Related Experiment Videos
Current status of intestinal transplantation in children
1Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, PA 15213, USA.
Insights
Intestinal transplantation (Itx) offers a viable treatment for intestinal failure, enabling 55% patient survival and allowing most recipients to live off total parenteral nutrition (TPN). While complications are frequent, Itx remains a crucial option for these complex cases.
Area of Science:
- Gastroenterology and Hepatology
- Transplantation Immunology
- Pediatric Surgery
Background:
- Intestinal failure necessitates total parenteral nutrition (TPN), which carries significant long-term risks.
- Intestinal transplantation (Itx) has emerged as a potential solution for select pediatric patients with irreversible intestinal failure.
- Tacrolimus and prednisone form the basis of immunosuppression in this clinical trial.
Purpose of the Study:
- To evaluate the efficacy and outcomes of intestinal transplantation in children with irreversible intestinal failure.
- To assess patient and graft survival rates following various types of intestinal allografts.
- To identify common complications associated with intestinal transplantation in a pediatric cohort.
Main Methods:
- A prospective clinical trial involving 55 pediatric patients (median age 3.2 years) receiving 58 intestinal transplants (isolated SB, LSB, MV) since June 1990.
- Utilized various immunosuppressive regimens including azathioprine, cyclophosphamide, and mycophenolate mofetil.
- Common indications included gastroschisis, volvulus, necrotizing enterocolitis, and intestinal atresia.
Main Results:
- Achieved a 55% patient survival rate and 52% graft survival rate, with 29 children living independently off TPN.
- High rates of immunologic complications (rejection, PTLD, CMV, GVHD) and surgical complications (perforation, leak, thrombosis, abscess) were observed.
- Graft loss was attributed to rejection, infection, technical issues, and TPN complications post-removal.
Conclusions:
- Intestinal transplantation is a valid therapeutic option for children with intestinal failure and TPN complications.
- Itx is associated with a higher complication rate compared to heart, liver, and kidney transplants but offers better outcomes than lung transplants.
- Despite challenges, Itx provides a life-altering solution for patients with otherwise intractable conditions.
Purpose:
A clinical trial of intestinal transplantation (Itx) under tacrolimus and prednisone immunosuppression was initiated in June 1990 in children with irreversible intestinal failure and who were dependent on total parenteral nutrition (TPN).
Methods:
Fifty-five patients (28 girls, 27 boys) with a median age of 3.2 years (range, 0.5 to 18 years) received 58 intestinal transplants that included isolated small bowel (SB) (n = 17), liver SB (LSB) (n=33), and multivisceral (MV) (n=8) allografts. Nine patients also received bone marrow infusion, and there were 20 colonic allografts. Azathioprine, cyclophosphamide, or mycophenolate mofetil were used in different phases of the series. Indications for Itx included: gastroschisis (n=14), volvulus (n=13), necrotizing enterocolitis (n=6), intestinal atresia (n=8), chronic intestinal pseudoobstruction (n=5), Hirschsprung's disease (n=4), microvillus inclusion disease (n=3), multiple polyposis (n=1), and trauma [n=1).
Results:
Currently, 30 patients are alive (patient survival, 55%; graft survival, 52%). Twenty-nine children with functioning grafts are living at home and off TPN, with a mean follow-up of 962 (range, 75 to 2,424) days. Immunologic complications have included liver allograft rejection (n=18), intestinal allograft rejection (n=52), posttransplant lymphoproliferative disease (n=16), cytomegalovirus (n=16) and graft-versus-host disease (n=4). A combination of associated complications included intestinal perforation (n=4), biliary leak (n=3), bile duct stenosis (n=1), intestinal leak (n=6), dehiscence with evisceration (n=4), hepatic artery thrombosis (n=3), bleeding (n=9), portal vein stenosis (n=1), intraabdominal abscess (n=11), and chylous ascites (n=4). Graft loss occurred as a result of rejection (n=8), infection (n=12), technical complications (n=8), and complications of TPN after graft removal (n=3). There were four retransplants (SB, n=1; LSB n=3).
Conclusions:
Intestinal transplantation is a valid therapeutic option for patients with intestinal failure suffering complications of TPN. The complex clinical and immunologic course of these patients is reflected in a higher complication rate as well as patient and graft loss than seen after heart, liver, and kidney transplantation, although better than after lung transplantation.