Long-term follow-up of patients on home parenteral nutrition in Europe: implications for intestinal transplantation.
BACKGROUND
The indications for intestinal transplantation (ITx) are still debated. Knowing survival rates and causes of death on home parenteral nutrition (HPN) will improve decisions.


METHODS
A 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.


RESULTS
The 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).


CONCLUSIONS
HPN 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.
Center for Chronic Intestinal Failure, Department of Gastroenterology and Internal Medicine, University of Bologna, Italy. loris.pironi@unibo.it
Loris
L
Pironi
Francisca
F
Joly
Alastair
A
Forbes
Virginie
V
Colomb
Malgorzata
M
Lyszkowska
Janet
J
Baxter
Simon
S
Gabe
Xavier
X
Hébuterne
Manuela
M
Gambarara
Frederic
F
Gottrand
Cristina
C
Cuerda
Paul
P
Thul
Bernard
B
Messing
Olivier
O
Goulet
Michael
M
Staun
André
A
Van Gossum
D000293:Adolescent; D000328:Adult; D002648:Child; D003657:Decision Making; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D007421:Intestine, Small / Q000637:transplantation*; D008286:Malabsorption Syndromes / Q000209:etiology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D008297:Male; D016331:Parenteral Nutrition, Home / Q000009:adverse effects; D018579:Patient Selection; D011379:Prognosis; D016896:Treatment Outcome; D055815:Young Adult