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Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Avitzur Y. An international multicenter validation study of the Toronto listing criteria for pediatric intestinal transplantation. Am J Transplant 2022; 22:2608-2615. [PMID: 35833730 DOI: 10.1111/ajt.17150] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Deciding which patients would benefit from intestinal transplantation (IT) remains an ethical/clinical dilemma. New criteria* were proposed in 2015: ≥2 intensive care unit (ICU) admissions, loss of ≥3 central venous catheter (CVC) sites, and persistently elevated conjugated bilirubin (CB ≥ 75 μmol/L) despite 6 weeks of lipid modification strategies. We performed a retrospective, international, multicenter validation study of 443 children (61% male, median gestational age 34 weeks [IQR 29-37]), diagnosed with IF between 2010 and 2015. Primary outcome measure was death or IT. Sensitivity, specificity, NPV, PPV, and probability of death/transplant (OR, 95% confidence intervals) were calculated for each criterion. Median age at IF diagnosis was 0.1 years (IQR 0.03-0.14) with median follow-up of 3.8 years (IQR 2.3-5.3). Forty of 443 (9%) patients died, 53 of 443 (12%) were transplanted; 11 died posttransplant. The validated criteria had a high predictive value of death/IT; ≥2 ICU admissions (p < .0001, OR 10.2, 95% CI 4.0-25.6), persistent CB ≥ 75 μmol/L (p < .0001, OR 8.2, 95% CI 4.8-13.9). and loss of ≥3 CVC sites (p = .0003, OR 5.7, 95% CI 2.2-14.7). This large, multicenter, international study in a contemporary cohort confirms the validity of the Toronto criteria. These validated criteria should guide listing decisions in pediatric IT.
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Affiliation(s)
- Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sue V Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Helen M Evans
- New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - David Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutritional Support and Intestinal Failure Team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jason Yap
- Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Paediatric Gastroenterology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
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2
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Nikoupour H, Arasteh P, Shamsaeefar A, Ghanbari F, Boorboor A, Almayali AMJ, Shafiekhani M, Samidoust P, Shahriarirad R, Shojazadeh A, Ranjbar K, Darabi MH, Tangestanipour S, Hosseini SM, Zahiri L, Nikeghbalian S. Experiences with intestinal failure from an intestinal rehabilitation unit in a country without home parenteral nutrition. JPEN J Parenter Enteral Nutr 2021; 46:946-957. [PMID: 34291839 DOI: 10.1002/jpen.2231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN). METHODS We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders. RESULTS Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died. CONCLUSION Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.
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Affiliation(s)
- Hamed Nikoupour
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Peyman Arasteh
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Alireza Shamsaeefar
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Fardin Ghanbari
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Arash Boorboor
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | | | - Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pirouz Samidoust
- Razi Clinical Research Development Unit, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shojazadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Sina Tangestanipour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Morteza Hosseini
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Leila Zahiri
- Department of Internal Medicine, Shiraz University of Medical Science, Shiraz, Iran
| | - Saman Nikeghbalian
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
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Small Bowel Dilatation Predicts Prolonged Parenteral Nutrition and Decreased Survival in Pediatric Short Bowel Syndrome. Ann Surg 2017; 266:369-375. [PMID: 27433892 DOI: 10.1097/sla.0000000000001893] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To analyze risk factors and prognostic significance of small bowel (SB) dilatation in children with short bowel syndrome (SBS). BACKGROUND In SBS, the remaining SB may dilate as part of intestinal adaptation. The impact of dilatation on parenteral nutrition (PN) dependence and survival has not been studied systematically. METHODS SB diameter of SBS children (n = 61) was measured in contrast SB series (n = 169, median age 0.94, range 0.32-2.7 years) during 2002 to 2015, and expressed as millimeters (SB width) and as ratio to L5 vertebra height (SB diameter ratio). Linear regression was used to examine risk factors for dilatation. PN weaning and survival were analyzed with Cox proportional hazards regression. RESULTS Maximal SB diameter ratio during follow-up was predicted by PN dependence and SB atresia, while maximal absolute SB width by birth weight, age, PN duration, and remaining bowel length. Weaning off PN was 14-fold more likely in patients with maximal SB diameter ratio <2.00 compared with >3.00 (P = 0.005), and 5.4-fold more likely when maximal SB width was <20 mm compared with >30 mm (P = 0.023). After adjustment for age, remaining SB length, and the presence of ileocecal valve, both estimates of maximal SB dilatation remained significant independent predictors for weaning off PN. When all measurements were included, the cumulative survival was worse if SB diameter ratio exceeded 2.00 (P = 0.002-0.042). CONCLUSIONS SB dilatation predicts prolonged PN duration and decreased survival in SBS children. Measurement of maximal SB diameter standardized to L5 vertebra height may be a valuable objective tool for patient follow-up and assessment of prognosis.
