Medical Policy: 07.03.05
Original Effective Date: November 2009
Reviewed: November 2020
Revised: November 2018
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
This policy addresses transplantation of the intestinal allograft in combination with liver allograft, and multivisceral transplant which typically includes the small bowel/liver in combination with one or more other abdominal visceral organs such as the stomach and pancreas. For isolated small bowel transplant see medical policy 07.03.04.
Solid organ transplantation offers a treatment option for patients with different types of end-stage organ failure that can be lifesaving or provide significant improvements to a patient’s quality of life. Many advances have been made in the last several decades to reduce perioperative complications. Available data supports improvement in long-term survival as well as improved quality of life particularly for liver, kidney, pancreas, heart, and lung transplants. Allograft rejection remains a key early and late complication risk for any organ transplantation. Transplant recipients require life-long immunosuppression to prevent rejection. Patients are prioritized for transplant by mortality risk and severity of illness criteria developed by Organ Procurement and Transplantation Network and United Network of Organ Sharing.
In 2019, 39,719 transplants were performed in the United States procured from almost 11,900 deceased donors and 7,400 living donors. Intestinal transplants occur less frequently than other organ transplants, with 10 or fewer patients receiving liver-intestine transplant each year from 2008 to 2019. Small bowel and liver or multivisceral transplant are usually considered in adults and children who develop serious complications related to parenteral nutrition, including inaccessibility (e.g., due to thrombosis) of access sites, catheter-related sepsis, and cholestatic liver disease.
Short bowel syndrome is a condition in which the absorbing surface of the small intestine is inadequate due to extensive disease or surgical removal of a large portion of small intestine. In some instances, short bowel syndrome is associated with liver failure, often due to long term complications of total parenteral nutrition (TPN).
Some conditions are more closely associated with pediatric intestinal failure while others are more common with intestinal failure in adults.
The following are pediatric conditions causing intestinal failure:
The following are adult conditions causing intestinal failure:
The chronic use of TPN is often associated with life-threatening complication including:
A small bowel/liver transplant or a multivisceral transplant includes the small bowel and liver and one or more of the following organs: stomach and pancreas. The type of transplantation depends on the underlying etiology of intestinal failure, quality of native organs, presence or severity of liver disease, and history of prior abdominal surgeries. A multivisceral transplant is indicated when anatomic or other medical problems preclude a small bowel/liver transplant. Complications following small bowel/liver and multivisceral transplants include acute or chronic rejection, donor-specific antibodies, infection, lymphoproliferative disorder, graft versus host disease, and renal dysfunction.
The purpose of small bowel and liver transplant alone or multivisceral transplant in patients who have intestinal failure and evidence of impending end-stage liver failure is to provide a treatment option that is an alternative to or an improvement on existing therapies.
The relevant population of interest is individuals with intestinal failure and evidence of impending end-stage liver failure.
The therapy being considered is small bowel and liver transplant alone or multivisceral transplant .
The following practices are currently being used to make decisions about intestinal failure and evidence of impending end-stage liver failure: medical management and parenteral nutrition.
The general outcomes of interest are overall survival (OS), morbid events, and treatment-related mortality and morbidity, including short and long-term graft survival and 1 and 5year OS.
The published literature consists of a registry study and case series, mainly reported by single centers in the U. S. and Europe. Many case series have included isolated small bowel transplantations.
Reasons for transplantations were mainly short bowel syndrome. Other reasons included congenital enteropathies and motility disorders. Most common outcomes reported were survival rates and weaning off total parenteral nutrition. Several studies have presented survival rates by type of transplantation, while others have combined all types of transplants when reporting survival rates. When rates were reported by type of transplant, isolated transplantations had higher survival rates than multivisceral transplants.
