Irreversible intestinal failure, nutrition support, and small bowel transplantation

OBJECTIVES: Prolonged total parenteral nutrition (TPN) is a palliative but life-saving treatment for patients with irreversible intestinal failure (IIF). During the past few years, intestinal transplantation (ITx) has become the most realistic alternative to TPN. METHODS: We identified potential candidates for ITx, reported clinical data of the international Intestinal Transplant Registry, and analyzed the intestinal function after transplantation and the common nutrition strategies usually adopted in the recipients. RESULTS: At present, candidates for ITx are patients with IIF who develop a life-threatening complication during TPN treatment. During the past few years, clinical results have improved mainly in relation to the progress in immunosuppression, but prevention of the acute cellular rejection (ACR) is still the key point. ACR, high doses of immunosuppressant drugs, and intestinal bacterial translocation can exacerbate intestinal malabsorption and sustain systemic complications such as sepsis and multiorgan failure. Early enteral alimentation is started after ITx and gradually increased. To prevent dehydration and malnutrition caused by persistent diarrhea, parenteral nutrition is frequently maintained for 1 to 2 mo. More than 66% of long-term recipients become nutritionally independent of TPN. CONCLUSIONS: ITx is now a life-saving option for patients with IIF and severe complications from TPN. Clinical and nutritional management of the recipients is a complex procedure and requires a great deal of expertise. After transplantation most adults maintain adequate nutrition status and children have normal growth. Multiple episodes of ACR, early and persistent dehydration, and malabsorption are still common problems that influence the recipient’s quality of life.