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Mira Dreesen,
Veerle Foulon,
Martin Hiele,
Kris Vanhaecht,
Lutgart De Pourcq, Loris Pironi,
André Van Gossum,
Jann Arends,
Cristina Cuerda,
Paul Thul,
Frederico Bozzetti,
Ludo Willems
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ABSTRACT: PURPOSE: Clear recommendations on how to guide patients with cancer on home parenteral nutrition (HPN) are lacking as the use of HPN in this population remains a controversial issue. Therefore, the aims of this study were to rank treatment recommendations and main outcome indicators to ensure high-quality care and to indicate differences in care concerning benign versus malignant patients. METHODS: Treatment recommendations, identified from published guidelines, were used as a starting point for a two-round Delphi approach. Comments and additional interventions proposed in the first round were reevaluated in the second round. Ordinal logistic regression with SPSS 2.0 was used to identify differences in care concerning benign versus malignant patients. RESULTS: Twenty-seven experts from five European countries completed two Delphi rounds. After the second Delphi round, the top three most important outcome indicators were (1) quality of life (QoL), (2) incidence of hospital readmission and (3) incidence of catheter-related infections. Forty-two interventions were considered as important for quality of care (28/42 based on published guidelines; 14/42 newly suggested by Delphi panel). The topics 'Liver disease' and 'Metabolic bone disease' were considered less important for cancer patients, together with use of infusion pumps (p = 0.004) and monitoring of vitamins and trace elements (p = 0.000). Monitoring of QoL is considered more important for cancer patients (p = 0.03). CONCLUSION: Using a two-round Delphi approach, we developed a minimal set of 42 interventions that may be used to determine quality of care in HPN patients with malignancies. This set of interventions differs from a similar set developed for benign patients.
Supportive Care in Cancer 12/2012; · 2.09 Impact Factor
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Loris Pironi,
Olivier Goulet,
Alan Buchman,
Bernard Messing,
Simon Gabe,
Manila Candusso,
Geoffrey Bond,
Girish Gupte,
Marek Pertkiewicz,
Ezra Steiger,
Alastair Forbes,
Andrè Van Gossum,
Antonio Daniele Pinna
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ABSTRACT: BACKGROUND & AIMS: Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx. METHODS: Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center. RESULTS: HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.
Clinical nutrition (Edinburgh, Scotland) 06/2012; · 3.27 Impact Factor
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Mira Dreesen,
Veerle Foulon,
Kris Vanhaecht,
Martin Hiele,
Lutgart De Pourcq, Loris Pironi,
Andre Van Gossum,
Geert Wanten,
Janet P Baxter,
Francisca Joly,
Cristina Cuerda,
Ludo Willems
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ABSTRACT: BACKGROUND & AIMS: HPN patients with benign diseases deserve professional care as they have to deal with complex techniques and risk potentially dangerous complications. The aim was to highlight main outcome quality indicators and to develop a set of key interventions to direct multidisciplinary teams in providing qualitative care. METHODS: A two-round Delphi approach was used to build consensus on the most important outcome indicators and on 59 interventions identified in existing guidelines on HPN. Comments and interventions newly identified in the first round were co-evaluated in the second round. RESULTS: 29 experts from 9 countries completed the two-round Delphi approach. The outcome indicators rated as the most important are 1) incidence of catheter-related infections, 2) incidence of readmission and quality of life (shared second place) and 3) incidence of dehydration. Sixty eight of a total of 89 interventions were considered as important for the quality of care, of which 46 are based on published guidelines and 22 were newly suggested by the Delphi panel. CONCLUSIONS: Using a two-round Delphi approach, consensus was reached for the majority of interventions concerning HPN patients with benign diseases. This set of 68 interventions could be of use as a starting point for quality-improvement programs.
Clinical nutrition (Edinburgh, Scotland) 05/2012; · 3.27 Impact Factor
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Gut 03/2011; · 10.11 Impact Factor
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Loris Pironi,
Francisca Joly,
Alastair Forbes,
Virginie Colomb,
Malgorzata Lyszkowska,
Janet Baxter,
Simon Gabe,
Xavier Hébuterne,
Manuela Gambarara,
Frederic Gottrand,
Cristina Cuerda,
Paul Thul,
Bernard Messing,
Olivier Goulet,
Michael Staun,
André Van Gossum
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ABSTRACT: The indications for intestinal transplantation (ITx) are still debated. Knowing survival rates and causes of death on home parenteral nutrition (HPN) will improve decisions.
