Treatment of Intestinal Failure: Transplantation or Home Parenteral Nutrition?

Abstract

See “Survival of Patients Identified as Candidates for Intestinal Transplantation: A 3-Year Prospective Follow-Up,” by Pironi L, Forbes A, Joly F, et al, on page 61.Intestinal failure (IF) is a condition is characterized by the inability to maintain protein energy, fluid, electrolyte, or micronutrient balance owing to gastrointestinal disease when on a normal diet. IF ultimately leads to increasing malnutrition and even death of not circumvented by home parenteral nutrition (HPN) or corrected by intestinal transplantation (IT).Long-term intravenous nutrition was introduced to treat IF through an arteriovenous fistula with limited success in the late 1960s,1Shils M.E. Wright W.L. Turnbull A. et al.Long-term parenteral nutrition through an external arteriovenous shunt.N Engl J Med. 1970; 283: 341-344Crossref PubMed Scopus (96) Google Scholar but it was in the 1970s2Tsallas G. Baun D.C. Home care total parenteral alimentation.Am J Hosp Pharm. 1972; 29: 840-846PubMed Google Scholar, 3Jeejeebhoy K.N. Zohrab W.J. Langer B. et al.Total parenteral nutrition at home for 23 months, without complication and with good rehabilitation.Gastroenterology. 1973; 65: 811-820PubMed Google Scholar, 4Broviac J.W. Scribner B.H. Prolonged parenteral nutrition in the home.Surg Gynecol Obstet. 1974; 139: 24-28PubMed Google Scholar, 5Shils M.E. A program for total parenteral nutrition at home.Am J Clin Nutr. 1975; 28: 1429-1435PubMed Google Scholar that a practically viable regimen of HPN was established. In brief, venous access was established by a silicone catheter introduced into the superior vena cava and the patient was taught to administer a complete nutrient admixture as well as fat through this catheter. The infusion was given at night and was disconnected during the day to facilitate daily activities without impediment. Long-term survival on this regimen was subsequently demonstrated from several centers. At our center, we have had patients surviving 2–3 decades with excellent quality of life. Unfortunately, HPN is associated with complications, including progressive steatohepatitis resulting in cirrhosis and liver failure,6Bowyer B.A. Fleming C.R. Ludwig J. et al.Does long term home parenteral nutrition in adult patients cause chronic liver disease?.J Parenter Enteral Nutr. 1985; 9: 11-17Crossref PubMed Scopus (127) Google Scholar, 7Cavicchi M. Beau P. Crenn P. et al.Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure.Ann Intern Med. 2000; 132: 525-532Crossref PubMed Scopus (543) Google Scholar catheter-related complications, repeated sepsis, and inability to cope with the HPN regimen.8Howard L. Michalek A. Home parenteral nutrition.Annu Rev Nutr. 1984; 4: 69-99Crossref PubMed Scopus (20) Google Scholar, 9Messing B. Lemann M. Landais P. et al.Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar, 10MacRitchie K.J. Life without eating or drinking: total parenteral nutrition outside hospital.Can Psychiatr Assoc J. 1978; 23: 373-379PubMed Google ScholarThese complications can result in failure of HPN and progressive malnutrition. Under these circumstances, the only alternative is IT. In theory, IT is the ideal solution for the treatment of IF. The patient who has had an IT can eat and enjoy normal food, does not need complicated machinery to deliver intravenous nutrition, avoids the complications of HPN, and enjoys an improved quality of life.11O'Keefe S.J.D. Emerling M. Koritsky D. et al.Nutrition and quality of life following small intestinal transplantation.Am J Gastroenterol. 2007; 102: 1093-1100Crossref PubMed Scopus (70) Google Scholar In practice, recent published data show that the 5-year survival with IT with or without liver transplant is about 54–58% owing to death caused by sepsis, rejection, or lymphoma. Five-year survival on HPN depends on the primary diagnosis12Howard L. Hassan N. Home parenteral nutrition: 25 years later.Gastroenterol Clin North Am. 1998; 27: 481-512Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar and can be as high as 82% for patients with Crohn's disease. By contrast, it is about the same as for IT in patients with ischemic bowel and radiation enteritis. However, in the latter group of patients or those with pseudoobstruction, the 35–40% patients living beyond 3 years have a very long survival.13Jeejeebhoy K. Allard J. Gramlich L. Home parenteral nutrition in Canada.in: Bozetti F. Staun M. Van Gossum A. Home parenteral nutrition. CAB International, Cambridge, MA2006: 36-42Crossref Google Scholar Although patient survival at 10 years after IT is about the same (43%), graft survival is much lower, at 23%,14Freeman R.B. Steffick D.E. Guidinger M.K. et al.Liver and Intestine transplantation in the United States, 1997–2006.Am J Transplant. 