Impact of parenteral nutrition-associated liver disease on intestinal transplant waitlist dynamics

BACKGROUND: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.