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Intestine

OPTN/SRTR 2018 Annual Data Report: Intestine

Abstract

Despite medical and surgical advances in treatment of intestinal failure, intestine transplant still plays an important role. However, the number of new patients added to the intestine transplant waiting list has decreased over the past decade, reaching a low of 135 in 2018. The number of intestine donors also decreased, reaching a low of 106 in 2018, and the number of intestine transplants performed declined to its lowest level, 104, of which 59% were intestine-liver transplants. Graft failure has plateaued over the past decade. Patient survival for transplants in 2011-2013 varied by age and transplant type. Patient survival was lowest for adult intestine-liver recipients (1- and 5-year survival 66.7% and 49.1%, respectively) and highest for pediatric intestine recipients (1- and 5-year survival 89.1% and 76.4%, respectively).

Introduction

Medical and surgical advances in treatments of intestinal failure led to a decrease in the number of intestine transplants from 2007 to 2012. However, since then, numbers appear to be relatively stable. Patient survival has improved, and morbidity associated with parenteral nutrition, particularly liver failure, has declined. Nevertheless, intestine transplant still plays an important role in the treatment of intestinal failure. Intestine transplants may be performed in isolation, with a liver transplant, or as part of a multi-visceral transplant including any combination of liver, stomach, pancreas, colon, spleen, and kidney. There are notable differences in patients and transplant outcomes for intestine transplants with and without liver. Information on the waiting list, transplants, and outcomes is presented for both types of transplants, referred to as intestine-liver and intestine transplants, respectively.

Waiting List

The number of new patients added to the intestine transplant waiting list has decreased over the past decade, reaching a low of 135 in 2018 compared with 273 in 2007; 62 new patients were added for intestine and 73 for intestine-liver transplant (Figure IN 1). Among the 244 prevalent patients on the waiting list at the end of 2018, 147 (60.3%) were waiting for intestine and 97 (39.8%) for intestine-liver transplant (Figure IN 2). Over the past decade, the age distribution of candidates waitlisted for intestine and intestine-liver transplant shifted from primarily pediatric to increasing proportions of adults (Figure IN 3). In 2018, 54.1% of candidates on the intestine waiting list were aged younger than 18 years, with a shift toward fewer aged younger than 6 years and more aged 6-17 years than in previous years. Adults accounted for 45.9% of candidates on the list (Figure IN 3). The racial/ethnic distribution remained relatively consistent over time; white patients represented almost 60% of those waiting for an intestine transplant in 2018 (Figure IN 5). The most common etiology of intestinal failure remained short-gut syndrome (SGS; 46.2%), which encompasses a large group of diagnoses (Figure IN 6).

Characteristics of intestine and intestine-liver candidates on the waiting list at the end of 2018 were similar with respect to age and race (Table IN 1). Intestine candidates were 57.8% female and intestine-liver candidates 39.2%. Considering disease etiology, congenital and non-congenital SGS were the leading causes of disease among intestine and intestine-liver transplant candidates (Table IN 2). Intestine-liver candidates were more often listed as status 1 than intestine candidates (51.5% vs. 33.3%; Table IN 2), and they were more often listed for retransplant (Table IN 3). Transplant rates varied by candidate age and transplant type (intestine, intestine-liver) but decreased for all groups over the past decade (Figure IN 10). In 2018, transplant rates were higher for intestine-liver candidates than for intestine candidates. Rates were 79.2 per 100 waitlist-years for pediatric intestine-liver candidates and 64.2 per 100 waitlist-years for adult intestine-liver candidates, and 51.4 for pediatric intestine candidates and 5.4 for adult intestine candidates (Figure IN 10).

Of the 63 candidates removed from the intestine waiting list in 2018, 42 (66.7%) underwent deceased donor transplant, four (6.3%) died, five (7.9%) were removed from the list because their condition improved, and three (4.8%) were considered too sick to undergo transplant (Table IN 4, Table IN 5). Of the 85 candidates removed from the intestine-liver waiting list, 62 (73.0%) underwent deceased donor transplant, ten (11.8%) died, seven (8.2%) were removed from the list because their condition improved, and four (4.7%) were considered too sick to undergo transplant (Table IN 4, Table IN 5). Regarding 3-year outcomes, 70.3% of intestine transplant candidates listed in 2015 underwent deceased donor transplant, 2.2% died, 9.9% were removed from the list, and 17.6% were still waiting in 2018 (Figure IN 11). Of intestine-liver candidates listed in 2015, 61.0% underwent deceased donor transplant, 11.4% died, 18.1% were removed from the list, and 9.5% were still waiting in 2018 (Figure IN 12). Among candidates listed in 2017-2018, median time to transplant was 6.0 months for intestine-liver transplant candidates, and 10.6 months for intestine transplant candidates (Figure IN 13).