2008; 8: 958-976Crossref PubMed Scopus (239) Google Scholar suggesting that HPN in general still offers a better long-term outcome (Figure 1). IT patients, although they do well initially, have a higher long-term mortality rate, although survival is continuously improving.14Freeman R.B. Steffick D.E. Guidinger M.K. et al.Liver and Intestine transplantation in the United States, 1997–2006.Am J Transplant. 2008; 8: 958-976Crossref PubMed Scopus (239) Google ScholarWhen faced with a patient undergoing IT, what should we recommend? HPN as primary therapy, IT as primary therapy, or HPN followed by IT if HPN fails? The answer to the question is not straightforward; outcomes on HPN depend on many factors, including the primary disease, the patient's age, the patient's ability to care for the catheter, the length of the surviving bowel, support for the patient, acceptance of HPN by the patient, and narcotic dependence. Furthermore, about 45% of patients,13Jeejeebhoy K. Allard J. Gramlich L. Home parenteral nutrition in Canada.in: Bozetti F. Staun M. Van Gossum A. Home parenteral nutrition. CAB International, Cambridge, MA2006: 36-42Crossref Google Scholar even after years of HPN can adapt, and come off HPN. Hence, IT for these patients may be premature. The success of IT also depends on pretransplant status, the experience of the transplanting center, immunosuppressive regimen, and transplant type (isolated intestine, intestine–liver, or multivisceral).15Grant D.W. Shah S.A. Results of intestinal transplantation.in: Langnas A.N. Goulet O. Quigley E.M.M. Intestinal failure. Blackwell, Malden, MA2008: 349-356Crossref Scopus (6) Google Scholar As a result, to give a firm recommendation in an individual patient about HPN or IT, we need outcome studies in which all these factors are considered.Presently, based on the recommendation of the American Society of Transplantation as well as Medicare and Medicaid the initial therapy for IF is HPN and IT recommended under the following conditions:1Failure of HPN.aImpending or overt liver failure from liver injury owing to parenteral nutrition.bThrombosis of ≥2 central veins.cTwo or more episodes per year of systemic sepsis, particularly those requiring hospitalization associated with septic shock and fungemia.dFrequent episodes of severe dehydration.2High risk of death.3Severe short bowel syndrome (gastrostomy, duodenostomy, residual small bowel <10 cm in infants and <20 cm in adults).4IF with frequent hospitalization, narcotic dependency, or pseudoobstruction.5Patient's unwillingness to accept long-term HPN.Contraindications to IT are similar to those for patients eligible for solid organ transplantation. The unanswered question is whether these recommendations promote the best outcome because they were based on retrospective data and expert opinion. In an effort to determine the impact of these recommendations, Pironi et al16Pironi 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: 61-71Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar undertook a 3-year prospective follow-up of 2 cohorts of patients. First, those who met the criteria for IT and second those who did not have either an indication or a contraindication to IT. The latter group could have been treated by transplantation, except that they did not meet the criteria for HPN-related complications, making transplantation a desirable or mandatory option. The primary endpoint was whether these recommendations for continued HPN or transplantation altered survival. The initial cross-sectional evaluation included a total of 854 patients, about 50% of whom had indications for transplantation; however, only 63% of those suitable for transplantation had contraindications that prevented transplantation. The cross-sectional analysis of all comers, therefore, suggests that the majority of patients in whom transplantation is desirable may not be transplantable. After removing patients who had contraindications for IT, there were 396 patients on HPN who were considered as having neither an indication nor a contraindication for IT. There were 156 patients who were considered eligible for transplantation and had no contraindication.Should IT rather than HPN be the primary therapy for IF? One way to examine this question is to compare the survival of patients not transplanted, who were considered for transplantation because of their disease and not for HPN complications with those who did not have an indication for transplantation. This comparison showed that 93% of patients on the transplant list who did not have HPN-related complications survived 3 years without transplantation, which is comparable to those who did not have an indication for a