Clinical intestinal transplantation: new perspectives and immunologic considerations

Effects of intestinal transplantation on postprandial motility and regulation of intestinal transit

BACKGROUND

The effects of intestinal transplantation on gut motility have not been completely defined. In this study we examine the effects of ileal transplantation on ileal smooth muscle contractility, together with gastroduodenal emptying, intestinal flow, and transit rates in a canine model of short-gut syndrome.

METHODS

Animals (n = 22) were instrumented with strain gauge transducers, collection cannulae, and infusion catheters to assess motility, intestinal flow and transit rates, and gastroduodenal emptying. Ten animals served to define normal parameters. Six animals underwent a 70% resection of the proximal small intestine to serve as short-gut controls. Six animals underwent removal of a 100-cm segment of the ileum, with cold storage, and autotransplantation the following day combined with a 70% resection of proximal bowel.

RESULTS

Transplant animals exhibited delayed gastroduodenal emptying, reduced intestinal flow rates, and postprandial phasic contractions that were similar to short-gut controls. However, transplant animals experienced rapid intestinal transit compared with short-gut controls (4.8 +/- 0.4 cm/min vs 2.0 +/- 0.3 cm/min; mean +/- SEM; P <.05).

CONCLUSIONS

The transplanted intestine, even with 18 hours of cold storage, exhibits a relatively normal postprandial motor response. However, adaptive responses of the transplanted intestine, such as regulation of intestine transit, may be impaired by neuromuscular injury associated with denervation or ischemia.

Immunomodulation for intestinal transplantation by allograft irradiation, adjunct donor bone marrow infusion, or both

BACKGROUND

The passenger leukocytes in the intestine have a lineage profile that predisposes to graft-versus-host disease (GVHD) in some animal models and have inferior tolerogenic qualities compared with the leukocytes in the liver, other solid organs, and bone marrow. Elimination by ex vivo irradiation of mature lymphoid elements from the bowel allografts is known to eliminate the GVHD risk. We hypothesized that infusion of donor bone marrow cells (BMC) in recipients of irradiated intestine would improve tolerogenesis without increasing the risk of GVHD.

METHODS

Orthotopic small intestine transplantation was performed with the GVHD-prone Lewis (LEW)-to-Brown Norway (BN) combination and the reverse GVHD-resistant BN-to-LEW model under a short course of tacrolimus treatment (1 mg/kg/day, days 0-13, 20, 27). Grafts were irradiated ex vivo, using a 137Cs source. In selected experimental groups, donor BMC (2.5 x 10(8)) were infused on the day of small intestine transplantation.

RESULTS

The unmodified LEW intestine remained intact, whether transplanted alone or with adjunct donor BMC infusion, but all of the BN recipients died of GVHD after approximately 2 months. Intestinal graft irradiation (10 Gy) effectively prevented the GVHD and prolonged survival to 92.5 days, but all of the BN recipients died with chronic rejection of the LEW grafts, which was prevented by infusion of adjunct donor BMC without causing GVHD. In the GVHD-resistant reverse strain direction (BN-->LEW), all intestinal recipients treated for 27 days with tacrolimus survived > or =150 days without regard for graft irradiation or adjunct BMC, but chronic rejection was severe in the irradiated intestine, moderate in the unaltered graft, and least in the irradiated intestine transplanted with adjunct BMC. Mild arteritis in the 150 day allografts of both strain combinations (i.e., LEW--> BN and BN-->LEW) may have been irradiation associated, but this was prevented when weekly doses of tacrolimus were continued for the duration of the experiment rather than being stopped at 27 days.

CONCLUSIONS

Recipients are protected from GVHD by irradiating intestinal allografts, but the resulting leukocyte depletion leads to chronic rejection of the transplanted bowel. The chronic rejection is prevented with adjunct donor BMC without causing GVHD. Although application of the strategy may be limited by the possibility of radiation injury, the results are consistent with the paradigm that we have proposed to explain organ-induced graft acceptance, tolerance, and chronic rejection.

