Intestinal and Multivisceral Transplantation 

  • Author: Richard K Gilroy, MBBS, FRACP; Chief Editor: Ron Shapiro, MD   more...
 
Updated: Aug 9, 2011
 

Background

Until recently, parenteral nutrition was the standard of care for all patients with intestinal failure. The success of kidney, liver, and heart transplantation has increased with the advent and application of new antirejection medications coupled with improved surgical techniques. Advances in intestinal transplantation, by contrast, have been slow to develop until recently. At the turn of the 20th century, Alexis Carrel demonstrated the technical feasibility of intestinal transplantation; however, acute allograft rejection was an insurmountable obstacle in the absence of immunosuppressive medications.[1] In the 1960s, surgeons demonstrated renewed interest in intestinal transplantation following early successes with kidney transplantation. This interest rapidly waned as the inadequacy of the immunosuppressive medications available at the time became apparent.

Total parenteral nutrition (TPN) became available in 1969, with a number of patients relying on it for complete support. At first, all patients on TPN required continuous hospitalization. Today, TPN is safely used in outpatient management. Pooled data from the North American Home Parental and Enteral Patient Registry show 1- and 4-year survival rates for patients with short bowel syndrome (SBS) who received TPN at home to be 94% and 80%, respectively. Only 5-11% of deaths were directly attributed to TPN, with the vast majority of deaths related to progression of the underlying primary disease.

The success of TPN supplanted the then urgent need to find solutions for the problems with intestinal transplantation, and TPN became the standard of care. Recently, however, intestinal transplantation has been offered to that minority of the patients on long-term TPN who have severe and life-threatening complications related to this therapy.[2, 3] This restricted indication is, however, likely to be broadened as a consequence of the improved patient and graft survival and cost-effectiveness data that have been seen in the last few years.

The complications of long-term TPN are listed below. Those marked (**) are also indications for intestinal transplantation:

  • Infection
    • Catheter sepsis (recurrent**)
    • Exit-site infection
    • Tunnel infection
  • Catheter occlusion
    • Thrombosis (≥ 2 access sites**)
    • Dislodgment or breakage
    • Mineral or lipid precipitate
  • Hepatic disease (15-40% after 3 y)
    • Hepatic steatosis (most common finding)
    • Cholestasis
    • Phospholipidosis
    • Progressive fibrosis**
    • Cirrhosis**
  • Renal disease
    • Electrolyte disturbance
    • Decreased glomerular filtration rate**
    • Recurrent acute renal failure**
    • Tubular dysfunction
  • Gastrointestinal disease
    • Gastroparesis
    • Bacterial overgrowth
    • Disuse enteritis
    • Intestinal hypoplasia
  • Metabolic bone disease
    • Osteomalacia
    • Osteoporosis
  • Biliary disease (up to 100% after 6 wk)
    • Biliary sludge (almost universal)
    • Gallstones
Next

History of the Procedure

Intestinal transplantation achieved a clear recognition in the management of complicated total parenteral nutrition (TPN) with Medicare approval (see below). The relatively brief history of this procedure before this included dismal outcomes prior to 1990 and a moratorium during 1994 as a consequence of the high morbidity and mortality associated with the procedure. However, in 1995, rapid improvements in outcomes were seen as results of technical and immunosuppression development.

On the immunosuppression side, the introduction of tacrolimus was one of the cornerstones to success.[4] On the technical side, programs were guided by the recommendations developed by the American College of Surgeons in 1995. Growth since then has been exponential, as is well illustrated in the 2007 report of the Intestinal Transplant Registry.

Intestinal transplants by year. Image courtesy of Intestinal transplants by year. Image courtesy of the Intestinal Transplantation Registry (ITR).

By and large, this success is a consequence of multiple endeavors. These include progress in immunosuppressive therapy, refinement to surgical techniques,[5] improvement in post-transplant care, better understanding of intestinal immunology, and protocols implemented for anti-infectious monitoring and prophylaxis (primarily against cytomegalovirus [CMV] infection). These actions have translated to improvements in patient and graft survival over the last few years. With this, intestinal transplantation will soon be cost effective; this author believes that intestinal transplantation is not far away from supplanting TPN in the management of short bowel syndrome that requires long-term TPN. Data from Sudan support the cost-effectiveness following 2 years after transplantation.

On October 4, 2000, the US Health Care Financing Administration (HCFA) approved coverage by Medicare for intestinal transplantation. Medicare agreed to cover all types of intestinal transplants for patients with irreversible intestinal failure who have specific life-threatening complications (noted with ** above) from long-term intravenous nutrition and TPN. Medicare's criteria for approved centers include an annual volume of at least 10 intestinal transplants and a 1-year actuarial survival of at least 65%. The decision was important because most state Medicaid and other third-party payers in the United States followed suit and provided reimbursement for intestinal transplantation.

Previous
Next

Problem

Intestinal failure is a term applied to individuals who are unable to maintain adequate nutrition with an enteric diet. These patients require TPN to maintain energy (caloric) intake. The causes of intestinal failure include anatomic and functional abnormalities and, along with the population affected, are listed as follows:

Patients with SBS have insufficient small bowel length to support energy (caloric) needs; this typically occurs when at least 80% of the small intestine has been resected. Resection of less than 80% of the length of the bowel is generally accompanied by intestinal adaptation and subsequent enteral tolerance. Considerable interindividual variability occurs among patients. Some individuals may require TPN despite having less than 80% of their small intestine resected, while others may not require TPN after more extensive resections. This fact emphasizes the importance of trials of enteral tolerance and nutritional rehabilitation while assessing an individual with SBS (see Intestinal rehabilitation).

Additional factors that may help predict those likely to achieve enteral tolerance include younger age, the presence of an ileocecal valve, and the presence of an ileum. The functional causes of intestinal failure in those with normal bowel length include intestinal aganglionosis, chronic idiopathic intestinal pseudoobstruction, and congenital mucosal abnormalities such as microvillous inclusion disease.

