Journal Article

Long-term follow-up of patients on home parenteral nutrition in Europe: implications for intestinal transplantation

Cuerda, Cristina, Messing, Bernard, Pironi, Loris, Gambarara, Manuela, Colomb, Virginie, Joly, Francisca, Thul, Paul, Lyszkowska, Malgorzata, Baxter, Janet, Goulet, Olivier, Van Gossum, André, Hébuterne, Xavier, Gottrand, Frederic, Forbes, Alastair, Staun, Michael, Gabe, Simon

2011

Overview

BackgroundThe indications for intestinal transplantation (ITx) are still debated. Knowing survival rates and causes of death on home parenteral nutrition (HPN) will improve decisions.MethodsA prospective 5-year study compared 389 non-candidates (no indication, no contraindication) and 156 candidates (indication, no contraindication) for ITx. Indications were: HPN failure (liver failure; multiple episodes of catheter-related venous thrombosis or sepsis; severe dehydration), high-risk underlying disease (intra-abdominal desmoids; congenital mucosal disorders; ultra-short bowel), high morbidity intestinal failure. Causes of death were defined as: HPN-related, underlying disease, or other cause.ResultsThe survival rate was 87% in non-candidates, 73% in candidates with HPN failure, 84% in those with high-risk underlying disease, 100% in those with high morbidity intestinal failure and 54%, in ITx recipients (one non-candidate and 21 candidates) (p<0.001). The primary cause of death on HPN was underlying disease-related in patients with HPN duration ≤2 years, and HPN-related in those on HPN duration >2 years (p=0.006). In candidates, the death HRs were increased in those with desmoids (7.1; 95% CI 2.5 to 20.5; p=0.003) or liver failure (3.4; 95% CI 1.6 to 7.3; p=0.002) compared to non-candidates. In deceased candidates, the indications for ITx were the causes of death in 92% of those with desmoids or liver failure, and in 38% of those with other indications (p=0.041). In candidates with catheter-related complications or ultra-short bowel, the survival rate was 83% in those who remained on HPN and 78% after ITx (p=0.767).ConclusionsHPN is confirmed as the primary treatment for intestinal failure. Desmoids and HPN-related liver failure constitute indications for life-saving ITx. Catheter-related complications and ultra-short bowel might be indications for pre-emptive/rehabilitative ITx. In the early years after commencing HPN a life-saving ITx could be required for some patients at higher risk of death from their underlying disease.

• Publisher: BMJ Publishing Group Ltd and British Society of Gastroenterology,BMJ Publishing Group,BMJ Publishing Group LTD
• Subject: Abdomen / Adolescent / Adult / adverse effects / Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy / Biological and medical sciences / Catheters / Child / Clinical Medicine / Congenital diseases / Death / Decision Making / Dehydration / Emergency and intensive care: metabolism and nutrition disorders. Enteral and parenteral nutrition / Epidemiologic Methods / etiology / Female / Gastroenterology. Liver. Pancreas. Abdomen / Home / home parenteral nutrition / Humans / Intensive care medicine / Intestinal failure / intestinal transplantation / Intestine / Intestine, Small - transplantation / Klinisk medicin / Lifesaving / Liver / Malabsorption Syndromes / Malabsorption Syndromes - etiology / Malabsorption Syndromes - mortality / Malabsorption Syndromes - surgery / Malabsorption Syndromes - therapy / Male / Medical sciences / Morbidity / mortality / Nutrition / Parenteral Nutrition / Parenteral Nutrition, Home - adverse effects / Patient Selection / Patients / Prognosis / Quality of life / Sepsis / Small / Studies / surgery / Survival / therapy / Thrombosis / Transplantation / Treatment Outcome / Young Adult