RESUMO
Intestine remains the least frequently transplanted solid organ, although the survival and quality-of-life benefits of transplant to individuals with irreversible intestinal failure have been well demonstrated. The trend seen over the past 15 years of fewer listings and fewer transplants appears to be continuing, most noticeably in infants, children, and adolescents. There were only 146 additions to the intestine waiting list in 2022, and the proportion of adult candidates continues to increase, so that now 61% of the intestine waiting list are adult candidates. There has been little change in the distribution by sex, race and ethnicity, or primary diagnosis on the waiting list, or for those receiving transplant. The transplant rate for adults has decreased to 55.6 transplants per 100 patient-years, but the pediatric transplant rate remains relatively stable at 22.8 transplants per 100 patient-years. The decrease in transplant rates for adults is primarily the result of falling rates for those listed for combined intestine-liver, and this is reflected in the pretransplant mortality rates, which are twice as high for candidates in need of both organs compared with those listed for intestine alone. Overall, intestine transplant numbers decreased to a total of 82 intestine transplants in 2022, only one above the lowest ever value of 81 in 2019. No major changes were seen in the immunosuppression protocols, with most recipients having induction therapy and tacrolimus-based maintenance. Graft failure rates appear to have improved at 1, 3, and 5 years for intestine without liver, but this is not seen for combined intestine-liver. Graft and patient survival are better for pediatric recipients compared with adult recipients for both liver-inclusive and liver-exclusive transplant. Rates of posttransplant lymphoproliferative disorder are higher for recipients of intestine without liver.
Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Adulto , Lactente , Adolescente , Humanos , Criança , Estados Unidos/epidemiologia , Intestinos/transplante , Terapia de Imunossupressão , Listas de Espera , Etnicidade , Sobrevivência de Enxerto , Doadores de TecidosRESUMO
There has been just over 30 years of experience in clinical intestine transplant. A rise in demand until 2007 with improving transplant outcomes preceded a subsequent fall in demand due, at least in part, to improvements in pretransplant care of patients with intestinal failure. Over the past 10 to 12 years, there has been no suggestion of an increase in demand and, particularly for adult transplant, there may be a continued trend toward fewer additions to the waiting list and fewer transplants, especially in those needing combined intestine-liver transplant. In addition, over the same period there has been no noticeable improvement in graft survival, with 1- and 5-year graft failure rates averaging 21.6% and 52.5%, respectively, for intestine-alone transplants and 28.6% and 47.2%, respectively, for combined intestine-liver allografts.
Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Transplantes , Adulto , Humanos , Estados Unidos/epidemiologia , Intestinos/transplante , Listas de Espera , Sobrevivência de Enxerto , Doadores de TecidosRESUMO
OBJECTIVES: To assess the natural history and outcomes of children with intestinal failure in a large, multicenter, geographically diverse contemporary cohort (2010-2015) from 6 pediatric intestinal failure programs. STUDY DESIGN: Retrospective analysis of a multicenter intestinal failure cohort (n = 443). Competing-risk analysis was used to obtain cumulative incidence rates for the primary outcome (enteral autonomy, transplantation, or death). The χ2 test and Cox proportional hazard regression were used for bivariate and multivariable analyses. RESULTS: The study cohort comprised 443 patients (61.2% male). Primary etiologies included short bowel syndrome (SBS), 84.9%; dysmotility disorder, 7.2%; and mucosal enteropathy, 7.9%. Cumulative incidences for enteral autonomy, transplantation, and death at 6 years of follow-up were 53.0%, 16.7%, and 10.5%, respectively. Enteral autonomy was associated with SBS, ≥50% of small bowel length, presence of an ileocecal valve (ICV), absence of portal hypertension, and follow-up in a non-high-volume transplantation center. The composite outcome of transplantation/death was associated with persistent advanced cholestasis and hypoalbuminemia; age <1 year at diagnosis, ICV, and intact colon were protective. CONCLUSIONS: The rates of death and transplantation in children with intestinal failure have decreased; however, the number of children achieving enteral autonomy has not changed significantly, and a larger proportion of patients remain parenteral nutrition dependent. New strategies to achieve enteral autonomy are needed to improve patient outcomes.