Allogeneic fetal small bowel graft in pigs treated with cyclosporin A

BACKGROUND

The functional integrity of transplanted fetal intestine was proven in rodents. The authors examined the morphology and development of intraperitoneally transplanted fetal intestine under cyclosporin A (CsA) monotherapy in a large mammal.

METHODS

Allogeneic fetal intestinal grafts were transplanted intraperitoneally in pigs. The graft was wrapped in omentum. Thirteen recipients received grafts harvested at 60 days of gestation and 5 at 105 days of gestation. All recipients received 25 mg/kg/d CsA. CsA blood levels were measured at the end of the study. The development of the grafts was assessed by inspection and histology studying revascularization, maturation, and immune rejection.

RESULTS

All grafts developed neovascularization. The intestinal wall in the 105-day-old group was thick enough to lead to complete mucosal destruction, whereas the 60-day-old group showed viable mucosa. All grafts induced an immune rejection. This immune response was correlated with the CsA blood level. The graft was destroyed within 15 days when CsA trough level was below 70 ng/mL, had a subacute rejection with villi atrophy when CsA trough level ranged from 70 to 150 ng/mL, and had a good appearance in spite of mild blunting of villi when CsA trough level was over 150 ng/mL.

CONCLUSION

Allogeneic fetal intestinal transplantation from 60-day-old embryos in pig achieved successful graft.

Recipient FK506 pretreatment regimens in rat small bowel transplantation: allograft survival, function, and systemic infection

PURPOSE

Successful small bowel transplantation requires effective immunosuppression that preserves intestinal function but avoids opportunistic infection. This study aims to evaluate FK506 as a single immunosuppressant in different pretreatment regimens in a rat high responder strain combination.

METHODS

Lewis --> DA rat heterotopic small bowel transplantation was performed. Studied groups were (1) untreated control, n = 12; (2) FK-1, n = 8; (3) FK-3, n = 8. FK506 (2 mg/kg/d, intramuscularly) was given to the recipients for 1 day (FK-1) and 3 days (FK-3) before small bowel transplantation, followed by 2 weeks of subtherapeutic treatment (0.3 mg/kg/d, intramuscularly) after small bowel transplantation. Syngeneic small bowel transplantation also was performed (n = 8). FK blood levels, maltose absorption test, histology, and bacteriology were performed at different postoperative days.

RESULTS

Allograft survival was prolonged significantly with FK pretreatment, being more so in FK-3 group (FK-1, 22.2 +/- 1.5 d; FK-3, 40.7 +/- 14.1 d; control, 6.6 +/- 0.8 d; P< .01). In the first postoperative week, FK blood level was significantly higher in FK-3 group (19.8 +/- 1.5 ng/mL) than in FK-1 group (5.0 +/- 0.4 ng/mL; P < .05). There was no evidence of systemic infection in either FK-treated group. For maltose absorption, control allograft was abnormal on day 7 correlating to severely damaged intestinal architecture. In contrast, FK-treated allografts showed well-protected intestinal structure and normal absorption on days 7 and 21.

CONCLUSION

High FK506 blood levels in the first postoperative week, achieved with FK pretreatment, prolonged intestinal allograft survival and preserved intestinal structure and function without allowing systemic infection.

Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor

OBJECTIVE

To assess a technique for simultaneous recovery of the intestine, pancreas, and liver from the same donor.

SUMMARY BACKGROUND DATA

With the more frequent use of pancreatic and intestinal transplantation, a procurement procedure is needed that permits retrieval of both organs as well as the liver from the same cadaveric donor for transplantation to different recipients. It is believed by many procurement officers and surgeons, however, that this objective is not technically feasible.

METHODS

A technique for simultaneous recovery of the intestine, pancreas, and liver was used in 13 multiorgan cadaver donors during a 26-month period, with transplantation of the organs to 33 recipients. The intestine was removed from 11 donors separately and in continuity with the pancreas in the other 2. Six additional pancreases were excised and transplanted separately. Thirteen livers were retrieved, one of which was discarded because of steatorrhea. Ten of the remaining 12 livers were transplanted intact; the other 2 were split in situ and used as reduced-size hepatic allografts in four recipients.

