Clinical

Referral to transplant center 'mandatory' for irreversible intestinal failure

Last Updated: 2010-12-02 13:51:27 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - Home parenteral nutrition is still the first-line treatment for intestinal failure, but early referral to an intestinal transplant program is "mandatory" for patients with desmoid tumors or liver disease, according to the European Society for Clinical Nutrition and Metabolism (ESPEN).

In the early days of small bowel transplantation, complications and long-term outcomes of total parenteral nutrition (TPN) formed the basis for candidate selection. But now, with many well-established intestinal transplant programs, an ESPEN study was able to compare five-year survival among similar groups of patients who either stayed on TPN or were listed for transplant.

The newer data show that TPN-associated liver disease and intra-abdominal desmoid tumors are the only conditions associated with a significantly increased risk of death when patients stay on TPN, according to a report by ESPEN's Home Artificial Nutrition & Chronic Intestinal Failure Working Group.

On the other hand, timely small bowel transplantation did not improve the odds of survival for patients with major complications of central venous catheters or those with ultra-short bowel, the authors reported online November 10th in Gut.

Patients at risk of liver failure need to be referred to a transplant center as soon as possible, in order to avoid the need for combined small bowel and liver transplantation, said lead author Dr. Loris Pironi from the University of Bologna, Italy, in e-mail to Reuters Health. A meeting with transplant surgeons should also be recommend for patients with invasive intra-abdominal desmoids, Dr. Pironi added.

"In all the other conditions, listing for intestinal transplantation should be decided on a case by case basis," Dr. Pironi advised. "However, at this time we have no clear parameters driving the decision."

Dr. Pironi and colleagues analyzed five-year survival rates and causes of death in 448 patients on home parenteral nutrition across Europe. The cohort included 297 patients with no indication for transplant (and no contraindication, either), and 151 candidates for transplant.

Ultimately, 22 candidates received a transplant.

On Kaplan-Meier analysis, five-year survival was significantly lower for transplant recipients (54%, with deaths in all cases related to the transplant itself) than for non-candidates (87%).

Survival among recipients was also significantly lower than among transplant candidates with HPN failure (73%), patients with high-risk underlying disease (84%), or patients with high morbidity intestinal failure (100%).

In transplant candidates compared to non-candidates, the hazard ratio for death was higher for those with desmoids (HR 7.1, p = 0.003) or liver failure (HR 3.4, p = 0.002).

Among candidates who died, the indication for transplant was the cause of death in 92% of those with desmoids or liver failure but in only 38% of those with other indications (p = 0.041).

But among transplant candidates with catheter-related complications or ultra short bowel, there was no significant difference in survival between those who stayed on TPN (83%) and those who received a transplant (78%), the authors report.

"It would be very important to carry out a cost-utility comparative study between (home parenteral nutrition) and intestinal transplantation," Dr. Pironi said. "The results could give us the information to define the indications for a rehabilitative intestinal transplantation. In the meanwhile, a specific tool for the measurement of quality of life on (home parenteral nutrition) has been developed, and a large multicenter and multi-country study is going on. We are planning to adapt this tool for intestinal transplantation recipients."

SOURCE: http://link.reuters.com/xyf38q

Gut 2010.