Immunosuppression in liver transplanted patients with short bowel syndrome

Short bowel syndrome (SBS) is the consequence of an extensive small intestine resection ranging from 50% to 80% of its length. This results in major hydro electrolyte disorders and severe malabsorption without specific management. The resulting pharmacokinetic/dynamic modifications could lead to erratic and inconsistent immunosuppressive blood trough levels. This condition has already been described in transplanted patients, but very few reports exist in liver transplanted (LT) adults. Moreover, no recommendations have been yet formulated for the management of immunosuppression in LT experiencing SBS. From three cases we assessed our practices retrospectively and suggest tacrolimus granules for oral suspension as a first alternative in short bowel syndrome liver transplanted patients. This would enhance absorption such as it was previously described in other organ transplanted patients. Also, a tight therapeutic drug monitoring should be based on trough levels associated with area under the curves measures in order to confirm the optimal immunosuppression level. Finally, intestinal continuity must be restored as fast as possible in order to allow a therapeutic balance.