Breaking the 5 Year Mark with 100% Survival for Intestinal Transplant -Time to become protagonist in the management of intestinal failure?

Abstract

Introduction: Historically intestinal graft survival declines continuously from 80% 1 year- to ~ 40% at 5 year-post transplant. Adult patient survival is ~ 60% 5 year[1]. Closer surveillance and better understanding of immunological events has led to intestinal transplant becoming a more efficient and safe procedure in our center. Methods: We described our experience with Isolated Intestinal Transplant in the last 6 years. Results: From December 2010 to December 2016 we performed 26 transplants in 25 patients. 19 of the patients were adults. Average age was 32 years. All the patients but one had complications from PN. Average donor age was 13 years. Blood type was identical in 19 of them and compatible in 7. Four patients had positive crossmatch. Colon was part of the graft in 80% of the patients. Portal drainage was used in 30% of the cases. All the patients received induction with anti-thymocyte + rituximab. Basiliximab was given on POD14 and then monthly for a total of 3 doses. Tacrolimus was used in association with mTor inhibitors. Steroids were weaned over 3 months. All the patients are alive. Overall graft survival is 85% (90% for adults). One adult patient lost the graft due to rupture of a mycotic aneurism 12 days post-transplant and one pediatric patient lost the graft due to a volvulus 6 weeks after the transplant. One pediatric patient developed refractory severe rejection. One adult patient was noncompliant and had the graft removed 21 months post-transplant. From these 4 patients, one child was retransplanted 6 months after graft loss and is well now >1 year post-retransplant. Moderate to severe rejection occurred in 3 adults and 1 child. One adult developed PTLD with total remission. None of the patients developed GVHD.FigureFigureDiscussion: No mortality associated with excellent graft survival achieved in this series makes intestinal transplantation the standard of care for intestinal failure. From the four graft losses, 2 of them were due to technical complications and one for noncompliance. Retrospectively, just one of the graft losses was completely unavoidable. Five year survival for patients in parenteral nutritional varies from 70 to 90%. Based on our experience, intestinal transplantation provides not only superior quality of life but also superior survival. This cohort represents patients with classic indications of intestinal transplant but preemptive transplant may be considered from now on based on these results. Reference: 1. Smith JM et al. OPTN/SRTR 2015 Annual Data Report: Intestine. Am J Transplant. 2017 Jan;17 Suppl 1:252–285.