Several investigators have reported higher survival rates in transplants conducted more recently than those conducted earlier. Reasons for improved survival rates in more recent years have been attributed to the development of more effective immunosuppressive drugs and the learning curve for the complex procedure. Authors of these publications, as well as related reviews have observed that while outcomes have improved over time, recurrent and chronic rejection and complications of immunosuppression continue to be obstacles of long-term survival.
|Raghu et. al. 2019||International||2080||
|Lacaille et. al. 2017||France||110||
55 patients alive
|Garcia Aroz et. al. 2017||U.S.||10||
||6 out of 7 alive at > 10 years|
|Dore et. al. 2016||U.S.||30||
||28 (4-175 months)|
|Rutter et. al. 2016||U.K.||60||
||21 (0-95 months)|
|Study||Interventions/Treatment, n||Survival||Off Total Parenteral Nutrition (TPN)|
|Raghu et. al. 2019||
All transplantations combined:
|Not reported (NR)|
|Lacaille et. al. 2017||
All transplantations combined:
|Garcia Aroz et. al. 2017||
All transplantations combined:
All transplantations combined:
|Dore et. al. 2016||
All transplantations combined:
|Rutter et. al. 2016||
||Not reported (NR)|
Several case series have focused on complications after small bowel and multivisceral transplantation:
In 2019, Spence et. al. performed a retrospective chart review of intra-abdominal and bloodstream infection in adults undergoing intestinal or multivisceral transplant at a single center in the U.S. A total of 103 adult patients (median age, 44 years) were included who received 106 intestinal or multivisceral transplants between 2003 and 2015. Intra-abdominal infection occurred in 46 (43%) patients, and concurrent bloodstream infection occurred in 6 (13%) patients. The median time to first intra-abdominal infection was 23 days (interquartile range, 10-48). All-cause mortality was not significantly different between patients with versus without intra-abdominal infections (p=0.654). The authors concluded intra-abdominal infections are common in intestinal or multivisceral transplant recipients, but despite this complication found no increased risk of mortality.
Nagai et. al. (2016) reported on cytomegalovirus infection after intestinal or multivisceral transplant at a single center in the United States. Cytomegalovirus (CMV) infection is the most prevalent infectious complication after solid organ transplantation, and recipients of isolated intestinal transplantation (IIT)/multivisceral transplantation (MVT) are among those at the highest risk. Limited clinical data exist regarding CMV infection after IIT/MVT. The aim of this study was to analyze risk factors for post-transplant CMV infection and to assess the efficacy and validity of their prophylaxis and treatment regimens in intestinal transplantation. Medical records of 210 IIT/MVT patients were retrospectively reviewed. Post-transplant CMV prophylaxis regimen consisted of ganciclovir followed by 1 year of valganciclovir. The addition of CMV immunoglobulin (CMVIG) was decided according to donor/recipient CMV serostatus (D/R). All results of CMV PCR and/or pp65 antigenemia, and pathological reports were reviewed. Time to the incidence of CMV infection (viremia and/or tissue invasive disease) and risk factors for CMV infection were investigated. CMV infection was observed in 34 of 210 (16%) with a median onset of 347 days. Rejection was significantly associated with CMV infection (P = 0.01, odds ratio = 2.61). In the high-risk serostatus group (D+/R-), prophylactic CMVIG and induction with high-dose rabbit antithymocyte globulin (>10 mg/kg) were associated with a lower CMV infection rate on univariate analysis. The CMVIG remained to be an independent factor on multivariate analysis (P = 0.04, hazard ratio = 0.93/dose). Mortality associated with CMV infection occurred in 4, and CMV infection adversely affected patient survival (P = 0.001, hazard ratio = 2.71).
