2017 - CIRTA


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5- Outcomes after Intestinal Transplantation

16.7 - Post-intestine transplant graft-versus-host disease associated with high mortality risk

Presenter: Jared, Clouse, Indianapolis, United States
Authors: Jared Clouse, Chandrashekhar Kubal, Jonathan Fridell, Burcin Ekser, Elizabeth Pearsall, Richard Mangus

Post-intestine transplant graft-versus-host disease associated with high mortality risk

Jared Clouse1, Chandrashekhar A. Kubal1, Jonathan A. Fridell1, Burcin Ekser1, Elizabeth J. Pearsall1, Richard S. Mangus1.

1Surgery, Indiana University School of Medicine, Indianapolis, IN, United States

Introduction: This study reports the incidence, location, and outcomes of graft-versus-host disease (GVHD) at an active intestine transplant center. Subgroup analysis is employed to assess for risk factors for the development of GVHD.

Methods: Records from an active transplant center were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports were reviewed to establish the diagnosis and location of GVHD. Pharmacy records were reviewed in documented cases to assess therapeutic interventions.

Results: A total of 236 intestine transplants were performed during the study period, with 37 (16%) patients developing GVHD. The mean time to onset of disease was 137 days, with all but four patients being diagnosed in the first year post-transplant. Overall mortality was 78% in patients who developed any GVHD. Mortality was higher in adults (83%) than in pediatric patients (57%).

Skin lesions were the most common manifestation of GVHD and seen in all but one affected patient. Other sites of disease included lungs, bone marrow, oral mucosa, colon, and brain, with disease in the lungs, brain, and bone marrow being universally fatal. In adult patients, the incidence of GVHD was 16%, with the incidence increasing from 4% in isolated intestine transplants to 14% in modified multivisceral patients, and 22% in multivisceral recipients. Pediatric patients had a slightly lower incidence at 13%, but in contrast to adults the incidence between transplant types was nearly equal (11% isolated intestine and 15% multivisceral). De novo GVHD after one year post-transplant was rare, suggesting the development of some level of graft-recipient tolerance.

Conclusion: Overall, 16% of patients receiving an intestine transplant developed GVHD. GVHD in the lungs, brain, and bone marrow was universally fatal. GVHD was associated with a high mortality risk. In adults, increasing graft volume (isolated versus multi-organ) was associated with an increasing risk of GVHD. A similar association was not observed in pediatric intestine recipients. Increased size difference between patients and donors, measured by height, weight, and BMI difference, did not correlate with increased incidence of GVHD. Further research should focus on determining patients at highest risk for GVHD to allow development of a therapeutic plan to prevent complications, including death. 


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