Indications for intestinal transplantation

Home parenteral nutrition is the primary treatment for patients with chronic intestinal failure. These patients have a high probability of long-term survival, but they may have also an increased risk of death due to factors related to parenteral nutrition or to the underlying disease that caused the intestinal failure. Intestinal rehabilitation programs based on medical treatments and non-transplant surgery can reverse intestinal failure in about one half of them. The risk of death after intestinal transplantation is higher than on home parenteral nutrition, mainly because of complications related to immunosuppressive therapy and of acute cellular rejection. A European prospective study on the survival probability and the causes of death on long-term home parenteral nutrition has identified liver failure, due to intestinal failure/parenteral nutrition associated liver disease, and invasive intra-abdominal desmoids as the only conditions associated with an increased risk of death on home parenteral nutrition and, therefore, the only indications for a life-saving intestinal transplantation. The other major complications of home parenteral nutrition, as well as the other causes of intestinal failure, were not associated with a statistically significant increased risk of death on home parenteral nutrition. For these conditions, a rehabilitative intestinal transplantation could be offered on a case-by-case basis, carefully selecting patients to avoid the risk of premature death following a transplant. The probability of survival after intestinal transplantation are increased in patients who are admitted directly from home to undergo transplantation, younger patients, those who receive a first transplant, and those who receive antibody induction therapy or maintenance sirolimus. These findings emphasize the timing of referral for transplantation and the importance of early referral of patients who are well enough to await transplantation at home and to tolerate aggressive In order to maximize the opportunity of weaning from home parenteral nutrition, to prevent major complications of the treatment, and to ensure timely intestinal transplantation when this is needed, an early referral of patients to intestinal rehabilitation centers with expertise in both medical and surgical treatment for IF, is recommended.