In 2016, Timpone et. al. performed retrospective review on all patients who underwent small intestine or multivisceral transplantation from November 8, 2003 through November 30, 2008. Those with Cytomegalovirus (CMV) viremia and invasive disease were identified. Intravenous ganciclovir (GCV) resistance was suspected in patients who continued to have viremic episodes or invasive disease despite appropriate GCV treatment. Genotypic analyses were performed to detect the presence of GCV resistance genes UL97 and UL54. During the study period, 88 small intestine or multivisceral transplants were performed on 85 patients. Of the 88 transplantations, 16 patients developed CMV viremia with or without end-organ disease (18.2%) and 5.7% developed GCV-R CMV infection. In patients diagnosed with CMV infection, 31.3% (5/16) had GCV-R CMV infection. Of patients with GCV-R CMV infection, 80% (4/5) developed CMV allograft enteritis, resulting in allograft explantation in 3 patients. All patients with GCV-R CMV infection were CMV donor positive/recipient negative. Patients with tissue-invasive CMV disease were 18 times more likely to be infected with GCV-R CMV (95% confidence interval 1.24-260.93; P-value 0.0341). The authors concluded, small intestinal and multivisceral transplant recipients have a higher rate of GCV-R CMV infection compared with other solid organ transplant recipients, which is often associated with tissue-invasive disease and allograft loss.
Wu et. al. (2016) investigated the incidence and risk factors of acute antibody-mediated rejection (ABMR) among patients undergoing intestinal transplantation (N=175). All patients were 25 years of age. Acute ABMR was diagnosed by clinical evidence; histologic evidence of tissue damage; focal or diffuse linear C4d deposition; and circulating anti-human leukocyte antigen antibodies. Of the 175 intestinal transplants, 58% were liver-free grafts, 36% included a liver graft, and 6.3% were retransplantations. Eighteen cases of acute ABMR were identified 14 (14%) among the patients undergoing first liver-free transplantation, 2 (3%) among patients undergoing liver and small bowel transplantations, and 2 (18%) among the patients undergoing retransplantation. Graft failure occurred in 67% of patients with acute ABMR. The presence of a donor-specific antibody and a liver-free graft were associated with the development of acute ABMR.
In 2016, Cromvik et. al. investigated the incidence, clinical picture, risk factors and outcome of graft-versus-host disease (GVHD) in a cohort of patients who underwent intestinal or multivisceral tansplant. All transplanted patients (n = 26) were retrospectively analyzed with respect to donor- and recipient-derived risk factors. The diagnosis of GVHD was based on clinical signs, chimerism analyses of leukocytes, and histopathologic findings in biopsy specimens. Five of 26 patients (19%) were diagnosed with GVHD, of which three had skin GVHD, one had skin and bone marrow GVHD, and one had passenger leukocyte syndrome. Only multivisceral-transplanted patients developed GVHD. Risk factors for development of GVHD were an underlying tumor diagnosis and neoadjuvant chemo- or brachytherapy administered before intestinal transplantation. All patients were given high-dose corticosteroids as first line treatment for their GVHD, and all survived their episodes of GVHD. The authors concluded, the risk of GVHD appears to be increased in recipients of multivisceral transplantations who received chemotherapy due to an underlying malignancy. The reasons may be the large amount of lymphoid tissue in these types of grafts, and the cytotoxic effects of the malignancy and chemotherapy on healthy recipient tissues. These patients should be monitored closely for the development of GVHD.
Intestinal transplantation procedures are infrequently performed and only one registry study and relatively small case series, generally, single center, are available. For patients experiencing significant complications from total parenteral nutrition (TPN) , which can lead to liver failure and repeated infections, the literature has shown reasonably high post-transplant survival rates in patients who have a high probability of death without treatment.
The purpose of small bowel and liver transplant alone or multivisceral retransplant in patients who have failed small bowel and liver or multivisceral transplant without contraindications for retransplant is to provide a treatment option that is an alternative to or an improvement on existing therapies.
The relevant population of interest are individuals with a failed small bowel and liver or multivisceral transplant without contraindications for retransplant.
The therapy being considered is small bowel and liver retransplant alone or multivisceral retransplant.
The following practices are currently being used to make decisions about failed small bowel and liver or multivisceral transplant when there are no contraindications to retransplant: medical management and parenteral nutrition.
