Shifting paradigms in Intestinal Transplantation: from rescue therapy to standard treatment?

E. Canovai, L. Ceulemans, I. Hoffman, G. de Hertogh, M. Hiele, M. Sainz-Bariga, D. Monbaliu, I.J. Jochmans, T. Vanuytsel, J. Pirenne

Thursday 15 march 2018

11:45 - 11:55h at Willem Burger Zaal

Categories: Clinical, Session (parallel)

Parallel session: Parallel session 3: Clinical

Introduction

Intestinal Transplantation (ITx) is the treatment of choice for patients with complicated intestinal failure. Furthermore, there is a growing indication in patients whose underlying disease is life-threatening, such as diffuse portomesenteric thrombosis. Traditionally, ITx has had inferior long-term survival compared to other solid-organ transplants. This often leads to late referral when malnourishment and vascular access problems increase perioperative risks.

Aim

To study the results from our single center cohort of ITx patients and discuss future directions in the field

Methods

We performed a retrospective analysis of our prospectively maintained database of our cohort of ITx patients transplanted from 2000-2017. All relevant data such as demographics, indication, graft type, rejection episodes, survival, costs and quality of life were recorded.

Results

In this period, 17 patients (13 adults (median age 43 years) and 4 children (median age 6 years) were transplanted. The majority of indications were short bowel syndrome (59%) and diffuse portomesenteric thrombosis (24%). There were 7 isolated ITx, 5 combined Liver-ITx and 4 multivisceral grafts. All patients received basiliximab induction therapy followed by tacrolimus, azathioprine and corticosteroids as maintenance therapy. 10-year all-cause survival was 87%. TPN could be stopped before discharge in all surviving patients. Median Karnofsky score amongst survivors was 90-100%. There were 10 acute rejection episodes in 6 patients which all resolved with medical treatment. 1 patient developed sclerosing mesenteritis which was treated with everolimus. 2 patients died in the first year after ITx due to invasive aspergillosis infections. The first year cost of ITx was more expensive than HPN (€185.662 vs €59.524). However, in the subsequent year ITx patients became far cheaper compared to HPN (Y1:€44.893, Y2: €18.976).

Conclusions

ITx has evolved from an experimental procedure to an established therapy for complicated intestinal failure patients. Diffuse splanchnic thrombosis is an increasing indication for multivisceral transplantation. Integrating intestinal failure and ITx care into a single care pathway allows for correct patient selection and timely listing. Excellent results matching HPN in addition to lower costs than HPN and good quality, suggest that indications for ITx should be cautiously expanded to more intestinal failure patients.