Intestine Transplantation in the United States, 1999-2008

Abstract

Improving short-term results with intestine transplantation have allowed more patients to benefit with nearly 700 patients alive in the United States with a functioning allograft at the end of 2007. This success has led to an increase in demand. Time to transplant and waiting list mortality have significantly improved over the decade, but mortality remains high, especially for infants and adults with concomitant liver failure. The approximately 200 intestines recovered annually from deceased donors represent less than 3% of donors who have at least one organ recovered. Consent practice varies widely by OPTN region. Opportunities for improving intestine recovery and utilization include improving consent rates and standardizing donor selection criteria. One-year patient and intestine graft survival is 89% and 79% for intestineonly recipients and 72% and 69% for liver-intestine recipients, respectively. By 10 years, patient and intestine survival falls to 46% and 29% for intestine-only recipients, and 42% and 39% for liver-intestine, respectively.Immunosuppression practice employs peri-operative antibody induction therapy in 60% of cases; acute rejection is reported in 30%-40% of recipients at one year. Data on long-term nutritional outcomes and morbidities are limited, while the cause and therapy for late graft loss from chronic rejection are areas of ongoing investigation.

Intestinal Regeneration, Residual Function and Immunological Priming Following Rescue Therapy After Rat Small Bowel Transplantation

“…Our findings clearly demonstrate increased graft fibrosis after the treatment and recovery from acute rejection, even after only one episode of rejection in this experimental setting. Although ACR frequency has decreased from historic levels of 80% to 20-40% in the early phase after intestinal transplantation (20), rejection episodes remain one of the most frequent complications after intestinal transplantation in the clinical setting.…”

The Current State of Intestine Transplantation: Indications, Techniques, Outcomes and Challenges

“…native organs are simultaneously removed and whether or not this contributes to the decision as to whether or not the term multi-visceral is used (17,19,24). Early series had suggested that inclusion of the colon might increase the risk for infection, several recent single center series and a recent review challenge this long held assumption.…”

“…The rates of intestine transplantation vary considerably across the country and, for the average patient, the financial burden is difficult if not impossible to manage (19). Further, the proportion of pediatric candidates is dramatically higher for intestine transplantation relative to other solid organ grafts and the predominant payor in this population is Medicaid.…”

“…Experts from major transplant centers around the world met at the 2007 International Small Bowel Transplant Symposium and concluded that the term multi-visceral meant different things in different programs (19). General consensus suggested that the old terminology be abandoned in favor of a descriptive system with two components; first, whether the intestine transplant was performed with or without simultaneous liver transplantation (due to the impact on outcomes demonstrated by review of the International Intestine Transplant Registry [IITR]) and second, whether or not evisceration of the recipient foregut was performed in association with the transplant procedure (19).…”

“…General consensus suggested that the old terminology be abandoned in favor of a descriptive system with two components; first, whether the intestine transplant was performed with or without simultaneous liver transplantation (due to the impact on outcomes demonstrated by review of the International Intestine Transplant Registry [IITR]) and second, whether or not evisceration of the recipient foregut was performed in association with the transplant procedure (19). Mazariegos et al (19) argued that failure to adopt more standardized terminology would hamper further advances in the field due to the inability to compare the contribution that technical variations play in outcomes.…”