Pretransplant Recipient Evaluation

AH individuals under consideration for intestinal transplant should be seen and evaluated by a multidisciplinary intestinal failure team including transplant surgery, gastroenterology, nutritional services, psychiatry, social work, anesthesia, and financial services. Further consultation with other specialties [i.e., cardiology, hematology, chest medicine, infectious disease, chemical dependency, dentistry, etc], will be required in some cases. Baseline laboratory investigations including routine blood work, ABO blood group determination, HLA status, and panel reactive antibody status will be performed. If not done previously, the GI tract should be assessed both radiologically and endoscopically to accurately determine the length and condition of the remaining bowel. It is also important to establish which large veins are available for vascular access, as many of the patients will have limited options. Living related donor transplantation can be discussed as an option if a potential living related donor is availabl.14

If after these evaluations there is consensus that the patient is a good candidate for intestinal transplantation, the patient will be listed. While waiting for a donor to become available the stable patient should be reassessed every three months to determine whether there is any change is their PRA status, deterioration in liver function, or development of other medical problems. Furthermore while waiting for intestine only transplantation, the HPN administration should be monitored very closely to ensure that it does not contribute further to the development of hepatic steatosis and fibrosis since optimal balancing of carbohydrates and lipids in the HPN solutions can minimize the development of hepatic pathology. These patients will also need ongoing maintenance of their central lines to minimize line-related complications such as infections and thrombosis. Furthermore while waiting for transplantation close attention must be paid to fluid and electrolyte disturbances which are common due to the often-excessive output from the residual GI tract, particularly in individuals who continue to eat or drink. In some instances patients who have dysfunctional intestine [i.e., dysmotility or malabsorption syndromes] or a blind loop, which result in stasis of intestinal contents, will develop severe problems with bacterial overgrowth and translocation resulting in recurrent, bacteremia and life threatening sepsis. Surgical revision to eliminate blind loops including, in extreme situations, total enterectomy of dysfunctional small bowel are sometimes warranted to keep these patients alive until transplantation can be performed.

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