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.
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).
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.
Gut 11/2010; 60(1):17-25. · 10.11 Impact Factor
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New England Journal of Medicine 12/2009; 361(24):2388-9; author reply 2389. · 53.30 Impact Factor
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Michael Staun, Loris Pironi,
Federico Bozzetti,
Janet Baxter,
Alastair Forbes,
Francesca Joly,
Palle Jeppesen,
Jose Moreno,
Xavier Hébuterne,
Marek Pertkiewicz,
Stefan Mühlebach,
Alan Shenkin,
André Van Gossum
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ABSTRACT: Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.
Clinical nutrition (Edinburgh, Scotland) 06/2009; 28(4):467-79. · 3.27 Impact Factor
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ABSTRACT: Infection by human parvovirus B19 is widespread and can be associated with a wide range of different pathologies and clinical manifestations. We provide the first evidence of localization of an active parvovirus B19 infection in the intestinal mucosa and its association with a severe inflammatory bowel disease, characterized by duodenal villous atrophy with increased intraepithelial lymphocytes and inflammatory infiltrates in the colonic mucosa. Virus in the intestinal mucosa was detected in cells of the inflammatory infiltrate, identified as T lymphocytes and selectively localized in sites of active tissue degeneration.
Journal of clinical microbiology 04/2009; 47(5):1591-5. · 4.16 Impact Factor
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ABSTRACT: In this study we compared the content of muscle free [Mg2+] assessed by 31P MRS to that of serum total Mg assessed by routine colorimetric assays in 15 patients affected by Chronic Intestinal Failure (CIF) on long-term Home Parenteral Nutrition (HPN) or who had undergone isolated intestinal transplantation. We also investigated in the same cohort of patients the relationship of muscle free [Mg2+] and serum total Mg with parathyroid hormone (PTH) serum content. All patients showed a normal cytosolic free [Mg2+] in the calf muscle despite about half of them having a content of total serum [Mg] below or at the lower edge of the boundary limits. Muscle free Mg2+ and serum total Mg displayed an opposite correlation versus serum PTH, showing that the intracellular free form possesses a different functional metabolic meaning in the regulation of PTH secretion.
Magnesium research: official organ of the International Society for the Development of Research on Magnesium 04/2009; 22(1):37-43. · 1.52 Impact Factor
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ABSTRACT: Home parenteral nutrition is the primary treatment for intestinal failure. Intestinal transplantation is indicated when home parenteral nutrition fails or when there is a risk of death because of underlying disease. Survival after transplantation is related to the appropriateness of the indication and the timing of listing for transplantation.
Recenti progressi in medicina 03/2009; 100(2):87-90.
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Takuya Kimura,
Augusto Lauro,
Matteo Cescon,
Chiara Zanfi,
Alessandro Dazzi,
Giorgio Ercolani,
Gian Luca Grazi,
Marco Vivarelli,
Matteo Ravaioli,
Massimo Del Gaudio,
Alessandro Cucchetti,
Matteo Zanello,
Giuliano LaBarba, Loris Pironi,
Tiziana Lazzarotto,
Antonio Daniele Pinna
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ABSTRACT: Induction therapy with daclizumab or alemtuzumab has been recently introduced for intestinal transplantation; however, the impact of such induction therapy on bacterial infections remains to be clarified. The purpose of this study was to evaluate the impact of induction therapy on the incidence of bacterial infections and long-term patient survival.
Over the past seven yr, we performed 39 intestinal (ITx) and multivisceral (MTVx) transplants in 38 adult patients. In the early period, daclizumab was used for induction, and tacrolimus and steroids were administered for maintenance [daclizumab and tacrolimus (DT) group; n = 11]. From 2002, we used alemtuzumab for induction, with low-dose tacrolimus maintenance [alemtuzumab and tacrolimus (AT) group; n = 23]. The incidence of bacterial infections and patient outcome were compared between the two groups.
There were no significant differences in recipient and donor demographics, procedure (ITx vs. MTVx), and cold and warm ischemic time between the two groups. Within 30 d after ITx, bacterial infections were observed in seven patients (64%) in the DT and in 14 patients (64%) in the AT group. Between 30 and 180 d after ITx, a total of 17 episodes of bacterial infections were observed in the DT and 26 episodes in the AT group. Three patients in the DT and eight in the AT group died, and all of the deaths were related to infectious complications except one each in DT and AT.