RESULTS

None of the 11 intestinal, 6 pancreatic, 2 intestinal-pancreatic, or 14 whole or partial liver allografts sustained serious ischemic injury or were lost as a result of technical complications. One liver recipient died 25 months after surgery of recurrent C virus hepatitis. The other 32 recipients had adequate allograft function with a mean follow-up of 8 months.

CONCLUSION

It was possible using the described technique to retrieve intestine, pancreas, and liver allografts safely from the same donor and to transplant these organs to different recipients.

Intestinal transplantation: indications, results and strategy

The term 'intestinal failure' is now often used to describe gastrointestinal function insufficient to satisfy body nutrient and fluid requirements. The first recognized condition of intestinal failure was short bowel syndrome. Severe motility disorders such as chronic intestinal pseudo-obstruction syndrome in children as well as congenital intractable intestinal mucosa disorders are also forms of intestinal failure, because no curative treatment for these diseases is yet available. Parenteral nutrition and home parenteral nutrition remain the mainstay of therapy for intestinal failure, whether it is partial or total, provisional or permanent. However, some patients develop complications while receiving standard therapy for intestinal failure and are considered for intestinal transplantation. Indeed, recent advances in immunosuppressive treatment and the better monitoring and control of acute rejection have brought intestinal transplantation into the realm of standard treatment for intestinal failure. Although it has been used in humans for the past two decades, this procedure has had a slow learning curve. According to the current results, this challenging procedure may be performed in children or adults, only under certain conditions.

Nutritional complications and management of intestinal transplant

Advances in intestinal transplantation provide a promising alternative to patients with intestinal failure and chronic dependence on total parenteral nutrition. However, many physiologic complications arising from the surgical procedure and high-dose immunosuppression, along with potential for rejection and infection, make successful graft function after transplantation a challenge. Nutrition issues unique to this patient population include recovery of normal intestinal motility and absorptive capacity. Diarrhea and high stomal output, which are common postoperatively, lead to deficits in macronutrients and micronutrients, especially electrolytes. Impaired gastrointestinal function affects ability to wean patients off hyperalimentation and enable them to tolerate nutrients enterally. In pediatric recipients of intestinal transplant, lack of experience with food or prior food aversions can lead to refusal to eat after transplant--additional challenges to achieving oral intake. Early and aggressive nutrition intervention is necessary for resolution of nutritional deficits and health of donor small bowel. This article presents an overview of the surgical procedure of intestinal transplantation and describes the physiologic adaptations that occur after the process. A case study demonstrates the clinical and nutritional hurdles associated with an intestinal transplant in a child and how dietitians can provide nutrition management. The potential role of individual nutrients in recovery of the transplanted bowel is also discussed.

Isolated intestinal transplantation for intestinal failure

OBJECTIVE

Parenteral nutrition sustains life in patients with intestinal failure. However, some experience life-threatening complications from parenteral nutrition, and in these individuals intestinal transplantation may be lifesaving.

METHODS

This is a retrospective review of 28 consecutive isolated small bowel transplants performed in eight adults and 20 children between December 1993 and June 1998 at the University of Nebraska Medical Center.

RESULTS

The 1-yr patient and graft survivals were 93% and 71%, respectively. The causes of graft loss were hyperacute rejection (n = 1), acute rejection (n = 5), vascular thrombosis (n = 1), and patient death (n = 1). The median length of time required until full enteral nutrition was 27 days. All 28 patients have experienced acute rejection of their small bowel grafts and rejection led to graft failure in five. Jaundice and/or hepatic fibrosis was present preoperatively in 17 of the 28 recipients and hyperbilirubinemia was completely reversed in all patients with functional grafts within 4 months of transplantation. Three patients developed post-transplant lymphoproliferative disease (11%). Three recipients developed cytomegalovirus enteritis and all were successfully treated.

CONCLUSIONS

Patient survival after intestinal transplantation is comparable to parenteral nutrition for patients with intestinal failure. Better immunosuppressive regimens are needed to decrease the risk of graft loss from acute rejection. The incidence of posttransplant lymphoproliferative disorder is higher after intestinal transplantation than after other solid organ transplants and the risk of cytomegalovirus enteritis is low with the use of cytomegalovirus seronegative donors. Liver dysfunction in the absence of established cirrhosis can be reversed.

