Is there a role for living donor intestine transplants?

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

Living donor transplantation also allows the procedure to be performed electively instead of under the semiemergent conditions that most deceased donor organ transplantations occur in. Consequently, transplantation will be less disruptive to the lives of the donor and recipient families because they have more time to prepare for the event. Second, a formal proper bowel preparation can be performed in the donor, and also in the recipient, if needed. Third, the medical team is likely to be better rested and less prone to cause errors.44 Finally, elective transplantations allow for greater versatility in the application of tolerogenic strategies such as simultaneous transplantation of donor bone marrow or stem cells or pretransplant administration of immunosuppressive agents.

Potential Disadvantages

Although the potential advantages of living donor intestinal transplantation will mostly be realized by the recipient, the potential disadvantages mainly apply to the donor. Little literature has addressed the post-operative course of the donor,45 and therefore the donor risks are largely undefined. However, it can be safely assumed that the donor evaluation and procedure will be disruptive to the donor's life. The donor process will mandate time away from work and family, and possibly some loss of earnings. Although in most circumstances the donor may be discharged from the hospital within 7 days,9,45 in some situations, it may take longer and any activity that requires significant exertion will have to be avoided for at least 6 weeks. The donor will experience some degree of pain and discomfort and this may be severe and/or prolonged in some individuals. Overall recovery may be expedited using minimally invasive techniques for intestine procurement.46 The donor will likely have some change in bowel habits after intestinal donation. Because donors have lost a significant segment of their intestine, most of them will have some degree of diarrhea and in some instances this may be severe. Donors may need to take antimotility drugs to control the diarrhea, which may be necessary for months or longer. Donors may develop fluid and/or electrolyte disorders mandating oral or intravenous supplementation, and donors may become vitamin B12 deficient and require monthly injections. Donors may also develop surgical complications including wound infections or disruptions, bowel obstructions, anastomotic leaks, or enterocutaneous fistulas. Although no reports of this exist thus far, a donor may require TPN and become an intestine transplant candidate if too much small bowel is removed. As with any patient undergoing a procedure under general anesthesia, donors may experience life-threatening complications including pulmonary embolus, aspiration pneumonia, anaphylactic shock, or cardiac arrhythmias.

Although the complication rate is not known for living intestine donors, 15% to 30% of living liver donors experience complications.47 Donors may also experience significant psychological trauma as a result of their experience. A significant percentage of living kidney donors reported that they were not fully informed before undergoing donation.48 As many as 13% have reported they felt they were pressured to donate, and in half of these donors the pressure was perceived to have come from the transplant team. Up to 50% of living donors considered the experience more painful than they had expected.49 Depression and anxiety may occur, especially if the transplantation is unsuccessful.