In the world of organ transplantation, achieving the perfect balance of immunosuppression is akin to walking a tightrope. Too little, and the body may reject the precious graft; too much, and the risks of infection and other complications rise. However, the stakes are even higher and the balance harder to achieve in patients with complicating factors such as Short Bowel Syndrome (SBS). The challenges faced in such a situation are profoundly illustrated by a case report published on October 1, 2018, in The Ulster Medical Journal, which examines the obstacles encountered by health professionals in managing a renal transplant recipient who developed SBS, and highlights the significance of personalized medicine in complex clinical scenarios.

Article DOI: 10.1016/j.ulmed.2018.10.001

Imagine the human digestive system as a meticulous machinery responsible for absorbing not just food, but the very medications designed to keep that machinery running smoothly after a transplant. This concept remains at the forefront when clinicians are presented with the difficult case of a kidney transplant patient who has developed Short Bowel Syndrome (SBS)—a condition characterized by the malabsorption of nutrients due to the surgical removal of a large portion of the small intestine.

The case at hand, as reported in The Ulster Medical Journal, involved an adult male patient who underwent a successful renal transplantation but subsequently developed SBS. The development of this condition posed a significant barrier to the conventional administration of oral immunosuppressive therapy, essential for the prevention of graft rejection. The peer-reviewed publication delves into the complexities of dosing and delivery of such crucial medications when the absorptive capacities of the gut are compromised.

The journal article, indexed with the DOI: 10.1016/j.ulmed.2018.10.001, is a testament to the intricate dance between drug pharmacokinetics and patient physiology. It underscores the necessity for healthcare providers to display both ingenuity and adaptability when faced with the hurdles of postoperative complications like SBS.


1. Renal transplant immunosuppression
2. Short bowel syndrome complications
3. Kidney transplant absorption issues
4. Oral immunosuppressive agents
5. Transplant pharmacokinetics

Clinical Backdrop

The primary challenge posed by SBS is the diminished capacity of the gastrointestinal tract to absorb drugs effectively. Immunosuppressive agents, such as tacrolimus and mycophenolic acid, are cornerstones in the prevention of organ rejection. Their absorption is primarily through the small intestine—a process grievously affected in patients with SBS.

According to McCloskey et al. in the referred case report, the patient in question required careful monitoring and dose adjustments of immunosuppressive medications to maintain therapeutic levels. The complexity of the condition demands a high level of expertise and precision in managing the dosages and routes of administration to maintain adequate blood levels of these drugs.

Revisiting the Case

The case highlighted by McCloskey O.M. and colleagues in The Ulster Medical Journal (PMID: 31061546) presents a narrative of meticulous medical management where oral administration of immunosuppressants became a daunting challenge. The patient’s remaining intestinal tract was not well suited for absorbing these critical medications, raising concerns about possible graft rejection.

The team had to navigate uncharted waters, balancing the precarious levels of the immunosuppressive agents without triggering adverse effects. This predicament called for an innovative approach to drug administration, considering alternate routes and varying pharmacokinetic models, to ensure the graft’s survival.

Innovative Solutions Drawing from Past Literature

A deep dive into previous research offers some insights into potential approaches to such conditions. Rogers et al. (PMC3660730) explored the pharmacokinetics of immunosuppressants post-gastric bypass surgery, offering valuable information for similar scenarios. Another study by Nishi et al. (PMID: 15050160) revealed the absorptive capacity of the colon for tacrolimus, thus providing hope for rectal administration in situations where oral intake is compromised. Patel et al. (PMID: 12955349) drew on a case demonstrating the feasibility of oral tacrolimus in a patient with SBS, while Hasegawa et al. (PMID: 11422824) touched on alternative oral administration methods post-surgery. Novelli et al. (PMID: 10654359) further discussed tacrolimus absorption in children with SBS, pointing towards age-related differences in drug absorption and metabolism in patients with compromised intestines.

