Introduction: Achieving enteral autonomy from parenteral nutrition (PN) is the ultimate goal of intestinal transplantation (ITX). While macronutrient absorption is typically adequate post-ITX, the degree of micronutrient absorption is poorly known. In pediatric ITX, micronutrient deficiencies after ITX may be common ^[1]. More specifically, pyridoxal deficiency after ITX and multi-visceral transplant has been reported ^[2]. In this study, we report preliminary findings on prevalence and risk factors for micronutrient deficiencies after adult ITX.

Method: Retrospective review of prospectively collected data on micronutrient levels (vitamins (vit) A, E, B6, B12, D 25-OH, zinc, copper, selenium, iron, folate, and ferritin) from a small cohort of patients who had achieved enteral independence after ITX.

Results: Micronutrients: Micronutrient levels were assayed at least once post-transplant and prior to any repletion (7 patients in first post-transplant year, 5 patients after the first year). All patients had at least 1 micronutrient deficiency. One patient had up to 4 different deficiencies (Vit E, D 25-OH, B12, zinc). Deficiencies were observed in all micronutrients, except selenium and folate. The most prevalent deficiency was vit D (n=11), followed by zinc (n= 6), ferritin (n= 5), vit B6 (n= 4), vit B12 (n=2), E (n=2), copper (n= 1) and A (n= 1).

Clinical Complications: Four patients had biopsy-proven acute rejection (severe, n= 2, mild, n= 2). They were treated with steroid (n= 2), thymoglobulin (n= 1), and a combination of steroid, thymoglobulin, plasmapheresis and IVIG (n= 1). Six patients had biopsy-proven non-specific enteritis. Patients with rejection and non-specific enteritis accounted for 90% (29/32) of observed deficiencies. Incidence of micronutrient deficiencies were same (16/32) between patients > 1-year post ITX and <1-year post ITX. Two patients did not have rejection or enteritis; only deficiencies observed in these 2 were vit D (n= 2) and ferritin (n= 1). 

Conclusions: Our preliminary data suggest that, consistent with limited available studies, micronutrient deficiencies are almost universally prevalent after ITX. Selenium and folate deficiencies seem uncommon. Patients with rejection and non-specific enteritis appear to be more likely to have micronutrient deficiencies. The length of time since transplant does not appear to confer adequacy of micronutrient status.

[1] Ubesie AC, Cole CR, Nathan JD, et al. Micronutrient deficiencies in pediatric and young adult intestinal transplant patients. Pediatr Transplant. 2013;17(7):638-645. doi:10.1111/petr.12132.
[2] Matarese LE. Nutrition and fluid optimization for patients with short bowel syndrome. JPEN J Parenter Enteral Nutr. 2013;37:161-170. doi:10.1177/0148607112469818.