Impact of Parenteral Nutrition-Associated Liver
Disease on Intestinal Transplant Waitlist Dynamics
, Irma Dixler,
, Valeria Cohran,
, Alan Buchman,
, Jonathan Fryer,
United Network for Organ Sharing (UNOS) reports indicate that waiting list mortality for
intestinal transplant candidates greatly exceeds that for all other organ transplant candidates.
But United Network for Organ Sharing outcomes reports have not routinely distinguished
between the intestine candidate subgroups that are listed only for an intestine and those that are
also listed for a liver.
Data were obtained by request from the collaborative Organ Procurement and Transplantation
Network (United Network for Organ Sharing)/Scientific Registry of Transplant Recipients
(University Research and Education Association) database. Waiting list data for intestinal
transplant recipients from 1995 to 2004 were divided into those candidates listed for only an
intestine and those listed for both an intestine and a liver. Additional data concerning overall
waiting list outcomes and posttransplant survival rates stratified into pediatric and adult subsets
were also obtained and analyzed.
The overall number of candidates on the intestinal transplant waiting list has increased steadily since
1995 and, consistently, the majority of candidates have also been listed for a liver. This subset was
found to have both a higher relative risk of dying while awaiting transplantation and lower relative
odds of receiving transplants. In addition, parenteral nutrition-associated liver disease is a major
problem across all age groups, as evidenced by the combined liver and intestine listings that compose
the majority of both adult and pediatric waiting list populations. Posttransplant survival data were
found to be superior for isolated intestine recipients compared with liver-intestine recipients.
The preponderance of dual listings and their associated inferior outcomes, before and after
transplantation, has skewed overall intestinal transplant outcomes. Because progression of
parenteral nutrition-associated liver disease can be insidious, and recognition of irreversibility is
often difficult, intestine-only transplants should be considered early for high-risk patients
before parenteral nutrition-associated liver disease progression mandates inclusion of a liver
graft also. (J Am Coll Surg 2007;205:755–761. © 2007 by the American College of Surgeons)
Short bowel syndrome (SBS) is the most common cause of
intestinal failure mandating longterm parenteral nutrition de-
pendency for survival. Surgeons can play a critical role in in-
fluencing the outcomes of SBS patients by optimizing small
bowel preservation at the time of their resective surgery, rees-
tablishing intestinal continuity, using gut lengthening proce-
dures to optimize the residual small bowel’s functional surface
area, and facilitating timely consideration for intestinal trans-
plantation in high risk patients destined for longterm paren-
teral nutrition (PN) dependency. Although the outcomes
with intestinal transplants have yet to achieve the overall suc-
cess of more established organ transplants such as liver and
kidney, this discrepancy is rapidly disappearing.
early experience, suboptimal outcomes have been largely
attributed to the complex immunobiology, higher risk of
rejection, and adverse affects of immunosuppression. Al-
though less attention has been focused on the impact of
pretransplant factors, such as timeliness of referral and de-
velopment of PN-associated complications, these influ-
ences may have profound significance.
Based on criteria established by Medicare, SBS patients
with intestinal failure are typically referred for transplanta-
Competing Interests Declared: None.
Data for this study were acquired from the United Network of Organ Sharing/
University Research and Education Association US Transplant Registry. The au-
thors alone are responsible for reporting and interpreting these data.
Received April 25, 2007; Revised June 13, 2007; Accepted June 19, 2007.
From the Departments of Surgery (Chungfat, Dixler, Abecassis, Fryer), Med-
icine (Buchman), and Pediatrics (Cohran), Northwestern University Feinberg
School of Medicine, Chicago, IL.
Correspondence address: Jonathan P Fryer, MD, Northwestern University
Medical School, Department of Surgery, Division of Transplantation, 675 N
St Clair, Galter Pavilion, Suite 17–200, Chicago, IL 60611.
© 2007 by the American College of Surgeons ISSN 1072-7515/07/$32.00
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2007.06.299