Is there a role for living donor intestine transplants?

Progress in Transplantation, Dec 2004 by Fryer, Jonathan, Angelos, Peter

The use of living donors with intestinal transplantation is controversial because it may not significantly improve candidate access to organs when intestine-only grafts are needed, and may involve excessive donor risk when combined liver-intestine grafts are required. Although limited data are available for comparison at this time, graft and patient survival rates for intestinal transplantations using living donors are no different than for deceased donor transplantations. Potential benefits that may be provided to the intestine transplant recipient through the use of living donors include better HLA matching, shorter ischemia times, better bowel preparation, and better opportunities for introducing immunomodulatory strategies. Conversely, living intestine donors are at risk for mortality, significant morbidity, financial loss, and psychologic trauma. The long-term outcomes of living intestine donors have not yet been reported. Ultimately, these data are essential before the wider use of living donors can be advocated for intestinal transplantation. (Progress in Transplantation. 2004;14:321-329)

Intestinal transplantation is a promising alternative to lifelong dependency on parenteral nutrition for patients with intestinal failure. However, its wider clinical application has been impeded by high posttransplant morbidity and mortality. The clinical results with intestinal transplantation have steadily improved, but still remain inferior to other organ allografts. Although the use of living donors has always been controversial in organ transplantation, the controversy associated with the use of living donors for intestine transplants is unique because waiting times for candidates requiring intestine-only transplants are relatively short. This article examines the issue of living donor use for intestinal transplantation.

History

Living donors have played an important role in the development of human organ transplantation. The first successful organ transplants were performed using kidneys from living donors because procuring organs from deceased donors was not yet an established practice.1 Furthermore, the lack of effective immunosuppression at the time warranted the optimal tissue matching provided by an identical twin. However, after utilization of deceased donor organs became a widely accepted practice, living donors continued to be used because the number of deceased donor organs available was inadequate to meet the needs of those waiting for transplants. Furthermore, the accumulative experience demonstrated that the use of living donor kidneys was safe for the donor and provided superior results for the recipients. Subsequently, the success with living donor kidney transplants and the critical shortage of deceased donor organs have led to the consideration of living donors for most other organ transplants.

Several of the earliest attempts at intestinal transplantation were also performed using living donors. Interestingly, the most encouraging results obtained with intestine transplants before the cyclosporine era involved living donors.2,3 When cyclosporine became available, several unsuccessful attempts with deceased donors were followed by the first successful isolated small bowel transplantation performed using a 60 cm segmental graft obtained from the half-sister of the recipient.4 When this and other early efforts5 demonstrated that clinical intestinal transplantation was feasible, larger series of intestinal transplantations were subsequently generated by a small number of transplant centers that were generally not advocates for the use of living donors. Furthermore, because the early results with intestine transplants were inferior to those achieved with other organs, consideration of living donors was generally considered less ethically acceptable. Therefore, the cumulative experience with intestinal transplantation, thus far, has primarily involved deceased donors. As other centers began to utilize living donors for liver, lung, and pancreas transplants, interest in living donor intestinal transplantation increased.

Since the first successful transplantation was performed,4 a modest number of intestinal transplantations have been performed using intestinal segments from living donors. Data on 32 transplantations performed with intestinal grafts from living donors and 957 performed with deceased donor intestines are provided by the International Intestinal Transplant Registry.6 Analysis of the registry data reveals no significant differences in patient and graft survivals between intestinal transplantations performed using deceased or living donors. Because of the small number of living donor transplants, the registry provides no subanalysis of this cohort with regard to issues such as graft function, donor and recipient age, length of small bowel grafts, HLA matching, cross-match, and incidence of rejection. Transplant centers have also published reports of individual cases or small series.7-14

Donor Selection