and technical performance exists. Therefore, an international expert group convened and discussed several aspects related to the surveillance endoscopy after ITx with the aim to summarize and standardize its practice. This article summarizes these considerations on endoscopic ITx monitoring and highlights practices of surveillance and for-cause endoscopy, biopsy techniques, pathologic evaluation, potential risks and complications, outsourcing, and less-invasive monitoring techniques.
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Affiliation(s)
- Jennifer Garcia
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Mihai Oltean
- Sahlgrenska Intestinal Failure and Transplant Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carolina Rumbo
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Lisa Sharkey
- Department of Gastroenterology, Intestinal Failure and Intestinal/Multivisceral Transplant, Cambridge University Hospital, Cambridge, United Kingdom
| | | | | | - Girish Gupte
- Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Mercedes Martinez
- Center for Liver Disease and Abdominal Organ Transplantation, Columbia University Medical Center, New York, NY
| | - Jang Moon
- Recanati Miller Transplantation Institute, New York, NY
| | - Vikram Raghu
- Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Cécile Talbotec
- Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Paris, France
| | - Jonas Varkey
- Sahlgrenska Intestinal Failure and Transplant Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - George Mazariegos
- Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA
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3
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Matsushima H, Sasaki K, Nair A, Tajima T, Soyama A, Eguchi S, Hashimoto K, Fujiki M. The impact of colonic allograft inclusion on intestinal transplantation outcomes: Results from UNOS/OPTN database analysis. Clin Transplant 2024; 38:e15213. [PMID: 38064299 DOI: 10.1111/ctr.15213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Outcomes of intestinal transplantation with colon allograft (ICTx) remain controversial. We aimed to assess the outcomes of ICTx in comparison to intestinal transplantation without colon (ITx) using the UNOS/OPTN registry database. METHODS We retrospectively reviewed 2612 patients who received primary intestinal transplants from 1998 to 2020. The rates of acute rejection (AR) within 6 months after transplant were compared between ICTx and ITx. Risk factors of 6-month AR were examined using logistic regression model by era. Furthermore, conditional graft survival was analyzed to determine long-term outcomes of ICTx. RESULTS Of 2612 recipients, 506 (19.4%) received ICTx. Graft and patient survival in ICTx recipients were comparable to those in ITx recipients. White ICTx recipients had a higher incidence of AR within 6 months compared to ITx during the entire study period (p = .002), colonic inclusion did not increase the risk of 6-month AR in the past decade. ICTx recipients who experienced 6-month AR had worse graft and patient survival compared to those who did not (p <.001 and p = .004, respectively). Among patients who did not develop 6-month AR, Cox proportional hazard model analysis revealed that colonic inclusion was independently associated with improved conditional graft survival. CONCLUSIONS In the recent transplant era, colonic inclusion is no longer associated with a heightened risk of 6-month AR and may provide better long-term survival compared to ITx when AR is absent. Risk adjustment for rejection and proper immunosuppressive therapy are crucial to maximize the benefits of colonic inclusion.
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Affiliation(s)
- Hajime Matsushima
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazunari Sasaki
- Division of Abdominal Transplant, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Amit Nair
- Department of Solid Organ Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tetsuya Tajima
- Division of Abdominal Transplant, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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von Ahrens D, Santeusanio AD, Weinberg AD, Moon J, Iyer KR. Risk factors for renal dysfunction after isolated intestinal transplantation. Clin Transplant 2024; 38:e15228. [PMID: 38289880 DOI: 10.1111/ctr.15228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/15/2023] [Accepted: 12/08/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Kidney dysfunction is a known complication of intestinal transplantation; however, the rate of development and risk factors for chronic kidney disease (CKD) remain poorly defined. METHODS This was a single-center retrospective review of isolated adult intestinal allograft recipients from 2011 to 2019. Patients who died or experienced graft loss within 1-year or had a prior transplant were excluded. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation at 0-, 6- and 12-months post-transplant, and multivariable linear regression was performed to identify variables associated with adjusted eGFR at 1-year. Independent variables included age, ethnicity, BMI, history of diabetes/hypertension, vasopressor use, TPN and stoma days, urinary or bloodstream infections, intravenous contrast exposure, rejection, concomitant immunosuppression, and time above the therapeutic range of tacrolimus. Variables with a p < .1 in univariate analysis were considered for multivariable modeling. RESULTS Thirty-three patients were included with a mean age of 43.9 ± 13.0. A mean 42.3% decline in eGFR was observed at 1-year post-transplant, with 15.2% of patients developing new stage 4/5 CKD. Factors associated with a greater decline in adjusted eGFR in the univariate model included increasing age, decreased BMI, stoma days, and vasopressor use. In the adjusted multivariable model patient age (β = -.77, p < .01) and stoma days (β = -.06, p < .01) remained significant. Tacrolimus and sirolimus exposure were not associated with decline in eGFR at 1 year. CONCLUSIONS Renal dysfunction is common following intestinal transplantation. The need for stoma creation should be carefully considered, and reversal should be performed when feasible for renal protection.
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Affiliation(s)
- Dagny von Ahrens
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Andrew D Santeusanio
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
- Department of Pharmacy, Mount Sinai Hospital, New York, New York, USA
| | - Alan D Weinberg
- Department of Population Health Science and Policy, Mount Sinai Hospital, New York, New York, USA
| | - Jang Moon
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Kishore R Iyer
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
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Raghu VK, Vetterly CG, Horslen SP. Immunosuppression Regimens for Intestinal Transplantation in Children. Paediatr Drugs 2022; 24:365-376. [PMID: 35604536 DOI: 10.1007/s40272-022-00512-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Pediatric intestinal transplant serves as the only definitive treatment for children with irreversible intestinal failure. Successful intestinal transplant hinges upon appropriate management of immunosuppression. The indications for intestinal transplant have changed over time. Immunosuppression regimens can be divided into induction and maintenance phases along with treatment of acute rejection. Intestinal transplant induction now often includes antithymocyte globulin or basiliximab in addition to corticosteroids. Maintenance regimens continue to be dominated by tacrolimus, with additional agents used to either decrease goal tacrolimus levels to limit toxicity or as an adjunct in sensitized patients. Careful monitoring can help to limit serious complications, such as rejection, infection, and malignancy. Future work will aim to decrease variation in practice and identify methods to determine optimal immunosuppression for a particular patient. Furthermore, there is a need for non-invasive monitoring of the intestinal graft and functional assessments of immunosuppression.
