Introduction: Graft versus host disease (GVHD) remains one of the most feared medical complications following intestine transplantation (ITx). Few contemporary studies have evaluated the incidence and outcomes of GVHD following ITx.

Methods: All ITx performed at our institution from 2003 through 2016 were included in this study and evaluated with the use of a prospectively maintained database. The incidence, associated clinical factors, treatment and outcomes were evaluated for all patients with GVHD.

Results: There were 234 transplants performed in 228 patients during this period, including 133 isolated intestine, 59 liver-intestine, 35 multivisceral and 7 modified multivisceral transplants. There were 13 (5.6%) cases of GVHD (6 adults and 7 pediatric) with a median presentation of 77 days (range 14-373) following transplantation. 8 patients received multivisceral or modified multivisceral grafts, 4 patients received isolated intestine grafts, and 1 liver-intestine. 8 patients had native splenectomy at time of transplant and 3 patients had a known immunodeficiency. The most common presentation was a rash (n=8), other clinical manifestations included native GI involvement (n=7), pulmonary involvement (n=3), and bone marrow involvement (n=3). Chimerism data was available for 8 patients and was positive in 7. Immunosuppression was augmented in all cases and median number of treatments/patient was 2 (range 1-4). Treatments included steroids (n=13), thymoglobulin (n=6), alemtuzumab (n=2), extracorporeal photopheresis (n=3), and bone marrow transplant (n=1). The majority of cases 9/13 (69.3%) were fatal despite aggressive treatment. The 5-year survival for patients with GVHD was 30.7% versus 70.5% for patients without GVHD (p=0.001). Statistically significant risk factors for GVHD included multivisceral graft and native splenectomy. Only 1 (7.6%) patient with GVHD had acute rejection compared to 17.7% in the patients without GVHD (p=0.001).

Conclusions: Despite modern immunosuppression regimens and advances in treatment, GVHD carries a high mortality. New therapies for GVHD are needed as well as aggressive surveillance protocols in multivisceral graft recipients and patients with a history of splenectomy.