Predictors of outcome after intestinal transplantation: An analysis of over 125 cases at a single center

Douglas G. Farmer¹, Laura J. Wozniak², Susan Ponthieux¹, Villy Hwang¹, Kanela Artavia³, Elizabeth A. Marcus², Vatche G. Agopian¹, Ali Zarrinpar¹, Sue V. McDiarmid², Ronald W. Busuttil¹, Robert S. Venick²

¹Surgery/Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; ²Pediatric Gastroenterology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; ³Care Coordination, UCLA Medical Enterprise, Los Angeles, CA, United States

INTRO: Intestinal transplantation (ITx) has had remarkable advancement over the past 2.5 decades. Outcomes are still limited by rejection and infection. Few large studies are available to analyze factors that affect results. The AIM of this study was to review a large, single center experience and perform an analysis of factors that impact outcome. METHODS: All recipients of ITx from 1991-2012 were included from an IRB approved prospective database. A battery of demographic and technical variables were included. Standard statistical analyses were performed including T test for variable comparison, Kaplan Meier for survival and Log Rank test for univariate analysis. RESULTS: 127 ITx were performed in 104 patients. The majority were male (58%), Latino (54%), children (72%) with surgical short gut etiologies (81%). The types of transplants included isolated intestine (23%), liver-intestine (57%), multivisceral (MVT, 14%), and modified MVT (m-MVT, 6%). At ITx, 43% were hospitalized and the mean MELD/PELD score was 15±11. Mean total ischemia time was 7.5±2 hrs. IL2RA was the most common induction immunosuppression (58%) followed by ATG (33%) and NONE (9%). Average LOS was 74±39 days. Major complications included acute rejection (59%), CMV disease (6%), and PTLD (11%). 5-YR overall patient and graft survival was 65% and 57%. The most common causes of patient death and graft loss were infection (57%) and rejection (43%). Noteably, 43% of grafts lost were functional at time of patient death. Predictor analysis demonstrated statistically (p <= 0.05) better graft outcomes with: children <24MO, liver-inclusive grafts, PRA <20%, negative B cell crossmatch, and WIT <60Min. Bordeline significant (p>0.05 <0.1) variables included era after 2000 of ITx, IL2RA induction, post-ITx intubation <7d, and DSA positive. Likewise, strong predictors of improved patient survival were WIT <60MIN, lack of recipient splenectomy, non-IL2RA induction immunosuppresion, and the more recent era of ITx. CONCLUSIONS: This large, single center experience confirms improved outcomes in the more recent era of transplantation likely related to experience gained and improved immunosuppression. Still, graft loss is common. This experience indicates that graft loss can be reduced by reducing PRA, avoiding DSA, and the use of liver-inclusive grafts. Technical advances to reduce ischemia time are also important. Ongoing efforts such as these are necessary to help further improve outcomes after ITx.