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INTRODUCTION This study reports the incidence of chronic kidney disease (CKD) after intestinal transplant (IT) at a single, adult center in the United Kingdom. METHODS A retrospective review of IT was undertaken. Methods of renal function assessment pre-transplant were compared. Post-transplant renal function and renal sparing strategies were analyzed. RESULTS There was a 30% variation (p

Summary Background Several authors have studied the transition from medical student to junior doctor. There have been several problems identified, one being prescribing. Junior doctors have been found to be the cause of most of the prescription errors in hospitals. These authors suggest improvements in prescribing teaching, and several describe their own innovations seeking to correct these problems. Context As junior doctors in a district general hospital in the UK we had the opportunity to provide teaching to small groups of final-year medical students. We had recently begun working as Foundation Year 1 doctors, and had fresh experience of the transition from medical student and the problems that we had encountered with prescribing. We were acutely aware of the commonly made mistakes. Innovation We have designed a short, five-session course covering the practical aspects of prescribing. Assuming that theory had been covered elsewhere, we focused on encouraging the students to prescribe on real drugs charts using information available to junior doctors on the wards. We measured the efficacy of the course by asking the students to rate their own confidence in prescribing in each of the scenarios before and after the session. Implications The intention was to design and deliver a course that would bridge the gap between pharmacological theory and prescribing in practice. Existing prescribing courses are often taught by senior doctors or pharmacists. We believe that the major strength of this course was that it was designed and delivered by junior doctors, under the supervision of a senior doctor.

Background Multivisceral transplantation (transplantation of the stomach, intestine, liver, and pancreas) is usually undertaken as a semi-elective procedure after thorough assessment in patients who have intestinal failure with cirrhosis, cirrhosis with portomesenteric venous thrombosis, or tumors such as desmoids involving the liver and mesentery. Study Design Data were collected prospectively from the time of referral and held in a central database. We used it to report the first cases of urgent multivisceral transplantation (MVT) in patients with widespread splanchnic ischemia (occlusion of the celiac axis and superior mesenteric artery) resulting in small bowel infarction and hepatic failure. Results Three women (ages 33, 48, and 50 years) were referred to our center with superior mesenteric artery and celiac axis occlusion. All other modes of treatment had been considered and/or attempted. After transfer to our institution, all patients were assessed, urgently listed, and underwent transplantation in 10, 7, and 5 days. Two patients are still alive after 2 years and 1 died at 8 months from multiorgan failure due to infections and graft vs host disease. Conclusions Treatment options for patients presenting with widespread splanchnic ischemia with hepatic and intestinal failure/infarction were previously limited to salvage surgery and attempted revascularization. In situations in which these failed, the only previous option would have been palliation. In selected cases, we propose that urgent multivisceral transplantation should be considered as a life-saving treatment. This represents a previously unreported indication for MVT.

Cambridge is one of two designated adult intestinal transplant centers in the United Kingdom and has performed 60 transplants on 54 patients since 2007; 52% of these were undertaken in the last 3 years. This increasing trend is in contrast with that reported worldwide; 27% were small bowel grafts (SBT), 15% modified multivisceral (MMVT), and 58% multivisceral (MVT). Median recipient age was 47 years; the female-to-male ratio was 27/33. Primary diseases included visceral arterial thromboses (17%), Crohn's disease (17%), motility disorders (12%), visceral venous thromboses (12%), familial adenomatous polyposis (FAP)/desmoids (8%), alcoholic cirrhosis (3%), nonalcoholic fatty liver disease (3%), ulcerative colitis (2%), and other (15%). Indications for transplant included intestinal failure-associated liver disease (IFALD) (27%), loss of central venous access (17%), FAP/desmoid disease (5%), extensive portomesenteric venous thrombosis (PMVT) (20%), widespread mesenteric arterial ischemia (WMAI) (13%), re-transplant (8%), and other (10%). Overall 1-year/5-year patient survival rates were 77%/62%. One-year/5-year patient survival rates were 92%/83%, 85%/65%, and 71%/33% for SBT, MMVT, and MVT. One-year/5-year survival rates for patients with IFALD, PMVT, and other indications who underwent MVT were 80%/20%, 65%/55%, and 55%/35%. The greatest proportion of patient deaths occurred during the first year after transplant (50% in year 1, 23% in year 2, 9% in year 3, 5% in year 4, and 14% in year 5), particularly in the MVT group. Referrals to our United Kingdom center are increasing, and the indications for transplant are becoming more diverse. Our patient survival rates remain comparable with figures reported worldwide.

