Therapeutic Efficacy of Intestinal and Multivisceral Transplantation: Survival and Nutrition Outcome

Abstract

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare& Medicaid Services (CMS) recognized intestinal, combined liver-intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life-threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long-term survivors, with full rehabilitation and restoration of quality of life.

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References

Medicare Coverage Policy Decisions Memo, Intestinal and Multivisceral Transplantation. CAG-00036, October 4 , 2000.

Abu-Elmagd K, Reyes J, Bond G, et al. Clinical intestinal transplantation: a decade of experience at a single center. Ann Surg. 2001;234:404– 407.

Grant D. Intestinal transplantation: 1997 report of the international registry: Intestinal Transplant Registry. Transplantation. 1999 ;67:1061– 1064.

Reyes J, Bueno J, Kocoshis S, et al. Current status of intestinal transplantation in children. J Pediatr Surg. 1998 ;33:243– 254.

Grant D. Current results of intestinal transplantation: the International Intestinal Registry. Lancet. 1996 ;347:1701– 1803.

Abu-Elmagd K, Bond G, Reyes J, Fung J. Intestinal transplantation: a coming of age. Adv Surg. 2002 ;36:65– 101.

Todo S, Tzakis AG, Abu-Elmagd K, et al. Intestinal transplantation in composite visceral grafts or alone. Ann Surg. 1992 ;216:223– 234.

Howard L, Hassan N. Home parenteral nutrition: 25 years later. Clin Nutr. 1998 ;27:481– 512.

Grant D, Abu-Elmagd K, Reyes J, et al, for the Intestine Transplant Registry. 2003 Report of the Intestinal Transplant Registry: a new era has dawned. Ann Surg. 2005 ;241:607– 613.

10.

Abu-Elmagd K, Fung JJ, Reyes J, et al. Management of intestinal transplantation in humans. Transplant Proc. 1992 ;24:1243– 1244.

11.

Reyes J, Tzakis AG, Todo S, et al. Nutritional management of intestinal transplant recipients. Transplant Proc. 1993 ;25(1 pt 2):1200– 1201.

12.

Abu-Elmagd K, Bond G, Matarese L, et al. Gut rehabilitation and intestinal transplantation. Therapy. 2005 ;2:853– 864.

13.

Starzl TE, Zinkernagel RM. Transplantation tolerance from a historical perspective. Nat Rev Immunol. 2001 ;3:233– 239.

14.

Starzl TE, Murase N, Abu-Elmagd K, et al. Tolerogenic immunosuppression for organ transplantation. Lancet. 2003 ;361:1502– 1510.

15.

Abu-Elmagd K. Intestinal transplantation for short bowel syndrome and gastrointestinal failure: current consensus, rewarding outcomes, and practical guidelines. Gastroenterology. 2006 ;130(2 Suppl):S132– S137.

16.

Crenn P, Vahedi K, Lavergne-Slove A, Cynober L, Matuchansky C, Messing B. Plasma citrulline: a marker of enterocyte mass in villous atrophy-associated small bowel disease. Gastroenterology. 2003 ;124:1210– 1219.

17.

Gondolesi G, Fishbein T, Chehade M, et al. Serum citrulline is a potential marker for rejection of intestinal allografts. Transplant Proc. 2002;34:918– 920.

18.

Pappas PA, Saudubray JM, Tzakis AG, et al. Serum citrulline as a marker of acute cellular rejection for intestinal transplantation. Transplant Proc. 2002 ;34:915– 917.

19.

Gondolesi G, Ghirardo S, Raymond K, et al. The value of plasma citrulline to predict mucosal injury in intestinal allografts. Am J Transplant. 2006;6:2786– 2790.

20.

Yu HC, Tuteja S, Moon JI, et al. Utilization of dried blood spot citrulline level as a noninvasive method for monitoring graft function following intestinal transplantation. Transplantation. 2005 ;80:1729– 1733.

21.

Pappas PA, Tzakis AG, Saudubray JM, et al. Trends in serum citrulline and acute rejection among recipients of small bowel transplants. Transplant Proc. 2004 ;36:345– 347.

22.

Konikoff MR, Denson LA. Role of fecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflamm Bowel Dis. 2006;12:524– 534.

23.

Poullis A, Foster R, Mendall MA, Fagerhol MK. Emerging role of calprotectin in gastroenterology. J Gastroenterol Hepatol. 2003;18:756– 762.

24.

Sudan D, Dijkstra G, Torres C, Ploeg R, Langnas A. Calprotectin: a useful non-invasive marker for intestinal transplant monitoring. Abstract presented at: IX International Small Bowel Transplantation Symposium; June 30– July 2, 2005; Brussels, Belgium.

25.

Abu-Elmagd K, Todo S, Tzakis A, et al. Three years' clinical experience with intestinal transplantation. J Am Coll Surg. 1994;179:385– 400.

26.

Matarese LE, Martin L, Koritsky D, et al. Vitamin B6 status after intestinal and multivisceral transplantation in adults. Abstract presented at: European Society for Clinical Nutrition and Metabolism; October 22–27,2006 ; Istanbul, Turkey.

27.

Horslen S. Optimal management of the post-intestinal transplant patient. Gastroenterology. 2006 ;130(2 Suppl 1):S163– S169.

28.

Abu-Elmagd K, Reyes J, Todo S, et al. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg. 1998;186:512– 527.

29.

Rovera G, Schoen R, Goldbach B, et al. Intestinal and multivisceral transplantation: dynamics of nutritional management and functional autonomy. JPEN J Parenter Enteral Nutr. 2003 ;27:252– 259.

