Is intestinal transplantation now an alternative to home parenteral nutrition?

Abstract

Patients with irreversible intestinal failure and complications of parenteral nutrition should now be routinely considered for small intestine transplantation. Despite attempts for > 40 years immunological graft intolerance presented an impenetrable barrier to successful engraftment until the development in the late 1970s of the powerful calcineurin-inhibitor immunosuppressive agents. Their use over the last 17 years has led to small intestinal transplantation being generally considered as a routine option for patients with irreversible intestinal failure and failing parenteral nutrition. The 1-year patient survival rates ( %) are now excellent for renal (95), liver (78), heart (82) and lung (75) transplantation. In contrast, survival rates for small intestinal transplantation have been slow to improve, although they are now approaching those for lung and liver transplantation (intestine 78 %, intestine and liver 60 %, multivisceral 66 %), and well-performing centres report recent 1-year graft survival rates as high as 92 %. Patient 5-year survival ( %) has also improved (intestine alone 50, intestine and liver 50 and multivisceral 62) and compares increasingly favourably with renal (85), liver (67), heart (67) and lung (46). Currently, small intestinal transplantation is reserved for patients with irreversible small intestinal failure who have a poor prognosis on parenteral nutrition. However, as 5-year patient survival following intestinal transplantation approaches that for parenteral nutrition there will be increasing pressure to offer this modality of treatment as an alternative to parenteral nutrition, especially for those patients who have a poor quality of life as a result of parenteral nutrition. Parenteral nutrition: Small intestinal transplantation: Risk assessment: Survival:Intestinal failureThe short answer to this now frequently-asked question is yes, but only for certain patients in certain circumstances. Perhaps as a consequence of the exponential rise in the sophistication of medical treatments, patients with catastrophic loss of the small intestine, at least in the developed countries, are no longer treated in a palliative manner and are now offered salvage surgery and parenteral nutrition (PN) as a routine. The main concern in the art of intravenous feeding is getting the simple aspects consistently correct and paying attention to detail. It is a highly-skilled practice and is well established in the UK because of a relatively small number of dedicated clinicians. It is not, however, easily accessed by some patients in geographically-remote regions, and this lack of accessibility is currently the subject of much interest and debate. When used prudently and with care PN allows patients to have a good quality and length of life (Baxter et al. 2006). Given this good profile of PN, why take the added risks of small intestinal transplantation (SIT)? From the patient's perspective life without dependency on the intravenous infusion of water and nutrients, often daily over 8 h, is very attractive as ...

A practical approach to the management of high-output stoma

“…Frequent severe dehydration associated with HOS in SBS is one of the indications for referral for consideration of intestinal transplantation. However, given that 5 year survival for small intestinal transplantation in the UK is approximately 50%,16 whereas long-term parenteral nutrition is approximately 73%,17 transplantation is generally reserved for those with severe intractable problems associated with long-term parenteral nutrition given for SBS and intestinal failure, such as intestinal failure-associated liver disease and recurrent line sepsis or thromboses resulting in loss of central venous access.…”

The future developments in nutrition

“…Although UK experience in small-bowel transplantation lags that of North America, recent 1-year survival rates in the UK are excellent42; however, whether these rates will be maintained in the longer term, over and above the survival rates that will be offered by HPN is, unknown. If survival rates following transplantation improve, and if—as hoped—small-bowel lengthening offers patients an option to reduce PN requirements, then it is likely that patient choice—based principally on quality of life—will determine the treatment of type 3 IF in the future.…”