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Nakamura H, Henderson D, Puri P. A meta-analysis of clinical outcome of intestinal transplantation in patients with total intestinal aganglionosis. Pediatr Surg Int 2017; 33:837-841. [PMID: 28600659 DOI: 10.1007/s00383-017-4107-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/26/2022]
Abstract
AIM OF THE STUDY Total intestinal aganglionosis (TIA) occurs in less than 1% of patients with Hirschsprung disease (HD), and TIA is the most severe form of HD. Survival has improved with the advent of parenteral nutrition and intestinal transplantation (ITx). The field of ITx has rapidly progressed in the last two decades and has now become an established treatment for patients with intestinal failure. The purpose of this meta-analysis was to determine the clinical outcome of ITx in patients with TIA. METHODS A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms: "total intestinal aganglionosis", "intestinal transplantation", and "Hirschsprung disease/Hirschsprung's disease" for studies published between 2003 and 2016. The relevant cohorts of ITx in patients with TIA were systematically searched for clinical outcomes. MAIN RESULTS Thirteen studies met defined inclusion criteria, reporting a total of 63 patients who underwent ITx for TIA. Majority of patients were males (71.0%), and median age of ITx was 4.3 (range 0.25-17.6) years. Isolated ITx was performed in 37% patients and multivisceral ITx in 63%. Mean follow-up period was 40 months (range 1-154). Overall survival rate was 66%; the longest survivor was 12.8-year-old after ITx. CONCLUSION ITx appears promising in the management of TIA. ITx can be considered a feasible treatment option for patients with TIA who suffer from life-threatening complications of intestinal failure.
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Affiliation(s)
- Hiroki Nakamura
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland.
| | - Davina Henderson
- Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland
- School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
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5
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Hukkinen M, Kivisaari R, Koivusalo A, Pakarinen MP. Risk factors and outcomes of tapering surgery for small intestinal dilatation in pediatric short bowel syndrome. J Pediatr Surg 2017; 52:1121-1127. [PMID: 28185632 DOI: 10.1016/j.jpedsurg.2017.01.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 11/20/2016] [Accepted: 01/24/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND In remains unclear why in some short bowel syndrome (SBS) patients, the remaining small bowel (SB) dilates excessively leading to requirement of tapering surgery. METHODS Among SBS children, we retrospectively analyzed risk factors for tapering surgery with logistic regression and compared the outcome of operated patients (n=16) to those managed conservatively (n=44) with Cox proportional hazards regression. RESULTS SBS was caused by necrotizing enterocolitis (NEC) (n=31), SB atresia (SBA) (n=13), midgut volvulus (n=12), or gastroschisis (n=4). Patients with spontaneous symptomatic SB dilatation unable to wean parenteral nutrition (PN) underwent tapering surgery at median age of 1.04 (interquartile range 0.70-3.27) years. Missing ICV was related to an 8-fold (p=0.003) increased risk while SBA diagnosis was related to a 13-fold risk of tapering surgery (p<0.001). Increasing SB length and NEC diagnosis were protective of tapering (p=0.027-0.004). Of operated patients, 75% reached enteral autonomy during follow-up and their postoperative adjusted PN weaning rate was similar to nonoperated children (p=0.842). CONCLUSION SBS children with short remaining SB, missing ICV, and SBA etiology are more likely while NEC patients are less likely than others to necessitate tapering surgery. Postoperative PN weaning rates were comparable to patients who initially had more favorable intestinal anatomy and adapted without surgery.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Koivusalo
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
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6
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Ramisch D, Rumbo C, Echevarria C, Moulin L, Niveyro S, Orce G, Crivelli A, Martinez MI, Chavez L, Paez MA, Trentadue J, Klein F, Fernández A, Solar H, Gondolesi GE. Long-Term Outcomes of Intestinal and Multivisceral Transplantation at a Single Center in Argentina. Transplant Proc 2017; 48:457-62. [PMID: 27109978 DOI: 10.1016/j.transproceed.2015.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.
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Affiliation(s)
- D Ramisch
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Rumbo
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Echevarria
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Moulin
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - S Niveyro
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G Orce
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Crivelli
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M I Martinez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Chavez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M A Paez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - J Trentadue
- Pediatric Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - F Klein
- Adult Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Fernández
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - H Solar
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina.
