Current status of intestinal and multivisceral transplantation

Impact of Recipient and Donor Body Mass Index on Survival Outcomes After Intestinal Transplantation: A United Network for Organ Sharing Database Analysis

BACKGROUND Long-term patient survival after intestinal transplantation (IT) remains low compared with other organ transplants despite years of advancement in clinical experience. While patients with extremely high or low body mass index (BMI) are often considered ineligible for IT, the impact of BMI on post-transplant IT survival remains understudied. MATERIAL AND METHODS Using the United Network for Organ Sharing Standard Transplant database, we conducted a retrospective cohort study on patients who underwent IT between April 11, 1994, and September 29, 2021. We assessed the association of recipient and donor BMI at transplant with post-transplant mortality using Kaplan-Meier survival curves and univariate and multivariate Cox regression analyses. RESULTS A total of 1541 patients were included in our final sample. Of these patients, 806 were females (52.5%) and most were in the normal-weight BMI subgroup (54.2%). Obese class II (mean; 36.8±10.92 years) and underweight patients (mean; 37.6±13.37 years) were significantly younger than patients in other BMI categories. The adjusted multivariate model demonstrated an increased risk of mortality in underweight IT recipients compared to normal-weight IT recipients (aHR=1.25, 95% confidence interval [CI], 1.02-1.54; P=0.032).There was no significant association between donor BMI categories and survival in IT recipients. CONCLUSIONS Recipient BMI below normal is associated with an increased risk of mortality after intestinal transplantation and represents a potentially modifiable patient characteristic to improve survival outcomes.

Alcohol consumption, alcohol use disorder and organ transplantation

In the present experience we have evaluated the link alcohol consumption/alcohol use disorder (AUD) and organ transplantation (OT) in order to provide adequate suggestions. The data used for the preparation of these recommendations are based on a detailed analysis of the scientific literature published before August 31, 2022 (Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted the guidelines/position papers of the scientific societies. With regard to the liver transplantation, there are position papers/guidelines that clearly define indications and contraindications for including the AUD patient in the transplant list. One of the major difficulties in this area is psychosocial assessment which can be influenced by stigma. To solve this problem, it is necessary to use objective tools. However, this assessment should be carried out after providing the patient and family adequate tools to be able to create or recreate reliable socio-family support. This behavior should also be used in the case of other OTs. For the latter, however, adequate guidelines must be created which at the moment do not exist or if there are, as in the case of heart transplantation, they are not sufficient. Even in the absence of obvious alcohol addiction, it is recommended to use alcohol use disorder identification test and to include the addiction specialist in the multidisciplinary transplant team. Besides, providing family members with the tools necessary to better support the patient is essential. They are patients with alcohol use disorder/ possible presence of psychopathological manifestations and alcohol-related pathology (cirrhosis, cardiomyopathy, liver-kidney disfunction, etc.). A cardiovascular and oncologic surveillance post-OT is recommended. For the selection of patients to be included in the list for non-LT (heart, lung, kidney, multivisceral, etc.) it is mandatory to include the diagnosis and treatment of AUDs in the guidelines. What has already been indicated for LT may be useful. Timing of alcoholic abstention in relation to clinical severity, optimal psychosocial activity, anticraving therapy in relation to the type of underlying disease and clinical severity. Close collaboration between scientific societies is required to better manage AUD patients who need OT.

The impact of targeted interventions aimed to improve quality of life in patients receiving home parenteral nutrition: A systematic literature review

BACKGROUND

Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings.

METHODS

Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment.

RESULTS

Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated.

CONCLUSIONS

The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.