Immunologic Aspects of Transplant Management: Pharmacotherapy and Rejection

The intensivist caring for the critically ill transplant patient must be knowledgeable in the management of immunosuppression or have expert help. Critical illness often has a major impact on the absorption and metabolism of immunosuppressive drugs, increasing or decreasing net immunosuppression. Too little immunosuppression brings the risk of graft loss, while too much increases the morbidity and mortality of serious infection. Optimum management often requires the skillful manipulation of dosage and/or routes of drug delivery. In many cases of life-threatening infection, immunosuppression must be discontinued altogether and restarted prior to significant graft injury. The cost of miscalculation is very high. Loss of a renal, pancreas, or small bowel transplant is tragic, while loss of a heart, lung, or liver is usually fatal. Unfortunately the management of immunosuppression is becoming more complex. As the field of transplantation matures, new immunosuppressants are being introduced. Also, more experience and growing numbers of clinical trials are making the required knowledge base ever larger. Each type of transplant has its own set of evolving immunosuppression strategies. This review presents the basic mechanisms of the most widely used drugs and the dangers of immunosuppression. The drugs are then discussed in the context of liver, small bowel, kidney, pancreas, heart, and lung transplantation. Finally, a brief section on the practical pharmacokinetics of the drugs is presented.

National sharing of cadaveric isolated intestinal allografts for human transplantation: a feasibility study

Most isolated intestinal graft losses are immunological. We conducted a pilot study to evaluate the feasibility of national sharing of HLA no-mismatch allografts for cadaveric isolated intestinal transplantation.

METHODS

UNOS data were analyzed in a theoretical model. Part I: All solid organ donors between 1/95-8/97 who would have met criteria for bowel donation were considered potential donors for all recipients who actually received isolated intestinal transplants during this period. We then determined how many donor intestines could have been directed to no-mismatch candidates had national sharing been in place. Donor exclusion criteria were CMV+ donors to CMV- recipients, hemodynamic instability, age >50, size mismatch (donor weight greater than recipient), and obesity. Mean and median waits for transplants, as well as theoretical mean and median waits for transplants that would have occurred given national sharing, were calculated. Part II: We estimated, based on registry graft survival data, the number of intestinal transplants necessary to demonstrate a no-mismatch graft survival advantage at 2 years.

RESULTS

Part I: Although no actual cadaveric no-mismatch transplant was performed, 12-17% of patients could have received no-mismatch allografts had sharing been in place, using various donor acceptance criteria. The impact on waiting time was variable. Part II: Accepting a 15% rate of no-mismatch cases and a survival advantage of 10% at 2 years, 793 transplants would be required to prove an advantage to HLA matching at P<0.05. If the graft survival advantage were 20% at 2 years, the time to show significance would be approximately 5 years. Using early acute rejection as an endpoint could require fewer transplants (93), and only a few years to complete the study.

CONCLUSIONS

National sharing of cadaveric isolated intestinal allografts is feasible. Median waits would not be significantly increased. The time necessary to prove graft survival advantage would be considerable, but a difference in the rate of acute rejection could be seen within 2 years. Additionally, a national sharing arrangement might improve the overall outcome of isolated intestinal transplantation.

Small bowel transplantation

The development of small bowel transplantation has long been hindered by the immunological and infectious barriers peculiar to the small bowel. Gradual progress has been achieved during the past decade with the use of tacrolimus and the availability of better anti-infection prophylaxis. The current status of small bowel transplantation as a life-saving option for patients failing on total parenteral nutrition and those who have developed irreversible liver failure is undisputed. Small bowel transplantation can be performed as either an intestine-only graft or as part of a composite graft with the liver and, on occasion, other organs. The various techniques of donor and recipient operations are relatively standardized. Despite the progress made, the most common causes of death and graft loss continue to be sepsis, rejection, and lymphomas. Further progress can be achieved by development of more effective immunosuppressive and immunomodulatory strategies. The role of inducing chimerism by adjuvant donor-specific bone marrow transfusions to promote graft tolerance is uncertain. Until the mortality and graft losses are further reduced, the role of small bowel transplantation will be limited to a salvage procedure for failure of total parenteral nutrition rather than a primary treatment of intestinal failure.