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Abstract
Intestinal transplantation (IT) is the least common form of organ transplantation; however, it has shown exceptional growth and improvement in graft survival rates over the past two decades mainly due to better outcomes achieved during the first year of transplantation (76 % at 1 year), due to improvement in surgical techniques and the development of better immunosupressive therapies as we understand more about the relationship between the recipient and host immune system. There are still ongoing issues with chronic rejection and long-term survival. Intestinal transplantation is still an acceptable therapy for patients with intestinal failure (IF), but it is generally reserved for patients who develop severe and life-threatening complications despite standard therapies, or those who are not able to maintain a good quality of life. The purpose of this review is to describe the current status, indications, outcomes and advances in the field of intestinal transplantation.
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Demir Z, Frange P, Lacaille F. Vaccinations, response, and controls before and after intestinal transplantation in children. Pediatr Transplant 2016; 20:449-55. [PMID: 26847771 DOI: 10.1111/petr.12669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 11/25/2022]
Abstract
Vaccination is an effective strategy to decrease infections in transplant recipients. Children after intestinal transplantation carry a high risk of infection due to increased immunosuppression. In a series of 22 children after intestinal transplantation, we studied the vaccination schedules and the antibodies against vaccine-preventable diseases before transplantation, and at one and five yr after transplantation. We reviewed whether the vaccination schedules were complete, and we analysed the factors that may influence serological immunity and the incidence of disease in patients with deficient immunity. All patients completed the recommended vaccination schedules for DTaP-IPV and HBV. After transplantation, the negative antibodies against vaccine-preventable diseases were mostly related to an antirejection therapy: for DTaP-IPV: four of four patients with no antibody had been treated for rejection, for HBV: two of five, HAV: three of four, MMR: three of seven, and VZV: three of four. A post-transplantation varicella infection was followed by acute rejection, with probability for a relationship between both events. We observed 50% of varicella cases in unvaccinated children, highlighting the importance of pretransplant vaccination. Waning immunogenicity mediated by antibodies against vaccine-preventable disease after transplantation indicated a need for boosters. The recommendations should be regularly enforced, as the reliance on routine immunizations schedules is not adequate in immunocompromised patients.
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Affiliation(s)
- Z Demir
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
| | - P Frange
- Microbiology Department, Necker-Enfants Malades Hospital, Paris, France.,Pediatric Immunology and Hematology Unit, Necker Hospital, Paris, France.,EA 7327, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - F Lacaille
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
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9
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Acquired causes of intestinal malabsorption. Best Pract Res Clin Gastroenterol 2016; 30:213-24. [PMID: 27086886 DOI: 10.1016/j.bpg.2016.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
This review focuses on the acquired causes, diagnosis, and treatment of intestinal malabsorption. Intestinal absorption is a complex process that depends on many variables, including the digestion of nutrients within the intestinal lumen, the absorptive surface of the small intestine, the membrane transport systems, and the epithelial absorptive enzymes. Acquired causes of malabsorption are classified by focussing on the three phases of digestion and absorption: 1) luminal/digestive phase, 2) mucosal/absorptive phase, and 3) transport phase. Most acquired diseases affect the luminal/digestive phase. These include short bowel syndrome, extensive small bowel inflammation, motility disorders, and deficiencies of digestive enzymes or bile salts. Diagnosis depends on symptoms, physical examination, and blood and stool tests. There is no gold standard for the diagnosis of malabsorption. Further testing should be based on the specific clinical context and the suspected underlying disease. Therapy is directed at nutritional support by enteral or parenteral feeding and screening for and supplementation of deficiencies in vitamins and minerals. Early enteral feeding is important for intestinal adaptation in short bowel syndrome. Medicinal treatment options for diarrhoea in malabsorption include loperamide, codeine, cholestyramine, or antibiotics.