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Affiliation(s)
- Vikram Kalathur Raghu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Carol G Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Simon Peter Horslen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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6
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Current review on the role of ileostomy following intestinal transplantation. Curr Opin Organ Transplant 2022; 27:126-130. [DOI: 10.1097/mot.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Intestinal transplantation has evolved to be a viable treatment option for patients with intestinal failure. This review shows the most current tendencies and practices of intestinal transplant centers and an overall comparison to intestinal rehabilitation. RECENT FINDINGS This review outlines that timing for referral and advances in preoperative and postoperative care of intestinal and multivisceral transplant candidates are crucial to achieve results comparable to intestinal rehabilitation. SUMMARY Current practices have shown that intestinal transplantation continues to improve overall results and could be considered in patients with permanent home parenteral nutrition. Timing for referral and preoperative and postoperative management are crucial to optimize long-term results.
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Affiliation(s)
| | - Gennaro Selvaggi
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Akin Tekin
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Rutter CS, Russell NK, Sharkey LM, Amin I, Butler AJ. Decline in renal function following intestinal transplant: is the die cast at 3 months? Clin Transplant 2021; 35:e14249. [PMID: 33565629 DOI: 10.1111/ctr.14249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/19/2020] [Accepted: 02/01/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION This study reports the incidence of chronic kidney disease (CKD) after intestinal transplant (IT) at a single, adult center in the United Kingdom. METHODS A retrospective review of IT was undertaken. Methods of renal function assessment pre-transplant were compared. Post-transplant renal function and renal sparing strategies were analyzed. RESULTS There was a 30% variation (p < .001) in estimated glomerular filtration rate (eGFR) and normalized GFR at assessment. In the first 3 months post-transplant, there was a 40% decline in eGFR which was irreversible. Liver inclusion was not protective with similar eGFR at 3 months (60 ml/min/1.73 m2 ) compared with IT (55 ml/min/1.73 m2 ). The rate of decline in the first 2 months was less in multivisceral transplant (MVT; 21%) than IT (52%) suggesting surgical magnitude did not contribute. Thirty percentage of recipients had acute cellular rejection post-transplant; 58% of these were in the first 3 months with a higher proportion in MVT (64%) than IT (27%). Tacrolimus exposure did not correlate with decline in renal function over the first 3 months post-transplant. CONCLUSION We demonstrated a 40% decline in renal function within 3 months post-IT which was irreversible despite renal sparing strategies. Early intervention should be considered in patients with an acute decline in this post-transplant period.
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Affiliation(s)
- Charlotte S Rutter
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil K Russell
- Department of Transplant Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lisa M Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Irum Amin
- Department of Transplant Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Abstract
PURPOSE OF REVIEW In this article, data from the intestinal transplant registry, recent publications and reviews in the field will be used to describe mortality, morbidity, complications, nutritional and psychosocial outcomes in intestinal transplant recipients with a focus on those furthest out from transplant. RECENT FINDINGS Registry data show static long-term survival data (41% 10-year survival in the most recent analysis), but experienced centres report improvements with survival between 60 and 70% at 10 years. Chronic rejection remains a problem for long-term graft survival, but understanding of humoral immunity is increasing. Nutritional outcomes are good with most recipients achieving enteral autonomy with an unrestricted diet. Health-related quality of life data generally shows improvement in the years after transplant, educational attainment is good, but some patients have ongoing psychosocial problems. SUMMARY Most patients do well in the long-term after transplant. Survival outcomes have improved in experienced centres, and nutrition and quality of life outcomes are good. Recognition of psychosocial outcomes is increasing. Nevertheless, challenges remain in areas such as infectious complications, renal function, chronic rejection, social support and mental health.
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Abstract
BACKGROUND Outcomes of pediatric intestinal failure (PIF) have improved recently, with other comorbidities, such as increased echogenicity/nephrocalcinosis on ultrasound (US) in long-term survivors now evident. We evaluated the significance of nephrocalcinosis over time in PIF and its impact on renal function. METHODS Retrospective analysis on a cohort of PIF patients was performed. Presence of nephrocalcinosis and/or increased renal echogenicity (identified on US), estimated glomerular filtration rate (eGFR; ml · min · 1.73 m2), renal tubular function, PN volume (ml · kg · day) and PN exposure time (hours/day) were reviewed annually over a follow-up period of 2 years. Outcomes in the nephrocalcinosis versus normal US groups were compared. RESULTS Forty patients (28 boys, median age 2.7 years) were followed for 2 years. Fifteen (38%) had either increased echogenicity or nephrocalcinosis (group 1) at initial US. US were normal in the remaining 25 (62%) on initial assessment (group 2). eGFR did not differ between group 1 and group 2 at baseline (118 vs 133, P = 0.51) and year 2 (130 vs 131, P = 1.00). The percentage of patients with abnormal markers of tubular function was similar in both groups at year 2 (high urine calcium: creatinine 33 versus 30, P = 0.83; high urine calcium: citrate 39 versus 42, P = 0.87; low urine citrate: creatinine 15 versus 17, P = 1.00; high urine oxalate: creatinine 39 versus 25, P = 0.77). CONCLUSIONS A large proportion of PIF patients with a history of parenteral nutrition (PN) exposure have nephrocalcinosis and/or increased echogenicity on US. Over a 2-year follow-up period, however, these abnormalities had no impact on eGFR or renal tubular function.
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Current status of pediatric intestinal transplantation in the United States. Curr Opin Organ Transplant 2020; 25:201-207. [PMID: 32073484 DOI: 10.1097/mot.0000000000000744] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review aims to describe in detail the characteristics, outcomes, and recent trends in the field of pediatric intestinal transplantation in the United States. It will examine the route cause and future implications of these developments. The review will draw from recent publications in the field, the Intestinal Transplant Registry, and contemporary data from large U.S. single centers. RECENT FINDINGS More than 1500 pediatric intestinal transplants have been performed in the United States since 1985, however, over the past decade there have been fewer than 50 transplants/year nationwide. This trend is largely a result of stagnant long-term ITx outcomes and advancements in intestinal rehabilitation programs. Nationally the overall 1-year and 5-year graft survival are 68 and 50% respectively, whereas certain high-volume centers have experienced significantly better results. Sepsis is the leading cause of death following pediatric ITx, whereas rejection is the leading cause of graft loss. Chronic kidney disease and posttransplant lymphoproliferative disorder are significant and relatively prevalent long-term complications. The majority of pediatric ITx recipients receive T-cell depleting induction agents and are on Tacrolimus-based immunosuppression. Most recipient are off parenteral nutrition, but may require supplemental tube feeds. Many pediatric ITx recipients require special education, and in certain domains some report lower health related quality of life. SUMMARY As intestinal rehabilitation has improved in the modern era, the volume of pediatric ITx in the United States has decreased. Although pediatric ITx results have room for improvement nationwide, successful outcomes have been reported at experienced American centers.