Composite liver--small bowel allografts with preservation of donor duodenum and hepatic biliary system in children

BACKGROUND/PURPOSE

Liver and intestinal transplantation is commonly required for children with intestinal failure who suffer concomitant total parenteral nutrition (TPN)-induced liver failure. Retrieval of such composite allografts using previously described "standard techniques" mandates reconstruction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications have been associated with significant morbidity and mortality. Also, size matching has limited the pool of donor organs for this patient population. To improve outcome and increase the donor pool the authors have utilized a duodenal-sparing composite liver small bowel allograft technique (DLSBTx) by preserving the head of the pancreas and the pancreatic-duodenal arteries. This precludes a biliary drainage procedure.

METHODS

Nine children (5 girls, 4 boys), with a mean age of 1.4 years (range, 1 to 17.4 years) received a DLSBTx. In 2 patients the liver was reduced; 1 patient received the whole pancreas. The mean recipient weight at the time of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age and mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 kg (range, 4 to 70 kg), respectively. All transplants were performed under tacrolimus and steroid immunosuppression.

RESULTS

With a mean follow-up of 419 days (range, 5 to 795 days), patient and graft survival rates are 78% and 67%, respectively. One patient underwent a combined retransplantation with the standard technique 31 days after the primary allograft was destroyed by a native pancreatic fistula. Currently, all surviving recipients are at home and off TPN. DLSBTx allowed the expansion of the donor pool by transplanting 6 patients with donor to recipient weight ratio > or =1 and utilizing 2 less than 5-kg donors, including a neonatal donor. In 55% of the patients, chemical pancreatitis was observed during the early postoperative period. None of the duodenal allografts experienced signs of ischemia or leak.

CONCLUSIONS

The technical advantages of this procedure include avoidance of a biliary reconstruction and simplification of the operative procedure. This, together with the feasibility of split or reduced liver grafting promises to increase the donor pool from neonates to adults.

Intestinal transplantation in children with chronic intestinal pseudo-obstruction

BACKGROUND

Children with chronic intestinal pseudo-obstruction (CIPO) often require total parenteral nutrition (TPN) which puts them at risk of liver failure and recurrent line infections. Intestinal transplantation has become a therapeutic option for TPN dependent children with intestinal failure who are failing management with TPN.

AIMS

To investigate the outcome of children with CIPO referred for intestinal transplantation.

METHODS

A retrospective review was carried out of records and diagnostic studies from 27 patients with CIPO referred for intestinal transplantation.

RESULTS

Five children were not listed for transplantation: two because of parental decision, two because of suspicion of Munchausen syndrome by proxy, and one because he tolerated enteral nutrition. Six are still TPN dependent and awaiting transplantation. Eight children died awaiting transplantation. Eight children underwent transplantation. Three died (two months, seven months, and four years after transplant). Five children are alive with a median follow up of 2.6 years (range two months to six years). All transplanted children were able to tolerate full enteral feedings. The postoperative course was complicated by dumping syndrome, Munchausen syndrome by proxy, narcotic withdrawal, and uncovering of achalasia. Conclusion-Intestinal transplantation may be a life saving procedure in children with CIPO. Early referral and thorough pretransplant evaluation are keys to successful transplantation.

Total parenteral nutrition and cholestasis

Hepatobiliary dysfunction is recognized as a major adverse effect of total parenteral nutrition (TPN). It is unknown if this is caused by a deficiency or toxicity of the TPN solution or the underlying pathophysiology of disease processes that require TPN therapy. This article presents algorithms for evaluating abnormal liver tests in patients on TPN and discusses treatment options and the current status of intestinal transplantation.

Nutritional support for the patient with short-bowel syndrome

Short-bowel syndrome refers to the clinical consequences that follow extensive resection of the small bowel. As a result of resection, malabsorption of macro- and micronutrients occurs. The prognosis after resection depends on the extent and location of resection, the presence of a colon, the function of the residual intestinal mucosa, and the extent of intestinal adaptation. Intestinal adaptation is influenced by the presence of intraluminal nutrients and various trophic peptides and hormones. This article discusses the dietary management of the patient with short-bowel syndrome and the recent literature on growth factors (ie, growth hormone and glutamine) and small-bowel transplantation.