Introduction Small intestinal transplantation was first undertaken in Cambridge in 1991 and with advances in immunosuppression agents, outcomes have improved. We present our survival figures from 2006 to 2014. Method A prospective database is used to record all patients who undergo small intestine (SB), liver/small intestine (LSB), modified multivisceral (MMVT – intestine and stomach) and multivisceral (MVT – intestine, stomach and liver) transplantation at Addenbrooke’s Hospital. All grafts may also contain pancreas, kidney and colon. The NHS Blood and Transplant service derived Kaplan-Meier survival curves for all patients undergoing their first transplant procedure between January 2006 and December 2014. Results 56 transplant procedures were performed on 50 patients (6 were re-transplanted, all are still alive). 1-year survival in patients transplanted is 92% (SB), 83% (MMVT), 67% (LSB) and 69% (MVT). 5-year survival is 92% (SB), 63% (MMVT) and 27% (MVT) – this data is not available for LSB transplants due to small numbers and follow-up duration of only 14 m. These data compare favourably with international transplant registry 5-year survival figures of 59% (SB) and 22% (MVT).1Overall 1-year survival for all patients transplanted in our unit is 76% and 5-year survival is 46%. Conclusion Cambridge is one of 2 UK centres performing intestinal transplantation in adults and we are undertaking an increasing number of procedures – 16 in 2013 and 10 in 2014. We are particularly encouraged by our 92% 5-year survival in patients undergoing isolated SB transplantation and would advocate early referral for assessment in patients with Type 3 intestinal failure who develop complications from home parenteral nutrition. Colon is routinely included in the graft to aid fluid balance and does not preclude regular endoscopic surveillance for rejection. We have performed continuity surgery in a number of patients post transplant (transplanted colon to native colon anastomosis) with good outcomes and no anastomotic leaks. Due to complications of the oesophagogastric anastomosis, gastroparesis and increased morbidity and mortality of MVT we are moving towards performing more LSB transplants and will monitor outcomes with interest. Detailed pre-operative assessment, individualised procedures, patient optimisation and an emphasis on the multidisciplinary team are essential when managing these complex patients. Disclosure of interest None Declared. Reference Intestinal Transplant Registry (ITR) – http://www.intestinaltransplant.org/itr/(Accessed May 2014)

Introduction Amongst patients on longterm parenteral nutrition, rates of osteoporosis vary between 41–67%. 1,2 In the United States, 77.4% of patients awaiting intestinal transplantation had low bone mineral density (BMD). 3 It is not known how prevalent low BMD is amongst patients undergoing intestinal transplantation in the United Kingdom. Method We retrospectively reviewed the notes and bone densitometry scans (DEXA) for all patients who had undergone isolated intestinal, modified multivisceral, or full multivisceral transplantation from December 2007 to December 2014. Results 49 patients were transplanted including 5 acutely (4 mesenteric ischaemia, 1 intestinal failure associated liver disease) with no time for pre-operative DEXA. It was not known whether pre-operative DEXA was performed in 6 patients. Of the remainder, 33/38 (87%) had DEXA performed a median of 329 days (range 12–986) prior to transplantation. Osteoporosis was seen in 13/33 (39%) with a median hip T-score -2.7 (range -1.3 to -4.8), median spine T-score -3.1 (range -1.6 to -5.4), and median age at transplant 46 years (range 18–64). Osteopenia was seen in 11/33 (33%) with 9/33 (27%) having normal BMD. Of those who did not have pre-operative DEXA but who were scanned within 1 year (n = 10), 7 had reduced BMD. Specifically, patients undergoing acute transplant demonstrated reduced BMD (osteopenia) in 2/5 (age 27 and 33 at transplant). Patients were managed with a combination of calcium/Vitamin D and/or bisphosphonates, with two patients referred to a metabolic bone clinic. There were no cases of fragility fractures. Of the surviving patients who have had sequential DEXA, including ≥2 scans post-transplant (n = 7), there is a trend towards increasing BMD over subsequent years. Conclusion Prevalence of low BMD is 72% in patients undergoing intestinal or multivisceral transplantation at our centre and these patients are often under the age of 50 years sometimes with profound osteoporosis (e.g. T -5.4). Poor bone health is not restricted to those on long term parenteral nutrition with intestinal failure but is also seen in patients with acute indications requiring transplant such as mesenteric infarction. As patients survive longer the sequelae of osteoporosis become important – addressing reduced BMD pre-operatively is important as improving bone health may take some years. Use of corticosteroid immunosuppression increases risk of reduced BMD in this cohort. Disclosure of interest None Declared. References Pironi L, et al . Clin Nutr. 2002;21:289–296. Cohen-Solal M, et al . J Bone Miner Res. 2003;18(11):1989–1994. Resnick J, et al . Am J Transplant. 2010;10:2331–2340.