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Courbage S, Canioni D, Talbotec C, Lambe C, Chardot C, Rabant M, Galmiche L, Corcos O, Goulet O, Joly F, Lacaille F. Beyond 10 years, with or without an intestinal graft: Present and future? Am J Transplant 2020; 20:2802-2812. [PMID: 32277553 DOI: 10.1111/ajt.15899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 01/25/2023]
Abstract
Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n = 26) and without (group 2, n = 9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87 mL/min/1.73 m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10 years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.
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Affiliation(s)
- Sophie Courbage
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Danielle Canioni
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Louise Galmiche
- Department of Pathology, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Olivier Corcos
- Department of Gastroenterology, Nutrition Support and Intestinal Transplantation, Beaujon Hospital, University of Paris, Clichy, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - Francisca Joly
- Department of Gastroenterology, Nutrition Support and Intestinal Transplantation, Beaujon Hospital, University of Paris, Clichy, France
| | - Florence Lacaille
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades Hospital, University of Paris, Paris, France
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Amin A, Farmer DG. Current outcomes after pediatric and adult intestinal transplantation. Curr Opin Organ Transplant 2020; 24:193-198. [PMID: 30676400 DOI: 10.1097/mot.0000000000000608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW In this article, we will review the outcomes of patients with intestinal transplant (ITx) with a focus on factors affecting long-term graft and patient survival. RECENT FINDINGS The most recent International Intestinal Transplant Registry reports a 1-, 5-, and 10-year graft survival of 71%, 50%, and 41% respectively, for ITx grafts transplanted since 2000. Over the past decades, significant improvements have been achieved in short-term graft and patient outcomes for ITx recipients. The improvement in short-term outcomes may be related to the focused treatment of antihuman leukocyte antigen antibodies, the use of induction immunotherapy protocols, refinements in surgical techniques, establishment of dedicated ITx units, and improved postoperative management.However, long-term graft and patient outcomes for ITx recipients remain stagnant. Issues impairing long-term outcomes of ITx include the challenges in the diagnosis and treatment of chronic rejection and antibody-mediated rejection, progressive decline in renal function, and long-term infectious and malignancy risks especially related to cytomegalovirus, Epstein-Barr virus and posttransplant lymphoproliferative disorder after ITx. SUMMARY Addressing and preventing early and late complications is the key to improving short-term and long-term outcomes after ITx.
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Affiliation(s)
- Arpit Amin
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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14
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Elsabbagh AM, Hawksworth J, Khan KM, Kaufman SS, Yazigi NA, Kroemer A, Smith C, Fishbein TM, Matsumoto CS. Long-term survival in visceral transplant recipients in the new era: A single-center experience. Am J Transplant 2019; 19:2077-2091. [PMID: 30672105 PMCID: PMC6591067 DOI: 10.1111/ajt.15269] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023]
Abstract
There is a paucity of data on long-term outcomes following visceral transplantation in the contemporary era. This is a single-center retrospective analysis of all visceral allograft recipients who underwent transplant between November 2003 and December 2013 with at least 3-year follow-up data. Clinical data from a prospectively maintained database were used to assess outcomes including patient and graft survival. Of 174 recipients, 90 were adults and 84 were pediatric patients. Types of visceral transplants were isolated intestinal transplant (56.3%), combined liver-intestinal transplant (25.3%), multivisceral transplant (16.1%), and modified multivisceral transplant (2.3%). Three-, 5-, and 10-year overall patient survival was 69.5%, 66%, and 63%, respectively, while 3-, 5-, and 10-year overall graft survival was 67%, 62%, and 61%, respectively. In multivariable analysis, significant predictors of survival included pediatric recipient (P = .001), donor/recipient weight ratio <0.9 (P = .008), no episodes of severe acute rejection (P = .021), cold ischemia time <8 hours (P = .014), and shorter hospital stay (P = .0001). In conclusion, visceral transplantation remains a good option for treatment of end-stage intestinal failure with parenteral nutritional complications. Proper graft selection, shorter cold ischemia time, and improvement of immunosuppression regimens could significantly improve the long-term survival.
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Affiliation(s)
- Ahmed M. Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt,St. Vincent Abdominal Transplant Center, St. Vincent Hospital, Indianapolis, Indiana
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Department of Surgery, Organ Transplant Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
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Outcomes of Adult Intestinal Transplant Recipients Requiring Dialysis and Renal Transplantation. Transplant Direct 2018; 4:e377. [PMID: 30255137 PMCID: PMC6092176 DOI: 10.1097/txd.0000000000000815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/02/2018] [Indexed: 11/30/2022] Open
Abstract
Supplemental digital content is available in the text. Background Data on dialysis and renal transplantation (RT) after intestinal transplantation (IT) are sparse. Whether changes in immunosuppression and surgical techniques have modified these outcomes is unknown. Methods Two hundred eighty-eight adult intestinal transplants performed between 1990 and 2014 at the University of Pittsburgh were analyzed for incidence, risk factors and outcomes after dialysis and RT. Cohort was divided into 3 eras based on immunosuppression and surgical technique (1990-1994, 1995-2001, and 2001-2014). Receiving RT, or dialysis for 90 days or longer was considered as end-stage renal disease (ESRD). Results During a median follow-up of 5.7 years, 71 (24.7%) patients required dialysis, 38 (13.2%) required long-term dialysis and 17 (6%) received RT after IT. One-, 3-, and 5-year ESRD risk was 2%, 7%, and 14%, respectively. No significant era-based differences were noted. Higher baseline creatinine (hazard ratio [HR], 3.40 per unit increase, P < 0.01) and use of liver containing grafts (HR, 2.01; P = 0.04) had an increased ESRD risk. Median patient survival after dialysis initiation was 6 months, with a 3-year survival of 21%. Any dialysis (HR, 12.74; 95% CI 8.46-19.20; P < 0.01) and ESRD (HR, 9.53; 95% CI, 5.87-15.49; P < 0.01) had higher mortality after adjusting for covariates. For renal after IT, 1- and 3-year kidney and patient survivals were 70% and 49%, respectively. All graft losses were from death with a functioning graft, primarily related to infectious complications (55%). Conclusions In intestinal transplant recipients, renal failure requiring dialysis or RT is high and is associated with increased mortality. Additionally, the outcomes for kidney after IT are suboptimal due to death with a functioning graft.
