Current Issues in Liver and Small Bowel Transplantation

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The authors concluded that despite those huge improvements, some transplanted patients develop severe ACR, culminating in graft loss and re-transplantation.

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Reports on multi-visceral and intestinal re-transplantation outcomes suggested that it is a viable procedure with appropriate patient survival after primary graft loss. Mangus et al reviewed the changing indications and outcomes for this procedure over a 7-year period.

Why Choose UCLA for Adult Intestinal Transplant?

This study was a retrospective case review of MVTs performed between and at a single center. Graft failure was defined as loss of the graft or complete loss of function. Graft function was monitored by clinical function, laboratory values, and serial endoscopy with biopsy. There were 19 patients who received a simultaneous kidney graft. There were 24 pediatric and 76 adult recipients age range of 7 months to 66 years. Indications included intestinal failure alone, intestinal failure with cirrhosis, complete PMT, slow-growing central abdominal tumors, intestinal pseudo-obstruction, and frozen abdomen.

All patients received antibody-based induction immunosuppression with calcineurin inhibitor-based maintenance immunosuppression. Outcomes have improved over time with many patients returning to full functional status and enjoying long-term survival. Varkey et al stated that the current treatment of choice for patients with intestinal failure is parenteral nutrition, whereas medical therapy or resection is preferred for patients with neuroendocrine pancreatic tumors NEPT along with liver metastasis.

As the survival of patients undergoing IT and MVT is improving, the discussion for expansion of treatment options has become a subject of debate. These researchers investigated the outcome for patients referred for IT and MVT and determined which patient group are the ones most likely to benefit the most from transplantation. Patients were classified according to proposed treatment strategy, and the outcome was evaluated.

A total of 43 adults and 19 children with either intestinal failure or NEPT with liver metastases were evaluated for transplantation. Of these patients, 15 adults and 5 children were transplanted. Among the adult patients with intestinal failure, the survival rate for patients considered to be stable on parenteral nutrition was higher than the transplanted adult patients.

The survival rate of patients with NEPT was similar to the results seen among patients transplanted for intestinal failure. The authors concluded that the results confirmed the poor prognosis of patients with intestinal failure awaiting transplantation and indicated that different transplantation criteria may be applied for adults and children, especially when early transplantation is the preferred treatment.

Kubal et al a stated that intestinal failure and associated parenteral nutrition-induced liver failure cause significant morbidity, mortality, and health care burden.

Intestinal Rehabilitation & Transplant Center

Intestine transplantation is now considered to be the standard of care in patients with intestinal failure who fail intestinal rehabilitation. Intestinal failure-associated liver disease is an important sequela of intestinal failure, caused by parenteral lipids, requiring simultaneous liver-intestine transplant. Lipid minimization and, in recent years, the emergence of fish oil-based lipid emulsions have been shown to reverse parenteral nutrition-associated hyper-bilirubinemia, but not fibrosis. Significant progress in surgical techniques and immunosuppression has led to improved outcomes after intestine transplantation.

Intestine in varying combination with liver, stomach, and pancreas, also referred to as multi-visceral transplantation, is performed for patients with intestinal failure along with liver disease, surgical abdominal catastrophes, neuroendocrine and slow-growing tumors, and complete porto-mesenteric thrombosis with cirrhosis of the liver.

Although acute and chronic rejections are major problems, long-term survivors have excellent quality of life and remain free of parenteral nutrition.

Small bowel transplant

Sudan et al stated that protocol endoscopy with biopsy is currently the gold standard of small bowel transplantation SBTx monitoring, however it is invasive, costly, needs skilled operator, may require anesthesia and may cause complications. These researchers investigated fecal calprotectin level FCL as a candidate non-invasive marker for monitoring patients after SBTx. Ileostomy effluents were collected at various post-operative days before endoscopy and biopsy.

Results were retrospectively evaluated in combination with clinical, endoscopic, and histopathological findings. Fecal calprotectin levels were measured in samples that were obtained from 29 patients after SBTx. Only 1 of 69 positive FCL did not accompany abnormal findings. Retrospective evaluation showed that 11 samples from 6 patients FCL: coincided with rejection episodes, 6 samples from 3 patients FCL: coincided with viral enteritis, 51 samples from 21 patients FCL: coincided with non-specific inflammation, 11 samples from 2 patients FCL: coincided with chronic intestinal ulceration, and finally 50 samples from 19 patients FCL: 43 coincided with normal findings.

