For referring clinicians
Indications for Intestinal Transplant
A clinical reference summarizing established criteria for referring adults with intestinal failure for intestinal or multivisceral transplant evaluation.
Background
Intestinal transplantation is reserved for a small subset of patients with irreversible intestinal failure. Parenteral nutrition (PN) remains the primary and preferred therapy for intestinal failure; adult 5- and 10-year survival on home PN is approximately 70% and 55%, respectively, and most PN-dependent patients are stable on medical management alone. Transplantation is generally considered only when PN itself becomes life-threatening or when survival on PN is expected to be worse than survival after transplant.
Early referral to a specialized intestinal rehabilitation and transplant program is preferred, since assessment and work-up can take several months, and central venous access — required for both survival on PN and for the transplant operation itself — may be progressively lost over time.
CMS-approved indications for intestinal transplantation
The Centers for Medicare & Medicaid Services (CMS) criteria, published in 2000 and still the standard reference worldwide, define “failure of parenteral nutrition” and related high-risk conditions warranting transplant evaluation. These criteria are organized into three categories.
1. Failure of parenteral nutrition
Any of the following constitutes PN failure and is an indication for transplant evaluation:
- Impending or overt liver failure due to PN-associated liver injury — impending: total bilirubin 3–6 mg/dL with progressive thrombocytopenia and progressive splenomegaly; overt: portal hypertension, hepatosplenomegaly, hepatic fibrosis, or cirrhosis
- Central venous catheter-related thrombosis of 2 or more central veins
- Frequent central line sepsis: two or more episodes per year of systemic sepsis secondary to line infection requiring hospitalization; a single episode of line-related fungemia; or septic shock or acute respiratory distress syndrome (ARDS) related to line infection
- Frequent episodes of severe dehydration despite intravenous fluid supplementation in addition to PN
2. High risk of death attributable to the underlying disease
Certain conditions carry a high intrinsic risk of death and may warrant transplant consideration independent of PN failure criteria:
- Desmoid tumors associated with familial adenomatous polyposis
- Congenital mucosal disorders (e.g., tufting enteropathy, microvillous inclusion disease — primarily pediatric)
- Ultrashort bowel syndrome (residual small bowel <20 cm in adults)
3. Intestinal failure with high morbidity or low acceptance of PN
- Frequent hospitalization
- Inability to function or maintain quality of life on PN
- Patient unwillingness to accept long-term parenteral nutrition
Common underlying conditions leading to adult intestinal transplant
Short gut syndrome accounts for approximately 60–65% of adult intestinal transplants. Etiologies differ substantially from the pediatric population:
| Condition | Approx. share of adult cases | Notes |
|---|---|---|
| Mesenteric ischemia/infarction | Most common cause of adult short gut | Arterial emboli (~50% of cases) from cardiac dysrhythmia, endocarditis, or aortic plaque; carries up to 80% mortality if untreated |
| Crohn's disease | ~11% | Recurrent resections for perforation, stricture, obstruction, or abscess; NOD2 gene mutations associated with higher graft failure risk |
| Intestinal motility disorders | ~11% | e.g., chronic intestinal pseudo-obstruction (CIPO); rehabilitative efforts generally unsuccessful |
| Intra-abdominal malignancy | ~15% | Chiefly desmoid tumors invading the mesenteric root; other indolent tumors (e.g., neuroendocrine) considered with caution given long-term immunosuppression |
| Acute volvulus | Less common | Increasingly reported after Roux-en-Y gastric bypass (Petersen's hernia) due to mesenteric fat loss |
| Retransplantation | ~7% | Increasing in frequency; isolated intestine retransplant has worse outcomes than liver-inclusive retransplant |
Anatomical predictors: enteral autonomy vs. transplant risk
Before pursuing transplant evaluation, aggressive intestinal rehabilitation should be attempted, since certain anatomical configurations are associated with a strong likelihood of achieving full enteral recovery:
- Residual small intestine >100 cm with a stoma (no colon in continuity)
- Residual small intestine >60 cm with jejunocolonic anastomosis (partial colon in continuity)
- Residual small intestine >30 cm, including the ileum and ileocecal valve, in continuity with the entire colon
Conversely, patients with the following features are more likely to remain permanently PN-dependent and may ultimately become transplant candidates:
- Very short residual jejunum with no ileum, no ileocecal valve, and no colon
- Underlying mucosal disease
- Motility disorders
- Abdominal wall defects
- Radiation enteritis
- High-grade intestinal obstruction
- Long duration of PN dependence (>2 years)
- Post-absorptive plasma citrulline level <20 µmol/L (approximately half of normal adult value) — a biomarker of residual functional enterocyte mass
Clinical note. The introduction of teduglutide (a GLP-2 analog) has meaningfully changed the rehabilitation landscape, allowing many patients to reduce or completely wean off PN who previously may have progressed toward transplant consideration. This should be factored into rehabilitation planning before transplant referral.
