Introduction: The decision to accept or not an intestinal graft can be difficult and it is based on the donor data and the clinical experience of the procuring surgeon. Our aim was to analyze potential donor-related risk factors impacting survival.

Patient/ Methods: Donor data from the last 50 intestinal transplants (IT) performed in 44 pediatric patients were retrospectively reviewed (2010-2018; median age at transplant 3.4 yo; 2 LSBT, 42 MVT, 2 modified MVT, and 4 ISBT; 40% retransplants). Analyzed variables were donor/recipient age and weight ratio, cause of death, chronic or infectious disease, cardiorespiratory arrest (CRA) or hypotension, days in the Intensive Care Unit (ICU), and macroscopic appearance of the graft at the procurement and at reperfusion. Results were measured as early graft loss (<6 months) and/or incidence of immunological events.

Results: Unstable donors and those with prolonged cardiac arrest were directly rejected at the offer. Median donor age and weight was 16 months (1 day-18yo) and 10 kg (range 3-68Kg), respectively. The main cause of death was traumatic brain injury (n=17), followed by cerebral hypoxia (n=14), cerebral hemorrhage or infarction (n=13), and meningitis (n=6). Ten donors had chronic disease before death, 14 had suffered a CRA (median duration of 20 minutes; range 1-45), and 18 hypotension. The mean length of stay in the ICU was 2.9 days (range 0.5-9). Graft reperfusion was poor in 2 cases.

In total, 19/50 grafts were lost in 17 patients, after an average time of 10 months (range 1-50), 68% early after transplant, and most of them due to immune complications (61%). In 2 patients the graft never functioned until death. Four patients were retransplanted (100% of the ISBT grafts). Patient and graft 1- and 5- year survival was 83%/73% and 70%/69%, respectively.

The data analysis showed a higher incidence of early graft loss in chronically ill donors and in longer CRA times (p<0.05), and when macroscopic appearance after reperfusion was suboptimal. Donor age or weight, donor/recipient age and weight ratio, cause of death, CNS infection, length of stay in ICU, did not significantly impact on graft survival.

Conclusions: Immune complications are the main reason for the early graft loss in IT. However, ischemia reperfusion injuries observed in marginal donors, as chronically ill patients or longer CRA times, can accelerate the appearance of these complications, leading to irreversible consequences.