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10
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Hukkinen M, Kivisaari R, Lohi J, Heikkilä P, Mutanen A, Merras-Salmio L, Pakarinen MP. Transient elastography and aspartate aminotransferase to platelet ratio predict liver injury in paediatric intestinal failure. Liver Int 2016; 36:361-9. [PMID: 26058319 DOI: 10.1111/liv.12887] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/01/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS We aimed to evaluate the value of AST to platelet ratio (APRI) and transient elastography (TE) as predictors of liver histopathology in children with intestinal failure (IF). METHODS Altogether 93 liver biopsies from 57 children with parenteral nutrition (PN) duration ≥3 months were analysed. APRI measurement and TE (n = 46) were performed at the time of biopsy. RESULTS IF was caused by short bowel syndrome in 75% of patients. At the time of liver biopsy, PN dependent patients (n = 42) were younger with longer PN duration compared to those weaned off PN (n = 51) (2.2 vs. 7.6 years, P < 0.001; 26 vs. 10.5 months, P = 0.043). Elevated transaminase or bilirubin levels were found in 51%, splenomegaly in 26%, and oesophageal varices in 3.5%. Histological fibrosis was present in 61% (Metavir stage F1; 27%, F2; 26%, F3-4; 9%), cholestasis in 25% and steatosis in 22% of biopsy specimens. TE was superior to APRI in prediction of any liver histopathology (fibrosis, cholestasis or steatosis) with areas under the receiving operating curve (AUROC) of 0.86 (95% CI 0.74-0.97) and 0.67 (95% CI 0.58-0.78) respectively. For prediction of ≥F1 and ≥F2 fibrosis, AUROC values for TE were 0.78 (95% CI 0.64-0.93) and 0.73 (95% CI 0.59-0.88), whereas APRI did not correlate with fibrosis stages. For detection of histological cholestasis, the AUROC for APRI was 0.77 (95% CI 0.64-0.89). CONCLUSIONS Both TE and APRI are promising noninvasive methods for monitoring the development of IF-related liver histopathology. TE values reflected the degree of fibrosis better while APRI detected histological cholestasis more accurately.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, HUSLAB, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Päivi Heikkilä
- Department of Pathology, HUSLAB, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Annika Mutanen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Laura Merras-Salmio
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Section of Pediatric Gastroenterology, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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11
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Postoperative outcome and survival in relation to small intestinal involvement of total colonic aganglionosis. J Pediatr Surg 2015; 50:1859-64. [PMID: 26103793 DOI: 10.1016/j.jpedsurg.2015.05.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/26/2015] [Accepted: 05/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognosis and treatment of total colonic aganglionosis (TCA) vary according to the presence and extent of small bowel involvement. METHODS Medical records of TCA patients treated in Helsinki University Children's Hospital during 1984-2013 (n=21) were reviewed. RESULTS The aganglionosis extended up to cecum or distal ileum (n=12), mid small bowel (n=4), or duodenojejunal flexure (n=5). Patients underwent resection of distal aganglionic bowel with ileoanal (IAA) or jejunoanal anastomosis (JAA) with (n=9) or without J-pouch (n=5), Lester-Martin pull-through (n=1), or were left with an end-jejunostomy (n=6). Further procedures included autologous intestinal reconstruction (n=3) and ITx/listing for ITx (n=2). Compared to distal ileum aganglionosis, patients with more proximal disease required parenteral nutrition (PN) more often (100% vs. 25%) and weaned off PN less frequently (p=0.001). At last follow-up 6.5 (interquartile range 2.5-14.5) years postoperatively, all patients with distal ileum aganglionosis were off PN and alive compared to 78% on PN (p<0.001) and 67% alive (p=0.063) of those with more proximal disease. All had normal plasma bilirubin and patients with preserved intestinal continuity (n=13) were continent. CONCLUSIONS Outcomes following restorative proctocolectomy for aganglionosis extending up to mid small bowel are promising, whereas long-term outlook in proximal small intestinal disease is dismal without ITx.
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Impact of Intestinal Rehabilitation Program and Its Innovative Therapies on the Outcome of Intestinal Transplant Candidates. J Pediatr Gastroenterol Nutr 2015; 61:18-23. [PMID: 25611029 DOI: 10.1097/mpg.0000000000000735] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The outcome of children with intestinal failure has improved during the past decade following the introduction of novel therapies by dedicated intestinal rehabilitation programs (IRP). The aim of the present study was to assess the impact of IRP on the outcome of intestinal transplant (IT) candidates and the transplant waiting list. METHODS A retrospective cohort study of children assessed for IT (n = 84) during a 10-year period. Comparisons were made among the following 3 time periods: before the establishment of our center's IRP (1999-2002; n = 33), early IRP (2003-2005; n = 18), and late IRP (2006-2009; n = 33). The following endpoints were used: patient outcome following IT assessment (not listed, listed and removed from the list, received transplant, died while on the list), patient characteristics at IT assessment, and patient status at the end of the study. RESULTS The late-IRP era was associated with an increase in patients who were not listed (42% vs 28% at other periods, P = NS) and patients who were removed from the IT waiting list because of clinical improvement (P < 0.0005), and a decrease in those who died before transplant (15% vs >60% at other periods, P < 0.0005). The cause of death shifted from traditional causes such as liver failure or sepsis to other comorbid conditions (P < 0.005). Improved liver function at listing was also observed during late IRP (P < 0.005). CONCLUSIONS Treatment by IRP, coupled with recent advances in the medical management of intestinal failure, is associated with improved survival and outcome of patients waiting for IT, and may lead to overall reduction in the number of IT in the future.
