Introduction: Worldwide there still is limited access to transplantation for patients suffering of intestinal failure with TPN associated complications. Despite favorable and improving outcomes there are still reluctancies to answer the obvious need for intestinal transplantation.
Methods: An intestinal transplant program was started at King Faisal Hospital and Research Center in Riyadh, Kingdom of Saudi Arabia in October 2017. A total of 11 adult intestinal transplants (ITX) have been performed in 11 recipients with a follow up of 2.8 years. The outcomes herein were analyzed retrospectively by a prospectively designed database. 
Results: Mean recipient age at time of transplant was 25 years for 6 male and 5 female recipients. Mean duration of total parenteral nutrition (TPN) prior ITX amounted to 34 months. Underlying disease was surgical short bowel syndrome in 5 patients. An additional 5 recipients were transplanted for intestinal motility disorder and 1 for microvillous inclusion disease. In case of intestinal failure associated liver disease (IFALD) pre-transplant liver biopsy was performed in order to rule out irreversible liver pathologies. All patients received a full intestinal allograft including the right hemicolon. Mean cold ischemic times were 218 minutes (range 75-335) and 24 minutes for warm ischaemia (range 17-40). Median length of hospital stay was 61 days (range 21-320). For endoscopic monitoring all recipients received a chimney stoma at the ileal region. All but one patient were discharged without any further TPN nor i.v.- fluid therapy. All of the recipients receiving thymoglobulin induction (n=3) developed biopsy proven rejection within the first year post ITX, whereas only 50% (4 out of 8) did following alemtuzumab induction. Rejections were monitored by protocol biopsies and HLA surveillance. Treatment consisted of steroid pulse, additional antibody administartion (ATG, Alemtuzumab, Infliximab, Vedolizumab, Rituximab), plasma exchange, immunoglobulins or their combination as per nature of the individual rejection. Immunosuppressive maintenance consisted of FK 506/steroids for the first 6 weeks followed by FK 506/mTor inhibition after stoma closure +-steroid withdrawal.
1-, 3- and 5-year survival are 91, 64 and 64 percent. Patient death were sepsis in 2 recipients following non-compliance induced rejections at 8 and 18, self-induced i.v. overdosing for 1 at 18 and a septic shock at 12. Death censored allograft survival was 100%. Average BMI increased from 18 before to 20 one year post transplant. GvHD and  PTLD incidence was 0%. 2 recipients developed severe CMV disease with CMV enteritis, being resolved following intensified management. 
Conclusion: ITX provides a challenging but valuable and life-changing therapeutical option for patients suffering of intestinal failure. It should be considered timely to avoid progression of IFALD with the necessity for combined liver and intestinal or multivisceral transplantation.