Contraindications to intestinal transplant
In general, the following will exclude or significantly complicate consideration for intestinal transplant:
- Potential for intestinal recovery through continued rehabilitation
- Severe wasting and cachexia
- Drug dependence considered likely to impair survival
- Primary or metastatic cancer (with the exception of desmoid tumors)
- Ongoing or recurrent infections not responding to treatment
- Significant cardiac or pulmonary pathology
- Demonstrated patient non-compliance, or significant psychiatric or social risk
- Potential complications from immunosuppressive therapy unacceptable to the patient
- Total loss of central venous access (though this is also an indication for urgent referral before access is fully lost)
Timing consideration. For patients where progressive loss of central venous access is the primary concern, referral should occur before all access is lost — adequate venous access is required both to survive the transplant operation and for postoperative care.
Three main types of intestinal transplant
| Type | Composition | Typical indication |
|---|---|---|
| Isolated intestine | Jejunoileum only, with or without colon | Irreversible intestinal failure with preserved liver function and life-threatening PN complications — most common graft type in stable adult recipients |
| Liver-intestine | Liver plus intestine (non-composite in adults; composite liver-pancreas-intestine in pediatrics) | Intestinal failure-associated liver disease (IFALD) causing impending or overt liver failure |
| Multivisceral (or modified multivisceral) | Stomach, duodenum, pancreas, intestine, +/- liver and spleen | Diffuse portomesenteric thrombosis (most common adult indication), extensive desmoid tumor infiltration of the foregut, or motility disorders affecting the foregut |
Colon inclusion in the graft has increased substantially over the past two decades (from ~10% in 2004 to nearly 60% in 2015) and is associated with superior 3-year graft survival, improved stool consistency after stoma closure, and greater likelihood of complete enteral independence.
Referral and assessment considerations
- Early referral is preferred. Assessment for intestinal transplant may take several months; early referral allows time to evaluate the patient, optimize medical management, and consider whether rehabilitation can still succeed before transplant becomes necessary.
- Age. There is no universal upper age limit, though most recipients are under 50 years of age.
- Psychosocial stability. A stable social and psychological history is essential given the intensity of pre- and post-operative care and long-term immunosuppression management.
- Venous anatomy. Detailed vein mapping is mandatory, as chronic PN access often causes thrombosis of major central veins (innominate, jugular, superior/inferior vena cava). Loss of major venous access may preclude transplant candidacy entirely.
- Comorbidities. End-stage kidney disease is common in this population (from chronic dehydration or renal oxalosis) and may require combined kidney-intestine transplant evaluation.
- Sensitization status. Preformed HLA antibodies (common after multiple prior surgeries, infections, and transfusions) can make donor matching difficult; virtual crossmatching is now standard to assess compatibility without requiring physical sample exchange.
Prevalence context
At any given time, an estimated 10–25% of adults and children on long-term home PN have at least one complication meeting formal transplant indication criteria — underscoring that transplant referral applies to a minority of the overall home PN population. Most PN-dependent patients remain candidates for continued medical management and intestinal rehabilitation rather than transplant.
For adult intestinal transplant candidates specifically, pretransplant waitlist mortality remains substantial — reported at approximately 19.6 deaths per 100 waitlist-years overall, and notably higher (19.9 per 100 waitlist-years) for those requiring a liver-inclusive graft compared with isolated intestine recipients (2.8 per 100 waitlist-years). This mortality gap is a key argument for early referral, before irreversible PN-associated liver disease develops and necessitates a higher-risk combined graft.
References
- Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). Intestinal and Multi-Visceral Transplantation: Program Memorandum Intermediaries/Carriers. Pub #60AB; CR #1629, AB-02-040. 2002.
- Matsumoto CS, Subramanian S, Fishbein TM. Adult Intestinal Transplantation. Gastroenterol Clin North Am. 2018;47(2):341-354.
- Fishbein TM. Intestinal transplantation. N Engl J Med. 2009;361(10):998-1008.
- Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr. 2016;35:247.
- Messing B, Crenn P, Beau P, et al. Long-term survival and parenteral nutrition dependence in adult patients with short bowel syndrome. Gastroenterology. 1999;117(5):1043-1050.
- Transplant Society of Australia and New Zealand (TSANZ). Clinical Guidelines for Organ Transplantation from Deceased Donors, Section 9: Intestine. tsanz.com.au, accessed 2026.
- Steinman TI, Becker BN, Frost AE, et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001;71(9):1189-1204.
- Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Intestinal and Multi-Visceral Transplantation (260.5).
- Colomb V, Dabbas-Tyan M, Taupin P, et al. Long-term outcome of children receiving home parenteral nutrition: a 20-year single-center experience in 302 patients. J Pediatr Gastroenterol Nutr. 2007;44(3):347-353.
This reference was prepared by the Advanced Intestinal Rehabilitation Institute (AIRI) for clinical and care-coordination use. It does not substitute for transplant center evaluation, individualized clinical judgment, or current payer medical policy. Transplant candidacy is determined individually by transplant center evaluation. Payer medical policy for intestinal transplant coverage should be verified independently, as specific criteria vary by insurer and are updated periodically.