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Burghardt KM, Wales PW, de Silva N, Stephens D, Yap J, Grant D, Avitzur Y. Pediatric intestinal transplant listing criteria - a call for a change in the new era of intestinal failure outcomes. Am J Transplant 2015; 15:1674-81. [PMID: 25809131 DOI: 10.1111/ajt.13147] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 11/10/2014] [Accepted: 12/01/2014] [Indexed: 01/25/2023]
Abstract
Current listing indications used for intestinal transplantation (IT) were proposed in 2001. We undertook the present single center study to see if these criteria are still valid. The 2001 criteria (advanced cholestasis, loss of >50% central venous catheter (CVC) sites, ≥2 sepsis/year, ultrashort bowel) were compared in children with intestinal failure in old era-1998-2005 (N = 99) to current era-2006-2012 (N = 91) to predict the need for IT using sensitivity, specificity, NPV and PPV. Two 2001 criteria had poorer predictive value in the current era: Advanced cholestasis (PPV 64% old vs. 40% current era; sensitivity 84% vs. 65%, respectively) and ultrashort bowel (PPV 100% old vs. 9% current era; sensitivity 10% vs. 4%, respectively). Three newly proposed criteria had high predictive value: ≥2 ICU admissions (p = 0.0001, OR 23.6, 95% CI 2.7-209.8), persistent bilirubin >75 mmol/L despite lipid strategies (p = 0.0005, OR 24.0, 95% CI 3.2-177.4), and loss of ≥3 CVC sites (p = 0.0003, OR 33.3, 95% CI 18.8-54.0). There was 98% probability of needing IT when two of these new criteria were present. The 2001 IT criteria have limited predictive ability in the current era and should be revised. A multicenter study is required to validate the findings of this single center experience.
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Affiliation(s)
- K M Burghardt
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant Centre, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - P W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant Centre, Toronto, Ontario, Canada.,Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - N de Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant Centre, Toronto, Ontario, Canada
| | - D Stephens
- Biostatistics Department, University Health Network and Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - J Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - D Grant
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Y Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant Centre, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Hukkinen M, Merras-Salmio L, Sipponen T, Mutanen A, Rintala RJ, Mäkisalo H, Pakarinen MP. Surgical rehabilitation of short and dysmotile intestine in children and adults. Scand J Gastroenterol 2015; 50:153-61. [PMID: 25421304 DOI: 10.3109/00365521.2014.962607] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS This is a descriptive study aiming to compare outcomes of intestinal rehabilitation surgery among pediatric and adult intestinal failure (IF) patients with either primary intestinal motility disorders or short bowel syndrome (SBS) treated by our nationwide program. METHODS Medical records of IF patients (n = 31, 71% children) having undergone autologous intestinal reconstructions (AIR) (n = 25), intestinal transplantation (ITx) (n = 5), or being listed for ITx (n = 2) between 1994 and 2014 were reviewed. RESULTS At surgery, median age was 3.4 (interquartile range, 1.0-22.1) in SBS (n = 22) and 16.5 (3.2-26.7) years in dysmotility patients (n = 9) who received median 60% and 83% of energy requirement parenterally, respectively. Median small bowel length was shorter in SBS than dysmotility patients (34 versus 157 cm, p < 0.001). Following AIR, none of the dysmotility patients achieved permanent intestinal autonomy, whereas 68% of SBS patients weaned off parenteral nutrition (PN) (p = 0.022) and none required listing for ITx. Five dysmotility patients who underwent ITx achieved intestinal autonomy. Regarding both AIR and ITx procedures, no significant difference in PN weaning was observed between the two subgroups. At last follow-up, 3.3 (0.6-8.0) years postoperatively, median plasma bilirubin was 6 (4-16) µmol/l, while liver biopsy showed fibrosis (Metavir stage 1-2) in 50% and cholestasis in 8%. Proportion of PN energy requirement had reduced significantly (p = 0.043) among PN-dependent SBS (n = 7) but not among dysmotility patients (n = 5). Overall survival was 90%. CONCLUSION AIR surgery was beneficial among selected SBS patients, whereas in intestinal dysmotility disorders, permanent PN weaning was only achieved by ITx.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, University of Helsinki , Helsinki , Finland
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Fredericks EM, Zelikovsky N, Aujoulat I, Hames A, Wray J. Post-transplant adjustment--the later years. Pediatr Transplant 2014; 18:675-88. [PMID: 25220845 PMCID: PMC4179879 DOI: 10.1111/petr.12366] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2014] [Indexed: 01/04/2023]
Abstract
As survival rates for pediatric solid organ transplantation have continued to improve, researchers and healthcare providers have increasingly focused on understanding and enhancing the HRQOL and psychosocial functioning of their patients. This manuscript reviews the psychosocial functioning of pediatric transplant recipients during the "later years," defined as more than three yr post-transplant, and focuses on the day-to-day impact of living with a transplant after the immediate period of adjustment and early years after surgery. Key topics reviewed include HRQOL, cognitive functioning, impact on the family, regimen adherence, and transition of responsibility for self-management tasks. Overall, pediatric transplant recipients evidence impairment in HRQOL, neuropsychological outcomes, and family functioning as compared to non-transplant recipients. However, the degree of impairment is influenced by a variety of factors including, disease severity, age, solid organ type, and study methodologies. Studies are limited by small samples, cross-sectional design, and the lack of universal assessment battery to allow for comparisons across solid organ populations. Areas for future research are discussed.
