Immunosuppression following intestinal transplantation

Mueller, A.R; Pascher, A; Platz, K.-P; Braun, F; Fändrich, F; Rayes, N; Seehofer, D; Radtke, C; Neuhaus, P; Kremer, B

doi:10.1016/j.transproceed.2003.12.017

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Volume 36, Issue 2 , Pages 325-328, March 2004

Immunosuppression following intestinal transplantation

A.R Mueller
- Department of Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany (A.R.M., K.P.P., F.B., F.F., B.K.)
- Address reprint requests to Dr Andrea Raffaella Mueller, Department of Surgery, University of Schleswig Holstein, Campus Kiel, Arnold-Heller-Str 7, 24105 Kiel, Germany.
A Pascher
- Department of Surgery (A.P., N.R., D.S., P.N.), Charité, Campus Virchow Clinic, Humboldt University of Berlin, Berlin, Germany
K.-P Platz
- Department of Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany (A.R.M., K.P.P., F.B., F.F., B.K.)
F Braun
- Department of Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany (A.R.M., K.P.P., F.B., F.F., B.K.)
F Fändrich
- Department of Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany (A.R.M., K.P.P., F.B., F.F., B.K.)
N Rayes
- Department of Surgery (A.P., N.R., D.S., P.N.), Charité, Campus Virchow Clinic, Humboldt University of Berlin, Berlin, Germany
D Seehofer
- Department of Surgery (A.P., N.R., D.S., P.N.), Charité, Campus Virchow Clinic, Humboldt University of Berlin, Berlin, Germany
C Radtke
- Department of Pathology (C.R.), Charité, Campus Virchow Clinic, Humboldt University of Berlin, Berlin, Germany
P Neuhaus
- Department of Surgery (A.P., N.R., D.S., P.N.), Charité, Campus Virchow Clinic, Humboldt University of Berlin, Berlin, Germany
B Kremer
- Department of Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany (A.R.M., K.P.P., F.B., F.F., B.K.)

Abstract

Acute rejection is still the main risk factor following intestinal transplantation. Potent immunosuppression decreases rejection frequency, but may increase immunosuppression-related complications. Isolated small intestinal transplantation was performed in 14 adult patients with short bowel syndromes. Immunosuppression included tacrolimus and rapamycin in combination with steroids for 6 months after ATG or daclizumab induction therapy. In addition to protocol biopsies, cellular immune status and soluble immune parameters were used to guide immunosuppression. CMV and EBV markers were determined on a routine basis. Ten of 14 patients (71%) survived for 1 to 38 months (median 26 months). Eight patients are at home, in good physical condition, completely on enteral nutrition. Among the 5 patients (36%) who developed acute rejection, 2 patients with early postoperative events underwent graft removal and 1 patient died due to multiple organ failure. Two patients developed severe acute rejection episodes at 10 and 24 months following transplantation. Both patients recovered following OKT3 rescue therapy and increased baseline immunosuppression with repeated methylprednisolone and infliximab treatment. Infections included peritonitis (n = 3), pneumonia (n = 3), central line infection (n = 5), urinary tract (n = 2), CMV (n = 2), and EBV (n = 4). Two patients developed anastomotic leaks at the esophageal and coloanal anastomosis. In conclusion, acute rejection episodes can be controlled by potent immunosuppression using tacrolimus in combination with rapamycin. Immunosuppression-associated complications, including infections, were in an acceptable range. However, even late after transplantation, reduction in immunosuppression may lead to severe rejection without major clinical symptoms.