Among candidates on the waiting list in 2017-2018, by age, pretransplant mortality was higher for adults, at 10.5 per 100 waitlist-years, and lower for pediatric patients, at 3.8 per 100 waitlist-years (Figure IN 14). Pretransplant mortality was similar for the different etiologies of organ failure (Figure IN 16). Regarding age and type of transplant, pretransplant mortality was highest for pediatric intestine-liver and lowest for adult intestine candidates (respectively, 16.5 vs. 1.8 deaths per 100 waitlist-years in 2017-2018) (Figure IN 17).

Donation

The number of intestine donors decreased over the past decade, reaching a low of 106 in 2018 (Figure IN 18). The proportion of intestine donors in 2018 aged younger than 18 years was 61.3% (Figure IN 19). Most intestine donors were white (57.6%) (Figure IN 21). The overall rate of intestines recovered for transplant and not transplanted was 3.6% in 2017-2018 (Figure IN 23). The most common cause of death among deceased intestine donors has been head trauma, 49.1% in 2018 (Figure IN 26).

Transplant

In 2018, the number of intestine transplants performed declined to its lowest level, 104, of which 59% were intestine-liver transplants (Figure IN 27). In 2018, 18 programs were performing intestine transplants, three only in children, eight only in adults, and seven in both adults and children (Figure IN 35). The median annual program volume was three intestine transplants in 2018; the 95th percentile of program volume was 20 transplants (Figure IN 36). In 2018, 47.1% of intestine transplants were performed at programs performing ten or more transplants per year, 43.3% at programs performing three to nine transplants per year, and only 9.6% at programs performing one to two transplant per year (Figure IN 37). New program requirements were introduced in 2018, but their effects cannot yet be determined.

The age distribution of intestine and intestine-liver transplant recipients changed over the past decade; pediatric recipient counts declined from 94 in 2009 to 37 in 2018, and adult recipient counts declined more modestly from 85 to 67 (Figure IN 28). In 2018, just over half of intestine-liver recipients were aged younger than 18 years, 52.5% vs. 11.6% of intestine recipients (Table IN 6). SGS (congenital and non-congenital) was the main cause of disease leading to both intestine and intestine-liver transplant (Table IN 7). Within 1 year of listing, 81.4% of intestine candidates and 77.0% of intestine-liver candidates underwent transplant (Table IN 8).

Immunosuppression

In 2018, T-cell depleting agents were used as induction in 63.9% of intestine transplant recipients, with and without a liver; 27.8% of recipients received no induction and 10.3% used IL-2 receptor antagonist therapy (Figure IN 32). The most common initial immunosuppression agent regimens in 2018 were tacrolimus and steroids (42.9%), followed by tacrolimus, mycophenolate, and steroids (28.6%)(Figure IN 33).

Outcomes

Graft failure has plateaued over the past decade. The unadjusted graft failure rate among intestine transplant recipients was 14.4% at 6 months and 22% at 1 year for transplants in 2016-2017, 38.7% at 3 years for transplants in 2014-2015, 54.9% at 5 years for transplants in 2012-2013, and 63.8% at 10 years for transplants in 2008-2009 (Figure IN 38). Among intestine-liver transplant recipients, the graft failure rate was 25% at 6 months and 28.2% at 1 year for transplants in 2016-2017, 42.7% at 3 years for transplants in 2014-2015, 42.1% at 5 years for transplants in 2012-2013, and 57.6% at 10 years for transplants in 2008-2009 (Figure IN 39). For intestine transplants with or without a liver in 2011-2013, 1- and 5-year graft survival was 74.2% and 51.1%, respectively, 72.8% and 46.9% for recipients aged 18 years or older, and 76.2% and 56.8% for recipients aged younger than 18 (Figure IN 40). One- and 5-year graft survival was 76.2% and 47.0%, respectively, for intestine recipients, and 72.9% and 55.8%, respectively, for intestine-liver recipients (Figure IN 41). The number of recipients alive with a functioning intestine graft continued to increase, to 1204, on June 30, 2018; pediatric intestine-liver transplant recipients were the predominant group at 43% (Figure IN 44). The incidence of first acute rejection in the first year posttransplant varied by age group and transplant type. Among recipients in 2016-2017, incidence of acute rejection was highest in pediatric intestine recipients (58.5%) and lowest in adult intestine-liver recipients (24.6%) (Figure IN 45). For recipients in 2006-2016, 8.9% of intestine recipients (Figure IN 47) and 7.4% of intestine-liver recipients (Figure IN 48) developed posttransplant lymphoproliferative disorder within 5 years posttransplant. Patient survival for transplants in 2011-2013 varied by age and transplant type. Patient survival was lowest for adult intestine-liver recipients (1- and 5-year survival 66.7% and 49.1%, respectively) and highest for pediatric intestine recipients (1- and 5-year survival 89.1% and 76.4%, respectively) (Figure IN 49).

