2017 - CIRTA


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1- Rejection of the Intestine Allograft

15.12 - Immunologic Consequences are Associated with Increased Mortality in Multivisceral/ Intestinal Re-transplantation

Presenter: Shekhar, Kubal, Indianapolis, United States
Authors: Shekhar Kubal, Burcin Ekser, Katherine Pennington, Kathleen Doan, Marco Lacerda, Jonathan Fridell, Richard Mangus

Immunologic Consequences are Associated with Increased Mortality in Multivisceral/ Intestinal Re-transplantation

Shekhar Kubal1, Burcin Ekser1, Katherine Pennington1, Kathleen Doan1, Marco Lacerda2, Jonathan Fridell1, Richard Mangus1.

1Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis, IN, United States; 2Department of Medicine, Division of Gastroenterology - Hepatology, Indiana University School of Medicine, Indianapolis, IN, United States

Background: Multivisceral/ intestinal re-transplantation is considered as a treatment option for patients with primary intestinal graft loss. In 2016, 16% of all intestine/ multivisceral transplants performed un the U.S. were re-transplants [optn.transplant.hrsa.gov]. As potent induction immunosuppression is often used, we sought to investigate the effect of double induction therapy in terms of immunologic consequences.

Methods: We analyzed outcomes of 21 patients receiving 22 intestinal/ multivisceral re-transplants at a single center from May 2005 to April 2015 with a particular focus on immunologic outcomes. Bone marrow suppression was defined as platelet count <50 k/mm3 and absolute lymphocyte count <200 /mm3. Patients with less than one year follow up were excluded (n=2).

Results: Six re-transplants were in pediatric patients and 16 in adults. All except one were liver inclusive transplants. 15/21 patients died at a median period of 12 (0.2-75) months after re-transplantation. Of 15, 4(27%) patients died as a result of recurrent severe rejection and in 9(60%), complications associated with immunocompromised state [GVHD affecting bone marrow (3), persistent viral infection (3), PTLD (1), metastatic cancer (1), multi-drug resistant polymicrobial sepsis (1)]. Characteristics of surviving versus non-surviving re-transplant recipients are compared in tables 1 and 2. Notably, the use of alemtuzumab f=to treat rejection and the incidences of bone marrow suppression, GVHD and death due to immunocompromised state were higher in non-survivors. Median time period between two transplants was numerically higher in survivors. 

Conclusions: Multivisceral/ intestinal re-transplantation is associated with significant mortality. Immunocompromised status and rejection are the major contributors to mortality. It is not possible to predict mortality prior to re-transplantation, however longer period between two transplants may be advantageous. Strategies such as allograft specific immunosuppression and donor treatment with depleting agents with less potent induction may spare the host from devastating effects of potent immunosuppression currently used.


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