It is now generally accepted that small-bowel transplantation is indicated in patients suffering from irreversible small-intestinal failure coexisting with failure of parenteral nutrition. The main causes of parenteral nutrition failure are recurrent line related sepsis, loss of venous access due to thrombosis and PN-related liver disease. Medicare and Medicaid Services in the US have established indications that include impending or overt liver failure due to TPN-induced liver injury, thrombosis of two or more central veins, the development of two or more episodes of systemic sepsis secondary to line infection per year that require hospitalization, a single episode of line-related fungemia, septic shock and/or acute respiratory distress, and frequent episodes of severe dehydration despite intravenous fluid supplementation in addition to TPN [13].

These criteria should help to avoid late referrals. A timely referral for pretransplant assessment is essential for allowing the optimization of physical and psychological factors and should be at a stage when the central venous access is adequate for surgery and management of postoperative complications which may include renal replacement therapy. Unfortunately, it is our experience, that most patients are not referred, but rather come on their own initiative.

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