1
|
Ferreira MA, Ouverney LFF, Figueiredo MC, David AI. Immunosuppression Protocols in Intestinal and Multivisceral Transplantation-A Literature Review. Transplant Proc 2023; 55:1431-1436. [PMID: 37088617 DOI: 10.1016/j.transproceed.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/03/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Intestinal transplantation (IT) and multivisceral transplantation (MVT) are curative therapies for patients with intestinal failure and severe complications associated with total parenteral nutrition. High levels of immunosuppression are required to prevent acute cellular rejection (ACR) from the bowel. Studies regarding pre-treatment, induction, and post-transplant therapy have improved graft acceptance, reducing immunosuppression doses and infectious complications. However, the low rate of IT and MVT and the small number of specialized centers have resulted in a limited number of evidence-based immunosuppression protocols. We reviewed immunosuppression in IT and MVT to draw useful conclusions regarding the best protocol strategies for the induction, maintenance, and management of ACR. METHODS A review was performed using the PubMed database. Articles on immunosuppression protocols in IT and MVT that addressed graft rejection, infection, or survival, published between 2006 and 2022, were selected. RESULTS A total of 690 articles were selected. Two researchers applied the inclusion and exclusion criteria and selected 14 articles independently. For induction, thymoglobulin, alemtuzumab, and basiliximab are the most frequently used immunosuppressants for induction. Classic maintenance therapy consists of a combination of corticosteroids and tacrolimus. Methylprednisolone with an increased tacrolimus dose is used most frequently to manage ACR. Depending on the receptor response, such as thymoglobulin, infliximab, adalimumab, or bortezomib, other immunosuppressants should be considered. CONCLUSIONS There have been great advances in IT and TMV immunosuppression. We conclude that the gold standard immunosuppressive protocol is triple therapy, comprising induction with thymoglobulin, maintenance with steroids for a few months, and tacrolimus and mycophenolate therapy. Innovative approaches for treating intestinal rejection episodes with more appropriate drugs, such as infliximab, adalimumab, or bortezomib, are necessary.
Collapse
|
2
|
Yue C, Wu X, Mo Z, Yang Q, Wang W, Zhou H, Gao R, Liang J, Yu P, Zhang Y, Ji G, Li X. Multidrug-resistant Klebsiella Pneumoniae Infection Led to Resection of the Graft in a Small Bowel Transplant Recipient: A Case Report and Review of the Literature. Transplant Proc 2023:S0041-1345(23)00254-3. [PMID: 37225551 DOI: 10.1016/j.transproceed.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Infection due to multidrug-resistant Klebsiella pneumoniae is a common cause of graft resection after small bowel transplantation. We report a failed case in which the intestinal graft was resected 18 days after the operation due to postoperative infection with multidrug-resistant K pneumoniae and a literature review of other common causes of small bowel transplantation failure have been reported. METHODS A female, 29 years of age, underwent partial living small bowel transplantation for short bowel syndrome. After the operation, the patient was infected with multidrug-resistant K pneumoniae, even though various anti-infective regimens were employed. It further developed into sepsis and disseminated into intravascular coagulation, leading to exfoliation and necrosis of the intestinal mucosa. Finally, the intestinal graft had to be resected to save the patient's life. RESULTS Multidrug-resistant K pneumoniae infection often affects the biological function of intestinal grafts and can even lead to necrosis. Other common causes of failure, including postoperative infection, rejection, post-transplantation lymphoproliferative disorder, graft-vs-host disease, surgical complications, and other related diseases, were also discussed throughout the literature review. CONCLUSIONS Pathogenesis due to diverse and interrelated factors makes the survival of intestinal allografts a great challenge. Therefore, only by fully understanding and mastering the common causes of surgical failure can the success rate of small bowel transplantation be effectively improved.