The aforementioned studies pave the way for a customized approach, underscoring the necessity for medical professionals to stay abreast of diverse research to cater to individual patient needs. These references demonstrate the critical nature of personalized medicine, especially in the domain of transplantation and complex post-surgical complications.

Managing Tacrolimus Levels

Tacrolimus, a formidable agent in the realm of immunosuppression, has a narrow therapeutic index with significant interindividual variability in its absorption and metabolism. Achieving stable blood concentrations is a feat when the patient presents with normal gastrointestinal function, and all the more formidable in patients like the one discussed. The team caring for the patient had to implement a rigorous drug monitoring protocol, tweaking the dosage based on meticulous blood level analyses.

The Role of the Multidisciplinary Team

The success in managing such intricate medical cases relies heavily on the collaboration of a multidisciplinary team. The dietitian, pharmacist, transplant surgeon, nephrologist, and nursing staff each play a pivotal role. Their cumulative expertise ensures that the therapeutic regimen is optimized, the patient’s nutritional status is maintained, and the psychosocial needs are addressed—all collectively enhancing the probability of a successful outcome.

Clinical Implications and Future Directions

This case report serves as a beacon, illuminating the path for future clinical practice. Medical practitioners, while facing such daunting scenarios, need to adopt a holistic and individualized approach. The key takeaway from this scholarly narrative is that personalizing medication regimens is not just a preference but a necessity in the nuanced world of organ transplant immunosuppression management, especially with complicating factors such as SBS.

The field of organ transplantation is evolving, with ongoing research working towards more effective and easily absorbed immunosuppressive agents. Additionally, advancements in pharmacogenomics hold promise for tailored therapies based on individual genetic profiles, potentially mitigating the challenges presented by conditions like SBS.


The complex interplay of drug pharmacokinetics, graft survival, and confounding medical conditions, as encapsulated in the case report from The Ulster Medical Journal, highlights the burgeoning need for precision medicine in transplantation. As we forge ahead, embracing innovation in pharmacology and patient care, the hope is to transform these arduous medical challenges into manageable conditions with successful outcomes.

“THE CHALLENGE OF ACHIEVING ADEQUATE ORAL IMMUNOSUPPRESSION IN A RENAL TRANSPLANT RECIPIENT WHO DEVELOPS SHORT BOWEL SYNDROME,” may not capture the daily headlines, but it encapsulates a critical avenue in which medical professionals strive to provide comprehensive and life-saving care despite formidable odds.


1. McCloskey O.M., Woodman A., Mitchell A., Smyth J. (2019). The challenge of achieving adequate oral immunosuppression in a renal transplant recipient who develops short bowel syndrome. Ulster Med J, 87(3), 200–201. PMID: 31061546
2. Rogers C.C., Alloway R.R., Alexander J.W., Cardi M., Trofe J., Vinks A.A. (2008). Pharmacokinetics of mycophenolic acid, tacrolimus, and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: a pilot study. Clin Transplant, 22(3), 281-91. PMC3660730
3. Nishi K., Ishii T., Wada M., Amae S., Sano N., Nio M., et al. (2004). The colon displays an absorptive capacity of tacrolimus. Transplant Proc, 36(2), 364-6. PMID: 15050160
4. Patel N., Smith S., Handa A., Darby C. (2004). The use of oral tacrolimus in a case of short bowel syndrome. Transpl Int, 17(1), 44-5. PMID: 12955349
5. Hasegawa T., Nara K., Kimura T., Soh H., Sasaki T., Azuma T., et al. (2001). Oral administration of Tacrolimus in the presence of jejunostomy after liver transplantation. Ped Transplant, 5(3), 204-209. PMID: 11422824
6. Novelli M., Muiesan P., Mieli-Vergani G., Dhawan A., Rela M., et al. (1999). Oral absorption of tacrolimus in children with intestinal failure due to short or absent small bowel. Transplant Int, 12(6), 463-5. PMID: 10654359