Previous
Next

Indications

Indications for transplantation

The most common cause of death for individuals permanently dependent on TPN is liver failure. Steatohepatitis and cholelithiasis with or without associated cholecystitis are common in patients on TPN and warrant exclusion before the physician makes a diagnosis of TPN-induced liver disease. Advanced TPN-induced liver disease is irreversible; however, when it is identified early it is often reversible with discontinuation of TPN.

Progressive liver disease is more common in young children on TPN and is often associated with a history of multiple resections and recurrent infection. Progressive and irreversible liver disease develops in 2-42% of children and adults with intestinal failure due to SBS.[6, 7, 8, 9, 10] The development of liver disease may be related to enteric stasis, the ability to establish some degree of enteral tolerance, catheter-related sepsis, age, a history of prematurity, the extent of bowel resection, the presence of an underlying inflammatory condition, or the length of time on TPN.[11, 12, 13, 14, 8, 10] The mediators and pathways responsible for the progression of TPN-associated liver disease to end-stage liver disease remain undefined.

Two other causes of life-threatening complications in patients with intestinal failure include recurring sepsis and loss of vascular access due to venous thrombosis.[15, 14] These problems are often concomitant. Sepsis associated with indwelling catheters is more common in children; in some patients, recurrent sepsis is related to gastrointestinal stasis and bacterial overgrowth. Overall, the mortality rate associated with catheter-related sepsis has progressively diminished with the introduction of flexible, silastic, silicone rubber catheters; tunneled, cuffed catheters; and improved line care.[16, 17, 18]

Less common indications for intestinal transplantation include locally invasive desmoid tumors, premalignant conditions (Gardener syndrome), and fluid and electrolyte losses unmanageable with TPN.[19]

In summary, intestinal transplantation is a salvage procedure applied to patients who have either anatomic or functional diseases that preclude enteral tolerance (eg, intestinal failure) and have life-threatening complications of TPN such as progressive liver disease, a history of catheter-related sepsis, or loss of vascular access.[20, 19] It cannot be overemphasized that measures to augment intestinal function and minimize the risk of complications of parenteral nutrition (PN) must be explored in every patient on PN to avoid the need for this procedure.

To illustrate the problems faced in the setting of intestinal transplantation, an illustration of the variables and the impact of these upon the patient need to be presented.

  • Patients who are admitted from home for their transplant procedure have better survival rates than those who are inpatients at the time they are taken to the transplant procedure. Some vascular access to the central system is required for the procedure. Loss of access potentially complicates the procedure by limiting alternative sites for central access at the time of transplantation and posttransplantation. This central access is important for the provision of perioperative PN and is essential for resuscitation and the fluid and medication maintenance required for transplantation. At some centers, clinicians have decided that the transplantation cannot be performed if all upper and lower central access is lost, which illustrates the necessity for referral if vascular access loss develops. Access loss of 2 major access sites is generally an indication for intestinal transplantation.
  • Patients with a significant loss to central vascular access may lose eligibility for transplantation. This illustrates the necessity of referral if vascular access loss begins to develop.
  • Advanced liver disease may not preclude isolated intestinal transplantation; however, in the presence of advanced liver disease, isolated intestinal transplantation may not be possible.
  • Waiting list mortality is higher in those awaiting LSBT than in those awaiting isolated liver transplantation or isolated bowel transplantation.

Patient evaluation

The goals of patient evaluation for intestinal transplantation are as follows:

  • Establish the primary diagnosis.
  • Evaluate and document TPN complications experienced by the patient.
  • Establish the length and function of the remnant native intestine.
  • Assess the function of the remnant intestine and potential for establishing enteral tolerance.
  • Determine the degree of liver dysfunction and the potential for reversibility.
  • Identify any comorbid conditions that may impact upon the outcome of intestinal transplantation, and identify potential problems (eg, thrombosis of major vessels).
  • Assess candidate suitability (including families) for the rigors of intestinal transplantation and the ability to comply with the often complex posttransplant regimens.[21]

One critical aspect of the evaluation process is to determine whether the patient's intestinal failure is potentially reversible. Most information regarding nutritional assessment comes from a carefully obtained patient history. Particular attention is given to TPN regimens, prior attempts to achieve enteral tolerance, current enteral feeding protocols, growth, development, and exclusion of nutritional deficiencies. Multidisciplinary consultation with experienced pediatric nutritionists, gastroenterologists, and hepatologists is invaluable before determining the presence or absence of nutritional deficiencies and complications from long-term TPN. Many routine screening studies are listed in Workup.

In addition to a thorough history and review of operative records, evaluation of the length and function of the remnant native bowel is further accomplished through radiographic contrast studies. These studies help delineate the length of the remaining small bowel, its anatomic location, the presence or absence of the ileocecal valve, the caliber of the remaining small and large intestine, and the transit time from the proximal to distal bowel. These studies also may help define surgically correctable diseases that permit enteral tolerance without transplantation. Occasionally, additional motility studies are necessary.

The medical and surgical team must be rigorous when establishing the presence of intestinal failure and when defining its cause because Munchausen syndrome by proxy has been reported in an intestinal transplant recipient.[22] For patients with functional disease, review of histopathologic findings following bowel biopsy is important to confirm the diagnosis and extent of bowel involvement.

During the assessment of TPN complications, the physician must decide whether a patient's TPN-related liver disease is reversible. This decision may be difficult, and considerations include liver biopsy findings and the likelihood of progression during the waiting period. The presence of dense, bridging fibrosis may prompt consideration of LSB transplantation. Minor amounts of fibrosis associated with cholestasis may allow ISB transplantation. However, if rapid progression of the disease is observed and a long waiting period is anticipated (eg, small infants), combined listing for LSB transplantation may be indicated.

An assessment for manifestations of portal hypertension is important, although diminished mesenteric blood flow secondary to the short remnant intestinal length provides protection against varices. Increasing splenomegaly, cytopenia, dilated superficial abdominal veins, and bleeding from gastrostomy sites or stomata provide clues to the presence of portal hypertension. The bilirubin level alone is not a good indicator of whether ISB or LSB transplantation is indicated. ISB transplantation in jaundiced patients has been shown to reverse liver disease, even in patients with a total bilirubin level of 20 mg/dL at the time of transplantation.[23]

Doppler ultrasonography is used to assess venous access and to determine the patency of the central veins. Intestinal transplantation is considered when the patient has lost 2 or more common venous access sites, such as the subclavian or internal jugular veins, or when unconventional sites such as the right atrial, transhepatic, or direct inferior vena caval catheters are required.