Intestinal Donation and Utilization: Single-Center Analysis Within Eurotransplant

Intestinal donor criteria are classically kept strict, thereby limiting donor supply. Indications for intestinal transplantation (ITx) are rare, but improved outcome and new emerging indications lead to increased demand and relaxing donor criteria should be considered. We sought to compare the donor criteria of intestines transplanted at our center with predefined (per protocol) criteria, and to determine how relaxing donor criteria could impact the potential donor pool. Donor criteria used in 22 consecutive ITx at our center between 2000 and 2020 were compared with predefined criteria. Next, multiorgan donors effectively offered by our Donor Network to Eurotransplant between 2014 and 2020 were retrospectively screened, according to predefined and effectively used intestinal donation criteria. Finally, utilization rate of offered intestines was calculated. In our ITx series, the effectively used donor criteria were less strict than those initially predefined. With these relaxed criteria, a favorable 5-year graft/patient survival of 75% and 95%, respectively was reached. Applying these relaxed criteria would lead to a 127% increase in intestinal offers. Paradoxically, 70% of offered intestines were not used. In conclusion, a significant increase in intestinal donation could be obtained by relaxing donor criteria, while still achieving excellent outcome. Offered intestines are underutilized.

Clinical characteristics and outcomes in CMV infection in intestinal transplant recipients: A single-center experience

BACKGROUND

Cytomegalovirus (CMV) infection is one of the most common posttransplantation infections and has been associated with increased rejection and mortality. Data in intestinal transplants recipients are limited.

METHODS

This is a single-center, retrospective cohort study of all intestinal transplants performed between January 1, 2009, and August 31, 2020. We included recipients of all ages who were at risk of CMV infection. To identify the risk factors, we conducted at first univariate and multivariate analysis. For the multivariate analysis, we developed a logistic regression model based on the result of univariate analysis.

RESULTS

Ninety five patients with a median age of 32 (interquartile range [IQR] 4, 50) were included. CMV donor seropositive/recipient seronegative were 17 (17.9%). Overall, 22.1% of the recipients developed CMV infection at a median time of 155 (IQR 28-254) days from transplant, including 4 CMV syndrome and 6 CMV end-organ disease. Overall, 90.4%, (19/21) developed DNAemia while on prophylaxis. Median peak viral load and time to negativity was 16 000 (IQR 1034-43 892) IU/mL and 56 (IQR 49-109) days, respectively. (Val)ganciclovir and foscarnet were utilized in 17 (80.9%) and 1 (4.76%) recipients, respectively. Recurrences of CMV DNAemia and graft rejection were observed in three and six recipients, respectively. Younger age was identified as a risk factor (p = .032, odds ratio 0.97, 95% confidence interval 0.95-0.99) to develop CMV DNAemia.

CONCLUSION

A significant proportion of intestinal transplant recipients developed CMV infection while on prophylaxis. Better methods such as CMV cell mediated immunity guided prophylaxis should be used to prevent infections in this population.

Short-Bowel Syndrome: Epidemiology, Hospitalization Trends, In-Hospital Mortality, and Healthcare Utilization

INTRODUCTION

Short-bowel syndrome (SBS) is a common cause of chronic intestinal failure and is associated with increased morbidity, mortality, poor quality of life, and an increased burden on healthcare costs.

METHODS

We used the US Nationwide Inpatient Sample database from 2005 to 2014. We identified adult SBS hospitalizations by using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes. We studied the demographics of the patients with SBS and analyzed the trends in the number of hospitalizations, in-hospital mortality, and healthcare costs. We also identified the risk factors associated with in-hospital mortality.

RESULTS

A total of 53,040 SBS hospitalizations were identified. We found that SBS-related hospitalizations increased by 55% between 2005 (N = 4037) and 2014 (N = 6265). During this period, the in-hospital mortality decreased from 40 per 1000 to 29 per 1000 hospitalizations, resulting in an overall reduction of 27%. Higher mortality was noted in SBS patients with sepsis (6.7%), liver dysfunction (6.2%), severe malnutrition (6.0%), and metastatic cancer (5.4%). The overall mean length of stay (LOS) for SBS-related hospitalizations was 14.7 days, with a mean hospital cost of $34,130. We noted a steady decrease in the LOS, whereas the cost of care remained relatively stable.

CONCLUSIONS

The national burden of SBS-related hospitalizations continues to rise, and the mortality associated with SBS has substantially decreased. Older SBS patients with sepsis, liver dysfunction, severe malnutrition, and metastatic cancer had the highest risk of mortality. Healthcare utilization in SBS remains high. healthcare utilization; hospitalization trend; mortality; research and diseases; short-bowel syndrome.