Introduction Calcium oxalate is the predominant component of most renal stones; they occur in 10% of patients with bile salt and/or fatty acid malabsorption due to enteric hyperoxaluria1. Patients who have undergone extensive ileal resection, jejuno-ileal bypass surgery or a Roux-en-Y gastric bypass, whose colon remains in continuity, are at a greater risk of developing enteric hyperoxaluria. It is managed by dietary restriction of oxalate and fat, a high calcium intake, and increasing water intake to ensure a daily urine volume of more than 3 litres. The latter is difficult to achieve in patients with short bowel syndrome. Ox-Absorb® is an organic marine hydrocolloid derived from plants and seaweed and was first described in the 1980’s as a promising new treatment for enteric hyperoxaluria. It was also noted that it thickened stools and reduced stool frequency. Ox-Absorb®is unlicensed in the UK and imported on a named patient basis from the USA. When it was used by the renal physicians at North Bristol NHS Trust to reduce oxalate stone formation, patients reported beneficial effect on stool frequency and consistency. Method We conducted a retrospective case note review of all patients prescribed Ox-Absorb® in North Bristol NHS Trust. Drug history, weight, change in stool consistency and urinary oxalate levels were documented. Net reduction in tablet burden and a cost analysis of the use of Ox-Absorb®were calculated. Results 8 patients were prescribed Ox-Absorb®. 7/8 patients reported thicker stools and reduced stool frequency and there was a reduction in tablet burden (mean 8.6 tablets; range 2 to 22; median 7). Mean net reduction of tablets was 22% (median 29%). There was a cost reduction in 3/8 patients, all of whom were taking higher doses of loperamide, codeine phosphate and Creon®(£1.09, £0.57 and £0.15 per day). 3/8 patients had to stop the drug due to supply problems and all noted worsening in diarrhoea symptoms which improved on restarting the drug. Urinary oxalate was reduced in only 2/8 patients. Conclusion In this small cohort, patients who were prescribed Ox-Absorb® reported thicker stools and were able to reduce their net anti-diarrhoeal tablet burden. This was cost effective in patients taking higher doses of loperamide, codeine and Creon®. We believe a larger study of this drug relative to standard treatments is justified. Disclosure of interest None Declared.

Introduction There is limited data on nutritional outcomes post intestinal transplantation in adults. This cohort of patients will inevitably be at high nutritional risk and undergoing major surgery is anticipated to have a further deleterious effect. Methods Pre and post transplant anthropometric data and nutritional status of all patients undergoing intestinal or multivisceral transplantation from 2007 to 2013 who survived more than 30 days post transplant was collected prospectively. A dynamometer was used to assess grip strength in the non-dominant hand. Bone density was measured by dual x-ray absorptiometry (DEXA). Results 42 patients have undergone transplant during the time period, full data is reported for 28 patients (Exclusions: 6 transplanted The mean BMI of patients at the time of assessment was 21.7 (Standard Deviation (SD) 3.5). Post-transplant, parenteral nutrition (PN) was given for a median of 24 days (range 2–134), enteral nutrition (EN) was given for a median of 57.5 days (range 0–262). The mean maximum weight loss post transplant was 16.6% of pre-transplant weight (SD 7.65%). Over one third of patients lost 20% or more of their pre-transplant weight and only 5 patients have returned to or exceeded their previous weight, though all but one patient has gained weight from their nadir weight. Mean BMI at latest follow-up in survivors is 20.64 (SD 4.6). The majority of patients (20/23 survivors, 87%) are maintained on an oral diet. 2 patients (8.7%) with an intact graft require PN and 1 patient (4.3%) requires parenteral fluids. One patient (4.3%) continues on EN. Handgrip strength was measured pre and post transplant (median 17 months post, range 7–34) in 13 patients, 7 demonstrated an improvement, 2 were stable ( Conclusion The majority of patients post intestinal and multivisceral transplant have nutritional autonomy; only a small number require parenteral or enteral nutritional support. Improvements in bone density and muscle strength can be demonstrated post transplant. However, significant weight loss does occur in the post-operative period; this should be taken into consideration when patients are being listed and every attempt made to optimise pre transplant. Disclosure of Interest None Declared.