There was no difference in incidence of bacterial infections and long-term patient survival between the two groups.
Clinical Transplantation 12/2008; 23(3):420-5. · 1.67 Impact Factor
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Loris Pironi,
Alastair Forbes,
Francisca Joly,
Virginie Colomb,
Malgorzata Lyszkowska,
André Van Gossum,
Janet Baxter,
Paul Thul,
Xavier Hébuterne,
Manuela Gambarara,
Frederic Gottrand,
José M Moreno Villares,
Bernard Messing,
Olivier Goulet,
Michael Staun
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ABSTRACT: The US Medicare indications for intestinal transplantation are based on failure of home parenteral nutrition. The American Society of Transplantation also includes patients at high risk of death from their primary disease or with high morbidity intestinal failure. A 3-year prospective study evaluated the appropriateness of these indications.
Survival on home parenteral nutrition or after transplantation was analyzed in 153 (97 adult, 56 pediatric) candidates for transplantation and 320 (262 adult, 58 pediatric) noncandidates, enrolled through a European multicenter cross-sectional survey performed in 2004. Kaplan-Meier and chi-square test statistics were used.
The 3-year survival was 94% (95% CI, 92%-97%) in noncandidates and 87% (95% CI, 81%-93%) in candidates not receiving transplants (P = .007). Survival was 80% (95% CI, 70%-89%), 93% (95% CI, 86%-100%), and 100% in parenteral nutrition failure, high-risk primary disease, and high-morbidity intestinal failure, respectively (P = .034). Fifteen candidates underwent transplantation. Six died, including all 3 of those who were in hospital, and 25% of those who were at home at time of transplantation (P = .086). Survival in the 10 patients receiving a first isolated small bowel transplant was 89% (95% CI, 70%-100%), compared with 85% (95% CI, 74%-96%) in the candidates with parenteral nutrition failure not receiving transplants because of central venous catheter complications, or 70% (95% CI, 53%-88%) in those with parenteral nutrition-related liver failure (P = .364).
The results confirm home parenteral nutrition as the primary therapeutic option for intestinal failure and support the appropriateness and potential life-saving role of timely intestinal transplantation for patients with parenteral nutrition failure.
Gastroenterology 08/2008; 135(1):61-71. · 11.68 Impact Factor
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ABSTRACT: Intestinal transplant wait-list mortality is higher than for other organ transplants. The objective of this workshop was to identify the main problems contributing to high mortality in adults and children candidates for intestinal transplantation and provide recommendations on how to correct them.
To facilitate this, 63 relevant articles identified from the medical literature from 1987 to 2007 were reviewed. Consensus was achieved on several important definitions relevant to this review. For children and adults on parenteral nutrition (PN) the main mortality risk factors were identified as were the main risks of mortality for those on the waiting list for intestinal transplants.
(1) Primary care givers managing intestinal failure patients should establish a link with an intestinal failure programs early and collaboration with intestinal failure programs should be initiated for patients whose PN requirements are anticipated to be more than 50% 3 months after initiating PN; (2) intestinal failure programs should include both intestinal rehabilitation and intestinal transplantation or have active collaborative relationships with centers performing intestinal transplantation; (3) National registries for intestinal failure patients should be established and organizations that provide home PN solutions should be expected to participate.
There are many unresolved issues in adults and children with PN dependent intestinal failure. To address these, a key recommendation of this group is to establish national intestinal failure databases that can support multicenter studies and lead to the adoption of universally accepted standards of patient care with the goal of improving outcomes in all long-term intestinal failure patients including those requiring intestinal transplantation.
Transplantation 06/2008; 85(10):1378-84. · 4.00 Impact Factor
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ABSTRACT: Intestinal failure is the outcome of a number of gastrointestinal diseases and characterized by significant reduction in functional gut mass. If not resolved patients often face long-term nutritional support. This study gathered information about how patients referred with intestinal failure are managed in specialised European centres.
A questionnaire was circulated in 7 European countries via representatives of the ESPEN-HAN working group to seek information about experience in treating patients with intestinal failure. We asked about clinical outcome, information about structure and organisation of the department, referral criteria, treatment procedures and guidelines.
