© 2013 John Wiley & Sons A/S.

Clin Transplant 2013: 27 (Suppl. 25): 49–55 DOI: 10.1111/ctr.12161

Indications for intestinal transplantation: recognizing the scope and limits of total parenteral nutrition Gotthardt DN, Gauss A, Zech U, Mehrabi A, Weiss KH, Sauer P, Stremmel W, B€ uchler MW, Schemmer P. Indications for intestinal transplantation: recognizing the scope and limits of total parenteral nutrition. Abstract: Total parenteral nutrition (TPN) is currently the treatment of choice for patients with intestinal failure. Intestinal failure in adults is mostly due to short bowel syndrome, which is most often caused by ischemia and Crohn’s disease. However, TPN fails in a substantial number of cases. For patients with TPN failure, intestinal transplantation (ITx) may be offered as a treatment. TPN failure is considered to be present either if nutrition itself is not possible or if complications of TPN occur. These complications can, for example, originate from recurrent line infections or thrombosis. As TPN is usually a lifelong therapy and is associated with substantial impairment of the quality of life, the tolerance of each patient to this procedure is another important consideration in the decision making about whether to perform transplantation. The survival rates of intestinal transplant recipients have now reached the same level as that of recipients of other solid organ transplants. A five-yr survival of up to 80% has been reported in specialized centers, whereas registry data show rates of 1.5 times the upper limit of normal in two of the following biochemical parameters: alkaline phosphatase, gamma-glutamyl transferase, and bilirubin (26). This disease has been attributed to, among others, impairment of the enterohepatic circulation and therefore to hepatocellular cholestasis, but not to large bile ducts as shown, for example, in primary sclerosing cholangitis (33, 34). Although bile analysis could reveal information on the pathogenesis of the disease, it has not been largely performed in these patients. A shift in bile composition could lead to progressive liver damage. It has been shown that mutation of the canalicular phosphatidylcholine transporter ABCB4 leads to an altered bile composition and to biliary cirrhosis (35). In addition, bile analysis could identify the pathways involved in inflammation (36). Notably, in patients receiving TPN who developed PNALD and are referred to a center with extensive experience of TPN and of providing optimized treatment for such patients, a significant decrease in bilirubin levels is observed. Cowles et al. (37) reported a significant reduction in the biochemical markers of cholestasis in such a patient group. However, even in patients who undergo ITx, a present fibrosis and liver dysfunction can regress, which would mean that even in the presence of PNALD, ITx alone can be sufficient to treat liver damage. Acute liver failure due to acute fatty liver is not a regular indication for liver transplantation (38). Overt liver failure and cirrhosis will probably not regress and, therefore, patients with these diseases are candidates for combined ITx and liver transplantation (39).

its incidence in the future. In a retrospective study of 170 adult patients with SBS evaluated at the University of Nebraska Medical Center between 1982 and 2000, 18% of patients had CD, the percentage being comparable to the data from other groups (41, 42). There are three main causes for the development of SBS in patients with CD, which all involve, usually multiple, surgical procedures: (i) recurrent disease; (ii) surgical complications, including obstruction and fistula formation; and (iii) false diagnosis of CD as ulcerative colitis with proctocolectomy and ileoanal pouch formation (40, 43). In addition, patients with inflammatory bowel disease were shown to have a higher risk of mesenterial thromboembolism, which, owing to mesenterial infarction, can also result in SBS (44, 45). The ileocolonic and small intestinal manifestations of CD were shown to imply a higher risk of SBS than isolated colorectal disease (40). The long-term survival of SBS patients with inflammatory disease, also including radiation lesions, seems to be similar to that of patients with non-inflammatory conditions (46). Novel conservative therapeutic strategies such as TNFa antibodies, if applied timely, should be able to significantly reduce the number of patients with CD developing SBS. If surgery is necessary, limited resection and strictureplasty are the preferred strategies for SBS prevention, if possible. Preserving the bowel length, the ileocecal valve, and an ileal remnant are important in preventing SBS (46). Another important factor that has to be considered is the presence of continuing intestinal disease and thus the functional length of the intestine. In patients with CD-related SBS and severe complications of parenteral nutrition, especially PNALD, the indication for ITx should be evaluated as in patients with SBS of other causes. Also, surgery to improve bowel function should be considered in a timely manner (see above). The outcome of CD-related SBS seems to be comparable to that of SBS of other causes (42). A specific feature of ITx in CD is that among small bowel transplant recipients, recurrence of CD in intestinal allografts might occur despite immunosuppression. Nevertheless, this does not necessarily represent a clinically relevant complication (47).

CD-related SBS as an indication for ITx

In adults, CD-related SBS is the second most common indication for ITx (13%) after vascular indications such as mesenteric infarctions (22%) (7). CD is still a common cause of SBS in adults (40), although new surgical techniques and progress in medical treatment are expected to reduce

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Other indications for ITx

Rarer indications for ITx are catastrophic intraabdominal neoplastic diseases such as desmoid tumors and neuroendocrine tumors (48), as well as diffuse thrombosis of the portomesenteric system (49).