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Moinuddin I, Yaqub MS, Taber T, Mujtaba M, Sharfuddin A. Kidney allograft survival outcomes in combined intestinal-kidney transplant: An analysis of the UNOS/OPTN database 2000-2014. Clin Transplant 2018; 32:e13213. [DOI: 10.1111/ctr.13213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Irfan Moinuddin
- Transplant Nephrology; Division of Nephrology; Indiana University; Indianapolis IN USA
| | - Muhammad Sohail Yaqub
- Transplant Nephrology; Division of Nephrology; Indiana University; Indianapolis IN USA
| | - Tim Taber
- Transplant Nephrology; Division of Nephrology; Indiana University; Indianapolis IN USA
| | - Muhammad Mujtaba
- Transplant Nephrology; Division of Nephrology; University of Texas Medical Branch; Galveston TX USA
| | - Asif Sharfuddin
- Transplant Nephrology; Division of Nephrology; Indiana University; Indianapolis IN USA
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Amin I, Rutter C, Barlow A, Russell NK, Bradley JA, Jackson A, Butler AJ. Simultaneous Intestinal and Kidney Transplantation in Adults. J INVEST SURG 2018; 32:283-289. [DOI: 10.1080/08941939.2017.1409849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Irum Amin
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Charlotte Rutter
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adam Barlow
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Neil K. Russell
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - J. Andrew Bradley
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew Jackson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew J. Butler
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
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Huard G, Iyer K, Moon J, Doucette JT, Nair V, Schiano TD. The high incidence of severe chronic kidney disease after intestinal transplantation and its impact on patient and graft survival. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Geneviève Huard
- Recanati-Miller Transplant Institute; Mount Sinai Hospital; New York NY USA
- Department of Medicine; Division of Liver Diseases; Mount Sinai Hospital; New York NY USA
- Department of Medicine; Division of Liver Diseases; Centre Hospitalier de l'Université de Montréal; Montréal Québec Canada
| | - Kishore Iyer
- Recanati-Miller Transplant Institute; Mount Sinai Hospital; New York NY USA
- Department of Surgery; Intestinal Rehabilitation and Transplantation Program; Mount Sinai Hospital; New York NY USA
| | - Jang Moon
- Recanati-Miller Transplant Institute; Mount Sinai Hospital; New York NY USA
- Department of Surgery; Intestinal Rehabilitation and Transplantation Program; Mount Sinai Hospital; New York NY USA
| | - John T. Doucette
- Department of Preventive Medicine; Division of Biostatistics; Icahn School of Medicine at Mount Sinai; New York NY USA
| | - Vinay Nair
- Recanati-Miller Transplant Institute; Mount Sinai Hospital; New York NY USA
- Department of Medicine; Division of Nephrology; Mount Sinai Hospital; New York NY USA
| | - Thomas D. Schiano
- Recanati-Miller Transplant Institute; Mount Sinai Hospital; New York NY USA
- Department of Medicine; Division of Liver Diseases; Mount Sinai Hospital; New York NY USA
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Choice of Allograft in Patients Requiring Intestinal Transplantation: A Critical Review. Can J Gastroenterol Hepatol 2017; 2017:1069726. [PMID: 28553630 PMCID: PMC5434314 DOI: 10.1155/2017/1069726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.
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Kosar C, De Silva N, Avitzur Y, Steinberg K, Courtney-Martin G, Chambers K, Fitzgerald K, Harvey E, Wales PW. Prevalence of renal abnormality in pediatric intestinal failure. J Pediatr Surg 2016; 51:794-7. [PMID: 26921935 DOI: 10.1016/j.jpedsurg.2016.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Outcomes of children with intestinal failure have improved over the last decade. However, with improved survival, other co-morbidities have become evident. The goal of our study was to evaluate the presence of renal nephrocalcinosis or increased echogenicity in a cohort of patients with pediatric intestinal failure (PIF). METHODS A cross-sectional prevalence design was performed in PIF patients followed by our intestinal rehabilitation program between 2013 and 2014. Renal function was evaluated using serum creatinine and urea, urine oxalate, creatinine, calcium, and calcium/creatinine ratios. Renal ultrasounds were performed to assess for echogenicity. Data was collected on intestinal failure related factors and nutritional intake. Data was analyzed using medians and Mann-Whitney U or proportions and chi square. RESULTS Fifty-four patients (median age 48months; 33 males (61%) were studied. Twenty-two patients (41%) had increased echogenicity or nephrocalcinosis on ultrasound. There were no differences in serum Creatinine or urea, but patients with nephrocalcinosis had statistically different calcium:creatinine ratio (1.69 vs 0.74; p=0.043), urine oxalate (108 vs 219; p=0.06), and serum phosphate (1.55 vs 1.75; p=0.044). Patients with echogenicity had a shorter colonic remnant (25cm vs 31cm; p=0.01), a history of longer PN exposure (928 vs 483days; p=0.05), percent PN calories (37 vs 0; p=0.05), PN h/day (13 vs 0; p=0.05), but no difference in PN Ca/phosphate/magnesium content (mmol/kg). CONCLUSION A large proportion of PIF patients have increased echogenicity/nephrocalcinosis on ultrasound that is associated with prolonged PN exposure. This has implications for long-term management. Regular surveillance is required, and further study is warranted to determine specific risk factors.
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Affiliation(s)
- Christina Kosar
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Nicole De Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Kathryn Chambers
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Elizabeth Harvey
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of Nephrology, The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Canada.
