Early enteral nutrition after Pancreas Kidney Transplantation (PKTx) with enteral drainage (a pilot study in five patients)

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Introduction

The use of early enteral nutrition, in particular formulas containing glutamine, arginine and omega-3-fatty acids (immunonutrition), may have an impact on the post-operative course of critically ill patients. Previous research has demonstrated a decrease in complication rates, morbidity, and mortality. Little data exist, so far, about the use in pancreas-kidney-transplant recipients with enteral drainage. Because of the enteral anastomosis, most surgeons restrain from feeding the patients enterally, and postpone the start of enteral nutrition until at least five days after the procedure. No data is published on early enteral immunonutrition in this type of patient. The aim of this preliminary study, is to analyze the feasibility and complication rates of early enteral immunonutrition in pancreas-kidney-transplant recipients with enteral drainage.

Patients and Methods

Prospective analyzes of five patients after PKTx was performed. Nasogastric feeding with Impact^® (Novartis, Switzerland), 25 cc/h was started immediately after surgery. This was continued for the first five days after PKTx. Additionally, patients recieve a parenteral standard nutrition program and substitution of fluids as needed to maintain diuresis. Further medication included propulsive agents (metoclopramide 20 mgs i.v. every 6 h, cisapride 10 cc p.o. every 6 h) and immunosuppression (tacrolimus 0.05 mgs/kg or cyclosporine 4 mgs/kg, ATG 5 mgs/kg, prednisolone 20 mgs/day, mycophenolatmofetile 2 g/day). During the study for each patient basic demographic and clinical characteristics including age, sex, SAPS II score, ICU and hospital mortality were recorded. The patients were screened for the occurrence of rejection, opportunistic infections and surgical complications.

Results

Early enteral immunonutrition was tolerated by all the patients. No surgical complications, especially no leakage at the enteric anastomosis, were observed. There was also no occurrence of transplant pancreatitis and a reduced incidence of bowel distention and vomiting. Except for one CMV-infection, no opportunistic infections or other infectious complications were observed. All patients developed rejection; rejection was mild and steroid-sensitive in four patients, one patient required OKT 3 treatment and tacrolimus rescue therapy.

Discussion and conclusion

The number of five patients is to small to make a valid conclusion and the results are rather descriptive. They show that early enteral feeding in this group of patients is possible without an increase in postoperative complications. Furthermore, early regeneration of mucosal gut barrier function may decrease infectious complications and improve patient outcome. In order to confirm this hypothesis further research should be performed to investigate the impact of this strategy. Variables like infection rates, surgical complications, and rejection, as well as length of ICU stay, morbidity and mortality will be analyzed.