Patient history and previous records should reveal the number and type of organisms responsible for previous central venous line infections. Fungal infections requiring mechanical ventilation or vasopressor support are most worrisome.[24, 15] Furthermore, a history of infection with multidrug-resistant organisms should raise concern for future mortality and should be considered in the overall assessment.

Comorbid conditions can greatly increase the likelihood of complications in the posttransplant period. Specific evaluations of other organ systems are dictated by patient history and are further directed by any abnormalities identified from the results of baseline studies. For example, intestinal failure as a consequence of necrotizing enterocolitis may be associated with a history of prolonged neonatal ventilation and bronchopulmonary dysplasia. These conditions are associated with repeated hospitalizations and a propensity for prematurity in infants, which may give rise to behavioral and developmental problems that should be identified and addressed as early as possible. However, controlled trials to support this are lacking. The authors strongly believe that early intervention facilitates posttransplant recovery and that such interventions are important. Portions of these evaluations are incorporated into the psychosocial assessment of the patient and the patient's support system.

Previous
Next

Relevant Anatomy

Relevant donor anatomy

For isolated intestinal transplantation, en bloc removal of the donor intestine commences at the pylorus and proceeds as far as the terminal ileum.

Anatomy of the donor operation, with procurement oAnatomy of the donor operation, with procurement of the liver, small bowel, pancreas, and spleen en bloc (AO, thoracic aorta; HA, hepatic artery; PV, portal vein; CBD, common bile duct; D1, first part of the duodenum; TI, terminal ileum).

Inclusion of the colon in the graft has been associated with worse patient survival, presumably because of increased septic complications as demonstrated by researchers from the University of Pittsburgh. Inclusion of the stomach has been associated with poor gastric motility (personal communications). The superior mesenteric artery and vein provide the blood supply to the organ.

When performing a combined LSB transplantation, the duodenum and head of the pancreas are retained in the allograft. In preparation for multivisceral transplantation, other abdominal organs are obtained at the time of intestinal procurement, most commonly the entire donor pancreas.

The allograft is prepared in the operating room before implantation.

The recipient's requirements dictate which technique should be performed; these requirements are described later. For all recipients, bowel continuity is the ultimate goal, and proximal and distal enteric anastomoses are performed at the time of allograft implantation.

A more comprehensive outline of these procedures is available in the 1999 article by DeRoover and Langnas.[25]

Previous
Next

Contraindications

Although not absolute contraindications to transplantation, the following is a list of conditions and situations in which transplantation may be contraindicated:

  • Profound disabilities that are not likely to be corrected by transplantation
  • Severe extraintestinal illnesses that are not likely to be corrected by transplantation
  • Uncontrolled sepsis
  • Immunodeficiency (with the possible exception of immunodeficiency associated with multiple intestinal atresia)
  • Nonresectable or disseminated malignancy (including large hepatoma)
  • Complete loss of vascular access or insufficient central access sites (lack of central access during transplantation and during the early posttransplantation period)
  • Absence of psychosocial support or willingness to comply with posttransplant regimens
Previous
Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Richard K Gilroy, MBBS, FRACP  Associate Professor, Medical Director of Liver Transplantation and Hepatology, Department of Internal Medicine, Kansas University Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jean Frederick Botha, MBBCh, FCS(SA)  Assistant Professor of Surgery, Transplant Surgeon, Department of Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Debra L Sudan, MD  Professor of Surgery, Chief, Abdominal Transplant Surgery, Vice Chair of Clinical Operations, Department of Surgery, Duke University School of Medicine

Debra L Sudan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Association of Women Surgeons, Association of Women Surgeons, International Liver Transplantation Society, Nebraska Medical Association, Society for Surgery of the Alimentary Tract, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Debra L Sudan, MD  Professor of Surgery, Chief, Abdominal Transplant Surgery, Vice Chair of Clinical Operations, Department of Surgery, Duke University School of Medicine

Debra L Sudan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Association of Women Surgeons, Association of Women Surgeons, International Liver Transplantation Society, Nebraska Medical Association, Society for Surgery of the Alimentary Tract, and Society of University Surgeons

Disclosure: Nothing to disclose.

Chief Editor

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: Astellas Honoraria Speaking and teaching; Brystol Meyer Squibb StemCell Data Monitoring Committee Consulting fee Review panel membership; Wyeth Honoraria Speaking and teaching; Stem Cells, Inc Consulting fee Review panel membership; Up To Date contracted Author

Acknowledgments

Dr. Wendy Grant, Assistant Professor of Surgery, Section of Transplantation, University of Nebraska Medical Center, for providing the multimedia images in this article.

The Intestinal Transplantation Registry (ITR) for providing the charts in this article.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sandeep Mukherjee, MD, to the development and writing of this article.

References

  1. Carrel A. The transplantation of organs. A preliminary communication. JAMA. 1905;45:1654.

  2. Fryer JP. The current status of intestinal transplantation. Curr Opin Organ Transplant. Jun 2008;13(3):266-72. [Medline].

  3. Sauvat F, Fusaro F, Lacaille F, et al. Is intestinal transplantation the future of children with definitive intestinal insufficiency?. Eur J Pediatr Surg. Dec 2008;18(6):368-71. [Medline].

  4. Abu-Elmagd K, Reyes J, Bond G, et al. Clinical intestinal transplantation: a decade of experience at a single center. Ann Surg. Sep 2001;234(3):404-16; discussion 416-7. [Medline].

  5. Selvaggi G, Tzakis AG. Small bowel transplantation: technical advances/updates. Curr Opin Organ Transplant. Jun 2009;14(3):262-6. [Medline].

