Living Related Donor Transplant May Be Efficacious for Short Bowel Syndrome

November 06, 2003

Alicia Ault

Nov. 6, 2003 (New Orleans) — Living related donor transplants might be an effective alternative for children with short bowel syndrome too sick to stay on a waiting list for cadaveric transplants, researchers reported here Sunday at the American Academy of Pediatrics National Conference and Exhibition.

Lead author Mark J. Holterman, MD, PhD, FAAP, presented a series of three cases transplanted by surgeons at the University of Illinois at Chicago. Dr. Holterman is the chief of the University's division of pediatric surgery.

All three children met the criteria for cadaveric transplantation, with multi-line sepsis and gastrochisis. But they were so ill that the surgeons decided to try living related donors instead of waiting for a cadaveric organ.

The procedures were not cleared by the hospital's institutional review board. In an interview with Medscape, Dr. Holterman said that the surgeries were conducted on a compassionate, emergency basis.

"One of the problems with cadaveric transplants is the mortality on the waiting list," Dr. Holterman told meeting attendees, stating that one third of children die while awaiting a donor organ.

In his series, the first child, aged four years, received 150 cm of ileum from his mother. The second children, aged 2 years, had spent nine months on the waiting list and also received a maternal donation. The third child was 14 months old and received ileum from a paternal grandmother.

Before surgery, children were given antithymocyte thymoglobulin to suppress immune response. Posttransplant, they received tacrolimus and glucocorticoids.

Because donor material was generally too large for the recipients, an absorbable mesh was used to cover the transplant. It was later covered with autologous skin grafts.

Children were monitored for rejection and degree of ileal mucosal transformation with magnification chromoendoscopy and regular biopsies. The two children who received maternal donations were discharged to home, weaned from total parenteral nutrition. They have been free of rejection or other complications. The third child, however, experienced multiple rejection episodes and lymphoproliferative disorder, and now has liver fibrosis. He will require a double liver-intestine transplant, Dr. Holterman told attendees.

The donors experienced fecal urgency for several weeks, but otherwise were unaffected, experiencing no problems with weight loss, vitamin absorption, or other nutritional deficits, he said.

Dr. Holterman told Medscape he would only attempt the living related transplant procedure in children who had the beginnings of liver failure, and who had failed bowel lengthening procedures. They should weigh at least 5 kg, he added.

Although the results so far are equivalent to cadaveric transplants, he noted that "obviously, there are still lots of unanswered questions at this point," including which children to operate on and when, and whether the living donor procedure will reduce morbidity and mortality.

Living related intestinal donation is rarely done in adults, and is even more rare in children, and raises many ethical questions, Andreas G. Tzakis, MD, PhD, director of the liver and gastrointestinal transplant division at the University of Miami School of Medicine, told Medscape in an interview.

"I think it is reasonable for people to try to do transplants from living donors," he said. "The main disadvantage is that you have to operate on a healthy individual. The main advantage is you can control the timing of the transplant," said Dr. Tzakis.

He added that there did not seem to be a severe shortage of available cadaveric donors, so he felt that using living donors was unwise without lengthy ethical scrutiny.

"There's a lot of ethical issues here that need be put on the table," agreed Alan Langnas,DO, chief of transplant at the University of Nebraska Medical Center in Omaha, in an interview with Medscape.

He said the report is "exciting" and "interesting," adding, "I'll be curious how both the donor and recipients do over the long term."

But agreeing that there's no pressing shortage of intestines, Dr. Langnas concluded that for living donor procedures, "Fundamentally, I don't think there's a compelling reason to do it."

AAP 2003 National Conference and Exhibition: Abstract 964. Presented Nov. 2, 2003.

Reviewed by Gary D. Vogin, MD

Alicia Ault is a freelance writer for Medscape.


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