Figure List

Waiting list

Figure IN 1. New candidates added to the intestine transplant waiting list
Figure IN 2. Candidates listed for intestine transplant on December 31 each year
Figure IN 3. Distribution of candidates waiting for intestine transplant by age
Figure IN 4. Distribution of candidates waiting for intestine transplant by sex
Figure IN 5. Distribution of candidates waiting for intestine transplant by race
Figure IN 6. Distribution of candidates waiting for intestine transplant by diagnosis
Figure IN 7. Distribution of candidates waiting for intestine transplant by waiting time
Figure IN 8. Distribution of candidates waiting for intestine transplant by medical urgency
Figure IN 9. Distribution of candidates waiting for intestine transplant by liver co-listing
Figure IN 10. Deceased donor intestine transplant rates among waitlist candidates by age and liver co-listing
Figure IN 11. Three-year outcomes for candidates waiting for intestine transplant without liver, new listings in 2015
Figure IN 12. Three-year outcomes for candidates waiting for intestine transplant with liver, new listings in 2015
Figure IN 13. Median months to intestine transplant for waitlist candidates by liver co-listing
Figure IN 14. Pretransplant mortality rates among candidates waitlisted for intestine transplant by age
Figure IN 15. Pretransplant mortality rates among candidates waitlisted for intestine transplant by race
Figure IN 16. Pretransplant mortality rates among candidates waitlisted for intestine transplant by diagnosis
Figure IN 17. Pretransplant mortality rates among candidates waitlisted for intestine transplant by age and liver co-listing

Deceased donation

Figure IN 18. Deceased intestine donor count by age
Figure IN 19. Distribution of deceased intestine donors by age
Figure IN 20. Distribution of deceased intestine donors by sex
Figure IN 21. Distribution of deceased intestine donors by race
Figure IN 22. Rates of intestines recovered for transplant and not transplanted by donor age
Figure IN 23. Rates of intestines recovered for transplant and not transplanted by donor sex
Figure IN 24. Rates of intestines recovered for transplant and not transplanted by donor race
Figure IN 25. Rates of intestines recovered for transplant and not transplanted, by donor risk of disease transmission
Figure IN 26. Cause of death among deceased intestine donors

Transplant

Figure IN 27. Total intestine transplants
Figure IN 28. Total intestine transplants by age
Figure IN 29. Total intestine transplants by sex
Figure IN 30. Total intestine transplants by race
Figure IN 31. Total intestine transplants by diagnosis
Figure IN 32. Induction agent use in intestine transplant recipients
Figure IN 33. Immunosuppression regimen use in intestine transplant recipients
Figure IN 34. Total HLA A, B, and DR mismatches among deceased donor intestine transplant recipients, 2014-2018
Figure IN 35. Number of centers performing adult and pediatric intestine transplants by center's age mix
Figure IN 36. Annual intestine transplant center volumes, by percentile
Figure IN 37. Distribution of intestine transplants by annual center volume