transplant. However, mortality of the few patients who were transplanted for the severity of their disease rather than for HPN complications was higher than those who were not transplanted. This difference needs to be interpreted with caution because the number of transplanted patients is few, but nevertheless does not favor early transplantation in subjects who did not have HPN-related complications. Furthermore, about 18% of patients with an indication for transplant and even 2% on the transplant list were ultimately weaned off HPN.These findings support the use of HPN as the first line of therapy for IF. The reduced long-term survival with IT may be acceptable if IT were associated with a better quality of life than HPN. Although not reported in this paper, a critical analysis does not indicate that IT results in a better quality of life than HPN.17DeLegge M. Alsolaiman M.M. Barbour E. et al.Short bowel syndrome: parenteral nutrition versus intestinal transplantation Where are we today?.Dig Dis Sci. 2007; 52: 876-892Crossref PubMed Scopus (65) Google ScholarThe next question is whether the criteria used to select patients for transplantation identified those with a higher mortality than those who did not meet the criteria for transplantation. The data showed that overall survival was significantly lower for patients on the transplant list who were not transplanted as compared with those who did not have an indication for transplantation (P = .007). Subgroup analysis demonstrated that the odds ratio for death was 5.7 for those with liver failure (P < .001), 2.8 for those with central venous catheter (CVC)-related thrombosis or frequent sepsis (P = .028), but was only 1.3 for those with high-risk underlying disease (P = .6). Furthermore, none of the patients who were selected for IT owing to high risk for morbidity or those unwilling to continue HPN died while waiting for a transplant. Taken together, these observations suggest that IT is most likely to benefit only patients with liver disease and CVC-related thrombosis or sepsis. On the other hand, posttransplant survival curves for patients who had liver disease or those with CVC sepsis-related complications were not statistically significant compared with those not transplanted. Perhaps this is because of the small number of patients transplanted in this case series. Patients with liver failure failed to survive after transplantation in this series.This study has limitations related to the small number of patients on the transplant list who were actually transplanted. Also, there are no data mentioned as to whether transplantation would have improved the quality of life as compared with HPN. Nevertheless, there are some conclusions that can be made. First, the survival of patients with CVC complications and liver failure is significantly impaired and there is an improvement in 3-year survival with IT. Because advanced liver disease was associated with increased mortality after IT, patients with liver disease owing to HPN should be transplanted early. By contrast, the group of patients with a high risk of HPN morbidity or those unwilling to continue HPN do not seem to have a poor outcome while continuing on HPN. In this group, IT is only likely to be beneficial if quality of life is better with IT than on continuing HPN.In conclusion, there are currently 2 ways of improving survival for IF patients. Both have different potential complications that reduce quality of life and survival. The use of HPN as the first therapy is well established and should be continued; it allows the patient to survive while deciding on long-term management. In the longer term, it is clear that progressive liver disease should be an indication for early transplantation. Early transplantation should also be considered for those who have CVC-related complications before losing all sites of venous access. Patients with Crohn's disease clearly benefit from prolonged HPN. However, in all other situations we need better designed long term-studies of both survival and quality of life to advise the patient about the pros and cons of continued HPN versus IT. The future depends in part on progress in techniques, experience, and improvements in immunosuppression for IT. See “Survival of Patients Identified as Candidates for Intestinal Transplantation: A 3-Year Prospective Follow-Up,” by Pironi L, Forbes A, Joly F, et al, on page 61. See “Survival of Patients Identified as Candidates for Intestinal Transplantation: A 3-Year Prospective Follow-Up,” by Pironi L, Forbes A, Joly F, et al, on page 61. See “Survival of Patients Identified as Candidates for Intestinal Transplantation: A 3-Year Prospective Follow-Up,” by Pironi L, Forbes A, Joly F, et al, on page 61. Intestinal failure (IF) is a