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A detailed analysis of the current status of intestinal transplantation in Latin America.
Gondolesi, GE, Doeyo, M, Solar-Muñiz, H
Current opinion in organ transplantation. 2020;(2):189-195
Abstract
PURPOSE OF REVIEW Latin America and the Caribbean represent a vast territory, with very different economic and healthcare realities, which result in significant disparities in the management of intestinal failure patients throughout the region. Since 1968, multiple attempts have been done to accomplish a successful intestinal transplant; but it was not until 2004, with the establishment of multidisciplinary programs, that large series with long-term results could be obtained. Currently, three countries (Colombia, Argentina, and Brazil) in the region are actively performing these procedures. RECENT FINDINGS A total number of 135 intestinal transplants have been performed; 11 attempts before 2004, and 124 after that period, 66 transplants were done in Argentina (42 in children), 40 in Colombia, 15 in Brazil (1 child), 2 in Costa Rica and 1 in México; 76% have been isolated, whereas 2 were done with living donors. SUMMARY Publications are still scarce, and compliance to existing registries remains limited. The challenge for the next years is to develop more 'comprehensive units' and extend home parenteral nutrition availability in the rest of the region. Regional cooperation and networking need to be set, in order to achieve regional self-sufficiency and improve long-term results.
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2.
Nutritional Feeding Strategies in Pediatric Intestinal Failure.
Olieman, J, Kastelijn, W
Nutrients. 2020;(1)
Abstract
Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.
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3.
Validation of the Micronutrient and Environmental Enteric Dysfunction Assessment Tool and evaluation of biomarker risk factors for growth faltering and vaccine failure in young Malian children.
Arndt, MB, Cantera, JL, Mercer, LD, Kalnoky, M, White, HN, Bizilj, G, Boyle, DS, de Hostos, EL, Choy, RKM
PLoS neglected tropical diseases. 2020;(9):e0008711
Abstract
Environmental enteric dysfunction (EED) is an intestinal disorder common among children in low-resource settings and is associated with increased risk of growth stunting, cognitive deficits, and reduced oral vaccine immunogenicity. The Micronutrient and EED Assessment Tool (MEEDAT) is a multiplexed immunoassay that measures biomarkers previously associated with child growth faltering and/or oral vaccine immunogenicity: intestinal fatty acid-binding protein (I-FABP), soluble CD14 (sCD14), insulin-like growth factor 1 (IGF-1), and fibroblast growth factor 21 (FGF21). MEEDAT also measures systemic inflammation (α1-acid glycoprotein, C-reactive protein), ferritin, soluble transferrin receptor, retinol binding protein 4, thyroglobulin, and Plasmodium falciparum antigenemia (histidine-rich protein 2). The performance of MEEDAT was compared with commercially available enzyme-linked immunosorbent assays (ELISAs) using 300 specimens from Malian infant clinical trial participants. Regression methods were used to test if MEEDAT biomarkers were associated with seroconversion to meningococcal A conjugate vaccine (MenAV), yellow fever vaccine (YFV), and pentavalent rotavirus vaccine (PRV) after 28 days, or with growth faltering over 12 weeks. The Pearson correlations between the MEEDAT and ELISA results were 0.97, 0.86, 0.80, and 0.97 for serum I-FABP, sCD14, IGF-1, and FGF21, respectively. There were significant associations between I-FABP concentration and the probability of PRV IgG seroconversion and between IGF-1 concentration and the probability of YFV seroconversion. In multivariable models neither association remained significant, however there was a significant negative association between AGP concentration and YFV seroconversion. GLP-2 and sCD14 concentrations were significantly negatively associated with 12-week change in weight-for-age z-score and weight-for-height z-score in multivariable models. MEEDAT performed well in comparison to commercially-available ELISAs for the measurement of four analytes for EED and growth hormone resistance. Adoption of MEEDAT in low-resource settings could help accelerate the identification of interventions that prevent or treat child stunting and interventions that boost the immunogenicity of child vaccinations.