  6. Colomb V, Goulet O, De Potter S, Ricour C. Liver disease associated with long-term parenteral nutrition in children. Transplant Proc. Jun 1994;26(3):1467. [Medline].

  7. Sondheimer JM, Asturias E, Cadnapaphornchai M. Infection and cholestasis in neonates with intestinal resection and long-term parenteral nutrition. J Pediatr Gastroenterol Nutr. Aug 1998;27(2):131-7. [Medline].

  8. Chan S, McCowen KC, Bistrian BR, et al. Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition. Surgery. Jul 1999;126(1):28-34. [Medline].

  9. Wasa M, Takagi Y, Sando K, et al. Long-term outcome of short bowel syndrome in adult and pediatric patients. JPEN J Parenter Enteral Nutr. Sep-Oct 1999;23(5 Suppl):S110-2. [Medline].

  10. Cavicchi M, Beau P, Crenn P, et al. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. Apr 4 2000;132(7):525-32. [Medline].

  11. Bowyer BA, Fleming CR, Ludwig J, et al. Does long-term home parenteral nutrition in adult patients cause chronic liver disease?. JPEN J Parenter Enteral Nutr. Jan-Feb 1985;9(1):11-7. [Medline].

  12. Stokes MA, Irving MH. Mortality in patients on home parenteral nutrition. JPEN J Parenter Enteral Nutr. Mar-Apr 1989;13(2):172-5. [Medline].

  13. Wolf A, Pohlandt F. Bacterial infection: the main cause of acute cholestasis in newborn infants receiving short-term parenteral nutrition. J Pediatr Gastroenterol Nutr. Apr 1989;8(3):297-303. [Medline].

  14. Williams N, Scott NA, Irving MH. Catheter-related morbidity in patients on home parenteral nutrition: implications for small bowel transplantation. Ann R Coll Surg Engl. Nov 1994;76(6):384-6. [Medline].

  15. Burnes JU, O'Keefe SJ, Fleming CR, et al. Home parenteral nutrition--a 3-year analysis of clinical and laboratory monitoring. JPEN J Parenter Enteral Nutr. Jul-Aug 1992;16(4):327-32. [Medline].

  16. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet. Apr 1973;136(4):602-6. [Medline].

  17. Flowers RH 3rd, Schwenzer KJ, Kopel RF, et al. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial. JAMA. Feb 10 1989;261(6):878-83. [Medline].

  18. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. Mar 7 2000;132(5):391-402. [Medline].

  19. Grant D. Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry. Transplantation. Apr 15 1999;67(7):1061-4. [Medline].

  20. Howard L, Hassan N. Home parenteral nutrition. 25 years later. Gastroenterol Clin North Am. Jun 1998;27(2):481-512. [Medline].

  21. Lacaille F, Vass N, Sauvat F, et al. Long-term outcome, growth and digestive function in children 2 to 18 years after intestinal transplantation. Gut. Apr 2008;57(4):455-61. [Medline].

  22. Kosmach B, Tarbell S, Reyes J, Todo S. "Munchausen by proxy" syndrome in a small bowel transplant recipient. Transplant Proc. Oct 1996;28(5):2790-1. [Medline].

  23. Sudan DL, Kaufman SS, Shaw BW Jr, et al. Isolated intestinal transplantation for intestinal failure. Am J Gastroenterol. Jun 2000;95(6):1506-15. [Medline].

  24. Howard L, Heaphey L, Fleming CR, et al. Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. JPEN J Parenter Enteral Nutr. Jul-Aug 1991;15(4):384-93. [Medline].

  25. DeRoover A, Langnas A. Surgical methods of small bowel transplantation. Curr Opin Organ Transplant. 1999;4(4):335-42.

  26. Asfar S, Atkison P, Ghent C, et al. Small bowel transplantation. A life-saving option for selected patients with intestinal failure. Dig Dis Sci. May 1996;41(5):875-83. [Medline].

  27. Quigley EM. Small intestinal transplantation: reflections on an evolving approach to intestinal failure. Gastroenterology. Jun 1996;110(6):2009-12. [Medline].

  28. Fishbein TM, Florman S, Gondolesi G, et al. Intestinal transplantation before and after the introduction of sirolimus. Transplantation. 2002;73(10):1538-42. [Medline].

  29. O'Keefe S, et al. Teduglutide, a Novel GLP-2 Analog, in the Management of Short Bowel Syndrome (SBS) Patients Dependent On Parenteral Nutrition: a Multicenter, Multinational Placebo-Controlled Clinical Trial. Clinical Science Plenary Session, Digestive Diseases Week, 2008. Available at http://www.drugs.com/clinical_trials/phase-3-gattex-results-presented-annual-digestive-week-congress-highlight-potential-new-short-bowel-4346.html. Accessed June 12, 2009.

  30. Jeppesen PB, et al. Abstract #906. Teduglutide, a Novel Analogue of Glucagon-like Peptide 2#906 (GLP-2), Is Effective and Safe in Reducing Parenteral Support Volume in Short Bowel Syndrome–Intestinal Failure Subjects: Results From a 24-Week, Placebo-Controlled Phase 3 Trial). DDW. 2011.

  31. Kato T, Selvaggi G, Gaynor JJ, et al. Inclusion of donor colon and ileocecal valve in intestinal transplantation. Transplantation. Jul 27 2008;86(2):293-7. [Medline].

  32. Matsumoto CS, Kaufman SS, Fishbein TM. Inclusion of the colon in intestinal transplantation. Curr Opin Organ Transplant. Jun 2011;16(3):312-5. [Medline].

  33. [Best Evidence] O'Keefe SJ, Emerling M, Koritsky D, Martin D, Stamos J, Kandil H, et al. Nutrition and quality of life following small intestinal transplantation. Am J Gastroenterol. May/2007;102(5):1093-100. [Medline].

  34. Todo S, Reyes J, Furukawa H, et al. Outcome analysis of 71 clinical intestinal transplantations. Ann Surg. Sep 1995;222(3):270-80; discussion 280-2. [Medline].