condition is characterized by the inability to maintain protein energy, fluid, electrolyte, or micronutrient balance owing to gastrointestinal disease when on a normal diet. IF ultimately leads to increasing malnutrition and even death of not circumvented by home parenteral nutrition (HPN) or corrected by intestinal transplantation (IT). Long-term intravenous nutrition was introduced to treat IF through an arteriovenous fistula with limited success in the late 1960s,1Shils M.E. Wright W.L. Turnbull A. et al.Long-term parenteral nutrition through an external arteriovenous shunt.N Engl J Med. 1970; 283: 341-344Crossref PubMed Scopus (96) Google Scholar but it was in the 1970s2Tsallas G. Baun D.C. Home care total parenteral alimentation.Am J Hosp Pharm. 1972; 29: 840-846PubMed Google Scholar, 3Jeejeebhoy K.N. Zohrab W.J. Langer B. et al.Total parenteral nutrition at home for 23 months, without complication and with good rehabilitation.Gastroenterology. 1973; 65: 811-820PubMed Google Scholar, 4Broviac J.W. Scribner B.H. Prolonged parenteral nutrition in the home.Surg Gynecol Obstet. 1974; 139: 24-28PubMed Google Scholar, 5Shils M.E. A program for total parenteral nutrition at home.Am J Clin Nutr. 1975; 28: 1429-1435PubMed Google Scholar that a practically viable regimen of HPN was established. In brief, venous access was established by a silicone catheter introduced into the superior vena cava and the patient was taught to administer a complete nutrient admixture as well as fat through this catheter. The infusion was given at night and was disconnected during the day to facilitate daily activities without impediment. Long-term survival on this regimen was subsequently demonstrated from several centers. At our center, we have had patients surviving 2–3 decades with excellent quality of life. Unfortunately, HPN is associated with complications, including progressive steatohepatitis resulting in cirrhosis and liver failure,6Bowyer B.A. Fleming C.R. Ludwig J. et al.Does long term home parenteral nutrition in adult patients cause chronic liver disease?.J Parenter Enteral Nutr. 1985; 9: 11-17Crossref PubMed Scopus (127) Google Scholar, 7Cavicchi M. Beau P. Crenn P. et al.Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure.Ann Intern Med. 2000; 132: 525-532Crossref PubMed Scopus (543) Google Scholar catheter-related complications, repeated sepsis, and inability to cope with the HPN regimen.8Howard L. Michalek A. Home parenteral nutrition.Annu Rev Nutr. 1984; 4: 69-99Crossref PubMed Scopus (20) Google Scholar, 9Messing B. Lemann M. Landais P. et al.Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar, 10MacRitchie K.J. Life without eating or drinking: total parenteral nutrition outside hospital.Can Psychiatr Assoc J. 1978; 23: 373-379PubMed Google Scholar These complications can result in failure of HPN and progressive malnutrition. Under these circumstances, the only alternative is IT. In theory, IT is the ideal solution for the treatment of IF. The patient who has had an IT can eat and enjoy normal food, does not need complicated machinery to deliver intravenous nutrition, avoids the complications of HPN, and enjoys an improved quality of life.11O'Keefe S.J.D. Emerling M. Koritsky D. et al.Nutrition and quality of life following small intestinal transplantation.Am J Gastroenterol. 2007; 102: 1093-1100Crossref PubMed Scopus (70) Google Scholar In practice, recent published data show that the 5-year survival with IT with or without liver transplant is about 54–58% owing to death caused by sepsis, rejection, or lymphoma. Five-year survival on HPN depends on the primary diagnosis12Howard L. Hassan N. Home parenteral nutrition: 25 years later.Gastroenterol Clin North Am. 1998; 27: 481-512Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar and can be as high as 82% for patients with Crohn's disease. By contrast, it is about the same as for IT in patients with ischemic bowel and radiation enteritis. However, in the latter group of patients or those with pseudoobstruction, the 35–40% patients living beyond 3 years have a very long survival.13Jeejeebhoy K. Allard J. Gramlich L. Home parenteral nutrition in Canada.in: Bozetti F. Staun M. Van Gossum A. Home parenteral nutrition. CAB International, Cambridge, MA2006: 36-42Crossref Google Scholar Although patient survival at 10 years after IT is about the same (43%), graft survival is much lower, at 23%,14Freeman R.B. Steffick D.E. Guidinger M.K. et al.Liver and Intestine transplantation in the United States, 1997–2006.Am J Transplant. 2008; 8: 958-976Crossref PubMed Scopus (239) Google Scholar suggesting that HPN in general still offers a better long-term outcome (Figure 1). IT patients, although they do well initially, have a higher long-term mortality rate, although survival is continuously improving.14Freeman R.B. Steffick D.E. Guidinger M.K. et al.Liver and Intestine transplantation in the United States, 1997–2006.Am J Transplant. 