Nutrition after Intestinal Transplantation

Nutritional Outcomes After Elimination Of Routine Steroid Therapy In Pediatric Intestinal Transplantation

Lori Kowalski, MS,RD1, Anita Nucci, PhD,RD1, Graciela Perez, PhD2, George Mazariegos, MD3 and Rakesh Sindhi, MD3. 1Clinical Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States; 2Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States and 3Pediatric Transplant Surgery, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, United States. 

Body: In March 2002, our immunosuppressant treatment for children post intestinal transplantation (ITx) was changed to the use of a lymphocyte depleting agent (rATG) pre-transplant with steroid-free, tacrolimus mono therapy and the elimination of routine steroids post-ITx. 

As steroids are now used for rejection episodes only, we hypothesized that this would result in improved growth and earlier initiation of enteral nutrition (EN). The aim of this investigation was to evaluate nutritional outcomes in patients managed before and after the institution of rATG. Children who received an ITx between June 1996 and March 2004 were stratified by rATG treatment status and whether steroids were ever used post-ITx. 

We evaluated achievement of nutritional autonomy, ostomy output in general and by the type of formula used, linear growth velocity and trends in z-scores up to 2 years post-ITx. 76 children received an ITx during this period (median age = 2.6 y). 34 received standard treatment while the remaining 42 were pretreated with rATG. Post-ITx EN therapy differed significantly (p<0.05) between the two groups in the time EN began after surgery (12 vs 6 d), time on PN post-ITx (41 vs 17 d) and time until full EN post-ITx (11 vs 4 m). Mean 6 month ostomy output differed between the groups (35 vs 68 ml/kg/d, p<0.05) and was lower for children who received rATG and peptide vs amino acid-based EN (50 vs 98 ml/kg/d, p<0.05). 

Children who received rATG reached 137% of their expected linear growth velocity vs 90% in those on standard therapy by 2 years post-ITx. Of those who received rATG, 48% were steroid free during the follow-up period. Mean z-scores for linear growth were less negative over time for the rATG non-steroid group (Table 1). Conclusions: Nutritional autonomy was achieved more rapidly and the potential for growth velocity was improved in ITx patients who received rATG pretreatment therapy. Peptide-based EN was used successfully post-ITx. Nutritional factors will continue to be evaluated to determine the best treatment regimen.

Table 1.

Treatment Group n z-score @ ITx z-score @ 1 y z-score @ 2 y
rATG/no steroids 16 -2.25 -1.91 -1.67
rATG/steroids 17 -2.96 -2.88 -2.02
Steroids/norATG 20 -2.28 -1.92 -2.02

Enteral Formula Use in Children Post Small Bowel Transplant

A.M.Nucci, PhD, RD; E.M. Barksdale Jr., MD; J.A. Yaworski, MSN, RN; N. Beserock, RD; and J. Reyes, MD. The Intestinal Care Center, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pa.

The ultimate goal of intestinal transplantation (ITx) is the maintenance of nutritional status enterally/orally. We retrospectively identified children who had received an ITx since the inception of our Intestinal Care Center in December 1996 (n=24, median age 2.6 years). Two patients died within two months of transplant. Enteral formulas used in the remaining 22 patients included: amino-acid, trace LCT (n=4); amino-acid, MCT/LCT fat mix (n=13); amino-acid, LCT fat (n=1) and peptide, MCT/LCT fat mix (n=3). Feedings were initiated on average 13 days after ITx. The median number of days to complete the TPN wean was 30 days and stoma output measured an average of 37 ml/kg/day at one month post-transplant. Nine patients (41%) advanced to oral intake alone within two to 30 months and five patients (23%) were diagnosed with milk allergy via RAST® test. No differences in the initiation of therapy, advancement to oral intake, stoma output or TPN weaning were observed by the type of formula used. Using z-score statistics, positive linear growth was achieved in seven of 21 children (33%) over the one-year period while linear growth velocity was maintained in an additional six patients (29%). Successful advancement to total enteral/oral intake and positive growth after ITx can be achieved with either an amino-acid or peptide based, partial MCT enteral formula initiated within two weeks of transplant. Monitoring for post-transplant allergy is recommended given the high rate of postoperative allergy symptomology.

Published in Nutrition in Clinical Practice, Vol. 17:113-117, April 2002

Interdisciplinary Management of Pediatric Intestinal Failure: A Five-Year Review of Rehabilitation and Intestinal Transplantation

A. Nucci, PhD, RD; E.M. Barksdale Jr., MD; J.A. Yaworski, MSN, RN; L. Kowalski, MS, RD, CNSD; K. Iurlano, BSN, RN, CCTC and J. Reyes, MD. The Intestinal Care Center, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pa. 

Purpose: The advantages of an interdisciplinary center to evaluate and treat children with intestinal failure include integration of expert management by subspecialists to improve the outcome of the disease process, communication of the treatment plan to the patient/family by the entire management team and continuity of care throughout all treatment options. The purpose of this report is to describe the long-term effectiveness of the interdisciplinary management approach on therapeutic outcomes in a large population of children with intestinal failure.

Method: The Intestinal Care Center (ICC) is staffed with a team of specialists, including a pediatric surgeon, transplant surgeon, gastroenterologist, clinical dietitian, nurse coordinators and research nutritionist. Patients referred to the ICC received a comprehensive medical history and physical examination as well as a review of current nutritional therapy and intestinal anatomy. Therapeutic goals, including elimination of parenteral nutrition (PN) support, linear growth and one- and five-year survival were evaluated with an established registry.

Results: Since the inception of the ICC in December 1996, a total of 252 patients have been evaluated. Of these, 34 patients subsequently received an intestinal transplant (ITx). The majority of patients (79%) were receiving PN upon initial consultation. Following intensive management of patients dependent on PN, 10% of those medically managed and 82% of those who received an ITx had been weaned to enteral and/or oral feedings. Z-score statistics for height were calculated for children >1 year post-transplant (n=23). Linear growth was maintained or accelerated in ~60%. The cumulative one-year survival rate for children who received an ITx was 87% compared to 69% at five years post-transplant.

Conclusion: The establishment of a data registry with concurrent interdisciplinary team management of children with intestinal failure provides a solid foundation for prospectively evaluating quality of care and effectiveness of treatment approaches for children who do or do not proceed to transplantation.

Presented at the 11th Annual UNOS Transplant Management Forum, New Orleans, La., May 5-7, 2003.