For the first time in the world a sequential transplant strategybefore fecal microbiota and, then, liver, made it possible to save the life of a 56-year-old man, suffering from polycystic disease with liver and kidney involvement since birth. A 120-day long marathon, managed by the doctors of the Molinette hospital of the City of Health in Turin, in collaboration with colleagues from the Fondazione Policlinico Universitario Agostino Gemelli Irccs of Rome.
The liver had reached a weight of 15 kilos
“The post-operative course of the liver transplant was free from major complications, in particular there were no infections of any kind. After only 20 days from the liver transplant (and 120 days from his arrival at Molinette), the patient returned home, having also regained such renal function that he does not require dialysis for now. The patient, supported with love by his extraordinary wife and daughter, is now in the full phase of nutritional and motor recovery and has been the risk of infection from intractable bacteria after liver transplantation has been averted“, underlines the Molinette hospital in a note. The clinical case has already received the first recognition in the international scientific literature, having been published in 'Transplant Infectious' Disease. “Last August the patient was transferred from the hospital's Nephrology Martini of Turin in the hepatological intensive care unit of the Molinette hospital (directed by Antonio Ottobrelli) following ascitic decompensation and septic state. The polycystic disease over the years had seriously damaged renal function to the point of requiring dialysis, and the considerable abdominal bulk, caused by a liver completely replaced by cysts and weighed around 15 kilos – says the Molinette hospital of the City of Health in Turin – caused a serious state of malnutrition, the development of liquid effusion in the abdomen and intestinal colonization by bacteria resistant to any antibiotic therapy currently available”.
“In consideration of the serious clinical conditions, the director of the Liver Transplant Center of Turin, Renato Romagnoli, and the director of the Kidney Transplant Center, Luigi Biancone – continues the hospital note – had agreed to give transplant priority to the life-saving organ, i.e. the liver, postponing the kidney transplant to a later date. Intestinal colonization by bacteria resistant to antibiotic therapies, in consideration of the comorbidities from which the patient was suffering, however risked making liver transplant futile, given the high risk of incurable infections in the immediate post-transplant period”. Doctor Silvia Martini of the Hepatological Intensive Care Unit and Professor Renato Romagnoli therefore contacted the director of Internal Medicine and Gastroenterology and of the Digestive System Disease Center of the Agostino Gemelli Irccs University Polyclinic Foundation of Rome, Antonio Gasbarrini, a pioneer in Italy, with the professors Gianluca Ianiro and Giovanni Cammarota, of fecal microbiota transplantation and author of the International Guidelines on faecal transplantation – reconstructs the Turin hospital -. Colleagues promptly offered their willingness to proceed with the transplant of feces in capsules, with a possibility of success in approximately 2 cases out of 3 in the decolonization of the intestine from otherwise intractable bacteria”.
Intestinal microbiota capsules
“With the preliminary authorization of the medical director of the Molinette hospital, Antonio Scarmozzino, the Regional Transplant Center of Piedmont (directed by Federico Genzano Besso) obtained a favorable opinion from the director of the National Transplant Center (Cnt) of Rome, Massimo Cardillo, for the transplant of feces in derogation by taking capsules orally, the only possible route of administration considering the considerable abdominal bulk which contraindicated the classic colonoscopic administration – continues the note – The Ethics Committee of the Policlinico Gemelli Foundation has in turn expressed its opinion favorable. Having consulted favorably the internal pharmaceutical commission of the City of Health, last November Ianiro, having organized the trip from Rome in a few hours, administered to the patient admitted to the Molinette 50 capsules of intestinal microbiotaprepare for the Microbiology of Gemini”.
Liver donation
The reduction in the bacterial load colonizing the intestine, “documented by colleagues from the Microbiology department of the Molinette hospital (directed by Cristina Costa) made it possible to activate the patient on the liver transplant list exactly 12 days after the fecal microbiota transplant. 'high priority on the liver list granted by the National Transplant Center, in order to exploit the transplant window that opened with the reduction of the intestinal bacterial load – recalls the note – At the end of November, thanks to the generosity of an Italian family who donated the liver of their deceased relativethe patient, exactly 100 days after the start of hospitalization at Molinette, entered the operating room”.
“The highly technically complex liver transplant was carried out by the director of the Liver Transplant Center of Turin, Professor Renato Romagnoli, together with his medical, surgical and nursing staff, in extracorporeal circulation with the collaboration of Cardiac Surgery (directed by Mauro Rinaldi) and the anesthetists of Anesthesia and Resuscitation 2, directed by Roberto Balagna – specifies the Turin hospital – During the transplant it was necessary to transfuse 18 units of red blood cells and the same number of fresh plasma from the Blood Bank and Immunohematology of the City of Health of Turin. It is important to remember that blood donation is indispensable for transplant activity. To allow the over 4,000 liver transplants carried out so far in Turin, a pool of over 150,000 people was needed who silently and with great generosity they donated their blood.” “Once again we are proud to make public a collaboration between Italian polyclinics on a very serious clinical case resolved with a cutting-edge and unprecedented healthcare solution”, concludes Giovanni La Valle, general director of the City of Health of Turin.
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