Comparison of jejunal and ileal surveillance biopsies in a porcine model of intestinal transplantation

BACKGROUND

The optimal biopsy site of bowel allografts for rejection surveillance remains controversial. We compared the results of jejunal (JBx) and ileal (IBx) biopsies after bowel transplantation in a porcine model.

METHODS

Eighteen Yorkshire-Landrace pigs served as donors. Eighteen recipient pigs underwent total enterectomy followed by orthotopic small bowel transplantation with or without the colon. A jejunostomy and a Bishop-Koop ileostomy were constructed for biopsies. Immunosuppression consisted of FK506 (target level 10-15 ng/ml by enzyme immunoparticle assay) and prednisone administered via the jejunostomy. Simultaneous JBx and IBx were performed twice weekly. Acute rejection was graded as mild, moderate, or severe based on previously published criteria.

RESULTS

Mean overall survival after the transplant was 17.4 days. A total of 162 specimens were collected and evaluated for rejection (JBx, 81; IBx, 81). Acute rejection was detected in 41 JBx cases (50.7%) and 40 IBx cases (49.4%). The presence or absence of rejection was concordant between JBx and IBx in 70 of 81 case pairs (86.4%). Of the 11 discordant case pairs, 6 were JBx positive/IBx negative, whereas 5 were JBx negative/IBx positive. A total of 35 case pairs were synchronously positive, 24 (68.8%) of which demonstrated the same degree of rejection.

CONCLUSIONS

The correlation between JBx and IBx of bowel allografts in diagnosing the presence of acute rejection is quite good. However, performing IBx alone would have missed about 7.5% of the rejection episodes. Because the early treatment of rejection in bowel transplantation is of paramount importance, in selected cases, biopsies from both the ileum and jejunum should be considered if technically feasible.

Multivisceral transplantation for megacystis microcolon intestinal hypoperistalsis syndrome

BACKGROUND

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare autosomal recessive disorder causing a functional neonatal bowel obstruction. Its etiopathogenesis is not fully understood. The prognosis is poor in the majority of cases; most patients die before the age of 6 months. In this report, we describe our experience with three patients with MMIHS in whom multivisceral transplantation was performed.

METHODS

Three patients with MMIHS underwent multivisceral transplantation. All patients were females with a history of long-term total parenteral nutrition (TPN) with TPN-related cholestatic liver disease.

RESULTS

Patient 1 died 17 months after transplantation because of aspiration after revision of her feeding gastrostomy. At the time of death, the graft was functioning and the patient was completely off TPN. Patient 2 is alive 17 months after transplant. She is a fully functional, active 2-year-old and has also recently begun oral feeding after intensive rehabilitation. Patient 3 died on day 44 of multisystem failure.

CONCLUSIONS

This is the first report in the literature of multivisceral transplantation for MMIHS. Although one of the three patients died 44 days after surgery from multiorgan system failure, the other two patients had long-term survival after transplant and both grew well on enteral feeding alone. One patient died 17 months from a non-transplant-related complication, while the other is living at home off of TPN, with almost complete dietary rehabilitation 17 months after transplant. Our case reports suggest that multivisceral transplantation is a valuable therapeutic option for patients affected by MMIHS with TPN-induced liver failure.

Intestinal transplantation

Intestinal transplantation might become the alternative to definitive parenteral nutrition in patients with permanent intestinal failure. Indeed, recent advances in immunosuppressive treatment and better monitoring and control of acute rejection have brought intestinal transplantation into the realms of standard treatment of intestinal failure. This procedure may be performed in adult or paediatric patients under certain conditions. This short review focuses on the current clinical results and indications for intestinal transplantation and discusses the strategy regarding this challenging procedure.

