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Intestinal Transplant

Process

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Intestinal Transplant Process

Section 1: Transplant Process

What is the patient evaluation process for intestinal transplant?


Intestinal transplant patients often have very extensive and complex medical histories. The transplant evaluation is a thorough process at the transplant center and involves many medical professionals.

The team involved usually consists of:

  • Transplant nurse coordinator

  • Transplant surgeon

  • Gastroenterologist

  • Anesthesiologist

  • Financial counselor

  • Psychiatrist

  • Pharmacist

  • Dentist

  • Gynecologist

  • Infectious disease specialist

  • Social worker

  • Dietician

  • Advanced practice nurse

  • Mid-level provider

  • Child life specialist (pediatrics)

  • Physical therapy

  • Occupational therapy

  • General surgery

  • Hepatology

  • Psychiatry or psychology

A comprehensive assessment of the patient is required during the evaluation phase of an intestinal transplant. This includes a thorough history and physical as well as a variety of lab tests, diagnostic tests, and consultations, which will vary by diagnosis, patient acuity, and history. Tests may include, but are not limited to:

  • Blood work

  • Chest x-ray

  • EKG

  • Urinalysis

  • Echocardiogram

  • Stress test and/or cardiac catheterization

  • CT scan and/or MRI

  • Endoscopy and/or colonoscopy

  • Motility studies

  • Pulmonary functions tests

  • Venous mapping

  • Pap smear

  • Mammogram

  • DEXA scan

  • Liver biopsy

Patients with intestinal failure who have failed surgical and medical treatment options are usually referred for an intestinal transplant when they develop complications from parenteral nutrition, including more frequent line infections, which can be life-threatening, and progressive PN-induced liver disease. Clinicians may also refer patients for quality of life concerns.

Please refer to (1,2) for more information.




What is the function of the psychiatric assessment in the intestinal transplant evaluation?


Intestinal failure affects not only the digestive system, but the whole person. The stresses of extended and multiple hospitalizations, procedures, surgeries and the complexity of care can lead to significant disruptions in normal psychosocial development, family life, school/work, and relationships. During the evaluation for an intestinal transplant, it is important that the transplant team has an assessment of the patient’s emotional, cognitive and behavioral health through a comprehensive evaluation by psychology/psychiatry.

Goals of Psychological Assessment: Comprehensively assess each patient for his/her ability to undergo an intestinal transplant, and their mental health, coping strategies, and family support.

History should include:

  • Prior psychiatric illness
  • Suicidality
  • Adherence history
  • Substance abuse history
  • Adaptation to past stressors and presence and quality of social support

Important Considerations to the Psychological Evaluation:

  • The use of a standardized psychiatric interview, such as the Mini International Neuropsychiatric Interview, is recommended.
  • In patients with liver disease who may have hepatic encephalopathy, a clinical interview and neuropsychological testing can help identify impairments.




What is the role of the transplant center selection committee?


Following the completion of the evaluation for intestine transplantation, the patient’s information is presented to the multidisciplinary selection committee. Recommendations for transplant are made by the committee after review and discussion of test results and consultations:

  • Intestine transplant may be recommended, and the patient will be formally listed with UNOS.
  • Transplant may be deferred and the patient will not be listed because additional information or tests are needed, medical management strategies may be indicated, or current psychosocial concerns are significant and must be resolved before listing.
  • In some cases, transplant may be denied due to medical issues that may affect survival or the patient will benefit from medical or other surgical interventions rather than transplant.

The members of the committee will vary by center and patient diagnosis, examples of members includes:

  • Transplant surgeons
  • Gastroenterologists
  • Nutritionists
  • Social workers
  • Ethicists
  • Psychiatrists
  • Mid-level providers
  • Advanced practice nurses
  • General surgery
  • Pharmacists
  • Anesthesiologists

If the selection committee determines the patient is an appropriate candidate for transplant, the proper paperwork is filed with UNOS, and the patient is placed on the national waiting list for organs. To learn more about UNOS, the waitlist, and organ procurement, please visit our site here.




What complications may be seen in the intestine transplant candidate with hepatic dysfunction?


  • Ascites requiring paracentesis

  • Hyponatremia

  • Variceal Bleeding

  • Encephalopathy

  • Hepatorenal Syndrome




How are donors selected for an intestinal transplant recipient?


Donor selection is based on the viability of the organs, ABO status, and donor and recipient size/weight. Donors are also screened for infection risks and CMV/EBV serology. (CMV and EBV mismatches are common – Adults are usually positive for both and kids are usually negative).

Each organ is listed separately and by status/score with UNOS.

  • Intestine

    • Status 1: Deteriorating liver function and decreased or limited venous access.

    • Status 2: Normal liver function and adequate venous access.

  • Liver allocation is based on the candidate’s score as calculated by the Model for End-Stage Liver Disease (MELD) and the Pediatric End-Stage Liver Disease (PELD).




What are the basic steps of the operative procedure for an intestine transplant and an intestine/liver transplant?


For another general overview of the operative steps, see pages 568-574 in:

Kosmach-Park B, DeAngelis M. Intestine Transplantation. In Core Curriculum for Transplant Nurses. 2nd edition. Eds: Cupples S., Lerret S., McCalmont V., Ohler, L. Philadelphia: Wolters Kluwer, 2017.

Or you may also refer to this article.





Section 2: Additional Resources

Journal Article: Imaging of Intestinal and Multivisceral Transplantation.


Journal Article: Imaging of Intestinal and Multivisceral Transplantation.




Handouts Useful For Your Patients and Their Caregivers


Evaluation Appointment Table: Helpful handout for your patients to keep track of their evaluation appointments. Evaluation Test and Procedure Table: Helpful handout for your patients to keep track of their evaluation tests and procedures. If you wish to refer your patient to an intestinal transplant center for evaluation, visit our page here for links to individual intestinal transplant center referral pages.




Page References


References here.