  35. Furukawa H, Kusne S, Abu-Elmagd K, et al. Effect of CMV serology on outcome after clinical intestinal transplantation. Transplant Proc. Oct 1996;28(5):2780-1. [Medline].

  36. Reynolds DW, Stagno S, Reynolds R, Alford CA Jr. Perinatal cytomegalovirus infection: influence of placentally transferred maternal antibody. J Infect Dis. May 1978;137(5):564-7. [Medline].

  37. Cohen Z, Silverman RE, Wassef R, et al. Small intestinal transplantation using cyclosporine. Report of a case. Transplantation. Dec 1986;42(6):613-21. [Medline].

  38. Masetti M, Rodriguez MM, Thompson JF, et al. Multivisceral transplantation for megacystis microcolon intestinal hypoperistalsis syndrome. Transplantation. Jul 27 1999;68(2):228-32. [Medline].

  39. de Ville de Goyet J, Mitchell A, Mayer AD, et al. En block combined reduced-liver and small bowel transplants: from large donors to small children. Transplantation. Feb 27 2000;69(4):555-9. [Medline].

  40. Karatzas T, Khan F, Tzakis AG. Clinical intestinal transplantation: experience in Miami. Transplant Proc. May 1997;29(3):1787-9. [Medline].

  41. Reyes J, Bueno J, Kocoshis S, et al. Current status of intestinal transplantation in children. J Pediatr Surg. Feb 1998;33(2):243-54. [Medline].

  42. Herlenius G, Fagerlind M, Krantz M, et al. Chronic kidney disease--a common and serious complication after intestinal transplantation. Transplantation. Jul 15 2008;86(1):108-13. [Medline].

  43. Abu-Elmagd K, Reyes J, Todo S, et al. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg. May 1998;186(5):512-25; discussion 525-7. [Medline].

  44. Sudan DL, Kaufman S, Horslen S, et al. Incidence, timing, and histologic grade of acute rejection in small bowel transplant recipients. Transplant Proc. Sep 2000;32(6):1199. [Medline].

  45. Rana A, Robles S, Russo MJ, et al. The combined organ effect: protection against rejection?. Ann Surg. Nov 2008;248(5):871-9. [Medline].

  46. Kusne S, Furukawa H, Abu-Elmagd K, et al. Infectious complications after small bowel transplantation in adults: an update. Transplant Proc. Oct 1996;28(5):2761-2. [Medline].

  47. Green M, Reyes J, Nour B, et al. Early infectious complications of liver-intestinal transplantation in children: preliminary analysis. Transplant Proc. Jun 1994;26(3):1420-1. [Medline].

  48. Manez R, Kusne S, Green M, et al. Incidence and risk factors associated with the development of cytomegalovirus disease after intestinal transplantation. Transplantation. Apr 15 1995;59(7):1010-4. [Medline].

  49. Nalesnik MA, Jaffe R, Starzl TE, et al. The pathology of posttransplant lymphoproliferative disorders occurring in the setting of cyclosporine A-prednisone immunosuppression. Am J Pathol. Oct 1988;133(1):173-92. [Medline].

  50. Nalesnik M, Reyes J, Mazieriegos G, et al. Posttransplant lymphoproliferative disorders (PTLD) in small bowel allograft recipients. Presented at: Sixth International Small Bowel Transplant Symposium. University of Pittsburgh Medical Center; Pittsburgh, Pa:. 1999.

  51. Elstrom RL, Andreadis C, Aqui NA, et al. Treatment of PTLD with rituximab or chemotherapy. Am J Transplant. Mar 2006;6(3):569-76. [Medline].

  52. Lee JJ, Lam MS, Rosenberg A. Role of chemotherapy and rituximab for treatment of posttransplant lymphoproliferative disorder in solid organ transplantation. Ann Pharmacother. Oct 2007;41(10):1648-59. [Medline].

  53. Vianna RM, Mangus RS, Fridell JA, Weigman S, Kazimi M, Tector J. Induction immunosuppression with thymoglobulin and rituximab in intestinal and multivisceral transplantation. Transplantation. May 15 2008;85(9):1290-3. [Medline].

  54. Pirenne J, Gruessner AC, Benedetti E, et al. Donor-specific unmodified bone marrow transfusion does not facilitate intestinal engraftment after bowel transplantation in a porcine model. Surgery. Jan 1997;121(1):79-88. [Medline].

  55. Matsumoto S, Tanaka S, Orita K. Effect of donor pretreatment on graft-versus-host disease (GVHD) after rat small-bowel transplantation (SBTX). Transplant Proc. Aug 1994;26(4):2306-8. [Medline].

  56. Bacigalupo A, van Lint MT, Frassoni F, et al. High dose bolus methylprednisolone for the treatment of acute graft versus host disease. Blood. Mar 1983;46(3):125-32. [Medline].

  57. Ojo AO, Held PJ, Port FK, et al. Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med. 2003;349(10):931-40. [Medline].

  58. Rovera GM, DiMartini A, Schoen RE, et al. Quality of life of patients after intestinal transplantation. Transplantation. Nov 15 1998;66(9):1141-5. [Medline].

  59. Sudan DL, Iverson A, Weseman RA, et al. Assessment of function, growth and development, and long-term quality of life after small bowel transplantation. Transplant Proc. Sep 2000;32(6):1211-2. [Medline].

  60. Grant D, Abu-Elmagd K, Reyes J, et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. Apr 2005;241(4):607-13.

  61. Fishbein TM, Schiano T, LeLeiko N, et al. An integrated approach to intestinal failure: results of a new program with total parenteral nutrition, bowel rehabilitation, and transplantation. J Gastrointest Surg. Jul-Aug 2002;6(4):554-62.

  62. Matarese LE, Seidner DL, Steiger E, Fazio V. Practical guide to intestinal rehabilitation for postresection intestinal failure: a case study. Nutr Clin Pract. 2005;20(5):551-8. [Medline].

  63. Higham SE, Read NW. Effect of ingestion of fat on ileostomy effluent. Gut. 1990;31(4):435-8. [Medline].

  64. Haderslev KV, Tjellesen L, Sorensen HA, Staun M. Effect of cyclical intravenous clodronate therapy on bone mineral density and markers of bone turnover in patients receiving home parenteral nutrition. Am J Clin Nutr. 2002;76(2):482-8. [Medline].

