6 SMALL INTESTINE TRANSPLANTATION IN A CHILD

Abstract

After an experimental stage on piglets small intestine transplantation(SIT)using Cyclosporine A(CsA)we now report a human case. A 9 yrs old girl, on home parenteral nutrition for short small bowel (volvulus)for 6 yrs was transplanted with 120cm small intestine harvested by an isoblood group A 17 yrs old boy pronouced brain dead. Cross match reaction donor and recipient was negative. After aorta and inferior vena cava anastomosis total ischemic time was 3h55mn;both graft and own intestine were exteriorized as stomas. Immunosuppression included solumedrol 2mg/kg/d and CsA as a continuous infusion to maintain serum levels between 200-300μg/l. Acute graft rejection (GR) occured on day 13 marked only with an increased ileostomy drainage;histologic pattern included progressively=villi oedema, Tcell infiltrates(CD4+/CD8+), increased HLADR expression by enterocytes, severe crypt damage and ultimately mucosal sloughing. GR was treated with antilymphocyte globulin. No GVH reaction has been observed. The course after GR was marked with a persistant protein losing enteropathy up to a progressive intestine recovery as shown by repeated histologic findings, baryum transit(day 30 and 80)and start oral feeding from day 60. Unfortunately from the 6°month the addition of prolonged CsA IV administration, long term PN and probable viral infection induced severe liver disease and hematologic disorders requiring graft removal after 6½ months. The patient died. This course demonstrate that 6 months survival is possible after SIT. Small bowel recovery can be achieved despite extensive mucosal destruction caused be acute graft rejection.