Intestinal Transplantation Workup

  • Author: Stuart M Greenstein, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Mar 5, 2012
 

Laboratory Studies

Pretransplant workup

The evaluation of a potential recipient needs to be done by a multidisciplinary team including transplant surgery, gastroenterology, nutritional services, psychiatry, social work, anesthesia, and financial services. Further consultation with other specialties may be required.

Laboratory studies should include CBC count, coagulation profile, complete metabolic panel, ABO blood group determination, human leukocyte antigen (HLA) status, panel reactive antibody status, and serologies for cytomegalovirus (CMV) and Epstein-Barr virus (EBV).

The GI tract should be assessed both radiologically and endoscopically. If liver disease is suspected, a liver biopsy should be performed.

Doppler ultrasonography or magnetic resonance venography should be performed to assess vascular access. Many patients will have at least one central venous stenosis or obstruction. Matsusaki et al reported no difference in recipient outcome between standard vascular access (percutaneous line via the upper body veins) and alternative vascular access (percutaneous line via the lower body veins; vascular access secured surgically, with interventional radiology, or using nonvenous sites).[9]

Patients with dysmotility disorders may require manometry of the stomach, esophagus, and rectum. Children with necrotizing enterocolitis (NEC) require a full neurologic and pulmonary workup to exclude the possibility of associated intraventricular hemorrhage and bronchopulmonary dysplasia.

Living related donor transplantation can be discussed as an option if a potential living related donor is available.

While on the waiting list, the stable patient should be frequently reassessed, with specific attention given to any change is their medical status, deterioration in liver function, or further loss of vascular access. These patients also need ongoing maintenance of their central lines to minimize line-related complications, such as infections and thrombosis.

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Other Tests

Cadaveric donors

Although ABO-compatible donors can be used, ABO-identical donors are preferred in most circumstances because of the risk of graft versus host disease (GVHD). The size of the donor must be 50-75% of the size of the recipient. In certain circumstances, segments of the intestine from a larger donor may be considered.

The donors should have no previous history of significant intestinal pathology. As with all organ donors, no significant hemodynamic instability, sepsis, history of malignancy or chronic infection, severe hypoxia, or severe acidosis should be noted, and negative serology for human immunodeficiency virus (HIV) and hepatitis B and C is preferable.

The role of a crossmatch and HLA matching in intestinal transplantation is unclear.

CMV and EBV serologic status of the donors and recipients should be taken in consideration. Transplantation of a serologically positive donor into a serologically negative recipient for either of these viruses can have serious consequences. In addition to the risk of a systemic CMV infection, CMV enteritis can occur, which can lead to graft loss. A new EBV infection combined with posttransplant immunosuppression puts the patient at high risk for developing a posttransplant lymphoproliferative disease (PTLD).

Living donors

A potential living donor also needs to be evaluated by a multidisciplinary team. As with any living donor procedure, possible complications including death should be explained in great detail. The living donor should have a complete workup, including CBC count, electrolytes, liver function tests, ECG, and chest radiography. The GI tract should be endoscopically evaluated, and, if any concerns are noted, GI contrast studies should be performed. The mesenteric vasculature should be studied to ensure that the terminal superior mesenteric artery and vein are adequate.

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Contributor Information and Disclosures
Author

Stuart M Greenstein, MD  Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center

Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Coauthor(s)

Javier Chapochnhick Friedmann, MD  Multiorgan Transplant Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center; Assistant Professor of Surgery, Albert Einstein College of Medicine

Javier Chapochnhick Friedmann, MD is a member of the following medical societies: American Hepato-Pancreato-Biliary Association, American Society of Transplant Surgeons, International Hepato-Pancreato-Biliary Association, International Liver Transplantation Society, International Pediatric Transplant Association, and Transplantation Society

Disclosure: Nothing to disclose.

Owen Prowse, MD, MPH, FRCSC  Assistant Professor, Department of Surgery, Northern Ontario School of Medicine, Lakehead University and Laurentian University

Owen Prowse, MD, MPH, FRCSC is a member of the following medical societies: Canadian Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Casimir F Firlit, MD, PhD  Director of Reconstructive Urology, Department of Neuro-Urology and Fetal Urology, SSM Cardinal Glennon Children's Medical Center

Casimir F Firlit, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Society of Transplant Surgeons, American Urological Association, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steve Dunn, MD  Chief, Solid Organ Transplantation, Department of Surgery, Alfred I DuPont Hospital for Children at Wilmington

Steve Dunn, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, American Society of Transplantation, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Ron Shapiro, MD  Professor of Surgery, Robert J Corry Chair in Transplantation Surgery, Director, Kidney, Pancreas, and Islet Transplantation, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center

Ron Shapiro, MD is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, Association for Academic Surgery, Central Surgical Association, and Society of University Surgeons

Disclosure: Brystol Meyer Squibb StemCell Data Monitoring Committee Consulting fee Review panel membership; Stem Cells, Inc Consulting fee Review panel membership; Up To Date contracted Author; Novartis Honoraria Consulting; Genentech/Valcyte Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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Number of candidates on the intestine waiting list active at year-end (1997-2006).
Number of candidates on the intestine waiting list by age at year-end (1997-2006).
Median time to transplant for new intestine waiting list registration (1998-2006).
Isolated small bowel graft.
Liver-small bowel graft, including the pancreas.
Multivisceral graft, including stomach-liver-pancreas-small bowel and right colon.
Isolated intestinal transplant. A gastrostomy tube, jejunostomy tube, and loop ileostomy are in place.
 
 
 
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