SOLID ORGAN TRANSPLANTATION

VII.  Intestinal Transplantation

Introduction
Causes of Intestine Failure
Indications for Transplantation
Discharge Planning

Introduction

Laurel Williams, RN, MSN, CCTC; Manger, Liver and Intestinal Coordinators, Organ Transplantation Program at the University of Nebraska Medical Center, Omaha, Nebraska; presented the following information at the United Resource Network’s, A Course In Transplantation For Case Managers, Newport, RI, October 2003.

Intestinal transplantation is a solution for intestinal failure.  There are 40,000 people on TPN due to small bowel disease.  Success of transplantation has increased due to advances in immunosuppression.  Intestines are lined with lymph nodes, which are prone to rejections.  Intestines have bacteria leading to frequent infection (Williams, L., RN 2003).

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Causes of Intestine Failure:

Structural Disease – gastroschisis, midgut volvulus, atresia, IBD and vascular events.

  • Necrotizing Enterocolitis – Short bowel syndrome (noted in infants when they begin to feed.)
  • Midgut volvulus – twisting.
  • Gastroschisis – Herniation, evisceration, extrusion of other organs.
  • Atresia / Stenosis – Congenital incomplete formation of bowel lumen.
  • Crohn’s Disease – Chronic transmural inflammation.
  • Ischemic Lesions – Decrease in blood flow to small intestine, trauma, abdominal surgery, hematologic disorders.
  • Familial adenomatous Polyposis / Gardner’s syndrome (Williams, L., RN 2003).

Functional Disease – pseudo obstruction, entercyte abnormalities.

  • Chronic intestinal pseudo-obstruction syndrome.
  • Microvillus Inclusion Disease – autosomal recessive disease (seen in first days or weeks of life.)
  • Megacolon / Hirschsprung disease – Congenital absence of intramural neural plexuses or aganglionosis.  Prevalence in male children.
  • Radiation enteritis – 2.4% to 25% of adults treated for pelvic or abdominal malignancy (Williams, L., RN 2003).

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Indications for Intestinal Transplant

  • Total dependence of TPN.  The annual average cost of TPN - $150,000 (excluding the cost of equipment and nursing care). (Williams, L., RN 2003).
  • Evidence of liver dysfunction.
  • Recurrent life threatening line sepsis.
  • Inability to place or difficulty finding central venous access (Williams, L., RN 2003).

Indications for Liver and Intestinal Transplant

  • Intestinal failure.
  • Biopsy proven liver cirrhosis or extensive bridging fibrosis.
  • Remnant bowel functional (Williams, L., RN 2003).

Rejection:

  • Surveillance biopsies (apoptosis).
  • Radiologic monitoring (gastric emptying / transit time.)  (Williams, L., RN 2003).

Prophylaxes Medications:

  • Alprostadil 5-6 days.
  • Pneumocystis (Bactrim, atovaquone, pentamidine) 1 year.
  • Antiviral (Acyclovir, IVIG, ganciclovir) 1 year.
  • Antifungal (Diflucan) 3 months.
  • Vaccinations pre-transplant (Williams, L., RN 2003).

Morbidity:  Related to Short Bowel Syndrome (SBS) – diarrhea, dehydration, hypocalcemia, hypomagnesemia, vitamin deficits, D-lactic acidosis, calcium oxalate stones, metabolic bone disease, gastric acid hypersecretion.  Related to TPN – Hyperglycemia, line sepsis, thrombosis, air embolus, catheter breakage, loss of venous access, hepatobiliary dysfunction (Williams, L., RN 2003).

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Discharge Planning / Home health Care:
Parenteral nutrition, enteral feedings, IV fluids (electrolytes, antibiotics); Cytomegaly hyperimmune globulin, ostomy care, central line care; lab draws, feeding tube care, accurate intake and output, oral medication administration, physical therapy, education development, occupational therapy, scheduled intestinal biopsies, clinic visits (Williams, L., RN 2003).

Long Term Care:
Lab work, nutritional management (low fat, convert to age appropriate diet at 2-3 months, manage oral aversions, ostomy takedown 3-12 months).
Physician visits (Williams, L., RN 2003).

Children make slow progress to catch-up in growth.

  • 65% take full oral diets.
  • 63% required developmental input.
  • 84% return to normal schooling.
  • 6% require supplemental parenteral nutrition.
  • 10% required IV fluid supplements (Williams, L., RN 2003).

The 2005 OPTN/SRTR Annual Report indicated that the number of intestine transplants performed in the United States continues to increase but is still relatively small compared with other organs.  In 1995, only 43 cases with data on immunosuppression were registered with the SRTR; this number increased to 148 in 2004. (2005 OPTN/SRTR Annual Report).

Post-transplant immunosuppression was noted in the 2005 OPTN/SRTR report for almost all intestine recipients to consist of tacrolimus.  The use of cyclosporine has diminished, reaching 1% in 2002 and 0% since.  Antimetabolites were used for 9% of patients; with mycophenolate mofetil the only prescribed antimetabolite in 2003 (9%).  Sirolimus was the only mTOR inhibitor used (16% in 2003).  Tacrolimus alone or with steroids has been the most commonly used regimen one year and two years following intestine transplantation.  (2005 OPTN/SRTR Annual Report).

The 2005 Milliman USA report noted that there was a 50% of a patient receiving a transplant within 227 days in 2002.  The cost for intestinal transplantation through the first year of follow-up, as outlined by Milliman, is as follows:  Evaluation - $34,300; Procurement - $74,600; Hospital $549,400; Physician - $70,700; Follow-up - $64,600; Immunosuppressants - $20,000.  (Milliman 2005).

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