*Purpose: There is no data in the literature about outcomes of pediatric intestinal transplant (IT) recipients, who require renal transplant after intestinal transplant (RTAIT). The purpose of this study is to highlight: i) technical challenges involved in RTAIT ii) graft / patient outcomes in RTAIT.

*Methods: Retrospective single-center study of pediatric IT recipients, who required RTAIT, from January 1, 2000 to December 31, 2018 was performed. Renal transplant (RT) graft failure was defined as re-institution of hemodialysis (HD) post-RT due to graft dysfunction or graft loss from patient death. IT graft failure was defined as re-institution of TPN post-IT due to graft dysfunction or graft loss from patient death.

*Results: Out of 200 pediatric IT recipients, 10 (5%) children required RTAIT. Median age at IT was 7 years (range 1-18). End-stage renal disease developed due to calcineurin toxicity in 5 patients and primary renal immunologic disorders in 5 patients. Median time to RT after IT was 5 years (range 1-16). Median age at RTAIT was 15 years (range 2-22). Renal grafts from ABO-compatible, crossmatch-negative living donors (n=5) and cadaveric donors (n=5) were utilized. Primary long-term immunosuppression in RTAIT recipients was tacrolimus.

Technical details and challenges

1) Bilateral iliac vein thromboses were present in 3 recipients requiring renal vein outflow anastomosis to inferior vena cava followed by renal arterial inflow anastomosis to infrarenal aorta. Exposure was achieved via intra-abdominal approach in 2 of these recipients and via right-sided retroperitoneal exposure in 1 recipient. 2) Among 7 recipients with patent bilateral iliac veins, presence of right lower quadrant (RLQ) ileostomy (n=4) and/or RLQ complex abdominal wall hernias (n=3) at time of RTAIT necessitated RT graft implantation in left iliac fossa in all 7 recipients to avoid injury to IT graft. 3) Vicryl inlay mesh was utilized to close fascia after RTAIT in 2 patients while native recipient nephrectomy was performed in 1 recipient to avoid RT graft compression due to small retroperitoneal / intra-abdominal compartment.

Outcomes

Median follow-up was 5 years (range, 1-14). No arterial, venous, or ureteral complications occurred in RTAIT recipients. No IT graft injury occurred at time of RT graft implantation in RTAIT recipients. Among RTAIT recipients, actual 1- year and 5-year RT graft survival was 100% and 80% respectively. Among RTAIT recipients, actual 1-year and 5-year IT graft survival was 100% and 80% respectively. Among RTAIT recipients, actual 1-year and 5-year patient survival was 100% and 90% respectively.

*Conclusions: Excellent RT / IT graft and patient survival in pediatric RTAIT recipients can be achieved through meticulous surgical technique, attentive donor-recipient immunologic matching, and multidisciplinary immunosuppression management of RT / IT grafts.

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