Outcome Analysis of 71 Clinical Intestinal Transplantations

TLDR

Intestinal transplantation remains a difficult and unreliable procedure despite modern immunosuppression, and bone marrow transplantation may improve outcomes by reducing rejection and infection barriers. The study aimed to identify risk factors for graft failure and mortality in intestinal transplantation and to explore potential solutions. A retrospective analysis of 71 transplantations performed from 1990 to 1995 in 66 patients used tacrolimus and low‑dose steroids, with grafts ranging from isolated intestine to multivisceral, and some recipients received perioperative donor bone marrow cells. Among the first 63 recipients, 32 survived (28 with functioning grafts, 4 resuming TPN); graft loss was mainly due to infection, rejection, and technical errors, and regression identified surgery duration, donor.

Abstract

The aim of the study was to determine risk factors associated with graft failure and mortality after transplantation of the intestine alone or as part of an organ complex.Even with modern immunosuppressive therapies, clinical intestinal transplantation remains a difficult and unreliable procedure. Causes for this and solutions are needed.Between May 1990 and February 1995, 71 intestinal transplantations were performed in 66 patients using tacrolimus and low-dose steroids. The first 63 patients, all but one treated 1 to 5 years ago, received either isolated grafts (n = 22), liver and intestinal grafts (n = 30), or multivisceral grafts (n = 11). Three more recipients of allografts who recently underwent surgery and one undergoing retransplantation were given unaltered donor bone marrow cells perioperatively as a biologic adjuvant.Of the first 63 recipients, 32 are alive: 28 have functioning primary grafts and 4 have resumed total parenteral nutrition after graft enterectomy. Thirty-five primary grafts were lost to technical and management errors (n = 10), rejection (n = 6), and infection (n = 19). Regression analysis revealed that duration of surgery, positive donor cytomegalovirus (CMV) serology, inclusion of graft colon, OKT3 use, steroid recycle, and high tacrolimus blood levels contributed to graft loss. All four intestine and bone marrow recipients are alive for 2-3 months without evidence of graft-versus-host disease.To improve outcome after intestinal transplantation with previous management protocols, it will be necessary to avoid predictably difficult patients, CMV seropositive donors, and inclusion of the graft colon. Bone marrow transplantation may further improve outcome by ameliorating the biologic barriers of rejection and infection and allowing less restrictive selection criteria.