Optical coherence tomography of small intestine allograft biopsies using a handheld surgical probe

SIGNIFICANCE

The current gold standard for monitoring small intestinal transplant (IT) rejection is endoscopic visual assessment and biopsy of suspicious lesions; however, these lesions are only superficially visualized by endoscopy. Invasive biopsies provide a coarse sampling of tissue health without depicting the true presence and extent of any pathology. Optical coherence tomography (OCT) presents a potential alternative approach with significant advantages over traditional white-light endoscopy.

AIM

The aim of our investigation was to evaluate OCT performance in distinguishing clinically relevant morphological features associated with IT graft failure.

APPROACH

OCT was applied to evaluate the small bowel tissues of two rhesus macaques that had undergone IT of the ileum. The traditional assessment from routine histological observation was compared with OCT captured using a handheld surgical probe during the days post-transplant and subsequently was compared with histophaology.

RESULTS

The reported OCT system was capable of identifying major biological landmarks in healthy intestinal tissue. Following IT, one nonhuman primate (NHP) model suffered a severe graft ischemia, and the second NHP graft failed due to acute cellular rejection. OCT images show visual evidence of correspondence with histological signs of IT rejection.

CONCLUSIONS

Results suggest that OCT imaging has significant potential to reveal morphological changes associated with IT rejection and to improve patient outcomes overall.

Surgical Resection of Native Viscera to Manage Persistent Ascites after Multivisceral Transplant

Multivisceral transplantation is the therapy of choice in patients with diffuse portomesenteric thrombosis. In the present case, we describe a patient who had persistent ascites after multivisceral transplant. The patient was initially diagnosed with a chyle leak which was cured via embolization. When this did not cure her ascites, reexploration proved the etiology to be at least partially attributable to persistent hypertension in the retained viscera. This was cured with the resection of her native viscera. This case highlights the importance of resection of all congested viscera at the time of transplantation in patients with diffuse portomesenteric thrombosis, the utility of preoperative embolization techniques in assisting this, and also the ability to perform delayed resection if necessary.

R-Spondin 1 (RSPO1) Increases Mouse Intestinal Organoid Unit Size and Survival in vitro and Improves Tissue-Engineered Small Intestine Formation in vivo

Introduction: Cell therapy and tissue engineering has recently emerged as a new option for short bowel syndrome (SBS) treatment, generating tissue engineered small intestine (TESI) from organoid units (OU) and biodegradable scaffolds. The recombinant human R-Spondin 1 (rhRSPO1) protein may be a key player in this process due to its mitogenic activity in intestinal stem cells.

Objective: Aiming at optimizing the TESI formation process and advancing this technology closer to the clinic, we evaluated the effects of rhRSPO1 protein on OU culture and TESI formation.

Methods: Intestinal OU were isolated from C57BL/6 mice and cultured in Matrigel in the presence or absence of recombinant human rhRSPO1. Throughout the culture, OU growth and survival rates were evaluated, and cells were harvested on day 3. OU were seeded onto biodegradable scaffolds, in the presence or absence of 5 μg of rhRSPO1 and implanted into the omentum of NOD/SCID mice in order to generate TESI. The explants were harvested after 30 days, weighed, fixed in formalin and embedded in paraffin for histological analysis and immunofluorescence for different cell markers.

Results: After 3 days, rhRSPO1-treated OU attained a larger size, when compared to the control group, becoming 5.7 times larger on day 6. Increased survival was observed from the second day in culture, with a 2-fold increase in OU survival between days 3 and 6. A 4.8-fold increase of non-phosphorylated β-catenin and increased relative expression of Lgr5 mRNA in the rhRSPO1-treated group confirms activation of the canonical Wnt pathway and suggests maintenance of the OU stem cell niche and associated stemness. After 30 days of in vivo maturation, rhRSPO1-treated TESI presented a larger mass than constructs treated with saline, developing a more mature intestinal epithelium with well-formed villi and crypts. In addition, the efficiency of OU-loaded rhRSPO1-treated scaffolds significantly increased, forming TESI in 100% of the samples (N = 8), of which 40% presented maximum degree of development, as compared to 66.6% in the control group (N = 9).

