Intestinal retransplant in a patient after fungal sepsis: considerations and issues

An adolescent female received an isolated intestinal transplant. She developed severe exfoliative rejection and required complete enterectomy. The patient developed a septic hip and lung lesions with biopsy-proven Aspergillus nidulans and was treated with caspofungin, ambiosome, and voriconizole. After completing a year of treatment and extensive physical therapy, the patient requested retransplant. The case was presented to the ethics committee, which determined that the patient demonstrated understanding of the risks and benefits. Infectious disease consultants presented data showing high risk for fungal recurrence. Quality of life as observed by our transplant team seemed good and the patient had no other indications. Retransplant is associated with higher risk than first transplants. Does the team have the right to deny retransplant if the competent patient requests transplant despite high risk? Guidelines for this indication are complex and evolving.