2008; 8: 958-976Crossref PubMed Scopus (239) Google Scholar When faced with a patient undergoing IT, what should we recommend? HPN as primary therapy, IT as primary therapy, or HPN followed by IT if HPN fails? The answer to the question is not straightforward; outcomes on HPN depend on many factors, including the primary disease, the patient's age, the patient's ability to care for the catheter, the length of the surviving bowel, support for the patient, acceptance of HPN by the patient, and narcotic dependence. Furthermore, about 45% of patients,13Jeejeebhoy K. Allard J. Gramlich L. Home parenteral nutrition in Canada.in: Bozetti F. Staun M. Van Gossum A. Home parenteral nutrition. CAB International, Cambridge, MA2006: 36-42Crossref Google Scholar even after years of HPN can adapt, and come off HPN. Hence, IT for these patients may be premature. The success of IT also depends on pretransplant status, the experience of the transplanting center, immunosuppressive regimen, and transplant type (isolated intestine, intestine–liver, or multivisceral).15Grant D.W. Shah S.A. Results of intestinal transplantation.in: Langnas A.N. Goulet O. Quigley E.M.M. Intestinal failure. Blackwell, Malden, MA2008: 349-356Crossref Scopus (6) Google Scholar As a result, to give a firm recommendation in an individual patient about HPN or IT, we need outcome studies in which all these factors are considered. Presently, based on the recommendation of the American Society of Transplantation as well as Medicare and Medicaid the initial therapy for IF is HPN and IT recommended under the following conditions:1Failure of HPN.aImpending or overt liver failure from liver injury owing to parenteral nutrition.bThrombosis of ≥2 central veins.cTwo or more episodes per year of systemic sepsis, particularly those requiring hospitalization associated with septic shock and fungemia.dFrequent episodes of severe dehydration.2High risk of death.3Severe short bowel syndrome (gastrostomy, duodenostomy, residual small bowel <10 cm in infants and <20 cm in adults).4IF with frequent hospitalization, narcotic dependency, or pseudoobstruction.5Patient's unwillingness to accept long-term HPN. Contraindications to IT are similar to those for patients eligible for solid organ transplantation. The unanswered question is whether these recommendations promote the best outcome because they were based on retrospective data and expert opinion. In an effort to determine the impact of these recommendations, Pironi et al16Pironi 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: 61-71Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar undertook a 3-year prospective follow-up of 2 cohorts of patients. First, those who met the criteria for IT and second those who did not have either an indication or a contraindication to IT. The latter group could have been treated by transplantation, except that they did not meet the criteria for HPN-related complications, making transplantation a desirable or mandatory option. The primary endpoint was whether these recommendations for continued HPN or transplantation altered survival. The initial cross-sectional evaluation included a total of 854 patients, about 50% of whom had indications for transplantation; however, only 63% of those suitable for transplantation had contraindications that prevented transplantation. The cross-sectional analysis of all comers, therefore, suggests that the majority of patients in whom transplantation is desirable may not be transplantable. After removing patients who had contraindications for IT, there were 396 patients on HPN who were considered as having neither an indication nor a contraindication for IT. There were 156 patients who were considered eligible for transplantation and had no contraindication. Should IT rather than HPN be the primary therapy for IF? One way to examine this question is to compare the survival of patients not transplanted, who were considered for transplantation because of their disease and not for HPN complications with those who did not have an indication for transplantation. This comparison showed that 93% of patients on the transplant list who did not have HPN-related complications survived 3 years without transplantation, which is comparable to those who did not have an indication for a transplant. However, mortality of the few patients who were transplanted for the severity of their disease rather than for HPN complications was higher than those who were not transplanted. This difference needs to be interpreted with caution because the number of transplanted patients