17 centres in 6 European countries completed the questionnaire: UK, n = 6, France, n = 4, Spain, n = 3, Denmark, n = 2, Italy, n = 1, Poland, n = 1. The experience of the centres in treating patients was in the range 12-30 years. The total number of patients on HPN in all centres was 590. The number of patients referred to centres with intestinal failure during the period January to December 2000 was n = 882: UK, n = 375 (range 2-175), France, n = 308 (range 24-182), Italy and Spain, n = 43 (range 9-52), Denmark n = 51 (range 14-37), the centre in Poland included 53 patients. Comparing all centres the following distribution among patients (median % (range%)) with regard to the endpoints were reported: Oral nutrition 32% (23-50%), enteral/tube feeding 11% (4-23%), HPN 36% (15-57%), lost to follow up 10% (0-35%), dead 9% (5-18%). No patients had an intestinal transplant.
The study provides information about how patients with intestinal failure are managed across Europe and the data indicates that treatment practice varies between countries.
Dynamic Medicine 02/2007; 6:7.
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ABSTRACT: To gather information about how adult patients on home parenteral nutrition (HPN) are monitored after discharge from the hospital.
A questionnaire about HPN monitoring practice was circulated to HPN centres in eight European countries through the representative of the ESPEN HAN-working group. Centres were asked about guidelines, home visits and how monitoring and handling of complications were managed.
Fourty-two centres in eight European countries completed the questionnaire: UK n=14, France n=9, Belgium n=4, Italy n=4, Poland n=4, Denmark n=4, Spain n=2, Germany n=1. The HPN experience of the centres was in the range 2-30 years. Centres ranged in size from 0 to 125 HPN patients representing a total number of 934 of whom 54% had received HPN for more than 2 years. The primary disease was non-malignant in 90% whilst 10% had been diagnosed with active cancer. Of the centres 92% had a HPN team and 66% had written guidelines for monitoring HPN. Home visits after discharge for monitoring purposes were carried out by 31 of the centres involving the HPN team, general practitioner, community nurse or home care agency. Stable patients on HPN for more than 12 months were monitored at the discharging hospital (73%), at a local hospital (12%), by the General Practitioner (11%) or by a home care agency (4%). Of the centres, 90% reported that the main responsibility for monitoring was assigned to a specific person. The intervals between monitoring visits for the stable HPN patient was in the range 1-6 months, 52% of the centres reported intervals of 2-3 months. In case of complications 76% of centres reported that patients got in touch with the HPN team, 2% the local hospital, 5% the home care agency, and 17% other. Re-admission to hospital was usually to the HPN centre and only occasionally to a local hospital.
In Europe a specialised team at the discharging hospital monitors HPN patients and 66% of the centres had some kind of written guidelines.
Clinical Nutrition 09/2006; 25(4):693-700. · 3.73 Impact Factor
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Gastrointestinal Endoscopy 08/2006; 64(1):130-1; discussion 131. · 4.88 Impact Factor
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Loris Pironi,
Xavier Hébuterne,
Andre Van Gossum,
Bernard Messing,
Malgorzata Lyszkowska,
Virginie Colomb,
Alastair Forbes,
Ann Micklewright,
Jose Manuel Moreno Villares,
Paul Thul,
Federico Bozzetti,
Olivier Goulet,
Michael Staun
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ABSTRACT: Epidemiology of candidacy for intestinal transplantation (ITx) and timing for referral for ITx are unknown. Patient candidacy and physician attitudes toward ITx were investigated among centers that participated in previous European surveys on home parenteral nutrition (HPN).
Patients on HPN for benign intestinal failure (IF) were evaluated by a structured questionnaire. Candidacy was assessed by USA Medicare and American Transplantation Society criteria, categorized as: (1) life-threatening HPN complications; (2) high risk of death because of the gastrointestinal disease; (3) IF with high morbidity or patient HPN refusal. Physicians judged candidacy as immediate or potential.