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Affiliation(s)
- Emily M. Fredericks
- Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital
| | - Nataliya Zelikovsky
- Department of Psychology, La Salle University and The Children’s Hospital of Philadelphia
| | - Isabelle Aujoulat
- Université Catholique de Louvain, Institute of Health & Society (IRSS), Brussels, Belgium
| | - Anna Hames
- Institute of Liver Studies, King’s College Hospital, London UK
| | - Jo Wray
- Critical Care and Cardiorespiratory Division, Great Ormond Street Hospital for Children, London UK
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Bodeur C, Aucoin J, Johnson R, Garrison K, Summers A, Schutz K, Davis M, Woody S, Ellington K. Clinical practice guidelines--Nursing management for pediatric patients with small bowel or multivisceral transplant. J SPEC PEDIATR NURS 2014; 19:90-100. [PMID: 24393230 DOI: 10.1111/jspn.12056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 10/08/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE Small bowel or multivisceral transplant is a relatively new treatment for irreversible intestinal damage, and no published practice guidelines exist. The purpose of this article is to report evidence regarding the best plan of care to achieve adequate nutrition and appropriate development for children. DESIGN AND METHODS An integrative review was conducted with 54 articles related to management of this transplant population. A nine-member nursing team integrated the findings. PRACTICE IMPLICATIONS This resulting guideline represents the best research and best practices on which to base staff education and competency validations to manage this medically fragile patient population.
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Affiliation(s)
- Cynthia Bodeur
- Northeast Clinical Services, Danvers, Massachusetts, USA
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Ting MJ, Chen Y, Chang SC. Factors affecting the duration of mechanical ventilation in patients after intestinal transplantation: preliminary results. ACTA ACUST UNITED AC 2013; 51:108-11. [PMID: 24148738 DOI: 10.1016/j.aat.2013.09.006] [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: 02/19/2012] [Revised: 06/03/2013] [Accepted: 06/06/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intestinal transplantation (ITx) is a definitive therapy for patients with intestinal failure. However, postoperative respiratory care in such patients remains a clinical challenge. In this study, we investigated the factors affecting the duration of mechanical ventilation in patients who underwent ITx. METHODS In this observational study, eight patients who underwent ITx between 2007 and 2013 were studied. They were divided into two groups, with Group E including three patients who could be successfully extubated within 72 hours and Group V including the remaining five, who could not be extubated. The differences in demographical and clinical data between the two groups were evaluated. RESULTS The surgery success rate, patient survival rate, and graft survival rate were 100%, 88%, and 75%, respectively. Compared with Group E, postoperative bleeding was significantly higher in Group V (700 ± 420.7 mL vs. 50.0 ± 2.0 mL, p = 0.021). In addition, postoperative respiratory complications including pleural effusion and pneumonia (p = 0.017 and p = 0.0714, respectively) were prone to occur in Group V. Other variables including demographic parameters and clinical data showed no significant differences between the two groups. It was not unexpected that the duration of ventilator use and the length of intensive care unit stay were significantly shorter in Group E. CONCLUSION Postoperative blood loss and postoperative respiratory complications might be the factors responsible for delayed extubation in ITx patients. Because the study had few examinees, further studies with a larger population are needed to verify these issues.
