Acute Rejection after Pediatric Intestinal Transplantation

Abstract

Background: Rejection is a major threat to the survival of intestinal allografts. As immunosuppression regimens have improved, the incidence of acute rejection has decreased significantly. The aim of our study is to report incidence and outcomes of acute rejection (AR) in pediatric intestinal transplantation at our center over the last decade. Methods: All pediatric intestinal transplants performed at our program between 2003–2016 were reviewed. Parameters analyzed included patient demographics, incidence, timing, severity, treatment and outcome of AR. Overall patient and graft survival was also analyzed. Results: The records of 111 pediatric intestinal transplants (n = 40, 36% isolated small bowel (SB), n = 49,45% liver-bowel (LB) and n = 22, 18% multivisceral) performed between 2003–2016 were analyzed; 61 (55%) male, median age 2 years (range 0.5 - 18). The most common indication for transplant was short gut secondary to gastroschisis (27, 24%) and necrotizing enterocolitis (19, 17%). Immunosuppression consisted of a combination of tacrolimus, mycophenolate mofetil, sirolimus and steroids. The overall incidence of AR was 34% after a median interval of 250 days (range 14–3,037) from transplant. The incidence of AR was 35% (14/40) in SB, 35% (17/49) in LB and 27% (6/22) in MV. The severity of acute rejection was classified as grade 1 in 34%, grade 2 in 20%, and grade 3 in 46%. The incidence of AR during 2003–2007 was 58% (22/38) with a median time to rejection of 296 days. The incidence of AR during 2008–2011 was 26% (9/35) with a median time to rejection of 362 days. The incidence of AR during 2012–2016 was 16% (6/38) with a median time to rejection of 21 days. Since 2003, the overall patient and graft survival was 81% and 77%, respectively, with patient and graft survival at 1-year reaching 89% and 87%. Conclusions: According to our experience over a thirteen-year time period, the incidence of acute rejection has decreased over time and current survival rates have improved significantly compared to the early era.