The general outcomes of interest are overall survival (OS), morbid events, treatment related mortality, and treatment related morbidity, including short and long-term graft survival and one and five year OS.
Evidence for the use of retransplantation to treat individuals who have failed intestinal transplantations includes several case series, mostly from single institutions. Among the case series reasons for retransplantations included: acute and chronic rejection, Cytomegalovirus (CMV), liver failure, lymphoproliferative disorder and graft.
Lacaille et. al. (2017) reported on the achievements in pediatric intestinal transplantation (ITx) and define areas for improvement. After a period (1987-1990) of nine isolated small bowel transplants (SBTx) where only one patient survived with her graft, 110 ITx were performed on 101 children from 1994 to 2014: 60 SBTx, 45 liver-small bowel, four multivisceral (three with kidneys), and one modified multivisceral. Indications were short bowel syndrome (36), motility disorders (30), congenital enteropathies (34), and others (1). Induction treatment was introduced in 2000. Patient/graft survival with a liver-containing graft or SBTx was, respectively, 60/41% and 46/11% at 18 years. Recently, graft survival at 5/10 years was 44% and 31% for liver-containing graft and 57% and 44% for SBTx. Late graft loss occurred in 13 patients, and 7 of 10 retransplanted patients died. The main causes of death and graft loss were sepsis and rejection. Among the 55 currently living patients, 21 had a liver-containing graft, 19 a SBTx (17 after induction), and 15 were on parenteral nutrition. ITx remains a difficult procedure, and retransplantation even more so. Over the long term, graft loss was due to rejection, over-immunosuppression was not a significant problem. Multicenter studies on immunosuppression and microbiota are urgently needed.
In 2018, Ekser et. al. reviewed and compared outcomes of intestinal retransplantation with primary intenstinal transplant (Itx), which included isolated ITx, modified multivisceral transplantation (mMVTx), and full MVTx, between 2003 and 2014 at Indiana University. Graft loss in intestinal transplantation (ITx) is close to 25% in the first year and 50% at 5-year post-transplantation. Although technically and immunologically challenging, intestinal retransplantation is now the 4th most common indication for ITx. Of 218 ITx, 18 (8.3%) were retransplantation. Causes of graft loss were rejection (78%), pancreatitis (11%), and severe intestine dismotility (11%). MVTx (16/18, 89%) was the preferred retransplantation option. In 7 (39%) patients, graftectomy was performed between primary and intestinal retransplantation. Median interval between primary ITx and retransplantation was 421 days. Although patient and graft survival rates at 1 year, 3 years, and 5 years were comparable between primary and retransplants, the number of retransplants was limited in the follow-up after post-transplant year 3.
Evidence for retransplantation derives mostly from single center case series. Although limited in quantity, the available follow-up data after retransplantation have suggested reasonably high survival rates after small bowel and liver transplants and multivisceral retransplantation in patients who continue to meet criteria for transplantation.
For individuals who have intestinal failure and evidence of impending end-stage liver failure who receive a small bowel and liver transplant alone or multivisceral transplant, the evidence includes a registry study and a limited number of case series. These transplant procedures are infrequently performed and few reported case series exist. However, results from the available case series have revealed fairly high post procedural survival rates. Given these results and the exceedingly poor survival rates of patients who exhaust all other treatments, transplantation may prove not only to be the last option but also a beneficial one. Transplantation is contraindicated for patients in whom the procedure is expected to be unsuccessful due to comorbid disease, or in who post-transplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in a meaningful improvement in net health outcomes.
For individuals who have failed small bowel and liver or multivisceral transplant the evidence for retransplant includes case series. Although limited in quantity, the available post retransplantation data have suggested reasonably high survival rates. Given exceedingly poor survival rates without retransplantation of patients who have exhausted their treatments, evidence of postoperative survival from uncontrollable studies is sufficient to demonstrate that retransplantation provides a survival benefit in appropriately selected patients. Retransplantation is contraindicated for patients in whom the procedure is expected to be unsuccessful due to comorbid disease or in whom post transplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in a meaningful improvement in net health outcomes.