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4.
[Evolution of patients with home parenteral nutrition: a systematic review of available studies].
Seisdedos Elcuaz, R, Mejías Trueba, M, Rodríguez Ramallo, H, Pérez Blanco, JL, Pereira Cunill, JL, García Luna, PP
Nutricion hospitalaria. 2020;(3):599-608
Abstract
Introduction: home parenteral nutrition (HPN) is a fundamental treatment for patients with intestinal failure who do not require hospitalization. We aimed to conduct an epidemiological and clinical practice analysis of HPN through a systematic review. Methods: the systematic review was conducted according to the PRISMA guidelines. A search was performed using the Healthcare Databases Advanced Search of PubMed® and EMBASE®, to identify articles which followed patients treated with HPN for at least 5 years, published between 2009 and 2019 in English or Spanish language. In addition, we manually retrieved other publications of interest. We excluded articles about subgroups of patients with a specific pathology, cancer or pregnant patients. We excluded studies collecting exclusively HPN complications. Results: a total of 267 references were identified, of which 9 met criteria (3 of pediatric population and 6 of adults). In adults, the main difference found between publications was the underlying pathologies. The most common indication was short bowel syndrome and the main cause of exitus was the underlying pathology. Most of the pediatric patients received this support in the first months of life. In addition, children showed a higher conversion rate to oral intake and a lower number of deaths when compared to adults. Conclusions: the use of HPN in cancer pathology is subject to wide geographic variability. It would be advisable to establish indication guidelines in patients with cancer and conduct quality studies, which provide rigorous and homogeneous information.
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Current status of pediatric intestinal transplantation in the United States.
Venick, RS, Duggan, E, Whatley, J
Current opinion in organ transplantation. 2020;(2):201-207
Abstract
PURPOSE OF REVIEW The present review aims to describe in detail the characteristics, outcomes, and recent trends in the field of pediatric intestinal transplantation in the United States. It will examine the route cause and future implications of these developments. The review will draw from recent publications in the field, the Intestinal Transplant Registry, and contemporary data from large U.S. single centers. RECENT FINDINGS More than 1500 pediatric intestinal transplants have been performed in the United States since 1985, however, over the past decade there have been fewer than 50 transplants/year nationwide. This trend is largely a result of stagnant long-term ITx outcomes and advancements in intestinal rehabilitation programs. Nationally the overall 1-year and 5-year graft survival are 68 and 50% respectively, whereas certain high-volume centers have experienced significantly better results. Sepsis is the leading cause of death following pediatric ITx, whereas rejection is the leading cause of graft loss. Chronic kidney disease and posttransplant lymphoproliferative disorder are significant and relatively prevalent long-term complications. The majority of pediatric ITx recipients receive T-cell depleting induction agents and are on Tacrolimus-based immunosuppression. Most recipient are off parenteral nutrition, but may require supplemental tube feeds. Many pediatric ITx recipients require special education, and in certain domains some report lower health related quality of life. SUMMARY As intestinal rehabilitation has improved in the modern era, the volume of pediatric ITx in the United States has decreased. Although pediatric ITx results have room for improvement nationwide, successful outcomes have been reported at experienced American centers.
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New Insights Into the Indications for Intestinal Transplantation: Consensus in the Year 2019.