Conclusion: rhRSPO1 treatment improves the culture of mouse intestinal OU, increasing its size and survival in vitro, and TESI formation in vivo, increasing its mass, degree of development and engraftment.

Small bowel transplant: state-of-the-art vascular and nonvascular imaging

BACKGROUND

Small bowel transplant (SBT) is a surgical procedure that may be used in patients with pathology resulting in severe intestinal failure resistant to conventional forms of surgical and nonsurgical treatment. Intestinal failure is defined as the failure of enterocytes to absorb sufficient macronutrients, water, and/or electrolytes to sustain homeostasis and/or promote growth. With the advancement of surgical techniques and advancements in perioperative transplant management, SBT has become an increasingly common treatment for intestinal failure, with survival rates for SBT comparable to those for other solid organ transplants.

MATERIALS AND METHODS

This review provides background on SBT, its variations, and the associated preoperative and postoperative imaging studies with regard to surgical planning and anticipated complications.

RESULTS AND CONCLUSIONS

With the increasing use of SBT, radiologists will be expected to be familiar with the diagnostic studies and available endovascular interventions associated with this procedure.

Familial Adenomatous Polyposis and Desmoid Tumor Treated with Multivisceral Transplantation and Kidney Autotransplantation: Case Report and Literature Review

Introduction

Desmoid tumours (DT) are commonly associated with Gardener's syndrome. Their surgical resection may be complicated by their close proximity to major vessels, multiple organ involvement, and frequent local recurrence. Multivisceral transplantation (MVTx) is an alternative treatment for patients with intestinal and liver failure. In patients with DT closely associated with renal structures but without end-stage kidney disease, concomitant excision of the patient's own kidney, ex vivo tumour resection with nephron-sparing surgery, or autotransplantation has been proposed.

Case Presentation

A 36-year-old Caucasian female weighing 60 kg with Gardener's syndrome with a history of abdominal surgery was presented to our department with progressive abdominal distention associated with paroxysmal pain. With the use of CT, the patient was diagnosed with a mass arising from the mesenterial region. The patient had normal kidney function and nonalcoholic steatohepatitis. The patient was indicated for MVTx.

Management and Outcome

After 16 months on the waiting list, the patient received a multivisceral graft from a deceased donor. Following the restoration of graft vascular flow, the patient's right kidney was removed and the DT dissected ex vivo before autotransplantation into the right pelvic fossa. The patient received immunosuppressive, antithrombotic, and antibiotic treatment. There was no acute rejection, though the patient experienced pulmonary infection, dysphagia, and oesophageal reflux with fungal infection. The patient had required temporary dialysis for acute renal failure for 75 days. One year after the surgery, nausea and violent vomiting caused delayed gastric emptying caused by spastic pylorus. Clinical improvement was achieved using gastric peroral endoscopic myotomy (G-POEM).

Conclusion

MVTx with kidney autotransplantation is a feasible treatment option in patients with familiar adenomatous polyposis complicated by an abdominal DT. Precise tumour dissection with nephron-sparing surgery was carried ex vivo. G-POEM was used to relieve MVTx-related gastroparesis. The patient had no disease reoccurrence after one-year follow-up.

Identifying the Growth Factors for Improving Neointestinal Regeneration in Rats through Transcriptome Analysis Using RNA-Seq Data