Forty-one centers from nine countries enrolled 688 adults (> 18 yr) and 166 pediatric patients; 70% of patients were from five countries which collected 60-100% of their HPN patients. Candidacy was 15.7% in adults and 34.3% in pediatrics (HPN failure, 62.1% and 28.1%; gastrointestinal disease, 25.9% and 59.6%; high morbidity IF or HPN refusal, 12.0% and 12.3%, respectively). Immediate candidacy was required for 14.8% of adult and 15.8% of pediatric candidates (< 50% of candidates because of HPN-related liver failure). Among centers, the candidacy rate ranged 0-100% and was negatively associated with the number of patients enrolled in the survey (R = -0.463, p = 0.002). Among the major contributing countries, candidacy ranged 0.3-0.8/million inhabitants for adults and 0.9-2/million inhabitants < or = 18 yr for pediatric candidates.
The rate of candidacy and the indications for ITx candidacy differed greatly among age groups and HPN centers; within countries candidacy was more homogeneous; physicians had a generally reserved attitude toward ITx.
The American Journal of Gastroenterology 08/2006; 101(7):1633-43; quiz 1679. · 7.28 Impact Factor
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ABSTRACT: The case of the gastrointestinal production of ethanol from Candida albicans and Saccharomyces cerevisiae in a Caucasian man with chronic intestinal pseudo-obstruction is reported. The patient, who declared to have always abstained from alcohol, was hospitalized for abdominal pain, belching and mental confusion. The laboratory findings showed the presence of ethanol in the blood. Gastric juice and faecal microbiological cultures were positive for C. albicans and S. cerevisiae. At home, he was on oral antibiotic therapy with amoxicillin plus clavulanic acid for a small bowel bacterial overgrowth, associated with a simple sugar-rich diet. Twenty-four hours after stopping both the antibiotic therapy and the simple sugar-rich diet, the blood ethanol disappeared. A provocative test, performed by giving amoxicillin plus clavulanic acid associated with the simple sugar-rich diet was followed by the reappearance of ethanol in the blood. A review of the literature is reported.
European Journal of Gastroenterology & Hepatology 08/2006; 18(7):799-802. · 1.76 Impact Factor
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ABSTRACT: Purpose of review: Citrulline metabolism is primarily regulated by the small intestinal mucosa (synthesis) and kidney (catabolism). This review first analyzes knowledge on plasma citrulline as a marker of status of the small bowel mucosa and kidneys. It then considers data on citrulline as a marker of graft mucosal status in intestinal transplantation recipients, who may develop both intestinal and renal damage.
Recent findings: Citrulline correlated well with small bowel remnant length in patients with a short bowel; it also correlated well with the degree of mucosal damage in patients with small bowel mucosal injury. In patients with renal failure citrulline appears to be a more reliable marker of uraemia than are the usual, classic markers. Intestinal transplantation recipients exhibited low citrulline levels during the earliest postoperative days, due to ischaemia/reperfusion mucosal damage, and in the presence of graft acute cellular rejection or viral enteropathy. A negative correlation with creatinine clearance was observed in recipients with renal failure.
Summary: Current data indicate that plasma citrulline could be a reliable marker of post-transplant graft mucosal damage in intestinal transplant recipients. Further studies are required to improve interpretation of plasma citrulline in recipients with renal failure.
Current Opinion in Organ Transplantation 05/2006; 11(3):256-262. · 2.97 Impact Factor
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ABSTRACT: The variations of bone mineral density (BMD) during home parenteral nutrition (HPN) and their relationship with general, life style, primary disease and HPN risk factors were investigated by a follow-up study.
Patients who had BMD assessment in a previous cross-sectional survey underwent a 2nd BMD at femoral neck (FN) and lumbar spine (LS). Data about risk factors were collected by a structured questionnaire. BMD Z-score (number of standard deviations from normal values corrected for sex and age) and the annualized percent BMD change were analysed.
Sixty-five adult patients were enrolled (follow-up: 18.1+/-5.5 months). The mean BMD Z-score significantly increased at the LS (P = 0.040) and remained unchanged at FN. In multiple regression analysis, the variations of the LS Z-score during HPN negatively correlated with the female sex (P = 0.021) and the age at starting HPN (P = 0.022). The analysis of the annualized percent BMD change confirmed the results obtained by the analysis of the Z-score. No factor was associated with BMD variation at FN.
HPN was not associated with a decrease of BMD in most of the patients; LS BMD Z-score variations were related to general risk factors rather than to HPN factors, showing a negative association with age and female sex.
Clinical Nutrition 01/2005; 23(6):1288-302. · 3.73 Impact Factor
