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Stool calprotectin in intestinal graft dysfunction: preliminary results in a new Italian transplant centre

Manila Candusso, Franco Collistro, Chiara Grimaldi, Antonella Diamanti, Fabio Panetta, Alessia Saccari, Francalanci Paola, Giuseppe D'Ambrosio, Paola De Angelis, Lidia Monti, Cristina Lo Zupone, Jean de Ville de Goyet, Giuliano Torre

Ospedale Bambino Gesù, Rome, Roma, Italy

Stool calprotectin is useful in monitoring rejection in small bowel transplantation. We report about our initial experience in Children’s Hospital Bambino Gesù in Rome on monitoring gut rejection by using stool calprotectin together with intestinal biopsies. Case 1. a 12 year-old boy underwent at the age of 8 SBTx for short gut syndrome; he experienced one ACR, recovered on steroid bolus and he did well for 6 months. Sirolimus was started for initial renal damage, but it had to be discontinue for severe thrombotic micro-angiopathy. A second severe ACR occurred 1 year after transplant and again medical therapy was effective in recovery. After 3 years of well being, with no previous evidence of rejection at histology, he was admitted in Rome for acute diarrhea following Rotavirus infection. Hystology revealed ACR, initially treated by steroid without any effects so repeated steroid bolus, infliximab and mesenchymal cell infusion were administered, but severe exfoliative rejection led to re-transplant, performed in Rome on TAC, steroid, MMF and basiliximab; at + 3 months, CMV enteritis occurred, successfully treated by ganciclovir. Before and after re-Tx, stool calprotectin levels were strict monitoring: normal levels (< 250 mcg/g ) were detected in the absence of any histological complication, but they were very high (> 1000 mcg/g) if severe ACR, while in CMV infection levels were always below 800 mcg/g. Case 2. C.S. is now a 10 yr-old boy affected by CIPO who underwent SBTx at the age of 7 for recurrence of severe dehydration and hemorrhagic events; surgical procedure was uneventful, on basiliximab, TAC and steroid therapy. Six months after transplant he experienced ACR and severe CMV enteritis, with complete recovery. The follow-up was continued in Rome, where he underwent protocol biopsies without any evidence of rejection so far. Stool calprotectin levels were always within normal ranges (< 250 mcg/g), according to histology. In our experience stool calprotectin levels appear to correlate to gut inflammation, and high levels seem to be more associated to rejection. This could be a useful tool to suspect graft dysfunction.