Kaufman, SS, Avitzur, Y, Beath, SV, Ceulemans, LJ, Gondolesi, GE, Mazariegos, GV, Pironi, L
Transplantation. 2020;(5):937-946
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Abstract
In 2001, a Statement was published that described indications for intestinal transplantation in patients with intestinal failure expected to require parenteral nutrition indefinitely. Since 2001, advances in the management of intestinal failure including transplantation and patient survival, both on extended parenteral nutrition and after transplantation, have improved, leading to a reduction in the number of intestinal transplants worldwide from a peak of 270 per year in 2008 to 149 per year in 2017. These changes suggest that the original 2001 Statement requires reassessment. All patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under care of these teams, patients should be considered for intestinal transplantation in the event of progressive intestinal failure-associated liver disease, progressive loss of central vein access, and repeated life-threatening central venous catheter-associated infections requiring critical care. Additional indications for transplantation include large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure, extensive mesenteric vein thrombosis and intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea. Quality of life typically improves after successful intestinal transplantation and may support the decision to proceed with transplantation when other indications are present. However, the requirement for life-long immunosuppression and its associated side effects preclude intestinal transplantation if motivated only by an expectation of improved quality of life. Increasing experience with intestinal transplantation and critical appraisal of transplant outcomes including graft survival and patient quality of life together with potential advances in immunosuppression can be expected to influence transplant practices in the future.
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The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients.
Vlug, LE, Nagelkerke, SCJ, Jonkers-Schuitema, CF, Rings, EHHM, Tabbers, MM
Nutrients. 2020;(1)
Abstract
Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.
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A detailed analysis of the current status of intestinal transplantation in the middle east.
Nikeghbalian, S, Arasteh, P, Nikoupour, H
Current opinion in organ transplantation. 2020;(2):169-175
Abstract
PURPOSE OF REVIEW Intestinal transplantations are among the most complex transplantations, which are performed in few centers in the world. When patients develop intestinal failure, different treatment modalities including parenteral nutrition, autologous gastrointestinal tract reconstructive surgery, and intestinal transplantations are considered. The Middle East is a region where reports on intestinal failures and intestinal transplantations are mainly lacking. In the present review, we highlighted the status of intestinal transplantations in the Middle East and focused on existing reports from this region. RECENT FINDINGS Very few countries in the Middle East have the facilities for home parenteral nutrition and only two countries including Iran and Turkey perform intestinal transplantations in the region. With advances in intestinal rehabilitation units and development of autologous gastrointestinal tract reconstructive surgery, some centers have been able to reduce the number of patients in need of intestinal transplantations. SUMMARY An overview of the condition of intestinal transplantations in the Middle East shows that the issue of intestinal failure and the treatment facilities still remain an unsolved problem. Although there exists a high need for intestinal transplantation, advances in reconstructive surgeries and the development of parenteral nutrition in this region can significantly reduce the need for intestinal transplantations among patients with intestinal failure.
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Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study.
Joly, F, Seguy, D, Nuzzo, A, Chambrier, C, Beau, P, Poullenot, F, Thibault, R, Armengol Debeir, L, Layec, S, Boehm, V, et al
Clinical nutrition (Edinburgh, Scotland). 2020;(9):2856-2862
Abstract
BACKGROUND & AIMS Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors. METHODS We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model. RESULTS At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes. CONCLUSIONS Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.
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10.
[Sitosterolemia (phytosterolemia)].
Lütjohann, D
Der Internist. 2019;(8):871-877
Abstract
Sitosterolemia or phytosterolemia is a rare autosomal recessive hereditary lipid storage disorder. It is caused by homozygous or compound heterozygous mutations in one of the two ABCG5 and ABCG8 genes encoding the intestinal and hepatic heterodimer ABCG5 (sterolin 1)/ABCG8 (sterolin 2) efflux transporters. These mutations lead to intestinal hyperabsorption and reduced hepatic secretion of cholesterol and plant sterols with subsequent accumulation of phytosterols and cholesterol in plasma and deposition in tissue (xanthoma). Phytosterols are found mainly in vegetable oils, margarine, nuts, grains, soybeans and avocados. Patients with sitosterolemia show extreme phenotypic heterogeneity from almost asymptomatic individuals to those with combined severe hypercholesterolemia at a young age, leading to increased atherosclerosis and premature cardiac death. Early abnormalities include hemolytic anemia with stomatocytosis, macrothrombocytopenia and splenomegaly. In addition to strict avoidance of phytosterol-containing foods, the use of the sterol absorption inhibitor ezetimibe, possibly in combination with the bile acid-binding resin cholestyramine, is the most effective treatment option.