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Abstract
OBJECTIVES Biopsies remain the criterion standard in the diagnosis of intestinal transplant (ITx) rejection, and gastrointestinal endoscopy plays a pivotal role in patient management. Herein, we describe a single-center 23-year endoscopic experience in pediatric ITx recipients. METHODS A retrospective review of endoscopy and pathology reports of all ITx recipients <18 years old transplanted between 1991 and 2013 was performed with the aim of describing the procedural indications, findings, and complications. RESULTS A total of 1770 endoscopic procedures within 1014 sessions were performed. A combination of esophagogastroduodenoscopy and ileoscopy was the most common procedure (36%). Increased stool output (35%) and surveillance endoscopy (32%) were the most common indications. A total of 162 episodes of biopsy-proven rejection were diagnosed. The first episode of rejection occurred at a median of 1 month after ITx. Of histology-proven rejections, 45% had normal-appearing endoscopies. The rate of procedural complications, including but not limited to bleeding and perforation, was 1.8%. CONCLUSIONS Endoscopy with biopsy plays a significant role in the care of ITx recipients. Multiple procedures are required for graft surveillance, diagnosis of rejection, subsequent treatment, and follow-up of therapy. The gross endoscopic appearance, particularly in mild to moderate acute cellular rejection, does not correlate well with histology. Complex anatomy, complication rates that are higher than patients with non-ITx pediatric endoscopy, and timely histologic interpretation by experienced pathologists are reasons that these procedures should be performed at centers accustomed to caring for ITx recipients. The field would benefit from the development of a noninvasive biomarker to reliably and efficiently detect rejection.
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Ceulemans LJ, Monbaliu D, De Roover A, Detry O, Troisi RI, Rogiers X, Reding R, Lerut JP, Ysebaert D, Chapelle T, Pirenne J. Belgian multicenter experience with intestinal transplantation. Transpl Int 2015; 28:1362-70. [DOI: 10.1111/tri.12615] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/03/2015] [Accepted: 05/27/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Laurens J. Ceulemans
- Abdominal Transplant Surgery; University Hospitals Leuven; Leuven Belgium
- Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
| | - Diethard Monbaliu
- Abdominal Transplant Surgery; University Hospitals Leuven; Leuven Belgium
- Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
| | - Arnaud De Roover
- Department of Abdominal Surgery and Transplantation; University Hospital of Liège; Liège Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation; University Hospital of Liège; Liège Belgium
| | - Roberto I. Troisi
- Department of General and Hepatobiliary Surgery; Liver Transplantation Service; Ghent University Hospital; Ghent Belgium
| | - Xavier Rogiers
- Department of General and Hepatobiliary Surgery; Liver Transplantation Service; Ghent University Hospital; Ghent Belgium
| | - Raymond Reding
- Department of Abdominal Surgery and Transplantation; University Hospitals Saint Luc - UCL; Brussels Belgium
| | - Jan P. Lerut
- Department of Abdominal Surgery and Transplantation; University Hospitals Saint Luc - UCL; Brussels Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary and Transplantation Surgery; Antwerp University Hospital; Antwerp Belgium
| | - Thierry Chapelle
- Department of Hepatobiliary and Transplantation Surgery; Antwerp University Hospital; Antwerp Belgium
| | - Jacques Pirenne
- Abdominal Transplant Surgery; University Hospitals Leuven; Leuven Belgium
- Department of Microbiology and Immunology; KU Leuven; Leuven Belgium
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Pineda C, Grogan T, Lin JA, Zaritsky J, Venick R, Farmer DG, Kelly RB. The use of renal replacement therapy in critically ill pediatric small bowel transplantation candidates and recipients: Experience from one center. Pediatr Transplant 2015; 19:E88-92. [PMID: 25818994 PMCID: PMC4420641 DOI: 10.1111/petr.12456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2015] [Indexed: 01/24/2023]
Abstract
Outcomes for pediatric SBT patients requiring perioperative RRT in the PICU remain unknown. The objectives were to document our center's experience with PICU SBT patients receiving perioperative RRT and to identify variables predictive of survival to discharge. A retrospective chart review of patients (ages, 0-18 yr) between January 1, 2000 and December 31, 2011 that received RRT within a SBT perioperative period and were transplanted at our university-affiliated, tertiary care children's hospital was performed. Six SBT patients received perioperative RRT (ages, 5-12 yr). Three patients (50%) survived to hospital discharge. Among survivors, RRT was required for a total of 1-112 days (mean, 49.7 days). All three survivors survived to hospital discharge without renal transplantation and free of RRT. There was a trend toward increased survival among older patients receiving RRT (p = 0.05). Survivors had a higher I-125 GFR prior to PICU admission (p = 0.045). A higher I-125 GFR prior to PICU admission among survivors may support this test's utility during SBT evaluation. In our experience, a high survival rate and freedom from RRT at the time of discharge support RRT use in the SBT population.
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Affiliation(s)
- C Pineda
- Mattel Children’s Hospital UCLA, Department of Pediatrics, Los Angeles, CA
| | - T Grogan
- UCLA Clinical and Translational Science Institute, Los Angeles, CA
| | - JA Lin
- Mattel Children’s Hospital UCLA, David Geffen School of Medicine at UCLA, Department of Pediatrics, Los Angeles, CA
| | - J Zaritsky
- Mattel Children’s Hospital UCLA, David Geffen School of Medicine at UCLA, Department of Pediatrics, Los Angeles, CA
| | - R Venick
- Mattel Children’s Hospital UCLA, David Geffen School of Medicine at UCLA, Department of Pediatrics, Los Angeles, CA
| | - DG Farmer
- UCLA Medical Center, David Geffen School of Medicine at UCLA, Department of Surgery, Los Angeles, CA
| | - RB Kelly
- Mattel Children’s Hospital UCLA, David Geffen School of Medicine at UCLA, Department of Pediatrics, Los Angeles, CA
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Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep 2015; 17:427. [PMID: 25613179 DOI: 10.1007/s11894-014-0427-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Intestinal failure and associated parenteral nutrition-induced liver failure cause significant morbidity, mortality, and health care burden. Intestine transplantation is now considered to be the standard of care in patients with intestinal failure who fail intestinal rehabilitation. Intestinal failure-associated liver disease is an important sequela of intestinal failure, caused by parenteral lipids, requiring simultaneous liver-intestine transplant. Lipid minimization and, in recent years, the emergence of fish oil-based lipid emulsions have been shown to reverse parenteral nutrition-associated hyperbilirubinemia, but not fibrosis. Significant progress in surgical techniques and immunosuppression has led to improved outcomes after intestine transplantation. Intestine in varying combination with liver, stomach, and pancreas, also referred to as multivisceral transplantation, is performed for patients with intestinal failure along with liver disease, surgical abdominal catastrophes, neuroendocrine and slow-growing tumors, and complete portomesenteric thrombosis with cirrhosis of the liver. Although acute and chronic rejection are major problems, long-term survivors have excellent quality of life and remain free of parenteral nutrition.