Intestinal transplantation in children

Intestinal transplantation has emerged in the last decade as a lifesaving procedure for patients with intestinal failure who are suffering from complications arising from the administration of total parenteral nutrition. Indications for transplantation include irreversible liver injury and loss of vascular access. At least 50 children in the United States may benefit from intestinal transplantation every year. In this article, indications, pre- and postoperative management, and outcomes of intestinal transplantation in children are discussed.

Quality of life in patients receiving home parenteral nutrition

BACKGROUND/AIMS

Quality of life is an important determinant of the effectiveness of health technologies, but it has rarely been assessed in patients receiving home parenteral nutrition (HPN).

PATIENTS/METHODS

The non-disease specific sickness impact profile (SIP) and the disease specific inflammatory bowel disease questionnaire (IBDQ) were used on a cohort of 49 patients receiving HPN, and the results compared with those for 36 non-HPN patients with either anatomical (<200 cm) or functional (faecal energy excretion >2.0 MJ/day (approximately 488 kcal/day)) short bowel.

RESULTS

In the HPN patients the SIP scores were worse (higher) overall (17 (13)% v 8 (9)%) and with regard to physical (13 (15)% v 5 (8)%) and psychosocial (14 (12)% v 9 (11)%) dimensions and independent categories (20 (12)% v 9 (8)%) compared with the non-HPN patients (means (SD); all p<0.001). The IBDQ scores were worse (lower) in the HPN patients overall (5.0 (4.3-5.7) v 5.6 (4.8-6.2)) and with regard to systemic symptoms (3.8 (2.8-5.4) v 5.2 (3.9-5.9)) and emotional (5.3 (4.4-6.2) v 5.8 (5.4-6.4)) and social (4.3 (3.4-5. 5) v 4.8 (4.5-5.8)) function (median (25-75%); all p<0.05), but only tended to be worse with regard to bowel symptoms (5.2 (4.8-6.1) v 5.7 (4.9-6.4), p = 0.08). HPN also reduced quality of life in patients with a stoma, whereas a stoma did not reduce quality of life among the non-HPN patients. Female HPN patients and HPN patients older than 45 scored worse.

CONCLUSION

Quality of life is reduced in patients on HPN compared with those with anatomical or functional short bowel not receiving HPN, and compares with that reported for patients with chronic renal failure treated by dialysis.

Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry

BACKGROUND

Small bowel transplantation is an evolving procedure. We reviewed the world experience since 1985 to determine the current status of this procedure.

METHODS

All of the known intestinal transplant programs were invited to contribute to an international registry using a standardized report form.

RESULTS

Thirty-three intestinal transplant programs provided data on 273 transplants in 260 patients who were transplanted on or before February 28, 1997. The number of procedures per year has increased at a linear rate since 1990, with 58 transplants performed in 1996. Two-thirds of the recipients were children or teenagers. The short gut syndrome was the most common indication for transplantation. The types of transplants included the small bowel with or without the colon (41%); the intestine and liver (48%); and multivisceral grafts (11%). The 1-year graft/patient survival for transplants performed after February 1995 was 55%/69% for intestinal grafts; 63%/66% for small bowel and liver grafts; and 63%/63% for multivisceral grafts. Transplants since 1991 and programs that had performed at least 10 transplants had significantly higher graft survival rates. Seventy-seven percent of the current survivors had stopped total parenteral nutrition (TPN) and resumed oral nutrition.

CONCLUSIONS

Transplantation has become a lifesaving procedure for (1) patients with intestinal failure who cannot be maintained on total parenteral nutrution and (2) patients who require abdominal evisceration to completely remove locally aggressive tumors. The 5-year survival rate of intestinal transplantation with large series is comparable to lung transplantation.

Survival of home parenteral nutrition-treated patients: 20 years of experience at the Mayo Clinic

OBJECTIVE

To present the largest single institutional review of demographics, associated primary diseases, and survival of patients receiving home parenteral nutrition (HPN).

MATERIAL AND METHODS

We conducted a retrospective review of medical records of all Mayo Clinic patients treated with HPN between 1975 and 1995. The probability of survival was calculated by using Kaplan-Meier analysis.