  65. [Best Evidence] Byrne TA, Wilmore DW, Iyer K. Growth hormone, glutamine, and an optimal diet reduces parenteral nutrition in patients with short bowel syndrome: a prospective, randomized, placebo-controlled, double-blind clinical trial. Ann Surg. 2005;242(5):655-61. [Medline].

  66. Jeppesen PB, Sanguinetti EL, Buchman A, et al. Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant glucagon-like peptide 2 analogue, improves intestinal function in short bowel syndrome patients. Gut. Sep 2005;54(9):1224-31.

  67. Bianchi A. Autologous gastrointestinal reconstruction. Semin Pediatr Surg. Feb 1995;4(1):54-9.

  68. Kim HB, Lee PW, Garza J, et al. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr Surg. Jun 2003;38(6):881-5.

  69. Howard L, Ament M, Fleming CR, et al. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States. Gastroenterology. Aug 1995;109(2):355-65. [Medline].

  70. Reyes J, Fishbein T, Bueno J, et al. Reduced-size orthotopic composite liver-intestinal allograft. Transplantation. Aug 27 1998;66(4):489-92. [Medline].

  71. Sigalet DL, Williams DC, Garola R, et al. Impact of FK506 and steroids on adaptation after intestinal resection or segmental transplantation. Pediatr Transplant. Feb 2000;4(1):12-20. [Medline].

  72. Muiesan P, Dhawan A, Novelli M, et al. Isolated liver transplant and sequential small bowel transplantation for intestinal failure and related liver disease in children. Transplantation. Jun 15 2000;69(11):2323-6. [Medline].

  73. Kato T, Selvaggi G, Gaynor JJ, et al. Inclusion of donor colon and ileocecal valve in intestinal transplantation. Transplantation. Jul 27 2008;86(2):293-7. [Medline].

  74. Abu-Elmagd KM, Reyes J, Fung JJ, et al. Evolution of clinical intestinal transplantation: improved outcome and cost effectiveness. Transplant Proc. Feb-Mar 1999;31(1-2):582-4. [Medline].

  75. Gupte GL, Beath SV, Protheroe S, et al. Improved outcome of referrals for intestinal transplantation in the UK. Arch Dis Child. 2007;92(2):147-52. [Medline].

  76. Schalamon J, Mayr JM, Hollwarth ME. Mortality and economics in short bowel syndrome. Best Pract Res Clin Gastroenterol. 2003;17(6):931-42. [Medline].

  77. Abu-Elmagd KM. Intestinal transplantation for short bowel syndrome and gastrointestinal failure: current consensus, rewarding outcomes, and practical guidelines. Gastroenterology. Feb 2006;130(2 Suppl 1):S132-7.

  78. Ahmed R, Segal I, Hassan H. Fermentation of dietary starch in humans. Am J Gastroenterol. 2000;95(4):1017-20. [Medline].

  79. Alican F, Hardy JD, Cayirli M, et al. Intestinal transplantation: laboratory experience and report of a clinical case. Am J Surg. Feb 1971;121(2):150-9. [Medline].

  80. Broviac JW, Scribner BH. Prolonged parenteral nutrition in the home. Surg Gynecol Obstet. Jul 1974;139(1):24-8. [Medline].

  81. Buchman AL. Etiology and initial management of short bowel syndrome. Gastroenterology. Feb 2006;130(2 Suppl 1):S5-S15.

  82. Buchman AL, Iyer K, Fryer J. Parenteral nutrition-associated liver disease and the role for isolated intestine and intestine/liver transplantation. Hepatology. Jan 2006;43(1):9-19.

  83. Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology. Apr 2003;124(4):1111-34.

  84. Carson KL, Hunt CM. Medical problems occurring after orthotopic liver transplantation. Dig Dis Sci. Aug 1997;42(8):1666-74. [Medline].

  85. Colomb V, De Potter S, Goulet O, et al. Potential candidates for small bowel transplantation in pediatric patients on home parenteral nutrition. Transplant Proc. Oct 1996;28(5):2698. [Medline].

  86. Connor FL, Di Lorenzo C. Chronic intestinal pseudo-obstruction: assessment and management. Gastroenterology. Feb 2006;130(2 Suppl 1):S29-36.

  87. Fishbein T, Schiano T, Jaffe D, et al. Isolated intestinal transplantation in adults with non-reconstructible GI tract. Presented at: Sixth International Small Bowel Transplant Symposium. New York, NY: The Recanati/Miller Transplantation Institute; Mount Sinai Hospital; 1999.

  88. Gambarara M, Goulet O, Bagolan P, et al. Long-term parenteral nutrition in the management of extremely short bowel syndrome. Transplant Proc. Sep 1998;30(6):2539-40. [Medline].

  89. Garcia M, Weppler D, Mittal N, et al. Campath-1H immunosuppressive therapy reduces incidence and intensity of acute rejection in intestinal and multivisceral transplantation. Transplant Proc. Mar 2004;36(2):323-4. [Medline].

  90. Gondolesi G, Fishbein T, Chehade M, et al. Serum citrulline is a potential marker for rejection of intestinal allografts. Transplant Proc. May 2002;34(3):918-20.

  91. Goulet OJ, Revillon Y, Cerf-Bensussan N, et al. Small intestinal transplantation in a child using cyclosporine. Transplant Proc. Jun 1988;20(3 Suppl 3):288-96. [Medline].

  92. Grant D, Lamont D, Zhong R, et al. 51Cr-EDTA: a marker of early intestinal rejection in the rat. J Surg Res. May 1989;46(5):507-14. [Medline].

  93. Grant D, Wall W, Mimeault R, et al. Successful small-bowel/liver transplantation. Lancet. Jan 27 1990;335(8683):181-4. [Medline].