Indications for intestinal transplantation Moon et al. (50) described patient and graft fiveyr survival rates of 69.2% and 50.0%, respectively, after transplantation in 14 patients with desmoid tumors. Other rare causes of ITx in children, but also in adult patients, are severe intestinal motility disorders such as chronic intestinal pseudoobstruction (CIPO). In patients presenting for ITx for large intraabdominal tumor masses and infiltration or thrombosis of intestinal vessels, the possibility of intestinal autotransplantation should be considered as it avoids the immunologic complications associated with intestinal allotransplantation (51, 52). When is the right time to decide on performing ITx?

With the improving outcomes of ITx, the questions on which patient should be evaluated for ITx and when the procedure should ideally be performed are being increasingly raised. Yet, it must be emphasized that measures to augment intestinal function and minimize the risk of complications of parenteral nutrition must first be evaluated in each patient to avoid the need for this procedure. An early interdisciplinary approach to patients with overt or pending intestinal failure is of great importance (53). It is imperative not to wait until end-stage liver disease has developed before evaluating a patient for ITx, as the outcomes of isolated ITx are better than those of combined intestinal and liver transplantation (54, 55). Isolated ITx, or ITx combined with liver transplantation, or MvTx?

After the decision to perform ITx is made, it should be determined whether isolated ITx would be sufficient for the specific patient. Especially in cases of liver failure due to TPN, simultaneous liver transplantation would be a valid option. Additionally, there is evidence that combined transplantation has better immunologic outcomes (7, 56). Of course, the selected approach needs to be judged against the implications a combined transplantation. In case of untreatable rejection or severe infection, removal of the intestinal transplant as a rescue strategy will no longer be easily possible if the liver also needs to be removed. Another potentially difficult situation for the decision making is the presence of fibrosis but not cirrhosis. As the liver is usually capable of regenerating and fibrosis is reversible, only highgrade fibrosis in transition to cirrhosis, or cirrhosis itself, is considered an indication for combined transplantation, whereas lower grades of fibrosis

should only be considered an indication under the viewpoint of potential immunologic advantage but not as a necessity due to impaired liver function. Some studies report the advantages of also transplanting the colon, although this is not required for adequately supplying the organism with nutrients (57). In selected patients especially after trauma, in case of desmoid or devastating surgery for CD, an MvTx including almost all abdominal organs might be an option. This would then allow for a near-complete restitution of the gastrointestinal tract. Furthermore, this is sometimes necessary because otherwise the anastomosis of the blood vessels would not be possible (58, 59). In patients with CIPO, a careful examination of the whole gastrointestinal tract needs to be performed to evaluate which part needs to be replaced. In these cases, often an MvTx including the stomach and potentially the creation of an endostomy is necessary to ensure the possibility of enteral feeding (60). Summary

The outcome of ITx has significantly improved during the last decades. As TPN is often a valid alternative for patients with intestinal failure, the indication for transplantation needs to be highly customized to the individual patient. Further prospective studies comparing these patients are warranted to identify further risk factors and to have a consensus on the indications. MvTx might give a specific group of patients access to an option when intestinal or liver transplantation alone is otherwise impossible. References 1. FISHBEIN TM. Intestinal transplantation. N Engl J Med 2009: 361: 998. 2. SMITH JM, SKEANS MA, THOMPSON B et al. OPTN/SRTR 2011 Annual Data Report: intestine. Am J Transplant 2013: 13(Suppl 1): 103. 3. Intestine Transplant Registry Report. 2011. 4. DELTZ E, SCHROEDER P, GEBHARDT H, GUNDLACH M, ENGEMANN R, TIMMERMANN W. First successful clinical small intestine transplantation. Tactics and surgical technic. Chirurg 1989: 60: 235. 5. STARZL TE, ROWE MI, TODO S et al. Transplantation of multiple abdominal viscera. JAMA 1989: 261: 1449. 6. PIRONI L, JOLY F, FORBES A et al. Long-term follow-up of patients on home parenteral nutrition in Europe: implications for intestinal transplantation. Gut 2011: 60: 17. 7. PASCHER A, KOHLER S, NEUHAUS P, PRATSCHKE J. Present status and future perspectives of intestinal transplantation. Transpl Int 2008: 21: 401. 8. PIRONI L, FORBES A, JOLY F et al. Survival of patients identified as candidates for intestinal transplantation: a 3-year prospective follow-up. Gastroenterology 2008: 135: 61.

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Indications for intestinal transplantation: recognizing the scope and limits of total parenteral nutrition.

Total parenteral nutrition (TPN) is currently the treatment of choice for patients with intestinal failure. Intestinal failure in adults is mostly due...
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