Proposed Listing Indications for Pediatric Intestinal Transplant in the New Era of Specialized Care for Intestinal Failure.

Abstract

The current listing indications for intestinal transplantation (IT) were proposed in 2001 and reflect the poor outcome of patients with intestinal failure (IF) in the previous century. Recently, the outcomes of IF have improved thanks to new medical and surgical approaches. Purpose: Determine if the 2001 pediatric listing criteria for IT are applicable in the modern era and propose new criteria. Methods: We compared factors associated with death or transplant due to IF in 2 cohorts of pediatric cases: old era (1998-2005; N=99) and current era (2006-2011; N=91). The sensitivity, specificity, NPV and PPV of each of the 2001 listing criteria (conjugated bilirubin >100 μmol/L, loss of >2 central venous catheter (CVC) sites, ≥2 sepsis/year, ultra short bowel of <20 cm) was examined and a univariate analysis was performed. Results: All of the 2001 listing criteria had a poorer predictive value in the current era compared with the old era, most notably progressive liver disease (PPV 64% old era vs. 40% current era; sensitivity 84% vs. 65% respectively) and ultra short bowel (PPV 100% old era vs. 9% current era; sensitivity 10% vs 4% respectively). A univariate analysis in the current era cohort showed that the only 2001 listing criterion associated with a poor outcome was progressive liver disease (p=0.0018) but with a low odds ratio of 1.7. However, three new factors were more strongly associated with a poor outcome: >2 ICU admissions (p=0.0001, OR 23.6, 95% CI 2.7-209.8), persistent liver disease following 6 weeks of lipid management strategies (p=0.0005, OR 24, 95% CI 3.2-177.4), and loss of >3 CVC sites (p=0.0003, OR 33.3, 95% CI 18.8-51.2). There was a 90% probability of poor outcome with IF when 2 of these newly proposed criteria were present. Conclusions: The current listing criteria for pediatric IT should be revised. This study has identified three factors strongly associated with poor outcome of IF in the modern era that could serve as new listing criteria for IT if our observations are confirmed in a larger, multi-center cohort of patients. DISCLOSURE:Wales, P.: Grant/Research Support, Fresenius Kabi.