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Affiliation(s)
- Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, 550 N University Blvd, Room 4601, Indianapolis, IN, 46202-5250, USA,
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Pironi L, Lauro A, Soverini V, Zanfi C, Agostini F, Guidetti M, Pazzeschi C, Pinna AD. Renal function in patients on long-term home parenteral nutrition and in intestinal transplant recipients. Nutrition 2014; 30:1011-4. [DOI: 10.1016/j.nut.2014.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/20/2013] [Accepted: 02/02/2014] [Indexed: 12/31/2022]
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Sudan D. The current state of intestine transplantation: indications, techniques, outcomes and challenges. Am J Transplant 2014; 14:1976-84. [PMID: 25307033 DOI: 10.1111/ajt.12812] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/19/2014] [Accepted: 04/17/2014] [Indexed: 01/25/2023]
Abstract
Intestine transplantation is the least common form of organ transplantation in the United States and often deemed one of the most difficult. Patient and graft survival have historically trailed well behind other organ transplants. Over the past 5-10 years registry reports and single center series have demonstrated improvements to patient survival after intestinal transplantation that now match patient survival for those without life-threatening complications on parenteral nutrition. For various reasons including improvements in medical care of patients with intestinal failure and difficulty accessing transplant care, the actual number of intestine transplants has declined by 25% over the past 6 years. In light of the small numbers of intestine transplants, many physicians and the lay public are often unaware that this is a therapeutic option. The aim of this review is to describe the current indications, outcomes and advances in the field of intestine transplantation and to explore concerns over future access to this important and life-saving therapy.
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Affiliation(s)
- D Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
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Harrison E, Allan P, Ramu A, Vaidya A, Travis S, Lal S. Management of intestinal failure in inflammatory bowel disease: small intestinal transplantation or home parenteral nutrition? World J Gastroenterol 2014; 20:3153-63. [PMID: 24696601 PMCID: PMC3964387 DOI: 10.3748/wjg.v20.i12.3153] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/21/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease and Crohn's disease in particular, is a common cause of intestinal failure. Current therapeutic options include home parenteral nutrition and intestinal transplantation. For most patients, home intravenous therapy including parenteral nutrition, with a good probability of long-term survival, is the favoured choice. However, in selected patients, with specific features that may shorten survival or complicate home parenteral nutrition, intestinal transplantation presents a viable alternative. We present survival, complications, quality of life and economic considerations that currently influence individualised decision-making between home parenteral nutrition and intestinal transplantation.
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Incidence, timing, and significance of early hypogammaglobulinemia after intestinal transplantation. Transplantation 2013; 95:1154-9. [PMID: 23407545 DOI: 10.1097/tp.0b013e3182869d05] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite recent advances in intestinal transplantation (ITx), infection (INF) and acute cellular rejection (ACR) remain major causes of patient and graft loss. Studies in other solid-organ transplantations indicate that low levels of serum immunoglobulin G (IgG) negatively impact outcomes. To date, there have been no studies on IgG after ITx. METHODS A retrospective review of an IgG measurement protocol in primary ITx recipients between 2007 and 2011 was undertaken. IgG levels were measured at the time of evaluation, transplantation, and at weekly intervals for 2 months. Hypogammaglobulinemia (HGG) was defined as IgG levels below the lower limit of the 95% confidence interval for age. Associations between HGG, INF, and ACR were tested, and the incidence and timing of INF and ACR were compared. RESULTS Thirty-four patients were transplanted at a mean (SD) age of 12.4 (17.2) years. Most were Latino children with gastroschisis who received multivisceral grafts. Relative to pre-ITx levels, a statistically significant decrease in IgG levels was observed after ITx (P<0.05). Twenty patients (59%) developed HGG during the post-ITx period at a mean (SD) of 9.8 days. No significant associations were identified between HGG and INF or ACR. CONCLUSIONS This is the first study to describe serum IgG levels after ITx. A marked decrease in serum IgG levels was observed early on, in most patients. The etiology is potentially related to immunotherapy. HGG was not associated with INF or ACR, possibly related to the sample size and our practice of exogenous intravenous immunoglobulin replacement.
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Boyer O, Noto C, De Serre NPM, Gubler MC, Dechaux M, Goulet O, Niaudet P, Lacaille F. Renal function and histology in children after small bowel transplantation. Pediatr Transplant 2013; 17:65-72. [PMID: 22882667 DOI: 10.1111/j.1399-3046.2012.01767.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CKD is a frequent long-term complication after SBTx. CNIs are a well-known factor, but probably not the only cause. We assessed the incidence, risk factors, and severity of CKD in 27 children with SBTx (15 combined liver/SBTx) and prednisone/TAC-based maintenance immunosuppression. Median follow-up was seven yr (3-21). A renal biopsy was performed in 14 patients, 1-18 yr post-SBTx. A reduced GFR was observed in 17 children (63%) during the follow-up with none requiring dialysis. CNI toxicity was observed in 11/14 biopsies, as early as two yr post-transplant, and could occur with a normal mGFR. The dose of TAC was reduced by 50% in 13 patients with CKD and/or significant kidney histological lesions, and six were also given MMF. This led to a significant improvement in renal function: mGFR normalized in eight patients and improved or stabilized in five. No rejection occurred. At last follow-up, 37% had CKD stage 2 and 15% had CKD stage 3. In conclusion, CKD is frequent in children after SBTx and probably multifactorial. Less nephrotoxic immunosuppressive protocols may improve mGFR and should be further considered. The kidney histology helps in designing personalized immunosuppression strategies for patients.