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Affiliation(s)
- Man-Ju Ting
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Chest Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
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Lauriti G, Zani A, Aufieri R, Cananzi M, Chiesa PL, Eaton S, Pierro A. Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. JPEN J Parenter Enteral Nutr 2013; 38:70-85. [PMID: 23894170 DOI: 10.1177/0148607113496280] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cholestasis is a significant life-threatening complication in children on parenteral nutrition (PN). Strategies to prevent/treat PN-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) have reached moderate success with little supporting evidence. Aims of this systematic review were (1) to determine the incidence of PNAC/IFALD in children receiving PN for ≥ 14 days and (2) to review the efficacy of measures to prevent/treat PNAC/IFALD. METHODS Of 4696 abstracts screened, 406 relevant articles were reviewed, and studies on children with PN ≥ 14 days and cholestasis (conjugated bilirubin ≥ 2 mg/dL) were included. Analyzed parameters were (1) PNAC/IFALD incidence by decade and by PN length and (2) PNAC/IFALD prevention and treatment (prospective studies). RESULTS Twenty-three articles (3280 patients) showed an incidence of 28.2% and 49.8% of PNAC and IFALD, respectively, with no evident alteration over the last decades. The incidence of PNAC was directly proportional to the length of PN (from 15.7% for PN ≤ 1 month up to 60.9% for PN ≥ 2 months; P < .0001). Ten studies on PNAC met inclusion criteria. High or intermediate-dose of oral erythromycin and aminoacid-free PN with enteral whey protein gained significant benefits in preterm neonates (P < .05, P = .003, and P < .001, respectively). None of the studies reviewed met inclusion criteria for treatment. CONCLUSIONS The incidence of PNAC/IFALD in children has no obvious decrease over time. PNAC is directly correlated to the length of PN. Erythromycin and aminoacid-free PN with enteral whey protein have shown to prevent PNAC in preterm neonates. There is a lack of high-quality prospective studies, especially on IFALD.
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Affiliation(s)
- Giuseppe Lauriti
- Department of Surgery, UCL Institute of Child Health, London, UK
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20
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Ordonez F, Barbot-Trystram L, Lacaille F, Chardot C, Ganousse S, Petit LM, Colomb-Jung V, Dalodier E, Salomon J, Talbotec C, Campanozzi A, Ruemmele F, Révillon Y, Sauvat F, Kapel N, Goulet O. Intestinal absorption rate in children after small intestinal transplantation. Am J Clin Nutr 2013; 97:743-9. [PMID: 23388657 DOI: 10.3945/ajcn.112.050799] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Small bowel transplantation has now become a recognized treatment of irreversible, permanent, and subtotal intestinal failure. OBJECTIVE The aim of this study was to assess intestinal absorption at the time of weaning from parenteral nutrition in a series of children after intestinal transplantation. DESIGN Twenty-four children (age range: 14-115 mo) received intestinal transplantation, together with the liver in 6 children and the colon in 16 children. Parenteral nutrition was slowly tapered while increasing enteral tube feeding. The absorption rate was measured from a 3-d stool balance analysis performed a few days after the child had weaned from parenteral nutrition to exclusive enteral tube feeding. Results were analyzed according to the resting energy expenditure (REE; Schofield formula). RESULTS All children were weaned from parenteral nutrition between 31 and 85 d posttransplantation. Median intakes were as follows: energy, 107 kcal · kg(-1) · d(-1) (range: 79-168 kcal · kg(-1) · d(-1)); lipids, 39 kcal · kg(-1) · d(-1) (range: 20-70 kcal · kg(-1) · d(-1)); and nitrogen, 17 kcal · kg(-1) · d(-1) (range: 11-27 kcal · kg(-1) · d(-1)). Median daily stool output was 998 mL/d (range: 220-2025 mL/d). Median absorption rates were 88% (range: 75-96%) for energy, 82% (range: 55-98%) for lipids, and 77% (range: 61-88%) for nitrogen. The ratios for ingested energy to REE and absorbed energy to REE were 2.2 (range: 1.6-3.6) and 1.8 (range: 1.3-3.3), respectively. CONCLUSION These data indicate a suboptimal intestinal graft absorption capacity with fat malabsorption, which necessitates energy intakes of at least twice the REE.
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Affiliation(s)
- Felipe Ordonez
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, National Reference Center for Rare Digestive Diseases in Children, APHP, Necker-Enfants Malades Hospital, Paris Descartes University, Paris, France
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Mangus RS, Subbarao GC. Intestinal transplantation in infants with intestinal failure. Clin Perinatol 2013; 40:161-73. [PMID: 23415271 DOI: 10.1016/j.clp.2012.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Intestinal failure (IF) occurs when a person's functional intestinal mass is insufficient. Patients with IF are placed on parenteral nutrition (PN) while efforts are made to restore intestinal function through surgical or medical intervention. Patients who fail standard IF therapies may be candidates for intestinal transplantation (IT). Clinical outcomes for IT have improved to make this therapy the standard of care for patients who develop complications of PN. The timing of referral for IT is critical because accumulated complications of PN can render the patient ineligible for IT or can force the patient to await multiorgan transplantation.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, 550 North University Boulevard, Room 4601, Indianapolis, IN 46202-5250, USA.