RESULTS

In the 225 study patients requiring HPN (median age, 51 years), the main underlying primary diseases were as follows: inflammatory bowel disease (IBD) (N = 50), nonterminal active cancer (N = 39), ischemic bowel (N = 35), radiation enteritis (N = 32), motility disorder (chronic pseudo-obstruction) (N = 26), and adhesive intestinal obstruction (N = 18). Other conditions included intestinal and pancreatic fistula, refractory sprue, dumping syndrome, and protein-losing enteropathy. The overall probability of 5-year survival during HPN was 60%. The probability of survival at 5 years based on the primary disease was 92% for IBD, 60% for ischemic bowel, 54% for radiation enteritis, 48% for motility disorder, and 38% for cancer. The probability of 5-year survival stratified by age at initiation of HPN was as follows: younger than 40 years, 80%; 40 through 60 years, 62%; and older than 60 years, 30%. Most deaths during therapy with HPN were attributable to the primary disease. Among the 20 patients who died of an HPN-related cause, 11 deaths were from catheter sepsis, 4 from liver failure, 2 from venous thrombosis, and 2 from metabolic abnormalities.

CONCLUSION

Survival of HPN-treated patients is best predicted on the basis of the primary disease and the age at initiation of HPN. Patients with IBD and age younger than 40 years have a better 5-year survival in comparison with other groups. Most deaths during treatment with HPN are a result of the primary disease; HPN-related deaths are uncommon.

Distribution of muscarinic receptor subtypes in rat small intestine

Despite its great promise, small intestinal transplantation in some patients is complicated by difficult postoperative management. The reasons for this are complex. In a rat model of small intestinal transplantation, frequencies of migrating myoelectric complexes during fasting are reduced in ileal isografts and muscarinic receptor density is decreased. We hypothesized that the distribution of muscarinic 1 receptors localized to enteric neurons is altered after small intestinal transplantation. Distal small intestine was orthotopically transplanted in Lewis-to-Lewis donor-recipient combinations. At 3 months, transplanted and normal ileum was obtained to prepare membrane fractions. [N-methyl-3H]Scopolamine served as ligand, while scopolamine methylbromide, pirenzepine, and methoctramine were used in competitive homologous and heterologous displacement experiments. Receptor subtype models were examined by nonlinear regression analysis. In normal and transplanted ileum, heterologous displacement was consistent with three site models (P < 0.05). In normals, the muscarinic 1 receptor subtype was most abundant, with a relative distribution of 69 to 78%. There was a relative distribution of 13 to 16% for muscarinic 3 receptor subtype. After transplantation, the muscarinic 1 subtype decreased to a mean of 45% but the muscarinic 3 subtype increased to a mean of 42%. Using pirenzepine, mean pKD values were not different between the two groups. It is concluded that the decrease in muscarinic 1 receptor subtype after transplantation could be related to neuronal cell loss or to downregulation of the expression of muscarinic 1 receptors. The results did not support defective posttranslational processing of receptor proteins.

Quality of life after small intestinal transplantation and among home parenteral nutrition patients

BACKGROUND

The purpose of the study was to quantify changes in the quality of life of small bowel recipients before and after transplantation and of home parenteral nutrition (HPN)-dependent patients before and after therapy. We examined quality of life across multiple areas of function including physical, social, and emotional indices.

METHODS

The Quality of Life Instrument in the form of a self-administered questionnaire was completed voluntarily by the recipients of small intestinal transplants and by a cohort of HPN-dependent patients.

RESULTS

Small intestinal transplant recipients reported significant improvement in the quality of their life and function. They also rated their quality of life and function during the pretransplant, TPN-dependent period to be worse than before the development of chronic intestinal failure. Similarly, HPN recipients reported significant worsening across most areas of quality of life when they compared their premorbid period to the HPN-dependent state.

CONCLUSIONS

TPN dependence causes significant impairment in the quality of life in most areas of functioning. In contrast, small intestinal transplantation restores the quality of life among recipients with functioning grafts.

Intestinal transplantation

Increasing experience with intestinal transplantation has led to the refinement of techniques to detect and treat rejection and infectious complications. Improved outcome has led to a broadening of the indications for intestinal transplantation, particularly solitary intestinal transplantation.