Using our novel surgical model of simultaneous intestinal adaptation "A" and neointestinal regeneration "N" conditions in individual rats to determine feasibility for research and clinical application, we further utilized next generation RNA sequencing (RNA-Seq) here in normal control tissue and both conditions ("A" and "N") across time to decipher transcriptome changes in neoregeneration and adaptation of intestinal tissue at weeks 1, 4, and 12. We also performed bioinformatics analyses to identify key growth factors for improving intestinal adaptation and neointestinal regeneration. Our analyses indicate several interesting phenomena. First, Gene Ontology and pathway analyses indicate that cell cycle and DNA replication processes are enhanced in week 1 "A"; however, in week 1 "N", many immune-related processes are involved. Second, we found some growth factors upregulated or downregulated especially in week 1 "N" versus "A". Third, based on each condition and time point versus normal control tissue, we found in week 1 "N" BMP2, BMP3, and NTF3 are significantly and specifically downregulated, indicating that the regenerative process may be inhibited in the absence of these growth factors. This study reveals complex growth factor regulation in small neointestinal regeneration and intestinal adaptation and provides potential applications in tissue engineering by introducing key growth factors identified here into the injury site.

Liver-inclusive intestinal transplantation results in decreased alloimmune-mediated rejection but increased infection

Background and aims

A co-transplanted liver allograft has been thought to protect other organs from rejection-mediated injury; however, detailed analyses of co-transplanted liver on intestinal allograft outcomes have not been conducted to date. The aim of the study was to compare immune-mediated injury, causes of graft failure and clinical outcomes between recipients who underwent either a liver-inclusive intestinal transplant (LITx) or liver-exclusive intestinal transplant (LETx).

Methods

Between May 2000 and May 2010, 212 adult patients undergoing LITx (n =76) and LETx (n =136) were included. LITx underwent either liver combined intestinal or full multivisceral transplantation. LETx underwent either isolated intestinal or modified multivisceral transplantation.

Results

During 44.9 ± 31.4 months of follow-up, death-censored intestinal graft survival was significantly higher for LITx than LETx (96.9%, 93.2% and 89.9% vs 91.4%, 69.3% and 60.0% at 1, 3 and 5 years; p =0.0001). Incidence of graft loss due to rejection was higher in LETx than in LITx (30.9% vs 6.6%; p <0.0001), while infection was the leading cause of graft loss due to patient death in LITx (25.0% vs 5.1%; p <0.0001). Despite similar immunosuppression, the average number (0.87 vs 1.42, p =0.02) and severity of acute cellular rejection episode (severe grade: 7.9% vs 21.3%; p =0.01) were lower in LITx than in LETx. Incidence of acute antibody-mediated rejection was also significantly lower in LITx than in LETx (3.6% vs 15.2%; p =0.03). Incidence of chronic rejection was reduced in LITx (3.9% vs 24.3%; p =0.0002).

Conclusions

Intestinal allografts with a liver component appear to decrease risk of rejection but increase risk of infection. Our findings emphasize that LITx has characteristic immunologic and clinical features. Lower immunosuppression may need to be considered for patients who undergo LITx to attenuate increased risk of infection.

Diagnostic Lessons from a Complex Case of Postintestinal Transplantation Enteropathy

Recent advances in the field of intestinal transplantation have been mitigated by the incidence of allograft rejection. In such events, early identification and appropriate timing of antirejection therapy are crucial in retaining graft function. We present the case of a patient who suffered severe postintestinal transplantation allograft enteropathy, primarily characterized by extensive mucosal ulcerations, and was refractory to all conventional therapy. This progressed as chronic rejection; however crucially this was not definitively diagnosed until allograft function had irreversibly diminished. We argue that the difficulties encountered in this case can be attributed to the inability of our current array of investigative studies and diagnostic guidelines to provide adequate clinical guidance. This case illustrates the importance of developing reliable and specific markers for guiding the diagnosis of rejection and the use of antirejection therapeutics in this rapidly evolving field of transplant surgery.

Intestinal Transplant in Children

The past decade has seen major advances in the field of transplantation; it is the treatment of choice for many with intestinal failure. One-year mortality from pediatric intestinal transplantation has significantly declined, from 30% to 10% to 15% nationally, mainly due to a multidisciplinary approach in transplant centers. Pediatric age carries special considerations along the spectrum of care that continue to cause challenges but also offers growth opportunities. Pediatric intestinal transplantation indications and timing are changing as a result of new developments in diagnostic and treatment tools. This article reviews updates on pediatric intestinal transplantation and highlights future directions.