Intestinal transplantation. Experience in the United States

This review presents recent experience with intestinal transplantation in the United States and Canada. Indications are for combined liver and small intestinal transplantation irreversible intestinal failure and end-stage liver disease, and - for isolated intestinal transplantation - intestinal failure associated with severe progressive complications of parenteral nutrition. With a proportion of 80 %, short-bowel syndrome represents the major disease complex thus treated. Long-term graft and patient survival exceeds 50 % in large series with better outcome for isolated intestinal grafts than for combined liver and small-bowel transplants. Limiting factors are infections (responsible for 60 % of graft losses), frequently due to CMV or EBV, technical and management errors (22 %), and rejection (14 %). One of the main problems of immunosuppression is post-transplant lymphoproliferative disease with an incidence of 20 % which seems especially linked with EBV infections, OKT3 and steroids. The first line immunosuppressive agent nowadays used is tacrolimus. Trials with unmodified donor bone-marrow infusions to promote graft acceptance have not proved successful so far. Hopes for the future include increasing use of living related donors in order to overcome the shortage of donor organs, and continuing progress in immunosuppression.