  94. Gross TG, Hinrichs SH, Winner J, et al. Treatment of post-transplant lymphoproliferative disease (PTLD) following solid organ transplantation with low-dose chemotherapy. Ann Oncol. Mar 1998;9(3):339-40. [Medline].

  95. Hanto DW, Fishbein TM, Pinson CW, et al. Liver and intestine transplantation: summary analysis, 1994-2003. Am J Transplant. Apr 2005;5(4 Pt 2):916-33.

  96. Horslen SP, Kaufman SS, Sudan DL, et al. Isolated liver transplantation in infants with total parenteral nutrition-associated end-stage liver disease. Transplant Proc. Sep 2000;32(6):1241. [Medline].

  97. Howard L, Malone M. Current status of home parenteral nutrition in the United States. Transplant Proc. Oct 1996;28(5):2691-5. [Medline].

  98. Iyer K, Kaufman S, Sudan D, et al. Long-term results of intestinal transplantation for pseudo-obstruction in children. J Pediatr Surg. Jan 2001;36(1):174-7. [Medline].

  99. Iyer KR, Horslen S, Torres C, et al. Functional liver recovery parallels autologous gut salvage in short bowel syndrome. J Pediatr Surg. Mar 2004;39(3):340-4; discussion 340-4.

  100. Jeppesen PB. Glucagon-like peptide-2: update of the recent clinical trials. Gastroenterology. Feb 2006;130(2 Suppl 1):S127-31.

  101. [Best Evidence] Jeppesen PB, Gilroy R, Pertkiewicz M, Allard JP, Messing B, O'Keefe SJ. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut. 2011 Feb 11. [Epub ahead of print]. [Medline].

  102. Jeppesen PB, Hartmann B, Thulesen J, et al. Glucagon-like peptide 2 improves nutrient absorption and nutritional status in short-bowel patients with no colon. Gastroenterology. Mar 2001;120(4):806-15.

  103. Kato T, O'Brien CB, Nishida S, et al. The first case report of the use of a zoom videoendoscope for the evaluation of small bowel graft mucosa in a human after intestinal transplantation. Gastrointest Endosc. Aug 1999;50(2):257-61. [Medline].

  104. Kimura T, Lauro A, Cescon M, et al. Impact of induction therapy on bacterial infections and long-term outcome in adult intestinal and multivisceral transplantation: a comparison of two different induction protocols: daclizumab vs. alemtuzumab. Clin Transplant. Jun-Jul 2009;23(3):420-5. [Medline].

  105. Lawrence JP, Dunn SP, Billmire DF, et al. Isolated liver transplantation for liver failure in patients with short bowel syndrome. J Pediatr Surg. Jun 1994;29(6):751-3. [Medline].

  106. Lee RG, Nakamura K, Tsamandas AC, et al. Pathology of human intestinal transplantation. Gastroenterology. Jun 1996;110(6):1820-34. [Medline].

  107. Lillehei RC, Idezuki Y, Feemster JA, et al. Transplantation of stomach, intestine, and pancreas: experimental and clinical observations. Surgery. Oct 1967;62(4):721-41. [Medline].

  108. Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K. Short bowel syndrome: clinical guidelines for nutrition management. Nutr Clin Pract. 2005;20(5):493-502. [Medline].

  109. Mazariegos GV, Soltys K, Bond G, et al. Pediatric intestinal retransplantation: techniques, management, and outcomes. Transplantation. Dec 27 2008;86(12):1777-82. [Medline].

  110. Messing B, Lemann M, Landais P, et al. Prognosis of patients with nonmalignant chronic intestinal failure receiving long-term home parenteral nutrition. Gastroenterology. Apr 1995;108(4):1005-10. [Medline].

  111. Murase N, Ye Q, Lee RG, et al. Immunomodulation of intestinal transplant with allograft irradiation and simultaneous donor bone marrow infusion. Transplant Proc. Feb-Mar 1999;31(1-2):565-6.

  112. Nousia-Arvanitakis S, Angelopoulou-Sakadami N, Metroliou K. Complications associated with total parenteral nutrition in infants with short bowel syndrome. Hepatogastroenterology. Apr 1992;39(2):169-72. [Medline].

  113. NPS Pharmaceuticals, Inc. New Findings Demonstrate Potential Benefits of GATTEX (teduglutide) in Phase 3 Study of Patients with Short Bowel Syndrome. Press Release. Available at http://finance.yahoo.com/news/New-Findings-Demonstrate-bw-15423422.html?. Accessed June 15, 2009.

  114. O'Keefe SJ, Buchman AL, Fishbein TM, et al. Short bowel syndrome and intestinal failure: consensus definitions and overview. Clin Gastroenterol Hepatol. Jan 2006;4(1):6-10.

  115. Octavio Ruiz J, Lillehei RC. Intestinal transplantation. Surg Clin North Am. Aug 1972;52(4):1075-91. [Medline].

  116. Olivier G, Rettori R, Olivier C. Homotransplantation orthotopique de l'intestin grele et des colons droit et transverse chez l'homme. J Chir. 1969;98:331-40.

  117. Reyes J, Green M, Bueno J, et al. Epstein Barr virus associated posttransplant lymphoproliferative disease after intestinal transplantation. Transplant Proc. Oct 1996;28(5):2768-9. [Medline].

  118. Scolapio JS. Short bowel syndrome: recent clinical outcomes with growth hormone. Gastroenterology. Feb 2006;130(2 Suppl 1):S122-6.

  119. Scott NA, Irving MH. Intestinal failure--the clinical problem. Dig Dis. 1992;10(5):249-57. [Medline].

  120. Seguy D, Vahedi K, Kapel N, et al. Low-dose growth hormone in adult home parenteral nutrition-dependent short bowel syndrome patients: a positive study. Gastroenterology. Feb 2003;124(2):293-302.

  121. Shaffer D, Maki T, DeMichele SJ, et al. Studies in small bowel transplantation. Prevention of graft-versus-host disease with preservation of allograft function by donor pretreatment with antilymphocyte serum. Transplantation. Feb 1988;45(2):262-9. [Medline].

