The changing landscape of intestinal transplantation: Insights from the first quarter of the 21st century of Eurotransplant experience

Background: Intestinal transplantation (ITx) remains one of the most complex procedures in solid organ transplantation. This study analyzes 25 years of Eurotransplant data to evaluate trends, outcomes, and prognostic factors. Methods: Retrospective analysis of all intestinal transplant candidates and recipients within Eurotransplant (2000-2024) was performed. Survival analysis used Kaplan-Meier curves and Cox regression models. Primary outcomes included transplantation rates, waitlist mortality, and post-transplant overall survival. Results: Among 303 patients, 215 received transplants and 88 remained non-transplanted. Transplanted patients were younger (37.7 ± 16.0 vs 42.3 ± 16.3 years, p = 0.030). Isolated intestinal transplantation comprised 46.0 % of procedures, while combinations with other organs accounted for 54.0 %. Cumulative transplantation incidence reached 70 % at four years, with significantly higher rates for liver-inclusive procedures (95 % vs 85 %, p = 0.00041). Waitlist mortality reached 40 % at four years, with trends toward higher mortality in adults versus pediatric patients. Post-transplant overall survival showed better univariate outcomes for transplants without liver components (HR=0.61, p = 0.034), though this difference disappeared after multivariable adjustment. Transplant year was independently associated with worse survival (HR=1.062, p = 0.005), reflecting changing selection criteria as non-transplant management improved. Annual transplant volume declined from 17 procedures (2007-2010) to 4 in 2023, despite stable donor reporting. Conclusions: Despite declining volumes, Eurotransplant ITx provides life-saving treatment with 70 % transplantation rates and outcomes comparable to international registries. The paradoxical survival trends reflect the field's success in expanding indications to more complex patients as parenteral nutrition advances. Strategic approaches including program consolidation and enhanced donor utilization could further optimize this essential therapeutic option for irreversible intestinal failure.