Outcomes

Figure IN 38. Graft failure among transplant recipients of intestine without liver
Figure IN 39. Graft failure among transplant recipients of intestine with liver
Figure IN 40. Graft survival among intestine transplant recipients, 2011-2013, by age
Figure IN 41. Graft survival among deceased donor intestine transplant recipients, 2011-2013, by transplant type
Figure IN 42. Graft survival among deceased donor intestine transplant recipients, 2011-2013, by metropolitan vs. non-metropolitan recipient residence
Figure IN 43. Graft survival among deceased donor intestine transplant recipients, 2011-2013, by recipients' distance from transplant center
Figure IN 44. Recipients alive with a functioning intestine graft on June 30 of the year, by age at transplant and procedure
Figure IN 45. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by age and transplant type, 2016-2017
Figure IN 46. Incidence of acute rejection by 1 year posttransplant among intestine transplant recipients by induction agent 2016-2017
Figure IN 47. Incidence of PTLD among recipients of intestine transplant without liver by recipient EBV status at transplant, 2006-2016
Figure IN 48. Incidence of PTLD among recipients of intestine transplant with liver by recipient EBV status at transplant, 2006-2016
Figure IN 49. Patient survival among deceased donor intestine transplant recipients, 2011-2013, by age and transplant type

Table List

Waiting list

Table IN 1. Demographic characteristics of candidates on the intestine transplant waiting list on December 31, 2018
Table IN 2. Clinical characteristics of candidates on the intestine transplant waiting list on December 31, 2018
Table IN 3. Listing characteristics of candidates on the intestine transplant waiting list on December 31, 2018
Table IN 4. Intestine transplant waitlist activity, 2018
Table IN 5. Removal reason among intestine transplant candidates, 2018

Transplant

Table IN 6. Demographic characteristics of intestine transplant recipients, 2018
Table IN 7. Clinical characteristics of intestine transplant recipients, 2018
Table IN 8. Transplant characteristics of intestine transplant recipients, 2018

A line plot for new candidates added to the intestine transplant waiting list; the in category decreases by 31.9% from 91 candidates at 2007 to 62 candidates at 2018; the in to li category decreases by 59.9% from 182 candidates at 2007 to 73 candidates at 2018; and the all category decreases by 50.5% from 273 candidates at 2007 to 135 candidates at 2018.

Figure IN 1. New candidates added to the intestine transplant waiting list
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Active and inactive patients are included. New intestine-liver candidates are those listed for both organs on the same day. IN, intestine without liver; IN-LI, intestine-liver.


A line plot for candidates listed for intestine transplant on december 31 each year; the in category increases by 47.0% from 100 candidates at 2007 to 147 candidates at 2018; the in to li category decreases by 16.4% from 116 candidates at 2007 to 97 candidates at 2018; and the all category increases by 13.0% from 216 candidates at 2007 to 244 candidates at 2018.

Figure IN 2. Candidates listed for intestine transplant on December 31 each year
Candidates concurrently listed at multiple centers are counted once. Those with concurrent listings and active at any program are considered active. IN, intestine without liver; IN-LI, intestine-liver.


A line plot for distribution of candidates waiting for intestine transplant by age; the  less than  6 category decreases by 50.3% from 53.4 percent at 2007 to 26.5 percent at 2018; the 6 to 17 category increases by 97.6% from 13.9 percent at 2007 to 27.6 percent at 2018; the 18 to 34 category increases by 84.7% from 10.4 percent at 2007 to 19.1 percent at 2018; and the  greater than or equal to 35 category increases by 20.1% from 22.3 percent at 2007 to 26.8 percent at 2018.

Figure IN 3. Distribution of candidates waiting for intestine transplant by age
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Active and inactive candidates are included.


A line plot for distribution of candidates waiting for intestine transplant by sex; the male category is 57.2 percent at 2007 and remains relatively constant with a value of 51.8 percent at 2018; and the female category increases by 12.6% from 42.8 percent at 2007 to 48.2 percent at 2018.

Figure IN 4. Distribution of candidates waiting for intestine transplant by sex
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive patients are included.


A line plot for distribution of candidates waiting for intestine transplant by race; the white category is 65.1 percent at 2007 and remains relatively constant with a value of 59.2 percent at 2018; the black category increases by 15.1% from 17.7 percent at 2007 to 20.4 percent at 2018; the hispanic category is 13.7 percent at 2007 and remains relatively constant with a value of 14.8 percent at 2018; the asian category increases by 49.4% from 2.4 percent at 2007 to 3.6 percent at 2018; and the other/unknown category increases by 104.9% from 1 percent at 2007 to 2 percent at 2018.

Figure IN 5. Distribution of candidates waiting for intestine transplant by race
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive candidates are included.