Assuntos
Enteropatias/epidemiologia , Enteropatias/terapia , Adolescente , Criança , Pré-Escolar , Progressão da Doença , Feminino , Seguimentos , Humanos , Incidência , Lactente , Recém-Nascido , Enteropatias/etiologia , Intestinos/transplante , Masculino , Nova Zelândia/epidemiologia , América do Norte/epidemiologia , Nutrição Parenteral , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
Background: Serious urethral damage or recurrent obstructions in felines require a urethrostomy to provide a return to and maintenance of urinary flow. In some cases, urethral reconstruction with complementary tissue is required. Grafting of autogenous vascularized intestinal segments is widely used in human medicine to promote the functional restoration of the urethra, but in veterinary medicine, its use is still incipient. Thus, the aim of this report was to analyze and describe the use of thein functional urethral repair in a feline diagnosed with a severe urethral rupture. Case: A castrated male cat presented with urethral obstruction. Emergency decompression cystocentesis was performed, and fluids and analgesics were administered. Catheterization and urohydropropulsion were attempted to relieve the obstruction, without success. An emergency perineal urethrostomy was indicated. After the procedure, the diagnosis (obstructive lower tract urinary disease) and the infeasibility of restoring urinary flow by conventional urethrostomy techniques were confirmed. We opted for a laparoscopic-assisted prepubic urethrostomy; the pre-prostatic urethra was transected, and its caudais end was brought through an abdominal incision cranially. However, urethral tension was noted after this maneuver was performed. Thus, we decided to use autogenous vascularized intestinal segment grafting for urethral reconstruction. A segment of the ileum was prepared for grafting, with preservation of irrigation and mesenteric innervation. A terminoterminal anastomosis was performed on the stumps of the remaining intestine, and the mesentery was sutured. The ileal graft was isolated and washed to remove...(AU)
Assuntos
Animais , Masculino , Gatos , Uretra/lesões , Uretra/cirurgia , Obstrução Uretral/cirurgia , Obstrução Uretral/veterinária , Transplante de Tecidos/veterinária , Intestinos/transplante , Transplante Autólogo/veterinária , Estomia/veterináriaRESUMO
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.
Assuntos
Enteropatias/terapia , Intestinos/transplante , Adolescente , Adulto , Criança , Humanos , América Latina , Adulto JovemRESUMO
Background: Serious urethral damage or recurrent obstructions in felines require a urethrostomy to provide a return to and maintenance of urinary flow. In some cases, urethral reconstruction with complementary tissue is required. Grafting of autogenous vascularized intestinal segments is widely used in human medicine to promote the functional restoration of the urethra, but in veterinary medicine, its use is still incipient. Thus, the aim of this report was to analyze and describe the use of thein functional urethral repair in a feline diagnosed with a severe urethral rupture. Case: A castrated male cat presented with urethral obstruction. Emergency decompression cystocentesis was performed, and fluids and analgesics were administered. Catheterization and urohydropropulsion were attempted to relieve the obstruction, without success. An emergency perineal urethrostomy was indicated. After the procedure, the diagnosis (obstructive lower tract urinary disease) and the infeasibility of restoring urinary flow by conventional urethrostomy techniques were confirmed. We opted for a laparoscopic-assisted prepubic urethrostomy; the pre-prostatic urethra was transected, and its caudais end was brought through an abdominal incision cranially. However, urethral tension was noted after this maneuver was performed. Thus, we decided to use autogenous vascularized intestinal segment grafting for urethral reconstruction. A segment of the ileum was prepared for grafting, with preservation of irrigation and mesenteric innervation. A terminoterminal anastomosis was performed on the stumps of the remaining intestine, and the mesentery was sutured. The ileal graft was isolated and washed to remove...
