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NOMENCLATURE/TERMINOLOGY1,2

  • Multivisceral transplant (MVT) graft includes

    • Small bowel

    • Pancreas

    • Stomach

    • Liver

  • Modified multivisceral transplant (MMVT): transplantation of the MVT graft without the liver

  • Types of intestinal transplantation: Intestine alone, MVT, and MMVT

  • Renal graft is not typically included within the standard MVT graft

  • Simultaneous kidney–MVT: MVT and kidney transplantation occurring at the same time

BACKGROUND: SIMULTANEOUS KIDNEY–MVT

  • Intestinal failure (IF) can occur both in adults and children secondary to a variety of causes.1,3

  • IF results in dependence on parenteral nutrition (PN).4

  • Long-term PN may become impossible to maintain due to treatment complications.

  • Intestinal transplant is an option to treat IF when PN cannot be maintained or for certain small bowel–related malignancy types.1,3,4

  • In a single-center study of 100 MVTs and MMVTs, renal failure was present in 25% of adult patients at the time of surgery.5

  • Patients with renal failure at the time of MVT or MMVT have worse posttransplant outcomes.5

  • Between 2000 and 2015, only 5% of the 2215 intestinal transplants performed in the United States included a simultaneous kidney transplant.6

    • 32.4% pediatrics vs. 67.6% adults

  • Organ Procurement and Transplantation Network data (Jan. 1988–Aug. 2020)7

    • 114 liver–kidney–intestine–pancreas transplants

    • 8 kidney–intestine–pancreas transplants

    • 4 liver–kidney–intestine transplants

SPECIFIC INDICATIONS FOR MVT3–5

  • IF with cirrhosis or severe PN-induced liver injury/failure

  • Significant portomesenteric thrombosis

  • Frozen abdomen

  • Certain tumors involving the liver and small bowel/mesenteric structures

SPECIFIC INDICATIONS FOR MMVTs3–5

  • IF and gastroparesis

  • Pancreatitis complicated by mesenteric thrombosis

  • Tumors involving the small bowel but sparing the liver

WHEN TO CONSIDER A SIMULTANEOUS KIDNEY–MVT

  • When indications for both kidney transplant and MVT are met

  • Loss of vascular access pre-MVT and marginal renal function6

    • Pretransplant glomerular filtration rate (GFR) <60 mL/min linked to >40% increased risk for mortality posttransplant8

    • Pretransplant acute kidney injury (AKI) is associated with a significant reduction in post-MVT long-term survival5

  • Guidelines are not concretely defined given the infrequency of this procedure

    • Case-by-case analysis/discussion is necessary

    • MVT recipients can be listed for kidney transplant with GFR >20 mL/min per United Network for Organ Sharing (UNOS) guidelines6

RENAL FAILURE AND MVT

  • Renal failure at time of MVT or MMVT confers worse posttransplant survival, especially in older patients5

  • ~25% of adult intestinal transplant recipients develop end-stage-renal disease (ESRD), requiring dialysis or kidney transplantation9

  • Dialysis after transplantation is associated with significantly worse outcomes9

  • Risk factors:

    • Baseline diabetes mellitus

    • Baseline hypertension

    • MVT > intestinal transplantation without liver

  • Possible contributing factors5,6,9

    • Nephrotoxicity related to posttransplant immunosuppression

    • High risk for sepsis leading to acute tubular necrosis

    • Use of nephrotoxic antibiotics (aminoglycosides, etc.)

    • Challenging volume and electrolyte management pretransplant in setting of IF

OUTCOMES OF SIMULTANEOUS KIDNEY–MVT/MMVT/INTESTINE ALONE (U.S. DATA 2000–2015)6

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