Acute Irreversible Intestinal Failure and Early Intestinal Transplantation: Indications and Survival Outcomes

Abstract

O61* Aims: The current established indications for intestinal transplantation are limited to intestinal failure patients who have failed TPN therapy. However, the recently documented compound negative impacts of chronic intestinal and TPN failure on outcomes after transplantation support the notion of modifying the current strict criteria and timing for transplantation. This study was designed to establish the medical indications for early transplantation and validate the assumed therapeutic benefits. Methods: Between July 2000 and March 2004, 15 (20%) out of 74 adult consecutive patients underwent intestinal transplantation within 6 months from the onset of TPN therapy with a median of 3 months (range: 0.5–6). Five patients were male and 10 were female with a mean (SD) age of 37 ± 13 (range: 17–57). The primary causes of intestinal failure were vascular thrombosis (n=6), volvulus (n=5), Crohn’s disease (n=3), and trauma (n=1). The indications for early transplantation were ultra-short gut syndrome/active duodenopancreatic fistulae (n=11), portal/hepatic artery thrombosis (n=2), extra-gastrointestinal autoimmune diseases (n=1) and brutal diabetes (n=1). The blood type was O in 6, A in 7, and AB in 2. The cytomegaloviral serology was negative in 7 and positive in 8 recipients. Thirteen patients underwent an isolated intestinal transplantation and the remaining 2 required an allograft that contained the stomach and/or pancreas en-bloc with the intestine. Results: With a mean (SD) follow-up of 22 ± 14 months, one patient died of cardiac arrest with a fully functioning graft with an overall survival rate of 93%. Of the 14 current survivors, 12 (86%) are off TPN enjoying unrestricted oral diet. The other 2 recipients required allograft enterectomy due to graft thrombosis in a hypercoagulable patient (n=1) and chronic rejection (n=1) and both are currently waiting for retransplantation. As expected, the postoperative course for most patients was uneventful and the initial hospitalization was relatively short with a median of 23 days. With our current tolerogenic immunosuppressive protocol, 10 (83%) of the 12 current survivors with functioning grafts are on spaced doses of tacrolimus and free of steroid therapy. Of particular interest is the full restoration of the nutritional autonomy and normalization of patient lifestyle at an earlier time compared to recipients transplanted after development of TPN failure. Conclusions: This study outlines the medical indications for early consideration of intestinal transplantation before the development of TPN failure. The reported herein successful outcomes and the expected long-term continuation of these therapeutic benefits may justify the need for early referral of patients with irreversible intestinal failure and timing of transplantation.