**6.1. Intestinal retrieval**

**5. Recipient assessment**

**Figure 5.** Abdominal wall transplant.

296 Organ Donation and Transplantation - Current Status and Future Challenges

Every assessment is 'tailor-made'.

both by imaging and endoscopy.

and Epstein-Barr virus (EBV) screening.

The assessment of a potential intestinal transplant recipient is robust and rigorous and needs to be done by a multidisciplinary team. This involves transplant surgery, gastroenterology, nutritional services, anesthesia, psychiatry and social work. However, due to the frequently pre-existing multiple comorbidities, consultation with other specialties may be required.

Laboratory studies always include: full blood count (FBC), electrolytes and renal function, coagulation profile, ABO blood group, human leukocyte antigen (HLA) typing, panelreactive antibody status, HIV and hepatitis B and C virus screening, cytomegalovirus (CMV)

Liver biopsy is indicated, if liver disease is suspected. The native intestine should be assessed


• Cross-clamping of the supraceliac aorta is performed simultaneously with or immediately following venting of the IVC or atrium and cold perfusion is commenced.

Stoma output is monitored daily and will indicate the appropriate timing to resume enteral feeding via nasogastric tube or jejunostomy/gastrostomy. Some centers start elemental enteral feeding very early and gradually increase volumes depending on nasogastric tube aspirates. TPN is maintained for at least 2 weeks and can be discontinued once enteral nutrition is sufficient. Chyle leak can often be seen post-operatively due to the severed intestinal graft lymphatics. A no-fat or low-fat diet (<10 g/day) can be initiated as a first measure. Absorption of long-chain triglycerides, depends on lymphatic drainage, whereas medium-chain triglyc-

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Antiviral prophylaxis with intravenous ganciclovir (5 mg/kg OD) is common practice and regular CMV polymerase chain reaction (PCR) DNA tests are sent for monitoring. Oral valganciclovir is usually prescribed for 1-year post transplantation (900 mg OD). Epstein-Barr virus (EBV) is also monitored regularly by PCR. Trimethoprim-sulfamethoxazole is commonly used to prevent pneumocystis pneumonia for 1-year post operatively. Routine cultures are sent from all lines and most centers perform regular intestinal transplant endoscopies and

Oral medication is generally avoided in the early phase due to the unpredictable absorption and thus, bioavailability. Tacrolimus can be given sublingually and regular trough levels are

Plasma citrulline levels have emerged as a measure for overall for intestinal health as it is an indicator of enterocyte mass. However, compromised renal function is an important factor when considering plasma citrulline levels as a marker of intestinal failure as this potentially can increase circulating citrulline values [31]. Reduced citrulline levels can indicate the need

The intestine is the largest lymphoid organ in the body and hence, appropriate immunosuppression has been a real challenge. The lack of effective immunosuppressive agents hampered the first attempts of ITx in the 1960s. Over the years, advances in immunosuppression have transformed ITx with the intent of attenuating the intestinal allograft immunity and shifting

Induction strategies to minimize rejection by reducing the recipient's T-cell load were implemented, initially with cyclophosphamide induction therapy, which was later replaced by daclizumab, an interleukin-2 receptor antagonist (IL2RA) [33]. Basiliximab, another IL2RA, in addition to tacrolimus and prednisone immunosuppression has also been utilized and shown

Alemtuzumab induction is becoming increasingly popular and Lauro et al. [36] reported significantly less early rejection episodes, with no sepsis implications. The use of Basiliximab monthly as part of maintenance immunosuppression has been associated with a decrease in

erides are directly absorbed into the portal circulation.

for urgent investigations and also, commencement of TPN.

to decrease the incidence of acute rejection [34, 35].

acute rejection in liver-excluding transplants [37].

biopsies via the stoma.

sent for confirmation.

**8. Immunosuppression**

it to a tolerogenic status [32].

