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Presenter: Ane, Andres, Madrid, Spain
Authors: Ane Andres, Francisco Hernandez, Mariela Dore, Vanessa Nuñez, Jose Luis Encinas, Alba Sanchez-Galan, Carlos De la Torre, Esther Ramos, Lorena Magallares, Jesus Sarria, Manuel Molina, Gerardo Prieto, Manuel Lopez-Santamaria
Ane Andres1, Francisco Hernandez1, Mariela Dore1, Vanessa Nuñez1, Jose Luis Encinas1, Alba Sanchez-Galan1, Carlos De la Torre1, Esther Ramos2, Lorena Magallares2, Jesus Sarria2, Manuel Molina2, Gerardo Prieto2, Manuel Lopez-Santamaria1.
1Pediatric Surgery, Hospital La Paz, Madrid, Spain; 2Pediatric Gastroenterology, Hospital La Paz, Madrid, Spain
Aim: To describe our experience after 100 intestinal transplants (IT) in a well-established Intestinal Rehabilitation Unit, with emphasis on the adaptive changes.
Patients/Methods: Demographic, clinical and short and long-term outcome data were reviewed. as well as the modifications to the initial protocols.
Results: A total of 78 out of the 240 patients referred for IT received 100 intestinal grafts between 1999 and 2017 at a median age of 37 months (6-238): 52 multivisceral (MVT, 3 modified), 26 isolated bowel (IBT), 22 combined liver-IT (LSBT). LSBT has been replaced by MVT in the last decade. The most common etiology was short bowel syndrome (68%, mostly NEC, volvulus and atresia) followed by motility disorders(18%) and intractable diarrhea (10%). Rare or unique indications have been Martínez-Frías syndrome, or unresectable hepatoblastoma, amongst others. General health status before transplantation was acceptable in 36%, poor in 31%, and very poor in 33%, although it has slightly improved over time. The large bowel was included in the graft since 2012 (33) improving absorption, without additional complications. Induction therapy consisted of basiliximab in <4yo and alemtuzumab for >4yo and/or retransplantation. Tacrolimus remains the standard for maintenance immunosuppression although Sirolimus has became a very good alternative, either in monotherapy (17) or combined with tacrolimus (6) since 2009. Overall incidence of rejection was 28%: graft loss rate was 31% and ultimately a second (23) and third graft (6) was necessary, with good results in 63%. Overall incidence of PTLD was 18%. Overall incidence for GVHD and hemolytic disorders was 14% and 15% respectively, decreasing significantly after native spleen preservation was implemented in 2011 (in 24 MVT/LSBT patients) compared with previous transplants where the spleen was removed (38)or where the donor spleen was included in the graft (12). After a 96-month (0-17,5 years) follow-up, 64% are alive and off PN. Twenty-eight patients died after a median of 7 months (0-50) from transplant, mainly due to sepsis and GVHD. Seventeen died during the first year after transplantation, 9 within the first 2 months.
Conclusions: Technical and immunological modifications are slowly but progressively improving short and long-term outcome of IT patients. Early referral, centralization of cases, a multidisciplinary approach, and a constant update is crucial to move on the right direction.
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