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Affiliation(s)
- Olivia Boyer
- Pediatric Nephrology Unit, Reference Center for Hereditary Renal Diseases in Children and Adolescent (MARHEA), Paris, France
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Hopfner R, Tran TT, Island ER, McLaughlin GE. Nonsurgical care of intestinal and multivisceral transplant recipients: a review for the intensivist. J Intensive Care Med 2012; 28:215-29. [PMID: 22733723 DOI: 10.1177/0885066611432425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intestinal and multivisceral transplantation has evolved from an experimental procedure to the treatment of choice for patients with irreversible intestinal failure and serious complications related to long-term parenteral nutrition. Increased numbers of transplant recipients and improved survival rates have led to an increased prevalence of this patient population in intensive care units. Management of intestinal and multivisceral transplant recipients is uniquely challenging because of complications arising from the high incidence of transplant rejection and its treatment. Long-term comorbidities, such as diabetes, hypertension, chronic kidney failure, and neurological sequelae, also develop in this patient population as survival improves. This article is intended for intensivists who provide care to critically ill recipients of intestinal and multivisceral transplants. As perioperative care of intestinal/multivisceral transplant recipients has been described elsewhere, this review focuses on common nonsurgical complications with which one should be familiar in order to provide optimal care. The article is both a review of the current literature on multivisceral and isolated intestinal transplantation as well as a reflection of our own experience at the University of Miami.
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Affiliation(s)
- Reinhard Hopfner
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Miami, Miller School of Medicine, FL, USA
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Siniscalchi A, Cucchetti A, Miklosova Z, Lauro A, Zanoni A, Spedicato S, Bernardi E, Aurini L, Pinna AD, Faenza S. Post-reperfusion syndrome during isolated intestinal transplantation: outcome and predictors. Clin Transplant 2011; 26:454-60. [PMID: 22004008 DOI: 10.1111/j.1399-0012.2011.01530.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Post-reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long-term outcome. The primary aim of this study was to determine the independent clinical predictors of intra-operative PRS, as well as to investigate the link between the severity of PRS and the intra-operative profiles and to examine the post-operative complications and their relationship with transplant outcome. METHODS This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre-unclamping value and lasted for at least one min within 10 min after unclamping. RESULTS AND CONCLUSIONS The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre-operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra-operative PRS was associated with significantly more frequent post-operative renal failure and early post-operative death.
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Affiliation(s)
- Antonio Siniscalchi
- Department of Anesthesiology, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
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Garg M, Jones RM, Vaughan RB, Testro AG. Intestinal transplantation: current status and future directions. J Gastroenterol Hepatol 2011; 26:1221-8. [PMID: 21595748 DOI: 10.1111/j.1440-1746.2011.06783.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Three decades after the first intestinal transplant was performed in humans, this life-saving procedure has come of age and now offers hope of long-term survival in a small group of patients with life-threatening complications of intestinal failure and parenteral nutrition. Success rates have greatly improved, largely through advances in immunosuppression protocols, improved surgical technique and postoperative care, and accumulated experience. Management of the intestinal transplant recipient entails careful surveillance, prevention, and treatment of rejection and infection, as well as optimization of feeding and nutrition. With this approach, survival and quality of life are demonstrably improved, such that intestinal transplantation is now an established and accepted procedure for this very select group of highly-complex patients.
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Affiliation(s)
- Mayur Garg
- Liver Transplant Unit Victoria, Austin Health, Victoria, Australia
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LaRosa C, Glah C, Baluarte HJ, Meyers KEC. Solid-organ transplantation in childhood: transitioning to adult health care. Pediatrics 2011; 127:742-53. [PMID: 21382946 DOI: 10.1542/peds.2010-1232] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric solid-organ transplantation is an increasingly successful treatment for solid-organ failure. With dramatic improvements in patient survival rates over the last several decades, there has been a corresponding emergence of complications attributable to pretransplant factors, transplantation itself, and the management of transplantation with effective immunosuppression. The predominant solid-organ transplantation sequelae are medical and psychosocial. These sequelae have a substantial effect on transition to adult care; as such, hurdles to successful transition of care arise from the patients, their families, and pediatric and adult health care providers. Crucial to successful transitioning is the ongoing development of a sense of autonomy and responsibility for one's own care. In this article we address the barriers to transitioning that occur with long-term survival in pediatric solid-organ transplantation. Although a particular transitioning model is not promoted, practical tools and strategies that contribute to successful transitioning of pediatric patients who have received a transplant are suggested.
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Affiliation(s)
- Christopher LaRosa
- Division of Nephrology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Abstract
LaR Pediatric solid-organ transplantation is an increasingly successful treatment for organ failure. Five- and 10-yr patient survival rates have dramatically improved over the last couple of decades, and currently, over 80% of pediatric patients survive into adolescence and young adulthood. Waiting list mortality has been a concern for liver, heart, and intestinal transplantation, illustrating the importance of transplant as a life-saving therapy. Unfortunately, the success of pediatric transplantation comes at the cost of long-term or late complications that arise as a result of allograft rejection or injury, immunosuppression-related morbidity, or both. As transplant recipients enter adolescence treatment, non-adherence becomes a significant issue, and the medical and psychosocial impacts transition to adulthood not only with regard to healthcare but also in terms of functional outcomes, economic potential, and overall QoL. This review addresses the clinical and psychosocial challenges encountered by pediatric transplant recipients in the current era. A better understanding of pediatric transplant outcomes and adult morbidity and mortality requires further ongoing assessment.
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Affiliation(s)
- Christopher LaRosa
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
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Pretransplant predictors of survival after intestinal transplantation: analysis of a single-center experience of more than 100 transplants. Transplantation 2011; 90:1574-80. [PMID: 21107306 DOI: 10.1097/tp.0b013e31820000a1] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Outcomes after intestinal transplantation (ITx) have steadily improved. There are few studies that assess factors associated with these enhanced results. The purpose of this study was to examine peri-ITx variables and survival. METHODS A review of a prospectively maintained database was undertaken and included all patients undergoing ITx from 1991 to 2010. The study endpoints were patient and graft survival. Data collection included 44 variables. Survival was computed using Kaplan-Meier methods. Univariate analysis was conducted (log-rank test) with significance set at P less than or equal to 0.20. Multivariate analysis of significant variables was conducted using model reduction by backward elimination variable selection method with significance set at P less than 0.05. RESULTS Eighty-eight patients received 106 ITx. The majority of recipients were male, Latino, and children. The leading causes of intestinal and liver failure were gastroschisis and parenteral nutrition. Grafts transplanted were isolated intestine (24%), liver-intestine (62%), and multivisceral (14%). Overall 1- and 5-year patient and graft survival were 80% and 65%, and 74% and 64%, respectively. Significant univariate survival predictors were weight less than 20 kg, children, liver-inclusive allograft, panel reactive antibody less than 20%, absence of donor-specific antibody, negative crossmatch, warm ischemia time less than 60 min, absence of recipient splenectomy, interleukin-2 receptor antagonist induction, and era. Significant multivariate survival predictors were absence of donor-specific antibody, absence of recipient splenectomy, and liver-inclusive graft type. CONCLUSION This large, single-center ITx experience confirms a marked improvement in outcome over time. Several important factors were associated with survival, and these factors can potentially be adjusted before ITx. These findings should refocus future efforts on strategies to improve treatment and prevent graft loss.