Assuntos
Masculino , Animais , Gatos , Intestinos/transplante , Obstrução Uretral/cirurgia , Obstrução Uretral/veterinária , Transplante de Tecidos/veterinária , Uretra/cirurgia , Uretra/lesões , Estomia/veterinária , Transplante Autólogo/veterináriaRESUMO
PURPOSE OF REVIEW: One of the most important challenges in the intestinal (ITx) and multivisceral transplant (MVTx) is to achieve a successful abdominal wall closure. RECENT FINDINGS: A tension-free primary closure should be our aim. In most of the cases, we need to perform a component separation technique, alone or combined, to the use of a synthetic mesh. If those options are not feasible, the abdominal wall composite vascularized allograft transplant (AW-CVA) utilizing direct orthotopic vascularization can be considered. The nonvascularized abdominal rectus fascia has also become an alternative method used worldwide, proving to be simple and well tolerated procedure. Furthermore, the use of the AW has been recently proposed as a new tool for a sentinel monitoring of the intestinal or pancreas allograft. SUMMARY: There are different validated options for abdominal wall closure following intestinal transplantation. The long-term benefits of transplanting the abdominal wall, full or partial thickness and vascularized or nonvascularised, were shown. New developments might help to expand their applications in different areas such as reconstructive surgery and immunology.
Assuntos
Parede Abdominal/cirurgia , Aloenxertos Compostos/transplante , Intestinos/transplante , Procedimentos de Cirurgia Plástica/métodos , HumanosRESUMO
BACKGROUND: Allospecific CD154+T-cytotoxic memory cells (CD154+TcM) predict acute cellular rejection after liver transplantation (LTx) or intestine transplantation (ITx) in small cohorts of children and can enhance immunosuppression management, but await validation and clinical implementation. METHODS: To establish safety and probable benefit, CD154+TcM were measured in cryopreserved samples from 214 children younger than 21 years (National Clinical Trial 1163578). Training set samples (n = 158) were tested with research-grade reagents and 122 independent validation set samples were tested with current good manufacturing practices-manufactured reagents after assay standardization and reproducibility testing. Recipient CD154+TcM induced by stimulation with donor cells were expressed as a fraction of those induced by HLA nonidentical cells in parallel cultures. The resulting immunoreactivity index (IR) if greater than 1 implies increased rejection-risk. RESULTS: Training and validation set subjects were demographically similar. Mean coefficient of test variation was less than 10% under several conditions. Logistic regression incorporating several confounding variables identified separate pretransplant and posttransplant IR thresholds for prediction of rejection in the respective training set samples. An IR of 1.1 or greater in posttransplant training samples and IR of 1.23 or greater in pretransplant training samples predicted LTx or ITx rejection in corresponding validation set samples in the 60-day postsampling period with sensitivity, specificity, positive, and negative predictive values of 84%, 80%, 64%, and 92%, respectively (area under the receiver operator characteristic curve, 0.792), and 57%, 89%, 78%, and 74%, respectively (area under the receiver operator characteristic curve, 0.848). No adverse events were encountered due to phlebotomy. CONCLUSIONS: Allospecific CD154+T-cytotoxic memory cells predict acute cellular rejection after LTx or ITx in children. Adjunctive use can enhance clinical outcomes.
