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Iyer KR. Indications for Intestinal Transplantation. Gastroenterol Clin North Am 2024; 53:233-244. [PMID: 38719375 DOI: 10.1016/j.gtc.2024.02.001] [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] [Indexed: 05/25/2024]
Abstract
Outcomes for patients with chronic intestinal failure have improved with organization of experts into multidisciplinary teams delivering care in intestinal rehabilitation programs. There have been improvements in understanding of intestinal failure complications as well as development of newer therapies that have amplified the improvements in survival. In spite of this encouraging trend, patients who fail PN are often referred too late for intestinal transplantation. The author proposes a more rational framework that might allow earlier identification of intestinal failure patients at risk for PN-failure, who could appropriately be considered earlier for intestinal transplantation with improvements in overall outcomes.
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Affiliation(s)
- Kishore R Iyer
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai and Mount Sinai Hospital, One Gustave Levy Place, Box 1104, New York 10029, USA.
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Ludwig EK, Abraham N, Schaaf CR, McKinney CA, Freund J, Stewart AS, Veerasammy BA, Thomas M, Cardona DM, Garman K, Barbas AS, Sudan DL, Gonzalez LM. Comparison of the effects of normothermic machine perfusion and cold storage preservation on porcine intestinal allograft regenerative potential and viability. Am J Transplant 2024; 24:564-576. [PMID: 37918482 PMCID: PMC11082874 DOI: 10.1016/j.ajt.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Abstract
Intestinal transplantation (IT) is the final treatment option for intestinal failure. Static cold storage (CS) is the standard preservation method used for intestinal allografts. However, CS and subsequent transplantation induce ischemia-reperfusion injury (IRI). Severe IRI impairs epithelial barrier function, including loss of intestinal stem cells (ISC), critical to epithelial regeneration. Normothermic machine perfusion (NMP) preservation of kidney and liver allografts minimizes CS-associated IRI; however, it has not been used clinically for IT. We hypothesized that intestine NMP would induce less epithelial injury and better protect the intestine's regenerative ability when compared with CS. Full-length porcine jejunum and ileum were procured, stored at 4 °C, or perfused at 34 °C for 6 hours (T6), and transplanted. Histology was assessed following procurement (T0), T6, and 1 hour after reperfusion. Real-time quantitative reverse transcription polymerase chain reaction, immunofluorescence, and crypt culture measured ISC viability and proliferative potential. A greater number of NMP-preserved intestine recipients survived posttransplant, which correlated with significantly decreased tissue injury following 1-hour reperfusion in NMP compared with CS samples. Additionally, ISC gene expression, spheroid area, and cellular proliferation were significantly increased in NMP-T6 compared with CS-T6 intestine. NMP appears to reduce IRI and improve graft regeneration with improved ISC viability and proliferation.
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Affiliation(s)
- Elsa K Ludwig
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Nader Abraham
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cecilia R Schaaf
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Caroline A McKinney
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - John Freund
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Amy S Stewart
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Brittany A Veerasammy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Mallory Thomas
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Diana M Cardona
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine Garman
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Debra L Sudan
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Liara M Gonzalez
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA.
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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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Iyer K, DiBaise JK, Rubio-Tapia A. AGA Clinical Practice Update on Management of Short Bowel Syndrome: Expert Review. Clin Gastroenterol Hepatol 2022; 20:2185-2194.e2. [PMID: 35700884 DOI: 10.1016/j.cgh.2022.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 05/24/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Kishore Iyer
- Recanati Miller Transplant Institute, Department of Surgery, Mount Sinai Hospital, New York, New York.
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona.
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
PURPOSE OF REVIEW Intestinal transplantation has evolved to be a viable treatment option for patients with intestinal failure. This review shows the most current tendencies and practices of intestinal transplant centers and an overall comparison to intestinal rehabilitation. RECENT FINDINGS This review outlines that timing for referral and advances in preoperative and postoperative care of intestinal and multivisceral transplant candidates are crucial to achieve results comparable to intestinal rehabilitation. SUMMARY Current practices have shown that intestinal transplantation continues to improve overall results and could be considered in patients with permanent home parenteral nutrition. Timing for referral and preoperative and postoperative management are crucial to optimize long-term results.
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Affiliation(s)
| | - Gennaro Selvaggi
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Akin Tekin
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Iyer K, Nisenholtz M, Gutierrez D, Winkler M, Tappenden K, Seidner D, Kirby DF, Spangenburg M, Potts R, Bonagura A, Bishop J, Metzger L, Arora S. Disseminating Knowledge in Intestinal Failure: Initial Report of the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) Project. JPEN J Parenter Enteral Nutr 2021; 45:1108-1112. [PMID: 33533531 DOI: 10.1002/jpen.2078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/21/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal failure (IF) is defined as an ultrarare disease, with an estimated prevalence of ∼25,000 cases in the US. There is a suspicion of disparities in outcomes in IF care, likely related to widespread lack of expertise. The Extension for Community Healthcare Outcomes (ECHO) model originally described by Dr Sanjeev Arora has been used to disseminate knowledge and best practices in many chronic diseases to improve outcomes. We examined our initial experience with using the ECHO model to disseminate learning in IF. METHOD This is a retrospective review of the launch, growth, and geographic reach of the Learn Intestinal Failure TeleECHO (LIFT-ECHO) program using prospectively collected data. RESULTS The LIFT-ECHO program has achieved significant geographic reach and clinician engagement. The program has reached close to two-thirds of the states in the US and several countries outside. Clinician engagement in the learning program appears to be growing exponentially. CONCLUSION It is feasible to use the ECHO model to disseminate knowledge in managing a rare disease like IF while maintaining fidelity to the proven model. Studies are underway to demonstrate direct benefit to patients.
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Affiliation(s)
- Kishore Iyer
- Mount Sinai School of Medicine, Intestinal Rehab and Transplant Program, New York, New York, USA
| | - Marjorie Nisenholtz
- Mount Sinai School of Medicine, Intestinal Rehab and Transplant Program, New York, New York, USA
| | - David Gutierrez
- Mount Sinai School of Medicine, Intestinal Rehab and Transplant Program, New York, New York, USA
| | - Marion Winkler
- Department of Surgery and Nutritional Support Service, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kelly Tappenden
- Kinesiology and Nutrition, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Douglas Seidner
- Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michelle Spangenburg
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | | | | | | | | | - Sanjeev Arora
- ECHO Institute, University of New Mexico, Albuquerque, New Mexico, USA
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