Organ Donation and Transplantation in Migrants: Piedmont Reality From 2004 To 2011

Background

Over the last 20 years, an increasing number of people have immigrated into Italy. On January 1, 2011, there were 4,570,317 foreign residents in Italy, including 398,910 in the Piedmont region (Italian National Statistics Institute data). The Romanian community was the largest, followed by the Moroccan and Albanian ones. The numbers are even layer if we consider illegal immigrants. As a result, the number of foreign people with brain death has increased, as well as the number of foreign people needing organ transplantations.

Methods

The Piedmont Regional Coordination Agency of Tissue and Organ Procurement has analyzed our 1781 brain death situations between January 2004 and December 2011, including 126 (7%) in people not born in Italy (migrants).

Results

Non-refusal for donation occurred in 79 cases (62.7%). The agency also analyzed each community looking at number of brain deaths and non-refusals of donation. We utilized 61 donors, for 174 transplantations. Migrants in Italy are not only potential tissue and organ donors, but also potential tissue and organ recipients. Between 2004 and 2011, 222 patients who had not been born in Italy had been transplanted with: a liver (n = 66), a kidney (n = 130), a heart (n = 21) or a lung (n = 5).     

Intestinal failure in gastrointestinal fistula patients

Intestinal failure due to gastrointestinal fistulae can be an extremely debilitating condition that significantly impairs quality of life. It can lead to serious life-threatening problems and may be fatal if left untreated. Patients may have a variety of underlying bowel diseases, or may have iatrogenic complications. Medical and psychological co-morbidities and complications present a further challenge in the successful management of these cases. In the acute stage, management of sepsis, fluid balance and acute surgical emergencies takes priority. Longer term maintenance of fluid and nutrient homeostasis, rehabilitation, psychosocial support and possible restorative intestinal surgery should all be addressed. A multidisciplinary approach is required to manage these patients appropriately. Services are usually concentrated in dedicated regional intestinal failure units comprising surgeons, gastroenterologists, radiologists, biochemists, nutritional support teams, stoma nurses as well as specialist wards equipped to manage these patients appropriately.     

Massive small bowel resection in neonates—Is weaning from parenteral nutrition the final goal?

Eight surviving cases from an original 15 pediatric patients who underwent massive small bowel resection during their neonatal period were reviewed for a period of 2–19 years to assess long-term prognosis. the primary diseases were congenital intestinal atresia in 6 cases and midgut volvulus in 2. The length of the residual small intestine ranged from 27–75 cm and the ileocaecal valve had been resected in 3 cases. All cases were able to be weaned from parenteral nutrition and at present, 6 of the children can tolerate normal meals but 2 are still receiving enteral nutrition, in the form of a low residue diet at home. Near normal somatic growth was achieved in the most recent 5 cases who received intensive nutritional treatment in the immediate postoperative period, whereas 3 who did not receive nutritional management exhibited growth retardation. The D-Xylose absorption test revealed gradual improvement and finally normal absorption in all except one case with the shortest remaining intestine (27 cm). However, the fat absorption test revealed abnormal absorption in cases with a residual intestine of less than 45 cm. Late metabolic complications such as renal calculi, cholelithiasis and pathologic fractures were encoutered in 3 cases.     

Diagnostic dilemma: Rare case of recurrent d-lactic acidosis leading to recurrent acute cardiac failure

d-Lactic acidosis is a rare form of anion gap acidosis and requires a high index of suspicion for appropriate diagnosis and treatment. We report a rare case of short bowel syndrome with recurrent episodes of antibiotic-induced d-lactic acidosis with the presentation of transient severe left ventricular failure. The patient's cardiac function returned to normal with the resolution of acidosis under conservative management and a low carbohydrate diet. d-Lactic acidosis has been known to be associated with only neurological symptoms, and cardiac failure has not been previously reported.     

