MORTALITY AFTER STEROID RESISTANT REJECTION AND CHRONIC REJECTION
EPISODES IN ADULT INTESTINAL TRANSPLANT: REPORT FROM
A SINGLE CENTER IN INDUCTION/PRECONDITIONING ERA
Augusto Lauro1, Alberto Bagni3, Chiara Zanfi1, Sara Pellegrini1, Alessandro Dazzi1, Matteo Cescon1, Giorgio Ercolani1, Massimo Del Gaudio1, Matteo Ravaioli1, Loris Pironi2, Antonia D' Errico3, Antonio Pinna1
1Liver and Multiorgan Transplant Unit, St Orsola University Hospital, University of Bologna, Bologna, Italy; 2Center for Chronic Intestinal Failure, St Orsola University Hospital, University of Bologna, Bologna, Italy; 3Pathology Unit of F. Addarii Institute of Oncology and Pathology, St Orsola University Hospital, University of Bologna, Bologna, Italy
Objective:Steroid resistant rejection (ACR) and chronic rejection (CR) are still a major concern after intestinal transplantation; over last 20 years the presence of liver has been shown to have a protective effect on rejection episodes.
Patients and methods: from December 2001 to December 2012 we performed 49 intestinal transplants: 85.7% were represented by grafts without liver. Induction protocol was initially used on 12 transplants (Daclizumab, Tacrolimus and Steroids); later we developed a preconditioning protocol, with Alemtuzumab and Tacrolimus, on 35 allografts; in 2 cases we used Thymoglobulin and Tacrolimus.
Results:Overall 10-year patient survival was 45 %, graft survival 41%. Steroid resistant ACR population: 13recipients experienced steroid resistant ACRs: 3 were successfully treated by OKT3, 1 by Alemtuzumab, 1 by Thymoglobuline, 1 case underwent re-transplantation after OKT3 treatment. Seven recipients died after ACR therapy mainly for sepsis: 2 after Thymoglobulin, 2 OKT3, 1 Infliximab, and 2 after combined treatment. Twelve allografts out of 13 were without liver. Chronic rejection population: 5 recipients were affected by CR (1 was primarly transplanted elsewhere): 4 experienced indeterminate to mild episodes of ACR before developing CR, 1 had severe ACR. Two are alive: 1 underwent graftectomy and was relisted, 1 recovered oral feeding after partial bowel resection. The remnant 3 patients died for sepsis. Steroid resistant ACR mortality was 50% while CR mortality was 60%: overall, 10 patients out of 19 (52.6%) died after steroid resistant ACR or CR. Notably, mortality after Daclizumab was 17.7% in steroid resistant ACR and CR population while after Alemtuzumab the percentage achieved 28.8%.
Conclusion: In our series steroid resistant ACR affected 29.1 % of our intestinal allografts (all but one without liver); CR was shown on 8%, all isolated grafts. Mortality related to steroid resistant ACR and CR still affects intestinal transplant population in induction/preconditioning era.