Intestinal Transplantation Workup

Updated: Jan 18, 2017
  • Author: Colin P Dunn, MA; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Workup

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 the following:

  • Complete blood count (CBC)
  • Coagulation profile
  • Complete metabolic panel
  • ABO blood group determination
  • Human leukocyte antigen (HLA) status
  • Panel reactive antibody status
  • Screening for HIV and hepatitis B and C virus infection
  • 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. Since 2007, 23 points are added to patients' Pediatric End Stage Liver Disease (PELD) score if their liver disease is due to intestinal failure. [18] This is because patients with intestinal failure–associated liver disease (IFALD) have higher mortality rates on the transplant wait list.

A newer scoring system, the Pediatric Hepatology Score (PHD), has been shown to be more specific for the detection of wait list mortality than the PELD. [18] Developed in the United Kingdom, this scoring system has yet to become prevalent in the United States. [18]

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). [26]

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. Most often, the terminal ileum is used [27] . It is possible to remove the graft laparoscopically to minimize cosmetic concerns [28] . The ethics of living donation are important. The risks and benefits of the procedure should be discussed, including the risk of complications from graft removal. [29]

It is also important to consider that there have been mixed results when patients are surveyed about their quality of life following intestinal transplantation. [30, 31] When parents were questioned regarding their child’s quality of life, scores were lower than when children were directly surveyed. Children’s responses did not reach statistical significance when compared with a general pediatric population. Furthermore, when compared with prior quality of life assessments, patients tended to score more highly once they were transplanted.

While on the waiting list, the stable patient should be frequently reassessed, with specific attention given to any change in 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

Plasma Citrulline

Plasma citrulline levels have emerged as a measure for overall for intestinal health. Citrulline is made almost exclusively by enterocytes. Thus, clinicians can measure citrulline trends to assess whether a patient is indeed in intestinal failure and not recovering bowel function. [32, 33, 34] This would support a more urgent need for TPN, and possibly transplantation. A study by Lopez et al noted that citrulline values greater than 15 micromoles/liter could predict successful withdrawal of TPN. [35] It is important to note that citrulline is excreted from the kidneys; hence renal damage can obscure interpretation of results.

Workup for 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). Research indicates that intestinal transplantation virtual crossmatch is comparable in terms of 1 year survival with in vitro crossmatching. [36] Flow cytometry was used, survival, freedom from rejection, and graft survival were comparable in patients with a high donor-specific antibody level and controls.

If a suitable match cannot be found, patients can successfully reduce their hazardous antibody load via a protocol involving intravenous immune globulin (IVIg), and possibly plasmapheresis and rituximab prior to transplant. [37] 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 donor should have no previous history of significant intestinal pathology. As with all transplants, the donor should have no significant hemodynamic instability, sepsis, history of malignancy or chronic infection, severe hypoxia, or severe acidosis, and negative serology for human immunodeficiency virus (HIV) and hepatitis B and C is preferable.

CMV and EBV serologic status of the donors and recipients should be taken in consideration. Transplantation from 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).

Workup for living donors

A potential living donor also needs to be evaluated by a multidisciplinary team. As with any living donor procedure, possible complications including bleeding and death should be explained in great detail. The living donor should have a complete workup, including CBC, electrolytes, liver function tests, electrocardiogram, 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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