谷氨酰胺对短肠综合征大鼠模型结肠黏膜作用的初步研究

目的 探讨谷氨酰胺联合肠内营养对动物模型结肠黏膜的影响。方法 将大鼠随机分为5组，即模型肠内营养组、谷氨酰胺大剂量＋肠内营养组，谷氨酰胺中剂量＋肠内营养组，谷氨酰胺小剂量＋肠内营养组。分为7天，14天2个时间点进行观察。结果 Gln各组肠壁肌层增厚明显，皱襞明显增高，肠腺数量增多，其中大、中剂量组的皱襞不仅高且密集，皱襞高度、肠腺密度均明显大于模型组（P〈0．01）。结论 谷氨酰胺＋肠内营养比单用营养的模型组更可以促进大鼠结肠的代偿，大、中剂量组优于小剂量组。     

Morbidity and mortality of short-bowel syndrome acquired in infancy: an update

The advent of total parenteral nutrition (TPN) has made survival beyond infancy possible for large numbers of patients who have sustained massive small intestinal loss due to a variety of intraabdominal catastrophes. However, the quantity and quality of life have been limited by the development of late sequelae due both to the protracted use of TPN and the long-term complications of foreshortening of the gut. To determine to what extent the morbidity and mortality of short-bowel syndrome (SBS) may have improved over the last 10 years, we reviewed our experience since 1973 with patients losing more than 50% of total small intestinal mass in infancy. The etiologies of SBS in the 16 study patients were necrotizing enterocolitis (6), midgut volvulus (5), multiple atresias (3), gastroschisis (1), and congenital SBS (1). Overall survival was 81%; total small intestinal length (SIL) at the time of diagnosis was 44.2 +/- 7.9 cm in survivors and 30.3 +/- 7.8 cm in nonsurvivors, probability values not significant. Although no patient survived without an ileocecal valve whose total SIL was greater than 20 cm, the three deaths in this series were not related directly to the SIL, but to end-stage liver disease resulting from TPN-associated cholestasis. Among the survivors, adaptation to enteral feedings required 13.8 +/- 2.5 mo, during which time weaning from TPN occurred; weight at adaptation was 6.87 +/- 1.32 kg.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Future of Replacement and Restorative Therapies: From Organ Transplantation to Regenerative Medicine

As we continue to have severe shortages of organs for transplantation, we need to consider alternatives for the future. The most likely to make a real difference in the long term is regenerative medicine (RM), a field that has emerged from the conjunction of stem cell biology and cell therapies; gene therapy; biomaterials and tissue engineering; and organ transplantation. Transplantation and RM share the same essential goal: to replace or restore organ function. Herein I briefly review some major breakthroughs of RM that are relevant to the future of organ transplantation, with a focus on the needs of people in the developing world. A definition of RM is provided and the ethical, legal, and social issues are briefly highlighted. In conclusion, I provide a projection of what the future may be for RM.     

Donor Choriocarcinoma Transmission From Solid Organ Transplantation: A Case Report

Transplantation of any organ has some inherent risk of disease transmission, such as infection and malignancy. The present study aims to describe 2 cases of choriocarcinoma transmission after kidney and liver transplantation originating from the same patient. The donor was a 17-year-old woman who died of cerebral hemorrhage. Both organ recipients died of metastatic choriocarcinoma few months after the transplantation, within days after starting chemotherapy. Retrospective hCG (human chorionic gonadotropin hormone) analysis in donor's blood stored at the time of donation had a result of 9324 mIU/mL. Despite its rarity, clinicians should be aware of the risk of transplant-related choriocarcinoma from female donors in childbearing age. In some cases, hCG dosage should be performed before donation.     

Intestinal lengthening via multiple in-continuity springs

Background

Short bowel syndrome is a debilitating condition with few effective treatments. Spring-mediated distraction enterogenesis can be used to lengthen intestine. The purpose of this study is to determine whether multiple springs in series can safely increase the total amount of lengthening.