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Desai CS, Maegawa FB, Gruessner AC, Gruessner RW, Gruesner RW, Khan KM. Age-based disparity in outcomes of intestinal transplants in pediatric patients. Am J Transplant 2012; 12 Suppl 4:S43-8. [PMID: 22642508 DOI: 10.1111/j.1600-6143.2012.04107.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Outcomes of intestinal transplants (ITx; n = 977) for pediatric patients are examined using the United Network for Organ Sharing data from 1987 to 2009. Recipients were divided into four age groups: (1) <2 years of age (n = 569), (2) 2-6 years (n = 219), (3) 6-12 years (n = 121) and (4) 12-18 years (n = 68). Of 977 ITx, 287 (29.4%) were isolated ITx and 690 (70.6%) were liver and ITx (L-ITx). Patient survival for isolated ITx at 1, 3 and 5 years, 85.3%, 71.3% and 65.0%, respectively, was significantly better than L-ITx, 68.4%, 57.0% and 51.4%, respectively, (p = 0.0001); this was true for all age groups, except for patients <2 years of age. The difference in graft survival between isolated ITx and L-ITx was significant at 1 and 3 years (Wilcoxon test, p = 0.0012). After attrition analysis of graft survival of patients who survived past first year, 3 and 5 years, graft survival for L-ITx patient was significantly better than those for isolated ITx. Isolated ITx should be considered early before the onset of liver disease in children >2 with intestinal failure but is not advantageous in patients <2 years.
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Affiliation(s)
- C S Desai
- Department of Surgery, University of Arizona, Tucson, AZ, USA.
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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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How can pathologists help to diagnose late complications in small bowel and multivisceral transplantation? Curr Opin Organ Transplant 2012; 17:273-9. [DOI: 10.1097/mot.0b013e3283534eb0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Saxena A, Ackbar R, Höllwarth M. Tissue Engineering for the Neonatal and Pediatric Patients. JOURNAL OF HEALTHCARE ENGINEERING 2012. [DOI: 10.1260/2040-2295.3.1.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Tsuruyama T, Fujimoto Y, Yonekawa Y, Miyao M, Onodera H, Uemoto S, Haga H. Invariant natural killer T cells infiltrate intestinal allografts undergoing acute cellular rejection. Transpl Int 2012; 25:537-44. [PMID: 22380521 DOI: 10.1111/j.1432-2277.2012.01450.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Immunological responses in human intestinal allografts are poorly understood and accurate diagnosis of acute cellular rejection remains difficult. Here, human intestinal allografts were analyzed by multi-color quantitative fluorescent immunohistochemical morphometry in order to monitor the clinical course of rejection. Morphometry gave two-dimensional plots based on size and circularity, and identified phenotypes of individual cells infiltrating the allograft by fluorescent staining. Using this method, invariant TCRVα24(+) NKT (iNKT) cells were observed in the intestinal allograft during rejection. Because these were not identified in the normal donor intestine before surgery, this finding was considered to be a signature of acute cellular rejection of the intestinal allograft. Infiltrating iNKT cells released IL-4 and IL-5, Th2-related cytokines that antagonize the Th1 responses that induce acute cellular rejection. Histological observation suggested eosinophilic enteritis in the mucosa with elevation of IL-4 and IL-5. In conclusion, iNKT cells were recruited to the intestine; however, because higher levels of IL-4 and IL-5 may contribute to eosinophilic enteritis, timely steroid administration is recommended for allograft injury due to enteritis, as well as acute cellular rejection.
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Affiliation(s)
- Tatsuaki Tsuruyama
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University Hospital, Kyoto, Japan.
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Desai CS, Gruessner AC, Khan KM, Fishbein TM, Jie T, Rodriguez Rilo HL, Gruessner RW. Isolated intestinal transplants vs. liver-intestinal transplants in adult patients in the United States: 22 yr of OPTN data. Clin Transplant 2011; 26:622-8. [DOI: 10.1111/j.1399-0012.2011.01579.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Martín-Dávila P, Fortún-Abete J, San Juan R. Profilaxis de la infección por citomegalovirus en el trasplante intestinal. Enferm Infecc Microbiol Clin 2011; 29 Suppl 6:60-4. [DOI: 10.1016/s0213-005x(11)70061-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sensoy G, Belet N. Invasive Candida infections in solid organ transplant recipient children. Expert Rev Anti Infect Ther 2011; 9:317-24. [PMID: 21417871 DOI: 10.1586/eri.11.6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Solid organ transplantation (SOT) is now an accepted therapy for many end-stage organ disorders and fungal infections are the principal cause of infection-related mortality in SOT recipients. Among invasive fungal infections, Candida species are the most common pathogens identified, associated with high mortality rates. The epidemiology and clinical manifestations of Candida infections vary with the type of organ transplantation. This article reviews invasive Candida infections in pediatric SOT recipients.
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Affiliation(s)
- Gülnar Sensoy
- Department of Pediatric Infectious Diseases, Ondokuz Mayıs University Hospital, Kurupelit, Samsun, Turkey.
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