30.

Kim J, Fryer J, Craig RM. Absorptive function following small intestinal transplantation. Dig Dis Sci. 1998 ;43:1925– 1930.

31.

Kaufman SS, Lyden ER, Brown CR, et al. Disaccharidase activities and fat assimilation in pediatric patients after intestinal transplantation. Transplantation. 2000 ;69:362– 365.

32.

Sudan DL, Iyer KR, Deroover A, et al. A new technique for combined liver/small intestinal transplantation. Transplantation. 2001 ;72:1846– 1848.

33.

Schmid T, Korozsi G, Oberhuber G, Klima G, Margreiter R. Lymphatic regeneration after small-bowel transplantation. Transplant Proc. 1990;22:2060– 2061.

34.

Winkelaar GB, Smith LJ, Martin GR, Sigalet DL. Fat absorption after small intestinal transplantation in the rat. Transplantation. 1997 ;64:566– 571.

35.

Liu H, Teraoka S, Ota K, et al. Successful lymphangiographic investigation of mesenteric lymphatic regeneration after orthotopic intestinal transplantation in the rat. Transplant Proc. 1992 ;33:1113– 1114.

36.

Kocandrle V, Houttuin H, Prohaska JV. Regeneration of the lymphatics after autotransplantation and homotransplantation of the entire small intestine. Surg Gynecol Obstet. 1966 ;122:587– 592.

37.

Langnas AN, Shaw BW, Antonson DL, et al. Preliminary experience with intestinal transplantation in infants and children. Pediatrics. 1996 ;4:583– 584.

38.

Nour B, Reyes J, Tzakis A, et al. Intestinal transplantation with or without other abdominal organs: nutritional and dietary management of 50 patients. Transplant Proc. 1994 ;26:1432– 1433.

39.

Kellermann R, Zhong R, Kiyochi H, et al. Lymphatic reconstruction has a long-term benefit after intestinal transplantation in rats. Transplantation. 1998 ;66:S25 .

40.

Shalimov AA, Kalita NI, Kotenko OG, Bulakov KI. Surgical treatment of ascites in cirrhosis of the liver. Khirugiia (Mosk). 1990;1:38– 41.

41.

Williamson RC, Buchholtz TW, Malt RA. Humoral stimulation of cell proliferation in small bowel after transection and resection in rats. Gastroenterology. 1978 ;75:249– 254.

42.

Kirsch AJ, Kirsch SS, Kimura K, LaRosa CA, Jaffe BM. The adaptive ability of transplanted rat small intestine. Surgery. 1991 ;109:779– 787.

43.

Schraut WH, Lee KK, Sitrin M. Recipient growth and nutritional status following transplantation of segmental small-bowel allografts. J Surg Res. 1987 ;43:1– 9.

44.

DeBruin RW, Heineman E, Jeekel J, et al. Functional aspects of small-bowel transplantation in rats. Scand J Gastroenterol. 1992;27:483– 488.

45.

Schroeder P, Deltz E, Seifert J, Sandforth F, Thiede A. Absorptive capacity of the transplanted small bowel. Gut. 1987 ;28(Suppl):275– 279.

46.

Reddy P, Malone M. Cost and outcome analysis of home parenteral and enteral nutrition. JPEN J Parenter Enteral Nutr. 1998 ;22:302– 310.

47.

Schalamon J, Mayr JM, Hollwarth ME. Mortality and economics in short bowel syndrome. Best Pract Res Clin Gastroenterol. 2003;17:931– 942.

48.

Abu-Elmagd KM, Reyes J, Fung JJ, et al. Evolution of clinical intestinal transplantation: improved outcome and cost effectiveness. Transplant Proc. 1999 ;31:582– 584.

49.

Sudan D. Cost and quality of life after intestinal transplantation. Gastroenterology. 2006 ;130(2 Suppl 1):S158– S162.

50.

Woodward RS, Schnitzler MA, Lowell JA, Spitznagel EL, Brennan DC. Effect of extended coverage of immunosuppressive medications by Medicare on the survival of cadaveric renal transplants. Am J Transplant. 2001;1:69– 73.

51.

Rovera GM, Abu-Elmagd K, Hutson WR, et al. Long-term nutritional monitoring after clinical intestinal transplantation. Transplant Proc. 1998;30:2515– 2516.

52.

Rovera GM, Graham TO, Hutson WR, et al. Nutritional management of intestinal allograft recipients. Transplant Proc. 1998 ;30:2517– 2518.

53.

Sudan DL, Iverson A, Weseman RA, et al. Assessment of function, growth and development, and long-term quality of life after small bowel transplantation. Transplant Proc. 2000 ;32:1211– 1212.

54.

Rovera GM, DiMartini A, Schoen RE, Rakela J, Abu-Elmagd K, Graham TO. Quality of life of patients after intestinal transplantation. Transplantation. 1998 ;66:1141– 1145.

55.

DiMartini A, Rovera GM, Graham TO, et al. Quality of life after small intestinal transplantation and among home parenteral nutrition patients. JPEN J Parenter Enteral Nutr. 1998 ;22:357– 362.

56.

Sudan D, Horslen S, Botha J, et al. Quality of life after pediatric intestinal transplantation: the perception of pediatric recipients and their parents. Am J Transplant. 2004 ;4:407– 413.

57.

O'Keefe SJD, Emerling M, Koritsky D, et al. Nutrition and quality of life following small intestinal transplantation. Am J Gastroenterol. 2007;102:1093– 1100.