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GENERAL INDICATIONS FOR INTESTINAL TRANSPLANTATION1–3

  • 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

KEY POINTS

  • Simultaneous kidney–intestine (alone) transplantation is exceedingly rare but can be performed when indications for both are met.

  • Much of the outcome data is combined with data from simultaneous kidney–MVT.

  • Expert centers should be consulted when the potential need for this transplantation exists.

REFERENCES

1. +
Kaufman  SS, Avitzur  Y, Beath  SV,  et al. new insights into the indications for intestinal transplantation: consensus in the year 2019. Transplantation. 2020;104:937–946.  [PubMed: 31815899]
2. +
Sudan  D. The current state of ...

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