CHAPTER 59: Simultaneous Kidney–Intestinal Transplantation

GENERAL INDICATIONS FOR INTESTINAL TRANSPLANTATION^1–3

• Intestinal failure (IF) with inability to continue parenteral nutrition (PN)

  • PN-induced liver injury or failure

  • Thrombosis of the majority of central veins necessary for PN access

  • Recurrent central line sepsis

  • Inability to maintain adequate hydration/nutrition despite PN

• Acute intestinal infarction

• Significant morbidity related to IF

• Intraabdominal desmoid tumors

BACKGROUND: SIMULTANEOUS KIDNEY–INTESTINAL TRANSPLANT

• Organ Procurement and Transplantation Network data (January 1988–August 2020)⁴

  • Thirty-nine simultaneous kidney–intestinal transplants in the United States

• Majority of available data does not separate kidney–intestine alone and kidney–multivisceral transplantation (MVT)

• Only ~25% of kidney–intestinal transplants do not include additional organ⁵

  • 73.9% includes simultaneous liver

  • 75.7% includes simultaneous pancreas

• Adult recipient characteristics (kidney–intestine alone/MVT/modified MVT)⁵

  • UNOS data 2000–2015

  • Mean recipient age: ~34 years and 55% male

  • 26.1% on dialysis at time of transplant

  • 21.3% dependent on PN

  • 27.9% intravenous fluid dependent

• Outcome data detailed in Chapter 60 “Simultaneous kidney-multivisceral transplant”

• Common indications/consideration for simultaneous transplant detailed in Chapter 60 “Simultaneous kidney-multivisceral transplant” rarer indications provided later

RENAL FAILURE AND INTESTINAL TRANSPLANTATION

• Among adult intestinal transplant recipients in the United States (56.6% intestine alone):⁶

  • Severe chronic kidney disease (CKD) (CKD stage 4 or 5 or end-stage renal disease [ESRD] requiring dialysis or transplant)

    • Cumulative 1-year and 10-year incidence 3.2% and 54.1%, respectively

  • Risk factors for severe CKD after transplantation:

    • Female gender

    • Increased age

    • Development of diabetes mellitus

    • Acute cellular rejection

    • Intestinal graft failure

    • Catheter-related sepsis as indication for intestinal transplantation

  • Majority of intestinal transplant recipients have excellent baseline glomerular filtration rate in this study

SPECIFIC CASE EXAMPLES OF KIDNEY–INTESTINE (ISOLATED) TRANSPLANTATION

• Secondary hyperoxaluria:⁷

  • Extensive small bowel resections related to diseases such as volvulus and inflammatory bowel disease

  • Excess intraluminal free fatty acids → decreased binding of oxalate and calcium

  • Uncomplexed oxalate absorbed in large intestine → calcium oxalate complex precipitates in the kidneys → ESRD

  • Simultaneous intestine–kidney transplant addresses renal failure and underlying cause

  • Literature cites cases of recurrent renal failure when kidney transplant is performed alone in these situations⁸

• Encapsulating peritoneal sclerosis (EPS)⁹

  • Complication of peritoneal dialysis

  • Surgical management with stripping, strictureplasty, and enterolysis can become risky in the most advanced cases

  • Combined kidney–intestinal transplant has been performed for a patient with EPS and history of kidney transplant with graft failure

REFERENCES