Intestinal transplantation for end stage Crohnʼs Disease: Therapeutic efficacy and risk of recurrence

Abstract

Intestinal transplantation has been recently evolved and more frequently utilized to rescue patients with irreversible intestinal failure who failed TPN therapy. End stage Crohn's disease has been the second leading indication for transplantation in adults. This report is the first to address the procedure's therapeutic efficacy in this unique population with special reference to disease recurrence. Between May 2, 1990 and March 31, 2006, a total of 196 consecutive adult patients underwent intestinal transplantation. Recalcitrant Crohn's disease (duration: 20±7 yrs) was the cause of intestinal failure in 38(18%) patients. The causes of TPN (duration: 65±48 mos) failure and indication for transplantation were multiple line infections (90%), limited venous access (60%) and elevated hepatic enzymes (84%). The male to female ratio was 1:1.5 with a mean age of 43 ± 10 yrs. All patients underwent multiple abdominal operations (mean 10±6) with proctocolectomy in 22(63%). Simultaneous replacement of the liver was required in 9(26%) patients due to liver failure with a mean serum bilirubin of 12 ± 11mg/dL. Rejection prophylaxis was with tacrolimus and prednisone with utilization of induction therapy in the recent 25 recipients. With a mean follow-up of 35±34 mos, the overall survival of the Crohn's disease patients after transplantation was 85% at 1 yr and 62% at 3 yrs with a retransplantation rate of 14%. With induction immunosuppression, survival has significantly (p=0.02) improved with 1 and 3 yr survival rate of 92% and 78%, respectively. Leading causes of graft loss were rejection (65%) and infection (34%). All survivors achieved full nutritional autonomy and enjoyed unrestricted oral diet. Disease recurrence was histologically documented in 3 (7.5%) allografts at 3, 15 and 18 months from the time of transplantation with no significant graft dysfunction. With similar distribution of type of transplanted allograft and immunosuppression, there was no significant (p=0.3) difference in survival between the Crohn's and non-Crohn's patients. However, the cumulative risk of graft loss due to acute and chronic rejection was significantly higher in the Crohn's disease compared to the non-Crohn's disease recipients. Intestinal transplantation is a life saving and an effective therapy for patients with end stage Crohn's disease. Disease recurrence is very low and at best histologic with no significant impact on survival and graft functions.