What is the success rate of small bowel transplant in adults?

Success Rate of Small Bowel Transplant in Adults

Small bowel transplantation in adults currently achieves approximately 80% one-year survival and approaching 50% five-year survival, with the majority of survivors achieving freedom from parenteral nutrition. 1

Current Survival Outcomes

The success rates for adult small bowel transplantation have improved substantially over the past two decades:

Short-Term Survival

• One-year patient survival: 69-80% for isolated small bowel transplants 1, 2
• One-year graft survival: 55-66% for isolated intestinal grafts 3, 2
• Combined liver-small bowel transplants show 66% one-year patient survival 2
• Multivisceral transplants demonstrate 63% one-year patient survival 2

Long-Term Survival

• Five-year patient survival: approximately 48-54% for isolated intestinal transplants 1, 3, 4
• Five-year graft survival: 34-46% for isolated intestinal grafts 3, 4, 2
• Combined liver-intestine transplants show 43% five-year graft survival 3
• Ten-year patient survival reaches 42% at experienced centers 3

Functional Success Beyond Survival

Over 90% of surviving transplant recipients achieve complete nutritional autonomy and discontinue parenteral nutrition. 1, 3

• The majority of survivors meet all caloric needs enterally without supplementation 2
• Some patients may require temporary enteral or parenteral supplementation during illness episodes 2
• Quality of life after transplantation is comparable to patients on home enteral nutrition and superior to those with complicated parenteral nutrition 1

Factors Influencing Success Rates

Type of Transplant

• Isolated small bowel transplants have better survival than combined or multivisceral grafts 2
• Adults more frequently require isolated intestine (55%) compared to children (37%) 1
• Combined liver-intestine grafts are needed in 21% of adults 1

Timing of Transplantation

• Patients transplanted while waiting at home have significantly higher survival rates than those hospitalized at time of transplant 1
• Early referral before development of severe complications improves outcomes 1

Center Experience

• Programs performing at least 10 transplants historically showed better outcomes, though recent data suggests good results can be achieved at any multiorgan transplant program with moderate volumes 2
• The largest centers report 72% one-year patient survival and 64% graft survival 2

Major Complications Limiting Success

Leading Causes of Mortality and Graft Loss

• Infection with subsequent sepsis accounts for 51.3% of deaths 2
• Graft rejection is the second leading cause of death (10.4%) and responsible for 57% of graft removals 2
• Acute rejection occurs in 51-83% of recipients, though most episodes are mild and steroid-responsive 2

Infectious Complications

• Cytomegalovirus infection occurs in 18-40% of recipients 2
• Post-transplant lymphoproliferative disease affects 21% overall (31% in pediatric recipients) and accounts for 7% of mortality 2
• Bacterial, fungal, and viral infections remain significant challenges 2

Surgical Complications

• Surgical complications occur in 85% of combined liver-small bowel transplants and 25% of isolated small bowel transplants 2
• Reoperations are required in 45-66% of patients, most commonly for intra-abdominal abscess 2

Evolution of Outcomes Over Time

Survival rates have continuously improved since the introduction of tacrolimus-based immunosuppression in the 1990s, which more than doubled survival compared to the cyclosporine era. 1

• Transplants performed since 1991 show significantly better survival than earlier procedures 2
• Novel immunomodulatory protocols using thymoglobulin or alemtuzumab for induction therapy have achieved 92% one-year patient survival and 89% graft survival at leading centers 1
• Current protocols allow many recipients to reduce tacrolimus to every-other-day dosing without maintenance steroids 1

Clinical Context and Indications

Small bowel transplantation should only be performed when total parenteral nutrition is no longer feasible, as parenteral nutrition outcomes remain superior (86% two-year and 75% five-year survival). 4, 2

Formal indications include 1:

• Irreversible liver disease with portal hypertension or cirrhosis from parenteral nutrition
• Loss of venous access (thrombosis of all but two major venous access points)
• Recurrent or life-threatening catheter-related bloodstream infections
• Inability to maintain adequate hydration/nutrition despite parenteral nutrition