Assuntos
Ligante de CD40/análise , Citometria de Fluxo , Rejeição de Enxerto/imunologia , Imunidade Celular , Testes Imunológicos/métodos , Intestinos/transplante , Transplante de Fígado/efeitos adversos , Linfócitos T Citotóxicos/imunologia , Doença Aguda , Adolescente , Área Sob a Curva , Biomarcadores/análise , Células Cultivadas , Criança , Pré-Escolar , Criopreservação , Feminino , Rejeição de Enxerto/prevenção & controle , Humanos , Imunidade Celular/efeitos dos fármacos , Memória Imunológica , Imunossupressores/uso terapêutico , Lactente , Intestinos/imunologia , Modelos Logísticos , Masculino , Análise Multivariada , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Linfócitos T Citotóxicos/efeitos dos fármacos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
The main cause of acute intestinal failure is short bowel syndrome, generally as a result of resection of extensive segments of small intestine. As a result, the main symptoms are watery diarrhea, malabsorption syndrome, chronic malnutrition, and death, if the patient is not properly treated. If the length of the remaining intestine is greater than 30 cm, complete adaptation is possible and the patient may not require parenteral nutrition. The currently recommended treatment includes the use of prolonged parenteral nutrition and enteral nutrition, always aimed at constant weight gain, in conjunction with surgeries aimed at elongating the dilated bowel. This set of procedures constitutes what is called an Intestinal Rehabilitation Program. This therapy was used in 16 children in periods ranging from 8 months to 7.5 years, with survival in 75% of the cases. Finally, the last resort to be used in children with complete resection of the small bowel is an intestinal transplant. However, to date there is no record of a Brazilian child that has survived this procedure, despite it being attempted in seven patients. We conclude that the results of the intestinal rehabilitation program are encouraging for the continuation of this type of treatment and stimulate the creation of the program in other pediatric care institutions.
Assuntos
Síndrome do Intestino Curto/reabilitação , Criança , Nutrição Enteral , Humanos , Intestinos/transplante , Nutrição Parenteral , Síndrome do Intestino Curto/mortalidade , Síndrome do Intestino Curto/terapiaRESUMO
Summary The main cause of acute intestinal failure is short bowel syndrome, generally as a result of resection of extensive segments of small intestine. As a result, the main symptoms are watery diarrhea, malabsorption syndrome, chronic malnutrition, and death, if the patient is not properly treated. If the length of the remaining intestine is greater than 30 cm, complete adaptation is possible and the patient may not require parenteral nutrition. The currently recommended treatment includes the use of prolonged parenteral nutrition and enteral nutrition, always aimed at constant weight gain, in conjunction with surgeries aimed at elongating the dilated bowel. This set of procedures constitutes what is called an Intestinal Rehabilitation Program. This therapy was used in 16 children in periods ranging from 8 months to 7.5 years, with survival in 75% of the cases. Finally, the last resort to be used in children with complete resection of the small bowel is an intestinal transplant. However, to date there is no record of a Brazilian child that has survived this procedure, despite it being attempted in seven patients. We conclude that the results of the intestinal rehabilitation program are encouraging for the continuation of this type of treatment and stimulate the creation of the program in other pediatric care institutions.
Resumo A principal causa da falência intestinal aguda é a síndrome do intestino encurtado, decorrente, em geral, de ressecção de extensos segmentos de intestino delgado. Em consequência, os principais sintomas são diarreia aquosa, síndrome de má absorção, desnutrição crônica e óbito, caso o paciente não seja adequadamente tratado. Se o comprimento do intestino remanescente for superior a 30 cm, poderá haver adaptação completa e o paciente poderá ficar livre da nutrição parenteral. O tratamento atualmente preconizado inclui a utilização de nutrição parenteral prolongada e de nutrição enteral, objetivando sempre o ganho ponderal constante, em paralelo a cirurgias que visem ao alongamento do intestino dilatado. Esse conjunto de procedimentos constitui o que se denomina Programa de Reabilitação Intestinal. Essa terapia foi utilizada em 16 crianças, em períodos que variaram de 8 meses a 7 anos e meio, com sobrevida em 75% dos casos. O último recurso utilizado em crianças com ressecção completa do intestino delgado é o transplante intestinal. Até o momento, não há registro de criança brasileira que tenha sobrevivido a esse procedimento, a despeito de sete pacientes terem sido submetidos a ele. Os resultados do Programa de Reabilitação Intestinal nos anima a continuar com esse tipo de tratamento e estimular a criação do programa em outras instituições de atendimento pediátrico.