Aim: To review the diagnosis, treatment and management of ACR after intestinal transplantation (ITx) in a single UK adult centre (Addenbrooke’s Hospital, Cambridge).

Method: We undertook a retrospective review of patients with intestinal containing grafts at Addenbrooke’s hospital from 2007 to 2016 who developed ACR. Biopsies were reviewed by an experienced GI pathologist and were graded based on the VIII International Small Bowel Transplant Symposium Consensus criteria with minor modifications for evaluation of colon biopsies. Each biopsy was graded either negative or positive for ACR. Resolution of ACR was the first normal biopsy without any features of rejection including any borderline features. Comparison between groups was with Chi-squared test.

Results: During the study a total of 71 ITx were performed in 65 patients (42 Multivisceral or Liver/Intestine, 9 Modified multivisceral and 20intestine only). Of these, 30 patients had at least one episode of rejection in 32 grafts. Two patients were re-transplanted for refractory rejection.

Of the patients who had rejection, 18/30  had colon-containing grafts and 20/30 were liver-containing grafts. The median time to first rejection was 8.60 months. 19 grafts had a single episode of rejection and 13 grafts had more than one episode of rejection. Of these rejections, 26% were mild, 40% were moderate and 34% were severe. The average time to resolution after the first episode of rejection was 61.07 days.  First line treatment for the episode of rejection was pulsed methyl prednisolone in 75% cases, of which 45% required second line treatment. The rates of rejection in liver containing vs non-liver containing grafts were not significantly different (p=0.81). However, the rates of rejection in patients with a colon as part of their graft is 64%, whereas in those without colon it is 32% (p=0.008)

Conclusion: The overall rate of rejection is 45% in our cohort, which is similar to previous reports in this organ type^[1]. However, contrary to those previous reports, we did not find that having a liver containing graft influenced the rate of ACR, but the presence of a colon did increase the risk. However, this needs to be balanced against the known benefits of having a colon.

[1] Grant et al. 2003 Report of the Intestine Transplant Registry Ann Surg 2005; 241(4): 607-613