In 2003, the American Gastroenterological Association produced a medical position statement on short bowel syndrome and intestinal transplantation. It recommends dietary, medical and surgical solutions. Indications for intestinal transplant mirror those of Medicare in patients who fail TPN therapy for one of the following reasons:
Until better data become available, these parameters are likely to be widely recognized as the indications for intestinal transplantation.
(Verified November 2020 this 2003 position statement remains as the current position statement)
In 2001, the American Society of Transplantation issued a position paper on indications for pediatric intestinal transplantation. The position paper included the following:
“Parenteral nutrition represents standard therapy for children with short bowel syndrome and other causes of intestinal failure. Most infants with short bowel syndrome eventually wean from parenteral nutrition, and most of those who do not wean tolerate parenteral nutrition for protracted periods. However, a subset of children with intestinal failure remaining dependent on parenteral nutrition will develop life-threatening complications arising from therapy. Intestinal transplantation can now be recommended for this select group. Life-threatening complications warranting consideration of intestinal transplantation include parenteral nutrition-associated liver disease, recurrent sepsis, and threatened loss of central venous access. Children with liver dysfunction should be considered for isolated intestinal transplantation before irreversible, advanced bridging fibrosis or cirrhosis supervenes, for which a combined liver and intestinal transplant is necessary. Irreversible liver disease is suggested by hyperbilirubinemia persisting beyond 3-4 months of age combined with features of portal hypertension such as splenomegaly, thrombocytopenia, or prominent superficial abdominal veins; esophageal varices, ascites, and impaired synthetic function are not always present.”
(Verified November 2020 this 2001 position remains as the current position statement)
In September 2020, the Organ Procurement and Transplantation Network (OPTN) policies for allocation of liver intestines and intestines are the following:
Each intestine candidate is assigned a status that reflects the candidate’s medical condition. Candidates may be assigned any of the following:
To assign an intestine candidate status 1, the candidate’s transplant program must submit a Status 1 Justification Form to the OPTN Contractor. A candidate may be assigned status 1 if the candidate has any of the following conditions:
Any active candidate that does not meet the criteria for status 1 must be registered as status 2.
If the candidate is temporarily unsuitable for transplant, then the candidate’s transplant program may classify the candidate as inactive and the candidate will not receive any intestine offers.
Adult liver candidates who are also registered and active on the waiting list for an intestine transplant at that transplant hospital will automatically receive an additional increase in their MELD or PELD score equivalent to a 10 percentage point increase in risk of 3-month mortality. Candidates less than 18 years old will receive 23 additional points to their calculated MELD or PELD score instead of the 10 percentage point increase. The transplant hospital must document in the candidate’s medical record the medical justification for the combined liver-intestine transplant and that the transplant was completed.
Small bowel/liver and multivisceral transplantation are surgical procedures and, as such, are not subject to regulation by the U.S. Food and Drug Administration (FDA).
The FDA regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation Title 21, parts 1270 and 1271. Solid organs used for transplantation are subject to these regulations.
Prior approval is required.
See related medical policy
A combined small bowel and liver transplant may be considered medically necessary for pediatric and adult patients when ALL of the following criteria is met:
A multivisceral transplant may be considered medically necessary for pediatric and adult patients who meet criteria above for the combined small bowel and liver transplant and require 1 or more abdominal visceral organs to be transplanted due to concomitant organ failure or anatomical abnormalities that preclude a small bowel and liver transplant.
A combined small bowel and liver transplant or multivisceral transplant for pediatric and adult patients performed for any other conditions not listed above will be considered not medically necessary.
Retransplantation in individuals of a combined small bowel and liver transplant or multivisceral transplant to include non-function of the grafted organ(s), acute or chronic rejection, or return of disease may be considered medically necessary if the individual meets the criteria above.
The following potential contraindications to solid organ transplant are subject to judgement of the transplant center:
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