**Author details**

**11. Quality of life**

**12. Future perspectives**

species predominate [84].

**13. Conclusion(s)**

**Conflict of interest**

becoming a realistic first-line therapy for IF.

The author declares no conflict of interest.

rejection [45].

Quality of life plays an important role in the decision-making for ITx candidates. ITx patients have reported better fatigue, gastrointestinal symptoms, stoma management/bowel movements, ability to holiday/travel and global health/QoL and probably better eating ability but worse sleeping patterns [79]. Others have found that ITx recipients have similar QoL to those who are stable on TPN, but both are better than those with complicated intestinal failure on TPN [80].

ITx and its secrets have not been deciphered yet. The main issue remains the challenging balance between appropriate immunosuppression and over-immunosuppression. Therefore, ITx teams have been trying to develop markers that will provide adequate warning in case of

Multivisceral organ transplantation may solidify its role in the treatment of slow-growing

Another challenge will be to understand the physiology of the transplanted small bowel, such as its altered microflora and altered motility. New research has suggested that the flora composition within the graft may be a risk factor for acute rejection when more immunogenic

Tolerance remains the 'Holy Grail' of transplantation and is characterized by increased allograft survival in the absence of immunosuppression and absent or reduced donor-specific response. Groups have used donor-specific blood transfusion in order to induce tolerance by upregulating graft protective memory Tregs [85]. Also, centers have introduced experimental models to induce microchimerism and tolerance by transplanting bone marrow along with the intestinal allograft [86]. These protocols could allow for sufficient immunosuppression with lower doses of immunosuppressants. This ongoing research may change the future of ITx.

ITx continues to evolve and graft survival rates are nowadays more comparable with the results of other solid organ transplants. The main challenge is to develop immunosuppression protocols that can ensure long-term intestine graft function and less infectious complications. When this is accomplished ITx could potentially change from being a life-saving treatment to

abdominal cancers that are deemed "non-resectable" [81–83].

304 Organ Donation and Transplantation - Current Status and Future Challenges

Georgios Vrakas

Address all correspondence to: georgiosvrakas@gmail.com

Oxford University Hospitals, Oxford, UK