Introduction Small bowel transplantation (SBT) was first performed in the UK in Cambridge in 1991. Recipients mow undergo small bowel (SBT), liver and small bowel (LSBT), modified multivisceral (MMVT – small bowel, stomach, pancreas, no liver) and multivisceral (MVT – intestine, stomach, pancreas and liver) transplantation. Cambridge is the only UK centre offering MVT in adults. The main indications for referral to a transplant centre are: Irreversible intestinal failure plus life threatening complications of parenteral nutrition (PN). Extensive surgery requiring partial or complete evisceration. Methods Prospective data was collected from all patients who underwent intestinal and multivisceral transplantation at Addenbrooke’s Hospital between 2003 and 2013. All patients are discussed and indications for transplantation agreed prior to listing at NASIT (National Adult Small Intestinal Transplant forum). Results 47 transplants were performed on 43 patients; 4 procedures (9%) were re-transplantation for a primary non-functioning graft (2/4) or acute rejection (2/4). The indications for transplant are presented below: Sixteen transplants were performed in 2013 - MVT (57%), SBT (31%), LSB (6%) and MMVT (6%). 50% of these were due to short bowel - arterial ischaemia (50%), Crohn’s (26%), venous ischaemia (12%) and other short bowel (12%). Colon is now routinely included in the graft to aid fluid balance and does not preclude endoscopic surveillance for rejection. Conclusion The number of small bowel and multivisceral transplants performed over the last 10 years has increased, and more than doubled in 2013. Short bowel remains the commonest indication for transplantation. Historically this was mainly due to Crohn’s disease however in 2013, it was mainly due to ischaemia; this trend was reflected worldwide. In our cohort, an increase in acute arterial thromboses causing coeliac/mesenteric ischaemia resulted in 3 recipients being listed urgently for MVT. There has also been an increase in the number of patients referred with portal vein thromboses extending into the superior mesenteric vein, precluding liver transplant alone. Disclosure of Interest None Declared.

Introduction Small intestinal transplantation (SBT) was first undertaken in the UK in Cambridge in 1991. Since the introduction of new immunosuppressive agents around the millenium, results have improved and we present our experience over the last 10 years. Since 2003, 47 tranplants have been performed on 43 patients. Grafts include small bowel or small bowel/colon (SBT), liver and small bowel (LSBT), modified multivisceral (MMVT – small bowel, stomach, pancreas, no liver) and multivisceral (MVT – intestine, stomach, pancreas and liver) transplantation. Cambridge is the only UK centre offering MVT in adults. Methods A review of all patients who underwent small intestine and multivsiceral transplantation at Addenbrooke’s Hospital between 2003 and 2013. Kaplan-Meier survival data are shown for each group of organs transplanted. Results Five year survival for all patients transplanted is 77%. Survival curves for each organ group transplanted is graphed below: Conclusion Five year survival in our patients transplanted since 2003 is 100% for SBT and LSBT and 65% for MVT, compared with international registry survival figures of 59% (SBT and LSBT combined) and 22% respectively. In recent years we have also experienced an increase in the number of urgent transplants performed and these patients are often critically unwell at the time of surgery. Our centre undertakes a relatively large number of procedures and this, coupled with a particular focus on multidisciplinary team working, may account in part for our favourable survival figures. Disclosure of Interest None Declared.

Patients undergoing multivisceral transplantation are particularly susceptible to post-operative infections due to immunosuppression and the inclusion of bowel in the transplanted graft. These patients typically receive broad-spectrum antimicrobial and antifungal agents as prophylaxis and treatment. However, evidence for this is limited due to the small number of patients undergoing the procedure. We present a case of occult disseminated invasive aspergillosis infection in a patient who underwent multivisceral transplantation.