  122. Shike M, Harrison JE, Sturtridge WC, et al. Metabolic bone disease in patients receiving long-term total parenteral nutrition. Ann Intern Med. Mar 1980;92(3):343-50. [Medline].

  123. Shils ME, Wright WL, Turnbull A, Brescia F. Long-term parenteral nutrition through an external arteriovenous shunt. N Engl J Med. Aug 13 1970;283(7):341-4. [Medline].

  124. Sigalet DL, Kneteman NM, Fedorak RN, et al. Intestinal function following allogeneic small intestinal transplantation in the rat. Transplantation. Feb 1992;53(2):264-71. [Medline].

  125. Sigurdsson L, Reyes J, Kocoshis SA, et al. Intestinal transplantation in children with chronic intestinal pseudo- obstruction. Gut. Oct 1999;45(4):570-4. [Medline].

  126. Sindhi R, Fox IJ, Heffron T, et al. Procurement and preparation of human isolated small intestinal grafts for transplantation. Transplantation. Oct 27 1995;60(8):771-3. [Medline].

  127. Sindhi R, Landmark J, Shaw BW Jr, et al. Combined liver/small bowel transplantation using a blood group compatible but nonidentical donor. Transplantation. Jun 27 1996;61(12):1782-3. [Medline].

  128. Starzl TE, Rowe MI, Todo S, et al. Transplantation of multiple abdominal viscera. JAMA. Mar 10 1989;261(10):1449-57. [Medline].

  129. Sudan D. Cost and quality of life after intestinal transplantation. Gastroenterology. Feb 2006;130(2 Suppl 1):S158-62.

  130. Sudan D, DiBaise J, Torres C, et al. A multidisciplinary approach to the treatment of intestinal failure. J Gastrointest Surg. Feb 2005;9(2):165-76; discussion 176-7.

  131. Sudan DL, Iyer KR, DeRoover A, et al. A new technique for combined liver/small intestinal transplantation. Transplantation. Dec 15 2001;72(11):1846-8. [Medline].

  132. Thompson JS, DiBaise JK, Iyer KR, et al. Postoperative short bowel syndrome. J Am Coll Surg. Jul 2005;201(1):85-9.

  133. Timmermann W, Hoppe H, Gasser M, et al. Noninvasive videomicroscopic monitoring of rat small bowel rejection. Transplant Proc. Sep 1998;30(6):2660-1. [Medline].

  134. Tzakis AG, Kato T, Nishida S, et al. Preliminary experience with campath 1H (C1H) in intestinal and liver transplantation. Transplantation. Apr 27 2003;75(8):1227-31.

  135. Vanderhoof JA, Langnas AN. Short-bowel syndrome in children and adults. Gastroenterology. Nov 1997;113(5):1767-78. [Medline].

  136. Williams JW, Sankary HN, Foster PF, et al. Splanchnic transplantation. An approach to the infant dependent on parenteral nutrition who develops irreversible liver disease. JAMA. Mar 10 1989;261(10):1458-62. [Medline].

  137. Wilmore DW, Groff DB, Bishop HC, Dudrick SJ. Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J Pediatr Surg. Apr 1969;4(2):181-9. [Medline].

  138. Wisecarver JL, Cattral MS, Langnas AN, et al. Transfusion-induced graft-versus-host disease after liver transplantation. Documentation using polymerase chain reaction with HLA- DR sequence-specific primers. Transplantation. Aug 15 1994;58(3):269-71. [Medline].

 
Previous
Next
 
Anatomy of the donor operation, with procurement of the liver, small bowel, pancreas, and spleen en bloc (AO, thoracic aorta; HA, hepatic artery; PV, portal vein; CBD, common bile duct; D1, first part of the duodenum; TI, terminal ileum).
Small bowel recipient operation (AOI, interposition graft of aorta; AOII, Carrel patch bearing celiac trunk and superior mesenteric artery; AOIII, aortic end oversewn below superior mesenteric artery take-off; SV, native splenic vein; P, pancreas, with duct and parenchymal edge oversewn; PB, proximal bowel anastomosis; DB, distal ileocolonic anastomosis; LS, diverting loop ileostomy).
Back table operation with mesenteric vessels held within the forceps and the donor intestine within preservation solution.
Intestinal graft within the abdominal cavity of the recipient at the time of revascularization.
Revascularized bowel prior to closure. In the lower right corner the anastomosis between the donor small bowel and recipient remnant colon can be seen.
Picture of the liver and small bowel allograft. The liver is to the left of the picture, and the spleen can be seen lying within the loops of the small bowel (spleen is removed later).
Removal of the native liver. Left behind is the cavity into which the liver and small bowel allograft will be placed.
Postrevascularization image of the liver and small bowel allograft.
The allograft, prior to closure, positioned within the recipient's abdomen. The wedge-shaped excision (biopsy site) seen on the donor organ was performed at organ procurement. These biopsies are selectively performed to review the suitability of organs in instances where issues of suitability are raised.
Survival figures 2007. Image courtesy of the Intestinal Transplantation Registry (ITR).
PN cholestasis. (This is a reversible pathology at this point as an absence of fibrosis.)
Intestinal transplants by year. Image courtesy of the Intestinal Transplantation Registry (ITR).
Table 1. Proposed Immunosuppression Targets
MedicationDays 2-29Days 30-89Days 90-179Days 180-365After 1 year
Tacrolimus (monotherapy levels)15-20 ng/mL12-15 ng/mL10-12 ng/mL7-10 ng/mLTaper to around 5 ng/mL
Tacrolimus (in combination levels)10-15 ng/mL8-12 ng/mL8-10 ng/mL5-8 ng/mL2.5-5 ng/mL
Prednisone (dose)20 mg15 mg10 mg7.5 mg5 mg
Rapamycin (to be used only in combination with tacrolimus)6-10 ng/mL5-8 ng/mL5-8 ng/mL5-8 ng/mL5-8 ng/mL
Mycophenolic acid (suggested dose as listed and to be used only in combination with tacrolimus; dose listed is adult dose; intolerance may be managed by lowering dose) 1000 mg bid1000 mg bidCease unless renal indication exists......
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.