P2B.19: Kidney Dysfunction after Intestinal Transplantation: Are We Headed in the Right Direction?

Abstract

Introduction: Acute kidney injury (AKI) is a common complication after Intestinal transplantation (ITx). There are different etiologies for AKI: high Tacrolimus (TAC) levels, dehydration due to ostomy outputs and acute tubular necrosis (ATN) from sepsis, ischemia, and hemodynamic instability. Modifications in immunosuppressive regimen combined with surgical modifications may decrease the reported incidence of AKI. Methods: Retrospective analysis of 92 intestinal transplants from 2013–2017: 94.6% (87/92) received the colon. Induction: Thymoglobulin (2mg/kg x5) and Rituximab (150mg/m2 x1); maintenance: 42=TAC + Everolimus (EVL), 24=TAC + Sirolimus (SRL), 26=TAC alone. Target TAC levels: 10-15ng/ml:0–3 months (mo), 5-10ng/ml:3–6 mo, and 4-6ng/mL:> 6 mo. EVL or SRL started after 30 days with target trough levels of 3–5 ng/mL. AKI was defined by recipients who developed an increase in nadir creatinine and required hospitalizations. Estimated glomerular filtration rate (eGFR) was calculated from routine serum creatinine using the CKD-EPI formula for adults and bedside Schwartz formula for children. Median follow-up: 27 [3–56] mo. Results: AKI occurred in 26.1% (24/92) of Itx; 75% (18/24) in the first 6mo. Median eGFR at 2, 3, and 12 mo was 113.5 [85.0–151.4], 99.8 [65.1–131.0], and 97.3 [55.1–125.9], respectively. Operative time wasmarkedly reduced (median time: 288 minutes) as compared to previous eras. Median TAC levels (ng/ml) at 7days and at 1, 2, 3, and 12 mo: 10.6 [7.7–14.1], 10.9 [7.9–14.3], 8.5 [6.8–12.1], 7.5 [5.8–10.5], and 5.7 [7.9-4.0], respectively. Cox regression analysis of the hazard rate (HR) of developing AKI found 2 significant predictors: sepsis (23/92, P<.0001) and acute rejection (AR) (7/92, P<.0001). Similarly, the HR of developing an eGFR<60ml/min/1.73m2: older age at transplant (P<.0001), AR (7/92, P=.01), and dehydration on > 2 hospitalizations (17/92, P=.02). Intestinal graft failure (IGF) occurred in 9/92 patients; death with a functioning graft (DWFG) was observed in 12/92. Neither the development of an AKI nor an eGFR<60ml/min/1.73m2 were associated with the HR of developing graft loss (P>.10) or DWFG (P>.5). Conclusion: Short-term renal dysfunction post Itx still exists. Both surgical modifications and changes in the immunosuppressive regimen have led to diminished AKI and impact on graft failure. Long term follow-up is needed and underway.