Collapse
Affiliation(s)
- Chao Yue
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Xiao Wu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Zhenchang Mo
- Department of Oncology, Affiliated Hospital, Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Qinchuan Yang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Weidong Wang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Haikun Zhou
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ruiqi Gao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Jiayi Liang
- Department of Pathology, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Pengfei Yu
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China
| | - Ying Zhang
- Department of Radiotherapy, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| | - Xiaohua Li
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Shaanxi, China.
| |
Collapse
|
3
|
Rumbo M, Oltean M. Intestinal Transplant Immunology and Intestinal Graft Rejection: From Basic Mechanisms to Potential Biomarkers. Int J Mol Sci 2023; 24:ijms24054541. [PMID: 36901975 PMCID: PMC10003356 DOI: 10.3390/ijms24054541] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023] Open
Abstract
Intestinal transplantation (ITx) remains a lifesaving option for patients suffering from irreversible intestinal failure and complications from total parenteral nutrition. Since its inception, it became obvious that intestinal grafts are highly immunogenic, due to their high lymphoid load, the abundance in epithelial cells and constant exposure to external antigens and microbiota. This combination of factors and several redundant effector pathways makes ITx immunobiology unique. To this complex immunologic situation, which leads to the highest rate of rejection among solid organs (>40%), there is added the lack of reliable non-invasive biomarkers, which would allow for frequent, convenient and reliable rejection surveillance. Numerous assays, of which several were previously used in inflammatory bowel disease, have been tested after ITx, but none have shown sufficient sensibility and/or specificity to be used alone for diagnosing acute rejection. Herein, we review and integrate the mechanistic aspects of graft rejection with the current knowledge of ITx immunobiology and summarize the quest for a noninvasive biomarker of rejection.
Collapse
Affiliation(s)
- Martin Rumbo
- Instituto de Estudios Inmunológicos y Fisiopatológicos, Facultad de Ciencias Exactas, Universidad Nacional de La Plata—CONICET, Boulevard 120 y 62, La Plata 1900, Argentina
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Department of Surgery at Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, 413 90 Gothenburg, Sweden
- Correspondence:
| |
Collapse
|
4
|
Fujimura T, Yamada Y, Umeyama T, Kudo Y, Kanamori H, Mori T, Shimizu T, Kato M, Kawaida M, Hosoe N, Hasegawa Y, Matsubara K, Shimojima N, Shinoda M, Obara H, Naganuma M, Kitagawa Y, Hoshino K, Kuroda T. Maintenance treatment with infliximab for ulcerative ileitis after intestinal transplantation: A case report. World J Clin Cases 2021; 9:5270-5279. [PMID: 34307578 PMCID: PMC8283613 DOI: 10.12998/wjcc.v9.i19.5270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/18/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evidence has been published on the successful applications of the anti-tumor necrosis factor alpha antibody infliximab, such as induction therapy, salvage treatment for acute cellular rejection, and treatment for chronic ulcerative inflammation, in intestinal transplant recipients. However, the optimal protocol for the effective use of infliximab remains largely undetermined due to scarcity of available clinical data. We report a continuative application of infliximab as maintenance therapy for recurrent chronic ulcerative ileitis in a recipient of isolated intestinal transplantation (ITx).
CASE SUMMARY The patient was a 11-year-old boy with intestinal motility disorder classified as a hypogenic type of intestinal dysganglionosis. The patient underwent living-donor related intestinal transplant. His immunosuppression regimen consisted of daclizumab, tacrolimus, and steroids. Although he did not show rejection while on tacrolimus monotherapy, routine screening endoscopy showed several ulcerative lesions in the distal end of the graft 2 years after the intestinal transplant. Endoscopic work up to evaluate the progression of anemia revealed stenosis with ulcerative inflammatory changes and multiple longitudinal ulcers in the graft. Since the endoscopic findings suggested ulcerative lesions in Crohn’s disease, infliximab treatment was considered. Treatment with infliximab and a small dose of oral prednisolone afforded successful withdrawal of total parenteral nutrition and maintenance of a well-functioning graft without infectious complications for 5 years since the administration of the first dose of infliximab.
CONCLUSION Infliximab is effective as maintenance therapy for recurrent chronic ulcerative ileitis in an isolated ITx patient.
Collapse
Affiliation(s)
- Takumi Fujimura
- Department of Pediatric Surgery, National Saitama Hospital, Wako Shi, Saitama 351-0102, Japan
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tomoshige Umeyama
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yumi Kudo
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hiroki Kanamori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Teizaburo Mori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Takahiro Shimizu
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Miho Kawaida
- Department of Pathology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Naoki Shimojima
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
- Digestive Diseases Center, International University of Health and Welfare, Mita Hospital, Tokyo 108-8329, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Makoto Naganuma
- Department of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| |
Collapse
|