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Siniscalchi A, Dante A, Spedicato S, Riganello L, Zanoni A, Cimatti M, Pierucci E, Bernardi E, Miklosova Z, Moretti C, Faenza S. Hyperdynamic circulation in acute liver failure: reperfusion syndrome and outcome following liver transplantation. Transplant Proc 2010; 42:1197-9. [PMID: 20534260 DOI: 10.1016/j.transproceed.2010.03.097] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS Liver transplantation (OLT) is a valid therapeutic option for patients with fulminant hepatic failure (FHF). The most critical phase during OLT is considered to be graft reperfusion, where in large changes in patient homeostasis occur. The aims of the present study were to evaluate the hemodynamic and cardiac changes among a large series of patients with FHF, to determine independent clinical predictors of the occurrence of postreperfusion syndrome (PSR) and its relationship to clinical and hemodynamic parameters and transplant outcomes. METHODS Systemic hemodynamic and cardiac functions were evaluated by Swan-Ganz catheterization in 58 patients before OLT. The patients were divided into two subgroups on the basis of PSR, which was defined as a mean arterial blood pressure 30% lower than the immediate previous value lasting for at least 1 minute within 5 minutes after unclamping. RESULTS PSR occurred in 24 patients (41%). Significant differences upon bivariate analysis was observed for the Model for End-stage Liver Disease score, which was significantly higher among patients with PSR, namely 32 (range = 18-43) versus 23 (range = 12-32) (P = .001). Higher serum creatinine values were significantly different among patients with PSR: 1.4 (range = 1.2-2.2) versus 2.1 (range = 2.5-3.2) mg/dL (P < .01). CONCLUSION Systemic hemodynamic alterations of FHF progressively worsen with increasing severity of liver disease. PSR developed in approximately 40% of patients; its prevalence was significantly related to the severity of the disease. Finally, patients with renal failure showed greater risk to develop an PSR during OLT.
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Affiliation(s)
- A Siniscalchi
- Division of Anestesiology, University of Bologna, Bologna, Italy.
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Long-term outcomes and quality of life after intestine transplantation. Curr Opin Organ Transplant 2010; 15:357-60. [DOI: 10.1097/mot.0b013e3283398565] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
This article reviews the current status of pediatric intestinal transplantation, focusing on referral and listing criteria, surgical techniques, patient management, monitoring, complications after transplant, and short- and long-term patient outcome. Intestine transplantation has become the standard of care for children who develop life-threatening complications associated with intestinal failure. The results of intestinal failure treatment have significantly improved in the last decade following the establishment of gut rehabilitation programs and advances in transplant immunosuppressive protocols, surgical techniques, and posttransplant monitoring. The 1-year patient survival is now 80% and more than 80% of the children who survive the transplant are weaned off parenteral nutrition. Early referral for pretransplant assessment and careful follow-up after transplant with prompt recognition and treatment of transplant-related complications are key factors contributing to superior patient outcomes and survival. The best results are being obtained at high-volume centers with survival rates of up to 75% at 5 years.
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Affiliation(s)
- Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
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Choquette M, Goebel JW, Campbell KM. Nonimmune complications after transplantation. Pediatr Clin North Am 2010; 57:505-21, table of contents. [PMID: 20371049 DOI: 10.1016/j.pcl.2010.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
As posttransplant longevity has increased, nonimmune complications related to the transplant and posttransplant course have emerged as important factors in defining long-term outcomes. The incidence of, and risk factors for these complications may vary by transplanted organ based on immunosuppressive protocols and preexisting risk factors. This article discusses the relevant nonimmune complications associated with posttransplant care, with a focus on risk factors and management strategies.
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Affiliation(s)
- Monique Choquette
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Research Foundation, Cincinnati, OH 45229, USA
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Mazariegos GV, Steffick DE, Horslen S, Farmer D, Fryer J, Grant D, Langnas A, Magee JC. Intestine transplantation in the United States, 1999-2008. Am J Transplant 2010; 10:1020-34. [PMID: 20420650 DOI: 10.1111/j.1600-6143.2010.03044.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Improving short-term results with intestine transplantation have allowed more patients to benefit with nearly 700 patients alive in the United States with a functioning allograft at the end of 2007. This success has led to an increase in demand. Time to transplant and waiting list mortality have significantly improved over the decade, but mortality remains high, especially for infants and adults with concomitant liver failure. The approximately 200 intestines recovered annually from deceased donors represent less than 3% of donors who have at least one organ recovered. Consent practice varies widely by OPTN region. Opportunities for improving intestine recovery and utilization include improving consent rates and standardizing donor selection criteria. One-year patient and intestine graft survival is 89% and 79% for intestine-only recipients and 72% and 69% for liver-intestine recipients, respectively. By 10 years, patient and intestine survival falls to 46% and 29% for intestine-only recipients, and 42% and 39% for liver-intestine, respectively. Immunosuppression practice employs peri-operative antibody induction therapy in 60% of cases; acute rejection is reported in 30%-40% of recipients at one year. Data on long-term nutritional outcomes and morbidities are limited, while the cause and therapy for late graft loss from chronic rejection are areas of ongoing investigation.
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Affiliation(s)
- G V Mazariegos
- Children's Hospital of Pittsburgh of UPMC Hillman Center for Pediatric Transplantation, Pittsburgh, PA, USA.
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Messing B, Corcos O, Amiot A, Joly F. Insuffisance intestinale : de l’adaptation à la transplantation. ACTA ACUST UNITED AC 2009; 33:648-59. [DOI: 10.1016/j.gcb.2009.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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