is few, but nevertheless does not favor early transplantation in subjects who did not have HPN-related complications. Furthermore, about 18% of patients with an indication for transplant and even 2% on the transplant list were ultimately weaned off HPN. These findings support the use of HPN as the first line of therapy for IF. The reduced long-term survival with IT may be acceptable if IT were associated with a better quality of life than HPN. Although not reported in this paper, a critical analysis does not indicate that IT results in a better quality of life than HPN.17DeLegge M. Alsolaiman M.M. Barbour E. et al.Short bowel syndrome: parenteral nutrition versus intestinal transplantation Where are we today?.Dig Dis Sci. 2007; 52: 876-892Crossref PubMed Scopus (65) Google Scholar The next question is whether the criteria used to select patients for transplantation identified those with a higher mortality than those who did not meet the criteria for transplantation. The data showed that overall survival was significantly lower for patients on the transplant list who were not transplanted as compared with those who did not have an indication for transplantation (P = .007). Subgroup analysis demonstrated that the odds ratio for death was 5.7 for those with liver failure (P < .001), 2.8 for those with central venous catheter (CVC)-related thrombosis or frequent sepsis (P = .028), but was only 1.3 for those with high-risk underlying disease (P = .6). Furthermore, none of the patients who were selected for IT owing to high risk for morbidity or those unwilling to continue HPN died while waiting for a transplant. Taken together, these observations suggest that IT is most likely to benefit only patients with liver disease and CVC-related thrombosis or sepsis. On the other hand, posttransplant survival curves for patients who had liver disease or those with CVC sepsis-related complications were not statistically significant compared with those not transplanted. Perhaps this is because of the small number of patients transplanted in this case series. Patients with liver failure failed to survive after transplantation in this series. This study has limitations related to the small number of patients on the transplant list who were actually transplanted. Also, there are no data mentioned as to whether transplantation would have improved the quality of life as compared with HPN. Nevertheless, there are some conclusions that can be made. First, the survival of patients with CVC complications and liver failure is significantly impaired and there is an improvement in 3-year survival with IT. Because advanced liver disease was associated with increased mortality after IT, patients with liver disease owing to HPN should be transplanted early. By contrast, the group of patients with a high risk of HPN morbidity or those unwilling to continue HPN do not seem to have a poor outcome while continuing on HPN. In this group, IT is only likely to be beneficial if quality of life is better with IT than on continuing HPN. In conclusion, there are currently 2 ways of improving survival for IF patients. Both have different potential complications that reduce quality of life and survival. The use of HPN as the first therapy is well established and should be continued; it allows the patient to survive while deciding on long-term management. In the longer term, it is clear that progressive liver disease should be an indication for early transplantation. Early transplantation should also be considered for those who have CVC-related complications before losing all sites of venous access. Patients with Crohn's disease clearly benefit from prolonged HPN. However, in all other situations we need better designed long term-studies of both survival and quality of life to advise the patient about the pros and cons of continued HPN versus IT. The future depends in part on progress in techniques, experience, and improvements in immunosuppression for IT. Survival of Patients Identified as Candidates for Intestinal Transplantation: A 3-Year Prospective Follow-UpGastroenterologyVol. 135Issue 1PreviewBackground & Aims: The US Medicare indications for intestinal transplantation are based on failure of home parenteral nutrition. The American Society of Transplantation also includes patients at high risk of death from their primary disease or with high morbidity intestinal failure. A 3-year prospective study evaluated the appropriateness of these indications. Methods: Survival on home parenteral nutrition or after transplantation was analyzed in 153 (97 adult, 56 pediatric) candidates for transplantation and 320 (262 adult, 58 pediatric) noncandidates, enrolled through a European multicenter cross-sectional survey performed in 2004. Full-Text PDF