300.7: Isolated intestinal transplantation: Are we shifting the paradigm?

Abstract

Introduction: Isolated intestinal transplant (IIT) is the definitive therapy for intestinal failure. Outcomes have improved tremendously in the last decade. Our center has performed almost 500 intestinal inclusive transplants. Intestine-Colon may be the best nomenclature for better defining the current procedure. Method: We describe all the patients who received IIT from 2013 to 2018 in our center. It represents our most recent Era with the evolution of surgical technique, immunosuppression regimen, graft monitoring and patient management. Immunosuppression consisted of induction with thymoglobulin and rituximab, maintenance with tacrolimus and mTOR inhibitor and use of basiliximab or vedolizumab for the first 3 months. Results: 31 IIT were performed in 30 patients at our center. 13 were male. 11 of the recipients were pediatric. Recipient age went from 1 year old to 65 years old. Main indication for transplant was short gut. Positive crossmatch was found in 14% of the transplants. Moderate or severe rejection has happened in 32% of the patients. Only 1 patient underwent to enterectomy within 90 days due to rejection. One patient lost the graft due to volvulus. One patient had the graft removed during emergent surgery due to rupture of mycotic aneurism. Two patients developed PTLD. GVHD was not seen in this cohort. Chronic rejection or chronic graft dysfunction was not observed. Kaplan Meyer 5 year patient and graft survival for primary, non-renal transplants, was 92% and 77% respectively. 5 year patient survival including re-transplants and intestine-kidneys transplants is 87%. Patient survival 1 year remains 100% for all the patients. Discussion: Survival of intestine-colon transplant has greatly improved over time. Historically, rejection was the main reason for graft and patient loss. In this cohort, only half of the graft losses were due to rejection. Mortality or graft loss due to causes unrelated directly to transplant was the majority in our experience. New immunosuppressive strategies have shown excellent results preventing rejection. Chronic rejection is a well-known long term complication for IIT, although no cases were seen up to date. 100% patient survival for the first year and 92% patient survival for 5 years surpasses all the data available not only for intestines but for all other organs. We believe we are entering a new era in intestinal transplant, with extremely high patient survival even when compared with other modalities of treatment for intestinal failure.