No significant FCL difference was found between rejection, infection, and inflammation. Evolution in FCL in transplant recipients showed that FCL can predict rejection days before histopathological diagnosis. The authors concluded that FCL is a promising clinical screening test for intestinal allograft rejection. The major drawback of this study was that it was a retrospective study of selected patient samples with known diagnosis.

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If the clinical utility of FCL is confirmed by prospective validation studies, its use may avoid unnecessary protocol endoscopy with biopsy. Kaneku and Wozniak noted that early outcomes following intestinal transplantation ITx have markedly improved in recent years. However, there has been a lack of improvement in long-term outcomes.

Increasing amounts of data suggested the humoral immune system is a major contributor to rejection and late allograft loss. These investigators summarized the available data on donor-specific human leukocyte antigen antibodies DSAs in ITx, with a focus on the clinical significance of DSAs, diagnosis of antibody-mediated rejection AMR , and available treatment modalities. Diagnosis and treatment of AMR remains challenging, but reports indicated that when optimal induction and maintenance immunosuppressive agents are used, the impact of DSAs may be negligible.

The authors concluded that although data are limited due to center differences with regard to patient population, induction and maintenance immunosuppression protocols, and monitoring strategies, DSAs are associated with poor outcomes following ITx. They stated that a consensus to define AMR and optimal treatment strategies is needed. Standard immunosuppression included thymoglobulin-rituximab induction and tacrolimus-prednisone maintenance. C4d staining was performed retrospectively on biopsies in patients that developed acute rejection AR.

Antibody-mediated rejection was diagnosed in 6 patients based on C4d staining, of these 2 patients had circulating de novo DSA at the time of biopsy.

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The authors concluded that de novo DSA formation, particularly early in the post-transplant course may be associated with trends toward worse outcomes. However, its significance in the pathophysiology of AR remains uncertain.

Current Issues in Liver and Small Bowel Transplantation : M. Kitajima :

They stated that studies focusing mechanisms of DSA-related graft injury and intra-graft DSA detection might provide further insight into this issue. Garcia and colleagues noted that pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. Since patients on immunosuppressive drugs are vulnerable to infections by bacteria and viruses, they are monitored for signs and symptoms of infection.

Particular attention is paid to wound care issues and fluid management. Following discharge, physicians and nurses from the Pediatric Intestinal Transplant Program and your local pediatrician monitor your child. Initially, your child visits the Pediatric Intestinal Transplant Clinic twice a week for laboratory work and exams by physicians. Surveillance biopsies to screen for organ rejection are initially done twice a week and then as determined by the physician.

As recovery progresses, these visits become less frequent. Our team will continue to be a part of follow-up care even after you and your child return home. Search Term. Menu Button. An individual can obtain nutrients intravenously through PN, bypassing food consumption entirely and its subsequent digestion.

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Long-term survival with SBS and without PN is possible with enteral nutrition , but this is inadequate for many patients as it depends on the remaining intestine's ability to adapt and increase its absorptive capacity. Although PN can meet all energy, fluid, and nutrient needs and can be performed at home, quality of life can be significantly decreased. On average, PN takes 10 to 16 hours to administer but can take up to Over this time frame, daily life can be significantly hindered as a consequence of attachment to the IV pump.

Another alternative treatment to transplant for patients with SBS is surgical bowel lengthening via either serial transverse enteroplasty STEP or the older longitudinal intestinal lengthening and tailoring LILT technique. There are four Medicare and Medicaid -approved indications for intestine transplantation: a loss of two of the six major routes of venous access , multiple episodes of catheter -associated life-threatening sepsis, fluid and electrolyte abnormalities in the face of maximal medical therapy, and PN-associated liver disease.

Transplants may also be performed if the growth and development of a pediatric patient fails to ensue, or in extreme circumstances for patients with an exceptionally low quality of life on PN. Psychological preparations should be made for the transplant team and patient as well. Early referral requires trust between all parties involved in the operation to ensure that a rush to judgment does not lead to a premature transplant.

Dr A S soin Intestinal Transplant

These criteria are similar to established guidelines for transplants of other organ types. There are three major types of intestine transplants: an isolated intestinal graft , a combined intestinal-liver graft, and a multivisceral graft in which other abdominal organs may be transplanted as well. In the most basic and common graft, an isolated intestinal graft, only sections of the jejunum and ileum are transplanted. In the event of severe liver dysfunction due to PN, enzyme deficiencies, or other underlying factors, the liver may be transplanted along with the intestine.