Charlotte Pither^1,2, Simon Gabe^1,3, Rajesh Sivaprakasam², Samantha Duncan^1,2, Helen Tincknell^1,2, Myla Manaligod^1,2, Beate Mengelkoch^1,2, Jeremy Woodward^1,2, Bridget Chukualim^1,2, Neville Jamieson², Andrew Butler², Stephen Middleton^1,2

¹Department of Gastroenterology, Addenbrooke’s, Cambridge University NHS Foundation Hospital, Cambridge, East Anglia, United Kingdom; ²Department of Transplantation, Addenbrooke’s, Cambridge University NHS Foundation Hospital, Cambridge, East Anglia, United Kingdom; ³Intestinal Failure, St Mark’s Intestinal Failure and Academic Unit, Harrow, London, United Kingdom

Introduction: Patient survival after intestinal transplantation has significantly improved over the last 10 years and is now much closer to that of liver, heart and lung at 5 years. Currently it is usually reserved for patients with life threatening complications of parenteral nutrition (PN). We investigated whether subgroups of PN patients might have a better prognosis from early transplantation even if they do not fulfil the usual stringent criteria.

Methods: The survival of a large cohort of patients with intestinal and multi-visceral transplants was compared to their preoperative Cambridge-Miami (CaMi) survival scores (as previously validated).

Patients receiving PN for intestinal failure were assessed retrospectively for factors that were associated with survival. These were evaluated to determine if subgroups with different survival rates could be identified.

These populations were then compared to determine if high risk subgroups of PN patients could be identified who might benefit from early transplantation.

Results: CaMi scores were found to accurately predict survival at 1,3 and 5 years with Receiver-Operator Characteristics (ROC) that gave a “C” statistic ( area under the ROC curve)  of 0.93, 0.95 and 0.84 respectively. Kaplan-Meier analysis revealed significant increases in mortality with increased CaMi scores.

The primary disease diagnosis and mode of intestinal failure were found to identify subgroups of PN patients with markedly different survival rates.

Comparison of the subgroups in these two patient populations suggests that patients in the PN subgroups associated with poorer survival who have low CaMi scores may have an enhanced survival chance if offered early transplantation, even though they do not fulfil the usual indications for intestinal transplantation as published.

Conclusion: Using the combination of PN survival subgroups to predict prognosis and CaMi scores to predict survival of patients following transplantation it may be possible to identify the optimal time for intestinal transplantation in individual patients.