Interdisciplinary Management of Pediatric Intestinal Failure: A 10-Year Review of Rehabilitation and Transplantation

Management of children with intestinal failure is optimized by interdisciplinary coordination of parenteral and enteral nutrition support, medical management of associated complications, surgical lengthening procedures, and intestinal transplantation. Three hundred eighty-nine pediatric patients have been referred to our center for interdisciplinary assessment of intestinal failure since 1996 (median age = 1 year; range 1 day–28.8 years). Factors predictive of weaning from parenteral nutrition without transplantation included increased mean bowel length for patients with gastroschisis (44 vs. 23 cm, p < 0.05) and atresia (35 vs. 20 cm, p < 0.01) and lower mean total bilirubin for patients with NEC (6.1 vs. 12.7 mg/dL, p < 0.05). Others were also more likely to survive if referred with a lower mean total bilirubin (NEC, 7.9 vs. 12.7 mg/dL, p < 0.05; pseudo-obstruction, 2.3 vs. 16.3 mg/dL, p < 0.01). Patients weaned from parenteral nutrition by 2.5 years after referral achieved 95% survival at 5 years vs. 52% for those not weaned. Bowel lengthening procedures were performed on 25 patients. Eight subsequently weaned from parenteral nutrition without transplantation. Aggressive medical and nutritional intervention along with early referral, intestinal lengthening procedures, and intestinal transplantation in children with intestinal failure dependent on parenteral nutrition can result in the achievement of enteral autonomy and improved survival. Presented at Digestive Disease Week on Tuesday, May 22, 2007 in Washington, DC.     

短肠综合征并肠外瘘的诊治(附32例分析)

目的研究短肠综合征合并肠外瘘的诊断与治疗方法的特点与规律。方法1995~2005年共收治剩余小肠<100 cm的肠外瘘病人32例,就肠外瘘发生原因、部位、治疗方法和肠康复方法进行分析。结果治愈20例,死亡6例,6例好转后中断治疗出院。病人残存的肠管平均(58.03±28.30)cm。28例接受了肠内营养,其中9例未进行肠康复治疗,肠管平均长度为(52.8±31.5)cm,肠内营养平均恢复时间为(129.6±89.8)d;19例接受了肠康复治疗,肠管平均长度(64.1±19.2)cm,肠内营养平均恢复时间为(61.8±54.0)d。结论短肠综合征合并肠外瘘的主要疾病为肠扭转,部位多在吻合口,原因是坏死范围较大,切除界限不易判断。早期使用生长抑素有减少肠液分泌的作用,还可减少短肠综合征急性期的腹泻症状。后期使用生长激素有促进肠外瘘自愈和肠康复的双重作用。     

短肠综合征病人的营养支持及肠道代偿治疗

目的探讨短肠综合征病人的营养支持以及肠道代偿、康复治疗体会。方法回顾性分析1986~2005年复旦大学附属中山医院64例短肠综合征病人治疗过程及随访情况,其中26例联合应用生长激素[GH,每天(0.10±0.06)mg/kg]和谷氨酰胺[GLN,每天(0.30±0.17)g/kg]进行肠道促代偿治疗。结果64例病人中死亡6例,存活58例,存活时间3个月至19年,平均(6.6±9.4)年。9例长期接受家庭肠外营养(HPN),13例接受部分PN或肠内营养(EN)支持,完全摆脱PN者36例,平均摆脱PN的时间为(8.6±14.2)个月。26例接受GH GLN治疗的SBS病人,其中9例(34.6%)治疗后近期内完全摆脱PN;8例(30.8%)经治疗后明显减少了PN用量[从每周需要PN支持(6.5±1.0)d下降至(4.2±1.0)d,每周PN需要量从(13.6±5.2)L降至(8.2±3.3)L];9例(34.6%)在治疗后仍依赖PN支持。64例共发生286次各种并发症。结论经过适宜的营养支持和肠道促代偿治疗,大多数短肠综合征病人的残留肠道可充分代偿,完全摆脱PN或减少PN用量,长期健康存活。     

An experimental model of a submucosally tunnelled valve for the replacement of the ileo-cecal valve

An enteric valve to prevent colonic content reflux and to prolong small bowel transit time was created by passing small bowel through a submucosal tunnel in the colon. Barium enema, Gl tract series, and iso- and antiperistaltic pressure measurements showed the valve to be of competence equal to the ileo-cecal valve. Late pathological examination revealed a patent valve with minimal scar formation. The optimal submucosal tunnel length was between 4 and 6 cm. This valve can, theoretically, increase the absorptive capacity in short bowel syndrome and may serve as a substitute for the critically important ileo-cecal valve.